Between February 2018 and November 2020, the National Academy for State Health Policy’s (NASHP) Health and Housing Institute supported five multi-agency state teams from Illinois, Louisiana, New York, Oregon, and Texas in their efforts to break down internal silos and strengthen services and supports to help low-income and vulnerable populations become and remain successfully and stably housed. This report outlines each state’s successes and outcomes in areas of financing, Medicaid policy, data sharing and impact analysis, stakeholder and community engagement, and responding to COVID-19.

Executive Summary

The National Academy for State Health Policy’s (NASHP) Health and Housing Institute supported the efforts of five multi-agency state teams in Illinois, Louisiana, New York, Oregon, and Texas, to break down internal silos and strengthen services and supports that assist low-income and vulnerable populations to become and remain successfully and stably housed.

From February 2018 to November 2020, states focused their efforts on making effective use of data, partnering across agencies to strengthen services, testing new models for tenancy support services and housing referrals, spurring capital investments, and weaving health and housing priorities into state system transformation to better meet the needs of those experiencing homelessness, struggling with behavioral health or substance use disorders (SUD), and those transitioning out of institutions.

This report outlines each state’s successes and outcomes in areas of financing, Medicaid policy, data sharing and impact analysis, stakeholder and community engagement, and COVID-19 response.

• States’ Medicaid programs were critical to increase housing-related services through federal waivers, value-based purchasing programs, and managed care.
• Funding for permanent supportive housing assisted states in creating more housing options and also strengthened partnerships between Medicaid programs and state housing agencies and authorities.
• Data sharing allowed states to coordinate services for individuals across multiple systems and identify gaps in services.
• Additionally, health and housing partnerships proved vital during the onset of the COVID-19 pandemic in early 2020.

This NASHP report draws on lessons learned during this first institute.

Background

States are predominately focused on two populations when designing supportive housing programs – individuals who are experiencing or at risk of homelessness and individuals with disabilities who are institutionalized and transitioning to community-based settings. On a single night in 2019, approximately 568,000 people experienced homelessness in the United States. These individuals are more likely to have chronic medical and behavioral health conditions and less likely to have health insurance and a usual source of care. Evidence shows that supportive housing programs can decrease use of hospitals and emergency rooms, save taxpayer resources, and support improved health outcomes for vulnerable populations.

Additionally, research indicates that community-based settings are more cost effective, less restrictive, and lead to better outcomes for individuals with disabilities in institutions. One reason states are focused on people in institutions is due to the mandates set by the US Supreme Court case, Olmstead, Commissioner, Georgia Department of Human Resources et al. vs. L.C. The case determined that institutional placement of individuals with disabilities who can be served in the community is “unjustified segregation,” and therefore states are mandated to move individuals into community-based settings. Deinstitutionalization has also been reinforced as a result of COVID-19, as the virus spreads rapidly in institutional settings.

Alignment between state health and housing agencies facilitates successful supportive housing programs, enabling braiding and blending of funding sources and data sharing. For example, Louisiana developed a permanent supportive housing (PSH) program after Hurricane Katrina, using federal funding from the Department of Housing and Urban Development (HUD) and, over time, its Medicaid program. Health and housing partnerships also benefit from entering into data-use agreements that allow them to share data across agencies. Successful data sharing between state or regional Homeless Management Information Systems (HMIS) and state Medicaid programs or Medicaid managed care organizations (MCOs) improves a state’s ability to identify and engage vulnerable populations.

The Medicaid program is an important partner in efforts to stably house vulnerable populations. While the program does not fund housing, it provides essential services and supports. States can use a variety of Medicaid policy levers including Medicaid Section 1115 waivers, home- and community-based services (HCBS) waivers, state plan amendments, and Medicaid managed care contract language to promote supportive housing. In many states, tenancy support providers are reimbursed by Medicaid programs.

In addition to Medicaid coverage for services, capital and rental assistance are important components of supportive housing. Through HUD, states can access capital for PSH through the Low-Income Housing Tax Credit (LIHTC), Home Investment Partnership Program (HOME), Housing Trust Fund (HTF), and Community Development Block Grant (CDBG) program. States and housing agencies can access rental assistance through project-based vouchers, Section 8 vouchers, 811 Project Rental Assistance, and HUD Continuum of Care PSH rental assistance.

In 2020, governors in Alaska, Connecticut, Hawaii, Maine, Massachusetts, New York, Rhode Island, South Dakota, Utah, Vermont and Virginia identified housing as a priority in their state of the state speeches. With housing increasingly identified as a social determinant of health, projects such as NASHP’s Health and Housing Institute can help state officials work together toward an aligned agenda.

Project Overview

Through the Health Resources and Services Administration’s (HRSA) National Organization of State and Local Officials (NOSLO) program, NASHP convened five states through its Health and Housing Institute from February 2018 to November 2020. The institute was designed to break down silos within states to better deploy resources to improve health and housing through an aligned agenda, for those experiencing homelessness, struggling with behavioral health or SUDs, and those transitioning out of institutions. Participating states were Illinois, Louisiana, New York, Oregon, and Texas.

A key strength of the institute is the multi-sector partnerships it facilitated between state team members. Teams were composed of representatives from state agencies and departments that include aging and adult services, developmental disabilities, health/public health services, housing and community services, human services, state Medicaid programs, and mental health services. In addition to collaborating with one another, these state agencies also partnered with local housing authorities, local housing providers, and health plans to advance their goals.

Table 1: State and State Agencies Participating in the Health and Housing Institute
State	State Agencies Involved
Illinois	·       Illinois Department of Human Services ·       Illinois Department of Healthcare and Family Services ·       Illinois Housing Development Authority ·       Illinois Council on Developmental Disabilities
Louisiana	·       Louisiana Department of Health, Office of Aging and Adult Services ·       Louisiana Housing Corporation, Louisiana Housing Authority
New York	·       New York State Department of Health ·       New York State Division of Homes and Community Renewal ·       New York State Office of Mental Health
Oregon	·       Oregon Health Authority ·       Oregon Housing and Community Services
Texas	·       Texas Health and Human Services Commission ·       Texas State Affordable Housing Corporation

Project goals for the five participating states included:

• Making effective use of data;
• Partnering across agencies to strengthen services;
• Weaving health and housing priorities into state system transformation initiatives;
• Developing pilot programs to leverage health systems as housing referral sources;
• Testing the impact of integrated housing and tenancy support services on Medicaid utilization and cost, including emergency department usage, inpatient hospitalization, institutionalization, and behavioral health services; and
• Utilizing policy levers to spur capital investment in affordable housing acquisitions and/or development.

The Institute’s activities included group teleconferences, individual calls with states, annual in-person meetings (virtual in 2020) and national dissemination of state models and approaches. State officials met quarterly to discuss their project’s progress and participated in peer learning and collaboration. NASHP connected states within the institute to each other and used its broader network to connect participants to other states with relevant expertise. These relationships were cultivated through individual targeted technical assistance sessions and webinar-style presentations. Conversations between states:

• Allowed leaders to adapt other states’ resources or policies in order to implement similar initiatives;
• Helped states facing similar challenges brainstorm solutions together; and
• Served to disseminate information on cutting-edge strategies for improving health through housing.

Some examples of cross-state collaborations that occurred as a result of the institute’s work include:

• Pennsylvania presented strategies for deinstitutionalization and described the state’s approach to meeting the needs of different patients and populations as they transitioned into the community.
• The New York Department of Health presented the results of its evaluation of emergency department use before and after its supportive housing pilot.
• Illinois highlighted its Statewide Referral Network system, which links vulnerable populations who are already connected to services to affordable, available, and supportive housing.
• The Connecticut Department of Housing and Connecticut Coalition to End Homelessness described its data sharing to increase understanding of correlations between homelessness, institutionalization, and health care utilization through matching Medicaid and HMIS claims data.

Information about health and housing state models, financing, data sharing, and evidence-based models was shared through NASHP’s Health and Housing Institute landing page and state participants received monthly newsletters that included relevant health and housing resources. State participants also benefited from the guidance of an advisory committee, composed of governmental and nonprofit housing policy experts. This group assisted NASHP by identifying emerging health and housing issues or populations and important state examples.

State Approaches and Successes

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.

Financing

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 Policy

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.

Stakeholder Collaboration

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.

Responses to COVID-19

Now more than ever, when homelessness is associated with high rates of coronavirus infection and renters are increasingly experiencing housing insecurity due to financial instability, housing assistance is critical in order to improve health outcomes and prevent individuals from living on the street or in crowded shelters. Given the extent of the public health emergency, there is an urgent need to help people access emergency housing and ensure they are simultaneously receiving critical health and support services. Coordinating case management and support services to ensure medication adherence and access to benefits, such as food stamps and health care coverage, can improve both health and housing outcomes.

During the institute, states noted challenges to health and housing programs as a result of COVID-19. States rapidly set up non-congregate shelters in motels and hotels with a goal of providing case management and infection control. As states engaged in rapid rehousing, they also focused on the challenge of providing services to support the transition of housing-insecure individuals into supportive housing settings, at a time when service providers are stretched thin.

Institutional settings remain a challenge for controlling the spread of COVID-19. In Texas, the state suspended admission to state-funded living centers and local mental health authorities provided services through telehealth. In Illinois, deinstitutionalization efforts were put on pause due to logistical challenges and a desire to give residents choice in their housing. Louisiana briefly paused nursing facility transition efforts and then resumed using technology and new procedures. States are also expecting budget cuts due to the economic downturn associated with COVID-19. These cuts could impact state support for supportive housing efforts.

Despite these new challenges, states cited cross-agency relationships formed during the institute as helpful in their responses to the COVID-19 pandemic. States have used Coronavirus Aid, Relief and Economic Security (CARES) Act funding and Medicaid emergency waivers to support populations with complex health care needs and residents at risk of homelessness during the pandemic.

The CARES Act provides additional funding for states through existing federal programs, including $45 billion for the Federal Emergency Management Agency (FEMA) Disaster Relief Fund, $4 billion for Emergency Solutions Grants (ESG), and $5 billion for Community Development Block Grants (CDBG). These funds can be used to secure, rehabilitate, and maintain sites for non-congregate shelters such as dorms, motels and hotels. Funding can also be used for supportive housing services, additional staff, personal protective equipment, and more medium and long-term solutions, such as rental assistance and housing navigation services.  Here are examples of state approaches:

• Illinois provided emergency flexibility for telehealth, developed an emergency rental and mortgage assistance program with CARES Act funding, and created an interagency workgroup on housing and homelessness.
• Louisiana used four state parks and more than 30 hotels to house people experiencing homelessness and others at risk of contracting COVID-19. Through targeted outreach and Medicaid data matching, approximately 40 homeless individuals with serious mental illness (SMI) have been transitioned directly from hotels into the state’s permanent supportive housing program.
• New York State started an emotional support line for crisis counseling and developed health guidelines in light of COVID-19 for housing and homelessness providers. The state is also using PSH providers to conduct telephone COVID-19 screenings and assist residents with medication management and refills.
• Oregon has a statewide Homeless Population Taskforce led by state housing and health agencies that provides technical assistance to local housing agencies and providers. The Oregon Department of Human Services and Governor’s Office are partnering with the Hospitality Association and Oregon Cities and Association of Counties to promote available resources, including $55 million dollars in rent relief from the CARES Act. General funds of $65 million were awarded in October 2020 to acquire motel and hotels to provide non-congregate shelter for wildfire-affected survivors and immediate shelter related to COVID-19.
• Texas is allocating $33 million of its Emergency Solutions Grants (ESG) funding to local governments and nonprofits to support people experiencing homelessness. Texas also received $6 million to provide crisis counseling in nontraditional settings and funding for a mental health support line.

States are also making changes to their Medicaid programs to adapt to the new challenges from COVID-19. States can use Medicaid, Children’s Health Insurance Program (CHIP), and Disaster Relief SPAs to make changes to program eligibility and services such as telehealth. When a public health emergency is declared, states can use Section 1135 Waivers to waive or modify certain Medicaid, Medicare, and CHIP requirements. States operate HCBS programs through Medicaid Section 1915(c) waivers. Appendix K allows states to make changes to their HCBS programs during emergencies. During the COVID-19 pandemic, states have used Appendix K waivers to add telehealth and service setting flexibility, increase provider payments, expand meal delivery services, and extend provider reporting and credentialing timelines.

• Louisiana, New York, and Oregon implemented Section 1915(c), Appendix K, and 1135 Medicaid waivers to suspend prior authorization, allow for virtual evaluations, expand allowable settings and increase reimbursement for services.
• Louisiana also submitted a SPA for COVID-19 testing and telehealth coverage.

Conclusion

The five states that participated in the institute drew on multi-sector partnerships to break down silos within states and strengthen services and supports that assist low-income and vulnerable populations in becoming and remaining successfully and stably housed. Maximizing levers available through the Medicaid program was critical to increasing housing-related services and tenancy supports, including flexibility available through federal waivers, value-based purchasing programs, and managed care requirements. State and federal funding for permanent supportive housing and for training about permanent supportive housing fostered development of more affordable housing programs. Advancements in data sharing between separate systems enabled identification of gaps in services, coordination of services for individuals using multiple systems, and impact analyses that can make the case for future investments.

With the onset of the COVID-19 pandemic, cross-sector partnerships are more important than ever to provide stable housing with essential services and supports. As the five states that participated in the institute continue to advance their integrated health and housing agendas, NASHP welcomes new states to join a second Health and Housing Institute in 2021, which will draw on the first group’s lessons. NASHP will also continue to support states by identifying promising practices, connecting states with peers and experts, and disseminating models for all states to adapt to fit their needs.

Cross-state Summary Chart

This chart highlights and categorizes the work of the five states participating in the National Academy for State Health Policy’s Health and Housing Institute. It is designed to share the work and accomplishments of Illinois, Louisiana, New York, Oregon, and Texas between 2018 and 2020 as they built sustainable partnerships between their health and housing agencies and advanced health care services for individuals experiencing homelessness and housing instability.

Data Strategies

Ilinois	Louisiana	New York	Oregon	Texas
Homeless Management Information System (HMIS)/Medicaid Management Information System (MMIS) data matching		Louisiana Department of Health is working with their HMIS manager to match Medicaid eligibility records with data on individuals experiencing homelessness. The match found that 64% of the individuals in the Balance of State CoC’s HMIS data are also enrolled in Medicaid.			Health and Human Services Commission (HHSC) is collecting and comparing data from three Texas homeless coalitions on the use of Medicaid services among homeless individuals before and after receiving permanent supportive housing (PSH).
Other cross-agency data agreements	Improved matching system for the IL Statewide Referral Network online waiting lists to include more accessible features.	Working with managed care organizations (MCOs) on using Medicaid claims systems to look at high-cost, housing- insecure members.	Working with MCOs to track reductions in emergency department utilization.	Created data-sharing agreements to share HMIS data with several behavioral health MCOs and Department of Housing and Urban Development (HUD) Continuum of Care.	Established memorandum of understanding (MOU) between HHSC and MCOs to allow HHSC to collect data on the housing statistics of MCO members

Data and Impact Analysis

Ilinois	Louisiana	New York	Oregon	Texas
Evaluation		Conducted an analysis of Medicaid utilization and cost among PSH recipients pre- and post-housing, including emergency department, inpatient, and behavioral health utilization.	Analyzed data on Medicaid spending and return on investment (ROI) for 11 individuals involved in one pilot project. The Medicaid Redesign Team (MRT) Supportive Housing initiative is analyzing the impact of PSH on health care utilization and cost. Information about past evaluations here.		Analyzing health care usage among individuals for whom MCOs reported information on ICD-10 Z-codes.
Development of gap analysis	Examining the Cook County Flexible Housing Pool Pilot on increasing supportive housing and coordination between housing and health care for individuals with complex health needs for use in more rural parts of the state.		Identified a need for a housing referral process.	COVID-19 has prompted the state to consider how policies and programs affect Black, Native American, and other people of color.	Received 4,000 responses to a survey regarding the increase of options for populations with serious mental illness (SMI), Intellectual and Developmental Disabilities (ID/D), behavioral health (BH), and substance use disorder (SUD). Also conducting focus groups and interviews.
Outcomes and outcomes measures			Found a 46% decrease in emergency department (ED) visits, a 99% decrease in emergency room (ER) costs, and a 47% reduction in Medicaid costs after housing.		Developed three outcome measures: 1) Participants’ housing status before and after receiving services; 2) Their housing cost burden as evidenced by the extent to which they pay more than 30% of their median income before and after receiving services; and 3) The number of months of housing is secured at time of exiting the program.

Stakeholder/Community Engagement

Ilinois	Louisiana	New York	Oregon	Texas
Engaged MCOs/Health Plans		Medicaid MCO request for proposal (RFP) includes housing as a priority social determinant of health.	MCOs are receptive to incorporating housing into value-based payment (VBP) under Medicaid Section 1115 waiver demonstration. MCOs use case managers for referrals and rental processes. Completed five pilots of partnerships between new capital development providers and MCOs.	Developed guidance on Coordinated Care Organization’s (CCOs) contractual obligations to address housing and other social determinants of health. OHA created a new position to consider how health intersects with housing and other social determinants of health. One MCO has formed a group to consider housing as a behavioral health issue.	Worked with MCOs to identify social determinants of health and data sharing regarding members’ housing status.
Formation of an intra-agency or cross-agency team	Worked with the Division of Developmental Disabilities on its behavioral health transformation Medicaid 1115 waiver tenancy supports project. Created a statewide interagency team to address impact of COVID-19 on homelessness.	In response to agreement between the state and the US Department of Justice (DOJ), the state’s Department of Health and Louisiana Housing Corporation developed a plan to create 1,000 housing units/subsidies for individuals with SMI to be transitioned and diverted from nursing facility placement. As part of the agreement and plan, Louisiana implemented its first state-funded rental assistance program within the PSH program.	Moved pilot into a full incorporation of normal rent-up process. Offering Empire State Supportive Housing Initiative (ESSHI) providers opportunity to work with health plan and managed long-term care programs; so far responses from providers have been positive and they are in the process of setting up calls with two programs looking to engage in a partnership with managed long-term care plans.	COVID-19 response teams forming have led to collaborative information systems efforts cross-agency and cross-sector.	Public-private partnership established between nonprofit statewide housing agency and Medicaid program to provide units to enrollees who need long-term services and supports. Pilot underway to provide technical assistance to local mental health authorities on billing Medicaid for tenancy support.
Established PSH Institute to train potential PSH project teams on implementing PSH				First cohort of PSH Institute trained 10 teams across the state. The institute met for five months, after which each team had the opportunity to apply for a mini-Notice of Funding Availability (NOFA). The second cohort of 10 teams started in late 2020.	Texas State Affordable Housing Corporation is sponsoring a PSH Institute for six teams across the state to provide technical assistance to developers, service providers, and property managers interested in creating and operating supportive housing in their communities.
Focus on special populations	Working with the Division of Developmental Disabilities to expand housing services available through 811 subsidies and referral networks. Provided points in latest PSH funding round to developments partnering with health care entities.	To address the needs of persons with SMI covered under the state’s agreement with the DOJ, Louisiana increased the existing incentives and requirements for housing developers to “set aside” units for PSH  under the Qualified Allocation Plan for  Low-Income Housing Tax Credit (LIHTC) developments. Louisiana expects this will create 200 additional units for individuals with SMI.	Focusing on individuals with needs that result in high utilization of the emergency department.	Applied for Medicaid 1115 waiver for individuals with SUD that covers housing services.	HHSC is developing a Housing Choice Plan to expand housing opportunities for persons with mental health conditions, substance use histories, and/or intellectual and developmental disabilities.

Financing

Ilinois	Louisiana	New York	Oregon	Texas
Used Value-Based Payment (VBP) to incentivize housing support	Pay-for-performance 1.5% quality withhold released back to MCOs in June 2020 to address COVID-related needs.		Required plans to invest in at least one social determinant of health intervention per value-based arrangement. About 50 different VBP contracts in housing.	Medicaid CCOs are required to collaborate with community partners on housing in 2020-2024 contracts. Pay for performance 5% quality withhold released back to MCOs to address COVID-19-related needs.	Currently tracking development of VBP agreements to encourage HHSC support for measures that incorporate housing.
State funding for supportive housing	Fifth round of PSH funding awards is underway. RFA included additional points for developments that connect health and housing.	Louisiana’s PSH is a partnership between the state’s Department of Health, the Louisiana Housing Corporation, and the Louisiana Housing Authority. The program uses a variety of federal rental assistance, LIHTC, and tenancy support services funded by Medicaid. The program also includes a state-funded rental assistance program.	Conducted three rounds of conditional awards for ESSHI, which provides service and operating funding to new supportive housing developments.	Awarded $64.5 million for PSH program. Eight of ten teams that participated in the PSH institute were awarded $37.3M in housing capital financing.

Policy Change

Ilinois	Louisiana	New York	Oregon	Texas
Legislative change				Passed the Improving People’s Access to Community-based Treatment, Supports and Services Program law, which allocates funding for individuals in correctional facilities and state hospitals and continues to improve the connection between health and housing.	SB 1116 filed in 2019 to create a state tax credit for MCOs that want to invest in PSH.
State plan amendment and/or waiver drafted or approved	Approved to use Medicaid 1115 waivers for housing; may transition to 1915(i).		Submitted a 1915(b)(4) Medicaid waiver for rehabilitative housing tenancy supports. Used a Medicaid section 1115 demonstration to pilot the integration of housing and health care providers into value-based payment.	Applied for a Medicaid 1115 waiver for people with SUD that includes housing-related services.
Medicaid contract changes				During re-procurement for CCO 2.0s, added new requirements to address social determinants of health. Released a Health Related Services (HRS) Guide for CCOs that focused on housing-related services and supports that qualify under the requirements for HRS detailed in Oregon Administrative Rule (OAR) and Code of Federal Regulation (CFR) and included policy changes to encourage CCOs to increase HRS spending​.	Changed MCO contracts to require MCOs to request information on ICD-10 social determinants of health using Z codes.

State Team Facts

Illinois

State Goals

• Make more effective use of data, data matching, and demonstrating return on investment (ROI):
  • Review Medicaid data on individuals with intellectual and/or developmental disabilities (I/DD)to identify those eligible for additional housing supports.
  • Create data sharing agreementsto share data among Medicaid, I/DD, mental health, and housing
• Explore capital investment strategies for affordable housing acquisition and development.
• Develop sustainable cross-agency financing.

Partners 

• Illinois Department of Human Services
• Illinois Department of Healthcare and Family Services
• Illinois Housing Development Authority
• Illinois Council on Developmental Disabilities

State Successes  

• Received approval for Behavioral Health Transformation Medicaid Section 1115 waiver that includes pre-tenancy and tenancy supports. Under the waiver, five independent pilot programs are currently being implemented. The state is exploring use of 1915(i) Medicaid authority to implement the remaining approved pilot programs, including a tenancy support project to support individuals at risk of institutionalization and homelessness.
• Compiled information from a state-operated facility to inform interventions for super-utilizer groups in Chicago.
• Examined the Cook County pilot’s success to determine statewide implementation possibilities in more rural areas of the state.
• Worked with the Corporation for Supportive Housing (CSH) to develop a state plan for supportive housing. CSH provided education and TA with a particular focus on supporting individuals living with developmental disabilities. This population remains a priority for the Illinois team.
• Facilitated five rounds of funding for supportive housing developments of 25 units or less through the Permanent Supportive Housing Development Program, with approximately 100 units approved per round. The 2020 Request for Applications has been released, and IHDA is encouraging applicants to develop larger and more creative housing projects.

Next Steps 

• Continue review of health and hospital projects for potential state system data matching and housing initiative opportunities.
• Continue work on pre-tenancy and tenant supports for Illinois residents.
• Explore expansion or new avenues for services typically covered through Medicaid Section 1115 waivers for other populations, especially I/DD populations.

Louisiana

State Agency Partners

• Louisiana Department of Health
• Louisiana Housing Corporation, Louisiana Housing Authority

State Goals

• Make more effective use of data:

• Match Homeless Management Information System (HMIS) and Medicaid Management Information System (MMIS) data.
• Improve data systems for ongoing program management, analysis, and reporting.
• Use data to determine and demonstrate return on investment.
  • Expand PSH program to address additional needs such as state’s agreement with the US Department of Justice (DOJ).
  • Implement a pay-for-success project targeted to nursing facility transitions and/or other high-risk populations.

State Successes

• Conducted an analysis of emergency department use among permanent supportive housing (PSH) recipients pre- and post-housing.
• Developing 1,000 housing units for individuals with serious mental illness transitioned or diverted from nursing homes as part of an agreement with the DOJ.
• Added language on permanent supportive housing to final MCO procurement.
• Received 50 Non-Elderly Disabled (NED) rental subsidies as part of the team’s work to expand their PSH program.
• Awarded an additional two rounds of NED vouchers to aid in COVID-19 response.
• Received an additional 189 Section 811 Project Rental Assistance program vouchers, which are being paired with CDBG funds and LIHTC to expand the PSH program and help meet the state’s agreement with the DOJ.
• Conducted data sharing with the Louisiana Health Authority’s Balance of States Continuum of Care.
• Added additional requirements and incentives to their 2019, 2020, and 2021 Qualified Allocation Plan (QAP) for developers to set aside housing for PSH.

Data Collected

• Successfully matched 64 percent of theCoC’s Homeless Management Information System (HMIS) data with Medicaid
• Pre- and post-housing comparison study showed reduction in overall costs; decreased ER and hospital, and increased use/cost of behavioral health services among Medicaid participants housed by PSH.
  • 26 percent reduction in emergency room visits.
  • 12 percent reduction in hospitalizations.
• PSH program facilitated approximately 450 new leases during the public health emergency for homeless individuals and persons transitioning from institutions.

Next Steps

• Update analysis that used comparison group to further understand impact of PSH on hospitalization, institutionalization, and total costs among permanent supportive housing recipients pre- and post-housing.
• Continue to develop data sharing agreements with Continuums of Care to match HMIS and MMIS data.
• Work with Louisiana’s HMIS provider to automate the data-matching system.

New York

State Agency Partners

• New York State Department of Health/Bureau of Social Determinants of Health
• New York State Office of Mental Health

 State Goals

• To develop and establish pilot programs that will follow the new Medicaid Redesign Team (MRT) referral process. Through this process, the team will:
  • Engage housing providers with hospitals, MCOs, and Performing Provider Systems (health systems);
  • Utilize these entities as a new referral source to help in identifying high cost, high-need Medicaid utilizers.

State Successes  

• Developed a housing referral process that connects Managed Care Organizations and housing providers to serve homeless high utilizers of Medicaid services.
• Conducted four rounds of awards for the Empire State Supportive Housing Initiative (ESSHI),* which provides service and operating funding to new supportive housing developments. Used this initiative for MCO and housing provider referral and connections.
• Completed five successful pilot projects with housing providers and MCO partnerships. Through the pilots, the state engaged MCOs in the referral and rental process and used case managers to follow up and ensure residents were receiving any needed services and supports.
• Moved the pilot to the program level, which will be implemented in all upcoming Department of Health ESSHI capital projects.
• Collected and analyzed data on Medicaid spending and return on investment for individuals housed through the pilot project; found that Medicaid spending decreased (see data below).
• NYS required plans to invest in at least one social determinant of health intervention per Value Based arrangement and to contract with community-based organizations.
• The NYS Roadmap approved by CMS in 2019** moved forward with the medical loss ratio provisions to include social determinants of health under “other medical.”

Data Collected

Data pre-housing and post-housing for New York’s first MCO/Housing provider project (n = 11 individuals):

• 46 percent reduction in ER visits
• 47 percent reduction in Medicaid costs
• 99 percent reduction in ER costs

Source: June 2020 New York presentation slides

Next Steps 

• Conduct in-depth evaluation of Medicaid Redesign Team supportive housing initiative.
• Continue to build partnerships between MCOs and housing providers across the state.
• Implement the housing pilot state-wide across all ESSHI capital projects.

*The Empire State Supportive Housing Initiative (ESSHI) is a New York State program that provides services and operating funding for supportive housing state-wide. It serves individuals and families who are both homeless and have a disabling condition or other life challenge (e.g., serious mental illness, HIV or AIDS, youth and young adults, and seniors).

**2019 Annual Update on the New York State Roadmap for Medicaid Payment Reform.

Oregon

State Goals

• Develop and evaluate strategies for Coordinated Care Organizations (CCOs) to invest in housing services and supports in their communities.
• Facilitate meaningful partnerships between CCOs and housing entities in local communities to support CCO spending on housing-related services and supports.
• Facilitate enhancements to existing data systems so that Oregon can be equipped to enable collaboration between housing and health sectors to be effectively data-driven.

Partners 

• Oregon Health Authority
• Oregon Housing and Community Services

State successes  

• Required Medicaid CCOs to collaborate with community partners on housing and other social determinants of health in 2020-2024 contracts.
• Operated a permanent supportive housing (PSH) institute, which trained and provided technical support to 10 teams across the state. The team was awarded $64.5 million for the program. The institute met for five months, after which eight of the ten teams applied for and received $37.3 million in capital funding to aid in the development of new PSH projects.
• Released a Health-Related Services (HRS) Guide for CCOs that focused on housing-related services and supports that qualify under the requirements for HRS detailed in Oregon Administrative Rule (OAR) and Code of Federal Regulation (CFR) and included policy changes to encourage CCOs to increase HRS spending.
• Saw historic investment from the legislature to build support for housing infrastructure and services including new PSH Capital program, support services, and rental assistance.
• Created data-sharing agreements to share Homeless Management Information Systems (HMIS) data with behavioral health Managed Care Organizations (MCOs).

Data

• Found that primary care visits increased and emergency department visits decreased after individuals moved into housing.

Next Steps 

• Working with Centers for Medicare and Medicaid Services (CMS) on waiver or State Plan Amendment (SPA) for people with Substance Use Disorder (SUD).
• Implement second Permanent Supportive Housing Institute beginning in late 2020 with eight teams participating virtually.
• CCO 2.0 to include increasing health and housing integration through contract years. There will be a SDOH health metric committee and a housing metric likely by year five.
• 101 sessions will help CCOs and community providers understand Health-Related Services reporting.

Texas

State Agency Partners

• Texas Health and Human Services Commission (HHSC):
  • Medicaid and CHIP Department
  • Intellectual and Development Disabilities – Behavioral Health Services Department
• Texas State Affordable Housing Corporation (TSAHC)

State Goals

• Analyze existing data, develop data sharing agreements, improve data collection, and determine appropriate health and housing outcome measures.
• Explore and, if feasible, implement pilots/studies to test impact of tenancy support services integrated with housing on reductions in healthcare and other systems utilization in target populations.
• Explore finance models that promote housing support services.
• Increase housing opportunities for Medicaid beneficiaries and low-income individuals with disabilities.

State Successes

• Convened a diverse group of stakeholders, including housing partners that had not previously worked with the state Health and Human Service Commission. This group developed new initiatives that will increase the supply of affordable housing for Medicaid beneficiaries and will continue meeting after the NASHP institute ends.
• Completed an evaluation of existing state-funded supportive housing programs and performance metrics used by Managed Care Organizations (MCOs) to better hold MCOs accountable for serving persons with serious mental illness.
• Developed a Memorandum of Understanding (MOU) template for data matching between the Texas Health and Human Services Commission and MCOs (as well as other entities) to allow for data collection on housing status of MCO members. As of September 2020, all Texas MCOs administering STAR+PLUS (managed care program for people who have disabilities or are age 65 or older) have signed the agreement.
• Amended the Texas Uniform Managed Care Contract to require MCOs that administer STAR+PLUS to ask providers to submit claims for members that include information on ICD-10 Z codes regarding socioeconomic and psychosocial circumstances, including housing status.
• Implemented contract for a pilot to train Local Mental Health Authorities (LMHAs) on billing Medicaid for tenancy support services. The pilot is funded by CMS, Money Follows the Person Demonstration.
• Matched data on Section 811 housing applicants and recipients with data on Medicaid-eligible individuals and those who visited a Local Mental Health Authority between 2014 and 2019. Identified nearly 1,400 households (61 percent) that matched with Medicaid data and 1,800 (80 percent) who matched with behavioral health data.
• The 2020 Qualified Allocation Plan includes a new permanent supportive housing (PSH) definition that allows for more projects to get points as a PSH project. The definition removed the provision that the project cannot carry debt, which was a barrier to smaller developers.
• Sponsored workshops on developing PSH, with one day workshops held in Austin, San Antonio and Houston. The workshops provided participants with information about planning and implementing successful PSH projects.
• Provided the groundwork for launching the Affordable Housing Partnership with the Texas State Affordable Housing Corporation to develop new or rehabilitate existing housing for up to 30 households. The project is funded with enhanced match earned from the Money Follows the Person Demonstration.
• Worked with the Texas legislature to file SB 1116, which seeks to address the funding shortage for PSH developments by creating a state tax credit for MCOs that want to invest in the construction of PSH.

Data Collected

• Texas conducted an analysis of MCOs’ reporting of Z codes, which identified which MCOs were using these codes, where in the state these codes were being reported, and which codes were reported most frequently. These data were compared to members’ utilization of health care services and identified significantly higher utilization of emergency departments among individuals for whom Z codes were reported. Among these individuals, those with housing and economic problems were the most frequent users of emergency departments.
• Texas is in the process of obtaining data files from MCOs that will allow analysis of members’ housing status and health care utilization.

Next Steps

• Complete pilot on Medicaid funding for tenancy supports and develop guidance to help local mental health authorities continue to do so​.
• Complete Housing Choice Plan with recommendations for improving the housing continuum​.
• Conduct data analysis on health care costs using housing data provided by MCOs.

Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank the state officials from Illinois, Louisiana, New York, Oregon, and Texas who contributed to this report as well as Health Resources and Services Administration Project Officer Carolyn Robbins and her colleagues for their feedback and guidance. The NASHP Health and Housing Institute was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under co-operative agreement number UD3OA22891, National Organizations of State and Local Officials.