Project 2.b.vi – Transitional Supportive Housing Services

Why FLPPS Chose this Project

Insufficient affordable permanent housing and limited supportive housing in the FLPPS region is a constraint to effectively addressing the full range of needs that may exist among chronic super utilizers and other high risk and high need patients targeted by DSRIP projects.

Access to safe transitional supportive housing is a key determinant in stabilizing chronically ill super-utilizers of health care.  The availability of secure housing and home care services must include services which will allow the discharged patient to stabilize in the community setting instead of re-admitting to the hospital due to housing instability.

Lack of stable housing tends to coincide with significantly higher rates of behavioral health disorders more than are seen in the general population and can drive patterns of super utilization of emergency and crisis services at a high cost to the health care delivery system. 

Data from homeless programs operated by Federally Qualified Health Centers (FQHCs) in the FLPPS region showed 56% of homeless patients had mental health (MH) or substance abuse (SA) disorders and averaged twice as many visits in 2013 as homeless patients with other primary diagnoses.


The Western Region Behavioral Health Organization found that 15% of patients with mental and behavioral health conditions were homeless at the time of admission, yet only 62% of patients had improved housing status at the time of discharge.


The historically limited range of solutions for housing unstable individuals under 55 years of age with medical frailty or physical disabilities has led hospitals to over-rely on skilled nursing facilities (SNF), even for relatively low acuity patients. This reality diverts SNF resources from higher need patients and unnecessarily increases health system cost.


In 2015, the Monroe County Department of Human Services made 7,455 emergency housing placements for individuals and families.  The second leading cause of homelessness (12% of cases) was release from an institution (hospital, substance abuse treatment program, jail) without a plan for permanent housing. 

(2015 Monroe County Annual Housing Report)


What Success Looks Like

Intensive short-term care management and a coordinated transition to a longer term care management which allows additional time to support stabilization, rehabilitation and recovery. Hospitals throughout our region would partner with community housing providers and home care service organizations to develop transitional supportive housing for high-risk patients who, due to their medical or behavioral health conditions, have difficulty transitioning safely from a hospital into the community. 

The ACA has expanded opportunities for home and community based services including supportive housing for a wider range of Medicaid members. Plans for transitional supportive housing could include innovative models such as Medical Respite.  FLPPS has created a multi-sector housing workgroup to strategize the use of these opportunities as well as permanent housing solutions that will support DSRIP outcomes.