NASHP compiled a fact sheet on each state’s goals and successes along with a Cross-State Summary of Successes and Outcomes from 2018-2020 to briefly capture the work of the five participating states. The information was categorized according to whether it addressed financing, Medicaid policy, data sharing and impact analysis, stakeholder and community engagement, or COVID-19 response. The following sections describe key issues that states addressed in their efforts to align health and housing agendas, along with approaches and successes.
Successfully and affordably housing individuals experiencing homelessness or moving out of institutional settings requires funding for health services, capital, and rental assistance. State agencies access federal funding through a variety of federal programs to provide affordable housing and appropriate services, and some states also allocate funding from their state budgets for these programs and services. Blending and braiding available funding to meet the variety of needs requires alignment between health and housing programs.
Supportive housing for individuals is assisted by capital and rental assistance. For capital, state housing agencies receive the Low-Income Housing Tax Credit (LIHTC) from the Internal Revenue Service (IRS). This tax credit is then provided to developers through a qualified allocation plan (QAP). HUD provides rental support through the Housing Choice Voucher program, Section 811 Project Rental Assistance, and Continuum of Care Rental Assistance. States can also use Community Development Block Grant (CDBG) funding, administered by HUD, to create and restore housing stock. CDBG can also be provided to help developers make units more affordable for tenants needing supportive housing. For example, Louisiana has used CDBG disaster recovery funds after Hurricane Katrina and subsequent disasters.
Medicaid plays an important role in supportive housing efforts. As a jointly administered federal-state program, states enter contracts with the Centers for Medicare & Medicaid Services (CMS) through state plans. States can use state plan amendments (SPAs), Medicaid Section 1115 waivers, and 1915(c) and 1915(i) Home- and Community-Based Services (HCBS) waivers to change their state plans and provide supportive housing services to specific populations. This flexibility allows Medicaid programs to go beyond traditional case management and identifies pre-tenancy and tenancy supports as separate, reimbursable services by Medicaid. Tenancy supports can include rental application assistance, communication with landlords, and assistance with developing living skills, medication management, and accessing community resources.
Other programs that fund supportive housing services include Ryan White, administered by the Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the US Department of Veterans Affairs, the CDBG administered by HUD, and the Social Services Block Grants administered by the Administration for Children and Families.
Blending funding from federal and state sources for capital, rental assistance, and supportive services is essential for supportive housing programs for individuals with complex needs. States can also braid public funding with private and philanthropic investment in social impact bonds and pay-for-success programs.
Institute member states implemented different financing models for supportive housing programs and housing stock. Financing solutions used by members included Medicaid value-based purchasing, pay-for-performance quality withholds, and state funding for supportive housing.
A majority of state Medicaid programs contract with MCOs to provide services. MCOs are important partners for housing support services and can connect Medicaid enrollees experiencing homelessness with services. Value-based payment (VBP) allows state Medicaid agencies through their MCOs to hold providers accountable for the quality of care provided. In New York, the state requires plans to invest in at least one social determinant of health intervention in their value-based arrangement and there are roughly 50 different VBP contracts in housing. In Oregon’s Coordinated Care Organization (CCO) 2.0 re-procurement, Medicaid CCOs will be required to collaborate with community partners on housing initiatives. Texas is currently tracking the development of VBP in Medicaid MCO contracts in order to implement models through its Health and Human Services Commission.
Two states, Illinois and Oregon, released a quality withhold back to their MCOs in order to address COVID-19-related needs. Oregon released a 5 percent quality withhold and Illinois released a 1.5 percent quality withhold in June 2020. In Illinois, MCOs spent their quality incentive on behavioral health, peer support programs, telemedicine infrastructure, and supportive housing.
State funding for supportive housing is an important financial resource to maximize available housing units, manage waiting lists, work with landlords, and administer subsidy programs. Illinois, Louisiana, New York, and Oregon funded permanent supportive housing programs.
- In Illinois, the state funded five rounds of PSH, with additional points rewarded to developments that integrate health and housing.
- In Oregon, $64.5 was awarded by the state for its PSH institute, which enabled teams to learn how to develop housing with supportive services. The institute included 10 teams, eight of whom received $37.3 million in capital financing.
- Texas worked with the Corporation for Supportive Housing to provide technical assistance to housing developers, service providers, and property managers interested in supportive housing in Dallas, Fort Worth, Houston, and Brownsville.
Also as a result of the institute:
- Several states integrated supportive housing into their qualified allocation plan (QAP). In Louisiana, additional points are awarded to developers who allocate 5 to 15 percent of units for the state’s permanent supportive housing program.
- In Oregon, the QAP awards additional points for projects that are aligned with a CCO’s community health improvement plan’s focus on housing.
- Texas removed a barrier for developers with debt and the 2020 QAP includes a definition of PSH and additional points for participating developers.
Medicaid programs are federal-state partnerships that permit the state to develop its specific program through a state plan with CMS. States can adapt their state plans by submitting state plan amendments and waiver applications. Medicaid cannot provide financing for housing or rent, but it can provide pre-tenancy and tenancy support to make sure individuals locate, secure, and remain safely housed. Examples of tenancy supports include:
- Education and training on the role, rights, and responsibilities of the tenant and landlord;
- Early detection and intervention for behaviors that may jeopardize housing, such as late rental payment and lease violations;
- Assistance with the housing recertification process; and
- Coordination with services and service providers for primary care, SUD treatment, mental health providers, and vocational and employment support.
To improve their health and housing programs, states enacted legislation, implemented Medicaid waivers or SPAs, and changed Medicaid MCO contracts to integrate supportive housing into their Medicaid programs.
- In Illinois, the state used a Medicaid Section 1115 waiver to provide pre-tenancy and tenancy support services to individuals with behavioral health needs, at risk of homelessness, institutionalization, and/or frequent users of emergency department services.
- New York used a Medicaid Section 1115 waiver to pilot VBP for housing support services and to add home rehabilitative services and tenancy sustaining services to individuals who meet HCBS eligibility criteria.
- Oregon passed SB 973, the Improving People’s Access to Community-Based Treatment, Supports and Services (IMPACTS) program to provide support services and PSH for individuals with mental health concerns and SUD that result in their incarceration or institutionalization.
- Oregon has a pending Medicaid Section 1115 waiver to provide people with SUD transitional housing support services and tenancy sustaining services.
In addition to state legislation and Medicaid waivers, states can use Medicaid managed care contracts to leverage what services Medicaid provides.
- In Oregon, CCO 2.0’s re-procurement includes requirements for MCOs to address social determinants of health including housing.
- Texas changed its MCO contracts to require MCOs to request information on ICD-10 Z codes which include information on patients’ social needs.
Data Sharing and Impact Analysis
States use Homeless Management Information Systems (HMIS) to collect and aggregate demographic and service-use information for individuals experiencing or at risk of homelessness. HMIS is an important tool for tracking population-wide housing needs, and when used in conjunction with Medicaid data, it can help identify individuals in need of both housing and health-related supports and strengthen care coordination.
One critical barrier to breaking down health and housing agency silos and providing coordinated services for individuals is separate and isolated data systems. Medicaid uses the Medicaid Management Information System (MMIS) to store health-related claims and eligibility data, while housing providers use HMIS. Interoperability of these systems is limited. Institute member states have therefore focused on improving health through housing by advancing data sharing and matching between separate data systems to identify and coordinate services for individuals using multiple systems.
Most of the states in the institute are working to improve data-sharing capabilities between MMIS and HMIS and/or matching MMIS and HMIS data in order to identify high-cost, housing- insecure members or provide housing data to behavioral health MCOs. States have used memorandums of understanding (MOUs) between health plans and housing agencies to facilitate this data exchange and matching. This allows for better identification of individuals who are both Medicaid recipients and experiencing housing instability. States are also using this information to identify individuals in their housing systems who frequently utilize the emergency department (ED) or have high health care costs. These data can help states improve care coordination across sectors and reduce costs.
Additionally, states are working to conduct impact analyses to identify gaps in services and to measure and track progress. States collect data from various agencies and providers in order to evaluate the impact of housing initiatives.
- In Louisiana, staff looked at Medicaid claims and encounter data to evaluate emergency department, inpatient hospital, and institutional utilization pre- and post-permanent supportive housing.
- New York analyzed its data on Medicaid spending pre- and post-supportive housing to determine its return on investment of permanent supportive housing.
- Oregon analyzed costs to the health care system, the number of primary care visits, and patient reports of access to care after individuals moved into affordable housing.
- Texas is using data collected via ICD-10 Z codes to determine whether there is a correlation between Z codes reported and health care costs for individuals.
Finally, most states are working on some form of gap analysis to determine what housing resources are needed and to understand the unique needs of various populations across the state. Details of the states’ findings can be found in the appendices.
States’ cross-agency partnerships were at the core of NASHP’s Health and Housing Institute. Every state formed an intra-agency or cross-agency team that brought together individuals from the health and housing sectors. Many of these teams also collaborated with other stakeholders to advance supportive housing initiatives. Among these are the Division of Development Disabilities (Illinois), Medicaid MCOs (Louisiana, New York, and Texas) or CCOs (Oregon), local mental health authorities (Texas) and continuums of care (Illinois and Louisiana).
MCOs have been a critical partner for improving health through housing. States have found ways to incentivize plans to invest in housing and other social determinants of health and worked with plans to identify members in need of housing assistance. States have designated positions within their Medicaid agencies to focus on housing and social determinants (New York, Oregon), and some MCOs have followed suit by designating housing coordinators or case managers (New York). State have developed guidance and contractual obligations for Medicaid MCOs to address housing and other social determinants of health.
States have also encouraged housing providers to become involved in supportive housing. Two states (Texas and Oregon) established Permanent Supportive Housing Institutes to train teams on opportunities for developing PSH. The institutes vary in size, ranging from six to ten teams from across the state. During the PSH Institute, state leaders provide technical assistance to developers, property managers and/or service providers detailing how to create and operate permanent supportive housing. Other states are working to engage the community by targeting initiatives to certain subpopulations, including expanding housing for individuals with severe mental illness or substance use disorders.