 But I'm very pleased to invite to have us and I want to say what this is the last thing today But this is certainly not the end of the discussion and part of what we will do Post this event is send out some information including all of the presentations that you saw but also to talk about who wants to Work on what and what good ideas or what thoughts or what connection did you make today? And how can we work together to further the issue as well to and to address the issues of housing for Many of the seniors that we all know so what we have with us today a group of folks Linda couch who you heard from earlier from leading age But next to her on the left is Kathy from Poa who's the vice president of resident services and community Improvement many of you know at the far, sorry, I'm doing you out of order here But Linda cats is in the red right at the end and it's the economic progress Institute co-founder and policy director And is the person I turned you when I want to know anything about health care in the state So glad to have Linda here and Roberta from Saint Elizabeth's is the executive vice president strategic initiatives and Saint Elizabeth I think you know has done a lot of great innovative work in the senior housing space So with that I'm going to just open it up for some discussion with our panelists and I'll throw the first question out and I'll let everyone jump in if you want to Answer this question, but can you give one example or a example of a successful partnership or model that connects housing and health care for seniors? Anyone want to jump in? Sure So you've heard a little bit about the sash program Periodically throughout the day and in our last session So I want to tell you a little bit about the sash program and Saint Elizabeth's Role in what we're doing here in Rhode Island. Can you hear me in the back? So sash is an evidence-based model that was started about eight or nine years ago in Vermont And it stands for services and supports at home and basically sash uses the elders home Affordable housing is the platform to provide services and it provides comprehensive care management and coordination in the affordable housing by embedding a sash wellness nurse and a sash coordinator and They work with a team of community agencies around the table to help provide Supportive services to the people who live in elderly housing The program is voluntary and it's free of charge So people have to decide to participate in the in the sash program in Vermont Every housing facility is now in sash. They started with one and that was their pilot project And now every entity is involved and 5,000 people are in the sash program in Vermont So it's evident again evidence-based Sashes demonstrated consistent and significant improvement in quality metrics and in many cases that even exceeds national benchmarks around things like advanced directives Immunizations controlled hypertension diabetes decrease in falls So sash is one model that Successfully links health care and housing Sectors to improve the health outcomes and reducing the growth of Medicare expenses as we talked earlier And they're saving about 1,536 dollars per member per year times 5,000 members is a lot of dollars that they're saving right now They're in the process of looking at their Medicaid savings and and they're being studied for that So we'll have more information forthcoming So thanks to the tusk health plan foundation for their support St. Elizabeth's community is piloting the sash program at St. Elizabeth's place in Providence So first I want to give you a snapshot of what St. Elizabeth's place is some of you may know We're right across the street from classical high school just down the road from crossroads 149 apartments with about 160 or 70 residents who live in those apartments And the makeup of those residents of those that are self-identifying the majority are Hispanic Followed by the residents that identify as black or African American Over 83 percent of the residents are over the age of 65 and the majority With the majority 38 percent between 75 and 84 and 15 percent are 85 and older So it's a very very old population that we serve there 95 of the households or 64 percent of the residents have an income of under $9,999 and 23 percent of the residents have an income between 10,000 and $15,000 and Just over two and a half percent have an income of less than $5,000 So we're talking about very frail very poor and a diverse population So now on to the pilot project with the tusk health plan foundation dollars We received support and consulting from sash So we don't have to reinvent the wheel to bring the program here and pilot it in Rhode Island We've hired a sash coordinator and a sash wellness nurse and they might be out here somewhere Raise your hand. You're still here One two back there And they're doing a great job We're really pleased we launched the program this spring and we have over 30 residents that have already decided to participate The sash coordinator helps each participant identify their goals and Facilitate access to health care programs and social needs while the wellness nurse provides each participant with an assessment and Coaching in particular issues around chronic conditions and we already talked about the importance and the the number of chronic conditions that people have in in subsidized housing and Then a collaboration of community partners and one of ours is the Providence Center Come around the table and really help us and the residents meet their needs And I think that that's probably the key to the program the goals of the residents is where we start It's very resident centered. So somebody may have many Comorbidities, but if that person and this is an example from Vermont wants to get up every morning and volunteer at the nursery school And there's something that's stopping that individual from doing that. That's where we start It's what do we need to do to get him back to his volunteer? You build that trust you build that relationship and before you know it you can work on the health issues so we're very excited about the the program and Look forward to continuing the pilot and if successful and have the partnership of the state We'd like to see this and obviously other other facilities as well So that sounds like a very successful partnership anyone else want to add any other Examples that they know either from Rhode Island or from other experiences Kathy. I'll jump in I'm from preservation affordable housing and we have properties and residents in nine states in the District of Columbia. So I get to See how different states respond first. I would say Rhode Island is in a leadership position So I'm not importing any ideas to you, but we are we are exercising a model Actually that we're aspiring to have across all our properties. We have now 86 properties for about 10,000 Residents 10,000 units sorry of housing So we're trying to figure out how to make absolute best use of resources and what we have done is decide First to build out our resident service coordination. We call them community impact coordinators because we only have those Heroic individuals in half of our properties and that's unacceptable That's the base because they are the trust link to the residents and here in Rhode Island What we've done is is take this another step to in many properties contract with CareLink To provide that coordination in our properties thereby Immediately getting a hundred percent smarter about the service system in Rhode Island Operating from Boston. Well, you all know this how stupid you can be operating from Boston, so We really believe and and have had it proven that contracting with local agencies that know the networks and know the resources Are an automatically better way of providing basic resident service coordination on top of which we're always striving to build Additional services and connections for services for our residents, but that partnership model. We're now taking across the country Basically saying we never I promise my health care friends. We never plan to be a health care provider We want to be a quality housing provider with green and healthy Communities where people can age in place, but we never plan to be a Service provider. We need partners who can do that both mostly social service providers But then occasionally health providers are necessary and we're obviously happy to host them So unless anyone else wants to add anything I'll just ask a throw out another question And how can what's the most powerful way or what is a way that housing developers can build partnerships with health care service? providers or vice versa somebody wants to talk about how to health service providers can partner up with Housing developers anyone want to take a saving for myself for number three Linda have you seen any great models across the country well, I guess I would say that it really varies I mean, it's a whole hodgepodge of ways that our housing providers are and our health care providers are working back and forth On the housing side, I know that More and more we are reaching more and more of our housing members are reaching out to insurance companies United health care is really big in this space and they're really interested in Figuring out ways to use the platform of affordable housing just the sheer number of people. So these Are the senior care or the sco's like it special needs plans, right? And so the Massachusetts, I think they're the schools and so the See, that's the jargon to right like I don't even know the healthcare jargon so the That's health jargon Figuring out so if you have a hundred residents in your affordable housing community and they participate in four or five different health plans Mostly, how do you bring those four or five different health plans together into your property in a way that they're going to work together and not fight over residents? But maybe you have to partner with another building or another couple of buildings and and then divide You know what I mean? And so it's figuring out who's willing who's able to come to the table But I know that our members are trying to have those those initial conversations and and really try to match Who's in their building and and figure out who's providing those services who's paying for those services? And and that's a huge incentive for people to come to the table and try to figure that out So I guess my advice is just to start those conversations with the insurance companies are a big a big link And I might even be easier than going to CMS All things being relatively Have you seen any particular state policies and both Kathy and Linda that work cross-state that have helped Encouraged those kind of relationships or or required insurers or others to invest in this No No, I think we talked in our Housing session about so-called mish-mash of regulations there are a lot and then they are a convergence of well-intended laws protecting our residents under the Fair Housing Act and Medicaid and Medicare recipients under HIPAA the health information So there there are many well-intended barriers to collaboration. They can all be overcome But you have to do it one side with the other very carefully to respect our residents Privacy the resident the our buildings are full of people who have choice about where they live What insurance they have they change it regularly so we don't have the luxury of having one insurance provider to talk to Other than well Rhode Island looks really attractive from that perspective because I think all roads lead to Medicaid I think we have the most shared purpose with Medicaid and Medicaid we've been told Many times cannot pay for housing right they can pay for housing support services, but I'm not convinced yet When when a state is really up against the wall with homeless elders That they won't figure out a creative way New York State has figured out how to take its Medicaid savings and committed to Increased supply of housing that's I like that because if what you do is set up a situation where health people are All really interested in the existing pool of section 8 We're all going to lose on that score We need more affordable housing to attend to the needs of vulnerable elders Vulnerable families vulnerable children So the supply has to be attended to in places like New York State put 50 I think it was 50 it was a lot of money 40 or 50 million dollars aside for Increased supply of housing. I love the sound of that and in the meantime Getting Medicaid policies and states are going to have a lot of flexibility. I think with this administration To use Medicaid money as glue money to to glue together people who are moving from Medicare Advantage programs to Medicaid eligibility all living in our We we're there with us almost forever, but they move through eligibility as their income Declines and their health gets more complicated And I would say so I think that and you'll know in like four seconds if you ever forget out of a I'm not a healthcare person, but the The money follows the for the person program right de-institutionalizing people who were Prematurely or without choice put institutional settings the Olmstead Supreme Court decision in 1999 that said people have a right to receive Services that they need to live in a community they need they have a right to get those services in a community based setting in a home setting and States can't comply with the Olmstead decision Unless they have affordable housing, right? There are services out there But if there's no affordable housing they can't do that One way that the federal government was trying to help states de-institutionalize people was to give people Was to these through these money money follows the person? Grants, I guess are they grants or cash? I think we've got some folks here And so one innovative thing that I mean and you can't use that money for for rental assistance I think you can maybe use it for move in this is moving assistance or maybe it's a security deposit But you can't use it for ongoing rental assistance somehow the state in New Jersey They said they got approval. I don't know they they have been using They use their money follows the person money To subsidize an operating subsidy so a rental assistance subsidy for low-income how through the look through their low-income housing tax credit Qualified application plan and somewhere along the way they talked to a lot of housing developers and said basically how much would We have to pay you to bump to the top of your housing waiting lists people coming from nursing homes And then the amount they came to was seventy five thousand dollars a unit and so Through the QAP in New Jersey And New Jersey was using its people who can be like They were using their money follows the person Cash to subsidize the the ongoing rents of tax credit tenants see they can't do it But it's true. It's like we've got a crack the health care. That's where the money is right the money is overwhelmingly on the health care side and Although the health care people tell us there isn't Well, that's the challenge, but I know but it seems like there is or at least like the systems need to be Yeah, well the other issue is is that there's money in the United States, right? It's like we have the cash to do it We're just using to spend our resources So Linda let's bring you into the conversation The what what next steps are there to take to to continue this cross-sector communication that we've Not started today. It's been ongoing, but continue to try to develop some new relationships But and what can we work on together to address a senior health and housing needs? So I guess I just I'd like Kathy saying all roads lead to Medicaid. I think in in Rhode Island If we could get Medicaid, right? That so one in ten seniors we are enrolled in Medicaid in our state So that's a lot of people in Medicaid and there are some opportunities with Medicaid not for Medicaid to pay for housing But there's a whole bunch of initiatives that have been going on in Rhode Island that we really could be Doing a better job at and in terms of putting Reality to the rhetoric of rebalancing care in our state which many in this room have been working on for When our hair was not Something it's been called very different different names, but I so I just want to throw out I guess a couple of things one is I know that I'm dr. Trilla from neighborhood was was Apologize I thank you Linda. He was I had an emergency and wasn't able to join us at the last minute So but I know there are some Medicaid reps at some neighborhood health plan folks here So neighborhood have been trying even before Rebalancing care and our integrated care initiative to try to figure out how to improve healthcare for seniors including creating a program where Surprise doctor the health team goes out to the person's home, right? That's a that's a great idea There is Rhode Island With with Medicaid the states can ask for waivers and Rhode Island as many people may know has operated our Medicaid program under an 1115 that's just the Federal law that says the state can waive some of the Medicaid rules Rhode Island has been one of the states That's really been trying to be creative about getting Waivers to certain Medicaid rules where you can use Medicaid service with Medicaid funding for things that aren't normally paid for by Medicaid And so what for example Rhode Island in its last waiver request got approval to pay for home stabilization Services and it took a really long time before Aid the waiver went in and CMS approved it then it took years before The state decided that it would fund it because it does always come back to the money, right? But there is now a home stabilization program where there are and this may be something that Housing folks can think about reaching out to Community providers or we can all think about a better way of engaging more people if you have resident service coordinators in in public housing Hopefully they are able to do the same sort of services that these home stabilization folks would do there are 10 Agencies in the state that are certified as home stabilization programs They include cap agencies behavioral health agencies domestic violence agencies and some homeless providers They're required to serve anybody not just sort of their target population and They The services that they provide are to help identify and Behaviors that may jeopardize somebody staying in their housing Provide education and training on the roles and rights responsibilities of landlord and tenant Coaching on developing and maintaining relationships with landlords and property managers Advocacy and linkage with community resources to prevent eviction assistance with housing recertification process if somebody isn't subsidized housing and needs to recertify and Coordinate develop a housing support plan with that tenant. So the whole idea there is to help people who are in housing Maintain their housing and then hopefully part of that is connecting with their Healthcare providers as well. There's another part of home stabilization, which Rhode Island has not yet funded but was approved by CMS Which was housing location? I think the problem with housing location is there's no housing defined So unless you're already in I mean and that's the problem, right? We really need to deal with in Rhode Island increasing the supply of housing increasing the supply of affordable housing and We need to as we're thinking about that. We need to be breaking down We can't be thinking about well Medicaid says they don't have the money for this and housing says they don't have the money for that We need to be thinking about anything. We're doing figuring out that this is a state obligation to provide stable affordable housing for folks along with the health care services, they need to stay healthy and That means things like Rhode Island is now moving down the road for accountable entities, right? We were fully managed care and that we had only two managed care plans We now have three those managed care plans were told by the state to do a lot in terms of truly managing care for their Populations, but then the state decided well, that's not enough of managing now We're going to push risk down to these accountable entities where we're going to now have There in other states called accountable care organizations. We're going to require that the health plans to contract with groups of Primary and acute care providers who deal with physical and behavioral health care hospitals specialists and These accountable entities are supposed to address the social determinants of health the state is now in the Now developing work on world peace No, so this is so this is so now what we need to do is hold them We have to hold those we have to hold the state accountable for the accountable and care entities and we have to say look Part of this is you're wanting to save some money, right? You're pushing risk down to this provider network They're going to have shared savings. Well that money a they have a those accountable entities need to be assessing people for Housing security and safety as well as food security and safety Those are the two basic things to me that as we're moving this forward The networks need to be assessing and then when they assess how well do they assess the patients in their networks? And once they find out that there is a need. What do they do? We know that they can probably sell some of the Food needs, right? You can refer somebody to a food bank. You can make sure they're getting snapped You can refer them to somebody who's going to help them get snapped But what are you going to do when you find out they're living in substandard housing or parked in a car, right? There isn't a solution there So we need to make sure that as Medicaid is doing these accountable entity things that those providers are tracking the need and Then we are going to the legislature together to say yeah Medicaid can't pay for housing But state if you want to achieve your Medicaid savings through these accountable entities Then you have to make sure that there's affordable housing for folks and it's not my pool your pool It's going to the it's going to the governor and it's going to the legislature to say this is all of a piece and you have to Breakdown those silos There's also the states 1115 waivers coming up for renewal That means that we have some opportunities to say to EOHHS Here's some other waivers of Medicaid rules I don't think we're I mean maybe under this administration They'll let us pay for rent, but I wouldn't support that I think because our Medicaid budget is so big You know if we try to get Medicaid to pay for housing We'll lose things elsewhere like just coverage for folks But I do think there's some ways for us to get together as a housing and health care community to say well Just like people had a push really to get the state to submit the home stabilization Proposal in its waiver. There may be some other things that we can do and I I know that the Secretary is interested in figuring out some of those things and maybe some of it is coming from the work that you're doing With the aging in community, right? Let's because here's an opportunity to say hey We can get the feds to share in the cost of X with Medicaid dollars not rent But other things so let's be creative about what some of those things well one of the things that came up in the housing Group is trying to repurpose Nursing homes and how can we can that be the thing that we look at and how do we make those? multi-generational or multi use Facilities to address the senior need and I'm just no and clearly you know if you look at the trend and the rebalancing Every year we lose to nursing facilities, and I don't know You know it's good to hear somebody said well There's oh, I think it was Joan there are more nursing home beds Going empty for longer periods time. I don't know that we have the data about You know why are we so behind and why can't we break through that issue and maybe repurposing as part of it But I think we need to be much stronger politically all together to make sure that we are truly moving the dollars and again It's the it's the Putting the money behind the rhetoric and it just feels like we keep getting stuck So that's another thing I think we need to work on together and the last thing I'll throw out is that there is the hospital community benefits Right, and I think that's also a resource that we've not been aggressive about in terms of talking to hospitals where Before community benefits for hospitals was just oh well What do we do about health care in the community with our community benefit program? But they have an obligation under state law to have a Community benefits plan and we have the opportunity to participate in that process. It's not just about health care anymore It's about health. So now that we have the mantra of social determinants of health and I Shouldn't be facetious about saying the mantra because I think people really do start to think now that of the intersection of safe housing Is health health needs of safe housing, right and and that's good And so how do we make that real on the ground and the community benefits route? I think is another place that we should be looking at together Before I open up for a few questions anyone on the panel have any last thoughts or comments And I'll open it up to see if anyone has a question for a panelist or a comment that they would like to make Didn't it tell you about the wine Yeah And that's true the sash program did start out with a demonstrate first of all they got foundation support Initially for their first year and then they got some CMS dollars. They also had some state dollars through their Sims grant As well. So they really put together a patchwork of dollars to make it work And now they're part of their Vermont all-payer system and and they're a permanent part of their their ongoing system Any other questions or comments No, I can't speak Speak to it because we haven't talked about Hospital systems and health plans other than United Actually investing their capital and housing housing, especially with the low-income tax credit Structure is a very good investment. It's not risky at all my view because I'm a houses So I could say that But the Catholic hospital systems dignity trinity Bonsecourt have been leaders in this area for over 15 years They understood, you know, the connection between housing and health and have made real dollar commitments There's a push a foot But it hasn't gotten an awful lot of traction to have that counted as part of the community benefit obligation Because those hospitals give out community benefit investments like year-to-year grants little little ones But they're sitting Obviously biased on a lot of money that they could very safely invest in low-income housing If they were encouraged to that may be where policy is a good idea because they generally treat their assets as a whole nother conversation United The irony is that the for-profit United has way ahead of the non-profits other than the Catholic hospital systems They are all over the country investing in things like this quite innovative work I'm sad to say I haven't scored any of that money Another day All right, so a lot of food for thought so before I let you go to the food Let me just tell you thank you again for coming and thanks to all of our Panelists and all of our participants Joan and and Jim and our sponsors We are going to follow up via email So make sure we have your email address if you didn't sign in to give you all of the materials But also to ask you if you're interested in participating in various working groups or other Other efforts to kind of keep this discussion going We know we can't stop because we know the demand and the need is is too great And the you people who are here in the room who are on the ground day-to-day know that even better But thank you all thank you to to my colleagues at housing works Amy and Emily We're helping with registration and that and Christina from our research team are here as well, too And thanks for your time and let's keep working till we get this right You