1. Supporting Successful “Aging in Place” for Lower Income Older Adults
Multidisciplinary Approaches to Housing, Social Services and Healthcare
Robyn I. Stone, DrPH
Senior Vice President for Research, LeadingAge
University of Maine Clinical Geriatrics Colloquium
Orono, ME | 12 October 2018

2. Demographics (Section 202 residents)
Poor
Average income (2015) = $13,2381
Aging
Average age = 791
Diverse
Hispanic = 13%2
Black = 19%
White = 56%
Other = 19%
Chronic conditions and functional limitations more prevalent among lower incomes, advanced ages, minorities 1
2 Section 202 Supportive Housing for the Elderly Program Status & Performance Measurement; Data is for residents of Section 202 housing properties, 2006

3. High Level of Chronic Illness
Approximately 68% of HUD-assisted beneficiaries age 65+ are dually enrolled in Medicare and Medicaid1,2
1 Of those who matched to Medicare
2 Number who matched to Medicare and Medicaid, not number eligible
Source: A Picture of Housing & Health, found at

4. Model Independent, affordable senior housing Service coordinator
Wellness nurse
Onsite staffing
Assessment
“Care coordination”
Wellness/prevention
Transitional care
Services

5. Model Population health approach Senior population focus
Principles
Population health approach
Senior population focus
Low-income population focus
Place-based

6. Model Advantages
Reach a concentration of at-risk individuals, including duals
Delivery efficiencies
Leverage existing service coordinator role, and presence of other housing staff
Trusting relationships with residents and know their preferences, needs and capacities

7. Model Advantages Observe a resident’s living circumstances
Monitor residents and notice potential emerging health issues before become a crisis
Help remind and encourage residents to participate in activities and appointments
Identify and help residents overcome barriers preventing following through on appointments and needed self-care management

8. Vermont’s Support And Services at Home (SASH)

9. Goals of the Program:
Meet the complex needs of older adults and individuals with disabilities to help them live in the community
Enable aging in place in housing sites serving older adults;
Avoid early transitions to institutional care, and;
Prevent unnecessary and often costly health care utilization-such as some emergency room visits and hospitalizations-for residents in HUD-assisted senior developments.

10. The Intervention
Housed within an affordable housing site (118 sites statewide)
Each “Panel” of 100 participants consists
1 full-time SASH coordinator
10 hours a week of a wellness nurse
Connected to Vermont’s Primary Care Medical Homes Community Health Teams (CHTs) created as part of the Medicare Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration (now 5 regional ACOs)
Some panels serve participants that are primarily in the housing site (site-based), some serve primarily community participants (community-based), and some serve a mix.

11. ASPE-HUD Evaluation (RTI International & LeadingAge)
Using HUD administrative data and Low-Income Housing Tax Credit (LIHTC) data linked to Medicare and Medicaid claims to develop an appropriate comparison group for quantitative findings
Also conducted a mail survey to SASH participants and non-SASH Medicare beneficiaries to collect data not available in claims
Complemented with site-visits to SASH sites and community providers in Vermont.

12. Summary of Impact on Medicare Expenditures
CSC = Cathedral Square Corporation; DRHO = designated regional housing organization.

13. Medicaid Findings
Half of the sample used in the evaluation are dually-eligible for Medicare and Medicaid
Analysis of claims data among dually-eligible SASH participants over the age of 65 indicates
Positive trend in the growth of Medicaid costs for home-based/community long-term care (though not significant) – consistent with SASH connecting participants to services
Negative trend in the growth of Medicaid costs for long-term institutional care among duals participating in SASH; the effect was statistically significant among certain types of panels (site-based panels, rural panels) – average impact of $400 per participant per year

14. Informing Policy Beyond Vermont
Findings informed HUD’s new Senior’s and Services Demonstration: “Integrated Wellness in Supportive Housing (IWISH)”
Based on site-visit findings, increasing the wellness nurse hours to 20 hours a week
Demonstration being tested 40 sites across 7 states
SASH being replicated in sites in Rhode Island and Minnesota

15. Key Issues Volume Not limiting focus to “super utilizers”
Property size
Split across insurers and providers
Not limiting focus to “super utilizers”
Property variation re: volume and staffing
Avoid triggering health or residential care licensing

16. Key Issues Billing and provider credentials
Geographic variation in Medicare/Medicaid products or initiatives
Healthcare operational strategy
Language differences

17. Medicare & Medicaid Issues
Medicare & Medicaid Broadly
Freedom of choice
Person-based payments
Eligible providers

18. Medicare & Medicaid Issues
Medicare Fee-for-Service
Limitations in type and delivery of benefits
Pay by single visit versus ongoing episode
Medically necessary focus; limited care coordination, prevention, education
Some expanded thought with chronic care management code and yearly wellness visit
Potential opportunities in FFS value-based initiatives

19. Medicare & Medicaid Issues
Medicare Advantage
Care coordination as a benefit
Uniformity of benefits
Supplemental benefits
Where benefit would get counted in rate or MLR

20. Medicare & Medicaid Issues
SNPs and MMPs
Care coordination
Concerns
Duplicity between plan care coordinator and housing “care coordination”
Service coordinators are certified/credentialed providers
Capacity of service coordinators

21. Medicare & Medicaid Issues
Medicaid FFS and managed care
Greater care coordination flexibility
Movement to managed care
“Care coordination”
Inclusion/level of services for well duals
Value-added and in-lieu-of services
Recognition of tenancy support services

22. Potential FFS Solutions
1. Create a housing-based service coordination benefit under Medicare Part B.
1a. Create an alternative payment model for place-based service coordination (e.g. à la CPC+) that could be paid through an umbrella entity (e.g. like a “mini-IPA”).
2. Create a mechanism that aggregates volume of attributed beneficiaries in housing properties for ACOs.
2a. Create an intermediary network similar to that described for managed care plans (see potential solution 2, next slide) or allow ACOs to also purchase services from intermediary.
2b. Assign buildings and the FFS beneficiaries to a specific ACO based on geography.

23. Potential Managed Care Solutions
1. Allow housing-based service coordination to be a MA supplemental benefit. (Single-plan approach)
1a. Plans work one-on-one with individual housing properties (or organizations with multiple properties).
1b. Plans work one-on-one with a network of housing providers (single organization or multiple organizations).
2. Create intermediary entities that serve network of housing properties through which MA plans purchase housing-based service coordination as a supplemental benefit. (Multi-plan, multi- property approach)

24. Other Medicaid Potential Solutions
3. Create a housing-based service coordination benefit under Medicaid.
4. Define service coordinators as allowable providers under Medicaid.
5. Allow establishment of some type of preferred provider relationship between managed care plan and housing property (e.g. housing buildings are assigned to Medicaid plans allowing for equitable distribution).

25. Next Steps Questions to spur discussion
Are there options to move forward without any demonstration/pilot or further research?
Rule or regulatory changes?
If research, what kind: CMMI demo, test at single or multi- plan-level, other?
Advocacy needed on Hill, with mayors, governors, state legislators or others?
Coalition building?
Data needed? If so, what?