A focus on health is necessary, Enterprise explains, because “a growing body of research has shown that quality, affordable housing has significant health benefits for vulnerable populations, and that providing coordinated health services in an affordable housing setting can both reduce costs and improve health outcomes.…”
Early efforts—conducted in collaboration with LeadingAge and SAHF—centered on the Oregon Health and Housing Learning Collaborative (OHHLC) and in Enterprise-provided support through HUD Section 4 Grants to four housing providers in Oregon, each of which was developing housing plus healthcare integration strategies.
The OHHLC may be the most extensive affordable housing coalition in any community for the prime purpose of learning from each other. Comprised of nine organizations—Cedar Sinai Park; Home Forward; Central City Concern; Innovative Housing, Inc.; Cascadia Behavioral Health; Northwest Housing Alternatives; Catholic Charities; REACH CDC; and Human Solutions—its main goals are to create and strengthen partnerships of affordable housing and healthcare providers and payers and to “develop strategies that improve the health and well-being of residents, while demonstrating cost savings to the healthcare system.”
Participants in this peer-to-peer collaborative shared experiences and ideas in what many OHHLC veterans describe as “a great learning space that served as a think tank environment for health and housing.”
Oregon was selected, says Laurel Blatchford, Senior Vice President, Solutions, at Enterprise Community Partners, “because it provided a unique opportunity in 2013 to build the capacity of community-based organizations that own and develop affordable housing in Portland. A growing number of Oregonians had been struggling with housing and health issues. The state was facing a $3.5 billion budget crisis, and there was concern that community-based organizations could be facing a shift in housing funding. These factors, paired with a new care model—which encouraged all healthcare providers to coordinate their efforts—introduced in 2012 thanks to federal changes to Medicaid and state-driven healthcare reform, created an opportunity to rethink ”how affordable housing residents access healthcare and the quality of their care.” Central to this, Blatchford emphasizes, was “to consider solutions outside of the traditional boundaries of healthcare services.”
Health in Housing: Exploring the Intersection Between Housing and Healthcare, published in April 2016, examines initiative-supported work in Oregon—and is among the first and most comprehensive studies examining the link between affordable housing and health.
Commissioned by Enterprise, the Portland-based Center for Outcomes Research and Education (CORE), at Providence Health Services, partnered with Health Share of Oregon, a local Medicaid coordinated care organization (CCO). They accessed a comprehensive Medicaid claims database to assess utilization and costs related to physical, behavioral health and dental claims; this database was then matched to 145 affordable housing properties in and around Portland.
The study’s population included residents of affordable housing living in family housing, permanent supportive housing, or housing for seniors and people with disabilities. In all, 513 residents were surveyed about their health care status, access and quality. The study also analyzed Medicaid claims data of 1,625 residents to measure changes in health care cost and utilization after moving into affordable housing.
Evidence of success
“The report provides invaluable insights on how we can work with new partners and advance programs that fulfill the promise of accountable care,” noted Health Share of Oregon CEO Janet L. Meyer. “Stable, affordable housing provides the foundation to provide readily accessible, patient-focused health care.”
Among the study’s findings:
- Total Medicaid expenditures declined by 12%, with the greatest savings among seniors and people with disabilities at 16%
- Outpatient primary care use increased 20% while emergency department use fell by 18%
- Residents reported improved access to health services and quality of care, with about 40% saying it was better after move-in
- Housing with integrated health services was a key driver of healthcare outcomes, suggesting that increasing these services may result in even greater cost saving
- Monthly savings per resident were $48 for “permanent affordable housing” and an additional $115 a month in savings for residents who also had “access to integrated medical services”
Megan T. Sandel, MD, MPH, Associate Professor of Pediatrics, Boston University School of Medicine calls the study “pioneering,” and says it can “elevate” public discussion because it documents that “housing is a critical vaccine that can pave the way to long-term health and well-being.”
Missing, according to Blatchford, are “replicable models for how coordinated partnerships can be effectively designed and operated.”
“The challenge,” she explains, “is demonstrating through research and action that we can design and build for improved health outcomes, incorporating healthcare services, and that there is a measurable social, environmental and/or economic return. The connection may seem apparent on an intuitive level but that’s not enough to disrupt the status quo.”
Meanwhile, Enterprise’s Health and Housing Initiative continues to generate momentum.
In Oregon, next steps include a Medicaid Flexible Funds pilot project that uses Flexible Funds—which by Oregon law can be shifted from one purpose to another within a county—and philanthropic funds to provide rental assistance and housing supports to people experiencing a health and housing crisis. This project will develop metrics to track the health outcomes and Medicaid costs to see if this is a more effective early intervention than traditional clinical interventions.
This pilot will test for what Enterprise describes as “Medicaid Flexible Services funding for rental assistance, eviction prevention, rapid re-housing, transportation and service coordination for people experiencing a health and housing crisis.”
At the same time, Enterprise is also partnering with the Jewish Community Housing for the Elderly and Leading Age to study the impact of affordable housing on healthcare. The goal, according to Blatchford, is to demonstrate that service-enriched housing reduces Medicare/Medicaid spending for seniors; identify the impact of specific services on spending rates; and demonstrate a positive return on investment for housing-based services.
And, the “Learning Collaborative” model itself is a learning process. Learning Collaboratives are flexible. Major variables include grants; in the case of the OHHLC, Enterprise gave grants to some member organizations, but also invited as members those who had applied and been rejected. All joined.
The basic goal of Learning Collaboratives, according to an Enterprise spokesperson, will be unchanged: “a transformative shift” that, among other things, “breaks down silos between affordable housing/community development and other sectors like health, education and transportation.”
Thus, Enterprise plans to keep encouraging what Blatchford calls “deep partnerships among affordable housing, health and service providers.” She also says
Enterprise can see “the momentum building in various cities, including Los Angeles and Denver.”
These efforts coincide with changes suggested in the Health in Housing study—which includes that the U.S. Department of Housing and Urban Development invest more in Section 4 grant dollars to build the capacity of community development organizations, and the U.S. Department of Health and Human Services provide more support for housing organizations to collaborate on housing and health.
Designing for health
“Housing-based health services” highlights the new terrain Enterprise is already exploring—the actual physical characteristics of housing.
At Enterprise, says Blatchford, “we’re demonstrating that the health and housing industries can design and build for improved health through ‘active design’—simple, low-cost things like improving stairwell access and visibility to encourage daily exercise and social interactions can improve physical and mental health, which is especially significant among low-income communities that experience high rates of obesity, heart disease, diabetes and mental health issues.”
In pre-design and continuing throughout the project, she says, developers must collaborate with public health professionals and others “to enhance health‐promoting features of the project and minimize features that could present risks to health.” Thus, Enterprise has already released Aging in Place Principles and other publications that address the built environment.
Such concern for health may sound like a new burden for developers, but it is already familiar. “Buildings must accomplish many tasks,” writes cultural scholar Witold Rybczynski in How Architecture Works: A Humanistic Toolkit, which argues that buildings must also “take into account long-term use, as well as immediate impact.” In this spirit, adding an extra dose of health to housing seems only natural.