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Bending the Healthcare Cost Curve: Four Policy Recommendations for Healthy Housing

Written by Megan T. Sandel, MD, MPH and Laurel Blatchford on June 27, 2016

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Dr. Megan T. Sandel and Laurel Blatchford of Enterprise Community Partners, Inc. give us the key to better health and well-being for affordable housing residents: integration of health care and services

Sometimes solving persistent problems requires a strange set of bedfellows. A collaborative of nine affordable housing organizations in Portland, Oregon has been proving that introducing health care and services into affordable housing is the key to improving the health and well-being of affordable housing residents nationwide. In fact, health integration seems to be the next piece of the puzzle toward achieving the health care sector’s highly valued “Triple Aim”: lower health care costs, better care, and better access to that care.

Enterprise Community Partners, Inc., a national organization that brings together the financing, policy and program solutions needed to create affordable housing for low-income people, recognized a unique opportunity in 2014 to build the capacity of community-based organizations that own and develop affordable housing in Portland. Up until that point, a growing number of Oregonians had been struggling with housing and health issues. The state was facing a $3.5 billion budget crisis, and there was concern that community-based organizations could be facing a shift in housing funding. These factors, paired with the fact that a new coordinated care model was introduced to the region in 2012 thanks to federal changes to Medicaid and state-driven health care reform, created an opportunity to rethink how residents access health care and the quality of their care. We at Enterprise began to consider solutions outside of the traditional boundaries of health care services.

The Oregon Health and Housing Learning Collaborative

Enterprise invited local affordable housing organizations that were piloting health and housing integration programs to apply for capacity building grants. Many applied, some were funded, and, in the end, nine organizations formed the Oregon Health and Housing Learning Collaborative (OHHLC), generously funded by the Meyer Memorial Trust. The nine organizations are: Cascadia Behavioral Health, Catholic Charities, Cedar Sinai Park, Central City Concern, Home Forward, Human Solutions, Innovative Housing, Inc., Northwest Housing Alternatives and REACH Community Development.

Beginning with the understanding that an affordable home connected to health care, along with good schools, jobs, and transit, is the foundation for a healthy, productive life, the OHHLC sought to demonstrate that investing in affordable housing can play a vital role in improving health outcomes, reducing health care costs, and helping low-income people achieve housing stability.

Over the course of two years, the OHHLC improved the link between housing and health care entities – by integrating health services in affordable housing, incorporating health stakeholders into the collaborative, and monitoring ongoing changes in health care. They developed tools and recommendations to help housing and health providers share information and work collaboratively. They also advocated for increased public funding for affordable housing at the state and local levels. In addition, the collaborative collected and used data to promote the integration of health and housing.

The members of the OHHLC developed and implemented health and housing integration strategies that improved the health and well-being of vulnerable residents living at their affordable housing properties. Such strategies included:

  • Targeting efforts to enroll residents from scattered housing sites into primary care as well as health and wellness services via Peer Wellness Specialists
  • Adding a dedicated health navigation component to resident services programs, providing assistance to residents to enroll in health care coverage and connect residents with community health agencies
  • Developing integrated partnerships with housing and health care providers to provide on-site health and social services (in-home follow-up after hospital discharge, on-site mental health staff and culturally specific health programming, etc.) to residents at affordable housing sites
  • Creating an inter-organizational project that coordinates delivery and payment for health services via a targeted needs assessment, streamlined referral processes, increased coordination between service providers, and in-housing programming
  • Training existing Resident Services staff and community leaders living in the affordable housing as volunteer community health coordinators
  • Partnering with local university nursing programs to bring on-site nursing services to affordable housing properties

The Link Between Affordable Housing and Healthcare Costs

To build on the OHHLC’s work, Enterprise commissioned Providence’s Center for Outcomes Research & Education (CORE) to conduct a study directly exploring the link between affordable housing and health care through the lens of national health reform metrics:

  • Better connection to primary care
  • Fewer emergency department visits
  • Improved access and quality of care
  • Lower costs

The study’s population included residents of affordable housing living in one of three common types of affordable housing – family housing, permanent supportive housing, and housing for seniors and people with disabilities – in the Portland metro area who were also enrolled in Medicaid health care coverage via Health Share, one of Portland’s two Coordinated Care Organizations. In all, 513 residents across 145 affordable housing properties were surveyed about health care status, access and quality. The study also analyzed the Medicaid claims data of 1,625 residents living across 145 properties to measure changes in health care cost and utilization after moving into affordable housing.

The study showed that costs to the health care systems were lower after people moved into stable, high-quality affordable housing.

The study, Health in Housing: Exploring the Intersection Between Housing and Health Care, revealed that residents of affordable housing are often sicker than the general population, experiencing much higher rates of health issues including affective disorder and depression. However, stable housing plus health-related services can yield significant cost savings and improve resident health outcomes. The study showed that costs to the health care systems were lower after people moved into stable, high-quality affordable housing – in fact, simply providing housing correlated to a marked decrease in total Medicaid expenditures; cost savings were even greater with the integration of services. Primary care visits went up more than 20 percent, emergency department visits went down 18 percent, and residents self-reported that access to care and quality of care improved 40 percent after moving into affordable housing.

Four Policy Recommendations for Bending the Healthcare Cost Curve Through Housing

The findings of the Health in Housing study undeniably inform and necessitate policy, program development, and funding changes that should be implemented in the early stages of health care reform at the national and state levels. We recommend the following:

1) States, localities and managed-care organizations should invest Medicaid dollars and other resources in housing solutions such as capital and rental assistance that research shows can improve health outcomes and reduce health expenditures for vulnerable populations.

2) Health services must be integral to affordable housing developments: States, policymakers and payers should explore devoting Medicaid resources to health-related services and resources such as resident services coordinators.

3) The Internal Revenue Service should require that nonprofit health organizations regularly include affordable housing in their community health-needs assessments and community improvement plans.

4) The Department of Housing and Urban Development should invest more in Section 4 grant dollars to build the capacity of community development organizations, and the Department of Health and Human Services should invest through the Health Resources and Services Administration to provide more technical assistance and support for housing organizations to collaborate on housing and health.

The work of the Oregon Health and Housing Learning Collaborative, including its important Health in Housing study, is focused on residents and health care services based in Portland. Nevertheless, it holds national implications for health care systems, payers and policymakers looking for upstream solutions to address major health care needs and fulfill health care reform goals. Housing with integrated health services is an important solution toward bending the health care cost curve.

Megan T. Sandel, MD, MPH Associate Professor of Pediatrics, Boston University School of Medicine | Board of Trustees, Enterprise Community Partners, Inc. Megan Sandel, MD, MPH, is an Associate Professor of Pediatrics at the Boston University School of Medicine, the former Director of Pediatric Healthcare for the Homeless at Boston Medical Center, a Co-Principal Investigator with Children’s HealthWatch and a nationally recognized expert on housing and child health. Dr. Sandel is the medical director of the National Center for Medical-Legal Partnership. She was the first Medical Director of the Family Advocacy Program in 1998, and was appointed Medical Director of the National Center in 2007. She served as a general academic fellow at Boston Medical Center with a concentration in environmental health in children, earning a Masters of Public Health with a dual concentration in environmental health and epidemiology and biostatistics in 2002. In 1998, she published, with other doctors at Boston Medical Center, a national report on how housing affected child health based on the DOC4Kids project. In 1999, she was an author of “There’s No Place Like Home,” a report documenting how asthma, lead, injuries, homelessness, food insecurity, chronic disease and educational attainment were all affected by housing. In 2000, she was a Co-Principal Investigator of the Boston Healthy Homes Partnership, made possible by a grant from the U.S. Department of Housing and Urban Development to the Boston Public Health Commission to study if housing changes improved the health of children with asthma. She is a founding member of the Asthma Regional Council of New England. Over the course of her career, Dr. Sandel has written numerous scientific articles and papers. She has served on numerous committees and advisory boards, such as the National Center for Healthy Housing, a national advocacy group, and the Massachusetts Chapter of the American Academy of Pediatrics.   Laurel Blatchford Senior Vice President of Solutions, Enterprise Community Partners, Inc. Laurel is Senior Vice President, Solutions at Enterprise Community Partners, Inc., one of the nation’s foremost social enterprises. Laurel leads the organization’s national programmatic and policy platforms, including the teams working in ten local markets across the United States, Enterprise’s groundbreaking initiatives focused on connecting people and communities to opportunity and the policy team, which focuses on policy change at the national, state and local levels. She is also responsible for Enterprise Advisors, the organization’s consulting and technical assistance platform; and the organization’s knowledge, impact and strategy functions. Laurel brings a wealth of experience toward helping Enterprise meets its ambitious goals. Prior to joining Enterprise, she held a number of senior positions in government and the private sector, including leadership roles at the U.S. Department of Housing and Urban Development (HUD) and in the administration of New York City Mayor Michael Bloomberg. Laurel graduated cum laude from Williams College and received a master’s degree in public policy from the Harvard Kennedy School. She currently serves on the board of the National Housing Trust, the Hopkins School Head’s Advisory Council, the Advisory Council of the International WELL Building Institute, and the National Resource Network governing board.