High Utilizers Initiative

The term “high utilizers” (also referred to as high system utilizers or frequent users) refers to a small percentage of unhoused individuals that are caught in a tragic spiral of involvement in crisis services—services provided at enormous expense to the public but that result in few or no positive gains for the individuals. In many instances, these people have serious mental illnesses, substance use disorders, or other significant health and social service needs. They repeatedly cycle through our communities’ health service, correctional, and emergency health care systems.

A high utilizer of the criminal justice system is an individual that has frequent encounters with the criminal justice system (i.e., police, prosecutors, courts, jails). The proposed program focuses on this subset of high utilizers because the largest community and individual impacts are aligned with criminal justice-involved high utilizers. There is, nonetheless, an overlap between high utilizers of the criminal justice system and high utilizers of all public services, including health care and emergency services. For example, in 2022, approximately 20% of Boulder’s high utilizers of the criminal justice system were also high utilizers of the Boulder Community Health Emergency Department. Many of the high utilizers of the criminal justice system are incarcerated frequently and are not accessing healthcare services while in jail, but case workers often see high utilizers ebb and flow between the criminal justice and healthcare systems depending on when they are in jail or unsheltered in the community.

To “exit” someone from homelessness means just that: they are no longer experiencing homelessness. They may be exited to permanent housing, but they can also be exited to transitional housing, to living with friends or family, in a long-term care facility, or long-term incarceration. In the case of the proposed program, the goal is to exit individuals into whichever alternative best applies to the individual, including permanent supportive housing. More information about the city’s overall homelessness strategy and solutions can be found on the city’s website.

The Taskforce has created a unified team of cross-agency professionals dedicated to working with high utilizers to limit community risk, reduce the impact on community resources, provide support for individual clients, and house the hardest members of the community experiencing homelessness. The proposed program will provide the team with the necessary resources (housing and intensive support services) to address the key barriers to exiting these high utilizers from homelessness.

A variety of agencies have and will continue to provide a range of services and programs in the City of Boulder that have made substantial impacts on exiting individuals from homelessness. None of the current programs, however, are designed to specifically focus on the unique needs of high utilizers or offer the combined package of services necessary to effectively exit them from homelessness. Interventions for a high utilizer’s needs require a complex set of responses that are targeted to the unique reasons that a high utilizer is not successful in traditional homelessness responses. The interventions proposed by the program respond to people at the very highest level of need across multiple strata: inability to obtain and maintain housing, substantial substance use disorders typically co-occurring with significant mental health issues, and little desire for engagement with service providers, support needs.

The proposal was developed by a collaborative of Boulder governmental and non-profit representatives, referred collectively as the Interagency Task Force on Boulder’s Unhoused High Utilizers. The task force includes senior officials from the following organizations, each which have individually endorsed the proposal:

• All Roads
• American Medical Response of Colorado, Inc.
• Boulder Community Health
• Boulder County (Commissioners Office, Community Services, Housing and Human Services, Sheriff’s Office)
• City of Boulder (City Attorney’s Office, City Manager’s Office, Fire, Housing and Human Services, Municipal Court, Police)
• Clinica Family Health
• Focus Reentry
• Mental Health Partners
• 20th Judicial District (Boulder County Probation and District Attorney’s Office)

Some of these individuals are sent to jail, usually for very short durations. Others are not. They are often chronic, low-level offenders whose crimes are not serious enough to warrant a prolonged sentence in either jail or prison. Many low-level offenses are not eligible for booking at the Boulder County Jail due to booking standards designed to keep the jail from becoming overcrowded as well as state law that mandates personal recognizance bonds for low-level, non-violent offenses. While the proposed program is not looking to extend the time high utilizers spend in jail, it does recognize that time in custody can provide an important opportunity to interrupt negative behaviors while also creating a receptivity to some services.

While these individuals are high utilizers because of a large number of low-level crimes, one of the key considerations for addressing their housing and support needs is to keep them from de-compensating and committing higher level crimes.

Communities might send people experiencing homelessness to other cities or states as a function of reuniting an individual with networks that offer better support. They, however, like all individuals, are free to choose whether they want to leave or stay. The high utilizers that are the focus of this proposed program have generally lived in Boulder for a long time and are not interested in leaving Boulder.

Both interventions are designed to address the needs of individuals experiencing homelessness with complex challenges. However, the needs of high utilizers are often so complex and the barriers to housing are so high that they don’t qualify for conventional programs. The proposed high utilizer program proposal incorporates additional services and a robust set of flexible and individually customized supports designed to address these unique and elevated needs.

There are, and will continue to be, a substantial amount of housing and human services provided in Boulder. Addressing the high utilizers is not at odds with continuing to provide those services. To ignore the disproportionate impact of high utilizers, however, and to not provide them services, is to turn a blind eye on those individuals causing the greatest impacts.

The program will involve greater targeted outreach. It will be tailored, flexible and individualized. The value of such a multi-agency approach is that the organization with the best relationship with the individual can work closest with the individual while coordinating other services with other agencies.

The program has budgeted funds for a robust program evaluation. The task force has a dedicated data and analytics team with representatives across multiple agencies that will help monitor utilization of individuals engaging in the program. Metrics of success may include decreases in criminal justice interactions, reductions in unnecessary utilization of emergency healthcare services, increases in engagement levels, and improvements in the length of time an individual remains housed. In addition, the task force will explore additional funding opportunities to create a study on the impact of the program that can be considered by policy makers in Boulder and beyond.

Individuals have made it onto the criminal justice system high utilizers list after months, if not years, of interaction with local law enforcement. In other words, they are not new to the city. Once removed from the list, those replacing them are by definition lower system users. A lower system user can of course have enough new interactions with the criminal justice system that they eventually meet or exceed the level of utilization of previous individuals. However, there is no reason to expect that serving this unique population would generate a demand for new high utilizers to move to Boulder.

The fundamentals of the proposed program are not untried. They are based on the FUSE (Frequent Users Systems Engagement) initiative developed by the Corporation for Supportive Services, a national non-profit focused supportive housing and person-centered growth, recovery and success that contributes to the health and wellbeing of the entire community. Following this same mode, Denver used a social impact bond to offer housing and supportive services to 363 unhoused high utilizers of local criminal justice and healthcare systems. 79% of participants were engaged and housed, and those individuals had fewer interactions with police, spent fewer nights in jail, and less time in detox.

While other communities have tried the FUSE approach, some aspects of the proposed program are unique and build on already established best practices. Specifically, the proposed program builds on the FUSE approach by providing unique interventions to barriers to housing identified by local providers.

People aren’t necessarily resistant to services; they’re unable to navigate the system. Even when the proposed program is put in place, we will still face challenges and won’t be able to house everyone on the first try. Critical timing and non-traditional coordination will aid in ensuring that when individuals are interested that we have a program that allows us to respond.

The proposed program follows the best practices in equitable, inclusive, and trauma-informed housing with wrap around services to set high utilizers up for success and support landlords who want to help. The combination of housing and intensive supportive services is a holistic and effective strategy for addressing the complex needs of high utilizers who are homeless, promoting stability, well-being, and community integration.

National evaluations of similar supportive housing programs show that housing individuals results in decreased criminal justice interactions. For example, 86% of participants in a New York FUSE program remained housed after two years, and they spent 40% less time in jail than a comparison group.

The initial proposed pilot program would rely on housing units or apartments that are dispersed throughout the city. In the future, additional housing program types, such as shared housing or site-based housing, may be added to the program. Ultimately, the choice between site-based and scattered site housing depends on the specific needs of the individuals being served. Having a robust support system is a critical component in ensuring that the individuals residing in scattered site housing are able to assimilate with mainstream apartment dwellers. Many successful housing programs use a combination of both approaches to provide a range of options for diverse populations.

The proposed program for high utilizers to transition into housing places significant emphasis on delivering comprehensive services within their homes. This initiative primarily involves intensive supportive services, encompassing treatment for both behavioral health and substance use, along with robust intensive case management. Additionally, the proposed program integrates valuable support from individuals with lived experience to aid in the adjustment to housing and to facilitate the seamless incorporation of individuals into the community.

The proposed program follows the national best practice of supportive housing by encouraging and making treatment services available, but not requiring individuals to be sober. While not endorsing or encouraging substance use within housing, the program treats participants as any other tenants and holds them accountable to the requirements of their leases. Recognizing that substance use is a complex issue that may require individualized support and treatment and that enforced sober living might be less effective for many, high utilizers are afforded supports, case management, and treatment options that would not be made available to other tenants.

The proposed program prioritizes the provision of stable housing as the initial and fundamental intervention for individuals experiencing homelessness, without imposing prerequisites. Several reasons underlie the decision to make services voluntary rather than mandatory. Some of those reasons are autonomy and choice, building trust, meeting individuals where they are, effective engagement, and using stability as a foundation.

While services are not mandatory, comprehensive support services are offered and encouraged. These services include mental health counseling, substance use treatment, medical care, and intensive case management. The voluntary nature of these services aligns with proven housing retention rates and align with the best practices of individual choice and empowerment.

The program's goal is to facilitate the integration of individuals into the community, thereby reducing their dependence and impact on the community as high utilizers. Individuals will have a team of professionals providing comprehensive supportive services to assist individuals in navigating this transition.

Currently Boulder estimates spending between $48,000 and $84,000 per year on criminal justice and healthcare resources for a typical high utilizer. This aligns with similar national estimates – Los Angeles previously reported spending approximately $51,000 per individual per year for the top 5% of their social service and criminal justice high utilizers. Other older studies suggest taxpayer costs of $27,000 (Sonoma), $29,200 (Denver), and $35,000 (National Alliance to End Homelessness) per person per year.

While there is a significant contribution of staff support to this effort, and the city has contributed to the cost of a consultant, there has not been any other direct outlays of city or county funding for this pilot program; however, the team is actively pursuing private and public funding opportunities

High system utilization and homelessness are complex and multifaceted issues that require a comprehensive and collaborative approach. By bringing together both public and private sectors, these partnerships leverage the strengths and resources of each, creating a more robust and sustainable strategy to address the needs.

Strategically looking at public-private partnerships for funding programs that address complex problems is critical because it capitalizes on the strengths of both sectors, diversifies funding sources, encourages innovation, fosters shared responsibility, and enhances accountability. The collaborative nature of these partnerships reflects a recognition that solving complex social issues requires a collective effort from various stakeholders.

The extent of influence that funders exert on the implementation of the program may vary depending on the specific terms set forth in funding agreements. While funders may express preferences aligned with their goals, the success of the program implementation also hinges on the service provider’s autonomy, expertise, and ability to meet the specified conditions. Effective communication and transparency will be essential to fostering a successful partnership between funders and the program/service provider.

Implementing a program to house high utilizers experiencing homelessness brings about various advantages for the business community, impacting both the economic and social aspects of the local community.

• By providing stable housing, the program contributes to community safety, thereby fostering a more comfortable atmosphere for businesses and patrons.
• Businesses actively involved in supporting housing programs exhibit corporate social responsibility, enhancing their public image and fostering goodwill among customers.
• As individuals stabilize through housing initiatives, they become positive members of the community.
• Decreasing reliance on emergency services and addressing associated costs, businesses may experience economic relief.
• Participating in initiatives specific to the unhoused also positions businesses as contributors to local problem-solving efforts, fostering community engagement, partnerships, and collaborative commitment for positive change. In essence, a program to provide housing to high utilizers experiencing homelessness not only addresses a critical social issue but also creates a more conducive environment for business growth and community well-being.

The proposed program has the potential to lower the cost of encampment clean ups once individuals are placed into housing, but it may not lead to significant impacts to the cleanliness of public spaces. While nearly all of the high utilizers in 2022 were experiencing unsheltered homelessness and not regularly staying in Boulder shelters, they make up approximately 30% of the people living unsheltered. Housing these high utilizers may reduce the safety concerns of public and open spaces overall, but improvements in reducing camping in public spaces is more likely impacted through the Safe and Managed Public Spaces effort.