The Impact of Supportive Housing on the Costs of Chronic Mental Illness - May 2021
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May 2021 The Impact of Supportive Housing on the Costs of Chronic Mental Illness Julia (Chrissie) Bausch, PhD, Research Analyst Alison Cook-Davis, PhD, Associate Director for Research Benedikt Springer, PhD, Postdoctoral Scholar
Research Collaborators The Center for Health Information & Research (CHiR), College of Health Solutions, ASU: Gevork Harootunian, Principal Statistical Programmer; Stephen LaCour, Data Science Specialist; Varnika Angampally, Statistical Programmer; George Runger, PhD, Director. Sponsors This study was sponsored by the Association for the Chronically Mentally Ill (ACMI), with funding from the Charles and Laura Ann Goldstein Philanthropic Foundation and BHHS Legacy Foundation. Acknowledgments Morrison Institute and CHiR thank the Arizona Health Care Cost Control System (AHCCCS), Copa Health, and Mercy Care for their support acquiring data for this research. We are grateful to Dr. Michael Franczak and John Moore of Copa Health, Ty Rosensteel of the Homeless Management Information System (HMIS), and others who provided informal consultation on this research. We also thank the interview participants for sharing their time, perspectives, and expertise. Many members of the Morrison Institute team contributed to this report: Andrea Whitsett, Steve Kilar, Ed Spyra, Kristi Eustice, Melissa Kovacs, Dan Hunting, Paige Riddle, Melina Cruz, Camryn Lizik, Kira Olsen-Medina, Hye Rin Yoon, Imani Cruz, and Pooja Paode. Recommended Citation Bausch, Julia C., Alison Cook-Davis and Benedikt Springer. “Housing is Health Care”: The Impact of Supportive Housing on the Costs of Chronic Mental Illness. Phoenix, AZ: The Arizona Board of Regents for and on behalf of Arizona State University and its Morrison Institute for Public Policy at the Watts College of Public Service and Community Solutions, 2021.
Contents Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Serious Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Chronic Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Outcomes for Health, Housing, Criminal Justice, and Public Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 The Case of Maricopa County, Arizona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 The Public Behavioral Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Options for Treatment and Housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 How Many Individuals in Maricopa County Were Identified as Having Chronic Mental Illness? . . . . . . . . . . . . . . . . . 11 The Settings Where People with Chronic Mental Illness Live . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Cost Comparison Across Housing Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Case Study: Lighthouse Model Community Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Average Annual Costs of Lighthouse Tenants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Expert Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Provide Higher Levels of Treatment and Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Coordinate Transitions Between Care and Housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Reduce Caseloads to Allow for Individualized Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Meet Long-Term Support Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Set Realistic Expectations for Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Align System Incentives with Recovery Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Increase Access to Quality Affordable Housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Invest in Housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Create Opportunities for Social Connection and Community Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Disparate Data Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Natural Comparisons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Small-N Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Appendix: Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Arizona Health Care Cost Containment System (AHCCCS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Homeless Management Information System (HMIS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Maricopa County Sheriff’s Office (MCSO) Booking Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 City of Phoenix Open Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Provider Data (Copa Health). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Population and Chronic Mental Illness Sub-Group Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Small-N Case Study: Copa Health Lighthouse Model Community Homes ...................................... 27 Housing Status of and Costs for Individuals with CMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Health Care Utilization and Costs for Individuals with CMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Criminal Justice Utilization and Costs for Individuals with CMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Interviews: Qualitative Data Collection and Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Executive Summary Some individuals with serious mental illness The results quantitatively delineated that experience severe, long-term symptoms of the financial costs of individuals with CMI in their disease. They may lack insight into their permanent supportive housing were 28.7% condition, not adhere to treatment, and have lower than individuals with CMI experiencing high support needs, among other challenges. chronic homelessness. Health care represented These individuals can be considered to have a the largest category of expenses across chronic form of serious mental illness. Without housing settings, within which behavioral health appropriate treatment, support, and housing, comprised the largest percentage of costs. they can experience recurrent crisis episodes, homelessness, and frequent interactions with In the small-sample case study of a high- emergency, criminal justice, and health systems, support housing setting, total average costs incurring great public expense. per person decreased 12.1% over two to three years of residence in that setting. Behavioral This study examines how housing and in-home health costs declined 36%, while spending on supports affect public spending on individuals physical health, pharmacy, and skills training with chronic mental illness in Maricopa County, increased, demonstrating a shift in spending Arizona. It does so through a comparative away from crisis management toward recovery analysis of average costs per person per year and personal development. The tenants in this across three housing settings: permanent setting had no criminal justice interactions during supportive housing, housing with unknown the study period. in-home support, and chronic homelessness. Specifically, it analyzes costs for housing, health Interview participants widely agreed that there is care, and criminal justice during the period of a need for more housing and in-home supports 2014-2019. It also features a small-sample for individuals with chronic mental illness (small-N) case study of a housing setting that in Maricopa County. Housing and in-home provides individualized, 24/7 in-home support to supports were seen as critical for stability and individuals with chronic mental illness (CMI) who recovery and as effective strategies for reducing have high support needs, examining average homelessness, crisis episodes, interactions costs per person before and after moving into with the criminal justice system, and costs. that setting (2016-2019). Finally, the study The results of the quantitative cost analysis outlines recommendations from interviews with support interviewees’ perspectives that providing dozens of experts who work with and care for permanent supportive housing to individuals with individuals with CMI in Maricopa County about CMI reduces overall costs. reducing costs and improving care. 4
Introduction home support to individuals who have CMI and high support needs, examining average costs Among individuals with serious mental illness, per person in the year prior to moving into this symptoms and support needs vary widely. setting, and two to three years after (2016-2019). Some are able to manage their illness and Finally, it outlines recommendations to reduce lead relatively independent and normal lives, costs and improve care from dozens of experts while others experience severe symptoms over who work with and care for individuals with many years and need a high level of support chronic mental illness in Maricopa County. to manage their disease. Those in the latter group may lack insight into their condition, not Background adhere to treatment, and require more recovery Serious Mental Illness time. Individuals with these characteristics can be considered to have a more chronic form of The National Institute of Mental Health defines serious mental illness, or more simply, chronic serious mental illness (SMI) as “a mental, mental illness (CMI).1,2 behavioral, or emotional disorder resulting in serious functional impairment, which Housing is a basic need and is widely substantially interferes with or limits one or recognized as a cornerstone for stability and more major life activities.”12 While theoretically recovery.3,4 But, many individuals with chronic any mental illness included in the Diagnostic mental illness struggle to access and maintain and Statistical Manual of Mental Disorders can housing. There are many reasons for this, be serious, it is most commonly schizophrenia, including the shortage of affordable housing severe major depression, or bipolar disorder that and the unique treatment and support needs of lead to serious functional impairment. Examples people with CMI. In many places, there are few of serious functional impairment include housing options with the high level of in-home problems with basic daily living skills (e.g., support that individuals with chronic symptoms eating, bathing, dressing), instrumental living need to stabilize and recover.5 Without skills (e.g., maintaining a household, managing appropriate treatment and housing, they can money, getting around the community, taking experience recurrent crisis episodes, frequent prescribed medication), and functioning in social, interactions with emergency, justice, and health family, or occupational contexts. Around 25% systems, as well as homelessness, incurring of individuals with SMI develop a Substance great public expense.6,7,8,9,10,11 Use Disorder (SUD).13 According to the National Survey on Drug Use and Health, in 2019, 20.6% This study examines how housing and in-home (or 51.5 million people) of adults 18 and older supports affect public spending on individuals had a mental illness; 5.2% (or 13.1 million with chronic mental illness in Maricopa County, people) had serious mental illness.14 Arizona. It does so through a comparative analysis of average costs per person per year SMI is caused by a complex interplay of across three housing settings: permanent genetic, environmental, and social factors, often supportive housing, housing with unknown resulting in a life-long illness.15,16 With proper in-home support, and 24/7 in-home support management, people with SMI can lead stable to individuals who have CMI and high support lives. One study estimates that 33% of people needs during the period of 2014-2019. It with SMI have been in remission for at least highlights a small-sample (N=9) case study of one year.17 With treatment, people can recover, housing that provides individualized, 24/7 in- which usually means they experience symptom 5
remission and progress in areas of their lives diverse state and local budgets.31 Their that they subjectively value.18 This is especially symptoms make finding and maintaining housing true when they are integrated within families, and support services a major challenge.32 workplaces, and communities.19 Unfortunately, treatment is difficult and expensive; it includes There is no commonly shared definition of medical and psychological treatment, as well CMI among mental health professionals and as housing assistance, job assistance, and researchers.33 Previous studies have focused social assistance.20 Appropriate treatments on this population; however, they typically define and supports are often difficult to access or CMI as those individuals who incur the highest not available to patients due to lack of financial costs rather than relying on a clinical definition.34 resources, lack of treatment options, lack of supportive networks, and stigma; 40-50% of Outcomes for Health, Housing, Criminal people with SMI are estimated to receive no Justice, and Public Costs treatment at all.21 As a result, individuals can experience frequent hospitalization, arrests, Serious mental illness (including CMI) can incarceration, victimization, family violence, or lead to poor economic and health outcomes. suicidality, all of which can make them even Nationally, it is estimated that 15-20% of people less likely to receive proper treatment.22 Since with SMI live beneath the poverty line, 80% individuals with SMI are often unable to pursue are unemployed, and 116,000 experience employment, especially without treatment, many homelessness (around 25% of all unhoused experience poverty and homelessness, making people).35,36 In 2019, 463,142 individuals with them more likely to be involved with the criminal schizophrenia and other psychotic disorders justice system instead of receiving treatment.23 received Supplemental Security Income (SSI),37 Poverty is a cause as well as a result of SMI.24 but monthly SSI payments are rarely sufficient to live on.38 These economic realities take a tragic Chronic Mental Illness health toll. People with SMI die on average 25 years earlier than the general population. While The current study focuses on the subset of 30-40% of excess mortality can be attributed individuals with SMI who experience severe, to suicide and injury, the rest is often due to long-term symptoms. We refer to this subgroup untreated medical conditions. Most of the excess as individuals with Chronic Mental Illness (CMI); death is therefore preventable.39 they are also referred to as having severe and persistent mental illness25 and as high utilizers.26 The consequences of non-treatment are not only They may lack insight into their condition, tragic for individuals and families but also costly have a co-occurring substance use disorder, to society.40 An area of particular concern is the not adhere to treatment, have high support criminal justice system. One survey found 10% needs, and require more recovery time.27,28,29,30 of law enforcement budgets and 21% of officer It is common for individuals with CMI to cycle time is spent dealing with individuals with SMI, repeatedly through the behavioral health system, often in crisis.41 Among booked jail inmates, the the criminal justice system, and homelessness estimated prevalence rate of current serious services, incurring costs at different stops mental illness is 14.5% for men and 31.0% for throughout the cycle, known as the “revolving women.42 Individuals with SMI are often charged door.” Many of these stops, or service nodes, with minor offenses like disorderly conduct.43 such as hospital emergency department visits Imprisonment for mental health issues is not or police interactions, can be costly, affecting only counterproductive for recovery but also 6
expensive. Studies show considerable savings sufficient to achieve remission of SMI or SUD from prison diversion and proper outpatient symptoms.59 Housing First programs have been treatment.44,45 criticized as “Housing Only” programs, which do not offer sufficient support.60 The traditional Given the high prevalence of homelessness Continuum-of-Care (CoC) approach has not and incarceration among people with SMI, any necessarily been more successful.61 CoC is a treatment must address housing. Advocates coordination of local service providers designed for individuals experiencing homelessness and for people with SMI to advance through various researchers have long argued and shown that stages: from outreach programs and drop- providing housing is more cost-effective than in centers to congregate living arrangements addressing homelessness-related crises.46,47,48 with varying levels of support, then finally to Studies often find that a small subset of independent living. At each stage, individuals people incurs a disproportionately large cost, must demonstrate housing readiness, which is chronically in crisis, and would benefit most includes being sober and complying with from intervention.49 A famous story by Malcolm psychiatric treatment. Because of the strict Gladwell, “Million-Dollar-Murray,” examines the requirements of CoC programs, people with CMI life of a man experiencing homelessness who have difficulty being admitted or maintaining cost Nevada an estimated $1 million over 10 participation, leading to eviction from the years, an amount much higher than the cost of programs.62 providing housing for him.50 A 2008 report by the Morrison Institute found similar potential A key factor in the success of housing for cost savings for helping people experiencing individuals with SMI and CMI is its combination chronic homelessness in Arizona.51 The main with treatment and supports.63,64 Yet, across conclusions of these and other studies support the United States, intensive community- “Housing First,” an approach that prioritizes based services and treatments are difficult to providing individuals experiencing chronic access due to a lack of providers, funding, and homelessness with permanent housing as a insurance coverage.65 Few people who would foundation for other needed supports and/or benefit from supportive housing actually receive treatments and recovery.52,53 it.66 Importantly, Medicaid funds cannot be used to pay for housing, including room and board, Housing First is based on the theory that a rental assistance, or non-medical services. stable place to live, with stable access to Community behavioral health organizations can, services, food, and a social network, is a however, collaborate with housing providers to necessary condition for people to improve comprehensively meet the housing, treatment, their quality of life and pursue other goals, like and support needs of individuals with serious recovery or employment. In this approach, mental illness.67 individuals are rapidly rehoused in permanent accommodations without requirements around The availability of housing, treatment, and sobriety or treatment adherence. It has been support for people with SMI and CMI is often shown to be successful and is promoted by a key question, but it is also essential to ask most organizations working toward ending whether a given option is appropriate for an homelessness.54 individual’s needs and preferences. Over time, an individual’s preferences and needs for While Housing First has helped people with SMI housing, treatment, and support may change as and reduced public costs,55,56,57,58 it is often not their clinical condition improves or deteriorates.68 7
The Case of Maricopa County, Arizona 34,451 adults with SMI. This is around 25% of adults with SMI in Maricopa County.73 Maricopa County is the economic and population center of Arizona. It is home to the state capital, The class action lawsuit Arnold v. Sarn, filed Phoenix. The Phoenix metropolitan area has in 1981, alleged that the Arizona Department grown rapidly over the last several decades. of Health Services (ADHS) and Maricopa In 2019, the population of Maricopa County County “did not fulfill their statutory obligations was 4,485,414, representing 61% of the state’s to provide a comprehensive community population.69,70 mental health system.” The suit was settled in 2014 and, among other things, required that Based on national proportions, there are an the state increase the number of individuals estimated 139,267 adults with SMI in Maricopa served by housing, employment, and other County.71 services. As a result, Mercy Care expanded its permanent supportive housing subsidy and The Public Behavioral Health System support services to include more recipients. It also offers assistance with activities of daily The Medicaid agency for Arizona is the living, skills training, transportation, and other Arizona Health Care Cost Containment System support services.74 Additionally, through its (AHCCCS). It provides coordination, planning, Whole Person Care Initiative (WPCI), AHCCCS administration, regulation, and monitoring for is engaging community stakeholders interested all of Arizona’s public behavioral health system. in augmenting the Medicaid system’s ability to AHCCCS contracts with Regional Behavioral address housing and other social determinants Health Authorities (RBHA) to deliver integrated that influence health outcomes.75 physical and behavioral health services to Medicaid-eligible individuals with SMI. In 2013, Options for Treatment and Housing the RBHA contract for Central Arizona (which includes Maricopa County) was awarded to There are various housing settings designed to Mercy Maricopa Integrated Care, now called meet a range of treatment and support needs for Mercy Care.72 In 2019, Mercy Care served individuals with SMI in Maricopa County (Figure 1). Figure 1: AHCCCS treatment and housing continuum.76 BH Community Scattered State Stabilization Secured ABHTH/TFC Flex Care/ Member Inpatient Residential Living Site/Bridge to Hospital Units BHRF* Homes TLP** Housing Facility Program Permanency Level of placement is not linear, but based on Individual Service Plan/clinical need • Treatment Focused • Treatment Focused • Housing Focused • Services Manatory • Services Voluntary • Services Voluntary • Length of Stay Clinically • Length of Stay Clinically • Length of Stay Member Determined Determined Determined • Restricted Egress Based Upon • 24 hour supervision • Renewable Leases Voluntary Status of Admission • Community Based • Independent Living • Site/Facility Based • Community Based 8
For individuals experiencing a behavioral health Community-based housing (housing that is crisis, there are treatment-focused restrictive integrated into the community) has become settings with professional supervision and more difficult to access as housing has become mandatory services, such as the Arizona increasingly unaffordable in Maricopa County.83 State Hospital and inpatient facilities. Secured It is estimated that 163,000 affordable housing Behavioral Health Residential Facilities (“secure units are needed to meet current demand in residential”) are another example of this type Phoenix alone.84 This shortage greatly affects of setting; currently, two such facilities are vulnerable populations, including people with in development in Maricopa County.77 For SMI, CMI, and other disabilities.85 Twenty-three individuals experiencing a behavioral health percent of the 107,100 individuals who receive issue who are at risk of going into a more federal rental assistance (such as Housing restrictive setting, there are settings focused Choice Vouchers) in Arizona have a disability, on treatment with professional supervision and a portion of whom have SMI. Still, four in ten voluntary services, such as personal care and low-income people in the state pay more skills training. Examples include Behavioral than half their income in rent or experience Health Residential Facilities (BHRFs) and homelessness but do not receive federal rental Adult Behavioral Health Therapeutic Homes assistance because of limited funding.86 There (ABHTHs). For individuals who are ready to live is consistently a waitlist for housing vouchers in independently but still require support, there Phoenix.87 Mercy Care operates a Permanent are settings focused on housing with voluntary Supportive Housing Program that helps services, such as case management, life skills, members with SMI experiencing homelessness and peer mentoring. An example of this type of access a supportive housing subsidy, as well as setting is permanent supportive housing, defined support services. Because there are not enough as “Community based housing with tenancy vouchers and subsidies to meet demand, the supports and outpatient services available up to Vulnerability Index-Service Prioritization Decision 24 hours a day to assist members with obtaining Assistance Tool (VI-SPDAT) is used to screen and/or maintaining housing … provided on or off qualified AHCCCS members and prioritize site, based upon a member’s choice.”78 individuals with the greatest need for housing.88 However, there is not enough supply of these Family, friends, advocacy groups, faith-based options to meet the needs of individuals with organizations, and other social groups constitute SMI and CMI. In 2018, AHCCCS reported 5,221 other vital sources of support and housing for beds in behavioral health residential facilities individuals with SMI. These sources fall outside and supportive housing in Mercy Care’s service any analysis of the formal AHCCCS system area (Central Arizona, which includes Maricopa but are a critical part of recovery for many County), covering about 15% of members with people.89,90 SMI.79 A 2020 service capacity assessment of AHCCCS found that supportive housing Homelessness, jail, and prison are not was more available to individuals with SMI uncommon housing situations for individuals with (especially Medicaid recipients) in Maricopa SMI and CMI.91 According to the 2020 count, County compared with the national average.80 7,419 individuals experienced homelessness in Yet, several studies (including this one) have Maricopa County.92 Of those, 965 self-reported documented that local experts feel more housing, having a mental illness. Officials estimate that treatment, and support are needed for individuals another 1,100 individuals with SMI are housed with SMI and CMI in Maricopa County.81,82 in Maricopa County jails.93 Statewide, 12,257 9
prison inmates (28% of the prison population) Methods received mental health services in 2019;94 a portion of these individuals can be assumed This study relies on a comparative analysis of to have SMI.95 In 2018, the state mental health public spending over six years (2014-2019) for agency treated 1,147 people in jail and 6,915 individuals identified as having chronic mental people in homeless shelters.96 In 2015, the illness to understand better the costs associated Maricopa County Board of Supervisors approved with different housing settings. The study the “Stepping Up” initiative to “safely reduce the compares individuals in permanent supportive number of people with serious mental illnesses housing with those who experience chronic in jails.”97 homelessness and those who are housed with unknown in-home support. The Center In 2020, the Maricopa County budget for SMI for Health Information & Research (CHiR) at mental health was over $61 million.98 However, Arizona State University (ASU) collected and mental health services are just one of many analyzed quantitative data on SMI and CMI areas of public spending on individuals with status, housing setting, and costs. To identify SMI and CMI; others include public safety, recommendations for improving care and homelessness services, and housing. The reducing costs of individuals with CMI, ASU’s 2021 public safety budget for Maricopa County Morrison Institute for Public Policy conducted is $1.36 billion and includes the sheriff’s and analyzed semi-structured interviews with department, adult probation, and emergency experts, individuals with chronic mental illness, management. In fiscal year 2020, the county and family members of individuals with chronic spent approximately $750,000 on homeless mental illness. Please refer to the appendix for a shelters, of which nearly 30% was focused on more detailed description of the methods used in permanent housing.99 A portion of each of these this study. budgets, as well as others at state and municipal levels, goes toward responding to and caring for Serious Mental Illness (SMI) is a designation individuals with SMI and CMI. for individuals with a mental, behavioral, or emotional disorder who need additional services To get a clear picture of whether access to and support to function in daily life and major supportive housing impacts public spending life activities.104 Within the population with SMI, on individuals with CMI across these diverse CHiR identified the subcategory of individuals budgets within Maricopa County, as well as with Chronic Mental Illness (CMI) for this study to emphasize the role of supportive housing by using the legal definition for secure placement in recovery, we conducted a comparative of individuals with SMI who are nonadherent analysis of average costs per person per year or nonparticipators in treatment and require across three housing settings. Other studies more restrictive settings of care.105 Specifically, have also examined housing and/or public individuals with CMI were defined as those costs for individuals with SMI in Maricopa who 1) are designated as SMI, 2) had at least County.100,101,102,103 This study adds to this body of two episodes requiring crisis assistance in the work by focusing on the subset of individuals with last two years, 3) did not adhere to the follow- SMI who experience chronic symptoms (CMI), up treatment within 14 days, and 4) had an analyzing a relatively long study period (2014- interaction with the criminal justice system, made 2019), comparing costs across three housing a claim for suicide or intentional self-injury or settings, and examining costs across several harm, or experienced recurrent crisis episodes. domains: health, housing, and criminal justice. CHiR combined individual-level data from 10
multiple sources to arrive at estimates of annual homelessness services providers, legal housing, health care utilization, and criminal professionals, and emergency responders. Five justice costs associated with individuals with individuals with CMI were also interviewed about CMI. Data from AHCCCS included information their experiences with housing and in-home about medical and social services, as well supports in Maricopa County. Participants were as incarceration events.106 Data on housing selected based on association with relevant status came from AHCCCS and the Homeless organizations and by recommendation (snowball Management Information System (HMIS), sampling). Interview notes and transcripts which many local service providers use to were analyzed inductively for themes related to track housing status.107 Additional data on improving care and reducing costs. arrests and incarceration were scraped from the Maricopa County Sheriff’s Office website108 Results and the City of Phoenix Open Data Portal.109 How Many Individuals in Maricopa Housing costs come from the U.S. Census110 and the U.S. Department of Housing and Urban County Were Identified as Having Chronic Development.111,112 For the small-N case study, Mental Illness? Copa Health provided roster data, which was Over the six-year study period (2014-2019), used to estimate costs for individuals living in 33,939 people enrolled in the Arizona Health their Lighthouse group homes. Care Cost Containment System (AHCCCS) in Maricopa County were determined to have a All of the results for costs are presented as serious mental illness (SMI). Of those, 6,291 average annual costs per individual, adjusted individuals (18.5% of the SMI population) were for inflation to 2020 dollars. Health care costs identified as having chronic mental illness (CMI), were calculated using allowed amounts for according to the criteria outlined for this study claims of individual AHCCCS plans that met (Figure 2; see Appendix). the parameters of this study. Criminal justice costs (i.e., incarceration, law enforcement, and legal system costs) were based on indirect Figure 2: People with chronic mental illness estimates113,114,115,116,117,118 and other studies.119 (represented in green) comprise 18.5% of the Therefore, they are to be treated with less total population of people with serious mental certainty, as they likely undercount actual costs. illness in Maricopa County. Costs of permanent supportive housing were approximated using the fair market rent for an efficiency unit, and costs of housing with unknown support services were estimated using median rental costs and average subsidies. Costs of chronic homelessness were based on annual shelter expenses.120 Researchers at Morrison Institute conducted confidential, semi-structured interviews via Zoom and phone with 36 experts, including family members of individuals with CMI, advocates, housing providers, behavioral health providers, 11
Of the 10% most costly AHCCCS members Cost Comparison Across Housing with SMI, 42.4% (1,441 people) were identified Settings as having chronic mental illness. These 1,441 people represent 22.9% of all individuals with The analysis reveals notable differences in total CMI identified in this study. This illustrates that, costs per person per year by housing setting, while there is considerable overlap between accounting for housing, health care, and criminal high-cost AHCCCS members and AHCCCS justice costs (Figure 4). Individuals with CMI members with CMI, these groups are not one who experienced chronic homelessness during and the same. the study period incurred the highest average cost per person per year at $72,969, while those The Settings Where People with Chronic in permanent supportive housing incurred the Mental Illness Live lowest, at $51,976; a difference of 28.7%. The average annual costs of individuals who are We identified three housing settings from the housed with unknown support services fall in the available data: permanent supportive housing, middle. This data indicates that when individuals housing with unknown support services, and with CMI have access to housing, especially chronic homelessness. An individual’s housing permanent supportive housing, it results in status was defined as the setting an individual overall public cost savings. lived in for a minimum duration of 180 days during or closest to when they met the study’s The breakdown of costs across spending criteria for a CMI designation (see Appendix for categories and housing settings is also more detail). Of the AHCCCS members identified informative. As Figure 4 illustrates, average as having CMI, 31.1% (1,956 individuals) met annual costs for criminal justice interactions the study criteria for housing setting. Figure 3 and housing were relatively low as a proportion shows the housing settings of those individuals. This breakdown allowed us to calculate average Figure 4: Average total costs of individuals with costs per person per year by housing setting. CMI in Maricopa County, per person per year, by housing setting. Figure 3: Sample frequency of individuals with $80,000 CMI, by housing setting. Total: $72,969 $70,000 $5,406 Total: $61,262 $12,585 Chronic 768 $60,000 $2,511 Homlessness Total: $51,976 $8,420 $50,000 $3,259 $11,315 $40,000 Unknown Support 955 $30,000 Services $50,330 $54,978 $20,000 $37,402 Permanent $10,000 Supporve 233 Housing $0 Permanent Supportive Housed with Unknown Chronic Housing Support Services Homelessness 0 200 400 600 800 1000 1200 Health Cost Housing Cost Criminal Justice Cost 12
of the total cost for all three housing settings. homelessness and lowest among individuals in These costs did, however, vary across settings. permanent supportive housing, with a difference Individuals in housing with unknown support of 32%. services had the lowest average costs per person per year for both housing and criminal The average cost of health services administered justice interactions; individuals experiencing in an inpatient setting represented a similar chronic homelessness had the highest costs in percentage of total health costs across housing all three categories. settings (29%-32%). Inpatient costs were highest among individuals experiencing chronic The category of criminal justice interactions homelessness at $17,778 (Figure 6). includes costs of police interactions, incarceration, and courts (Figure 5). Police Figure 6: Average inpatient costs of individuals interactions represent the largest percentage of with CMI in Maricopa County, per person per costs in this category across housing settings, year, by housing setting. followed by incarceration costs. $20,000 Figure 5: Average criminal justice costs of $18,000 individuals with CMI in Maricopa County, per $16,000 $17,778 person per year, by housing setting. $14,000 $14,485 $6,000 $12,000 $11,992 Total: $5,406 $10,000 $305 $5,000 $8,000 $6,000 $4,000 $2,365 $4,000 Total: $3,259 $3,000 $214 $2,000 Total: $2,511 $1,122 $159 $0 Permanent Supportive Housed with Unknown Chronic $2,000 $906 Housing Support Services Homelessness $2,735 $1,000 $1,923 Health costs consisted of three major categories: $1,446 $0 pharmacy, physical health, and behavioral health. Permanent Supportive Housing Housed with Unknown Support Services Chronic Homelessness Average annual physical health expenses per Police Costs Incarceration Costs Court Costs person were similar across housing settings, ranging from $9,094 among individuals experiencing chronic homelessness to $10,072 Health costs represent the majority of average among individuals in housing with unknown spending for individuals with CMI across all three support services. Average pharmacy costs varied housing settings, ranging from 72.0% of total more by housing setting. Among individuals costs for individuals in permanent supportive experiencing chronic homelessness, average housing to 82.2% for individuals in housing pharmacy costs of $17,208 were nearly double with unknown support services (Figure 4). that of individuals in permanent supportive housing Average total health spending per person was and 45% higher than costs for individuals in highest among individuals experiencing chronic housing with unknown support services (Figure 7). 13
Figure 7: Average health costs of individuals Figure 8: Average costs for “Other mental with CMI in Maricopa County, per person per health and substance use treatments” of year, by housing setting. individuals with CMI in Maricopa County, per person per year, by housing setting. $60,000 Total: $54,978 $10,000 Total: $50,330 $50,000 $9,000 $9,155 $17,208 $10,879 $8,000 $40,000 Total: $37,402 $7,000 $10,072 $6,000 $8,761 $9,094 $30,000 $5,000 $9,303 $4,000 $4,981 $20,000 $3,000 $29,379 $28,676 $2,000 $2,103 $10,000 $19,338 $1,000 $0 $0 Permanent Supportive Housed with Unknown Chronic Permanent Supportive Housed with Unknown Chronic Housing Support Services Homelessness Housing Support Services Homelessness Behavioral Health Costs Physical Health Costs Pharmacy Costs Within the study sample of individuals with CMI, Behavioral health comprises the largest we identified 78 people who transitioned from percentage of health costs across all three chronic homelessness (the highest-cost setting housing settings. Average behavioral health per person per year) to permanent supportive costs were lowest among individuals in housing (the lowest-cost setting per person permanent supportive housing at $19,338 per year) within the study period (2014-2019). (51.7% of health spending for that setting), and Among this group, average costs per person costs were highest among individuals housed declined $5,854, or 10%, after transitioning to with unknown support services (58.4% of health permanent supportive housing (Figure 9). spending; Figure 7). Figure 9: Average public spending per person Within the category of behavioral health, the per year on individuals with CMI who transitioned average costs of “Other mental health and from chronic homelessness to permanent substance use treatments” (an aggregated supportive housing in Maricopa County. category that includes residential treatment $65,000 programs, alcohol and drug services, therapy, $64,000 $64,195 mental health assessments, mental health $63,000 services not otherwise specified, and psycho- $62,000 $61,000 educational services) showed variation across $60,000 settings. Among individuals in housing with $59,000 unknown support services, the average of $58,341 $58,000 $9,155 was over four times that of individuals $57,000 $56,000 in permanent supportive housing and nearly $55,000 double that of individuals experiencing chronic Chronic Homelessness Permanent Supportive Housing homelessness (Figure 8). 14
A Copa Health Lighthouse Group Home in Maricopa County. (Photo by Jeff Bayer/Copa Health) Case Study: Lighthouse Model shopping, getting to appointments, help with Community Homes employment and volunteer opportunities—and are trained to respond to behaviors associated In Maricopa County, there are only two group with SMI. In this regard, Lighthouses are most homes that offer stable, long-term housing with 24/7 in-home professional support. These homes, managed by Copa Health, are called Lighthouses. The goal of the Lighthouses is to improve tenants’ symptoms under stable and supportive conditions in a community-based setting. Advocates argue that the Lighthouse model is an example of how housing with higher levels of support can improve the stability and wellbeing of individuals with chronic mental illness (CMI), as well as reduce costs and shift expenses from crisis management toward recovery and personal development.121 Lighthouse Model Community Homes embrace a person-centered approach to housing and support. Tenants sign an annual lease and pay 30% of their income in rent. Each tenant has an individualized treatment plan, and they can come and go per that plan. Their autonomy falls between that of a nursing home and independent living. Behavioral health technicians Tenants of a Copa Health Lighthouse Group Home in provide 24/7 on-site support—such as cooking, Maricopa County. (Photo by Jeff Bayer/Copa Health) 15
similar to Behavioral Health Residential Facilities residential programs. For most individuals with (BHRFs) but differ in their tolerance for SMI SMI, hospitalization or residential treatment is symptoms otherwise deemed “bad behavior.” If needed for a short time to stabilize and prepare a tenant experiences a crisis episode, they can for the next phase, usually independent living. go to a hospital for treatment and return to the This group of individuals, however, had chronic Lighthouse when they are ready. Other housing symptoms and among the highest support programs, even those designed for individuals needs of Maricopa County’s SMI population. with SMI, may eject residents on the grounds Professional clinical judgment considered them of substance use, unpredictable behavior, to have CMI and to need a higher level of in- disregard of schedules or other rule violations, home support than what was available at the hospitalization, or incarceration. In contrast, time. at the Lighthouses, these behaviors and experiences are recognized as characteristic Copa Health developed the Lighthouse model of CMI; when they occur, the staff pursues to meet these individuals’ need for long- appropriate options for treatment and support term housing and person-centered support rather than eviction. There is no limit on tenants’ and reduce the costs of their care. The first length of stay at the Lighthouses, but there are Lighthouse group home opened in December criteria for when an individual may be ready for 2016 with four tenants; the second opened in housing with less intensive support.122,123,124 October 2017 with five tenants. All nine original tenants continue to live in the Lighthouse group homes today. There’s people here on-site to help me that are behavioral health techs that are trained, and they’re good people, and it’s a nice living situation. … There’s people here to help you cook. … I love the house. It’s great. I’ve lived here for three and a half years, and it’s a great environment, the location’s spectacular. —Lighthouse tenant [I]t’s going great. Real great. I love my roommates. I liked the staff support I get here day in and day out. … It helps me a Tenants of a Copa Health Lighthouse Group Home in lot to be here and in a group home with Maricopa County. (Photo by Jeff Bayer/Copa Health) roommates. It’s awesome. —Lighthouse tenant The idea of the Lighthouse model began in 2014 when family members of individuals with Average Annual Costs of Lighthouse serious mental illness, mental health advocates, Tenants and Copa Health recognized a small group of Copa Health members who were experiencing Figure 10 shows average health care costs severe, long-term mental health symptoms and per person per year for Lighthouse tenants repeated or prolonged stays in hospitals and/or over the period 2016-2019. It represents costs 16
Figure 10: Average health costs pre- and post- SMI population, as reflected in the high average Lighthouse setting, 2016-2019, per person per health costs per person per year. At $108,098, year. average annual spending on overall health care per Lighthouse tenant was 12.1% lower in $140,000 2019 (two to three years after moving into the $120,000 $123,036 Lighthouses) compared with spending in 2016, $100,000 $112,487 $108,098 the year before the first Lighthouse opened. $101,204 The decline in spending after placement in $80,000 Lighthouse group homes was realized primarily $60,000 in average behavioral health costs per person $40,000 per year, which fell 36% between 2016 and 2019 (Figure 11). $20,000 $0 While overall costs declined over the study 2016 (Pre-Lighthouse) 2017 (Half in Lighthouse) 2018 2019 period, some costs increased, particularly those associated with recovery and personal development (Figure 12). For example, for one year before this group moved into the pharmacy spending increased 212% from 2016 Lighthouses (2016) and two to three years after to 2019. Physical health costs increased 127% they moved into the Lighthouses (2017-2019). over the same period, likely because increased stability of the Lighthouses made diagnosing For the majority of 2017, only four of the nine and treating tenants’ physical ailments easier. tenants lived in the Lighthouses; the remaining Spending on skills training increased dramatically five tenants moved into the second Lighthouse over this period—2,176%—which suggests group home in October. Costs are included for all Lighthouse tenants were able to spend more nine individuals. Lighthouse tenants have among time on activities that helped improve their the highest support needs of Maricopa County’s autonomy and independence. Figure 11: Breakdown of average health costs Figure 12: Average spending on select health pre- and post-Lighthouse setting, 2016-2019, services in Lighthouse setting, 2016-2019, per per person per year. person per year (N=9). $120,000 $80,000 $73,752 $109,317 $70,000 $100,000 $87,013 $60,000 $80,000 $70,055 $70,379 $50,000 $43,842 $39,054 $60,000 $40,000 $28,471 $30,000 $24,249 $40,000 $21,309 $24,249 $20,000 $17,979 $21,309 $20,000 $17,335 $7,780 $10,000 $7,780 $17,335 $5,371 $13,470 $9,896 $9,840 $0 $5,939 $8,139 $0 $1,716 2016 2017 2018 2019 2016 2017 2018 2019 (Pre-Lighthouse) (Half in Lighthouse) (Pre-Lighthouse) (Half in Lighthouse) Behavioral Health Pharmacy Physical Health Skills Training Other Mental Health Pharmacy 17
Tenants of a Copa Health Lighthouse Group Home in Maricopa County. (Photo by Jeff Bayer/Copa Health) Notably, none of the Lighthouse tenants had expected that average costs would continue to criminal justice interactions during the study decline as Lighthouse tenants improve and gain period (2016-2019), meaning no costs were independence. However, these experts also incurred for this category of expenses. noted that Lighthouse tenants are very likely Professionals who work with Lighthouse tenants to need in-home support over the long-term, if not over their lifetime, and that their total costs are likely to remain higher than average for individuals with CMI. This case study of Copa Health’s Lighthouse Community Homes is a starting point for understanding the costs of individualized care for CMI individuals with among the highest support needs in Maricopa County. Because of the small sample size of nine individuals and a relatively brief time series of four years, only limited conclusions can be drawn from this analysis. However, as one of the few housing settings in Maricopa County with 24/7 in-home care that is Medicaid-supported and long-term, it is an informative empirical case of how localized costs Tenant of a Copa Health Lighthouse Group Home in for individuals with CMI changed over time when Maricopa County. (Photo by Jeff Bayer/Copa Health) receiving a high level of in-home support. 18
Expert Recommendations cognitive function. The majority of existing supportive housing options are not appropriate Interview participants from a range of for individuals experiencing symptoms of perspectives and experiences offered SMI, and too often result in eviction. As a law suggestions for improving care for people with enforcement professional explained: chronic mental illness (CMI) and reducing costs in Maricopa County. Stable, affordable [If] you put people in housing that has housing was widely considered essential for both rules—substance use, noise, cleanliness— improving care and reducing costs. However, when symptomatic, they’re gonna get many participants argued that for housing to be themselves kicked out. So, there’s not really successful on both fronts, it must be combined a lot of places that can manage people with appropriate long-term treatment, quality when they’re symptomatic and keep them support services, and community integration: housed. I mean, there’s, quite frankly, people that need supervision 24/7, but we Housing is health care. And that means don’t have enough beds. … So, it’d be nice mental health and physical health. It’s way to have something in the middle, between more expensive for somebody to hit our complete lockdown-secure hospital setting emergency rooms, our behavioral health to out in the community. systems, than to provide them with support and housing. There’s a cost savings of A family member and advocate further explained having that—supportive services and a how housing with higher levels of support safe place to live—versus that person being and supervision can facilitate a turning point on our streets and hitting all of our crisis in recovery: “[N]o one wants to have [to] tell systems. someone you’re gonna have to be treated. The —Homelessness benefit is … often it’s enough time to get them services provider insight, and then they’re on a different path for the rest of their lives. … It gives them a chance Provide Higher Levels of Treatment and at being able to create a life and step down to Support living on their own, living in an apartment. They’ll never have that chance if they keep cycling Many interview participants recommended through going to jail and prison.” providing higher levels of treatment and support to individuals with CMI than what is currently Coordinate Transitions Between Care and available through AHCCCS. This includes Housing residential treatment, such as secure residential or inpatient treatment for co-occurring substance To help ensure individuals with CMI receive use disorders, as well as 24/7 in-home support the housing and in-home support they need, in independent living and congregate settings. participants recommended better coordination of care and housing during transitions from Participants argued that individuals with hospitals, jails, residential treatment, and new CMI could benefit from these more intensive housing. Too often, participants explained, support options because they allow more time individuals are discharged from the hospital or and structure to stabilize, during which their jail with no housing or are placed in housing that medication can take effect, and they might gain does not meet their support needs because of insight into their mental illness and/or recover lack of coordination and/or availability. Or, an 19
individual is placed in housing, and their supports to be able to help the member with the fall away. When this occurs, the individual may transition and then with the follow-up end up cycling back through crisis services, the doctor’s appointments and such. behavioral health system, the justice system, and/or experiencing homelessness. To prevent Reduce Caseloads to Allow for this, several participants recommended that care providers in inpatient and outpatient settings, Individualized Care caseworkers, housing providers, and family members coordinate more through discharge Caring for individuals with CMI can be intensive planning and data sharing. Some noted that in terms of time and effort. Participants observed federal regulations from the Health Insurance that the level and quality of attention and Portability and Accountability Act (HIPAA) could individualized support they need is often not be a barrier to sharing information among provided, however, because the professionals providers and family members but still saw charged with their care—caseworkers, Assertive opportunities for coordination. Participants Community Treatment (ACT) Teams, doctors, suggested developing centralized databases in-home support staff, and others—have such to track important information about shared high caseloads and turnover. To address this patients and clients, such as their medication, challenge, participants recommended reducing care providers, caseworkers, emergency caseloads and increasing pay to attract and contacts, and contact information. For example, retain qualified, committed professionals to the a behavioral health provider stated: field and avoid burnout. As a behavioral health provider stated, “If we were to address it as a system, we will be increasing salaries to get There seems to be a fragmented system quality people who have a desire to provide between those who are hospitalized and quality services to people who are receiving those who are discharged. So, I think, as a individualized support because caseloads are system, we need to come together, and we smaller and because I can meet your needs and need to have better communication related help identify what it is before it’s too late for you.” to members who are being hospitalized, and then just providing that good follow-up outpatient care for those members. ... As Meet Long-Term Support Needs a starting point, hospitals and outpatient providers need to start to come together. Some participants compared CMI with other We’ve done better as a system in the last chronic conditions like Alzheimer’s disease couple years, but it’s—certainly, there needs or diabetes: More severe forms require more to be further improvement in that area. We intensive care. They noted that the system could need to have a centralized database where better accommodate the time individuals with not only are we seeing which members CMI need to stabilize and recover; some may are going in and out of the hospitals, but need intensive support for their whole lifetime. we should also be able to see each other’s A CMI advocate and family member put it this documentation on shared members so that way: “We have people who have cancer who are we know where our members are. ... We more severe than others, we have people who have to have a better discharge planning have heart disease that are more severe than process in place where those hospitals others and need care for the rest of their lives. are reaching out to outpatient and then If you have diabetes, you need care literally for outpatient … staff are there on premises your whole life, and some people’s diabetes 20
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