Health - Resident Service Coordinator Call

A large and compelling body of evidence accumulated over the last twenty year confirms that social determinants of health (SDOH) - where people are born, live, work and age- impact health outcomes more than traditional medical care. These SDOH are at heart of population health management outcomes but often on the fringes of residents care and are the missed "common denominators” driving health, recidivism, productivity and behavioral risk across all populations. The demographic similarities between affordable housing residents and public health program beneficiaries are two sides of the same “social determinants” coin; our member communities are at the heart of any solution to improve health in low-income populations because of the trusted relationships with residents which facilitates engagement and service delivery initiatives. 

Through a Population Health Management (PHM) approach, HPN and our members are leveraging technology and the trusted staff at member properties to deliver an integrated solution to provide targeted health and other life management resources to residents based on their unique needs. This effort is not JUST technology, it is a delivery system for supporting Resident Service Coordinators (“RSCs”) in their work assisting residents in accessing supportive resources and care guidance to improve resident health and well-being, which will minimize health risk and reduce unnecessary demand on the health system.

We have been convening groups of members to design a pilot to deliver this integrated solution over a 12-month period, beginning later in 2018, at 5,000-10,000 member units. We are working with Trestle Health and Housing LLC to create a pilot to validate our hypothesis that treating behavioral health conditions effectively, especially those of low-income residents with co-occurring chronic medical conditions, can lead to a healthier population and result in significant long-term cost savings for the healthcare system. Our goal is to attract capital from insurers for this work and longer term, for affordable housing acquisition and development. Trestle’s PHM solution provides access to supportive community resources to help residents address early risk indicators (stress, anxiety and depression) and receive needed support. Effective care-coordination capabilities include psychosocial and claims data analytics (proprietary algorithms), stratification and prioritization of high-risk residents. Our model connects behavioral health (masters level clinicians) capabilities with existing health system resources dedicated to residents transition, care coordination, access to primary care and ongoing SDOH challenges. The pilot will:

  • Provide life management tools to residents and member staff, including:
    • A mobile application that provides intuitive search tools to locate and access local resources to alleviate psychosocial problems (e.g. hunger, transportation barriers, lack of child or elder care, substance abuse, etc.) and includes current information on resident eligibility for publicly financed benefits (e.g. Social Security/SSI, SNAP, Medicare, Medicaid, Veteran’s benefits, etc.)
    • A call center staffed with Masters level clinicians who can assist with more in-depth resident problems and guide property staff toward solutions
    • Simple and easily digestible educational articles and videos for residents that provide tips and advice on medical care or other programs and services.
  • Facilitate care delivery: Through proprietary algorithms, we will integrate member property and tenant data (provided through self-assessments) with Medicaid claims data, assess population risk and stratify patients based on risk and gaps in care. We will work with Managed Care Organizations (MCOs) to implement care coordination and provide targeted educational materials, reminders and notifications (for doctor appointments, prescription refills, daily medications, upcoming social or mental/physical well-being events, etc.) to residents through their preferred contact modality.
  • Coordinate in-place services based on common resident needs throughout the property.

On April 3rd we hosted a peer exchange conference call with member staff (primarily Resident Service Coordinators) to refine some of our assumptions and key issues such as modality and how residents most successfully respond to information, how they seek it and shared experiences on accessing and delivering services and benefits to tenants. The call was very insightful and member contributions and feedback helped us refine the proposed pilot and value proposition for discussion with insurers and other funders. Our next steps relating to this work include setting up calls with interested members to discuss pilot logistics and existing relationships with Managed Care Organizations (MCOs) and other health insurers, finalizing the group of properties at which the Trestle solution will be piloted, continuing to secure grant funding for this effort from foundations and continuing to engage with MCOs, foundations, academics, and other health care providers to determine the right metrics and outcomes to track over the course of the pilot and build out a partnership model.