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

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.

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.

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.

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.

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?

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

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

145 properties: Health services Food Resources 68% Medical Resources 54% Insurance Assistance 36% Mental/Behavioral Health Resources 35% Fitness Resources 29% Nutrition/cooking Resources 23% Transportation Resources 19% Dental Resources 15% 145 properties:

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

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

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

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

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%

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

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

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

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%

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%

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

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

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

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.

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

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.

Enterprise Community Partners Amanda Saul Maggie Weller, MS Enterprise Community Partners Center for Outcomes Research and Education, Project Manager Senior Program Director Asaul@EnterpriseCommunity.org Maggie.Weller@Providence.org www.EnterpriseCommunity.com Center for Outcomes Research and Education