Payer organizations having been targeting social determinants of health as a way to drive lower healthcare spending and improve clinical outcomes. Housing – in particular – has become one barrier to care that has received increasing focus.

A few recent examples include Kaiser Permanente’s $200 million pledge to combat homelessness and boost affordable housing in its communities, as well as United Healthcare’s partnership with Phoenix nonprofit Chicanos Por La Causa to protect affordable housing stock.

Charlotte, North Carolina-based Cardinal Innovations Healthcare has taken its own approach to helping at-risk individuals find a home and live independently, driving a 71 percent reduction in its crisis services cost in the process.

Dubbed the Transitions to Community Living Initiative (TCLI), Cardinal’s program helps to re-house patients in independent living situations, provide housing subsidies and moving assistance and offer wraparound services to help individuals stay in their homes.

The program was launched in 2013 as a result of a settlement between the federal government and the North Carolina Department of Health and Human Services (NCDHHS) because of the over-institutionalization of mental health patients.

Since then, Cardinal has honed their approach to not just provide housing, but associated social support to help individuals live independently. Crisis events among the patient population decreased by 42 percent and only 18 percent of participants have an emergency department visit in the year after they’re housed.

I think it really illustrates how housing plays in the social determinants of care and what big impact housing and wraparound supports can do to just keep people out of the ED,” said Mike Bridges, the director of Cardinal’s program.

Cardinal is one of the state’s largest managed care organizations and oversees treatment for high-need Medicaid populations including individuals with mental health issues, developmental disabilities and substance abuse disorders.

A total of 827 people have been housed through the program since its launch, with 214 moved in 2018. Out of that number more than 75 percent have remained in independent housing.

The link between housing and health has long been established. Being chronically homeless can lower life expectancy by 20 years and those with housing instability experience much poorer health in comparison to their stably housed peers. Studies have shown that having access to stable housing decreases hospital stays and emergency room visits.

For the first three to four months after a person agrees to take part in the program, Cardinal helps participants pick where they want to live, what type of housing they’re interested in and other associated neighborhood resources. That could involve tours to introduce individuals to local businesses, restaurants and community centers.

“We take this stuff for granted, but for many people who have been in-and-out of homelessness, shelters or adult care homes, they’ve never been able to think about what it’s like to actually live in a community,” Bridges said, citing an improvement in socialization measures for patients in independent housing situations.

Alongside the housing support, the participants are linked to healthcare services to help manage their chronic conditions like doctor’s appointments as well as food resources.

This requires an interdisciplinary team that includes a certified peer specialist to help initially engage the patient, a clinician and nurse that oversees their care and a housing specialist that finds a suitable living arrangement and helps with logistics in helping the person sign a lease.

Once the person moves into their new home, Cardinal contracts with outside providers to provide continuing wraparound support like transition management services to help residents understand their rights and responsibilities as a tenant. The organization also maintains contact with the resident through in-person and telephonic check-ins and follow-ups.

Bridges said having a stable housing situation – and a regular line of communication to their healthcare team – has helped make patients more engaged with their health and better educated in how to maintain a healthy lifestyle. One example he provided was a 20 percent increase in people reporting regular exercise after being into their new home.

Financial assistance comes in the form of $2,000 to $5,000 in transition support funding, alongside housing subsidies that cover rent outside of the 30 percent income contribution from participants. Additional housing vouchers are also available if necessary.

While the housing assistance is supported through funding from the state agencies, residents are housed only in non-publically owned housing.

That has necessitated engagement with local landlords to explain the program, share successful stories and educate them about mental health first aid and resources for potential mitigation if there happen to be issues.

“We have dedicated positions that are focused on trying to grow our housing stock by meeting with landlords and reducing the stigma,” Bridges said. “Honestly though, we have more people doing this out of the goodness of their heart than anything else.”

In order to ensure a sustainable stock of affordable housing, which can be difficult to have been looking at new models of partnership with the real estate industry and other stakeholders.

One potential model Bridges has been working on has been to provide financing to developers in exchange for a portion of the units being rent-controlled and dedicated to Cardinal members.

“I’ve seen a bunch of creative projects to increase the housing stock that people never would have been open to even five years ago,” Bridges said.

Picture: Natali_Mis, Getty Images

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