An experimental program providing extra services to help keep once-homeless Marylanders in stable housing appears to be working — with participants not only staying under a roof but out of the hospital and healthier.
But more than 200 households in Baltimore could lose that support if funding pledged by hospitals comes to an end in June and no other funding source is secured.
“We think everyone sees something pretty clear in the relationship between where you live and your health care outcomes,” said Kevin Lindamood, president and CEO of Health Care for the Homeless, which is the service provider for the program in Baltimore. “The health consequences for homelessness are severe.”
The pilot, called Assistance in Community Integrative Services, or ACIS, serves “the poorest of the poor and the sickest of the sick,” Lindamood said. Those eligible to participate must be enrolled in Medicaid, experiencing homelessness, and have at least four hospital visits in a year or two or more chronic conditions. Caseworkers help participants get identification cards and bank accounts, find doctors, and access medications, among other supports that can help them stay housed and out of hospitals.
ACIS has been enrolling clients since 2019 under an agreement with U.S. health officials overseeing Medicaid, the federal-state health program for people with low incomes. Medicaid officials have long resisted paying for housing or rent directly, but have warmed to financing other supports that can keep people healthy and able to manage a household.
With preliminary data showing significant drops in emergency room visits and better management of chronic conditions, Medicaid in 2021 extended the pilot for five more years and expanded the number of households slots to 900 from an initial 300 statewide. Medicaid will continue paying a share of the program.
At issue is the requirement of a local funding match. In Baltimore, 10 hospitals agreed to pay for the initial years of the pilot, and then most extended the commitment for an additional year, ending with the current fiscal year in June. Now hospitals and advocates want the state’s Medicaid program to pick up all local costs, amounting to about $7.2 million a year. In Montgomery, Prince George’s and Cecil counties, which have fewer participants enrolled than Baltimore, county governments pay the local match.
As the clock ticks, state health officials called initial results “promising” but are waiting for data expected this spring before committing to funding the program. Advocates fear that will come too late and jeopardize the gains in housing and health for hundreds of city residents. Program participants may not immediately lose their housing if the program were to end, but they may struggle to maintain it without their case managers’ help.
There are more than 215 Baltimore households enrolled, with room for dozens more. An assessment of about 100 participants based on data collected from CRISP, a state health information exchange, showed a 90% drop in hospitalizations related to alcohol use disorders in the year following housing placement; a 69% decrease in hospitalizations related to depression; and a 60% reduction in emergency department visits. Of the first 200 households enrolled in Baltimore, 98% maintained their housing after entering the program.
In 2020 statewide data collected by The Hilltop Institute at the University of Maryland, Baltimore County, 84% of participants had no inpatient hospital admissions, 55% did not have any visits to the emergency department, and 97% did not have any mental health disorder inpatient admissions.
Preliminary data pulled from the state’s hospital reporting system also shows large declines in participants’ health care costs, hospital visits and hospitalizations for chronic obstructive pulmonary disease, alcohol use disorders, COVID-19, and depression after entering the program.
Those involved say the key ingredient to the program’s success is the individualized case management services. Advocates say some people, particularly those who have long been without homes, can’t always access a rental apartment without assistance getting identification cards, bank accounts and clearing old utility bills. They may not be able to stay housed if they don’t have food or have unmanaged health conditions or can’t access medications, doctor’s appointments and treatment for substance use disorders.
For Arnetta Dansbury, having a Rolodex of therapists, doctors and case managers she can consult around the clock is one major program perk. She’s found help staying clean, accessing disability income and finding health care providers. She said she also has learned coping skills and can better control her anger.
“They help you set up a support system, they give you tools to use to take care of your life as far as financial, mental, everything,” said Dansbury, who now lives in East Baltimore. “It’s not like other programs I’ve seen where the program ends up leaving you after a while.”
Participants are eligible to stay in the program as long as they are considered to be low-income earners and Medicaid eligible.
“I’ve had people go back to school, start their associate’s degree, get their certified nursing assistant certificate and licenses, take care of their homes, get nice cars — the sky’s the limit if the client is in the right space to do so,” said Syandene Underwood, a case manager for about 30 program participants.
Underwood said the initiative provides long-term stability for clients who may have been incarcerated, institutionalized or severely traumatized. Most of Underwood’s client are Black men, she said, though some are women with children. “Everybody comes from all sorts of backgrounds, and what has happened to them shapes their behavior,” she said.
Officials at the Maryland Department of Health, however, are awaiting on additional analysis this spring from Hilltop before making any decisions about funding the program.
“While initial results are promising, MDH [Maryland Department of Health] is awaiting completion of the full evaluation before assessing next steps,” said David McCallister, a spokesman, in an email.
State officials would not say if they are considering adding the $7.2 million needed annually to a supplemental budget request to the General Assembly during the current session ahead of the comprehensive Hilltop report.
The study will provide analysis over five years, researchers said, though Hilltop officials warn it will have limitations. The ACIS group is statistically small and may not show how well it would work in a larger population, the researchers said.
“And, there’s no comparison group there,” said Cynthia Woodcock, Hilltop’s executive director. “We won’t really know how the experiences of the ACIS group compare to those of similar people who were not in ACIS.”
Even as hospitals benefit from the program, which helps keep participants out of overburdened emergency rooms, they’re unlikely to agree to funding it long-term. The Maryland Hospital Association has reported budgets remained tight from the pandemic, inflation and labor shortages, as well as surging rates of patients with mental health and substance use disorders that they are not equipped to manage.
Representatives from the University of Maryland Medical System, Mercy Hospital and Johns Hopkins Medicine, representing five hospitals, said they have been pleased by ACIS’ results and agreed to extend funding beyond their initial commitments, until at least June. But some of these officials said they are hoping for Medicaid to step in.
Sinai Hospital, part of LifeBridge Health, said it would focus on its own programs and stopped funding the local match once its initial commitment ran out. Ascension Saint Agnes Hospital did not comment on its funding.
MedStar Health, which has three hospitals participating in Baltimore, plans to continue funding the ACIS program for now, said Dr. Lucas C. Carlson, an emergency room doctor who also serves as regional medical director for care transformation for MedStar in Baltimore.
Carlson said the program saves the hospitals money and helps meet the top need identified by patients: housing.
“We need a permanent funding source for this program, 100%. We supported the hospitals funding this for proof of concept, but I don’t think any of us feel the hospitals are the proper source for longer term housing support,” Carlson said.
Expanding programs such as ACIS is vital to tackling historic housing troubles that stem from decades of disinvestment in vulnerable populations, said Irene Agustin, director of the Mayor’s Office of Homeless Services in Baltimore. Recent counts of people lacking housing on a given night in Baltimore run into the thousands, and even more are in temporary housing or shelters.
“Typically, when you have to make budget cuts, unfortunately, it’s the supportive services, the case management services, that typically get caught,” she said. “But research shows that it’s an essential part of keeping people housed, and actually a cost-savings measure for the community.”