The third panel featured presentations of specific successful and promising models of affordable and accessible housing in various regions across the United States. Peggy Bailey, the director of the Health Integration Project at the Center on Budget and Policy Priorities, provided an overview of the link between housing and health. The remaining panelists—Katina Washington, a program analyst in the Grants and New Funding Branch of the U.S. Department of Housing and Urban Development (HUD); Lisa Sloane, a senior policy advisor at the Technical Assistance Collaborative (TAC); Sarah Szanton, an associate professor of community and public health in the Johns Hopkins School of Nursing; Molly Dugan, the statewide director of the Support And Services at Home (SASH) program at Cathedral Square; and Rose Englert, a senior business leader of CareOregon’s Community Health Innovation Program—then described their specific programs. Following the presentations, Craig Ravesloot, a research professor of psychology and the director of research and training at the Center on Disability in Rural Communities at the University of Montana, led a moderated discussion with the panelists and then opened up the discussion to the workshop participants.
Director, Health Integration Project
Center on Budget and Policy Priorities
The Center on Budget and Policy Priorities,1 Bailey explained, is a nonpartisan think tank based in Washington, DC, whose purpose is to ensure that low- and moderate-income families have access to the services they need. Bailey joined the center in January 2016 to lead its program Connecting the Dots: Bridging Systems for Better Health, which engages in cross-policy conversations that promote broad-based efforts to improve health at the population level. Her job, she explained, is to ask what work her colleagues are doing that is related to the federal Temporary Assistance for Needy Families program, how their efforts will help people with behavioral health needs, and what improvements they need from the behavioral health system.
The U.S. health system is focusing on housing and employment as social determinants of health, Bailey said, because there are successful models and opportunities for the integration of efforts. “From a housing standpoint, we know that lack of housing or poorer housing can dictate whether [individuals] are healthy or not,” she said. “If someone is [living] on the street and has hypothermia, it is their lack of housing that is dictating their health, not just affecting their health in an indirect way.” Therefore, it is relevant to talk about housing as a component of achieving the Triple Aim. “How can housing help reduce health system costs, improve health system quality, and improve access?” she asked, referring to the three goals of the Triple Aim. She said it is important to talk in terms that health care system leaders understand and to appreciate what those leaders are trying to achieve for the health care system. Meanwhile, those working in health care need to talk with their housing policy colleagues about what can be achieved through the housing system.
A number of small studies have shown that for high-need, high-cost populations, supportive housing can reduce costs while improving the utilization of the health care system, Bailey said. The best studies in this field have examined individuals living with HIV/AIDS (Aidala et al., 2007; Schwarcz et al., 2009) and have shown that supportive housing improves health status, lowers viral load levels, reduces the risk of death, and reduces risky behaviors. However, researchers have done little to show the impact that housing has on other chronic illnesses. More data linking better health outcomes with supportive housing could induce
health systems to advocate for and invest in affordable housing as a means of meeting their mission and improving the measures by which they are judged.
Evidence does exist that shows that making housing improvements other than providing supportive housing has a positive effect on health. Research has shown that removing lead paint and managing the internal environment of a home to remove allergens and lung irritants can improve occupants’ health (Sandel et al., 2010). Some managed care organizations have paid for air conditioning units, removing carpet, and taking other steps to decrease asthma attacks in children (Bryant-Stephens and Li, 2008; Sandel et al., 2004). More research is needed on the effects of overcrowding and housing instability on mental health, Bailey said. “There are things we intuitively think that housing can do, and we maybe have some evidence, but we do not have much really firm evidence . . . from a research standpoint,” she said.
There is a range of types of housing models, Bailey said. There are housing services models that span single-site settings and provide onsite services as well as scattered-sites settings that aim to deliver services in homes distributed throughout the community. Housing specifically for older adults is an example of a single-site setting, and having services co-located with housing improves the ease of access, particularly for individuals with a disability. Single-site settings also make it easy for health systems to know where their clients are coming from. The main challenge for scattered-site settings lies in determining how to deliver the widest range of services possible in someone’s home.
Designing programs to provide services can be challenging because individuals’ need for services are not linear—they vary over time. “That makes thinking about profit margin and how much money [an organization is] going to earn difficult,” Bailey said. Programs should be designed so that they provide services based on need, not on the amount of income a program needs to generate, she said. Another challenge is to match interventions to needs. “We need to stop making programs where we make people fail first so that we can figure out what they need,” She said. “We need to do a better job of figuring out how to help people choose what is right for them and making sure that we can provide what they want.”
Policy makers, Bailey said, also need to address workforce shortages, particularly given the effect that Medicaid reimbursement rates have on salaries and earnings. Furthermore, she said, service providers must do a better job communicating the value they bring to the health care system and developing cross-sector partnerships. “If we are thinking about the complex needs of people,” she said, “we need to do better when it comes to partnerships.” The same can be said for making the case for rental
assistance. Bailey said that her organization has plans to conduct a big rental assistance initiative to increase rental assistance nationwide but is working on how to maintain the little money that is available. “It is going to take a collective effort of health care, housing, and everyone else who understands that affordable housing is important to health,” she said. Other steps that need to be taken include making sure the low-income housing tax credit goes low enough from an affordability standpoint and protecting the Medicaid program, including strengthening Medicaid state plan amendments to affect the social determinants of health, she said.
Bailey recounted hearing Geoffrey Canada speak at a recent conference about the Success Academy Charter Schools2 in Harlem; he challenged the audience to think about why it is necessary to prove that low-income people should have access to the same services as middle-income people. “How about we help figure out how to get those same kind of outcomes for low-income people?” Bailey said, adding that the Skid Row Housing Trust’s Star Apartments3 in Los Angeles, the National Church Residences program,4 and the Camden Coalition of Healthcare Providers5 are examples of programs that are successfully blending housing and health services for low-income individuals.
Program Analyst, Grants and New Funding Branch
U.S. Department of Housing and Urban Development
Senior Policy Advisor
Technical Assistance Collaborative
Katina Washington of HUD began this joint presentation by explaining that HUD originally provided both capital and operating assistance to nonprofit organizations to construct or rehabilitate housing for individuals with disabilities. However, with declining appropriations and
6 For more information, see https://portal.hud.gov/hudportal/HUD?src=/program_offices/housing/mfh/grants/section811ptl (accessed March 8, 2017).
changes in the rental market, the capital investments were not adequate. The U.S. Congress passed the Frank Melville Supportive Housing Investment Act of 20107 to accelerate the development of affordable housing options for non-elderly individuals with disabilities, Washington said. The Melville Act added several new components under the Section 811 program, including the Section 811 Project Rental Assistance (PRA) Program, which provides rental assistance only to state-level housing agencies. The Melville Act encourages integration by requiring that no more than 25 percent of the housing can be designated for individuals with disabilities and that the units must be dispersed throughout a development. HUD works to ensure that tenants pay no more than 30 percent of their income for housing. In addition, services are made available to those who receive rental assistance, although participation is voluntary. The Melville Act also allows states to target specific populations with the greatest needs, such as people who are homeless or who are living in institutions.
When HUD developed the Section 811 PRA Program, Washington said, it wanted to ensure that services were in place for individuals with disabilities and that states’ housing agencies were creating partnerships with states’ health and human services agencies because state agencies often work in silos. In addition, the program incentivized states to develop innovative, replicable, and systemic strategies to provide housing with services for people with disabilities. HUD also wanted to determine an approach that would be faster than a brick-and-mortar process at increasing the number of accessible and affordable units available for individuals with disabilities and that would create more efficient and effective uses of housing and health care resources.
Today HUD places the onus of securing funding on the individual states, which have greater flexibility in putting together financing packages to develop this type of housing, Washington said. Many states use the low-income housing tax credit program, other HUD programs such as the HOME Investment Partnerships Program8 and the Community Development Block Grant program, and funds from nonprofit foundations to construct housing units for people with disabilities. HUD then provides operating assistance in the form of rental assistance for these units. Washington said the agency encourages states to work with their local housing authorities to use existing public housing as additional housing for people with disabilities, or to use the Housing Choice Voucher program or other state-level affordable housing programs.
7 Frank Melville Supportive Housing Investment Act of 2010, Public Law 111-374, 111th Cong. (January 4, 2011).
8 For more information, see https://portal.hud.gov/hudportal/HUD?src=/program_offices/comm_planning/affordablehousing/programs/home (accessed March 15, 2017).
Congress funded new Section 811 PRA program units in fiscal years 2012, 2013, and 2014. The 2012 PRA demonstration awarded $89 million to 12 grantees which built some 3,000 units. In fiscal years 2013 and 2014 the program awarded $150 million to 24 grantees which built an estimated 4,500 units. More than 230 tenants currently live in units created by the fiscal year 2012 grants. Some 44 percent of these individuals came from institutions or were at risk of institutionalization, and 40 percent had been homeless or were at risk of becoming homeless. The units have stable tenure, Washington said, with about 8 percent of the tenants having exited the program for personal reasons.
Lisa Sloane of TAC then discussed how the state of Louisiana has implemented its Section 811 PRA program, which it established in 2012 when HUD awarded the Louisiana Housing Corporation (LHC) more than $8 million to create 200 PRA units. Louisiana’s program focuses on central and northern Louisiana, including the cities of Shreveport, Monroe, and Alexandria, and was designed to build on the state’s 3,000-unit permanent supportive housing program developed in the aftermath of Hurricane Katrina. Partnership between LHC and the Louisiana Department of Health (LDH) is a key component of the program, Sloane said. The collaboration was formalized through an interagency agreement that details roles and responsibilities for outreach, referrals, identifying target populations, and providing support services. An executive management council, consisting of the LDH deputy secretary, LDH program office assistant secretaries, the state Medicaid director, the LDH permanent supportive housing director, and the LHC housing authority administrator, meets at least once each quarter to assist with program implementation, management, and monitoring.
TAC has aided in Louisiana’s development of its PRA program by encouraging the program to map how it plans to get an individual from housing application to tenancy (see Box 5-1). All of the partners have to work together and carry out their individual responsibilities to make the program work, Sloane said. “They sat down and put this together because if agencies and staff are not clear on their roles and responsibilities, you are not going to transition somebody from a nursing facility into an apartment in the time frame that unit has to be rented,” she said. The program provides only 2 months of payments for vacancy, and transitioning an individual from a nursing home into a unit in that timeframe has been challenging.
There are program requirements and program preferences related to identifying the target population. To be eligible for the program, one must be between the ages of 18 and 62, have an income that is 30 percent or less of the area median income, have a disability as described in the statute, and be eligible for services at the time of admission. The Louisiana
program provides preference to individuals who are institutionalized or at risk of institutionalization, who are homeless or at risk of losing their housing, who have been affected by a hurricane, or who are youth aging out of foster care. When the program opened for applications, 585 people applied, of whom 188 had physical disabilities, 299 had serious mental illness, and 98 had an intellectual or developmental disability. The eligible properties have been identified—some units are currently filled and waiting for turnover to occur—and as of September 30, 2016, 43 tenants had been placed in 8 properties, with only 1 tenant having exited the program over the previous year. “Many of the tenants had difficult tenancy histories, including evictions,” Sloane said, “but the Louisiana program has really managed to create a service and support system with a lot of stability.” Services are largely funded by Medicaid, she added, and there is at least one certified service provider in each of the three cities. It took approximately 1 year to train the providers so that they could deliver services consistent with the model, Sloane said. “The partnership is working. The supports are there.”
Associate Professor of Community and Public Health
Johns Hopkins School of Nursing
The Community Aging in Place—Advancing Better Living for Elders (CAPABLE)9 program differs from many other care delivery models in that it is preventive—i.e., it aims to help people before they are in crisis—and it is framed as person-directed rather than patient-centered care, said Sarah Szanton of the Johns Hopkins School of Nursing. In addition, she said, CAPABLE is focused equally on health and housing, as opposed to being a housing program that might address health issues, or a health program that includes consideration of housing issues.
To provide an example of a typical individual participating in CAPABLE, Szanton told the story of Mrs. B. Mrs. B. has diabetes, hypertension, congestive heart failure, and arthritis—a set of chronic conditions common among older adults. She had lived in her home for many years and, as is true for many older adults, had fallen behind on home maintenance tasks to the point that her home had fallen into disrepair and large parts of it had become largely inaccessible to her. As a result, Mrs. B. was barely able to move around her home, spent most of her day in bed watching television, and ate poorly, all of which exacerbated her health conditions. Szanton said that those who have low incomes tend to have fewer resources to identify trustworthy people to help them fix things. She also said that she hears regularly from CAPABLE participants that in life, people receive training on how to be an adolescent and a young adult, but there is no training for aging. “You do not learn that you could have a three-dollar pull string on your ceiling fan and be able to turn the light on more easily,” Szanton said. She also noted that people are more likely to be high spenders or high users of health care if they have a functional difficulty (see Figure 5-1). The health care system may focus on the chronic conditions that can cause functional difficulties, such as diabetes and congestive heart failure, Szanton said, but then it ignores the disability once the person is assessed as being “disabled.” “The medical system does not assess for disability,” she noted. “It does not assess whether you can take care of yourself, if you can stand long enough to cook or get your foot into the bathtub, but those are the things that will cause you to go into a nursing home.”
9 For more information, see http://nursing.jhu.edu/faculty_research/research/projects/capable (accessed March 8, 2017).
Szanton and her colleagues developed CAPABLE based on the success of the Advancing Better Living for Elders (ABLE) study conducted in Philadelphia (Gitlin et al., 2006; Jutkowitz et al., 2012). The ABLE study employed a combination of occupational and physical therapy sessions and home modifications to improve the ability of older adults to engage in instrumental activities of daily living (IADLs). Szanton said that, based on her experience as a home visit nurse practitioner, she and her team added nursing and home repair to the program. Each person’s care program, which the individual directs, focuses on that individual’s strengths, deficits, and goals with regard to IADLs and activities of daily living (ADLs).
The program is 4 months long and costs approximately $3,000—paid for with money from grants—which covers six visits from an occupational therapist, four visits from a nurse, and up to $1,300 in repairs and modifications by a licensed repair person.
During the first CAPABLE visit, the occupational therapist assesses the ADLs that the client prioritizes, such as bathing or dressing. In the second visit, the therapist watches how the client engages in those activities in his or her home in order to identify the modifications needed to enable the client to engage in those activities in a safe manner. Together, the occupational therapist and client create a work order. In Baltimore, the work order goes to Civic Works,10 a nonprofit, job-training program that pairs an experienced contractor with an apprentice. The Civic Works team completes the repairs and modifications in the order in which the client listed them. Szanton said that all of the repair tasks must be strictly functional, not cosmetic. With the repairs and modifications underway, the nurse begins visiting the client at the beginning of the second month. Those visits focus on pain, depression, strength and balance, communication with the client’s primary care provider, and medication. Over the remaining months of the program, the nurse makes three more visits and the occupational therapist works with the client four more times on the goals they identified.
Data from studies funded by AARP Foundation, the Centers for Medicare & Medicaid Innovation Center, The John A. Hartford Foundation, the National Institute on Aging, and the Robert Wood Johnson Foundation (Szanton et al., 2011, 2014a, b, 2015, 2016) showed that CAPABLE cut in half the number of ADL difficulties that participants experienced. Almost 75 percent of the participants, all of whom received Medicaid support, improved on measures of ADL limitations, and 65 percent improved on IADL limitations, such as managing medications, getting groceries into their home, and doing laundry (see Figure 5-2). Measures of depression also improved in more than half of the participants, with many individuals experiencing improvements in depression that were equivalent to taking an anti-depressant medication. “We are not giving them a pill,” said Szanton. “We are giving them the ability to get out and get to church or to prepare a meal for a grandchild who comes over.” The number of home hazards also fell in nearly 78 percent of the homes. Compared with a matched comparison group, individuals who participated in the CAPABLE studies required fewer stays in nursing homes and fewer hospitalizations. Szanton and her colleagues estimated that CAPABLE saves Medicaid an average of $10,000 per individual in medical costs. “That will be even more for Medicare because Medicare pays for hospitalization,”
she said.11 Because CAPABLE costs approximately $3,000 per person, Szanton said, the cost savings is enough to pay for the program not only for the individual’s participation but also for the participation of two additional people.
Szanton concluded her presentation by describing the experience of the first CAPABLE client, Mrs. D. When Mrs. D. joined the program she was so disoriented that she sat on a commode chair all day, and the occupational therapist and nurse both thought she might be beyond the capacity of the CAPABLE program to help. On the first day with the occupational therapist, it took Mrs. D. 30 minutes to walk the 30 feet to her bathroom, which was why she sat on a commode chair all day. Mrs. D.’s husband, Szanton said, was so frail himself that all he could manage was to pull her out of bed in the morning, get her to the commode chair, and help her back to bed in the evening.
A review of Mrs. D.’s 26 different current prescriptions found that many of them were for pain and likely contributed to her disorientation. The nurse created a medication calendar and explained which medications were to be taken in the morning, afternoon, and evening. Soon after, Mrs. D. became more alert and able to talk with her care team about her goals, one of which was to be able to go downstairs in her home and wash her hair in her kitchen sink. She came up with the idea of placing plastic deck chairs along the way, about a foot apart, so that she could get up, walk to the next chair, and then sit for a while. After 1 month, she was able to travel the 30 feet to the bathroom, and by the end of the study she was able to walk the 30 feet in 7 minutes. Meanwhile, the repair crew installed a second railing on the staircase and added a light to illuminate the stairs, and once Mrs. D. was able to get down the stairs and wash her hair in the kitchen sink, she started going downstairs every day. “This was a woman who went from ‘I do not know if we can do anything for her’ to someone who could use her whole house,” Szanton said, ending the story by reporting that a few months after Mrs. D. finished CAPABLE, her granddaughter called to say that the entire family was going to Atlantic City.
In summary, Szanton said, loss of function is costly. “It is what older adults care about, yet it is almost ignored in the medical system.” Making simple changes to a home and providing short-term services can have a life-altering effect on the ability of older adults to retain function, remain independent, and live healthier lives, all at a relatively low cost.
Statewide Director, Support And Services at Home
SASH uses affordable housing as a platform for realizing population health, said Molly Dugan of Cathedral Square. She commented that while the program’s partners—home health agencies, mental health agencies,
Area Agencies on Aging, hospitals, and medical homes—had been working in the community for years to keep people healthy and at home, their efforts did not include participants from the nonprofit housing world. Noting that there are many symmetries between CAPABLE and SASH, she said that her organization would be implementing CAPABLE on the SASH platform beginning in January 2017.
Dugan and her collaborators started developing the SASH model in 2009 with the help of 54 residents in a senior housing site in Burlington, Vermont. Today, SASH serves 5,000 individuals with health care needs of every sort. Some participants are healthy and working full time, while others are extremely frail or have Alzheimer’s disease. Once someone enrolls in SASH, he or she can remain in the program forever if desired. Some 80 percent of the participants receive Medicare benefits, 25 percent live in the community, 57 percent have a disability, and 27 percent are under age 65. Most of the participants live in traditional congregant affordable housing sites, though SASH does serve Medicare-eligible individuals in single-family homes, mobile homes, and private apartments. A Medicare demonstration grant funded the program through the end of 2016, and SASH will continue to receive funding through an all-payer waiver agreement between Vermont and the Centers for Medicare & Medicaid Services.
SASH is person-centered, Dugan said, and SASH staff members are embedded in the communities they serve. For example, the SASH care coordinator and the SASH wellness nurse have their offices in the affordable housing communities, enabling them to see participants regularly. The program is also oriented toward prevention and wellness, as opposed to crisis intervention, and relies on data-driven healthy living plans. Written memorandums of understanding formalize all partnerships with SASH. “Everybody knows what their roles and responsibilities are,” Dugan said. “This is not lip service about partnership. It is real partnership. It is doing the hard work of explaining what we are all trying to do together and all agreeing to a certain set of rules.” Partnership requires information sharing, and all SASH participants sign consent forms to allow for readily sharing information among the program partners.
Participants in SASH are assigned to a “panel” of clients served by one care coordinator, one wellness nurse, and a team of community providers that together build relationships that support being healthy at home, Dugan explained. Each month, staff members from the community providers meet with the housing-based staff, and SASH participants are always welcome to attend these meetings. “Basically, we are building this platform to provide population health with the housing organization as the host,” Dugan said.
Cathedral Square, the nonprofit housing organization Dugan works
for is 1 of 22 affordable housing organizations in Vermont that operate SASH out of 140 housing sites around the state. Some are in the most rural parts of the state, while others are in the most urban areas. Typically, panels have 70 to 100 participants, and panels in the rural parts of the state include individuals from multiple small housing properties. For example, SASH in Vergennes—which is in rural western Vermont—is based in the Armor Lane Senior Housing site, and 40 of the participants live there. The other 50 members of the panel live in the community, in either mobile homes or single-family homes near Armor Lane. The members in this panel average 76 years of age.
The SASH coordinator in Vergennes is Diana, who grew up in the town. When Diana enrolls someone in SASH, she conducts what Dugan called a person-centered interview in the person’s home. This interview aims to learn about the individual, not just the individual’s health needs. Dugan explained that staff members receive training in person-centered interview techniques. For example, during Diana’s first interview with a new client, Larry, she learned that the 75-year-old was a sports fan, particularly of the Boston Red Sox, and that he liked to attend football games and other sporting events at the local high school. Larry also loved to cook and socialize. In a subsequent interview, Diana asked Larry about his goals, which were to be able to attend local sporting events again and to be able to cook his own meals again. Controlling his diabetes was not on his list of goals.
Next, the SASH wellness nurse conducted a uniform assessment with Larry during which she learned that he had diabetes with some associated nerve damage and that he had bacterial infections and generalized anxiety disorder. Larry also experienced frequent falls. With the information the nurse and Diana gathered, the SASH team created a healthy living plan for Larry, which included health coaching, regular check-ins with Diana to help with his generalized anxiety disorder, and attendance at a local diabetes class. The Area Agency on Aging designated a staff person to accompany him to sporting events and help him cook meals, and the home health agency made sure Larry was eligible to receive some personal care and housekeeping services. “It is truly a team effort,” Dugan said.
The process Diana followed with Larry is the same process she uses for all 90 members of her panel. From the initial survey data, she learned that 54 percent of her panel had arthritis and 53 percent had hypertension. Dugan explained that Diana was charged with bringing in the appropriate partners and programming to meet those needs. She also operated from a community healthy living plan that focuses on exercise, walking groups, nutritious meals, mental health and social engagement, and other activi-
ties, such as offering a weekly blood pressure clinic, a foot care clinic, and a falls prevention class.
Dugan said that some 59 percent of SASH participants have documented advanced directives, compared to the national average of 26 percent, and the percentage of those who received vaccinations for shingles, pneumococcus, and seasonal influenza rose steadily over 18 months. The percentage of SASH participants who fell over the course of 12 months remained below 30 percent, which is lower than the World Health Organization’s fall rate in the elderly. In addition, 77 percent of SASH participants had their hypertension under control, compared with the U.S. average among older adults of 30 percent. Finally, in 3 years of implementation, the growth in annual Medicare expenditures for SASH participants was lower by an estimated $1,536 per beneficiary.
Senior Business Leader, Community Health Innovation Program
CareOregon is a nonprofit health plan and health services organization, Rose Englert said, and the Community Health Innovation Program is what she called CareOregon’s social determinants team. CareOregon has some 230,000 low-income members, which is large by Oregon standards. It is a Medicaid plan and a dual special needs plan for Medicare. She said that the reason that CareOregon as a payer took an interest in housing was not because it has a dedicated community benefit fund—it does not—nor because it was required by law to do this work—it is not—but rather because CareOregon’s leaders felt it was the right thing to do for their clients.
CareOregon has personnel specifically dedicated to housing, and the organization works with the Housing with Services consortium to provide onsite services. Staff members go into 11 low-income housing sites, and the program provides what Englert called light-touch health care and behavioral health care. When these care teams visit building sites, they assist residents in navigating health care services, regardless of insurance provider—or lack thereof—including helping veterans get care from the local Veterans Health Administration health care facilities. CareOregon staff conducts one-on-one follow-ups with its clients who received treatment either in the emergency department or as inpatients. These visits take place within 1 week and serve as a wellness check. They also help create and strengthen relationships with these individuals and get them
more involved in their own health. “That is a huge part of the model,” Englert said. “We cannot stress that enough.”
CareOregon provides a range of services to its clients, Englert said. CareOregon has a transitions-of-care staff team that conducts a home visit after someone leaves the hospital rather than simply making contact via the phone call that Medicare requires. “It is amazing what you can learn with a home visit,” Englert said. The organization also has a Go Mobile team that provides enrollment assistance for individuals in the community who need help finding care, figuring out whether they have insurance, or whether they are eligible for care as a veteran. The organization also has two housing case managers who work on internal and clinical referrals. Englert said that many of the people who receive the housing case management services have “burned out of the more traditional housing case management or even more intense community-based housing case management because of health issues.” The housing case managers on her team have received training so they know how to work with the health care system to get the services these individuals require.
Englert said that her program has staff who are members of the Joint Office on Homelessness in Multnomah County and that her program is also working with the HUD Continuum of Care Program.12 Together, they are trying to gain access to the region’s Homeless Management Information System13 to enable CareOregon members to get on the waiting list for HUD housing assistance. Englert said that CareOregon has made a capital investment in housing, working with five health systems to raise $21.5 million to address the shortage of affordable housing in Oregon. A large percentage of the $21.5 million fund is for construction of 3 buildings with 358 new units, including an onsite clinic with respite care beds for individuals who are homeless and trying to avoid hospitalization and recuperative care beds for individuals who have been hospitalized but do not have adequate housing to which they can return. Palliative care and hospice care will also be included. Englert said that the housing community should start thinking about palliative and hospice care when addressing the needs of aging adults. “We have to start thinking about hospice,” she said, “because it is not just aging at home and staying at home—it is dying at home that is also really important.” In fact, CareOregon is considering purchasing a hotel or an apartment space in southern Oregon, where there are no facilities that provide recuperative or respite care or
13 The Homeless Management Information System is required by HUD and is used to collect client data on people experiencing homelessness or individuals who are at risk of homelessness.
that provide advanced illness care for older, low-income individuals. Her program is also working with care providers who make house calls as part of its palliative and hospice care initiative.
Overcoming Program Barriers
Craig Ravesloot first asked the panelists to talk about some of the barriers their programs encountered while building their program or that have arisen now that their programs are operating. Dugan replied that with housing being the “new kid on the block,” it became an early barrier for SASH. “We had to take a lot of time in meeting with [existing community] providers ahead of time and trying to get on the same page about what were the gaps that remained even though some of these organizations had been at this difficult work for 30 to 40 years.” Through a series of “delicate conversations,” she said she was able to convince the existing community-based providers that SASH could add value, such as with the trusting relationship that the SASH staff build with SASH participants. “We work where they live so they see us day in and day out,” said Dugan. Even the home health care nurses who are in these buildings, she added, only see their clients after an acute episode or at most once or twice per week. “We were making the case that as housing staff on the ground, we would be able to fill in missing information, and that is how it has played out,” she said.
Dugan noted that turnover in the leadership staffing of SASH’s provider partners can be challenging because the new staff do not always appreciate the value of the housing-based staff. To address the turnover challenges, she invites executive leadership from all of the partner organizations to attend SASH team meetings. “They get to see how when you walk into these SASH team meetings it feels like you are walking into a meeting with people that work for the same organization. It is truly an integrated team,” said Dugan. “I cannot say that we have completely overcome that challenge, but we know what we need to do to keep confronting it,” said Dugan. In the same vein, Szanton said that she is frequently told, “We already do that,” when talking about the services CAPABLE provides. In fact, Szanton said, such programs rarely take their lead from what their clients desire, nor do they supply their clients with the skilled labor to help them make changes.
Englert said a big challenge for her program has been addressing privacy barriers arising from the Fair Housing Act, the Health Insurance Portability and Accountability Act (HIPAA), and other policies. CareOregon will not partner with housing organizations unless they agree to put a
release of information related to HIPAA and the Fair Housing Act in the tenancy packets, she said. She said that in her opinion, advocates should have a conversation with regulators about creating waivers for specific projects or rethinking how privacy laws interact with one another so that they do not create silos that prevent the kind of integration needed to address housing- and health-related problems. Szanton added that when her program thought about writing letters to their clients’ primary care providers informing them about their patients’ goals and what they have achieved, she quickly realized that they had to get people to first sign privacy waivers.
Bailey noted that while there are ways to overcome the privacy barrier, this work would be easier if policies related to information exchange were harmonized and widely disseminated. At the same time, she said that some of the larger payers have lengthy contracts they expect their housing partners to sign, assuming that they have lawyers on hand to help them navigate the legalese. Perhaps, she said, payers could be more flexible in thinking about what these contracts really need to include.
In terms of payment Englert said a barrier arises when programs restrict how funds can be spent. Oregon is fortunate, she said, because its Medicaid waiver enables organizations like CareOregon to spend money on what it calls flex or health-related services, although some policy changes would make it easier to get more payment models involved.
Sloane said she and her colleagues in Louisiana have found that staff retention makes a big difference in the long-term success of their programs, in large part because the programs are very complicated and have many moving parts. In time, she said, the infrastructure can become strong enough to continue on when key personnel turn over, but staff stability at the beginning of a program is important. Englert noted that strong workflows contribute to staff retention and continuity. “If you are basing your program on an individual, it is not a replicable model,” she said.
Szanton referred back to a comment Erika Poethig made in her keynote presentation about the “wrong pocket problem,” referring to the inability to capture the savings in health care expenditures that result from an expenditure on housing. “What we have tried to do is measure the outcome of all of the pockets,” she said. Her program, for example, calculated what CAPABLE saves in terms of Medicaid spending. She then approached Medicaid and asked what portion of the savings it could spend on services that would add value to the system. She noted that the often-used approach of calculating quality-adjusted life years14 is not
14 Quality-adjusted life years (QALYs) is a measure often used to show potential savings from a social program or a health improvement intervention. A QALY value of 0 is equivalent to being dead, while a QALY value of 1 is equivalent to being in perfect health.
concrete enough for Congress. “If we can say we are saving you dollars or saving nursing turnover . . . I think that is where we can make a difference,” said Szanton.
Factors Contributing to Housing Program Success
Ravesloot then asked the panelists to comment on the factors that contributed to the success of their programs. Englert said her program was lucky to have strong executive leadership that believed in and funded the program. “You have to have those organizations that have the guts to go out there and do this and try new things and evaluate,” she said. Similarly, Dugan said that she made a point of identifying the executive directors in Vermont’s affordable housing network who were willing to take a risk and go into health care, which was new for many of them. Vermont has six designated regional housing organizations that have the leadership to disseminate the SASH model statewide, and this core group has been implementing it since 2011. “If you have champions, you are better off because then you have that sustainability,” said Dugan. She added that what brought this core group together was identifying the common challenge of housing an aging population and the common goal of not merely putting a roof over someone’s head but also providing them with services to enable them to stay in their homes.
CAPABLE’s success, said Szanton, comes from focusing on housing and the individual, and homing in on each individual’s goals. In terms of demonstrating impact, the key has been to measure a wide range of outcomes, including stories and quotes from those benefiting from the program. For the Section 811 PRA program, Washington said it was important to have external technical assistance on a one-on-one basis, which HUD itself cannot provide. “In HUD, we do not have the knowledge or experience to give grantees personal attention, but with the technical assistance [providers] we have been able to do monthly peer-to-peer calls with grantees to talk about policy updates and give them the opportunity to discuss their issues and their successes,” said Washington. The technical assistance mechanism, she added, enables the grantees to create working groups and focus groups without having to involve HUD.
The Section 811 PRA program has also benefited from looking at a broader range of outcomes using reporting that goes much deeper than it used to. Instead of just counting the numbers of people living in subsidized units, HUD is looking at where the residents are coming from and how they got into these units, for example. Washington noted that the program is now being evaluated and she said her hope is that this evaluation will highlight more successes and identify cost savings that come with moving from a brick-and-mortar approach to a more holistic approach.
Making a Business Case for Housing Programs
Ravesloot next asked the panelists how they make a business case for their programs. Englert replied that it is necessary to first articulate goals clearly at the very beginning of the program and that such goals need to go beyond saving dollars or reducing hospitalizations. She said she works in the context of goals that are SMART: specific, measurable, actionable, replicable, and time-bound (Doran, 1981). She also said when she tries making a business case based solely on overall cost savings, that is when she sees the different organizations bumping heads.
Bailey said the business case will differ depending on who one is trying to engage in a hospital system. “Telling them you are going to save money is not going to work because they are not in the business of saving money. They are in the business of making money,” she said. Instead, a hospital administrator will be interested if the business case involves reducing the number of people who use the emergency department for routine medical care and who take time away from those who truly need emergency services and whose insurance will pay for those services. She suggested that when engaging a managed care organization, first tell the organization what a program does and ask them what parts of that program interest them and would help them meet their goals. When speaking to the government, a straight dollars and cents argument is appropriate because government policymakers want to know how much money an investment will save or how it will enable funds to be used more efficiently. Bailey recommended talking to peers in other states to find out what measures they are using and to ask them to share their outcomes data.
Teresa Lee asked if the cost-effectiveness of these programs changes when funding from foundations is added to funding from the federal government. Englert replied that CareOregon used federal government funds to prove the care model and now foundations are stepping in to fund dissemination in other places. For example, the Visiting Nurse Association of Colorado has received a grant to deploy CAPABLE as a means of reducing hospitalization rates for Kaiser Permanente clients in Colorado. Four cities in Michigan have received funds from the Hillman Foundation and Michigan Medicaid to deploy CAPABLE in those cities. Michigan Medicaid has pledged to make CAPABLE available to all 15,000 Medicaid beneficiaries in the state if the 4 cities can show that the program delays nursing home admissions by an average of 1 day. A workshop participant commented that tracking dollars is important but expressed fears
that the Triple Aim combined with elements of the Patient Protection and Affordable Care Act have led everyone to believe that it is possible to deliver better quality care for less money and give money back to the system. This participant said that living in a community is a civil rights issue and an important thing to do regardless of whether it saves money or generates money.
Winston Wong of Kaiser Permanente asked the panelists if there is a way to empower the people whom these programs affect so that they can advocate for themselves, rather than only having service providers tout the benefits of these programs. “I think this is an equity question with regard to empowering the individuals in communities to say this is not a question of trying to convince someone but about seizing their right for integration into society,” Wong said. Bailey said that there are examples of this and that it is an idea that she supports. “This is exactly what we want to do—to explain what happens to care for low- and moderate-income people if we are not thinking about this holistically,” Bailey said. However, she added, her worry is that populations will be pitted against each other, given the limited funds that are available and the fact that states will have to make choices about who will and who will not receive coverage. She said that organizations such as Families USA15 have been successful in helping organizations tell the stories of the people they serve. She also said that her organization has just announced it was a founding member of the Protect Our Care Coalition to protect Medicare and Medicaid and that part of that effort will involve telling stories of what providers are doing.
In the future, Bailey said, it will be important to hold officials accountable for the effects that their policy decisions have on social justice and social equity and to not be shy about doing so. “We have to call attention to that and explain why it is not acceptable,” Bailey said. Dugan noted that the 5,000 Vermont residents who are enrolled in SASH have been very vocal about how the program has changed their lives and have made a difference in ensuring that the program has continued to receive funding. She added that it is important for those who benefit from these programs to feel invested in them. “I think that is where your compelling story for continuation is going to come from,” Dugan said. Ravesloot said that the disability community has been a leader in this approach for 30 to 40 years. “I think that joining forces and breaking down silos creates a larger voice,” he said. Englert suggested everyone read an article in The New Yorker by Atul Gawande that makes the case that the community needs to refocus its attention to make sure that the general population, and not just the people who attend workshops such as this one, understand why social
services are important, why health care is important, and why access to care is a basic human right (Gawande, 2016).
Dara Baldwin said her organization is always working to ensure that the different beneficiaries of non-defense discretionary funding are not making deals to cannibalize each other’s programs. “I have to say that not all social justice groups are following this, and it is a shame,” Baldwin said.
Bailey remarked that the Center on Budget and Policy Priorities has been known for its long papers filled with charts and graphs. Now, however, the center is turning its focus to conveying its message to the public and using its technical expertise to translate its message so that it speaks to everyone with regard to various races, geographic diversity, and religious diversity. Her concern is that every time she talks about the working class, people now assume she is talking about only white Caucasians, Christians, or heterosexual individuals. “How do we have a more holistic conversation without putting everyone into groups that are now targeted against each other?” she asked. “It is not easy, but it is something I can honestly say we are committed to. It may be bumpy at first, but it is something that has to happen in order . . . [to explain] what social programs do across the country.”