New York has demonstrated a strong commitment to addressing social determinants of health. At the center of this effort is supportive housing, which combines stable, affordable housing with services to meet the needs of homeless individuals facing multiple complex challenges like serious mental illness, substance use disorders and chronic medical conditions. Significant investments by both the State and City of New York over the past five years have greatly expanded the use of supportive housing to improve health outcomes and reduce public spending.
Medicaid Redesign Team
Recognizing both the cyclical nature and causal relationship between poor health outcomes, multiple crisis systems use and homelessness, New York State policy leaders sought to break this pattern in 2011 through the Medicaid Redesign Team (MRT), which fundamentally changes how services are delivered and paid for under the State’s Medicaid program.
While MRT is a multi-faceted, multi-year action plan to transform the State’s Medicaid program with well over 200 initiatives, a key and pioneering endeavor has been its investment in supportive housing. New York MRT has led the nation in identifying supportive housing as a health care intervention and invested the state-share of Medicaid savings into various innovative pilots and programs linked to it. MRT created numerous supportive housing programs to provide vulnerable high–cost Medicaid members with rental subsidies, new capital construction financing, and grants for pilot projects testing new models of care. Since 2012, over 11,000 high acuity Medicaid members have been served.
The recent first installment of a three-year evaluation performed by the State University of New York (SUNY) Research Foundation´s MRT Supportive Housing initiative observed early findings demonstrating investments in social determinants like housing can have a profound impact on health care costs and utilization, including: 40% reduction in inpatient days; 26% reduction in emergency department visits; and 15% reduction in overall Medicaid health expenditures.
While further analysis of MRT supportive housing investments is needed to assess the impact on health outcomes and quality of life, there already exists a large body of research demonstrating supportive housing’s efficacy in helping individuals with disabilities maintain stable housing and improve outcomes.
Approved in 2014, the Delivery System Reform Incentive Payment (DSRIP) program is the main mechanism by which New York State fundamentally restructures how it pays for and delivers health care services under Medicaid, with the primary goal of reducing avoidable hospital use by 25% by the year 2020.
Doubling Down on What Works
Facing daunting and unprecedented homelessness and recognizing the efficacy and cost-effectiveness of supportive housing in improving outcomes for high-need homeless individuals and families, New York State and City have responded with robust initiatives. New York Governor Andrew Cuomo, in his 2016 State of the State address, unveiled his plan to create 20,000 units of supportive housing statewide over 15 years. This announcement was preceded by New York City Mayor Bill De Blasio’s pledge to create 15,000 units of supportive housing over 15 years. The initiatives combined will create 35,000 units of supportive housing statewide – marking the largest commitment in the nation. These actions follow in the footsteps of the NY/NY agreements, a series of long-term pacts between New York City Mayors and New York State Governors to increase the pipeline of supportive housing for high-need homeless individuals.
NY/NY III, the last iteration before the recent announcements, is fully leased up and provided supportive housing for nine distinct populations in New York City through a diagnosis-driven and siloed structure. The new initiatives by the Governor and Mayor are somewhat more flexible, recognizing that eligibility categories must be comprehensive and accommodating enough to encompass the needs of individuals with multiple, co-occurring challenges, a variety of housing requisites and a range of homelessness histories. Requests for proposals for operating and service contracts for this new supportive housing are released and target resources to address vulnerable populations experiencing homelessness and/or significant life challenges. The Governor’s plan includes a five-year goal of developing more than 6,000 congregate, newly constructed supportive housing units for vulnerable populations through the Empire State Supportive Housing Initiative (ESSHI). The Mayor’s plan, known as NYC 15/15, will develop 7,500 new congregate units and 7,500 scattered site units.
Deeper Targeting to Screen in the Most Vulnerable: Reduce Costs
Anchored by a HUD directive and a desire to ensure new and existing resources are effectively used to end homelessness, CSH is helping lead systems transformation efforts in New York City by supporting the development and implementation of a Coordinated Assessment and Placement System (CAPS). CAPS will streamline access to housing for homeless clients by establishing a single assessment process for housing types and a prioritization process taking vulnerability factors into account when determining priority for supportive housing. When fully implemented, New York City will have a more efficient process to identify and prioritize the most vulnerable individuals in greatest need of supportive housing. Also, supportive housing providers will likely be serving a more medically complex cohort with significant behavioral health, social and long-term care needs. It is therefore imperative providers have appropriate staffing models, comprehensive and flexible service arrays and accessible physical environments to support what will likely be a more medically frail population.
Communities are spending millions on services for vulnerable individuals and families trapped in a revolving door of costly public systems use, often reflected in numerous emergency room visits and hospitalizations. Individuals frequenting these crisis systems suffer from multiple and debilitating co-occurring chronic medical, social, behavioral health and long-term conditions and fall victim to a fragmented health care system, all of which greatly exacerbate their unmet health and other needs. CSH’s Frequent Users of Systems Engagement (FUSE) model works to solve this problem. FUSE helps to break the cycle of homelessness and multiple systems use among individuals with complex health challenges who are the highest users of costly crisis services by targeting limited housing resources to the most vulnerable and increasing housing stability. FUSE reduces multiple and avoidable crisis service utilization, which means a more effective use of public funds. In the Bronx, CSH and its partners, the Bronx Health and Housing Consortium, the Bronx RHIO, managed care entities and about a dozen supportive housing providers are working on a FUSE initiative focused on homeless frequent users of hospital systems.
Demonstrating the Value-Add
While the future of Medicaid coverage remains uncertain, it is clear that states will have to operate more efficiently. As such, it is of paramount importance that states look to innovative and cost-effective solutions like MRT and supportive housing, which enjoys wide bi-partisan support because of its positive return on investment, to address the needs of their most vulnerable and costliest Medicaid members. As we embark upon value-based arrangements under Medicaid that seek to drive innovation through transformative delivery and payment reform, and effectively bend the healthcare cost curve, new and more meaningful integrated partnerships between the health and housing sectors will be required. Supportive housing providers have already entered into many of these partnerships. Their efforts foster stability, reduce avoidable healthcare usage and improve outcomes through stable housing, intensive case management and wrap-around community supports. And at a fraction of the cost of what managed care entities currently pay for avoidable re-admissions that yield no positive health returns.
Kristin Miller, MSW, is Director and Pascale Leone, MPP, is Senior Program Manager, at the Corporation for Supportive Housing. For further information, visit CHS at www.csh.org.