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Harm reduction Project 25: Meeting of the Minds
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Harm reduction Project 25: Meeting of the Minds

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Started in 2011, Project 25 aims to solve the many difficulties associated not just with chronic homelessness, but especially those who are frequent users of public systems such as local hospitals and …

Started in 2011, Project 25 aims to solve the many difficulties associated not just with chronic homelessness, but especially those who are frequent users of public systems such as local hospitals and law enforcement. In its first year alone, Project 25 demonstrated the following results and these trends have continued into subsequent years. First year results include:
• 56 percent decline in number of hospitalizations
• 58 percent decrease in days spent in the hospital
• 62 percent drop in ambulance rides
• 66 percent reduction in emergency room visits
• 63 percent cut in costs

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  • 1. Using Harm Reduction Strategies with Frequent Users of Emergency Services: Project 25 Marc Stevenson David Folsom Kris Kuntz
  • 2. Project 25 Background  3 year pilot funded by the UnitedWay  Unprecedented Collaboration  35 chronically homeless “Frequent Users”  Outreach with partner agencies  Housing First Model  Intensive case management  Emphasis on data collection
  • 3. Goals  Decrease use and cost of emergency services  Housing stability and sustainability  Improved quality of life  Preventative care through medical home  Obtain income
  • 4. Housing  Housing First Model  25 Sponsor Based HousingVouchers  10 Housing subsidies through MHSA funds  Scattered site model  33 permanently housed
  • 5. Who are the “Frequent Users”?  Chronically homeless  13 men and 3 women  Avg. age of 50 with range of 41 to 61  >90% have severe alcohol dependence  >90%have co-occurring disorder  >80% have complex medical problems  Failed multiple treatment programs
  • 6. Intensive Case Management Services  Outreach/relationship/basic needs  Jail/hospital visits and D/C planning  Prescription P/U & delivery  Life Skills Coach home visits  Weekly/daily med management  Identification & education about trauma  Landlord mediation/education/relationship  Quick response to crisis in housing  Go-Phones/landlines/24 hour emergency number  Payee services  Harm reduction with tobacco/alcohol
  • 7. What is Harm Reduction?  A range of public health policies and interventions designed to reduce harmful consequences of human behavior- even if this behavior is illegal (Wikipedia)  Starts where the client is  Moves towards better health and responsibility  Goal is improved quality of life  Achievable without demand for abstinence as a condition for assistance http://gilgerald.com/storage/research-papers/09%20report%20harm.pdf
  • 8. Examples of Harm Reduction  Needle exchange programs  Condoms/safe sex, STD/HIV prevention  Seatbelts  Designated driver  Methadone clinics  Managed Alcohol Programs
  • 9. Key Features (Drug Use)  Focus on reducing harm rather than use  Drugs are a reality of society  Harm reduction should provide a comprehensive public health framework;  Priority on immediate (and achievable) goals  Harm reduction values pragmatism and humanism (Ritter and Cameron 2006)
  • 10. Needle Exchange  Most studied harm reduction intervention  Became more prominent with HIV  Reduce risk/incident of HIV and Hep C  Enhancements can include case management, primary care, and referrals  In San Diego, needle exchange programs allowed in City, but not in County
  • 11. Harm Reduction:Alcohol  Meets people where they are at with drinking  Does not label people as “diseased” or “alcoholic”  Empowers people to choose own goal: safer drinking, reduced drinking, or quitting  Realistic goals that they can accomplish Anderson, Kenneth. (2010) How to ChangeYour Drinking:A Harm Reduction Guide to Alcohol.The HAMS Harm Reduction Network
  • 12. Managed Alcohol Programs  Originated in Canadian homeless shelters  In winter, many homeless alcoholics froze to death rather than enter shelters that required sobriety  Provide alcohol to shelter residents- quantity varies  Goals are typically pragmatic (reduce ER use) and humanitarian (prevent people from freezing to death on the streets)
  • 13. Past Research  Shelter Based Managed Alcohol Program, Ottawa, Canada Podymow et al (2006). Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol. Canadian Medical Association Journal, 174(1), 45-49.  1811 Eastlake, Seattle,Washington Larimer et al. (2009). Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems. Journal of American Medical Association, vol. 301, n13.  Glenwood Residence and Wakigun Residence, Hennepin County, Minnesota Thornquist et al. (2002). Health Care Utilization of Chronic Inebriates. Academic Emergency Medicine, vol 9, n4.
  • 14. Harm Reduction Alcohol: Concepts  Harm Elimination/Abstinence  Recovery Readiness  Moderation Management/Controlled Use  SubstitutionTherapy  Relapse/Overdose Prevention  Environmental Prevention  Alternative Approaches  Stages of Change http://gilgerald.com/storage/research-papers/09%20report%20harm.pdf
  • 15. P-25: Harm Reduction Alcohol  Abstinence is our main goal  For some HR is not an option…  Some are going to drink with or without us ◦ Reduced drinking ◦ Safer drinking ◦ Encourage abstinence  Reduce harm in other areas such as health, mental health, and trauma
  • 16. Reduced Drinking  Drinking later in the day  Switching to lower alcohol beverages  Establishing reduced drinking goals  Planned drinking with monitoring  Assistance with alcohol purchase to support reduced drinking plan  Daily/weekly drinking allowance
  • 17. Safer Drinking  Drinking in home ◦ TV, DVD’s, and radio  Make it back to apartment ◦ Decrease interaction with Police and Ambulance  Eating before drinking  Vitamins  Cell phones/House phones ◦ 24 Emergency On-Call Phone
  • 18. Encouraging Abstinence  Setting goals for abstinence days ◦ Setting goals for abstinence hours  Participation in home detox  Agreeing to an in-patient detox program  Agreeing to residential S/A treatment  Encouraging 12-step meeting attendance  Developing a HR Group
  • 19. Harm Reduction Psychotherapy  All problems including trauma  No punitive sanctions for substance use or for refusing medications  Encourages open and honest talk  Encourages plans and decisions about life, health and substance use  Not an all-or-nothing process
  • 20. HR and Trauma Informed Care  Recognition of trauma  Focuses on improving functioning over “fixing” something “broken.”  Healing occurs in context of relationship  Promotes safety  Objective, neutral language  Goal of practicing healthier adaptive behaviors SAMHSA National Center forTrauma Informed Care http://www.samhsa.gov/nctic/ www.traumainformedcare.com National Alliance to End Homelessness,“Addressing PostTraumatic Stress Disorder Caused by Homelessness.” 2012
  • 21. Medical Home  Using St.Vincent de PaulVillage Family Health Center on site at SVdPV  Federally Qualified Health Center  Serves homeless and tenants in FJV PH  UCSD Dual Residency Program- “One white coat”  Limited dental services
  • 22. Accessing Medical Home  Home visits/street visits  Incentives to make appointment  Created “Urgent Care” for Project 25 patients  High frequency of appointments  Strong communication between case manager and doctors  Case manager transports to and from and sit in appt.
  • 23. Medications  Use of medications that would not normally be prescribed to these patients  Tied to the plan and treatment goals  CM delivers meds to participant daily  Does not deliver if intoxicated  Constantly assessing and reassessing  Close communication with doctor
  • 24. Results: Is it working?
  • 25. Data Partners  Hospitals ◦ Alvarado Hospital ◦ Alvarado Pkwy Inst ◦ Kaiser Foundation ◦ Palomar Pomerado Health ◦ ParadiseValley/Bayview ◦ Promise Hospital ◦ SD Sheriff Psych Unit ◦ SD County Psych Hospital ◦ Scripps Health ◦ SHARP HealthCare ◦ Tri-City Medical Center ◦ UCSD Medical Center ◦ VA Medical Center  Ambulance ◦ EMS Rural/Metro ◦ American Medical Response  Other Partners ◦ County of SD HHSA ◦ SD Sheriff’s Dept ◦ SD County Public Defender  Shelters ◦ Catholic Charities ◦ Salvation Army ◦ SD Rescue Mission ◦ St.Vincent de PaulVillage ◦ Veteran’sVillage of San Diego
  • 26. Change in Service Use 0 100 200 300 400 500 600 Baseline 2010 Last 12 months Ambulance ER Visits Hosp Admis Hosp Days Arrests Jail Days Perm Housing Days
  • 27. Client 1 Example: 1Year Prior to P25  Homeless 57 year old male  Each month spent entire check on alcohol in a few days  Soiled clothing  Amassed $131,404 in emergency services costs
  • 28. Services Participating In  Agreed to P-25 as payee  Assisted with alcohol purchase and delivery  Progressed to daily alcohol allowance  P25 Life Skills Coach assists with grocery shopping  Now has IHSS worker weekly  Improved self-care and hygiene  Sees his SVdPV Clinic Doctor twice a month  Participates in med-management
  • 29. Results  Maintains daily drinking plan  Some abstinence days with home detox  Later start time for daily drinking  Maintained housing18 months  Pays his rent portion  Pays for his entertainment (cable)  Supplements with available food resources
  • 30. 2010 Pre Cost: $131,404 56 ERVisits , $29,010 34 Ambulance Rides , $10,966 53 Hospital Days, $82,961 2 Arrests, 41 Jail Days , $6,317 48 Shelter Days , $2,112
  • 31. Last 12 Months Total Cost: $41,914 3 ERVisits, $2,532 3 Ambulance Rides, $1,209 5 Hospital Days, $11,636 Housing, $3,228 Supportive Services, $23,309 Savings: $89,490
  • 32. Client 2 Example: 1Year Prior to P25  Homeless on streets since 1986  Ostomy patient (alcohol related condition)  Covered in feces in a blanket  Severe and persistent mental illness  Vodka on daily basis  Failed out of an ACT Model
  • 33. Services Participating In  Obtained SSI through HOPE SD  Agreed to P25 as his payee  Weekly clinic visits with doctor  Grocery shopping trips  Calls P25 staff on daily basis  Planned monitored drinking episodes
  • 34. Results  Maintained housing for18 months  Long periods of abstinence  On moderated drinking plan  Faced lease violations for behavioral issues due to alcohol  Substitution to low alcohol content beverage
  • 35. 2010 Total Cost: $171,912 48 ERVisits, $19,995 45 Ambulance Rides, $13,478 64 Hospital Days, $129,485 1 Arrest, 4 Jail Days, $698 149 Shelter Days, $6,556 4 PERT Visits, $1,700
  • 36. Last 12 Months Cost: $27,211 1 ERVisit, $830 Housing, $3,072 Supportive Services, $23,309 Savings: $144,701
  • 37. Overall Progress SVdPV 15 Homeless in 2010 Enrolled from July 2011 to June 2012 Enrolled from July 2011 to June 2012 Category Services Costs Services Costs Service Decrease Cost Decrease Ambulance Rides 462 $147,922 123 $48,246 73% 67% ERVisits 600 $416,885 148 $99,524 75% 76% Hospital Admissions 111 NA 38 NA 66% NA Hospital Days 439 $1,055,787 166 $505,768 62% 52% Arrests 52 $7,800 12 $1,800 77% 77% Jail Days 309 $42,333 191 $26,167 38% 38% $1,670,727 $681,505 58%
  • 38. Things to consider…
  • 39. Not for Everyone  Is HR possible in your program?  Is HR a fit for your population?  Is there a sub-set of your population that have poor outcomes?  What is your agency’s view on HR?  Are there options other than abstinence?  Are you equipped for the these labor intensive services?
  • 40. Advocacy  Discussing the “why” with participants  Explaining Harm Reduction Model to landlords ◦ “Aren’t they in a program?”  Discussing model with judge and legal system  Discussing the model with funders  Budgeting for Harm Reduction
  • 41. Lessons Learned  Extremely labor intensive  Getting staff on board  Needs constant attention and assessment  Understand cycles of progress  Apply strategy to stage of progress
  • 42. Questions?  Contact Info: Marc Stevenson 619-233-8500 x 1070 Marc.stevenson@neighbor.org Dave Folsom dfolsom@ucsd.edu Kris Kuntz 619-233-8500 x 1033 Kris.kuntz@neighbor.org