There’s a Doctor in the Building

10 min read

The alliance of Housing & Healthcare

A New Paradigm
It is a widely accepted proposition that one of the key foundations for a healthy and productive life is stable, good-quality affordable housing. Housing and health go hand-in-hand with proper nutrition, adequate employment for those of working age and secure retirement for seniors, as well as a solid, emotional support system for all. Yet for a long time, housing and healthcare have been relegated to separate realms, with little programmatic or financial connection between them.

Lately, though, there are signs that this gulf is being bridged in significant ways, creating a new paradigm in which health and housing are inextricably related. And the most significant factor in the emerging landscape is the Affordable Care Act.

According to the 2015 Health Impact Assessment of the World Health Organization, “Housing is an important social determinant for health, meaning that the quality, location and cost of housing impact residents’ health.”

Determinant is an increasingly invoked concept, underscoring the direct connection. The Bipartisan Policy Center’s 2016 report, Healthy Aging Begins at Home, states, “An ability to see important connections that span across the seemingly disparate disciplines of housing, architecture, healthcare, information technology, telecommunications, transportation, urban planning, and financial services is critical.”

Though the officially named Patient Protection and Affordable Care Act has been a partisan political football and the subject of two rancorous Supreme Court challenges since its passage in 2010, the ACA is literally changing the way healthcare delivery models, metrics and payment systems are evolving as few other factors have in recent times, especially for those served by affordable housing.

Clearly, the intended purpose of President Barack Obama’s landmark legislative initiative was to give more Americans access to regular healthcare. The actual working strategy is to improve individual outcomes while, at the same time, containing costs. Traditional terms, such as “fee for service,” are gradually giving way to new models, such as “pay for performance.” Under this standard, CMS – the Centers for Medicare & Medicaid Services that administers both programs – is imposing both rewards and penalties based on outcomes. For example, in many cases, if a senior has been admitted and treated at a hospital, is released and then must be readmitted within 30 days for the same condition, there may be a financial penalty to the hospital. CMS established a goal of tying 30% of Medicare payments to this outcome-based model by the end of 2016, but reached that threshold in March.

Measured Accountability
This type of measured accountability is leading to a natural fit between seniors and their housing providers, and the conceptual term here is “continuum of care.” [See Talking Heads] By tracking each resident’s health condition, needs, and ability to perform activities of daily living, many hospital admissions – particularly emergency admissions – can be avoided. At the other end of the process, the need for recuperating residents to be readmitted becomes less frequent. These follow-up services at the affordable housing facility may be as simple as making sure the resident understands hospital discharge instructions, as well as medication dosage and timing, or as detailed as physical and rehabilitative therapy.

Several studies have shown that if seniors have two or three days of 24-hour oversight and medication management after leaving the hospital, the likelihood of a return for the same condition drops significantly. Hospitals and healthcare facilities, recognizing the financial benefit, are often eager to participate in this approach.

This synergistic relationship goes beyond the Medicare and Medicaid parameters, with a potential to impact the entire affordable housing field. Under the ACA, as a requirement for maintaining their tax-exempt status, nonprofit hospitals must complete a community health needs assessment (CHNA) every three years. This involves determining what the community served by the hospital most needs in terms of healthcare and services, understanding the barriers to residents receiving those services, and then formulating a strategy with local stakeholders to meet those health needs.

This development gets local affordable housing providers a seat at the table in advocating for their residents’ needs, encourages local government support, and is actually leading hospitals in some areas to invest in affordable housing because they know such well-run facilities will lead to better healthcare maintenance for residents of all ages, fewer hospital readmissions of Medicare and Medicaid patients, and clear public recognition that they are fulfilling their CHNA requirements.

This is just plain good policy. According to a 2015 report by the Center for Housing Policy of the National Housing Conference, Ideas for Housing Policy and Practice by Janet Viveiros, even before ACA, “the St. Joseph Health System has invested in affordable housing in Orange County, California because it recognized the major impact the lack of affordable housing had on the health of its community.”

Beacon Communities, LLC, in Boston, Massachusetts, for example, has successfully forged relationships with a wide range of healthcare providers, including hospitals, physicians, dentists, physical therapists and psychiatric social workers, among others – all under the heading of wellness programs. And by developing standard metrics, they are able to demonstrate on the basis of outcome and expenditure which programs and efforts are yielding best practices and most cost-effective results.

Upsides and Downsides
In the senior affordable housing realm, owners and providers who go this route are becoming, in essence, care coordinators in addition to landlords. While this costs more than simply providing housing, the financial benefits to healthcare reimbursers – whether Medicare, Medicaid, state and local agencies, private insurers, or charitable organizations – is substantial, both in terms of hospitalization and avoiding temporary or long-term transfer to nursing homes. Both of these scenarios are far more expensive for the provider and disruptive to the individual than stable affordable housing.

The trend across the industry, therefore, is to be able to show that dollars from whatever source are being spent most efficiently for better outcomes and that the continuum of care approach within the affordable living facility is the most workable one for most situations. Many in both housing and healthcare predict this will become the new norm.

As with any government program, there are bound to be complications and potential pitfalls. The federal Improving Medicare Post-Acute Transformation Act of 2014 (IMPACT) requires the reporting of standardized after-hospital assessment data. The intent is to assess various types of facilities, geographical areas and approaches to see how results and “bang for the buck” compare. But some healthcare managers, both within and outside of affordable housing, have likened IMPACT to the now ubiquitous Standards of Learning operating in public schools across the country.

Teachers complain that by placing undue emphasis on meeting specific standardized educational benchmarks at the end of each academic year, they are forced to teach to test rather than produce well-rounded, inquisitive students. In the same manner, healthcare providers claim that by placing the emphasis on defined outcomes and setting payments accordingly, CMS is detracting from their ability to give residents or patients the specific care and monitoring each might need.

Accountable Care Organizations
Another new concept arising from the ACA is the ACO, or Accountable Care Organization. (As we know, in the federal government, acronyms beget acronyms, beget still more acronyms.) CMS defines ACOs as groups of doctors, hospitals, and other healthcare providers who come together to give coordinated care to their Medicare patients. The goal is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

When an ACO succeeds both in delivering high-quality care and spending healthcare dollars more efficiently, it shares in the savings it achieves for the Medicare program. This provides strong incentives for ACOs to partner with affordable housing providers to positively affect the determinants of residents’ health. This idea can be approached from either the housing or healthcare end, when both sets of providers realize they can influence each other’s performance and bottom line.

Families and Children
While most of the thrust of new integrative health and housing legislation and programs has been aimed at seniors, the ACA and Medicaid are also focusing on children of low-income households. Another 2015 Center for Housing Policy report, this one by Nabihah Maqbool, Ms. Viveiros and Mindy Ault, entitled The Impacts of Affordable Housing on Health: A Research Summary, states:

“Researchers have found that children in low-income families that receive housing subsidies are more likely to have access to an adequate amount of nutritious food and to meet “well child” criteria—including the absence of developmental concerns, maintenance of a healthy weight, and classification as being in good or excellent health – than children of similar families on the waiting list for housing assistance.”

Prior to 2013, only physicians and licensed medical practitioners could receive Medicaid reimbursement for what were termed “preventative services” to keep children healthy. But in July of that year, CMS updated its rule to allow for reimbursements to non-medical personnel so long as those services are officially recommended by a doctor or licensed medical practitioners. Guidelines vary by state, but affordable housing organizations may now seek Medicaid funding for improvements or maintenance to their facilities if they can demonstrate that such expenditures positively affect the health environments of families with children.

The idea is being adopted at the state level, too.

In New York City, Enterprise Community Partners has received a $150,000 grant from the New York State

Health Foundation to enable multifamily affordable housing building owners and public agencies to identify potential health-focused improvements in rehabs. The grant will go specifically to establish a Healthy Green Physical Needs Assessment intended to become a standard tool to help affordable housing managers and organizations ensure that their residences and programs support optimum resident health and well-being. This is part of Enterprise’s initiative targeting the relationship between housing and health, entitled Capitalizing Health and Housing.

Across the country, Enterprise supports collaborations between housing providers and the services and health communities who are working to improve resident health outcomes and better coordinate how residents receive services. So far, these include Boston,

Los Angeles and Portland, Oregon.

Throughout the nation, more state and local agencies are beginning to deal with the twin needs together as they see the close relationship between them.

Healthy Futures
Private and nonprofit organizations are routinely accepting the wisdom of merging housing and ongoing health needs. As reported in the June 2016 Tax Credit Advisor in a story about So Others Might Eat’s Conway Center in Washington, D.C., the Healthy Futures Fund (HFF) is a $200 million initiative formed by the Local Initiatives Support Corporation (LISC), Morgan Stanley and The Kresge Foundation that connects healthcare and affordable housing for low-income residents. It responds to the clear association between poverty and disease by incorporating a health lens into traditional community development work. The fund uses a unique financing structure that leverages New Markets Tax Credits, Low Income Housing Tax Credits, grants, and loans to help new developments get off the ground and to connect existing housing and health services to each other.

The takeaway message is that affordable housing and continuum of healthcare are not zero-sum games. Resources for one need not, and should not, detract from resources for the other. Rather, they work best when they work together for what the ACA drafters, sponsors, and backers had in mind: improved outcomes for all, leading to healthy lives in healthy environments.

As Viveriros’s Center for Housing Policy’s report concludes:

“The next steps for affordable housing organizations are to make connections with the healthcare community to share information; to promote housing’s role in the health of individuals, families and communities; and to learn how they can help implement the provisions of the ACA and expanded Medicaid to improve the quality of life for low-income individuals and families around the country.

“Looking forward, the affordable housing sector must help the healthcare sector better understand the value of housing organizations as stakeholders in supporting the health and well-being of low-income individuals of all ages and health needs.”