Providing reasonable accommodation to individuals with disabilities in compliance with the Department of Housing and Urban Development’s Fair Housing Act requirements is an important role for housing providers, and state leaders can help guide them through the process. NASHP recently added new resources exploring HUD’s reasonable accommodations requirements to its Housing and Health Resources for States webpage. The new additions are designed to help states understand reasonable accommodations requirements and the appeals process.
When Rhode Island health policymakers read the U.S. Centers for Disease Control and Prevention’s Healthy People 2010 report, they realized their children’s generation could face a shorter life expectancy than their own unless they changed their approach to public health. In response, Department of Health officials doubled down on their commitment to address health disparities and improve the social factors that directly affect health, such as housing and nutrition.
At the same time, they understood they needed a new financial approach to support their growing focus on improving health and health equity and reducing obstacles such as poverty, discrimination, poor education, and unsafe environments. Their solution: braided funding from a number of sources to help realign staff, break down organizational silos, and promote cross-sector collaboration.
The department first tested its innovative, collaborative approach through integrated projects, such as bringing together staff from diabetes, obesity, and maternal and child health programs and recruiting community partners to work on a shared initiative. When those initial projects proved successful, they took stock of their funding sources and looked for opportunities to divest from disease-specific funding sources and invest instead in more community-focused funding.
“Where is the funding for doing this kind of work?” observed Ana Novais, executive director of health in Rhode Island’s Department of Health. “There is no health equity funding being given to us, but nearly every proposal or grant we receive mentions health disparities.”
Rhode Island ultimately designed a method for “braiding” together funds from several sources to support its work to improve health equity. Officials wove together federal funds from the Maternal and Child Health Bureau of the Health Resources and Services Administration, the Substance Abuse and Mental Health Services Administration, the Preventive Health and Health Services Block, and two different chronic disease grants from the U.S. Centers for Disease Control and Prevention. They combined these federal funding streams with state funds, designed their work plan to meet both the department’s health equity goals as well as the various federal grants’ requirements, and then requested proposals from community organizations to improve health equity.
Novais explained the proposal asked communities to define themselves as health equity zones and submit proposals to prevent chronic diseases, improve birth outcomes, and improve the social and environmental conditions of neighborhoods across the state. See NASHP’s In the Zone for more about Rhode Island’s work to advance health equity and community health.
Novais recently shared her expertise and experience when she chaired a session on braiding and blending funds for improved population health at the annual 2017 NASHP state health policy conference held in late October. The session, presented in partnership with the de Beaumont Foundation, also featured state officials from Louisiana, Vermont, and South Carolina. Each state uses innovative braiding or blending models to address non-clinical health needs that affect public health through programs such as supportive housing and nurse home visiting for low-income, first-time mothers.
These innovative strategies may become even more important — and more widespread — in the wake of federal proposals to create block grants and cut state public health funding. A number of state health policymakers expressed concern that the flexibility provided by block grants may not adequately compensate for cuts to already lean public health budgets. To help state health policymakers prepare for and respond to such proposed changes, NASHP, the de Beaumont Foundation, and the Association of State and Territorial Health officials recently convened a group of state health policymakers from 11 states to strategically address opportunities and challenges that may result from potential changes to the federal funding landscape.
A new NASHP report, Blending, Braiding, and Block-Granting Funds for Public Health and Prevention: Implications for States, charts a way forward for states interested in maximizing their abilities to coordinate work and resources across programs. It distils ideas from the recent meeting of state leaders and explores state responses to possible federal funding scenarios. The report also:
- Surveys historic and existing sources of block grants and disease- or condition-specific federal funding;
- Examines how states currently use those funds; and
- Poses key questions for officials to ponder in the months ahead.
In this time of rapid policy changes, it is important to learn from states working to align their funding sources to advance their population health and prevention goals. “This paper is an important and much-needed resource for state officials seeking to improve health and health equity by investing in building stronger, healthier, and more resilient communities during this time of change,” said Novais.
Presented in partnership with the de Beaumont Foundation.
More than 200 state health officials crowded into a National Academy for State Health Policy’s (NASHP) annual conference session recently to learn about strategies to improve population health and reduce costs while simultaneously transforming their state’s health care finance and delivery models.
|An Accountable Community for Health (ACH) is:
They came to hear representatives from California, Michigan, Oregon, and Washington State discuss their approaches to building population health priorities into their health system transformations through “accountable health” organizations. These entities invest in population health improvement through Accountable Communities for Health (ACHs) and care delivery structures that are accountable for population health, such as Accountable Care Organizations and Coordinated Care Organizations (CCO).
During the standing-room-only session, the four state presenters described their unique models, including financing and measurement strategies and relationships to broader health system transformation. Officials shared examples of how these new delivery models invest in social determinants of health to increase health and well-being and control costs. Examples include:
- Several of California’s Accountable Communities for Health have chosen to focus on reducing violence and trauma as a priority. One conference participant observed, “It doesn’t matter how many times people who are victims of domestic violence see a doctor, it won’t improve their health until the violence stops.”
- Michigan’s Community Health Innovation Regions identified the intersection of housing, homelessness, and health as a priority area. Its goal is to strengthen collaboration between health and housing agencies and develop solutions for Medicaid beneficiaries whose housing needs put their health at risk.
- Oregon CCOs’ global budgets give them flexibility to provide non-medical services that result in better health and lower costs, such as supporting home improvements and rental assistance, embedding mental health professionals in school systems, and promoting gym memberships.
- Washington state’s Accountable Communities of Health are addressing the opioid use public health crisis.
During the conference, NASHP also facilitated a half-day convening of state policymakers from 10 states, across departments and agencies, to advance state accountable health models. During the session, state officials discussed models, shared strategies, and identified multi-sectoral funding to support their focus on population health, health disparities, and social determinants of health. This cross-sector convening included officials from Medicaid and public health agencies and state health transformation offices, along with some key partners.
NASHP will continue to convene meetings, analyze, and report on the evolution of these state models, and build on previous analysis of State Levers to Advance Accountable Communities for Health, to help states advance these transformational efforts. Stay tuned for an upcoming cross-state comparison chart and accompanying issue brief that share lessons and themes related to accountable health models gathered during the NASHP annual conference.
For more information about NASHP’s work on state accountable health models, e-mail NASHP Senior Program Director Jill Rosenthal at firstname.lastname@example.org.
Individuals experiencing homelessness are disproportionately impacted by chronic medical and behavioral health conditions, and many of these individuals lack health insurance or a usual source of care. State Medicaid agencies and safety net providers are important partners in meeting the medical, behavioral health, and social service needs of individuals and families experiencing homelessness. In this new issue brief, along with the companion summary, NASHP explores how states have leveraged a range of federal authorities and care models to increase access to housing-related services, including Section 1115 Demonstrations, home and community-based services waivers and state plan options, contracted managed care organizations, accountable care models, and the health home state plan option. For additional information and detail, please see the full issue. This work was funded through a cooperative agreement with the Health Resources and Services Administration.
States are increasingly looking at housing as a component of health and well-being, particularly for individuals who are homeless or at risk of becoming homeless. Numerous studies show that housing supports for certain populations can improve health and reduce hospital expenditures and other costs for state and local governments. Some states are leveraging federal health care reform initiatives and Medicaid waivers to pay for housing services and supports; others are exploring private investment to support state efforts or examining successful local initiatives. In fact, the Centers for Medicare and Medicaid Services (CMS) Center for Medicaid and CHIP Services (CMCS) recently issued a bulletin describing state options for using Medicaid funding to support housing-related activities. Watch for additional NASHP projects on health and housing, as we bring our cross-agency Medicaid, public health, and behavioral health policy experience to bear on the pressing issues of health care and homelessness.
This chart contains state strategies to support health through housing services. The information is derived from state and federal documents, program descriptions, and other sources you will find linked in the text below. Special thanks to the Corporation for Supportive Housing, whose resources on Medicaid and housing have been invaluable.
Do you know of any state activities or emerging strategies that belong in this chart? Are you eager to update a fact we’ve included? Please send your suggestions, corrections or additions to email@example.com. We rely on your contributions to keep our community’s real-time learning fresh and relevant. Thank you!
|Initiative Name||Funding Mechanism||What is Paid For||Target Population||Notes||Partners||Status|
|California||California Bridge to Health Reform||1115 waiver proposal||Rental subsidies, housing-based case management services, recuperative care.||Individuals who:
||Concepts: “Health plans could use a portion of capitation payments to pay a case rate for housing-based case management services for eligible populations.”The Integrated Care Savings Pool [plans, counties, local donors contribute] would be used to fund rental subsidies, housing-based case management services, and recuperative care for eligible populations.”Alternatively, the State would allow health plans to fund housing costs as allowable costs for eligible populations.”||Regional partnerships of managed care organizations, city and county governments, hospitals, and housing and social service providers.||Proposal submitted March 2015; pending|
|California||ACA Section 2703 Health Homes||A care manager will facilitate referrals to supportive housing and social services.||High-cost, high-risk individuals with chronic conditions and/or serious and persistent mental illness.||Community-based care management entities (FQHCs, hospitals, clinics) and community support services.||Intends to submit 2703 SPA application in summer/fall 2015.|
|California||Los Angeles County Housing for Health||County funding–Housed within the LA County Department of Health Services (DHS)||High utilizers of DHS services with complex medical and behavioral conditions.||Housing for Health is a county-run program that integrates health and behavioral health care with stable housing.||Case managers, health care providers, housing finance agencies, housing developers, philanthropic entities.||Active|
|District of Columbia||1915 (c) waiver||One-time transitional services, including security deposits, furniture and linens, set-up fees or deposits for utilities. Lifetime max. of $5000 per individual.||Individuals with intellectual and developmental disabilities.||Providers of services including supportive employment, habilitative, and shared living services.||Active|
|District of Columbia||DC Permanent Supportive Housing Program||District Department of Mental Health funding||Permanent housing and supportive services||Homeless individuals and families who:
|Housed in Department of Human Services; Department of Mental Health uses its own funds to subsidize rent, and works with the DC housing authority to get rent subsidies.||District shelters or homeless service providers assess potential beneficiaries.||Active|
|Illinois||The Path to Transformation||1115 waiver proposal||Performance incentive payments to MCOs could be reinvested into supportive housing capital, rental assistance, or services.||Individuals with serious mental illness and/or substance use disorders, including those who are homeless.||Illinois’s 1115 waiver would incentivize Medicaid health plans, Accountable Care Entities, and Care Coordination Entities who are at risk financially to invest in housing and housing supports for their patients by establishing an incentive-based bonus pool.||MCOs||Pending|
|Louisiana||1915 (c) [and other 1915 waivers] Home and Community- Based Services waivers||Support for acquiring and securing housing, budgeting, establishing credit, and meeting tenancy obligations. Communicating with landlords about necessary accom- modations for disability. Also provides assistance when housing is jeopardized.||Individuals with a significant, long-term physical disability, and disabilities related to behavioral health and who meet low-income requirements.||Permanent supportive housing is part of the Community Choices 1915 (c) waiver.||Louisiana Housing Corporation||Active|
|Massachusetts||Pay for Success||Social impact investment:
||Supportive housing||Chronically homeless individuals||The initiative aims to provide up to 500 units of housing over six years.||Corporation for Supportive Housing, Mass. Housing & Shelter Alliance, United Way||Launched in December 2014|
|Minnesota||Hennepin Health (Hennepin County)||Medicaid ACOs||Housing and transportation assistance, work and financial support, care coordination. Housing navigation services to prioritized population.||Medicaid recipients who are enrolled in the Hennepin Health Managed Care Organization, including adults, families and children who are: homeless or unstably housed, identified as high risk for future costs, and whose health is directly impacted by their housing.||A 2014 Health Affairs article on Hennepin Health found that the program shifted care from hospitals to outpatient settings.||County Human Services and Public Health Departments; Metropolitan Health Plan, NorthPoint Health and Wellness Center; Hennepin County Human Services.||Active|
|New York||Health Home SPA||Comprehensive case management; health home networks partner with supportive housing providers.||Individuals with chronic conditions, including mental health or substance use disorders.||More information available here, here, and here.||Supportive housing providers, shelters, corrections systems.||Active|
|New York||DSRIP/1115 waiver||Supportive housing services||Medical or behavioral health patients who are at risk during transitions into the community.||Select DSRIP projects address supportive housing.||Community housing providers home care service providers, others.||Active|
||Community organizations; state and county agencies.||Active|
|Oregon||Oregon Congregate Housing with Services (Pilot sites)||SIM||Social, support, and health services provided to individuals living in low-income housing or communities.||Low income single adults and people with disabilities in subsidized low-income housing or other low-income communities.||More information in the SIM grant narrative.||State agencies; housing, mental health, CCO constituent service organizations.||Active|
|Texas||DSRIP/1115 waiver||Varies by regional project:Supportive housing services; transitional housing services; patient navigators.
||Varies by regional project: Adults with SMI, HIV or TB; teens and young adults; chronically homeless individuals.||Other providers; community organizations.||Active|
|Texas||The Money Follows the Person (MFP) behavioral health pilot.||Money Follows the Person||A local relocation specialist works with the Texas Department of State Health Services to secure housing for individuals transitioning into the community.||Individuals transitioning from nursing facilities to the community.||See the June 2015 CMCS bulletin for more information on the Texas MFP program.||State and local housing agencies and organizations.||Active|
|Washington||Roads to Community Living||Money Follows the Person||Individualized housing-related services, including one-time-only moving expenditures. The program pays for services for one year after the person has moved into the community.||People with complex long-term care needs transitioning into the community from facilities||See the June 2015 CMCS bulletin for more information on Washington MFP program.||State and local housing agencies; human service agencies.||Active|
|Washington||Section 2703 Health Home SPA||Care coordination including referrals to housing resources.||Individuals with at least one chronic illness and at risk for another.||More information is available in the December 2014 interim report.||Community housing organizations; the state housing finance commission.||Active|