space, and of funding. and of grants, and in order to really put that off and it takes about 5 years, sometimes, up to ten years, to develop a new site. >> okay. >> thank you. >> so, if we saw 58 percent reduction in the emergency room used and i will talk about that more when it gets to mission creek, 57 percent reduction in hospital inpatient bed use and reduction in the length of the hospitalizations and those are in the first year of, and so the people are stabilizing and the whole community, and they are in a building like that and it is stabilizing. so out comes and just the ones and the reduction in the emergency, medical cost and of course, stable housing and we had a turn around rate of 8.8 in 2013. and the over all eviction rate which includes those where we

were actually able to avoid an eviction and the people surrendered their units and it was 2.6 percent and it was improved freedom and improved quality of life and we cannot put a dollar value to of course. and so the average length of stay for those who left, was around 3 years and so the longest was 6.3 years. and of those, who left, they set a one, and actually died in supportive housing. and then you heard the age of our population, and then you heard about the medical condition of our population that is probably not surprising, so we have a turnover of about 12 units. a month, if we don't bring new housing stock on. and i will talk to you about the richardson, and where the people are coming in from terms of out reach and in terms of case management and community clinics and all trying to send, and 50 percent from the other and 5 percent from the hiv

providers and that brings us to the mission creek. mission creek is a beautiful affordable housing, and building, and it is on the street at 4th, and when it was first opened, we were very concerned about our residents actually was there was no infrastructure and not a lot of buildings around and so it was right by the park. and of the 139 units, 51 of them are set aside for homeless seniors and also i just want to mention that ten percent of that ten of them are set aside for the people living with hiv for half of the funding and apply earlier to speak for the mayor's office on the housing and community development and so altogether, you have at least, 61 people, there. and that, have severe health issues and are mental health and issues and mission creek alone at that time, did get 12

people from laguna honda and so just to look at the health check off and the year before and the year after, so the year before and this was 51 and we don't know about the ten clients, and so the 51 tenants, and there was a 82 percent reduction in the total cost. and because the year after house, i think, is pretty off and it is 2.7 million the year before, and $500,000 and the year after, $451,. >> what was the cost to build them? >> the cost of building that building? >> well, i would have to guess, because it is the health center and the library in there and i would say it years ago, something like $50 million. >> is that. >> yeah? >> okay, because we can all place bets, but that you know, at times it was a shocking amount of money for us at the health department because we are not in affordable housing world. >> i understand that. but what i think is that we are

looking at these are stark numbers that you have a reduction of costs one year from the individual services and from a city's administrative perspective, it is a big difference and if costs $100 million to save, 2 million a year, that will take 75 years for break even on that. you know it could cost a lot less. >> right. >> so i think that one without the other does not really paint the picture. >> yeah, so let's say that it was $40,000 because the public library cost a certain amount of money and then at the health center in there and which is not exclusive to mission creek, represents. >> but not to guess, i think that hopefully, we have that information and also as we analyze. >> i wanted to point it out. >> as we analyze these things, i think that it is, and again, it does not and you can't, and this in and off itself is great. is awesome and everyone will agree with that and better out comes just for being in the housing. >> but i think as we talk about

this, from a city perspective, and part this is analyzing and we have the cost from the city and we talk about the pipeline and i know that is a big, larger topic and not just homeless and affordable and otherwise. >> absolutely, and i would, you know, i would mention to guess that part of the drying out of the pipeline and has to do the economic down turn and these projects take 5, 6, 7, 8, years to come on. and so there was some slowing down of the affordable housing. >> and i will add to that, in this environment, if we are talking get and we need to plan for the long term and do the things short term and thes a balancing act for my perspective and i know that people have stark opinions on both sides of that. but, if we are talking about heightened real estate market and the static health savings cost will not increase that much. >> yeah, going up. >> medical cost and inflation, but the real estate prices are going up and i think that is

the difference here about whether this is a great way for our city to are spending the dollars verses another program to achieve the same goal at the end of the day. >> yes. >> so, i also wanted to show you what it is in terms of the individual, so this is the average, and the average cost in healthcare was 35,000 and the year after was about 6,000. and so, again, 82 percent reduction and those are the averages. and the cost of healthcare utlyization broken down by emergency department visits and by inpatient days and by inpatient days and you can see it as a really large decrease in terms of the inpatient days, and a little bit of a smaller, decrease in terms of the emergency department visit and then, also, a large decrease in site custody, and if you and

you know, and if you move it back, scott? >> and it shows it and i can't see it on the slides and maybe you can see it. it actually shows you, what the skills are missing and the care utlyization was and knows that we have the laguna honda and we have the many slots there and there is always a wait list, to for the people to get into laguna honda and you only get to the wait list if you have been found eligible and so everyone who is on the wait list needs to go there and also the dph and outside of the county, and then plates them and spends millions of dollars on long term cares and beds. and so, the utilization and the cost of the facility all of

laguna honda was the cost over $2 million and the translates into $380,042 beds and those days, decreased to 533, and to a cost of $287,. >> so i think that the one thing that i would love to ask a follow up to today and you can give it to all of our offices is all of these numbers are fantastic. but, i would love to see for every example that you are giving me, the cost to build or to lease and the facilities that we are using and the cost overlay on that, i think from the city perspective we will see what is working, and the investments going to ward. and just at least from my perspective and at least the dialogue is about and what we should be doing going forward and the cost effectively to achieve the great out comes and

better out comes. >> right. >> thank you. >> 1500 and now that does not take into consideration, what other healthcare koflts the people use and but that is some of what you are hearing here but you need to and we can give you a table that is like that. and >> but, mission creek, the cost to build could be... >> well, that is the cost, yeah, yeah, so i am not talking about the cost. >> but i am, and we are not doing our job if we are not talking about capitol costs that is why. we need to. >> and i am specifically asking you to overlay the capitol costs in every one of these projects in order to look at this. >> and order, the mayor's office on housing sxim sure that they have it at their fingertips. >> we can work on it. >> okay. >> but i want to make the point that i think that we are going to be strategic about this, it has to be step one of the equation. >> absolutely. you are right.

>> so, we looked at the before and after, of the level of care, and you know, you wanted to talk more about money and now i am bringing in the slides that is actually about the human picture. >> and. >> which is great, and this is such an important part of it as well. and it is my ending slide and so i was ending on that note. and being ahead of a cohort of 683 people living with hiv, who were homeless, and we don't know what happened to them, other than that 73 of them entered the direct access to housing and 610 did not and my guess, and then it might have found our housing and might still be homeless, and if you look at the line up on top, and that is the mortality rate for those that moved into the direct access to housing, and if you look at the other line, and the staircase going down, that is the mortality rate for those that did not go into the

direct access to housing. >> stark difference. >> yeah. >> okay. >> so, we will make sure that you get more information in terms of the actual cost and are there any other questions that i can answer? >> colleagues any questions? >> no. >> thank you so much for all of your hard work on this. >> and so, last, we have well, steven, i believe is coming from supportive housing and your colleague as well, i believe. >> okay. >> and char on. thank you for being here and we have not had a chance to meet, but thanks for being here. >> thanks for asking us to be here, i am with the corporation for supportive housing and i work on the state and local policy. and so, i think that steven is going to bring up the next slide. okay, there they are.

csh is a national non-profit, it has been around for 22 years, and we promote housing as a platform to improve the lives of vulnerable individuals. to maximize these of public resources, and to build strong healthy communities. we do this through our 4 lines of business. and so i am just going to launch into our presentation again, thank you very much for inviting us here today. and i am going to be talking about research regarding cost effective strategies, around homelessness, and first of all, just to mention that housing is the most basic determinant of anybody's well-being and without it, the people cannot access hygiene sources, of food and nutrition food and they can't store medication and they can't find places to sleep.

and they are frequently incarcerated much more often than others who are housed. for that reason, homelessness is very expensive as you have been hearing this morning and some of the great studies that confirm this. and the first major study proving that homelessness is expensive to our public systems, match the data of the supporting residents in new york to county, records on the cost of those individuals, both before and after they became residents of supportive housing. and this study revealed homelessness costs 40,000 dollars per year and shelter hospital and incarceration costs and later studies, due to reveal the cost of homelessness, and as he mentioned the economic roundtable report and that

looked at 10,000 recipients who are homeless and looked at county data and compared that to 1,000 people who are living formally resipants who are homeless and living in supportive housing. and the roundtable, researchers found that homeless gr recipients encouraged an average of $2897 per month, and county costs whereas formally homeless individuals, living in support of housing, encourages $605, in costs. and other studies since then, documented all for the supportive housing, and go to the next slide, thanks. >> homeless people were serious with the illness remain stablely housed and get healthy when connected to housing, people with hiv who remain homeless have strikingly shorter life spans than people living in supportive housing and the people living in

supportive housing significantly decrease their hospital intake patient days and their jail days. and residents of supportive housing decrease state mediid expenditures including nursing home expenditures and savings of almost $9,000 per year, after taking into consideration the cost of this housing program. and you were asking, supervisor farrell about the cost of capitol. it does include it. >> was that ground up or readapted use of existing buildings. >> i am not sure, and sorry i can't answer that question, i am not sure what the combination of costs were. the one thing to keep in mind that when you do fund capitol expenditures you are loeg the cost of operating the building, so there is over time, those costs are usually, and it is actually usually less expensive to build a new building than it is, to master lease, and

provide operating subsidies for that building, over time. i understand, and i understand that it is a balancing act and over time, it is what amount of time, >> right. >> and the opinion, if you say fabulous and ten years and 75 years. >> right. >> you will have to do more research. >> i am not aware of any research out there right now. >> probably, the most, celebrated study was one that was published in the journal of american medical association, and using a randomized control group that compared the cost of housing and the use of public services among the supportive housing residents. and this study, found cost among the supportive residents was $2449 per month less than the cost of healthcare detox and incarceration and emergency medical services among the control group who remained chronically homeless. and research has also allowed us to piece together what it

takes to end homelessness as well as house public systems can achieve the greatest cost of effectiveness. so thank you. >> and so we know from the research, that the most people experiencing homelessness are homelessness for a short periods and fall into it simply because they cannot afford the housing on their income. and it is important to remember that these individuals and families, do not need support of housing, but they need short and medium term assistance to break down the barriers to allow them to access housing such as the security departments, and back utility payments. and, in many communities, like san francisco, they also need a permanently affordable place to live. but they do not need the intensive prolonged services that usually come with the supportive housing. >> do you find that across, and i find that interesting. >> do you find that across all jurisdictions as well?

>> yes. >> to the truth, almost? >> yes, it was actually a recent study of rapid rehousing programs which is this model that i just described and that joyce mentioned, and in 14 communities across the country, they were very diverse communities and they found out that rapid rehousing program, that generally, they cost about 4,000 in just, these short term solutions if they can connect that person to an affordable place to live and the individual will remain, safely housed for at least a year, and there are more studies being done to see if those individuals and families remained housed beyond that. >> okay. thanks. >> you are welcome. >> others who are homeless, and those who have the severe barriers to housing stability need more than an affordable place to live. thank you. >> and it is this population about 20 to 26 percent, of homeless people in california,

that encouraged the highest cost for the public systems. and the economic roundtable study and i mentioned it earlier revealed a minority of homeless people, acquired disproportionate county costs and that study, ten percent of the homeless gr recipients, studied incur the costs of over 6,000 to 8,000 dollars per month. and 2 thirds of those costs ran the healthcare system. and we will know from the trends in the healthcare spending that some homeless people are going to be more expensive after the implementation of the affordable care act, than others. and even though many of these people are now eligible for medical, and medical will not reimburse for an inpatient stay that is longer than medically necessary and so we know people who are frequent user of emergency rooms, are often homeless, and more than half

are homeless. and they are often, they are also associated with high end patient frequency. and the people who are chronically homeless, samely stay housed longer than those who are housed and with the same conditions and the same severity. so, because an inpatient stay under medical cannot be reimbursed if it is longer than medically necessary, this means potentially losing a patient who is in-patient stay can be paid by medical or other insurance, to a person who is homeless. hospital staff keep on those patients longer we know that for research. staff generally know that a homeless patient once they are released cannot recover because they are on the streets, and for all of the reasons that i mentioned at the beginning of my presentation, we cannot get well. and in addition, to that, there

has been tremendous negative around the hospital dumping and that has led to a lot of hospital staff keeping the patients longer who are homeless as well. because county hospitals care for a disproportion ate number of patients who are homeless and we think that this research and reality will have the significant bearing on the county budgets. >> finally, chronically homeless people are more likely to be readmitted to the hospital than the patients who are housed again for the simple fact that homeless people cannot get well on the streets. for readmissions under the affordable care act will simply impact the county budgets, again because county hospitals see a disproportionate number of homeless people. research has always revealing how to identify reach and house individuals, experiencing these severe barriers to housing stability. and we know that research shows

that public systems recoup on average, a return on investment of over 2 dollars, for every dollar invested as you have heard already. and research is showing that identifying county residents according to high health cost by risk of hospital readmission and jail recidivism and a combination of these issues and out reaching and engaging these individuals where they are and assessing housing and services needs and targeted those in need of support of housing, for supportive housing, and have all about now evidence based practices, my colleagues, steven stum will talk more about how they are telling those models further and i look forward to any questions that you may have. >> colleagues any questions? >> okay. >> thank you for your presentation, much appreciated.

>> >> good morning, supervisors and members of the public i'm steve shum and i am a senior program manager with csh and work out of the san francisco office and in addition of sharing our account of the recent research on the cost effectiveness for the supportive housing for the most vulnerable populations we wanted to spot light the social fund here in san francisco. and talk about how supportive housing, may be a viable alternative to the resolving door of crisis services for homeless men and women who are high cost frequent users of these same publicly funded services and so the social initiative is our national effort to replicate a model of housing that is linked to case management and care coordination services with access to integrated primary

care, and deliver health services all targeted to high cost frequent users of crisis and health services for homeless. csh received the five year award for the national community service and the same federal agency that funds the americor program and granting a good chunk of the socialization funds to support the housing initiatives across the country, and this includes, san francisco, los angeles, washington, county, michigan and the state of connecticut. our strategy is to work with the local partners tho develop and refine this model of supportive housing, and two, build a solid base for residents and that supportive housing is the effective intervention for the high cost users and three, develop the blueprint for replication and bau we are confident that the csh evaluation will show that providing supportive housing

will result in reduced healthcare costs and improve health out comes. >> and in san francisco, we are fortunate to partner with the tender loin development organization and direct access to housing program and two organizations with a vast amount of experience providing supportive housing. and here, in the community, they are providing affordable housing and an array of service and access to primary care and behavior health service to 172 formally homeless individuals, at the community, and the beautifully renovated ymca building at the corner of golden gate and levenworth. 50 of the tenants who moved into the building, were identified by the san francisco health plan as their highest cost utilizers for the homeless, and 122 were identified by dph, as medically

fragile users. the on site housing and services team at the community, is a robust one, and it includes, property manager staff and social workers and case managers and on site, dph staff including a nurse, and lutheran social services money management staff. >> the on sight team is working closely to coordinate care for a population where 92 percent of the tenants have a chronic health condition and 87 have a mental health issue and 76 percent of attendant have a history of substance abuse and so they are working with the tenants to improve their health and well-being and quality of life and as she mentioned we have seen several studies over the years that have documented how access to supportive housing is improved out comes for vulnerable populations, resulting in reduced substance use, fewer visits to the

emergency department shorter hospital stays, reductions in detox and psychiatric services and reduced costs. the social fund evaluation, aims to be the first study on supportive housing impact on healthcare utilization and healthcare cost and outcomes and some preliminary results from the csh fund initiative in los angeles, are pretty promising. for the 89 high cost frequent users of the public services are housed in supportive housing this cohort experienced an estimated public cost avoidance or reduction in public services of nearly 48,000 per person per year. according to the evaluation, the estimated annual cost of accessing public services when homeless was approximately

67,per individual per year, and compared with approximately 19,000 per individual, per year which housed in supporting housing. these early results from the los angeles are a hopeful find that improve the quality of care by stabilizing high cost frequent users in support of housing can reduce the costs and improve the health out comes. thank you for this opportunity, to speak with you folks today. thank you, very much. and for being here, steven. and colleagues any questions? >> supervisor avalos? >> just some comments. i really appreciate the work and the analysis and something that we you know, hear about you know, over and over again, and it is very politicalized and the people who are user or frequent users of the various systems who are homeless and it is clear that as a good body of evidence, that shows that providing the level of support helps, and now i am not sure if every homeless person is going to ned this level of support

but i think that it actually gives us, you know, an indication, that either of those levels that we need to be providing, and we have to debate every year, and you know, dph, and hsa and what level of support do we want to include with our supportive housing and you know, we actually make the decisions at the very end of the budget process and we try to move a little bit of money, towards you know the great every support, for the people who are homeless, and i would like to be able to use some of this evidence, to say that you know, in all cases, you know, we are going to need to do that at that level of support and it actually has a great deal of effectiveness, and we see better out comes. so, i just want to thank you for showing this and i think that it is something that we need to be able to look at across and not just dph, but hsa as well. hsa is actually kind of where we see kind of the greatest difficulty in trying to make sure that we are not just from

a funding, or, you know, beds, but actually we are funding supportive services, and to help people, and find the greater opportunities, and so the case management, and the employment, and you know, counseling, and things of that sort as well. so i appreciate it, the presentation, thank you. >> and i think that the important take away is that the supportive housing intervention when targeted to the most vulnerable folks and that is where you are seeing the most cost safe ands making sure that this intervention is targeted to the most vulnerable folks and i think that is definitely part of the equation as san francisco is looking at coordinated entry systems or some sort of coordinated accessment process as they are trying to match up the vunerbility of the homeless individuals and families with some kind of meaningful intervention that is going to have an impact on their lives. >> thank you very much. >> i also want to take this moment very quickly to introduce, a colleague of min