Where Health and Housing Meet
Promising strides are being made in the health and housing industries to assist low income and underserved populations, but ask just about any expert in either field and they will agree that despite the close interconnection between them there is much more collaboration that can be done. Healthier people are better able to maintain stable housing, and people with stable housing are better able to maintain their health. But with so much work to be done within each industry, reaching outside their walls takes the kind of time and dedication that understaffed, underfunded, and overworked teams frequently aren’t able to commit to.
Leading Community Organizations Partner for Change
Housing Partnership Network (HPN), a business collaborative of 100 of the nation’s leading affordable housing and community development nonprofits, believes that health, education and economic opportunities begin with stable, affordable homes. According to data collected annually by HPN from our 94 members, over 5,050 affordable housing properties currently serve 550,000 low-income individuals. Of those individuals, over 100,000 residents may require extra assistance because they are elderly or have special needs such as disabilities or conditions resulting from being formerly homeless, veterans or victims of domestic abuse. This only scratches the surface of the residents who need additional support due to chronic illness.
According to the most recent Center for Disease Control data, low-income individuals suffer from a 50% higher prevalence of multiple chronic conditions and 100% higher prevalence of behavioral co-morbidities than the average American. Low-income communities are especially costly to the healthcare system, with chronic illness driving over 85% of overall health spending and the majority of provider expenses relating to just 30% of the population.
In 2017, HPN engaged Community Catalyst, a national nonprofit advocacy organization with deep experience building consumer and community leadership to transform the American health system. Together we explored how HPN can help our members promote better health outcomes for residents and families by creating partnerships that integrate and connect the systems for housing and health care, including providing recommendations from Community Catalyst’s Center for Consumer Engagement and Health Innovation.
The U.S. Health Care System Today
Americans understand that the US health care system is broken, providing unequal access to health care services, which can be of poor quality, expensive, or both. At the same time, it has become widely accepted that health is not entirely dependent on clinical services, but rather on a broad set of factors. These so-called social determinants of health include education, the built environment, and housing.
As the health care system shifts from a fee-for-service system to value-based health care, health entities are recognizing the need to look outside their walls to address these social determinants of health. However, health systems and hospitals readily admit that doing so falls outside their expertise. They seek trusted partners who can help them address local needs beyond the medical services they provide. Affordable housing organizations, many with existing relationships with social services agencies, are well-suited to be invaluable partners in this work.
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”World Health Organization
Based on learnings from deep dives into 4 HPN member organizations, and work with organizations in 40 states across the US, the Center created a set of recommendations for organizations to develop policy and programs for investing in housing as a key determinant of health, raise awareness for their organizations, and become more familiar with health care entities in their regions. Those recommendations, and HPN member case studies follow.
General Recommendations: Approaching Health Players for Partnership
Community Health Needs Assessments
The Center’s top recommendation is for housing organizations to engage in local hospitals’ community health needs assessments (CHNA). This recommendation is timely – all US tax-exempt hospitals began engaging in the third round of CHNAs in 2018, which must be completed and approved in 2019. Under the CHNA rules, tax-exempt hospitals must assess the health needs of the community they serve, prioritize those needs and develop a plan to address them in the years ahead using community benefit dollars. Hospitals must seek input from those representing broad community interests, which explicitly includes members of medically underserved, low-income, and minority populations, or those serving or representing them. Based on the CHNA, hospitals are required to write health improvement plans for how they will address community needs through community benefit programming.
How to get engaged in the Community Health Needs Assessment process:
- Identify the nonprofit hospitals in your organization’s service areas
- Review the hospital website or reach out to the hospital/ investigate the status of CHNA
- Assess your organization's ability to actively pursue collaboration with the hospital
- Share existing assessment on economic development or housing-related issues
- Provide data on residents of properties, including demographics and health
- Assist with CHNA by helping to solicit information from residents through town hall meetings, surveys, or focus groups
- Submit written input on CHNA
- Measure the effectiveness of efforts by tracking whether health/housing issues are elevated in CHNA
Participating in CHNAs is a clear and timely action to take, but for ongoing representation of housing in community health conversations, the Center provides the following recommendations:
Actively Participate at “Key Tables” - The Center recommends that housing organizations become active participants in several tables at which the intersection of health and housing is relevant. Being at these tables will help housing organizations get to know health care stakeholders, understand who the influential decision makers are, share useful information about their organization, and ensure that stable, affordable housing becomes a priority. Examples of key tables include the Mayor’s or Governor’s Roundtable on Homelessness or a Local Multi-Stakeholder Workgroup on Mental Health.
Get Familiar with Relevant Health Programs - The Center recommends that housing organizations become familiar with a set of health care programs for low-income populations (and the players that serve them) in the areas in which the housing organizations operate. These programs may offer an opportunity for partnership. Examples of health programs include the State Medicaid, Mental Health or Aging Departments and the City or County Health Departments.
Monitor Health Care Bodies and Processes - The Center recommends that housing organizations closely monitor spaces where key health care conversations are occurring in order to identify opportunities to collaborate with health care entities. Examples include the Massachusetts Health Policy Commission.
Charting a Path Forward to Successful Collaboration
The Center’s work with HPN and its members confirmed the widely-held perception that, with some exceptions, the housing and health sectors are still largely operating in isolation. Both sectors use terminology that is often indecipherable to others. Too often, even housing organizations interested in collaborating with health entities do not have a deep understanding of the health policy environment, know who the key health care decision makers are, know how to effectively initiate discussions, or know what type of information would help to make a compelling case for partnership. Breaking down the barriers between the health care and the housing sectors is possible when the right steps are taken.
Translate – Players in the sectors do not necessarily speak the same language. Before entering into discussions with health care entities, housing organizations need to familiarize themselves with key terms, regulations and programs in order to facilitate productive conversations and show the potential partner that you are working together to try and solve the same problems. The Building Healthy Places Network has created a useful “Jargon Buster”. The Center has created two glossaries: one of basic health care terms and one that is more specific to health system transformation.
Understand Mutual Interest – As the health care system shifts emphasizing value over volume, health care entities are increasingly open to partnerships that improve quality, reduce risks and reduce or stabilize costs. In order to establish mutually beneficial partnerships with health care entities, housing organizations should take the time to understand the current dynamics of the health care system, and understand and effectively articulate the assets they possess that can help health care entities achieve this goal. Staff or programs that assist people with complex health and social needs to better manage their health will be considered a valuable asset.
Collect the Right Data – It is critical for housing organizations to be able to describe in concrete terms what they bring to a collaboration. This begins with data. Housing organizations can collect standardized data on specific health care-related needs for their residents through an annual survey, a tool that many housing organizations already use, augmented with additional questions, at the least to ascertain if residents have a primary care physician and their source of insurance. Additional data may cover chronic diseases (diabetes, heart disease) and the number of annual emergency room visits since these tend to be substantial drivers of cost and a target for health entity interventions.
There are sample surveys available that contain questions in the areas of housing stabilization, health, education, workforce development and asset building. Health data in conjunction with existing property management data, is valuable in efforts to develop deeper partnerships with health care institutions since it allows a housing organization to tell the story of who they serve and how their partnerships and services benefit resident families.
Connect Your Data to the Health Entity’s Catchment Area – A starting place for connecting resident health data to the those serviced by a local health entity is to map resident locations to hospitals and health centers. Housing organizations can also compare their residents’ needs with those living in the communities served by local health entities. Opportunity360 is a tool that enables users to create customized reports that examine five foundational criteria shown to have the greatest impact on how we live: housing stability, education, health and wellness, economic security and mobility.
Within this tool’s health and well-being category, users can obtain information about a community’s health status and access/ affordability of health care. County Health Rankings created by the Robert Wood Johnson Foundation allows users to get a county-by-county snapshot of health outcomes, quality of life, health behaviors, clinical care, and social & economic factors. Both resources help housing entities demonstrate to health entities the similarity between their own residents’ needs and those of the larger community served.
Dedicated Staff - To prepare to leverage collaboration opportunities, housing organizations need to devote staff who can invest the time to build relationships with health entities; ideally at both the leadership level and at an implementation level. Having staff in place with informative data in hand, will greatly increase a housing organization’s ability to take advantage of opportunities as they arise. Housing organizations may augment existing staff capacity by seeking grants from philanthropic organizations or hiring graduate-level fellows or interns.
Create Your Narrative – With data in hand, a housing organization should create a narrative that tells the story of its organization, its residents and their needs and the assets it brings to any potential partnership. Often, resident service coordinators are critical to health and housing collaborations. As the eyes and ears in the buildings, they are trusted, have a sense of residents’ needs, and can assist in the coordination of care. This is a valuable asset for health insurers and providers, who understand the importance of coordinating care for the most complex patients or members in order to avoid expensive emergency room visits, hospital admissions and readmissions.
Get to Know the Right People – A strong lesson from the Center’s work with HPN and its members is that local housing and health entities do not necessarily know one another. Getting to know health care stakeholders requires being at the health care tables where social determinants, including housing, are likely to be discussed or should be part of the discussion. Complex health care entities tend to have many points of entry, so identifying key staff with commitment and influence to promote partnerships can be challenging. It requires working with knowledgeable people in the health care field who can make introductions to the trustworthy and competent people in the health sector. A health organization’s Board of Directors may also play a role in facilitating introductions. It is important to recognize that partnerships need to be built at multiple levels of each organization.
Seek External Support – Housing organizations may consider approaching local foundations to seek support. For example, they might seek philanthropic funding to build internal capacity or, should the opportunity present itself, to support a pilot project with a health care entity.
Recognize This Takes Time – Most of all, housing organizations, especially those that are new to collaborating with health entities, should recognize that building the relationships that lead to formal partnerships takes time. Relationships may build over time through smaller projects and then advance to bigger ones. This was the case with the partnership between United Healthcare and Arizona-based Chicanos Por La Causa (CPLC). This relationship started with a “getting-to-know-you” period, followed by a modest partnership to develop software to help a CPLC health center track its clients and service referrals. It then grew into a pilot program to improve the health of low-income people with diabetes. The success of that pilot program led to greater joint investment into staff who were placed at the CPLC health center, and ultimately led to a $20 million investment by United to CPLC to renovate 500 apartments for low-income and market rate housing. The United Healthcare and CPLC collaboration is a remarkable success story, but one that took over five years to build.
Four Case Studies Show What’s Possible
Housing Partnership Network, our members, and the Center partnered to find ways to make partnerships between the health and housing sectors mutually beneficial and encourage increased engagement not only to improve the health and well-being of our communities, but also to increase business efficiencies, reduce population health risk and prevent overutilization of costly health resources. The Center’s work with four HPN members, and our publication of these findings is intended to reduce the amount of discovery required for future housing organizations to dive into seeking partnerships with their local health providers. The case studies provide models for health and housing organizations to follow and advance. And the learnings from the Center are a road map for housing organizations interested in taking the first step toward successful partnerships that yield not only better health outcomes for their residents, but ongoing investments from local and national healthcare organizations – like the $1 million low-interest loan Cinnaire received as a result of their partnership with a local branch of the Trinity health system.
Case Study: CommonBond Communities
CommonBond Communities is the Upper Midwest’s largest nonprofit provider of affordable housing with services. It develops, owns, or manages more than 6,800 affordable rental apartments and townhomes throughout 57 cities in Minnesota, Wisconsin and Iowa. CommonBond serves more than 11,700 people every year, including youth, families, veterans, formerly homeless people, older adults and people with disabilities. In 2017, CommonBond’s board approved a three-year strategic plan that included the major goal of maximizing its resident services. Among the key strategies for achieving this goal was to build health and housing collaborations.
Key Findings: CommonBond has resident service coordinators in approximately two-thirds of its sites who build relationships with residents in their buildings and are trusted sources of information. The resident service coordinators’ deep understanding of resident needs allows them to provide better access to services, which is critical to improving residents’ health and wellbeing. CommonBond has additional structures in place that afford it the opportunity to learn about and track resident needs over time, including biannual resident surveys, new resident orientations, program outcomes and participation data, and the “Live Well at Home” assessment, which assesses older adults’ needs for supports that would allow them to thrive in their homes.
Key Opportunities: Utilizing resident data and clearly describing their needs will allow CommonBond to better present itself to health care entities as a valuable partner. The Center recommends CommonBond:
- Increase data collection and its understanding of resident needs, including enhancing its Resident Survey and New Family Certification/Orientation Process to gather data on a broader set of measures, such as resident hospitalization rates, readmission rates, ambulance transfers and the use of behavioral health services.
- Strengthen its value proposition by becoming more expert in a set of health care programs for low-income Minnesotans, such as the Integrated Health Partnerships (IHP) program, which aims to deliver higher quality and lower cost health care to Minnesota’s Medicaid beneficiaries using innovative approaches to care and payment.
- Establish itself as the go-to partner by engaging in local hospitals’ Community Health Needs Assessments (CHNAs) and participating in initiatives like the East Metro Mental Health Roundtable (a collaboration of law enforcement, social service agencies, health systems, hospitals, etc. that addresses mental health care in the Twin Cities) as well as two counties’ Community Health Improvement Plan (CHIP) processes, which convene public and private stakeholders to identify and tackle local priority health areas.
Case Study: Mission First Housing Group
Mission First Housing Group is a family of nonprofit organizations working together to ensure all people have access to a safe, affordable place to call home. Mission First initially provided housing for a small number of adults living with serious mental illness in Philadelphia; today, it provides a critical combination of housing and services to a diverse group of more than 4,500 residents in over 3,300 affordable apartments across the Mid-Atlantic. A key tenet of Mission First’s growth strategy is to utilize mergers, acquisitions and alliances to preserve affordable housing assets and service programs for vulnerable individuals and families. In 2014, it merged with ACHIEVEability, a West Philadelphia-based nonprofit that first provides families with stable affordable housing and then works with them over a five-year period to help them access education and job opportunities while supporting their overall health and wellbeing.
Key Findings: Mission First and ACHIEVEability already have several connections to health care organizations in place, which they can leverage to further demonstrate their value to the health care system and ultimately expand their services. For example, ACHIEVEability has partnered with a local hospital to access state funds that provide lead remediation to families referred to ACHIEVEability from that hospital. Mission First also collaborates with a nonprofit that provides mental and behavioral health case management to many of the 1,000 households referred by the city and state to Mission First. While the organizations would like to deepen this relationship, they are limited by the fact that they do not share data and lack access to health care claim data from Medicaid. Thus, they are currently unable to quantify or track the precise health care cost savings of a Housing First model.
Key Opportunities: The Center recommends that Mission First:
- Prioritize internal capacity to present itself to health care entities as a valuable partner and focus on enhancing its understanding of resident needs by analyzing information on their resident health and devoting leadership-level staff to invest in building relationships with health entities that are key opportunities for Mission First.
- Strengthen its value proposition by becoming more expert in a set of health care programs for low-income Pennsylvanians, such as Community Health Choices (CHC), a new managed care program for individuals receiving long-term services to assist them with eating, bathing, dressing, preparing meals, managing medication, and housekeeping.
- Establish itself as the go-to partner by engaging in local hospitals’ Community Health Needs Assessments (CHNAs) and participating in initiatives like Together for West Philadelphia, a new coalition including health care providers that formed to collaborate on projects for the benefit of the West Philadelphia community.
- Create an urgent care referral center in which it can co-locate and integrate with a health care provider as an onsite clinic or a host for health care provider staff who work directly with residents to ensure that support systems are in place to adequately meet resident needs.
Case Study: Cinnaire
As a Community Development Financial Institution with a presence in nine states, Cinnaire supports the development of vibrant neighborhoods by focusing on the social determinants of health, community stabilization, and economic development. With the election of Mayor Purzycki in Wilmington, Delaware, 2017 presented an opportunity for Cinnaire to play an active role in his effort to address over 1,500 vacant properties across the city. More specifically, Cinnaire was interested in establishing the Wilmington Healthy Neighborhood Initiative (HNI) that would include a revolving loan fund to help with the redevelopment of properties from the Wilmington Neighborhood Conservancy Land Bank and promote affordable homeownership. HNI would also identify and support other components of healthy neighborhoods such as improved community facilities, healthy food options, and linkages to social services.
Key Findings: The Center found that Cinnaire’s Healthy Neighborhood Initiative was consistent with the interests of area hospitals and those of the Delaware’s State Health Care Innovation Plan. The Innovation Plan, supported by a grant from the federal Center for Medicare and Medicaid Innovation, seeks to improve the health of Delawareans, improve health care quality and patient experience, and control the growth in health care costs.
Key Opportunities: The Center recommended that Cinnaire take steps to shape the direction of policy and programs toward investing in its HNI revitalization effort. These steps included active participation in the Innovation Plan’s Healthy Communities Delaware initiative, which yielded new opportunities for collaboration with health care entities and other important players, as well as relevant local and national meetings, such as the National Summit of the Root Cause Coalition, the Delaware Governor’s Conference on Housing, and the National Alliance of Community Economic Development Association’s Annual Summit.
Partnership Successes: Aided by the Center, Cinnaire met with a Wilmington-based health system, Christiana Care, to explore their interest in contributing to the HNI fund. Cinnaire also met with with representatives of Trinity Health, a health system that operates 92 hospitals across 22 states, including Saint Francis Hospital in Wilmington, which had identified expanding neighborhood development and revitalization efforts as one strategy to address public safety. Trinity Health itself has a Community Investing Program, through which it provides low-interest loans to CDFIs focused on underserved communities, and approved a $1 million loan to Cinnaire for its HNI revolving fund. This commitment has been instrumental in furthering other fundraising efforts with local financial institutions.
Case Study: The Planning Office of Urban Affairs
The Planning Office of Urban Affairs is a nonprofit social justice ministry that strives to create vibrant communities through the development of high-quality affordable and mixed-income housing, where people of modest means can live with dignity and respect in homes they can afford. The Planning Office has over 2,900 units of affordable and mixed-income housing across Eastern Massachusetts, and provides homes for more than 11,000 people, most of whom are low-income families and individuals, including the elderly, people with disabilities, people with multiple chronic conditions and those that have experienced homelessness. Many of the Planning Office’s residents have MassHealth or are dual-eligible beneficiaries with both Medicare and MassHealth. The Planning Office is focused on building partnerships with health entities in the Boston area.
Key Findings: Though the Planning Office has not yet entered into formal collaborations with health care entities, it is increasingly developing partnerships with organizations that provide other critical services to its residents, including management services at its properties serving individuals who have experienced homelessness as well as one serving as a safe haven for victims of human trafficking in Boston. In total, 16 Planning Office properties have full or part-time resident service coordinators through third party contracts with property managers or social service providers. These resident service coordinators can also collect standardized data about resident needs. Planning Office properties can capitalize on this opportunity by establishing data collection protocols.
Key Opportunities: The Center recommends that the Planning Office:
- Prioritize increasing its internal capacity including hiring mid-level staff who can lead efforts to enhance the Planning Office’s understanding of resident needs by gathering additional information and devoting senior staff’s time toward building relationships with health entities. This will bring high value to health care entities.
- Strengthen its value proposition by becoming more expert in health care programs serving low-income people in Massachusetts, such as the state’s Accountable Care Organization (ACO) program for MassHealth (Medicaid) members in which provider-led organizations are paid based on care outcomes rather than on the volume of services provided. ACOs are required to conduct an assessment of each enrollee’s needs, including health-related social needs, and whether the enrollee would benefit from receiving community services like housing stabilization to address those needs.
- Closely monitor spaces where critical health care conversations are taking place, such as the Massachusetts Health Policy Commission and the Massachusetts Department of Health, to identify relevant initiatives and viable partnership opportunities. The latter, for example, has a Community-Based Health Initiative (CHI) in which it mandates that health care facilities contribute to a fund or implement their own project connected to the state’s six Health Priorities: social environment, built environment, housing, violence and trauma, employment, and education.