By Emma Opthof, Center for Health Care Strategies
As the older adult population in the U.S. continues to grow, so does the number of older adults experiencing homelessness. By 2030, the number of adults over 65 who are experiencing homelessness is expected to triple. This population has a complex array of health and social needs. Adults in their 50s and 60s experiencing homelessness, for example, have rates of cognitive and functional impairment, falls, frailty, chronic medical conditions, and premature death similar to or higher than 80-year-old housed adults. With this comes high medical costs and frequent and unnecessary emergency department visits.
Permanent supportive housing ― a model that combines long-term housing, health care, and supportive services, including personal care and behavioral and physical health care management ― has shown promising results in reducing homelessness and emergency department visits and hospitalizations. Commonwealth Care Alliance (CCA), a non-profit community-based payer and provider serving people with significant needs, including those who are dually eligible for Medicaid and Medicare, partnered with Hearth, a non-profit community-based organization focused on ending elder homelessness, to provide permanent supportive housing for eligible CCA members. CCA provides a wide variety of services to their plan members, including primary care, long-term services and supports, behavioral health care, community paramedicine, crisis stabilization units, telehealth, transitional care, and assistance with social determinants of health. Hearth currently operates 228 units of permanent supportive housing in and around the Boston area and provides a multidisciplinary approach to meeting resident needs.
Roughly five to 10 percent of CCA’s beneficiaries, most of whom are dually eligible for Medicare and Medicaid and over the age of 65, experience homelessness at any given time. CCA and Hearth collaborate to provide the services components of permanent supportive housing, which include home-based primary care, behavioral health care, care management, and social supports that help enrollees obtain and retain housing while addressing any other unmet health-related social needs. The Social Security Act, however, prohibits health plans like CCA from using Medicaid funds to pay directly for housing. CCA sought a solution to help their members gain access to affordable housing more quickly, which can take years in Massachusetts.
Meanwhile, Hearth was struggling to find adequate financial support to provide the quality wraparound services needed by their population of older adults experiencing homelessness. The two organizations began working together in 2004 when CCA started Senior Care Options, a health plan for dually eligible older adults. They forged a partnership in which their services fill each other’s gaps and support a whole-person approach for older adults experiencing housing instability or homelessness.
Workflow and Team Structure
Both organizations refer individuals to each other’s services. CCA members work with CCA-employed care managers who assess medical, social, and behavioral health needs. CCA members who indicate housing instability or risk of housing instability are referred to CCA’s community health workers and housing specialists to assist them in gaining or retaining housing. These CCA staff refer members to Hearth if they have a housing voucher, meet age criteria, and could benefit from supportive housing. CCA members living in Hearth housing can continue to receive CCA services, including home visits by the nurse care managers. On the flip side, Hearth staff assist residents in understanding the CCA services available to them, including health insurance options. If residents choose CCA as their plan, then they receive CCA’s care model services in partnership with Hearth’s multidisciplinary team. Currently, 17 percent of Hearth residents are enrolled in a CCA plan.
In addition to the care managers and community health workers, CCA’s interdisciplinary care teams include nurses, advance practice clinicians, physicians, and behavioral health clinicians, among other interdisciplinary staff. Hearth’s team for all of their residents includes program managers, resource specialists, an activities coordinator, clinical case managers, adult community clinical services clinicians, peer support specialists, nurse case managers, and personal care homemakers. CCA and Hearth collaborate to provide an individualized service plan using the most efficient delivery possible. Since Hearth-based staff are on-site, the partnership can address emergency events immediately and draw on CCA resources as needed for follow-up and case resolution.
Program Financing and Payment
Alignment of financial incentives between health care and permanent supportive housing can be challenging because organizations that rely on fee-for-service payments do not always have the resources or incentive to invest in housing programs. CCA is a payer and provider that bears financial risk for the total cost of care, which enables more flexibilities to create a successful partnership. Because CCA manages the full set of Medicare and Medicaid services for dually eligible members in Massachusetts, it is able to understand the scope of each member’s needs and service patterns, which helps make the program more effective and reduces some of the challenges faced in non-integrated settings. CCA provides per member per month funding to Hearth to support a portion of the services for their members housed in Hearth facilities. Hearth also receives funding through program service revenue, municipal, state, and federal agencies, grants, and donations.
Since the CCA-Hearth partnership began, more than 300 CCA beneficiaries have been housed through Hearth. According to recent analysis, permanent supportive housing at Hearth for 57 CCA members enrolled between 2015 and 2019 was associated with decreases in total medical expenses, medical expense ratio, and acute care claims, which were all growing costs prior to the intervention. Potential savings on total medical expenses were estimated to be $1,153 per member per year, while potential savings for acute care amounted to about $399 per member per year. There was a net reduction of nearly 17 percent in the medical expense ratio. Lauren Easton, VP of Integrative Program Development and Clinical Innovation at CCA, shared why she was impressed with the partnership: “Generally we see our health care costs trending down slowly after about 18 months when we engage with a member, but with this particular partnership and the data analysis we did within six months, we saw a dramatic decrease in cost and utilization. It happened very quickly when somebody was stabilized.”
Other positive outcomes related to the partnership include excellent member satisfaction from a CCA satisfaction survey and a high value case for Hearth to obtain philanthropic funding because of CCA’s access to Medicaid and Medicare claims data ― something not often at the disposal of community-based organizations.
Mark Hinderlie, Hearth’s President and CEO, shared a patient story of someone living in Hearth’s assisted living facility experiencing respiratory issues who was able to receive needed care coordination services because Hearth was able to connect her to CCA’s Senior Care Options health plan. It helped her to feel supported and avoid the emergency room, something that many Hearth residents have had negative experiences with.
Staff from both CCA and Hearth shared lessons for maintaining a partnership between a community-based organization and a provider or payer trying to address homelessness.
- Having a shared mission is instrumental. When asked about partnership challenges, staff from Hearth and CCA expressed that their partnership revolved more around opportunity and excitement, mostly due to the shared mission and the way their services complemented one another. Going to community meetings or engaging in advocacy work can help organizations find like-minded partners.
- An upfront strategy about data and evaluation can facilitate smoother operations. Monitoring and tracking data over time can help communicate impact to public and private funders looking to fund housing and health programs. It is especially important to share data across the partner organizations, not only for funding, but for quality improvement. It is important to develop data collection and storage solutions that allow for interoperable databases and real-time analytics. In addition, health care organizations should consistently capture housing status in patient medical records without making this burdensome for providers.
- A lot of the biggest challenges are outside the partnership. External forces, especially limited supply of affordable housing and the lack of understanding the importance of housing to health, can pose barriers to supporting people experiencing housing instability homelessness. CCA and Hearth believe that increased local, state, and federal public funding for permanent supportive housing is necessary to scale partnership models like theirs.
For more information on this partnership, see this article in NEJM Catalyst.
Thank you to the following individuals who helped to inform this blog post:
- CCA: Leah Smith, Director, Public Policy; Lauren Easton, Vice President, Integrative Program Development and Clinical Innovation; Michelle Herman Soper, Vice President of Policy Development
- Hearth: Mark Hinderlie, President and CEO; LaTanya Wright, Director of Outreach; Hariel Morency, Director of Behavioral Health; Linda Vendola, Controller
- Hearth Board of Directors, Research and Advocacy Committee: Rebecca Brown, geriatrician and Assistant Professor of Medicine at the University of Pennsylvania Perelman School of Medicine; Thomas Byrne, Associate Professor at the Boston University School of Social Work