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10th Decile Project to House High Need Homeless

Social Innovation Fund (SIF) Grant Awarded to the Economic Roundtable Team, 2012-2015


The Economic Roundtable Team was one of four groups working on homelessness selected from across the U.S. to receive a national Social Innovation Fund grant underwritten by the Corporation for National and Community Service. The grant was awarded through our intermediary, the Corporation for Supportive Housing (CSH) as part of its SIF Intitiative taking place in Los Angeles, San Francisco, Washtenaw County, Michigan and statewide in Connecticut. The Roundtable team of five key partners and a total of 38 hospitals, clinics, housing providers, and homeless service providers is identifying 107 high-need, high-cost homeless individuals in hospitals and clinics and providing them with immediate, ongoing, affordable housing with services. This project builds on Economic Roundtable research, a pilot project initiated in partnership with CSH, and service delivery teams created by CSH’s Los Angeles office.

The 10th Decile Project uses the triage tool (free download) developed by the Economic Roundtable to identify individuals experiencing homelessness who continuing crises in their lives that create very high public costs. The Roundtable research that led to developing the triage tool is presented in Where We Sleep: The Costs of Housing and Homelessness in Los Angeles (2009) and Crisis Indicator: Triage Tool for Identifying Homeless Adults in Crisis (2011). This is the only tool for prioritizing the needs of homeless individuals that is based on cost data for a generally representative sample of homeless persons.

Program Description

The project team included the foremost organizations leading and implementing humane, evidence based initiatives to end chronic homelessness in Los Angeles County. The five key partners are Housing Works, Homeless Health Care Los Angeles, OPCC (formerly Ocean Park Community Center), PATH (People Assisting the Homeless), and Ascencia (formerly PATH Achieve Glendale). The Economic Roundtable brings strengths for developing and improving evidence-based tools for identifying homeless individuals with acute needs and high public costs, and for analyzing and using data to inform program decisions.

The project team moved 107 high-need, high-cost homeless individuals into permanent supportive housing using the triage screening tool developed by the Roundtable. These are frequent users of emergency health services and inpatient hospital care who, in the absence of ongoing case management and permanent affordable housing, will have ongoing health crises and be frequent user of emergency health services.

All team members are using a “whatever it takes” approach to reach and retain the individual. The overall goal is to provide patient-centered health homes with fully integrated comprehensive health, mental health and substance use and housing treatment, with a seamless, no-wrong-door, non-linear, holistic, client-driven model that incorporates an ongoing array of opportunities to achieve overall health and wellbeing. The result is improved housing stability and health, and reduced use of emergency health services.

This project is supported by the elected leadership and health and housing agencies of the city and county of Los Angeles and neighboring cities. This support and the size and competence of the project team position this 10th Decile Project to achieve systemic change for addressing homelessness.

The participating hospitals treat over 4,000 homeless inpatients and 9,000 homeless emergency room patients each year. Each hospital will receive training and technical assistance from the Economic Roundtable in using the triage tool and will use the tool to identify high-need homeless individuals, who will be handed off to the team’s intensive case management and housing placement/retention service providers.

The participating Federally Qualified Community Health Centers (FQHCs) are partners for providing primary care and patient-centered medical homes for participants. Each FQHC has extensive experience and strong capabilities for providing high need individuals who have experienced homelessness with a system of coordinated care that integrates primary care, behavioral health, and other social services to care for all aspects of their patients’ health. Each FQHC will also receive training and assistance from the Economic Roundtable in using the triage tool and will collaborate in screening and identifying high-need individuals for enrollment in the project.

The participating permanent supportive housing organizations provide ongoing housing with supportive services. Each organization is committed to a housing first approach, allowing each individual to create the home and community that best allows him/her to build a rich and meaningful life. The housing providers collaborate with the team’s intensive case management and housing placement/retention service providers to identify available permanent supportive housing units and lease those units to participants.

10th Decile Project Triage Tool

Download the 10th Decile Triage ToolsThe triage tool (free download) was developed based on two key propositions:

  1. The greatest risk to homeless individuals is of continuing crises in their lives, particularly crises that cause encounters with hospitals and jails.
  2. The most compelling basis for prioritizing access of homeless individuals to the scarce supply of permanently subsidized supportive housing is the public costs that will be avoided when they are housed.

The triage tool was developed by the Economic Roundtable’s statistician, Jay Sumner. It is a system-based tool for identifying the one-tenth of homeless persons with the highest public costs, and the acute ongoing crises that create those high costs. This 10th decile is the highest need segment of a much larger homeless population needing housing.

This tool equips gatekeeper institutions such as hospitals and clinics to identify accurately individuals experiencing homelessness whose acute needs create the greatest public costs, and to make credible requests to housing providers that these individuals be given first priority for the scarce supply of permanently affordable housing with supportive services.


When people in the 10th decile are living in permanent supportive housing, jail costs decrease 97 percent and health care costs decrease 86 percent. These cost savings are contingent on retaining people in permanent supportive housing, which is facilitated by higher rather than lower levels of on-site services, particularly given the severe problems of many individuals in the 10th decile.10th_Decile_Project_Current_Projects_img_03

The Economic Roundtable is the 10th Decile Project lead and is facilitating team collaboration and communication, as well as providing training, technical support and hands-on assistance in using the triage tool to identify high-need individuals who get enrolled in the project.10th_Decile_Project_Current_Projects_img_04


The team’s intensive case management and housing placement/retention service providers are the service delivery managers for this project. They maintain long-term, high-touch contact with participants, starting with immediate temporary housing (in a shelter or motel) , connection with a FQHC, placement in permanent supportive housing, and continuing throughout the duration of the project. All five are committed to using housing first and harm reduction service delivery models for high-need individuals experiencing homelessness. They are responsible for the delivery of all needed client services. This begins with assertive outreach in clinics and hospitals to recruit members of the target population and continue with care management and service coordination. They engage and case manage clients, empowering them to identify and define their own service goals and needs, and help them connect to needed health, behavioral health, vocational/educational, transportation, medication, management, nutrition education, assistance with daily living, and other services.10th_Decile_Project_Current_Projects_img_05


Hospital and clinic patient records are used to identify high cost users of crisis health care services to target high-need homeless patients for outreach and enrollment. At le ast 24 of the organizations on the project team will be trained in using the triage tool and will participate in outreach and screening. This includes all intensive case managers, housing placement/retention staff, hospitals and medical clinics on the team. In the early stages of the project, Roundtable staff has been working on-site with agency staff to assist in screening. As agency staff become more experienced and confident in using the screening tool, the Roundtable has shifted into a role of providing technical support and backup assistance.10th_Decile_Project_Current_Projects_img_06



The 10th Decile Project builds on the service delivery network and experience from the Los Angeles FUSE (Frequent User Systems Engagement) Project piloted by CSH’s Los Angeles office and the Economic Roundtable, in collaboration with Housing Works and OPCC, as well as Homeless Health Care Los Angeles. This 10th Decile Project is expanding these pilot programs by adding 2 service provider teams, 11 hospitals, 3 FQHC health care providers, and 5 interim and 6 permanent housing partners. The project is enrolling eligible individuals in downtown Los Angeles, West Los Angeles/Santa Monica, the southeast San Fernando Valley, Whittier, Glendale, Pasadena and the San Gabriel Valley, Hollywood, East Los Angeles, and South Los Angeles.

Theory of Change

The Economic Roundtable Team expects to achieve systems change and replication of our 10th Decile Project model at the regional level and beyond, building financial sustainability for a new approach to screening referring and housing homeless adults. The model consists of a triage tool, methods, strategy and outcomes that affect a variety of stakeholders, including service providers, FQHCs, hospitals and local government.



This project is demonstrating the long-term cost savings for hospitals and public agencies from screening using the triage tool, and demonstrating why the public sector and health care providers should invest to support this screening, referral and permanent supportive housing model.



This project also demonstrates a new model for helping the highest need homeless adults get priority access to permanent support housing with intensive case management, while reducing costs for public agencies and private health care providers. Larger scale success of this model in Los Angeles County will be a springboard for broader implementation across the country, with the broader involvement of policy makers, the private sector and philanthropy.

Knowledge Network

For team members, enter CSH’s national-level discussion forum and document hosting web site:


About the Social Innovation Fund (SIF)

Scaling and Sustainability

During year 3 of this SIF-funded 10th Decile Project, the Los Angeles SIF team is focused on housing retention for existing clients, and operationalizing our plan for scaling and sustainability. More information about the LA SIF team’s scaling and sustainability plan will be posted here soon:



Links for scaling and sustainability:


Research by the Economic Roundtable produced the data-driven tools that will be used in this project to identify the highest-need group of individuals experiencing homelessness. These reports can be accessed below:

  • Getting Home: Outcomes from Housing High Cost Homeless Hospital Patients. September 2013. This evaluation of outcomes for the first 163 patients screened with the triage tools found that every $1 dollar in local funds spent to house and support 10th decile patients reduces public and hospital costs for individuals who are housed by $2 in the first year and $6 in subsequent years. The most difficult problem is long delays in obtaining permanent supportive housing. Underwritten by the Conrad N. Hilton Foundation, UniHealth Foundation, the Corporation for National and Community Service, the Corporation for Supportive Housing, and the Economic Roundtable.
  • Crisis Indicator: Triage Tool for Identifying Homeless Adults in Crisis. August 2011. The triage tool, or crisis indicator, identifies homeless individuals in hospitals and jails who have continuing crises in their lives that create very high public costs. The triage tool for identifying high-need individuals is provided along with the report. Underwritten by the Corporation for Supportive Housing and the Conrad N. Hilton Foundation.
  • Where We Sleep: The Costs of Housing and Homelessness in Los Angeles. November 2009. The central question investigated in this study is the public costs for people in supportive housing compared to similar people that are homeless. The typical public cost for residents in supportive housing is $605 a month. The typical public cost for similar homeless persons is $2,897, five-times greater than their counterparts that are housed. This remarkable finding demonstrates that practical, tangible public benefits result from providing supportive housing for vulnerable homeless individuals. The stabilizing effect of housing plus supportive care is demonstrated by a 79 percent reduction in public costs for these residents. Prepared for the Los Angeles Homeless Services Authority.

Articles and related reports by others: