MRT Affordable Housing Work Group January 10, 2013 - 10 AM to 3 PM New York State Department of...

MRT Affordable Housing Work Group

Redesign Medicaid in New York State

Goals for Today

o Update the MRT Work Group on the progress of the three Sub Workgroups. The 3 Workgroups met in December and January. The ideas were developed by Members of the Sub Workgroups.

o Facilitate discussion on the presentation. Encourage Members to provide comments and questions throughout

the presentation.

o Gather Feedback which can be incorporated into final Sub Work Group recommendations.

Medicaid Redesign Affordable Housing Work Group 2

MRT Affordable Housing Work Groups

o Program Model and Development Brenda Rosen, Chair Tony Hannigan, Co-Chair

o Funding Ted Houghton, Chair

o Planning and Service Coordination Constance Tempel, Chair


Program Model and Development Workgroup

1. Identify barriers to moving high-need individuals into supportive housing.

2. Identify New Affordable/Supportive Housing Models.

3. Define “Supportive Housing.”

Program Model and Development Work Group


Define “Supportive Housing”

o Adapted from “The Seven Dimensions of Quality for Supportive Housing” by CSH.

o Intended to represent all populations w/o specifying individual groups.


Define “Supportive Housing1”

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. 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. Should we include other models or definitions?


Barriers Moving High-Need Individuals Into Supportive Housing

o Limited housing stock to accommodate individuals with mobility impairments.

o Lack of flexibility in service delivery: Residents eligible to “move on” require/want minimal services, but

services tied to units not individual.

Transitional support needed for individuals moving from institutions to community settings.

Residents need enhanced services at specific intervals during tenancy to maintain housing and avoid institutions.


(continued)

Barriers Moving High-Need Individuals Into Supportive Housing


o Current funding limits to “head of household”o Fear of admittance of having mental illness, SA issues etc. (i.e.

victims of DV).o At-risk of becoming high need users do not currently qualify.

o Sub-group focused on Individuals with Multiple Health Problems.

Wide range of recommended target populations. (seniors “aging in place”, individuals transitioning from nursing homes, disabled individuals that are not “head of household”, chemically dependent individuals not ready for abstinence, etc.)

New Affordable/Supportive Housing Models



o RFP Directly Linking Health Homes to Housing

Covers services and rental subsidy in scattered site setting; Capital funding for congregate in this year's round w/ operational and services funding attached.

Funding for operating and services would be RFP’d to housing providers applying in partnership with Health Homes.

Contracts would be held by housing providers.

RFP needs to provide flexibility with regards to who should deliver care coordination.



o Care coordination either conducted directly by the housing provider, or through explicit agreements spelling out how care coordination will be integrated with housing based services.

Government agency (i.e. HRA) would act as gatekeeper to determine eligibility determined by DOH criteria.

Health Homes would oversee the referral process and prioritize clients for housing.



o Promote flexibility of services and adjustment to dollar amounts (i.e. flexible contracts, etc.).

o Focus on prevention of future high-cost users.

o Refine categories to include individuals with undocumented health problems (i.e. victims of DV who may lose child custody if diagnosed).

o Explore various models for seniors “aging in place”.


Next Steps

o Profile senior populations not served/included in current supportive housing models.

o Discuss what supports essential for this senior population.

o Follow up discussion based on feedback from larger group; finalize supportive housing definition.

o Define models “not” targeted to Individuals with Multiple Health Problems.

o Develop a “Moving On” Initiative.


Funding Workgroup


1. Develop principles for a new supportive housing initiative (to follow NY/NY III).

2. Advise the State on appropriate set-asides and incentives for supportive housing.

3. Advise the State on how to allocate 2013-14 MRT Supportive Housing funds.

4. Develop a plan to create “social impact investment bonds.”

5. Identify ways to leverage federal and private funds.

Funding Workgroup

1. Develop Principles for a new Supportive Housing Initiative


o Statewide Supportive Housing Partnership Initiative: Build on the success of 3 previous NY/NY City-State supportive housing

development collaborations; Expand statewide; Broaden target population to include both high-cost Medicaid

recipients, as well as other homeless, vulnerable and at-risk individuals and families who require support to remain housed;

Favor residences that mix special needs tenants with low income individuals and families;

Single RFP for capital, service and operating funds.

Statewide Supportive Housing Partnership Initiative Key Components:


o Broader, more flexible target population categories, high-cost Medicaid recipients; homeless individuals with behavioral health issues; homeless and at-risk families with special needs; homeless and at-risk youth;

o Coordination of housing-based services with behavioral health and medical care to decrease Medicaid and other public costs;

o Multiple referral sources, including homeless systems, outreach programs and health homes;

o Tenant eligibility approvals made by government;o Prioritization for housing determined by Health Homes (for

units reserved for high-cost Medicaid recipients) and local homeless service agencies (other pops).

(continued)

Statewide Supportive Housing Partnership Initiative Key Components:


o Adequate service and operating funds: Explicit coverage of front-desk security and general case management

(OTDA NYSSHP)

Annual budget adjustment to reflect changes in rental costs

Service funding levels to reflect needs of new MRT populations;

o The Health Homes & Housing Pilot Program evaluation will inform model principles and implementation strategies.

2. Advise the State on Appropriate Set-Asides and Incentives for Supportive Housing

o Fully fund HCR’s QAP NOFA $4 million set-aside for supportive housing projects that designate at least 30% of units for people with special needs;

o Set goal to make supportive housing 25% of all HCR tax credit-funded units produced;

o Direct HCR Section 8 vouchers to fund supportive housing for high-cost Medicaid recipients;

o Increase OMH and HHAP capital development funds;

o Review HCR housing stock to identify underutilized units set aside for persons with special needs.


o SFY 2013-14 Supportive Housing Fund - $75 million: $28 million for SFY2012-13 scattered site programs

$47 million available for new initiatives

o Additional dollars from hospital and nursing home bed closures.


3. Advise the State on SFY2013-14 MRT supportive housing funds

MRT Supportive Housing Capital Questions:

o How much goes to capital, how much to service and operating? last year:

$25 million – NYS HCR MRT RFP targeted to NY/NY III high cost Medicaid recipients

$14.4 million – NYS OTDA HHAP targeted to upstate

o Consensus that MRT capital dollars should not be used to pay for prior capital commitments made under NY/NY III.

o Which development agencies are best situated to build effective housing?

HCR, HHAP, OMH or HPD?


MRT Supportive Housing Capital Questions:


o Which developers?o How to speed development?

Acquisition & pre-development funds

Operating funds available for underwriting

Proposed New Pilot Programs:


o Health Homes & Housing Scattered Site RFPo New Senior Supportive Housing Modelo Deinstitutionalization Demonstration Initiativeo Crisis Residence/Step-down Bed Pilot

Health Homes & Housing Scattered-Site RFP:


o Enhanced “housing first” harm reduction, supportive housing model administered by experienced supportive housing providers 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.

(continued)

Health Homes & Housing Scattered-Site RFP

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 would be held by housing providers, managed by OTDA; Government agency would determine eligibility; Health Homes would manage the referral process and prioritize clients for housing; Health Home care coordination is conducted directly by the housing provider, or

through explicit agreements that spell out how care coordination will be integrated with housing-based services;

Population neutral; Active, collaborative, real-time evaluation and data collection.


o Flexible grant project to fund capital and services projects that will save Medicaid dollars.

o Eligible applicants are nonprofit entities that operate public or publicly assisted multi-family housing projects administered or regulated by HUD, HCR or HPD.

o Targets low-income seniors (62 years or older) who are high-cost Medicaid users, and/or at risk of institutionalization paid for by Medicaid.

o Can be used to fund a resident services advisor, security, transportation, meal planning, technology, entitlements advocacy and other non-medical services.

o Funding can also cover capital renovations not funded through the Access to Home program, which can be coordinated with this funding.

o Funded projects must address gaps in service or financing, and would not replicate existing services.


New Senior Supportive Housing Model

Deinstitutionalization Demonstration Initiative:

o Transition individuals with mobility impairments and chronic illness now in nursing homes into accessible, affordable apartments. Key program components include:

Outreach component to nursing homes; Comprehensive assessment plan; Customized services that are person-centered to meet each individual’s

needs; Some funding available for accessibility modifications; after

maximizing other options; Ongoing rental assistance.


Crisis Residence/Step-Down Bed Pilot

o Hospital stays (psychiatric & medical) could be significantly shortened or avoided if individuals could transition or be diverted to a short-term residential program enhanced with clinical staff and peer supports.

o This program can be a “step down” from inpatient services in a secure setting to crisis and prevention programs to reintegrate individuals into the community and avoid costly admission and readmission to hospitals, enhanced staffing patterns and designated residential treatment slots.

o This model will be less expensive to operate than care provided at inpatient facilities and emergency rooms.



Crisis Residence/Step-Down Bed Pilot: Options

o Convert some number of existing community residences to crisis/step-down/hospital diversion beds: Requires some one-time capital for renovation to downsize the beds and

reconfigure the spaces;

Requires some recurring supported housing to replace lost beds;

Requires recurring dollars to pay for enhanced staff including psychiatry and nursing; or

o Set aside some beds in a number of CRs around the state for crisis/step-down/hospital diversion: Requires recurring dollars to pay for enhanced staff including psychiatry and

nursing;

Pay providers at a minimum level to hold the beds even if vacant.

4. Develop a plan to create “social impact investment bonds”

o Recommendation: Set up a subcommittee to identify where Social Impact Investment Bonds (SIBs) have potential to add value and recommendations for a pilot program targeted at high-cost Medicaid users

o SIBs, also known as “pay for success” contracts, are a tool for scaling up the social interventions that have potential to result in considerable cost savings to government


(continued)

Develop a plan to create “social impact investment bonds”

o Examples of promising interventions and programs which could be well suited for a Medicaid savings SIB include: Housing for undocumented persons in nursing homes, with long hospital

stays, or frequent ED and inpatient utilization;

Implement the FUSE model to reduce crisis health care costs of frequent users of criminal justice and shelter systems; and/or

Provide technology-driven, housing-based services to seniors to improve their health outcomes and allow them to successfully age in place.

o SIBs are currently being tested in a number of applications in NY State, New York City, elsewhere in the US, and abroad. The MRT Affordable Housing Work Group should continue to investigate this promising tool for bringing private investment to bear in bending the cost curve on Medicaid.


5. Identify ways to leverage federal and private funds


o Redirect State and local Section 8 Resources to high-cost Medicaid recipients.

o Maximize bed closure dollars.

o Leverage local capital contributions of HOME, CDBG, McKinney-Vento and other resources.

o Ensure that Health Home Care Coordination dollars can flow to, and be integrated with, housing-based services.

Next Steps


o Finalize Details of Allocation Plan

o Finalize Model Design Elements of Pilot Programs

o Explore SIB possibilities

Planning and Service Coordination Workgroup

Planning and Service Coordination Work Group

o Improve Interagency Coordination.o Improve the Capital Development Process.o Evaluate perceived barriers to utilization of supportive

housing. o Provide advice on overall coordination and implementation of

supportive housing policy.o Improve the coordination and timing of the availability of

housing.


Charge of Subgroup


Make short/long-term recommendations to the larger group to:

1.Plan to improve interagency coordination of supportive housing policy and implementation.

2.Identify and improve supportive/affordable housing capital development process.

3.Evaluate and provide advice to barriers in utilization of existing SH.

o Plan to improve interagency coordination of supportive housing policy and implementation.


Charge 1

Guiding Principles for Interagency Coordination

o Coordinate around a person, not an agency.o No wrong door to SH for high need/cost Medicaid recipient with

inappropriate or no housing.o Build upon MRT inclusive and constructive process.o Coordinate/streamline state policy and resources among agencies. o Need constant and predictable intake/placement process that is yet

flexible based on location or as target populations or needs change.o Capture learning and make mid-course corrections.o Solicit tenant feedback.



Recommendation: Create State Coordinating Mechanism

o Purpose:

Coordinate statewide planning, policy development and implementation.

Maximize state resources and expertise targeted to high need/cost Medicaid recipients that are inappropriately housed/institutionalized/homeless.

Ensure implementation based on advancing policies and plans created through the MRT process.

Mechanism’s Responsibilities


o Implement housing and services plan, budget and timeline.o Coordinate housing development process.o Consolidate tenant identification, assessment and placement

system.o Monitor and evaluate annual goals, benchmarks and

outcomes.o Commission ad hoc work groups to advise on implementation

issues.

Option 1: Council


o Option 1: Create Interagency Coordinating Council

Executive Order/Legislature creates Council

Members including Governor’s Office, DOB, “O” agencies, health, housing, corrections, aging

Memorandum of Understanding signed by all member agencies

MRT Affordable Housing Work Group representatives monitor for accountability and oversight

Pros and Cons of Council Option

o PROS Governor’s authority and priority

Creates a spotlight and priority on needing to work together

Agencies have equal standing and accountability

Could create both policy and implementation

o CONS May create another bureaucracy that is not nimble

May not be as results-oriented


o Option 2: Formalize State Agency MRT Implementation Work Group on Supportive Housing

Governor’s Office creates and leads;

Joint agency design, review, and sign-off processes and projects;

Transparency in reporting;

Others brought in if issues arise to make mid-course corrections.


Option 2: Implementation Work Group

Pros and Cons of Work Group Option

o PROS Leaner, less layers

More implementation-focused, tactical

Governor’s office still leads, so still a priority

Modeled after successful NYC NY/NY 3 coordination

o CONS Less high profile

Staff still need to go “up the ladder” for final signoffs

Goes against national best practice of creating interagency councils


Charge 2

o Identify and improve supportive/affordable housing capital development process


Principles to Improving Development Process

o Build upon development processes and efficiencies that work

o Preserve SH models that work while updating/creating others with appropriate level of services

o Ensure an active role for nonprofits

o Create least expensive and quickest way to get housing to high cost/need users

o Process needs to facilitate leveraging federal, state and local resources and reinvest Medicaid savings into SH


Challenges to Development Financing

o Several state agencies currently finance SH/AH: HCR – capital and tax credits

HHAP – capital for homeless or at-risk often in combination with other capital and tax credits

OMH – capital, operating and services for mentally ill only often in combination with other capital and tax credits

OASAS – operating and services tied to capital

OPWDD – capital, operating and services

Various sources for assisted living


Challenges to Development Coordination

o Difficult to coordinate funding streams into one integrated project because each agency has: Own application; Own timetable for receipt of application, review and award; Different underwriting standards; Different point system for awards; Different design standards; Different construction documents, requirements, processes.

o Difficult to leverage federal resourceso Conflicting eligibility requirements



Recommendation: Consolidate Development Function

o Consolidate State unit production that creates SH.

o Create standardized development processes including RFPs, underwriting, design, timetables, legal docs.

o Option 1: Two Agencies

Combine unit production functions and dollars of HHAC, “O” agencies, health and aging agencies;

Work with HCR to leverage other capital sources.


Option 1: Consolidate Development Function into Two Agencies

Pros and Cons: Two Agencies


o PROS Retain expertise of human service agencies

Could build upon existing infrastructure, such as HHAC

Ensure human service agencies still have ownership of the process and product

Can tie in with services and operating

o CONS Less constituent agencies

Housing may become less specialized for particular populations

Option 2: Consolidate Development into One Agency

o Option 2: Consolidate all supportive housing capital into one agency, HCR:

Create a supportive housing unit within HCR that reviews and monitors any special processes needed for SH.


Pros and Cons to Development Recommendations

o PROS

Predictable timeframe, process, standards

o CONS

One big roadblock if denied

Total resources may be reduced


Pros and Cons to One agency


o PROS Know where to go Predictable timeframe, process, standards Easier to leverage affordable housing resources Modeled after effective NYC HPD

o CONS Less constituent agencies One big roadblock if denied Less SH expertise in HCR Could be more competition with for-profits Total resources could be reduced

Charge 3

o Evaluate and provide advice to barriers in utilization of existing SH, specifically:

State’s interpretation of Section 504 requirements for accessible housing;

Whether providers are maximizing opportunities for accessible units;

Whether compliance reviews are included in regulatory agreements and monitored for set aside projects.


o No wrong door to SH for high need/cost Medicaid recipient with inappropriate or no housing.

o Need constant and predictable intake/placement process that is yet flexible based on location or as target population or needs change.

o Solicit tenant feedback.

o Promote tenant mobility and choice.


Principles to Utilization of Existing Supportive Housing

Barriers to Utilization of Existing SH

o Current housing is tied primarily to chronically homeless.

o No master data system provides for identification and sharing of high need/high cost persons in need of SH.

o No master vacancy list or mechanism to identify.

o Supportive housing and Section 504 set aside units are not monitored for compliance in filling vacancies.

o Tenant mobility and choice are not fully realized given system rules and capability.

o Not all units are accessible.

o Accessible units not always occupied by intended tenants.



Recommendation: FacilitateTargeting High need/cost Medicaid Users

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;

Assessment of type of housing needed by person.

o Assist providers in accepting high need referrals Review intake criteria;

Provide training and resources, as needed.

Recommendation: Improve Targeting and Intake Process


o Create shareable real time master list through data sharing agreements.

o Learn from CDIP and MATs programs.

o Create single point of entry/eligibility modeled on NYC’s HRA process while ensuring ‘no wrong door’: from health homes, clinics and hospitals, shelters and correctional

health facilities, nursing homes, adult homes, assisted living, MCOs

o Consider use of Patient Navigators and Peer Supports for difficult to engage.

o Create incentives for county/regional coordination.

Recommendation: Track Housing Inventory and Vacancy


o Create web-based master housing and vacancy inventory mechanism at county/regional or major city level for all SH including Section 504 and tax credit units:

Provides applicant ranked list of housing options by eligibility

Provides application forms, housing contact information

o Provides funder notice of vacancy rates.

Pros and Cons to Targeting Recommendations

o PROS Maximizes targeting to intended recipients

Enables more tenant choice

o CONS Less provider/developer independence in selecting tenants

Tracking is time consuming


Next Steps

o Further refine proposals based on feedback from Affordable Work Group and subgroups:

Review in detail effective targeting and data matching strategies;

Review web based placement and vacancy control systems;

Conduct thorough analysis of state unit production processes and make specific recommendations for streamlining and consolidating.


Questions?

o Comments or questions?

o Goal: Achieve general consensus on a series of policy recommendations for how to move forward on Supportive Housing in Medicaid.

o Meeting Schedule:

o February 22, 2013

o March (TBD)


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MRT Affordable Housing Work Group January 10, 2013 - 10 AM to 3 PM New York State Department of...

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