Dealing with health issues can be stressful and expensive. For vulnerable populations, especially people experiencing homelessness, housing instability can worsen and perpetuate health problems, and poor health can make it even harder to obtain or maintain stable housing.
By working together to serve vulnerable populations, health care and housing providers can improve health outcomes, lower health care costs, and reduce the number of people experiencing homelessness. Recent Affordable Care Act (ACA) and other health care payment and delivery system reforms have created new opportunities for health and housing providers to work together.
This brief examines key issues for health and housing collaborations and highlights lessons from three such programs: the New York Medicaid Redesign Team Supportive Housing Initiative, the Houston Integrated Care for the Chronically Homeless, and Portland’s Housing with Services initiative. We found that the challenges to health and housing integration are significant, but not insurmountable.
From conversations with health and housing policy and program experts, we found the following:
- Policymakers and providers are interested in integrating housing and health care, but lack relationships and capacity. Health and housing systems have separate bureaucracies, and federal regulations can sometimes create barriers to cross-sector collaboration. Though many experts we spoke with said that recent ACA reforms have raised awareness of housing and other social determinants of health, this awareness has not necessarily translated into new resources. Still, with strong leadership and commitment from stakeholders, several states, counties, and provider organizations have used aspects of the ACA and other health care delivery reforms to integrate housing and health services.
- Successful collaboration can occur at the state, county, and local levels. No other state has invested as much of its state funding into housing as New York, which has pursued a comprehensive and systematic approach to increasing access to supportive housing for vulnerable populations through its Medicaid reform initiatives. But integrating health with housing can also be successful on a smaller scale and with fewer resources, as other programs that have developed around the country have proven.
- Careful planning and patience are important. Fostering collaboration for new initiatives takes time and effort, beginning with deliberate planning and continuing through program operation. Some programs established communication channels and developed education, training, and technical assistance strategies to help service providers adopt new, integrated approaches to health and housing.
- Funding opportunities for collaborations are varied. In addition to leadership and planning, successful collaborations also require money. The initiatives we examined use various funding sources to provide housing assistance, health care, and other services to program participants.
- Managed care organizations face challenges collaborating with housing and other social service providers. State Medicaid programs, and particularly Medicaid managed care organizations, may be interested in helping members find housing to improve health outcomes and reduce costs. But these organizations often have limited data to inform design and reimbursement for housing-related services. In addition, the current Medicaid managed care rate setting methodology does not count certain expenses, such as the cost of housing-related services, as medical spending. Still, experts we spoke with indicated that some managed care organizations cover housing-related services for eligible members.
- Acquiring and using data to support collaboration is difficult. Health care providers and payers generally lack information about patients’ and members’ housing status. Part of this stems from a lack of data-sharing infrastructure, but providers are also frustrated by regulations guiding the disclosure of sensitive health information and requirements to obtain a person’s consent. The programs described in this brief have yet to figure out how to integrate data systems between housing and health care providers.
- Sustainability is an ongoing issue. Whether a new program is funded initially through a grant or supported by state funds, long-term sustainability is often a concern. Collecting data and building a comprehensive evaluation component into programs can be critical to demonstrating impacts on health and other outcomes and to improving collaborations’ long-term financial prospects.
Increasing activity over the last few years has demonstrated that state and local governments have tools to foster health system integration with housing and social services. They can attach incentives to health plans to address social determinants of health, create links between state and local agencies and providers on the ground, and encourage integration by establishing outcome measures. The federal government, too, can provide guidance and resources to states and localities on tools and authorities available.
But many interested in collaboration struggle with how to do it and where to start. We have developed technical assistance materials based on what we learned examining current collaborations and talking to health and housing policy experts. These guides are designed to help those interested in collaborations take the first steps in identifying and engaging partners and planning a program.