The design and operations of supportive housing programs in New York State has been positively impacted in numerous ways by the state’s Medicaid Redesign process over the last six years. The state’s Medicaid Redesign Team (MRT) recognized early on that housing is a major social determinant of health that can significantly impact the health of vulnerable populations, as well as health care costs and utilization. According to NY State Department of Health data, MRT-funded supportive housing provided to over 11,000 high acuity Medicaid members since 2012, has reduced: inpatient days by 40%; emergency department visits by 26%, and overall Medicaid health expenditures by 15%.
This funding has supported a variety of extremely high-need persons, including those with serious mental illness, substance use disorder, HIV + diagnosis, and other chronic medical conditions; and has taken many forms. It has provided construction capital grants, rental subsidies, case management services, home modifications (ramps, handrails, etc.), crisis/respite and step-down residence capital conversion, and other kinds of supports.
An additional MRT initiative, the Delivery System Reform Incentive Payment (DSRIP) program, promoted community wide collaborations of hospitals, health care providers and other community-based organizations, also to further the state’s goal of a 25% reduction of avoidable emergency room and hospital admissions over a 5-year period. There are 25 such collaborations across NY State, supporting a variety of healthcare projects, but ALL are required to address and promote the integration of primary care and behavioral health services. There has historically been a woeful lack of communication between the clinicians providing physical health care and those providing behavioral health care, but also between medical clinicians and community-based providers of such services as housing and other social determinants of health, including employment, access to food, transportation, etc.
While agencies in NY State that provide housing services have been able to increase housing opportunities through the MRT process, they have also been active participants in the DSRIP projects, and have engaged in actions to integrate the primary care and behavioral health services of their housing tenants. Our agency, Human Development Services of Westchester (HDSW), a housing and Health Home care management provider, has engaged significantly with our two Westchester County DSRIP partners, Montefiore Medical Center and Westchester Medical Center in this integration endeavor.
In recent years, NY State has seen an increase in clients utilizing emergency departments often as a means to quick access to care or to have multiple unmet needs addressed: HDSW tenants also participated in increased emergency room visits, which often exacerbated rather than reduced their mental health crises. In 2016, as one step in addressing this rise, and in the interest of improving medical and behavioral health integration by providing in-house medical expertise, HDSW hired a full time Registered Nurse who has over 25 years of community-based and hospital experience serving those impacted by behavioral health issues. She understands both the complex medical needs of our population and the interconnection with behavioral health issues. The RN is responsible for the coordination of the medical and behavioral health needs of clients in all HDSW programs. She has been working closely with each department Director and providing critical consultation services to individual staff members as needed, and insuring that clients are linked to proper medical care. She is a key component in current agency Recovery Services, and in direct client care, and as a resource/partner to peer counselors and social work staff. To date, the RN has had over 2,800 medical and behavioral health education interventions, either through direct individual or group contact services with clients, or education and consultation with staff.
On at least 4 occasions, the RN’s direct intervention saved an HDSW client from a life-threatening situation by providing encouragement and education, which offered the client the knowledge and support required to attend to health crises or undergo diagnostic procedures.
- During an HDSW family event, the RN was concerned after seeing a young child in our housing program in apparent serious medical distress. After she talked with the parent to share her concerns, the child was brought to the hospital and was found to have a critical medical condition.
- During four initial Health Home care management visits, new clients were found living in dire conditions in their own housing. The RN and care managers worked in tandem to convince the clients to allow their homes to be cleaned of accumulated dirt, feces, bed bugs, roaches and fleas. These individuals were steadfast in their unwillingness to allow anyone into their homes, afraid that their belonging would be destroyed or removed. The RN spent critical hours with each person explaining the health-related complications each person might be facing if work did not begin to remediate the situation. After making a commitment to each client that she would assist in the clean-up herself and oversee each task, to ensure that their belongings were safe, all of the four clients agreed to the cleaning of their apartments. New furniture, new clothing, and new household supports were required for some clients. All were thankful and said if not for the RN, they would still be living the way they had been for so many months, and in some cases, years.
- The nurse has assisted one supportive housing tenant to follow through in the lengthy preparation needed for a specific medical procedure, including fasting. She stayed with the tenant for 24 hours, to make sure the she adhered to the guidance of her physician. The procedure was completed, important recommendations made, reviewed with the tenant, and implemented, resulting in greatly improved tenant health. The tenant had had four previous failed attempts to complete the procedure.
- The nurse was a significant support to a tenant who required a medical procedure which included an overnight stay in the hospital. In addition to the psycho-education of the importance of completing the procedure, she was able to assist the hospital nurses in supporting the tenant, who was extremely anxious and uncooperative with hospital staff and procedures.
These are just a few examples of how the RN supportive housing team member provides critical support to the health and well-being of our tenants, education and support to our housing care managers, and cost savings to our communities by preventing further deterioration in tenants’ health that would require high-cost medical care. PROBLEM: none of the nursing services described above are funded by public dollars. Housing providers are woefully under-resourced in our system – they have lost 40% of their budgets due to inflation over the last 15 years (Association for Community Living data). Nursing services ARE funded by state and federal dollars in other housing programs (OPWDD) and should also be funded in Office of Mental Health residential services. In recognition of New York State’s determination that, indeed, HOUSING IS HEALTHCARE, we all need to advocate for the dollars to support this critical nursing services healthcare resource.