Transcript Document 7310011

Redesign Medicaid in New York State
MRT Affordable Housing
Work Group
February 22, 2013 – 10:00 AM to 3:00 PM
New York State Department of Health
Metropolitan Regional Office
New York City
Goals for Today
o
Update the MRT Work Group on the progress of the sub
work groups:

o
These are ideas developed by members of the sub work
groups.
Achieve general consensus on a series of policy
recommendations.
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MRT Affordable Housing Work
Groups
o
Program Model and Development & Funding
Ted Houghton, Chair
 Brenda Rosen, Chair
 Tony Hannigan, Co-Chair

o
Planning and Service Coordination

Constance Tempel, Chair

Kristin Miller, Co-Chair
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Program Model and Development
& Funding Work Group
Program Model and Development
& Funding Work Group
1.
Identify barriers to moving high-need individuals into supportive
housing.
2.
Identify New Affordable/Supportive Housing Models.
3.
Define “supportive housing.”
4.
Advise the State on how to allocate 2013-14 MRT Supportive
Housing Funds.
5.
Advise the State on appropriate set-asides and incentives for
supportive housing.
6.
Develop principles for a new supportive housing initiative.
7.
Develop a plan to create “social impact investment bonds.”
8.
Identify ways to leverage federal and private funds.
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Updates & Discussion Items
o
Supportive housing definition.
o
MRT Supportive Housing Allocation Plan Recommendations.
o
Model Design Elements of Pilot Programs.
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Defining Supportive Housing
o
Supportive housing is defined as affordable rental housing operated
by non-profit organizations, in which all members of the tenant
household have easy, facilitated access to a flexible and
comprehensive array of supportive services designed to assist the
tenants to achieve and sustain housing stability and to live more
productive lives in the community.
o
Supportive housing units are intended to meet the needs of people
with special needs who are homeless or would be at-risk of
homelessness-or cycling through institutional care-were it not for
the integration of affordable housing and supportive services.
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Defining Supportive Housing
A supportive housing unit is defined by the following elements:
o
The unit is available to, and intended for, a person or family whose head of
household or member is homeless, or at-risk of
homelessness/institutionalization, and has multiple barriers to
employment and housing stability, which might include mental illness,
chemical dependency, and/or other disabling or chronic health conditions;
o
The tenant household ideally pays no more than 30% household income
towards rent and utilities, and never pays more than 50% of income
toward such housing expenses;
o
The tenant household has a lease (or similar form of occupancy
agreement) in permanent affordable rental housing with no limits on
length of tenancy, as long as the terms and conditions of the lease or
agreement are met;
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Defining Supportive Housing
(continued)
o
The unit’s operations are managed through an effective partnership
among representatives of the project owner and/or sponsor, the property
management agent, the supportive services providers, the relevant public
agencies, and the tenants;
o
All members of the tenant household have easy, facilitated access to
flexible and comprehensive array of supportive services designed to assist
the tenants to achieve and sustain housing stability;
o
Service providers proactively seek to engage tenants in on-site and
community-based supportive services, but participation in such supportive
servicers is not a condition of ongoing tenancy; and
o
Service and property management strategies include effective,
coordinated approaches for addressing issues resulting from substance
use, relapse, mental health crises and medical circumstances, with a focus
on fostering housing stability
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$91 Million Allocation Plan Recommendations
Approximate NYS SFY
13-14 Funding Amount
(in millions)
Total Approximate
Annual Cost (in millions)
Committee
Support
Continued Funding of SFY2012-13 Initiatives
$28.0
$28.0
96%
NFTD Housing Subsidy
$2.5
$2.5
93%
Total Existing Commitments
$30.5
$30.5
Total Capital Housing Development
$42.5
Proposed MRT Housing Initiative Spending Plan
Existing Commitments
Pilot Programs
Health Homes Supportive Housing Pilot
$5.0
$10.0
96%
Step-down/Crisis Residence Capital Conversion
$4.2
$4.2
82%
Nursing Home to Independent Living Rapid
Transition
$2.1
$3.6
OMH Supported Housing Services Supplement
$3.0
$8.0
74%
DHS Homeless Senior Placement Project
$2.5
$5.0
69%
Health Home HIV+ Rental Assistance Demo
Project
$1.2
$3.6
Total Pilot Programs
$18.0
$34.4
Total Supported Initiatives
$91.0
82/65%
58%
Pilot Program Descriptions
$34.4 million Annual Cost
$18 million SFY 2013-14
Health Homes Supportive
Cost: $10 million ($5 million SFY2013-14)
Housing Pilot Total
Per Person Cost: House and serve 500 high
cost Medicaid recipients at $20,000 each
o
Serve 500 rent and service subsidies to experienced supportive housing
services providers to house and serve unstably housed high cost Medicaid
recipients in scattered-site market-rate rental apartments.
o
Enhanced “housing first,” harm reduction supportive housing model to
house and serve persons referred by Health Homes.
o
Services will be offered in an ongoing effort to link and transition tenants to
community-based care, services and supports.
o
Person-centered, wrap-around services aimed at increasing independence
and housing stability, augmented with Health Home Care Coordination to
provide a new overlay of assistance aimed at helping tenants re-organize
medical care to reduce use of emergency systems and improve use of
preventive and primary care.
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Health Homes Supportive
Housing Pilot
o
Key program components include:

Scattered Site units available to Health Homes across state;

Funding for operating and services would be RFP’d to housing
providers applying in partnership with Health Homes;

Contracts of 25 to 50 units would be held by experienced
supportive housing providers, managed by OTDA;

Contracts will provide $20,000 per individual per year to cover
rental costs, service and support staff;
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Health Homes Supportive
Housing Pilot (continued)
o
Key program components include:

Government agency (NYC HRA, DOH, OMH SPOA) would certify eligibility;

Health Homes would manage referral process and prioritize clients for
housing;

Health Home care coordination is conducted directly by the housing
provider, or through explicit Health Home-Supportive Housing Provider
agreements that spell out how care coordination will be integrated with
housing-based services;

Specific diagnoses will not be a criteria for eligibility

Once placed in housing, tenants will receive person-centered, wraparound case management services aimed at increasing independence and
housing stability

Active, collaborative, real-time evaluation and data collection.
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Nursing Home to Independent
Living Rapid Transition
Total Cost: $3.6 million ($2.1 million in SFY2013-14)
Per Person Cost: Will serve 200 individuals at approximately $24,000
each per year
o
Offer individuals with mobility impairments or other severe physical
disabilities an alternative pathway to community living.
o
Housing subsidies, combined with MLTC enrollment or service funding will
allow targeted high cost Medicaid recipients who live in nursing homes or
are nursing home eligible to move into an apartment in the community.
o
Program activities will include educational outreach and identification of
eligible, interested and capable high cost Medicaid recipients who are
homeless or living in nursing homes with physical disabilities.
Comprehensive assessment relating to living environment, transitional
needs, and long-term care needs and customized retrofitting of
apartments will follow.
o
The individual’s move and full transition to independent living will be
facilitated by the support team of staff, funded through the MLTC waiver
or a relatively modest services contract.
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Step-down/Crisis Residence
Capital Conversion
Total Capital Cost: $800,000 (one-time cost)
One year’s operating costs: $3 million for twelve residences with 24-36 beds total (NYC-5; Long Island-2;
Rest of State-5)
Per Person Cost: 2 week avg LOS = 100 high cost Medicaid recipients in crisis.
o
Transition individuals from psychiatric hospitals into community settings
and divert individuals in crisis from use of such services.
o
Short-term level of intensive behavioral health respite care for individuals
being discharged from psychiatric hospitals, not quite ready for a full
transition into the community.
o
The designated providers would work in partnership with hospitals to
identify and assess individuals in need of transitional services, as well as
screen and assess individuals in crisis who may require short-term
diversionary placement services.
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Step-down/Crisis Residence
Capital Conversion (continued)
o
This type of pilot program would allow for a specified number of existing
community residential service providers to convert a certain number of
beds into crisis or step-down service units.
o
The proposed model would require funding for startup costs, including
one-time capital improvement dollars to reconfigure spaces to be able to
provide crisis and transitional services, and staff training.
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OMH Supported Housing Services
Supplement
$8 million ($3 million in SFY2013-14)
Per Person Cost: 1,600 high cost Medicaid recipients at $5,000 each per year
o
Supplementary funding to allow nonprofit OMH Supported Housing
providers to offer a time-limited service enhancement to SPMI high-cost
Medicaid recipients enrolled in Health Homes and living in scattered-site
apartments.
o
The augmented services will supplement the minimal services in OMH
Supported Housing in order to provide necessary day-to-day continuity of
place-based, wraparound support services through a flexible critical time
intervention approach
o
More direct and active engagement to achieve successful adjustment and
stabilization during a flexible12-month transition from institutions
(psychiatric hospitals, adult homes, shelters, street, jails/prisons) to the
community.
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OMH Supported Housing Services
Supplement (continued)
Program elements will include:

A focus on managing the social determinants of health that
impact tenure in housing.

Evidenced-based practices delivered in a housing context to
assist with the adoption of a healthy life style.

Leading and supporting the individual to engage in, and follow
up with, medical and behavioral services, in conjunction with
health home care coordination.

Connect the individual to opportunities for forging healthy and
naturally occurring relationships in the community, critical for
people with SMI who tend to isolation and recidivism to
shelters and hospitals.
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Homeless Senior Placement Project
Total Cost:$2.5 million/$5.0 million Total
Per Person Cost: 300 individuals at approximately $14,000 per person per year
o
A Housing intervention intended to reduce Medicaid spending that
is predictive – targeting a group of individuals who are likely to
become high Medicaid users rather than those that have been in
the past.
o
Among the current shelter population, there are 578 single adults
age 55 and over and receiving SSI who, as a group, are largely
defined by these characteristics.
o
Annual $2.3m in rent subsidy, $1.4m for an increased amount of
aftercare transitional services provided by shelter provider and
$300k in apartment locator, inspection and placement services.
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Health Home HIV+ Rental Assistance
Demonstration Project
Total Cost:$3.6 million (SFY 13-14: $1.2 million )
Per Person Cost: Serve 200 persons
o
Rental assistance for 200 homeless and unstably housed Health Home
participants diagnosed with HIV infection but medically ineligible for the
existing HIV-specific enhanced rental assistance program for New Yorkers with
AIDS or advanced HIV-illness (AIDS Rental Assistance).
o
Provides rental subsidies, apartment locating services, broker’s fees and
security deposits for 200 HIV+ individuals
o
Administered by Health Home providers as a component of Care Coordination
o
Available to HIV+ Medicaid-eligible households who have an immediate
housing but whose HIV disease has not progressed to the point of eligibility for
the AIDS Shelter Allowance
o
The project would employ an experimental design to evaluate health care
utilization, outcomes and costs in the periods before and after receipt of rental
assistance for the pilot group of HIV+ Health Home participants.
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Additional Considered Pilots
Senior Supportive Housing Models
o
Provide stable, affordable senior housing plus services to enable
low-income seniors to remain in the community; provide a platform
for Medicaid Managed Long Term Care and Health Home services;
and support the transition of people from nursing homes to the
community and independent living.
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Additional Considered Pilots
Senior Supportive Housing Models
Program Elements Proposed:
o
Capital grant: capital funding would be available to incorporate supportive
housing features such as universal design modifications, renovation and
reconfiguration including co-location of supportive services, gap financing
for new senior housing “pipeline” construction, security systems and other
technologies for residents to maintain safety and independence, vehicles
to provide transportation for residents, or other projects as determined by
the department of health.
o
Supportive services: assistance with obtaining meals, access to groceries
and pharmacy, transportation, referral services related to resources
available in the community, housekeeping, and security. Grant funding will
be limited to funding for the services explicitly stated above.
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Planning and Service
Coordination Work Group
Planning and Service
Coordination Work Group
1.
Improve interagency coordination.
2.
Improve the Capital Development process.
3.
Evaluate perceived barriers to utilization of supportive
housing.
4.
Provide advice on overall coordination and
implementation of supportive housing policy.
5.
Improve the coordination and timing of the availability of
housing.
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Principles to Improving Planning
and Services Coordination
o
Build upon development processes and efficiencies that
work:

New York has mature supportive housing development
system with great expertise that works well overall.

New monies (ACA/MRT, Olmstead, and yet unidentified) are
opportunity for building upon and improving what already
works.

Preserve existing successful SH models while updating/
creating others with appropriate level of services.

Facilitate growing trend of mixed population, integrated
housing.
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Principles (continued)

Ensure an active role for nonprofits

Create least expensive and quickest way to get housing to high
cost/need users

Streamlining process via coordinated requests for funding,
shared-decision making, and amending conflicting
development requirements will:

Decrease length of time to get units on line.

Decrease total costs of project development because of duplicative
development regulations and requirements.
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Current Prototype A: 60 unit, 9% LIHTC
SH project @ $275,000 per unit
CAPITAL PROGRAM 30% SPECIAL NEEDS 60% SPECIAL NEEDS
NOTES
18 High Need
18 Homeless, 18 High N
OTDA/HHAP
HCR/HOUSING
FINANCE
AGENCY/MRT
HCR/HOUSING
TRUST FUND (HTF)
_
$37,500
18 HOMELESS AT
$125,000 PER UNIT
$37,500
$37,500
18 HIGH NEED AT
$125,000 PER UNIT
$40,000
$40,000
HCR/DHCR/9%
LIHTC
$197,500
$160,000
TOTAL
$275,000
$275,000
PROGRAM MAX OF
$2.4 MILLION BY 60
UNITS
$19,750 vs. $16,000
ANNUAL CREDIT PER
DU. $16,000 IS MORE
COMPETITIVE
Prototype B: 100 units, Bond/As-of-right
4% LIHTC project @ $300,000 Per Unit
PROGRAM
30% Special
Needs,34
units
60% Special
Needs,67
Units
HFA/4% Tax Credit Equity
$150,000
$150,000
HCR/HFA Loan
HCR/HFA Loan
$35,000
$10,000
$35,000
$6,250
OTDA/HHAP
HCR/HFA/MRT
$42,500
$41,250
$42,500
Federal Home Loan Bank (FHLB)
$10,000
$10,000
Deferred Developer Fee
$15,000
$15,000
TOTAL
Gap
$262,500
$ 37,500
$300,000
Calculation
For project in NYC with 30% Basis
Boost. Smaller raise outside NYC.
Additional raise if combined with
SLIC.
First Mortgage, self- amortizing.
Subsidy Loan at 1%. HFA has
limited capacity for these loans
33 Homeless at $125,000 per unit
34 High Need Medicaid Users at
$125,000 per unit
Subsidy Loan for affordable
housing
42% of Developer Fee paid thru 10
plus years of net income
Additional Source of Subsidy Loan
Needed
Recommendation 1: Streamline SH
Capital Development Function
o Build upon existing HHAC model.
o Create development process that coordinates timing of awards and
requirements of various RFPs, underwriting, design, timetables, legal
docs.
o HPD SH Loan Program-like model: responsible for SH capital awards
but consults/ties in with health & human service agencies for
operation and services.
o Retain expertise of health & human service agencies.
o Ensure health & human service agencies still have ownership of the
process and product.
o State partners with SH developers and continue to share risk of SH
development.
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Recommendation 2: Create Funding
Council to Facilitate Integrated Housing
o Create Coordinated Funding Council to assure timely awards of capital,
operating and service dollars from various agencies to individual projects
o The Funding Council’s impact on SH development:

Retain rolling RFP’s yet allow HHAP to inform Unified Funding Application
determinations for early vetting of projects.

Maintain value of OTDA/HHAP connection to LSS districts & CoCs plans.

Set minimum for on-site service provisions & quality of services.

Retain SH underwriting provisions, e.g., larger operating reserves, design
specifications, rent-up provisions.

Ensure robust asset management capacity.
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Create Funding Council to Facilitate
Integrated Housing (continued)
o
Maintain ability to fund different models of PSH (without
tax credits, very small projects).
o
Maintain lead role/ownership of supportive housing
development for non-profit developers.
o
Provide adequate pre-development and acquisition funds.
o
Maintain set-aside and point preferences for SH at HCR.
o
Funding Council examples include NJ, WA and CT’s joint
release and review of supportive housing funding requests.
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Recommendation 3: Create
Targeting Mechanism
o Principles to Targeting Utilization of Supportive
Housing:

No wrong door to SH for high need/cost Medicaid
recipient with inappropriate or no housing.

Constant and predictable intake/placement process that is
flexible based on location, changing target population
and/or changing population needs.

Promotes tenant mobility and choice, and solicits tenant
feedback.
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Targeting Pilot for High Users
of Medicaid
o Create standardized eligibility and assessment process
modeled on Money Follows the Person:

Data-driven identifying high cost Medicaid users through data
matching and/or case finding predictive algorithms that look at
multiple years of data;

Matched with homeless or inappropriately housed; and

Assessment of type of housing needed by person.
o Assist providers in accepting high need referrals.
o Provide training and resources, as needed.
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Example: DESC’s 1811 Eastlake
(Seattle, WA)
o Supportive housing for 75 individuals with chronic alcohol
addiction.
o Tenants identified through County data analysis of highest
users of county detox and jail services.
o Evaluation found decrease in use of detox and jail services
resulting in a 76% decrease in public costs (including 41%
decrease in Medicaid costs) and significant decreases in
alcohol use.
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New York Medicaid Targeting Pilot
o Data match between Medicaid and homelessness data
systems (e.g. NYC CARES or HMIS (Upstate)) to identify
homeless, high-cost Medicaid clients:

Begin with Health Home Health Status/Severity Groups.

Match HH groups to homelessness data to identify individuals
with specific threshold of homelessness (e.g. at least 120 days).

Determine prevalence of homelessness among groups.

Matched individuals become eligible for housing unit/subsidy
plus care management services corresponding to severity/acuity
rating.
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Recommendation 4: Create
Placement and Tracking System
o Medicaid High Utilizer Placement System must:

Clearly define process for prioritizing populations based on cost
and clinical appropriateness for housing, not diagnostic or
population group priorities

Efficiently identify available supportive housing units


Web-based master list of all housing appropriate for supportive
housing placements, including set-asides

Track Section 504 accessible units = coming on line through
development and vacancies
Effectively match people, housing and appropriate support
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Placement and Tracking System
(continued)
o Transparent feedback loop

Tracking health outcomes, cost outcomes, and process
outcomes (e.g., how long the matching process takes,
comparative performance of contracted agencies, satisfaction
of individual patients with housing and housing stability) to
drive quality improvement.

Local systems set metrics at the outset and report key data
monthly to MRT leadership. Regional learning network regularly
share challenges and innovative solutions to overcoming
barriers to enable effective and rapid implementation.
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Examples of Placement Systems
o
CSH Housing Options Tool (HOT):

Web-based tool that quickly and easily connects users
with a ranked list of customized housing options .

Currently in use in Chicago, Indiana, and is in development
in Connecticut.

Can be used as a universal housing application and
centralized waitlist.

Streamlines the process of accessing housing for clients,
organizations and the system.
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Examples of Placement Systems
o
CUCS:

Database that identifies all vacancies in NY/NY I & II
funded units (NYC).

SPOA: Single Point of Access.
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Impact of Recommendations
Coordinated financing
and agencies
Targeted identification
of tenants
Efficient system that best meets individual
tenant needs
Right placements with
right services
SH system operated at
capacity in real time
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Coordination Next Steps
o
Placement and Tracking System: Undergo a Needs Assessment
to determine:
Tracking systems already in place;
 Requirements of new system;
 Where to pilot the new system.

o
Earmark $10,000 - $50,000 for Needs Assessment and
$50,000-$150,000 for programming new system.
o
Similar process and numbers for Targeting Tool.
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Next Steps
o
March Meeting

Moving On Initiative

Salient Education and Training

Social Impact Bonds
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