1. Health in Housing The intersection between housing and health care Lane County Equity Coalition Amanda Saul, Enterprise Community Partners June 22, 2017
Center for Outcomes Research and Education

2. ENTERPRISE’S MISSION
To create opportunity for low- and moderate- income people through affordable housing in diverse, thriving communities.
Hi, I’m Amanda Saul. I work for Enterprise Community Partners, a national non-profit that is over 30 years old. We are a family of organizations that provides capital and expertise for affordable housing in diverse, thriving communities.
We do this by creating opportunity for low- and moderate-income people through affordable housing by providing equity, loans, grants to build the capacity of our NP partners, policy advocacy and affordable housing expertise.
Since 1983 in Oregon we’ve invested:
Over $600 Million in equity and loans and $12 Million in Grants
Nationally we’ve helped to create or preserve over 380,000 homes.

3. Why are we focusing on health?
Housing is a foundation for good health, jobs, educational attainment, asset building, access to health foods and transportation and connection to community.
We know that your zip code, more than anything else, determines your health outcomes and your life expectancy.
We know that 70% of ou4 health status is associated with people’s social and physical environment including the quality, affordability, stability and location of a person’s home.
Medicaid provides health coverage to 69 million Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. In the 32 states that expanded Medicaid, it provides coverage to all adults with incomes below 138% of the federal poverty level.
The low-income population served by Medicaid is, in most cases, the same population that is unable to afford a quality, stable home connected to resources and opportunity in US.

4. HEALTH & HOUSING INITIATIVE
Enterprise’s Health and Housing Initiative Goals
Improve health outcomes and reduce health inequities among residents living in affordable housing.
Establish health as an essential factor in community development and quality affordable housing development.
Lower health care costs to individuals, government, insurers, and hospitals.

5. KEY AREAS OF FOCUS Validate Demonstrate Innovate
Develop health planning tools and define outcomes data to strengthen the evidence base for housing as a means to improve resident and community health.
Demonstrate
Support housing as a platform for wellness through innovative approaches to housing-based health services, and evaluate health care savings and improved resident health.
Innovate
Collaborate with anchor health care institutions to co-invest in communities, creating scalable models and technical tools with our partners.
Today we are going to talk about validating with the CORE study and demonstrating with best practices and pilots.

6. CORE Study Asks… ?
What is the effect of stable, affordable housing on health care outcomes in a low-income population who has experienced housing instability?
What role do integrated health services play in health care expenditures and quality?

7. What’s different about this study
Uses claims data to assess health care costs and utilization
Looks across several different affordable housing types
Looks at the effect of integrated health services
An analysis of impact on Medicaid cost and utilization across 145 affordable housing projects that serve more than 10,000 residents in major metropolitan area

8. 145 properties: Health staff Resident Services Coordinator 88%
Community Health Worker or Health %
Navigator
Social Worker %
Doctor, Nurse, or Nurse Practitioner 6%
Activities Coordinator 6%
Other Health Professional 11%
145 properties:

9. 145 properties: Health services Food Resources 68%
Medical Resources %
Insurance Assistance %
Mental/Behavioral Health Resources 35%
Fitness Resources %
Nutrition/cooking Resources 23%
Transportation Resources 19%
Dental Resources %
145 properties:

10. Prevalence of physical health diagnoses (claims data)
Hypertension
Asthma
Diabetes
Obesity
COPD

11. Prevalence of behavioral health diagnoses (claims data)
Affective Disorder
Depression
Chemical Dependency
Non-Organic Psychosis

12. Analyzing changes in health care cost & utilization
Medicaid claims of 1,625 residents
Includes all physical, behavioral, mental, and dental claims

13. KEY FINDING Health care costs went down significantly
Per member, per month costs
Before move-in:
$ 386
After move-in:
$ 338
$ 48
Overall Cost Reduction:
12%
KEY FINDING Health care costs went down significantly
Extrapolated annual cost reduction:
$936,000 a year across 1,625 residents

14. Costs down across all housing types
* Statistically significant change, paired t-test, p<.05
-14% *
Pre
Post
-16% *
-12% *
Avg. pre/post cost (PMPM)
-8%

15. KEY FINDING Residents used health services differently when they had housing
Emergency Department
-20%
Primary Care
+18%

16. Emergency Department use down across all housing types
* Statistically significant change, paired t-test, p<.05
-37% *
Pre
Post
-18% *
-18% *
-10% *

17. Primary care visits up across all housing types
* Statistically significant change, paired t-test, p<.05
Pre
+23% *
Post
+19% *
+20% *
+17% *

18. Ability to get care same or better across all housing types
64%
59%
54%
50%
40%
35%
% of Survey Responses
32%
Same
27%
Better
Same
Same
Triple aim – lower costs, better experiences, better health outcomes.
We wanted to make sure that just because costs were going down that people were still getting the care they needed.
Better
Worse
Worse
Worse
Better
Same
Worse
Better 6% 4% 4% 3%

19. Quality of care same or better across all housing types
62%
48%
46%
43%
42%
40%
38%
% of Survey Responses
Same
23%
Same
Better
Worse
Same
Worse
Better
Same
Worse
Better
Worse
Better 8% 7% 6% 7%

20. Analyzing impact of integrated services
Bucketed staff and services into three categories to assess impact
Health Staff & Services – Includes medical, mental health, and dental staff and services
Social Staff & Services – Includes Social Workers, Community Health Workers, Health Navigators
Wellness Staff & Services – Includes food/cooking services, fitness services and other residential activities
Utilized multivariate regression models to measure impact of each service category

21. Adjusted impact of health services Awareness of select services
Expenditures
$ 115 per member per month
ED Visits
0.43 visits per year
Awareness of select services
Medical
33%
Mental Health
26%
KEY FINDING Integrated health services drove outcomes …even though awareness was low
When we controlled for other factors, the presence of health services including:
integrated medical and dental
mental health
substance use
Nurses and doctors
and coordinated transportation to off-site services

22. Emerging Best Practices
Cornerstone Community Housing provides on-site health care navigators that provide:
Immediate on-site resources, referrals, and temporary crisis/health coaching
Connections between vulnerable populations and healthcare systems
Informal counseling and education on chronic disease prevention
Patient activation and participation in their personal and family’s health
Project goals include:
Increased access to health and wellness services
Improved patient outcomes
Reduced costs for residents and health care system overall

23. Emerging Best Practices
Housing With Services – A collaboration of 3 housing owners, 5 services providers and funders have come together to serve 1400 senior and disabled residents in 11 buildings located in downtown Portland.
Services include:
A Resident Services Coordinator
Health Navigators funded by a Medicaid insurer, available to all residents, even if not insured by them
A health and wellness center
Primary and urgent care
A Providence ElderPlace PACE program
Prescription medication management
county agencies and health and social service organizations work to engage residents, assess needs and present a range of service and support options.

24. Emerging Best Practices
Housed and Healthy (H+H) Program – a collaborative project which coordinates communication and services between Resident Service Coordinators in affordable housing and care teams at local health clinics. The program includes:
Needs assessments at move-in to identify high-need individuals
Standardized Release Of Information forms
Streamlined referral processes
Increased coordination between service providers, and in-housing programming to improve residents’ health

25. Emerging Best Practices
Flexible Funds Pilot – a collaboration with FamilyCare, Human Solutions, Project Access NOW and Enterprise
A two-year pilot using grant funds and actual Medicaid Flexible Benefits to provide rental assistance, eviction prevention, rapid rehousing and supportive services to Multnomah County residents experiencing a housing and health crisis due to physical or mental health challenges, for a period of up to 12 months.
As of June 2017 we’ve served:
73 clients
An average of $723/month
For 2.1 months
Tell story of mom of triplets with son with damaged hip.
Almost all of our clients are still stably housed 3 months after intervention and we will continue to track for one year.

26. Enterprise Community Partners
Amanda Saul
Maggie Weller, MS
Enterprise Community Partners
Center for Outcomes Research and Education, Project Manager
Senior Program Director
Center for Outcomes Research and Education