Investing in Supportive Services
According to Peggy Bailey, of the Corporation for Supportive Housing (CSH), supportive housing is a healthcare intervention that should be paid for in the same way as hospital stays and nursing homes. While supportive housing is for people with significant needs, affordable housing is also aimed at those who often need light supportive services.
“If we want to create more affordable housing,” Bailey said, “we need to bring more voices to the table demanding affordable housing, and the health care system is beginning to see their role in that space.”
Bailey explained that services funding comes from a wide variety of sources and is unpredictable because it’s based on the budgetary circumstances of the moment. Funding can also be uncoordinated because reporting standards and the way funds are earmarked and divided can create an extensive administrative burden.
It’s that services component that is the secret sauce that makes supportive housing work.
While Medicaid has been used for clinical services in the past, decision-makers are starting to understand that softer support services are essential to achieve better outcomes. CSH has started to look for opportunities to ensure supportive services have long-term funding under Medicaid expansion.
A recent informational bulletin from the Centers for Medicare and Medicaid services clarified that there are greater opportunities to fund long-term care and supportive services, and some states are proposing changes to their own Medicaid plans. For example, Texas has a 1115 waiver to experiment with regional networks providing housing support, California has a 1115 waiver for managed care and Louisiana is distributing housing dollars alongside service dollars as part of a package.
Bailey also identified opportunities in the Health Homes network model, which New York, Minnesota and Oregon have used to leverage better supportive housing. CSH also continues to work on managed care by encouraging supportive housing providers to form relationships with other community providers to avoid duplication of services.
Health Policies to Support Food as Medicine
During her presentation on food security, Karen Pearl discussed opportunities to provide food services through the Ryan White program and the Affordable Care Act.
When Ryan White was reauthorized in 2006, service providers successfully pushed for a new clause specifying that food and nutrition can be considered core medical services. Pearl explained that, as Medicaid expansion and the Affordable Care Act begin to pay for more medical services for people living with HIV, there is now an opportunity to reinvest Ryan White funds into structural inventions such as food and nutrition services.
Pearl’s organization, God’s Love We Deliver, has been reimbursed by health care companies for delivering 230,000 meals a year through a New York state waiver to Medicaid. She emphasized that this was a voluntary choice on the part of health care companies, and that they had elected to cover food and nutrition services because it helped them meet their goals.
Pearl emphasized that there is a high level of variation in the coverage people receive through the Affordable Care Act. There is still work to be done to ensure that the standard of care set out by the Ryan White CARE Act, including access to food and nutrition services, is available to all people living with HIV.
Redesigning HIV Care in British Columbia
Miranda Compton, of Vancouver Costal Health, explained the process used to develop the Vancouver STOP HIV initiative. This pilot program, begun in 2010, uses a treatment as prevention approach. In British Columbia, residents have universal access to antiretroviral treatment and no direct barriers to care, which means other factors are interfering with treatment.
The program invested $20,000,000 over three years in expanding capacity, developing new partnerships and funding new initiatives (initiatives were evaluated every six months and either renewed or changed). The first two years focused on developing activities to reach people who were not suppressed and not engaged with HIV services. This included expanding point of care testing and developing a peer navigator program, treatment adherence programs, drop-in programs and housing programs – which, Compton explained, were supported by research presented at previous Summits. Housing programs, specifically, were associated with dramatic decreases in viral load within six months.
This STOP project is making our lives a living hell.
Follow-up with service providers revealed that their workloads had increased and that they were seeing clients with more complex needs. While this was positive in that the STOP HIV initiative was reaching its target client base, it was also overwhelming for service providers. The takeaway message was that adding money to the system of care wouldn’t be a magic bullet; the province had to look at the whole health care system from the ground up.
The project team decided to map everything they wanted in a system of care and then figure out how to turn those pieces into a continuum of care that included an integrated service delivery system for prevention, testing, care and treatment. Since then, Compton explained, the program has been expanded and granted continuing funding.
Contracts with AIDS service organizations have been redefined based on the new HIV care model. A random sample of clients leaving intensive case management revealed that, while only 39% were virally suppressed at intake, 67% were suppressed at discharge and 79% were suppressed six months after discharge. Of 134 clients who received housing services, 30% were virally suppressed at intake and 70% were suppressed at the group’s most recent measure.
The initiative’s next challenge is to integrate more effectively with mental health and addictions services.
Redesigning State Medicaid in New York
Meghan Gleason, Director of Government Health Care Transformation at KPMG, outlined New York state’s approach to redesigning its Medicaid system. With a budget of sixty billion dollars each year, New York’s Medicaid system is the second largest in the United States and, in 2010, Governor Andrew Cuomo developed a multi-year plan to refine it.
Key components of the plan include a global spending cap and capped spending on Medicaid, which increases by only 2% each year. The state can innovate as long as total spending stays under the cap, and there is a requirement that 1115 Medicaid waivers be budget-neutral.
Gleason reported that Medicaid redesign has led to seventeen billion dollars in savings, and that New York was able to broker a deal that would allow it to reinvest eight billion dollars of that money back into state health care through the Delivery System Reform Incentive Payment (DSRIP) Program, putting the state on the forefront of transformation.
The aim of the DSRIP program is to change the healthcare delivery system through creating Performing Provider Systems (PPS): large networks of providers who are jointly responsible for a set of Medicaid beneficiaries. There are 25 PPS networks in the state, and each did a community needs assessment to create an implementation plan, projects and strategies.
The state’s plan also included a large investment in infrastructure to sustain new initiatives after the DSRIP funding ends. “If you don’t also fundamentally change the way that you pay for healthcare,” Gleason explained, “at the end of 5 years when the [funding] goes away, everything sort of just reverts back to the way it was before.” New York’s strategy is to create a delivery and payment system as two sides of the same coin, so that incentives align once DSRIP is finished.
One of the methods the state has used to do this is the introduction of value-based payment. In the past, moving to value-based payment was a threatening proposition because it would have meant less funding for providers. The introduction of a global cap means that spending stays flat even in the event of savings, so that savings will be reinvested in the system. Gleason emphasized that this is only possible because the move to value-based payment is not, in itself, intended as a cost-containment measure.
Gleason outlined the levels of value-based payment developed in New York, explaining that service providers who opt into higher levels experience more freedom in how to spend their Medicaid funding, but they also carry more risk. In one example, a service provider decided to spend Medicaid funding on air conditioning for elderly patients to reduce emergency room visits in the summer. Gleason noted that funding could also be used for supportive housing based on the same principle.
Practice Learning Institute on Housing Interventions to Improve the Continuum of Care
Sponsored by the US Department of Housing and Urban Development (HUD), this full-day learning institute focused on the connection between stable housing and improved outcomes along the HIV care continuum. The session featured a mixture of guided discussion and strategic planning sessions to help participants develop community strategies to improve and measure client health outcomes, create strategic partnerships and use local data to demonstrate the link between health and housing.
Through the process of designing an HIV Housing Care Continuum, participants were able to identify new opportunities for collaboration as well as develop a powerful advocacy tool to support cross-system dialogue on HIV.
In an interview with OHTN staff, Russell Bennett explained that, when housing interventions are introduced, “we see remarkable changes across the continuum… so, if … through this institute [we can] help communities build their own HIV Housing Care Continuums we think we can help enhance the system of care and also begin to bring together disparate systems.”
Building Housing, Health and Other Partnerships for Client-Centred Care
Breaking barriers, creating access, nurturing recovery
Eleshia Fahy, Coordinator, McEwan Housing and Support Services/Loft Community Services
The Positive Service Coordination Program based at LOFT Community Services in Toronto provides short- and medium-term intensive case management for people living with HIV who cycle through the health and judicial systems as a result of being homeless, living with a mental illness, using substances and/or experiencing a physical or mental health crisis. The program is supported and guided by the Advisory Committee, comprised of our membership/clients. Case managers work with members and community partners in collaboration with 17 cross-sectoral agencies to: find permanent, stable housing; ensure members have appropriate identification documents and are receiving their maximum social assistance benefit; engage members in HIV-specific care, primary care and mental health care; and make active linkages to appropriate community organizations. The slides describe the program and discuss partnerships, access to primary care providers, member involvement and other issues.
HIV Addiction Supportive Housing (ASH): Successes of a Housing First model within a continuum of care
Kay Roesslein, Program Director, McEwan Housing and Support Services/Loft Community Services and Michael Blair, Director of Residential Programs, Fife House Foundation
The HIV Addiction Supportive Housing Program was developed to address gaps in service for homeless people living with HIV in Toronto experiencing health, mental health and severe substance use challenges, and cycling in and out of hospitals, prisons and withdrawal management units. The program aims to: 1) increase the health and social outcomes of people living with HIV who have problematic substance use issues and frequent emergency room and hospitalizations, and 2) increase access to and the quality of care and support services for people living with HIV who have problematic substance use issues. The slides highlight lessons and key recommendations learned from implementing the program.
Lessons learned and recommendations from the implementation of a multi-agency cross-sector collaboration addressing the needs of people living with HIV experiencing aging-related illnesses, accelerated aging, complex care and cognition issues
Michael Blair, Director of Residential Programs, Fife House Foundation
The HIV/AIDS Complex Care Pilot Project (CCPP) is a multi-agency pilot project aimed at increasing cross-sector collaboration and partnerships that address gaps in the service, care and support needs of people living with HIV who are experiencing aging related illnesses, accelerated aging, complex care and cognition issues. Ten separate partner agencies offered coordinated wraparound clinical and community support services, and a new high-support housing model. The slides outline some of the lessons learned and recommendations about implementing a collaborative project. Key recommendations include: the leadership of a “backbone organization” that can provide the structure and guidance for the development of the partnership; taking an improvement approach by continuously monitoring for challenges and conducting an ongoing review of implementation; and creating space and time for the interdisciplinary care team to articulate goals, tasks, roles, leadership, decision-making, communication, conflict resolution, role definitions and scope.
Translating research data into new funding opportunities: “Cashing in on the value of an AIDS or supportive housing unit”
Arturo Bendixen, Executive Director, AIDS Foundation of Chicago
A group of AIDS and supportive housing providers in Chicago and Cook County organized themselves into a collaborative representing almost 80% of all funded units in the area. From this position of strength and value, the collaborative, now named Better Health Through Housing (BHH), is engaging and negotiating with managed and accountable care organizations administering Medicaid funds in Illinois. Using published research data, as well as recently acquired Medicaid claims data of homeless individuals who are high users of health care services, BHH has negotiated for health dollars to help complement HUD and HOPWA funds for housing the homeless. As the value of an AIDS or supportive housing unit is recognized by health care payers, and as the demand continues to be greater than the available supply of existing units (mostly paid for by HUD and HOPWA dollars) health care payers are becoming an important funding source for units especially serving high users.
Integrating for impact: The origins and practice of the Structural Interventions Working Group of the Federal AIDS Policy Partnership
Suraj Madoori, Manager, HIV Prevention Justice Alliance, AIDS Foundation Chicago
In 2014, the head of the National AIDS Housing Coalition and the Federal AIDS Policy Partnership’s (FAPP) Housing Working Group, Nancy Bernstein, recognized that, in order to address the needs of people living with HIV, advocacy efforts would need to incorporate more than just housing. Working with other advocacy leaders, she expanded the FAPP working group to create the Structural Interventions (SI) Working Group. The slides examine the genesis of SI, and the lessons and best practices learned over the last year. They highlight the merits of combined advocacy efforts, the implications of integration at the local, state and federal level, and the challenges of being in a mixed coalition (e.g. messaging to internal and external constituencies, rallying support from Boards of Directors, shared decision making).