Multnomah County commissioners and members of the County’s Local Public Safety Coordinating Council (LPSCC) Executive Committee heard results from a first-of-its-kind local project this month that identifies frequent users of jails, homeless and health systems — and then offers strategies for breaking those cycles.
The FUSE (Frequent Users Systems Engagement) project breaks down silos between the three systems by matching data from each, then honing in on the acute needs of people who most frequently use all three.
The effort has been called FUSE which focuses on people, presenters shared. But it’s clear that people are not failing systems, rather systems are failing them.
The project’s initial findings reinforced support for a shared solution. Supportive housing, which pairs deeply affordable housing with tailored wraparound support services, was proven to reduce negative and costly outcomes in the justice and health care systems. People in supportive housing were also less likely to be booked into jail and less likely to need certain emergency medical and behavioral health interventions.
That finding comes just as Multnomah County and the Joint Office of Homeless Services prepare to invest more than $50 million from the Metro Supportive Housing Services Measure approved last May. The County’s high-level strategy for those funds suggests more long-term rent assistance, more behavioral health resources and more supportive housing.
“This is a project that is near and dear to my heart,” said Commissioner Sharon Meieran, who advocated for the study since her tenure as a Multnomah County commissioner began in 2017.
“As an emergency physician, I see the issues. I see people cycle through our systems — multiple systems — and end up in places of crisis. The question is what can we do to intervene upstream to prevent this from happening.”
Commissioner Meieran said the data will allow the County to better characterize and quantify how supportive housing, in particular, can improve outcomes across sectors, and bring in partners from other systems to help fund services.
“We can better make the case for health and justice system investments in supportive housing,” she said.
FUSE is a proven model, said Heather Lyons, who serves as director of the Pacific Northwest and Northern California region for the Corporation for Supportive Housing (CSH), a national organization that collaborates with communities on how to use housing as a platform to help resolve homelessness and its causes.
CSH has conducted a FUSE project in over 30 communities nationally, many centered on either health and homelessness or justice involvement and homelessness. But Multnomah County focused on all three systems.
“The FUSE approach necessitates data sharing and system collaboration,” said Lyons.
The work began in 2018 from a partnership between Multnomah County’s Local Public Safety Coordinating Council, the Multnomah County Sheriff’s Office, Health Share of Oregon and the Joint Office of Homeless Services.
The effort to get data sharing agreements in place that yielded the information shared today cannot be overstated, shared Marc Jolin, director of the Joint Office of Homeless Services.
FUSE reports are also utilized by some jurisdictions, including Multnomah County, involved in the MacArthur Foundation Safety and Justice Challenge Foundation, a national initiative designed to address the greatest drivers of over-incarceration in America — the misuse and overuse of jails.
“These are people and not just numbers,” said Abbey Stamp, executive director of the Local Public Safety Coordinating Council.
“Jail is where people go when all the systems fail them. These are members of our community and we fail them. The challenge remains as to how we can bring these tables and systems together to move forward.”
How it Works
Data must be matched between sectors and systems, which is no easy feat. The study is complex and considers that jail bookings and other data points can change year to year.
It also looks to what's known as the community’s “Coordinated Access” list for housing, a by-name list of people who are considered chronically homeless and eligible for supportive housing that is managed by the Joint Office.
“That was our vision when we first started this project,” said Stamp. “Let’s bring all of our data together and figure out who needs permanent supportive housing and do it.”
Katie Cadigan, a data analyst for Health Share of Oregon — a coordinated care organization that serves Medicaid members in the tri-counties — shared a Venn diagram of the system crossover, indicating 1,371 adults who touched all three sectors.
Of those, 1,088 adults were not housed in permanent supportive housing, accessed the systems and were booked into jail.
The more systems someone engaged, the higher the rate of inpatient psychiatric visits, bookings, avoidable emergency department visits, and authorizations for substance use and mental health services.
Compared to a baseline group of Medicaid recipients from 2018 who weren’t engaged in homelessness services and hadn’t been booked into jail, Medicaid recipients with jail involvement were over six times more likely to need inpatient psychiatric care. If they also had involvement with homelessness services, that number jumped to 10 times.
For someone who was booked into jail more than 10 times in 2018, the rate of psychiatric visits was 38 times higher than the baseline group.
Presenters shared data that showed the difference permanent supportive housing can make in bending those curves, comparing outcomes for those who were housed in permanent supportive housing for more than 365 days against outcomes for the 862 people on the Joint Office’s Coordinated Access list for housing who were chronically homeless in 2018.
The numbers showed reductions across the board for inpatient psychiatric visits, bookings, and other hospital and emergency visits if they are in supportive housing, said Cadigan.
Housing is the Game Changer
If those 862 people had been housed, the total cost to Medicaid for their care would have been about $3.6 million lower, said Cadigan.
That translates to over $4,000 per member for the year, and roughly $345 per member per month.
Along with those savings, supportive housing for those 862 Medicaid recipients also would have translated to:
- Over 400 fewer jail bookings;
- Over 50 fewer jail bookings;
- Over 17,000 fewer Emergency Department (ED) visits;
- Over 200 fewer hospitalizations; and,
- Over 5,000 fewer avoidable ED visits.
Taken further upstream — if chronic homelessness had been avoidable for all 1,138 individuals in the first place, their stable housing would have translated to over $10 million in Medicaid savings, Cadigan said. That’s roughly $9,000 savings per member per year, or $758 per member per month.
“We receive $400 to $450 per member per month,” said James Shroeder, CEO of Health Share of Oregon. “If we prevented chronic homelessness, it’s almost double the amount we receive when you think about what we would usually spend on an adult member.”
Disparities Observed Across Communities
Based on the analysis of the data performed by FUSE's equity work group, the findings showed structural racism present across all systems, said Lyons.
Almost all communities of color experience disparities in the system, said Lyons. But American Indian/Alaskan Indian community members experienced the highest rates. The next highest level of disparity is among people who identify as multi-racial, and then as Black and African American.
“There needs to be more analysis to reverse this trend and create more equitable outcomes,” said Lyons.
The study included an assessment of existing community engagement efforts, which resulted in recommendations for more community voice at decision-making levels; more housing with services; and to address the lack of access to and resources for behavioral health resources for communities of color.
The presenters were clear that this report was not the final one, and that it should serve as a springboard for further action. The final comprehensive report will be released this spring.
“This has to be one of the most dynamic processes that I have been involved in,” said Lyons. “It has been an honor to witness the evolution of relationships over time.”
The only data element from the criminal legal system in Multnomah County’s analysis was booking data provided by the Sheriff’s Office, Stamp added.
“We know not everybody who has law enforcement contact or who ends up in the criminal legal system comes to the booking facility. So I want to thank the Multnomah County Sheriff’s Office.”
Additional considerations that the group will account for moving forward include:
Continued work on data integration;
Commitments by and among other systems;
LPSCC’s Transforming Justice Initiative;
Moving forward with long-term solutions such as supportive housing; and
The implementation of Metro’s Supportive Housing Services measure.
“I have been in the Medicaid space for over 25 years. We’ve been talking about social determinants of health for a long time and I’m hopeful this data will point us in a direction to take some action on that,” said Health Share’s Shroeder.
“We have opportunities right now with the Metro Supportive Housing work, Measure 110, the Medicaid waiver discussion at the state level — lots of opportunities to do something with this information.”
Commissioner Lori Stegmann
The fact that we got out of our own way — working in all of these bureaucracies and silos — I just want to say how remarkable that is — the fact that you have come up with this data...
It reminds me of when I read about the Bud Clark Commons. We know the data, anecdotally, but you were able to prove it and I think we know what to do but talking about what the next steps are. I believe it was a successful way to address chronic homelessness...
We’re not talking about a million, we’re talking about 1138 individuals that you all just proved how much money we could save our systems. The question is, ‘Can we really afford not to do this work?’...
Let’s go and let’s see if we can get this on the fast track.
Chair Deborah Kafoury
I want to thank all of you for your work in getting this data together. I know it was a challenge…
You’re right, the Bud Clark commons was ahead of its time way back when, and I can’t think about that program without thinking about my dear friend Nick Fish. It just highlights to me the game changer that is the Metro Services Measure.
Having the ability to actually put the dollars into what we know works — combined with this data — it is going to change the lives of so many people in our community. Yes, it’s frustrating that it hasn’t happened to date but since that measure passed last May, the departments at Multnomah County, in partnership with our community partners have come together in ways that they never have before.
Commissioner Sharon Meieran
Thank you all for this incredible work. I appreciate my fellow commissioners' questions and appreciate what this work means, what this kind of data means and how transformative this can be in terms of what we do across systems.
While we may know some of this information has been there and a lot of people feel that we know this; housing is health; people in crisis often intersect with multiple systems — it is just so powerful to see it laid out in a specific way.
It’s really valuable to understand some of the additional depth around things we might not have assumed or stand to explore in greater detail especially around the behavioral health crisis services by people who are unhoused and who are housed. As many of you have said, this is really an important springboard for further inquiry and I would like to see this work built directly into the supportive housing services measure. It’s what I have been envisioning since I started at a Home for Everyone… I want to highlight the opportunities in the supportive housing measure... We do have few enough people now that we can get our arms around this...
I want to thank you again all for getting this done. There have been significant barriers along the way but I appreciate and am so glad and proud to see it come to fruition.
Commissioner Jessica Vega Pederson
I want to thank all of you who have been doing the work to break down the silos as much as possible. It’s good to hear that of the 65 FUSE studies you’ve seen, this is the best data report...
We don’t see other public safety jurisdictions engaged in this work and sharing the data and I want to note that. Our efforts to build on this work and springboard solutions based on this data we’re limited by not having the full picture. The fact that we didn’t have the Portland Police Bureau or whatever information that could have added to this is a shame. I encourage jurisdictions to do this because we can see the impact it has on our jail systems and safety systems…
I appreciate that supportive housing is the pivot point for any action to make change. This allows us to go from the big finding and look at the specific, tailored interventions that we need. Supportive housing, we hear that phrase all the time, but really what does that mean and what are the treatments there so we know how to spend our dollars…
I’m excited for the next steps of what we can do with this data and looking at how the Metro housing programs and LPSCC’s work in Transforming Justice, how we use this data to inform that work..
Commissioner Susheela Jayapal
The process is/was as important as the outcome. The challenges that you all worked through; the data challenges; the relationship challenges — those are things that will also extend in the future and help us continue this work.
I want to call out, as I did the last time I saw this presentation, that we use the term frequent user, but it’s really about frequent system failure and that the failure lies with the systems and not the people cycling through the system.
We can’t remind ourselves enough of that.