Slide 1: Boston Health Care for the Homeless Program: Evolution of a Practice and Impact of Payment Reform
Jim O’Connell, MD, President
Mary Takach, MPH, RN, Senior Health Policy Advisor

September 10, 2024

Note: The Boston Health Care for the Homeless Program logo is shown on this slide. This slide also includes a photo of four adults, two are White and two are Black. They are standing in a city park with their arms around each other. Everyone is smiling and looking towards the camera, and one man is giving the peace sign.
Slide 2: Outline
•	Evolution of a practice designed for those living chronically in shelters and on the streets
•	A changing world: realities and opportunities 
•	Implications for BHCHP care model 

Note:  this slide includes a photo of two Black men sitting beside each other in what looks like an exam room. One man is wearing street clothes and sitting in an office chair. He is looking at the camera with concerned eyes. The other man is sitting in a wheelchair wearing a hospital robe, pants, and johnny top. He’s looking at the camera with gentle eyes and a slight smile. 
Slide 3: Image only
Note: this slide includes a large photo, which covers the whole slide, of a diverse group of 11 adults.
Slide 4: BHCHP Basic Goals 1984
•	Establish a health services care delivery model to provide continuity of care from shelter and street to hospital;
•	Provide care through multidisciplinary outreach teams;
•	Establish the capacity to meet the needs of homeless individuals for home-type respite care 
Slide 5: 1985
•	4-year RWJ grants to mayors of 19 large US cities
•	Modeled after St. Vincent’s Hospital in NYC
•	Stakeholder driven

Note: this slide includes a photo of White man sitting on a chair in a cramped room. He is wearing a winter jacket and has his pants rolled up to just below his knees while his gauze-wrapped feet soak in small tubs with dark, murky water. He is looking up at the camera with a twinkle in his eyes.
Slide 6: 1987
•	Comprehensive medical care
•	Multi-disciplinary teams
•	HCHs designated as FQHCs (OBRA 1987)

Note: this slide includes a large black and white photo, which covers the whole slide, showing an old, very cramped, inpatient ward with eight beds lined up on opposite walls with low partitions between every two beds. There are adult male patients laying in the two beds closest to the camera and a third adult male sitting on a bed opposite one of them talking with a caregiver who has her hand on his shoulder.
Slide 7: Image only
Note: this slide includes a photo of a Black adult male sitting in a makeshift patient area with boxes piled high beside him and an IV pole crowded next him while he is given medication intravenously. 
Slide 8: Image only
Note: this slide includes a large photo, which covers the whole slide, showing three White people (perhaps one unhoused person and two outreach counselors) relaxing and smiling on what looks like a low sitting wall of a city park. They appear to be engaged in conversation with one person laughing, and the others smiling.
Slide 9: Image only
Note: this slide includes a large photo of a Black adult man with a beard wearing a winter coat and a fur-lined hat.
Slide 10: 1986
•	DPH funds PSI Overnight Van

Note: this slide includes a large photo, which covers the whole slide, that shows the Pine Street Inn Outreach passenger van on a dark snowy night in front of an ornate building. An outreach counselor is shown in the background checking on someone who is huddled under a blanket in the darkened archway of the building. 
Slide 11: Image only
Note: this slide includes a large photo, which covers the whole slide, of a group of people who may be outreach counselors, smiling at the camera with snowflakes floating down all around them. 
Slide 12: Image only
Note: this slide includes a large photo, which covers the whole slide, in the background there are glowing streetlights with snow falling around them on city street and in the foreground an outreach counselor standing over a person covered with a dirty blanket huddled in the corner of a snow-covered building entryway. 
Slide 13: Image only
Note: this slide includes a large photo of a bearded Black man dressed in hoodie and woolen hat leaning against a stone building while he’s squinting and looking into the sun.
Slide 14: Image only
Note: this slide includes a large photo, which covers the whole slide, showing a group of four White people (perhaps one unhoused person and the others outreach counselors) standing on a city sidewalk and smiling into the camera.
Slide 15: 1990s
Note: this slide includes a large photo, which covers the whole slide, showing a younger White man and older White woman in conversation at café table inside what looks like the lobby of a city office building. Beside the woman there is walker with a seat with a bag filled with her belongings on the seat and some newspapers in the basket below the seat.
Slide 16: Image only
Note: this slide includes a large black and white photo, which covers the whole slide, showing a younger adult White woman and older White man in conversation at small table inside what looks like the coffee shop. Both are dressed in winter coats. The woman is wearing a winter hat.
Slide 17: Image only
Note: this slide includes a large photo of a bearded Black man dressed in polo shirt and a Boston baseball cap. He is sitting on the steps of a stone building looking deep in thought.
Slide 18: Image only
Note: this slide includes a large photo, which covers the whole slide, showing a Black adult male in a hospital bed wearing a black beanie cap. There are two adult female caregivers, one on each side of the bed. All are smiling at the camera. 
Slide 19: 1992
•	Consumer Advisory Board forms
•	Barbara McInnis House opens
Note: this slide includes a large photo, which covers the whole slide, showing the entrance to The Barbara M. McInnis House with the sun shining on the entrance which has a maroon awning above the entrance door. 

Slide 20: 2000s
•	Jean Yawkey Place opens at 780 Albany Street
•	MA passes Chapter 58 of the Acts of 2006

Note: this slide includes a large photo, which covers the whole slide, showing the entrance to Carey W. Akins Pavilion, within the Boston Health Care for the Homeless building.
Slide 21: Image only
Note: this slide includes a large photo, which covers the whole slide, showing a Black man and Dr. Jim O’Connell sitting at each end of a dark blue sofa with a full-grown Labrador Retriever filling the space between them. The men are petting the dog and smiling at the camera. The dog is wearing a service dog vest and looking into the camera with dark gentle eyes.
Slide 22: 2010s
•	Stacy Kirkpatrick House
•	SPOT
•	ACA passes
•	Triple Aim
•	NCQA PCMH
•	MassHealth ACOs launch

Note: this slide includes a large photo, which covers the whole slide, showing the Stacy Kirkpatrick House. It is a three-story brick building on a corner lot.

Slide 23: Image only
Note: this slide includes a photo of a Black adult male sitting at a desk signing a piece of paper. He has a black beanie cap on and a wide-striped grey and maroon hoodie. He is looking towards the camera and smiling. 
Slide 24: Image only
Note: this slide includes a photo of the same Black adult male who is now standing and holding an adult cat. The man is wearing a warm hoodie sweater and is smiling. The cat is looking directly into the camera with wide, alert, bright eyes. 
Slide 25: Image only
Note: this slide includes a photo of the same Black adult male who is now sitting on a sofa in what looks like an apartment. The sun is shining through a window brightening the room with light. There is a box fan on the floor next to the sofa. There is also a coffee table in front of the sofa which holds incidentals, including a T.V. remote control.
Slide 26: Image only
Note: this slide includes a large photo, which covers the whole slide, showing the drop off area of Massachusetts General Hospital. This includes entrance doors to the main lobby and to the Emergency Department.
Slide 27: Image only
Note: this slide includes a large photo, which covers the whole slide, showing the same Black adult male who is standing outside a building with a White female caregiver. The caregiver is wearing an MGH ID badge. Both are wearing surgical masks and looking directly at the camera. 
Slide 28: Image only
Note: this slide includes a large photo, which covers the whole slide, showing the Black adult male from the previous slides who is sitting at a dining table in what may be a hospital cafeteria. He is enjoying French toast and a large cup of hot coffee. He is wearing a grey hoodie with a surgical mask pulled down around his chin, and he is smiling into the camera with sparkling eyes. 
Slide 29: Image only
Note: this slide includes a photo of the same Black adult male who is back sitting on his sofa in his apartment wearing a warm hooded robe. The coffee table is pulled close to him with a large jug of cranberry juice on the floor beside it while a drinking glass filled with the juice sits on the coffee table. He is wearing a surgical mask, and his eyes look sad. The curtains are pulled closed to keep the sunlight out. His cat is on the floor to his right and is looking into the camera with pensive eyes.
Slide 30: Image only
Note: this slide includes a photo of the same Black adult male who is now sitting at the edge of what looks like an inpatient hospital bed. He is wearing a hospital robe and is smiling at the camera. He has a hamburger in his hands looking like he’s about to take his first bite.
Slide 31: Image only
Note: this slide includes a large photo, which covers the whole slide, showing a group of nine White men and one White woman relaxing on a long bench in a city park (perhaps some are unhoused persons and others are outreach counselors). Some are looking at the camera, some are reading, some are looking at each other, and one is showing the thumbs up sign to the camera.
Slide 32: JAMA Internal Medicine | Original Investigation
Mortality Among Unsheltered Homeless Adults in Boston, Massachusetts, 2000-2009
Note: the text included here is shown as a “picture” on the corresponding PPT slide.

Jill S. Roncarati, ScD, MPH, PA-C; Travis P. Baggett, MD, MPH; James J. O’Connell, MD; Stephen W. Hwang, MD, MPH; E. Francis Cook, ScD; Nancy Krieger, PhD; Glorian Sorensen, PhD, MPH
RESULTS
Of 455 unsheltered adults in the study cohort, the mean (SD) age at enrollment was 44 (11.4) years, 229 participants (67.2%) were non-Hispanic white, and 72.4% were men. Among the 134 individuals who died, the mean (SD) age at death was 53 (11.4) years. The all-cause mortality rate for the unsheltered cohort was almost 10 times higher than that of the Massachusetts population (standardized mortality rate, 9.8; 95% CI, 8.2-11.5) and nearly 3 times higher than that of the adult homeless cohort (standardized mortality rate, 2.7; 95% CI, 2.3-3.2). Non-Hispanic black individuals had more than half the rate of death compared with non-Hispanic white individuals, with a rate ratio of 0.4 (95% CI, 0.2-0.7; P < .001). the most common causes of death were noncommunicable diseases (eg, cancer and heart disease), alcohol use disorder, and chronic liver disease.
CONCLUSIONS AND RELEVANCE
Mortality rates for unsheltered homeless adults in this study were higher than those for the Massachusetts adult population and a sheltered adult homeless cohort with equivalent services. This study suggests that this distinct subpopulation for homeless people merits special attention to meet their unique clinical and psychosocial needs.
Slide 33: Image only
Note: this slide includes a large photo, which covers the whole slide, is shows three men (one White and two Black) sitting on a stonewall expressing friendship with the man in the center with his arms around the shoulders of the two men on each side of him. All are wearing winter jackets, two are wearing winter beanie caps, one has a walking cane next to him.
Slide 34: Image only
Note: this slide includes a photo of an unhoused Indigenous man sitting on a stone bench in a city park and looking down at the ground. He is wearing a warm winter jacket with a gray quarter-zip sweater and T-shirt under it.
Slide 35: Image only
Note: this slide includes a large photo, which covers the whole slide, showing three people standing on what appears to be a church altar. There is a White man at a lectern, an Asian woman playing a piano, and Yo-Yo Ma beside her playing a cello.
Slide 36: 2020s
•	Covid pandemic
•	New 1115 waiver

Note: this slide includes a large photo, which covers the whole slide, showing an area of a city park. In the foreground, there is a caregiver administering a medication shot in a White man arm while he is sitting on a park bench. In the background, there are approximately nine people sitting and standing around other benches. One of the people appears to be an outreach worker wearing a backpack filled with supplies while the others may be unhoused persons.
Slide 37: Image only
Note: this slide includes a photo of an older Black women looking directly at the camera. She is wearing a gray hoodie sweatshirt over a pink T-shirt, and gold wire-rimmed eyeglasses.

Slide 38: Street Team House Calls

Note: the text included here is shown as a “picture” on the corresponding PPT slide.

Street Team House Calls
2005-2011

2005	6
2006	14
2007	37
2008	213
2009	743
2010	943
2011	1062

Slide 39: Original Article
Housing Boston’s Chronically Homeless 
Unsheltered Population
14 Years Later

Note: the text from an academic journal article shown here is shown as a “picture” on the corresponding PPT slide.

Jill S. Roncarati, ScD, MPH, PA-C*; Henning Tiemeier, MA, MD PhD,†‡ Rebecca Tachick, BA,§ Tyler J. VanderWeele, PhD,║¶ and James J. O’Connell, MD#

Objective:  The long-term outcomes of permanent supportive housing for chronically unsheltered individuals, or rough sleepers, are largely unknown. We therefore assessed housing outcomes for a group of unsheltered individuals who were housed directly from the streets after living outside for decades.

Methods: Using an open-cohort design, 73 chronically unsheltered individuals were enrolled and housed in permanent supportive housing directly from the streets of Boston from 2005 to 2019. Through descriptive, regression, and survival analysis, we assed housing retention, housing stability, and predictors of survival.

Results: Housing retention at ≥ 1 year was 82% yet fell to 36% at ≥ 5 years; corresponding Kaplan-Meier estimates for retention were 72% at ≥ 1, 42.5% at ≥ 5, and 37.5% at ≥ 10 years. Nearly half of the cohort (45%) died while housed. The co-occurrence of medical, psychiatric, and substance use disorder, or trimorbidity,” was common. Moves to a new apartment were also common; 38% were moved 45 times to avoid an eviction. Each subsequent housing relocation increased the risk of a tenant returning to homelessness. Three or more housing relocations substantially increased the risk of death.  

Conclusions:  Long-term outcomes for this permanent supportive housing program for chronically unsheltered individuals showed low housing retention and poor survival. Housing stability for this vulnerable population likely requires more robust and flexible and long-term medical and social supports.

Key Words: unsheltered, rough sleepers, chronically homeless individuals, permanent supportive housing
(Med Care 2021;59: S170-S174)

Homelessness in the United State is a complex public health issue intersecting many areas of society. In January 2019, an estimated 567,715 people in the United States were experiencing homelessness.1 Thirty-seven percent were unsheltered individuals or “rough sleepers,” who sleep outside or in areas not meant for human habitation, an increase of 9% from 2018.1 Nearly two-thirds of adults who are homeless for a year or longer are unsheltered, and have worse health outcomes, experience homelessness longer, and have higher mortality rates than those who are sheltered.1-6

Permanent supportive housing (PSH) combines affordable housing with services and is based upon the “Housing First” model rather than linear mode of housing readiness.7 Barriers are removed and housing, offered directly from the streets and shelters become the foundation for the… (Note: the picture of article cuts off at this point.)

Slide 40: Long-term Outcomes of Permanent Supportive Housing for Chronically Unsheltered Individuals.

Note: the text on this slide is shown as a “picture” on the corresponding PPT slide. It is broken up into sections as noted below. We include these details here in case the presenter refers to the sections during the meeting.

First section – shown on the left side of the slide. There is a graphic of a person in a hoodie, pants, and shoes sitting under a streetlight shining down on them with a cardboard box beside them and outlines of tall city buildings behind them. 

The following points are included in this section:
•	Homelessness is a complex public health issue in the US
•	Around 567,715 people were homeless in 2019
•	Permanent supportive housing (PSH) aims to improve the health and living conditions of the homeless population: 
o	Affordable housing
o	Range of health and social services
•	What are the housing retention, stability, and participant survival outcomes for unsheltered individuals in a PSH program in Boston?

Second section – shown on the right side of the slide. These statistics are illustrated by a large group of people next to the Open-cohort design number with an arrow pointing to a Boston neighborhood map highlighting the PSH locations.

14-year longitudinal study (2005-2019) 
•	Open-cohort design 
o	73 chronically unsheltered individuals
•	Medicaid-funded scattered-site PHS program in Boston

The next part of this section is broken into three columns. 
•	Housing retention
o	At ≥ 1 year	82%
o	At ≥ 5 year	36%
o	At ≥ 10 year	12%
•	Housing stability
o	Number of persons evicted	8
o	Number of tenants moved	28
o	Total number of moves	45
•	Survival characteristics
o	Deaths in cohort	45%
o	Trimorbidity	86%
o	Kaplan Meier probability 
of survival at 5 years 	<50%

The text below is shown stretched along the bottom of all three of the above columns.

A Medicaid-funded scattered-site PSH program for chronically unsheltered individuals in Boston found high mortality, low housing stability, and poor long-term housing outcomes

Fourth section – shown on the left and right corner on the bottom of the slide.

Housing Boston’s Chronically Homeless Unsheltered Population: 14-years later
Roncarati et al. (2021) | Medical Care | DOI: 10.1097/MLR. 0000000000001409

Medical Care
Official Journal of the Medicare Care Section, American Public Health Association
Slide 41: Image Only
Note: this slide includes a large photo, which covers the whole slide, showing a group of two women and two men on a city sidewalk smiling towards the camera. The White woman is standing on the left wearing a dress and holding a notebook and a tote bag. The Black man next to her is using a wheelchair and is wearing a dark blue jacket and a Red Sox baseball cap. The Black man standing next to him is wearing a white collared shirt with a straw fedora hat and sunglasses. The White women next to him is using a wheelchair and is wearing white blouse and a royal blue sweater while holding a purse.
Slide 42: Discussion
Note: this slide includes an image of a triangle and a square with confused faces, trying to figure out how to fit into a circle, or hole, in the ground.