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Permanent Supportive Housing Exits Indicative of Higher Support Needs Among Medicaid Enrolled Adults: Differences in Healthcare Utilization Patterns and Likelihood of Returns to Homelessness

Abstract

Research Objective:

Permanent supportive housing (PSH) is a critical resource for unhoused individuals with disabilities. However, this population is at high risk for disconnection from housing and health services. Given the potential for adverse health and housing events after PSH exit, we were interested in measuring differences in profile characteristics between those who exit PSH unsuccessfully and those who remain. We operationalized a definition of “unsuccessful exit” based on exit destinations, determined social-ecological characteristics and housing program features associated with unsuccessful exits, and measured differences in inpatient and outpatient health care utilization.

Study Design:

This work draws on linked Homelessness Management Information System (HMIS) and Medicaid Management Information System claims in New Jersey. Pooled person-year files (2016-2022) were analyzed using a linear probability model of unsuccessful exit from PSH with year and county-level fixed effects. Models included demographics, behavioral health conditions, total number of chronic health conditions, veteran status, program size and case mix, and area rental housing affordability (i.e., the proportion of very low-income renters paying more than 50% of their income toward rent, 0 to 100).

Population Studied:

Medicaid enrollees who exited PSH unsuccessfully after 2016 or not at all based on the HMIS definition of the PSH project type (i.e., “A project that offers permanent housing and supportive services to assist homeless persons with a disability – individuals with disabilities or families in which one adult or child has a disability– to live independently”). “Unsuccessful exit” includes undesirable destinations recorded at exit (e.g., institutional settings, removal for rule violations, and homelessness).

Principal Findings:

2,675 Medicaid-enrolled adults met the study criteria; 476 (17.8%) had an unsuccessful exit from 2017-2022. Factors associated with the likelihood of unsuccessful exit include not being part of a household or family unit (i.e., ”individuals”) (10.5pp, P=.001), living situation before PSH was an institutional setting (20.8pp, P=.011), housing unaffordability in PSH program county (7.7pp, P=.015), veteran status (-5.8pp, p=.038), history of substance use disorder [non-alcohol] (4.2pp, P=.050), age (-0.002pp for each additional year of age, P=.059), and history of alcohol use disorder (3.4pp, P=.084). The likelihood of all-cause inpatient utilization (35.2% vs. 23.1%) and of inpatient utilization for mental illness (26.6% vs. 15.1%) are higher among those with an unsuccessful exit. However, primary care visit rates are lower (2.2 vs. 2.9 per year). Excluding those who exited to homelessness, 14.0% of enrollees who exited unsuccessfully have HMIS-recorded services indicative of homelessness (e.g., emergency shelter) within 24 months of PSH exit.

Conclusions:

Our findings draw attention to the acute needs of those who exited PSH unsuccessfully. Members of this group are more likely to be younger, enter PSH as individuals, have a substance use disorder, enter PSH from an institutional setting, and reside in PSH programs within relatively less affordable rental markets.

Implications for Policy or Practice:

Medicaid enrollees in PSH programs who meet these profile characteristics warrant concerted policy and programmatic efforts to address their unique needs as they exit PSH or to support their continued enrollment in PSH programs.