2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Working with High Risk, High Need, High Utilizers in a Mixed Use Setting: One Agency’s Experience

In a post DSRIP era, where sources of value based funding are scarce and community based organizations are still struggling to find a foot in the door partnering with the managed care industry and hospital settings, I thought it would be worth highlighting a few successful initiatives Concern for Independent Living launched in recent years that demonstrate how housing can be the lynchpin for healthcare and recovery.

In 2016, Concern for Independent Living opened the first single site Medicaid Redesign (MRT) mixed use supportive housing program in The Bronx (Norwood Terrace), a 115-unit supportive SRO for high cost Medicaid users living alongside affordable households. In 2017, Concern opened a second MRT mixed use housing program, Renaissance Village (123 apartments) in Middle Island on Long Island.

A pilot program under Medicaid re-design, these pioneering single site programs offer fully furnished studio apartments to chronically homeless adults with the highest healthcare expenses under the working philosophy that “Housing is Healthcare”, that by offering someone a safe and beautiful place to live with limited on site supports, perhaps their healthcare outcomes would improve and costs would eventually go down. MRT housing has since become a well promoted concept in the supportive housing industry and is now a funding requirement of Empire State Supportive Housing Initiative (ESHHI) and other development awards.

While MRT projects have been piloted on a scattered site basis, Norwood Terrace represented the first time in New York (and the across the United States for that matter) that a single site supportive housing program had attempted to integrate 100% of their supportive tenants from a high utilizer pool into one building, alongside affordable households. It required a distinct partnership between multiple government agencies (OMH, DOH, HRA, DHS and HPD) and non-profit community partners (care coordination, outpatient programs, outreach and crisis respite care).

At Norwood Terrace, 58 individuals with healthcare expenditures in the upper deciles (over $45,000 Medicaid expense in 11 months, or over $85,000 in 13 months) were transitioned from chronic homelessness into studio apartments in a permanent supportive housing setting with on-site case management supports. Staff worked with mobile integration teams, such as Pathway Home through Coordinated Behavioral Care (CBC) and other health homes to link tenants to local outpatient supports and provide ongoing care coordination and skill building. Not only did this help fill a huge gap in care for a population that accounted for a large percentage of health care costs, it provided a central construct to finally begin to address their social determinants of health (neighborhood and physical housing, community and social context, healthcare system, economic stability, food insecurity and education). Many tenants were originally from the Bronx, or returning to the Bronx, now to a challenged neighborhood with one of the highest concentration of preventable ER visits and with a rent burden over 63%. However, with the right complement of services, Concern was able to make a marked difference in tenant use of crisis services within the first year of occupancy, cutting medical and psychiatric ER visits and inpatient mental health care expenses in half. A recent pre/ post cost analysis prepared by DOH showed an average costs savings of $12,471 per tenant based on Medicaid claims data (equal to almost $750K in savings) in the first year of operation alone. In addition, the shared residency in a building between supportive and affordable households (there are 53 children also living at Norwood) has also served to demonstrate that fully integrated residential buildings are the hallmark of community integration and tenant social determinants of health are often the same.

Similarly, at Renaissance Village on Long Island, an analysis of estimated costs savings for the 123-unit supportive housing program for individuals transitioning from homelessness and expensive nursing home settings forecasted annualized savings of close to $2 million. Clearly, both programs are closing gaps of care in both urban and rural communities. Their sustainability has gained attention from health care and insurance providers looking at practice-based approaches examining value based payment proposals as a model that can be fiscally viable in addressing homelessness and healthcare in a comprehensive and localized manner. Concern has since partnered with Empire HealthPlus as part of the pioneering Corporation for Supportive Housing’s Bronx Frequent User Service Initiative (Bronx FUSE) to engage high cost utilizers around supportive housing needs in a value-based demonstration project that aims to funnel federal healthcare savings into housing through enhanced service provision. Alongside three other non-profit/ MCO partnerships, BronxFUSE is the first partnership of its type with managed care and has the potential to set the trend in addressing gaps in our housing and healthcare systems.

So, there you have it. One agency’s experience with attempting a bold and innovative practice-based endeavor with two large mixed-use projects, with a special focus on program rollout/ lease up transition, tenant healthcare outcomes/ needs and the delicate balance between servicing supportive and affordable households in both urban and rural neighborhoods. Social determinants of health can be both measured and leveraged in a single site setting and additional supports/ local partnerships are truly needed to make a MRT project successful in the community (including in this instance, CBC network health home partners to provide valuable care coordination between the housing setting and healthcare sites, access to usable real time health care data, and vital crisis respite and diversion programs focused on keeping tenants out of expensive cycles of institutionalization and in their homes). Housing is healthcare and it works!

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