Emerging Strategies for Integrating Health and Housing

Transcription

1 SOCI AL DETER MINA NTS OF HE AL TH R E S E AR C H R EP O R T Emergig Strategies for Itegratig Health ad Housig Iovatios to Sustai, Expad, ad Replicate Coriae Payto Scally July 2017 Elaie Waxma Ruth Gourevitch sade adeeyo

2 ABOUT THE URBAN INSTITUTE The oprofit Urba Istitute is dedicated to elevatig the debate o social ad ecoomic policy. For early five decades, Urba scholars have coducted research ad offered evidece-based solutios that improve lives ad stregthe commuities across a rapidly urbaizig world. Their objective research helps expad opportuities for all, reduce hardship amog the most vulerable, ad stregthe the effectiveess of the public sector. Copyright July Urba Istitute. Permissio is grated for reproductio of this file, with attributio to the Urba Istitute. Cover photo courtesy of Foudatio Commuities.

3 Cotets Ackowledgmets Executive Summary Case Study Highlights i iii vi Housig as Health: A Brief History of Bridgig Silos 1 Housig Remembers Its Roots 1 Health Care s Awakeig: Housig as a Social Determiat 3 Purpose ad Methods 8 Sustaiig, Expadig, ad Replicatig Cross-Sector Parterships 11 Decidig to Act 11 Seekig Allies 13 Attractig Resources 15 Commuity Egagemet 18 Data Itegratio 20 Outcome Measuremet ad Evaluatio 22 Ca Cross-Sector Parterships Be Expaded? 23 Notes 26 Refereces 27 About the Authors 29 Statemet of Idepedece 31

4 Ackowledgmets This report was fuded by the Robert Wood Johso Foudatio as part of the Urba Istitute s Policies for Actio grat o social determiats of health. We are grateful to them ad to all our fuders, who make it possible for Urba to advace its missio. The views expressed are those of the authors ad should ot be attributed to the Robert Wood Johso Foudatio or the Urba Istitute, its trustees, or its fuders. Fuders do ot determie research fidigs or the isights ad recommedatios of Urba experts. Further iformatio o the Urba Istitute s fudig priciples is available at We are grateful to the followig people for sharig their thoughts ad experieces with us o this growig itersectio of housig ad health: Nacy Adrews, Low Icome Ivestmet Fud (LIIF) Mary Ayala ad Vruda Vaghela, Eterprise Commuity Parters Ic. Kevi Barett, Public Health Istitute Peggy Bailey, Ceter for Budget ad Policy Priorities Adrew Beck, Ciciati Childre s Hospital Pablo Bravo, Digity Health Emily Che, Local Iitiatives Support Corporatio Colby Dailey ad Doug Jutte, Build Healthy Places Network Nacy Eldridge, Natioal Ceter for Healthy Housig Fred Karas, Kim Dempsey, Cris Kabel, ad Napoleo Wallace, The Kresge Foudatio Jey Ismert ad Kate Paris, UitedHealthcare Commuity ad State Be Hecht, Livig Cities Amy Murphy, Public Health Cosultat Sue Polis, Natioal League of Cities ACKNOWLEDGMENTS I

5 Julia Resick, America Hospital Associatio Samuel Ross, Curtis Clark, Talib Hore, ad George Kleb, Bo Secours Baltimore Health System Mega Sadel, Bosto Uiversity School of Medicie ad Childre s HealthWatch Deis Shea, Bipartisa Policy Ceter Ed Sivak, Phil Eide, ad Corey Wiggis, HOPE Eterprises Julie Trocchio, Catholic Health Associatio Sarah Norma, NeighborWorks America Kamillah Wood, Stewards of Affordable Housig for the Future We also thak the stakeholders who cotributed their kowledge o the six case studies i this report. Withi Urba, we thak Lisa Dubay for her careful review ad questios o drafts, Lauda Aro for her support ad isights, ad Jillia West for her editorial assistace. We also thak Sara McTaragha for iterview ad traslatio assistace. II ACKNOWLEDGMENTS

6 Executive Summary For decades, housig professioals, public health officials, ad city leaders have recogized the lik betwee people s homes ad their health ad well-beig. Residets of substadard housig may face health hazards such as toxic lead pait or mold, ad the struggle to cover housig expeses may cotribute to chroic stress ad reduce resources available for other basic eeds such as a adequate diet or access to health care. The housig sector has historically led the charge to create healthy homes ad livig eviromets, focusig o improvig affordability ad housig quality, ad forgig coectios with health services. Oly recetly, with icreased attetio o the social determiats of health, have health care leaders embraced itervetios that address ohealth factors such as housig. This study examies emergig itervetios that itegrate housig ad health services for lowicome people, with a focus o itervetios where health care orgaizatios have take a sigificat leadership role. Our research pairs over 30 expert iterviews with six i-depth case studies briefly profiled below ad available as separate publicatios to pait a detailed picture of emergig strategies ad their potetial to be sustaied, expaded, ad replicated elsewhere. The itervetios we profile differ i scope, geography, populatio, ad parter characteristics. Some were motivated by exteral iflueces, such as policy chages or commuity pressure. Others grew out of a evolvig busiess strategy or leadership shake-up. Despite their differeces, they are all rooted i a idea that is gaiig tractio amog health care leaders across the coutry: ivestig i housig is ivestig i health. I our i-depth ivestigatio, we idetified the followig themes to buildig effective, sustaiable parterships aroud housig ad health: Allies are everywhere. Housig leaders ca call upo a diverse set of health care parters, icludig hospitals, Federally Qualified Health Ceters, Catholic health systems, maaged care orgaizatios, ad local public health departmets. Similarly, stakeholders i the health sector ca cosider collaborators such as affordable housig developers, public housig authorities, commuity developmet corporatios, homeless service providers, ad supportive housig developers. Fidig a orgaizatio with a shared missio ad goals, committed leadership, ad a willigess to overcome the challeges associated with traslatig across sectors is key. Public ad private fudig sources are essetial. Successful parterships ofte rely o braided fiacig, which combies fudig from multiple sources across sectors. Fuds from withi a parter orgaizatio, such as a hospital s edowmet or a housig authority s

7 operatig fuds, ca offer icreased flexibility ad cotrol. Exteral fuds ca also be secured from public sources, such as the Low-Icome Housig Tax Credit, or private sources, such as a local foudatio. Strog cross-sector collaboratios come together to avigate siloed fudig streams ad create iovative ways to avoid the wrog pocket problem, where oe orgaizatio ivests i a iitiative, but the cost savigs are realized by a differet orgaizatio. Commuity residets are a asset to the work. Our case study sites experimeted with several commuity egagemet strategies, icludig residet educatio, participat feedback, ad direct cosultatio, but this work ca be ufamiliar to health care orgaizatios. Itegratig commuity egagemet practices ito program desig ad orgaizatioal structure icreases the likelihood that projects will be embraced by the commuity, empowers people to take owership of a solutio, ad icreases trust betwee residets ad health ad housig parters. Data itegratio is difficult, but essetial. Although most participats uderscored the power of data to desig more effective itervetios, few had comprehesively itegrated trackig tools as part of their day-to-day work. May oted that data security protocols were burdesome ad data-sharig cotracts betwee parters were too complex. Yet, the power of cross-sector data itegratio caot be uderstated. Parters ca share data to idetify clustered health problems or high health care users ad the places where they live, ad better coect those people with the services they eed. By perseverig to bridge data systems across sectors, parters ca develop more targeted itervetios, preservig limited resources ad maximizig impact. Measuremet matters. Parterships ofte drew o data to idetify problems ad make the case for solutios. Measurig specific health ad housig outcomes, however, was ofte still aspiratioal. Rudimetary trackig of outputs (e.g., the umber of uits built or reovated, the umber of services accessed) was fairly commo. But i a few istaces, i-depth evaluatio offered importat isights, such as short-term icreases i health care use followed by evetual stabilizatio, or decreases i health symptoms (e.g., asthma) followig housig quality improvemets. Without uderstadig impact, parters will face difficulty expadig, sustaiig, or replicatig their work. Havig stroger outcome evaluatios that prove efficacy will motivate fuders ad commuity leaders to ivest time ad resources ito creatig these cross-sector itervetios. IV EXECUTIVE SUMMARY

8 Health ad housig professioals are poolig resources ad expertise to meet shared goals of improvig idividual ad populatio health, particularly withi disadvataged commuities ad at-risk populatios. Yet, despite the growig iterest i collaboratio, there has bee little evidece to iform how to build ad sustai meaigful cross-sector parterships. Breakig dow etreched silos is ot easy, but the isights ad perspectives i this report help pave a path for policymakers, city leaders, ad health ad housig providers to work together to address housig as a social determiat of health. EXECUTIVE SUMMARY V

9 Good Neighbors Make Better Parters Columbus, Ohio July 2017 The Healthy Neighborhoods Healthy Families (HNHF) iitiative, created by Natiowide Childre s Hospital, seeks to remove barriers to the health ad well-beig of local families. The iitiative facilitates access to affordable housig, quality educatio, health ad welless programs, safe ad accessible eighborhoods, ad workforce developmet opportuities. I 2008, Natiowide partered with Commuity Developmet for All People ad lauched the HNHF Realty Collaborative, a real estate subsidiary to rehabilitate existig housig stock ad develop ew affordable homes o vacat lots. Overall, the HNHF Realty Collaborative has helped reduce the umber of vacat ad abadoed properties more tha 50 percet. Case Study Fast Facts Partership Type: Childre s hospital + commuity developmet corporatio Strategy: Block-by-block eighborhood revitalizatio Geography: Neighborhood Key Take-Aways Lessos for local parterships workig o commuity revitalizatio strategies. ANCHOR INSTITUTIONS Havig the fiacial, social, ad political ifluece of a achor istitutio was critical to the success of this iitiative. Ivestig i physical improvemets i the commuity positively affected the relatioship betwee the hospital ad its eighbors. We are a achor that has bee here ad proved positive that we would ot relocate...we really wated to be ivestig more broadly i placebased iitiatives. ANGELA MINGO Natiowide Childre s Hospital STRONG LEADERSHIP Commuity Developmet for All People s solid reputatio i the eighborhood allowed Natiowide Childre s to trust them as a parter early o. Numerous stakeholders poited to Revered Joh Edgar, the executive director of CD4AP, as a persuasive, committed, ad iovative leader whom Natiowide Childre s could rely o as a collaborator. FUNDING The ability to iclude a diverse set of fudig sources is key to esurig the stability ad sustaiability of this kid of work. The hospital s fiacial resources were ivaluable, ad early successes have motivated other fuders to support this work. Establishig a diverse portfolio of fudig strategies ca allow for flexibility ad log-term impact despite public fudig chages. Before ad after image of a rehabilitated home through the HNHF Realty Collaborative. VI CASE STUDY HIGHLIGHTS

10 A Natioal Isurer Goes Local Multiple Markets Natiowide July 2017 UitedHealthcare provides health isurace beefits to more tha 40 millio people across the coutry. I the past decade, it has addressed housig as a social determiat of health at the atioal level through policy leadership ad fiacial ivestmets, ad at the state level workig with local commuities to coect Medicaid participats to stable housig. Through this work, UitedHealthcare has overcome a myriad of challeges associated with siloed health ad housig fields at all levels of policy ad implemetatio. As a payer, UitedHealthcare is uiquely positioed to aalyze how differet itervetios targetig social determiats of health may affect health outcomes. Case Study Fast Facts Partership Type: Payer ad maaged care orgaizatio + local housig orgaizatios Strategy: Housig ivestmet, local programmatic efforts Geography: Natioal Partership Spotlight: Workig Together to Ed Homelessess The Edig Commuity Homeless Coalitio (ECHO) is a oprofit coalitio operatig i Austi, Texas, that tracks idividuals who have received US Departmet of Housig ad Urba Developmet fuded homeless services. After learig about its iovative work, UitedHealthcare partered with ECHO to match ames of idividuals receivig services from both orgaizatios. The parters could the idetify the most cliically at-risk with the highest rates of health care use, ad ECHO could begi workig to secure housig for these idividuals. Key Take-Aways Lessos for large health orgaizatios workig across sectors. DATA AND EVALUATION As a payer, UitedHealthcare has a robust database of patiet claims data, which it is workig to icorporate ito its evaluatio techiques. Data-sharig agreemets betwee health care ad housig orgaizatios ca lead to more targeted ad effective itervetios ad help demostrate the cost savigs outcomes associated with health ad housig strategies. ORGANIZATIONAL STRUCTURE By havig multiple departmets that icorporate housig strategies ito their operatios, coupled with a cetral poit of cotact withi the compay, it ca respod quickly to ew opportuities ad be flexible i its programmatic strategies. We ca t move fast eough, give the magitude of the problem. CATHERINE ANDERSON UitedHealthcare Commuity ad State DIVERSE PARTNERSHIPS Ulike may health ad housig parterships, which ted to rely o oe health care parter ad oe housig parter, this case highlights how a large orgaizatio with a atioal scope ca participate i umerous parterships at a variety of geographic scales. By egagig i may types of parterships, UitedHealthcare has bee able to create a toolbox of strategies that ca target social determiats of health, creatig opportuities to replicate certai itervetios i localities facig similar health ad housig issues. CASE STUDY HIGHLIGHTS VII

11 Everythig i Oe Place Washigto, DC July 2017 The Coway Ceter is a project of a oprofit housig ad services orgaizatio, So Others Might Eat (SOME), ad a federally qualified health ceter, Uity Health Care, i Washigto, DC. This $90 millio commuity developmet iitiative will colocate employmet traiig, health care services, ad affordable housig uder oe roof i Ward 7, a area of DC experiecig high poverty ad uemploymet ad poor health outcomes. The partership aims to improve access to affordable retal housig, icrease livable-wage job attaimet, ad coect residets to high-quality health care services. The Coway Ceter is slated to ope at the ed of Case Study Fast Facts Partership Type: Health cliic + oprofit housig developer Strategy: Colocatio of housig ad health cliic Geography: Neighborhood/parcel Key Take-Aways Lessos for developers seekig to colocate housig ad health services. COLOCATING SERVICES Brigig health services together with housig ad employmet traiig ear public trasportatio recogizes the multiple challeges that prevet some idividuals ad families from accessig health care. Give the high rates of chroic disease i the surroudig commuity, improvig access to primary care services may promote better health maagemet ad reduce the eed for acute-care services. The colocatio of health care ad housig is a attempt to circumvet traditioal barriers experieced by uderserved commuities. MICHAEL CRAWFORD Uity Health Care LEVERAGING CAPITAL Workig with Local Iitiatives Support Corporatio (LISC) allowed this partership to access Healthy Futures Fud ivestmet, which offers readiess programs to commuity developmet orgaizatios that are thikig creatively about embeddig health ad housig i their projects. EXISTING RELATIONSHIPS Leaders at both orgaizatios had bee lookig for ways to collaborate ad thus came to the table with a similar philosophy about how to serve their cliets. They had a aliged missio, visio, ad values that iformed their proposed work, which has positioed them to cotemplate scalig the model i other locatios. Mai rederig of the Coway Ceter. Image courtesy of Wiecek + Associates Architects + Plaers. VIII CASE STUDY HIGHLIGHTS

12 A City Takes Actio Bosto, Massachusetts July 2017 I Bosto, Massachusetts, the Bosto Housig Authority, Bosto Public Health Commissio, the city s Ispectioal Services Departmet, the Bosto Foudatio, ad local uiversities ad medical istitutios have come together over the last decade-plus to address the itersectio of health ad housig. Motivated by a desire to improve the lives of Bosto s most vulerable residets, these orgaizatios bega collaboratig to address asthma ad, more recetly, to prioritize housig ad health eeds for pregat wome. By bridgig achor istitutios, foudatios, ad city agecies aroud health ad housig iitiatives citywide, Bosto has made strides toward providig healthier housig optios ad itegrated health maagemet ad referral systems. Case Study Fast Facts Partership Type: Public health commissio + public housig authority + local uiversities Strategy: Collaboratio to target health issues i public housig residets Geography: Citywide Evaluatig Success Bosto Uiversity researchers recetly evaluated Healthy Start i Housig, a program that idetifies pregat wome who are curretly homeless or at immiet risk of homelessess i Bosto ad, therefore, are at elevated risk of a adverse birth outcome. The researchers foud that the program reached its target populatio, with 100 referrals aually. They also foud statistically sigificat improvemets i the participats metal health; after oe year i the program, the proportio of program participats reportig cliically sigificat depressive symptoms decreased 20 percet. Key Take-Aways Lessos for stakeholders iterested i udertakig a citywide, cross-sector iitiative. A CITYWIDE APPROACH The Bosto Housig Authority ad the Bosto Public Health Commissio leveraged their idividual resources to work together o joit missios ad collaborated with uiversities for evaluatio support. This uderscores how workig with city agecies ca exted the reach of populatio health efforts beyod idividuals egaged i the health system. FUNDING SOURCES This case illustrates how a mix of iteral operatig reveues ad exteral fudig ca fiace cross-sector iitiatives. I additio, the cotributios of the Bosto Foudatio demostrate how local fuders ca support tailored programs desiged to serve the eeds of local residets. I additio, housig authorities ad health commissios ca collaborate to leverage existig resources to desig programmatic itervetios ad work with uiversities to apply for grats to evaluate these programs. COMMUNITY INVOLVEMENT Effectively egagig commuity members ca be challegig for ay iitiative. The Bosto Housig Authority ad the Bosto Public Health Commissio have worked to build residet perspectives ito several of their iitiatives, ad that iput has resulted i specific program adaptatios. Developig the capacity to be flexible is a importat take-away for orgaizatios lookig to address the itersectio of health ad housig eeds. CASE STUDY HIGHLIGHTS IX

13 Coectig a Commuity Austi, Texas July 2017 Foudatio Commuities is a oprofit affordable housig developer i Texas that serves over 3,000 idividuals ad families with permaet supportive housig ad affordable family uits. I 2012, Foudatio Commuities lauched its Health Iitiatives project to provide free utritio, exercise, ad chroic disease maagemet classes to its Austi residets, usig a commuity health worker model. By providig housig ad health services i a cetral locatio, Foudatio Commuities aims to promote a Culture of Health, icrease its residets access to care, ad empower them to live healthier lives. Case Study Fast Facts Partership Type: Affordable housig developer + local health foudatio Strategy: Housig with multiple osite services ad commuity health workers Geography: Citywide Key Take-Aways Lessos for affordable housig developers lookig to address the itersectio betwee health ad housig. RESIDENT ENGAGEMENT Havig both formal ad iformal mechaisms for egagig residets i the desig ad outreach efforts of its programmatic activities has allowed Foudatio Commuities to cultivate trustig ad mutually beeficial relatioships with its participats. CITYWIDE PARTNERSHIPS The Health Iitiatives team has cultivated relatioships with dozes of parters citywide to help provide services to their residets. Because of these uique parterships, Foudatio Commuities ca be more flexible i its programmig activities, ofte relyig o its parters to provide the expertise ad o-site services. While housig is ot a direct health care itervetio, it ca be more powerful tha access to a really good doctor. KIMBERLY MCPHERSON St. David s Foudatio TRACKING OUTCOMES Foudatio Commuities activates its commuity health workers to help track housig, health, ad program-level outcomes, allowig the orgaizatio to regularly assess the effectiveess of its itervetios. By havig clear roles for the employees ivolved, the data collectio process ca proceed smoothly ad efficietly. Foudatio Commuities residets participate i a exercise class. X CASE STUDY HIGHLIGHTS

14 Tappig ito a Collective Visio Stamford, Coecticut July 2017 The Vita Health & Welless District is a oe-mile corridor i Stamford, Coecticut, that has positioed itself as a healththemed eighborhood, offerig mixed-icome housig, health care services, commuity farmig, early childhood educatio programmig, ad supportive services to residets. Led by the city s public housig authority, Charter Oak Commuities, ad Stamford Hospital, this collaboratio of city agecies ad commuity-based orgaizatios has focused o buildig physical ad social capacity i a distressed eighborhood, with a emphasis o leveragig collective ivestmets to yield a positive impact o eighborhood health ad well-beig. Case Study Fast Facts Partership Type: Hospital + public housig authority Strategy: Neighborhood revitalizatio with colocatio of services Geography: Neighborhood Key Take-Aways Lessos for eighborhood orgaizatios buildig a collective impact effort to improve health ad well-beig. ANCHOR INSTITUTIONS Havig the fiacial ad social capital of two achor istitutios was fudametal to the developmet ad evolutio of the Vita Health & Welless District. MUTUAL BENEFITS AND GOALS Charter Oak Commuities, Stamford Hospital, ad all the Collaborative members realized that they were servig (or eeded to serve) the same populatio. This was itegral to their goal settig for holistic commuity health improvemets. By takig a collective impact approach, we could be more effective at achievig agreed-upo goals. TANIA RECINOS Family Ceters STRATEGIC LEADERSHIP Leaders cotiual ivestmet icreased the visibility of complex issues such as the social determiats of health, especially for local policymakers. Respodets stressed the beefits of workig closely with the housig authority ad the hospital, give their political acume ad ability to make the case for the city ad state s ivestmets. COMMUNITY ENGAGEMENT This partership has built bridges betwee istitutios ad programs that were previously siloed ad uable to thik about strategic collaboratio or collective impact. Beet harvest at Fairgate Farm, a commuity farm servig local residets, soup kitches, food baks, ad shelters. CASE STUDY HIGHLIGHTS XI

15 Housig as Health: A Brief History of Bridgig Silos Housig is key to health. People eed shelter to be secure ad stable. A adequate home does ot make you sick ad is ot stressful, usafe, or difficult to avigate (Briggs, Popki, ad Goerig 2010; Bo sher et al. 2015). A good home is located where exposure to pollutio ad abadoed buildigs is low ad access to healthy activities, foods, ad health services is high (Day 2006; De Leo ad Schillig 2017). Although these seem like commosese propositios, oly recetly have researchers ad practitioers started buildig evidece o what works ad usig it to implemet iovative strategies to address health through housig. Housig Remembers Its Roots The coectios betwee public health ad housig i the Uited States go back to the 19th cetury, whe jouralist Jacob Riis (1890) exposed the appallig coditios of teemets i New York City. Teats suffered from overcrowdig, poor saitatio, iadequate vetilatio ad light, ad price gougig by corrupt ladlords. The associated health impacts malutritio, illess, disease, ad high mortality rates were the catalyst for the atio s first Teemet Laws, which created buildig stadards for habitability ad health (Fairbaks 2000). Sice the, the housig sector has cotiued to create healthy homes ad livig eviromets, usig resources desigated for housig. These have geerally followed oe of three methods: 1. Stabilizig households. Affordable housig programs focus o people facig vulerable housig circumstaces: homelessess, evictio, domestic violece, livig doubled-up with frieds ad family, or strugglig to pay their housig costs without makig trade-offs with other basic eeds. These programs try to stabilize households by helpig them afford a decet place to live through public housig, publicly assisted housig, ad private retal housig with the help of public retal assistace programs (Schwartz 2015). Table 1 summarizes these federal housig affordability programs. (May state ad local retal housig programs support housig affordability for vulerable households, but without the deeper subsidies provided by federal programs. 1 )

16 TABLE 1 Major Federal Housig Affordability Programs to Stabilize Low-Icome Households Program Public housig Assisted multifamily programs Housig Choice Vouchers Low-Icome Housig Tax Credit Descriptio Provides public retal uits at reduced cost to low-icome households. No ew uits are beig built. Several programs (e.g., HOPE VI ad Choice Neighborhoods) have helped reovate, demolish, ad rebuild public uits for ew developmets cotaiig a mix of publicly subsidized ad private market-rate uits. The Retal Assistace Demostratio program allows public housig authorities to trasitio public housig uits to other housig programs to leverage private fuds for reovatio. Provides privately owed retal uits with a capital grat or low-iterest loa for costructio or public retal assistace attached to reduce cost to low-icome households. This icludes Project-Based Sectio 8, Sectio 202 Housig for the Elderly, Sectio 811 Supportive Housig for People with Disabilities, ad Sectio 515 Rural Retal Housig. Few assisted multifamily uits are beig built today. Gives vouchers for public retal assistace to households to reduce cost of retig a eligible uit o the private market. Gives a private ivestor credit toward their federal icome taxes for a qualifyig equity ivestmet i a eligible affordable retal housig developmet. This is the primary source of affordable retal housig costructio ad preservatio fiacig. Source: Authors compilatio. For a historic descriptio of these programs, see Schwartz (2015). 2. Improvig housig quality. These itervetios address usafe livig coditios i the home, icludig lead-based pait, mold, pests, ad dust, as well as structural hazards. Programs focus o remediatio ad weatherizatio, with sigificat fudig through the US Departmet of Housig ad Urba Developmet s (HUD) Office of Lead Hazard Cotrol ad Healthy Homes. Federal block grats to state ad local govermets iclude the Commuity Developmet Block Grat ad the HOME Opportuity Ivestmet Partership block grat. A fial rule published i December 2016 also prohibits smokig withi public housig properties to improve idoor air quality ad reduce egative health outcomes Coectig residets to health services. Over the past several decades, there has bee growig recogitio that ustably housed idividuals ad families struggle to access adequate health services. The supportive housig model uses housig as a platform to stabilize lowicome chroically ill or homeless people with the additio of wraparoud services (Gubits et al. 2016). Examples iclude HUD-fuded local Cotiuum of Care programs for homeless idividuals ad families ad the HUD Veteras Affairs Supportive Housig program that combies retal assistace for homeless veteras with US Departmet of Veteras Affairs medical services. The residet services model focuses o likig households receivig housig 2 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

17 assistace to case maagemet ad coordiator commuity services to improve well-beig ad self-sufficiecy (Gillespie ad Popki 2015). The web of housig programs that has expaded dramatically sice the emergece of teemet housig laws is overstretched ad thily resourced. Housig assistace is ot a etitlemet, ad programs oly reach about oe i four eligible low-icome households (Joit Ceter for Housig Studies 2016). Additioally, most productio programs have ot bee fuded for years, ad existig buildigs are agig ad costly to maitai. Most affordable housig strategies have bee implemeted by public, oprofit, ad market-based developers ad ladlords, with little ivestmet from the health care sector. I some cases, ew parterships were required betwee health service providers ad housig providers, but the mai itervetio was still via a housig program. Emergig evidece, however, shows housig stakeholders parterig with health-sector parters to leverage resources across sectors to tackle housig istability, quality, ad access to health services to improve the health ad well-beig of childre, families, ad idividuals. This has accompaied a awakeig withi the health care sector that housig status is a key idicator of health. Health Care s Awakeig: Housig as a Social Determiat Although the Uited States boasts a techologically advaced health care system, may critical iputs for good health are ot foud i the doctor s office or o pharmacy shelves (Marmot 2015; World Health Orgaizatio 2008). 3 The coditios i which people live, lear, play, ad work have a eormous impact o health. These liks have bee amplified through research o disparities i morbidity ad mortality betwee the Uited States ad other atios (Istitute of Medicie ad Natioal Research Coucil 2013) ad i aalyses of wide variatios i health outcomes across commuities withi the Uited States (Dwyer-Lidgre et al. 2017). I respose, health care leaders icludig providers, hospitals, public ad private payers, ad health-focused foudatios have icreasigly explored how to egage with housig eeds, territory largely ufamiliar to cliicias ad admiistrators. Early resposes were spearheaded by Catholic health systems that cosidered addressig commuity eeds a part of their social missio. These orgaizatios icludig Digity Health, a etwork of Catholic hospitals i the wester Uited States, ad Bo Secours Baltimore Health System ofte bega with their ivestmet portfolios, leveragig EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 3

18 these resources to support affordable housig i their commuities. These istitutios frequetly fuctio as achor istitutios i low-icome commuities, ad ivestmets address patiets eeds, the quality of the eviromet surroudig the istitutio, ad opportuities for staff to access affordable housig ear where they work (see Norris ad Howard [2015] for a geeral discussio of hospitals as achor istitutios). A secod set of resposes emerged followig the 1999 Supreme Court case Olmstead v. LC, which foud that states have a resposibility uder the Americas with Disabilities Act to pay for publicly fuded services for the disabled i the least restrictive commuity settig. The case had sigificat implicatios for state Medicaid programs, which are a major payer for log-term services ad support for low-icome disabled people (Musumeci ad Claypool 2014). Sice Olmstead, attetio has tured to promotig greater use of oistitutioal settigs, especially home- ad commuity-based services (HCBS) that support disabled people livig i the commuity. Although state Medicaid programs ca ow elect to offer HCBS as a beefit available to all participats, HCBS have ofte bee offered through a waiver mechaism istead, which gives states permissio to target services oly to certai populatios or i limited geographic areas. I may states, waiver services have bee offered oly up to a certai amout of fudig or to a certai umber of participats to miimize budget impact. 4 As a result, idividuals seekig services i a waiver state may ecouter waitig lists for services (Musumeci ad Claypool 2014). The Olmstead case, coupled with the growig umber of people seekig to live i the commuity as they age ad a desire to reduce the costs associated with istitutioal care, have brought a greater focus o the itersectio of housig ad health eeds, icludig the challege of securig affordable housig where people who eed these supportive services ca reside. HUD s Sectio 811 Project Retal Assistace Demostratio Program is oe cocerted effort to address this by brigig federal housig dollars together with state Medicaid programs to house ad serve idividuals with disabilities. 5 A third set of opportuities has emerged i respose to the Affordable Care Act (ACA) ad the growig emphasis o paymet icetives to decrease the use of high-cost ipatiet services ad icrease value (Spillma et al. 2017). The ACA has augmeted the policy ad programmatic tools available to state Medicaid programs ad to providers, icludig (1) expadig Medicaid eligibility to ew groups of low-icome people (may of whom may be particularly at risk for beig ustably housed); (2) expadig Medicaid beefit optios that permit states to offer the types of HCBS services previously available uder waivers o a statewide basis, such as support to help idividuals i istitutios move ito the commuity (e.g., movig expeses, security deposit) or to retai their housig placemets (e.g., through ladlord-teat services); (3) requirig oprofit hospitals to coduct periodic 4 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

19 commuity health eeds assessmets that iclude social eeds, alogside expaded opportuities for ew kids of commuity ivestmet by oprofit hospitals that are required to demostrate commuity beefits to retai their oprofit status; ad (4) icreasig focus o ew paymet iovatios that has heighteed the iterest of public ad private payers i strategies to reduce costs for people with high health eeds, icludig those whose poor health is exacerbated by umet basic eeds such as housig. As Spillma ad colleagues (2017, 1) report i their recet evirometal sca of reforms relevat to housig eeds itroduced through the ACA, programs that provide vulerable populatios with better access to stable, appropriate housig ad health care ad other services ca beefit the health system through improved care ad reduced costs. Table 2 summarizes the mai policy levers that emerged from the ACA. A more detailed aalysis ca be foud i Housig ad Delivery System Reform Collaboratios: Evirometal Sca Report, prepared by Spillma ad colleagues (2017) for the US Departmet of Health ad Huma Services Assistat Secretary of Plaig ad Evaluatio. Expaded Medicaid eligibility. Uder the ACA, states could exted Medicaid coverage to oelderly adults with icome at or below 138 percet of the federal poverty level. Thirty-oe states ad Washigto, DC, opted to implemet this expaded coverage by sprig This expasio is sigificat because most childless low-icome adults were ot previously eligible for Medicaid, ad parets of covered childre were typically eligible oly with very low icomes. 6 Housig issues have become more visible to health care providers servig ewly covered low-icome people, especially give the complexity of umet physical ad metal health eeds for may of them ad the risk of cyclig i ad out of expesive ipatiet care i part because of the lack of affordable housig. Home- ad commuity-based services coverage. The ACA created ew state optios for expadig accessig to HCBS. Oe ew optio is Commuity First Choice (CFC), also kow as 1915(k), which allows states to provide HCBS to people at risk of istitutioalizatio with icome up to 150 percet of the federal poverty level. Relevat for health ad housig collaboratios is Medicaid s associated ability to cover expeses related to helpig people move out of istitutios (e.g., first moth s ret), security ad utility deposits, ad basic household supplies (Spillma et al. 2017). The ACA also expaded states ability to cover all HCBS without a waiver, icludig services for metal health ad substace use disorders. States that elect this optio must offer services statewide ad without waitig lists, but they are allowed to target services to specific populatios (e.g., people with metal illess or substace use disorders). EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 5

20 TABLE 2 Major Health Policy Levers at the Itersectio of Housig ad Health Policy mechaism Home- ad commuity-based services Health delivery models ecompassig social determiats of health Expaded Medicaid coverage of people vulerable to housig isecurity Commuity health eeds assessmets ad commuity beefits requiremets for oprofit hospitals Relevace for addressig housig ad health State Medicaid programs ca cover home- ad commuity-based services to meet the eeds of people who prefer to get log-term care services ad supports i their home or commuity, rather tha i a istitutioal settig. Coverage ca be structured as a optioal state beefit ad through various waiver provisios. Recet optios created through the Affordable Care Act iclude Commuity First A ew state optio is available uder Medicaid to create health homes for highcost, high-eed patiets with chroic physical or behavioral health coditios. These programs provide comprehesive care maagemet ad referral to eeded commuity supports ad social services, icludig housig. A Iovatio Ceter, admiistered by the Ceters for Medicare ad Medicaid Services, provides state iovatio awards for experimetatio with health delivery models uder Medicaid or Medicare that foster collaboratio betwee cliical ad ocliical supports for high-eed patiets. These iclude patietcetered medical homes, health homes, ad accoutable care orgaizatios ad accoutable care commuities. The Affordable Care Act gave states the opportuity to exted Medicaid coverage to certai groups of people ot previously eligible, specifically oelderly people with icome up to 138 percet of the federal poverty level. The Affordable Care Act requires hospitals with tax-exempt status to coduct a commuity health eeds assessmet with a focus o populatio health ad social eeds, as well as adopt a implemetatio strategy at least oce every three years. Iteral Reveue Service rules have also clarified that some housigrelated ivestmets may cout toward commuity beefits requiremets for maitaiig oprofit status. Source: Authors compilatio. Commuity health eeds assessmets ad commuity beefits. Most US hospitals operate as oprofits ad must meet certai requiremets for beefitig the commuity to retai that status. Expectatios that oprofit hospitals documet broader cotributios to the commuity beyod charity care date back to a 1969 Iteral Reveue Service (IRS) policy (James 2016). I the years leadig up to the ACA, how well hospitals were providig sigificat commuity beefit was the subject of debate ad figured ito some ACA provisios that aimed to stregthe the focus o commuity health. The ACA required that hospitals with tax-exempt oprofit status coduct a commuity health eeds assessmet ad adopt a implemetatio strategy at least oce every three years. The IRS rules goverig how commuity health eeds assessmets should be coducted emphasize that hospitals should examie ot oly the eed to address fiacial ad other barriers to care but also the eed to prevet illess, to esure adequate utritio, or to address social, behavioral, ad evirometal factors that ifluece health i the commuity. 7 New coversatios have emerged betwee health care cliicias ad admiistrators ad other commuity orgaizatios, icludig those focused o housig. 6 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

21 Followig ACA passage, the IRS issued additioal guidace o what activities ad ivestmets could cout toward commuity beefits, icludig commuity health improvemet activities, ad expeditures i coectio with certai commuity buildig activities (Rosebaum, Byres, ad Hurt,.d.). Examples of commuity buildig activities iclude physical improvemets ad housig rehabilitatio for vulerable populatios such as removig harmful buildig materials (e.g., lead abatemet), eighborhood improvemet ad revitalizatio, housig for vulerable people upo ipatiet discharge, housig for seiors, ad parks ad playgrouds to improve physical activity. Paymet iovatios. Spillma ad colleagues (2017, 2) ote, While efforts to itegrate health care with housig ad other supports predate the ACA, the law created ew icetives for providers to promote prevetio ad better coordiate care, icludig physical, behavioral health, ad social services. These iclude ew delivery ad paymet system models ad expasio of preexistig opportuities. Despite cosiderable policy iterest ad ew tools, however, may states ad commuities are still i the early stages of aligig health care ad housig resources for vulerable populatios. Amog these iovatio opportuities is a ew state optio available uder Medicaid to create health homes for high-cost, high-eed patiets with chroic physical or behavioral health coditios. These programs provide comprehesive care maagemet ad referral to eeded commuity supports ad social services, icludig housig. I additio, a Iovatio Ceter, admiistered by the Ceters for Medicare ad Medicaid Services, provides state iovatio awards for experimetatio with several health delivery models uder Medicaid or Medicare that foster collaboratio betwee cliical ad ocliical supports for high-eed patiets. These iclude patietcetered medical homes, health homes, ad accoutable care orgaizatios that provide services to Medicare patiets ad ecourage iovatio i service delivery by allowig providers to share i cost savigs. Accoutable Health Commuities are aother ew experimet i collaboratios betwee health providers ad social service ad commuity orgaizatios. Several health policy treds have coverged to egage the health care sector s attetio o the importace of social determiats such as housig, ad this egagemet has bee accelerated i the wake of the ACA. I 2017, the ACA s future is ucertai, but the icreased focus o social determiats is likely to persist. Uder ay sceario, cotaiig the rate of growth i health care costs will be a priority. The evolutio of value-based paymet strategies, which aim to tie reimbursemet more closely to outcomes tha to volume of services, will provide icetives for addressig social eeds that udermie health outcomes ad icrease expeditures. Ad, as the case studies i this report attest, ew parterships betwee the housig ad health sectors have take root ad have become a itegral part of health care providers strategies. EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 7

22 Purpose ad Methods This study part of a Policies for Actio research project o the social determiats of health (box 1) examies emergig itervetios that itegrate housig ad health services for low-icome people, focusig o those where health care orgaizatios have take a sigificat leadership role. Give the cosiderable evidece that exists o supportive housig models with wraparoud services, particularly those that serve homeless idividuals ad families (Cuigham, Gillespie ad Aderso 2015; Cuigham et al. 2014), we sought emergig models focused at least i part o families with childre facig a wide rage of housig istability issues, icludig affordability ad quality issues. Our research pairs 31 expert iterviews with six i-depth case studies to pait a detailed picture of emergig strategies ad their potetial to be sustaiable, expaded, ad replicable. BOX 1 Policies for Actio: Policy ad Law Research to Build a Culture of Health A sigature research program of the Robert Wood Johso Foudatio, Policies for Actio seeks to help build the evidece base for policies that ca help build a Culture of Health. The Policies for Actio Research Hub at the Urba Istitute focuses o three broad groups of health-related policies: housig ad food-sector policies, state fiscal ad icome-related policies, ad health care policies. Natioal Expert Iterviews Our research team iterviewed 31 atioal experts to solicit their perspectives o emergig iitiatives at the itersectio of health ad housig. We were iterested i idetifyig health care orgaizatios that aim to alig health services ad housig i oe place, optimize health-sector ivestmets i housig, or use housig ad commuity developmet policies to promote health. 8 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

23 Our key iformats represet oprofit housig ad health providers, foudatios, health payers, evirometal health leaders, ad commuity developers. I additio to their perspective geerally o cross-sector collaboratio, we asked them to share examples of iovative health ad housig work. From this list, we chose six promisig itervetios to ivestigate further. Case Study Iterviews The six case studies provide a rage of geographic cotexts, parterships, ad strategies, as summarized i Table 3. For each case study, we iterviewed betwee 5 ad 10 people. These respodets icluded leaders ad employees i the parterig orgaizatios, fuders of the itervetio, local govermet stakeholders, commuity health workers ad public health urses, ad additioal commuity stakeholders. TABLE 3 Summary of Case Study Sites Name Locatio Partership type Iitiative strategy Geography Coway Ceter Washigto, Neighborhood/ DC parcel Health cliic + oprofit housig developer Colocatio of housig ad health cliic (oe parcel) Healthy Neighborhoods Healthy Families Vita Health & Welless District Columbus, OH Stamford, CT Childre s hospital + commuity developmet corporatio Hospital + public housig authority Block-by-block eighborhood revitalizatio Neighborhood revitalizatio with colocatio of services Neighborhood Neighborhood Iovative Health ad Housig Parterships, Bosto Bosto, MA Public health commissio + public housig authority + uiversities Citywide collaboratio to target health issues i public housig residets Citywide Foudatio Commuities UitedHealthcare Austi, TX Multiple markets atiowide Affordable housig developer + local health foudatio Payer ad maaged care orgaizatio + local iovative housig orgaizatios Housig with multiple osite services ad commuity health workers Housig ivestmet, local programmatic efforts Citywide Natioal EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 9

24 Research Questios Although addressig housig to improve health outcomes is still a ascet cocept, early fidigs from the field ca highlight how ew iitiatives ca bridge silos ad egage across sectors. The followig questios guided our research: Why parter o health ad housig ow? How ca differet types of health care ad housig orgaizatios create parterships, ad what are the key orgaizatioal igrediets to successful parterships? How essetial is public ad private fudig to creatig ad sustaiig cross-sector itervetios? What role does commuity egagemet play i desigig strategies? How are parters haressig data tools ad measuremet to desig more effective itervetios? How does buildig outcome ad evaluatio trackig ito the fabric of a partership ehace uderstadig of programmatic impact? 10 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

25 Sustaiig, Expadig, ad Replicatig Cross-Sector Parterships Decidig to Act Policy Eviromet The Affordable Care Act has motivated health care etities be more aware of social determiats of health ad focus o prevetio. As oe atioal expert oted, the ACA helped shift hospitals uderstadig of health from patiet-cetered to commuity-cetered. With the ACA s expasio of Medicaid eligibility, which icluded more people who are likely to be chroically homeless, maaged care orgaizatios (e.g., UitedHealthcare) that serve may Medicaid erollees bega focusig o how ustable housig ca exacerbate health issues. Chages to the commuity beefits protocol uder the ACA did ot motivate ay of the case study parterships examied here ad did ot have a strog effect o their implemetatio. The impact of commuity beefits chages may take loger to emerge i the field, but several iformats suggested that this policy lever was ot likely to drive sigificat fiacial ivestmets by the health care sector, although it may foster ew coversatios betwee hospitals ad potetial parters. Rather, a growig emphasis o reducig ipatiet costs ad rewardig cost savigs, such as through accoutable care orgaizatios, seems to be a more sigificat source of iovatio. I cotrast, federal housig policy has bee relatively stagat, with few ew tools ad resources available to icrease stability, improve housig coditios, ad brig services together with housig. Istead, orgaizatios such as commuity developmet fiacial istitutios are steppig ito the gap to leverage federal resources ad programs i ew ways, ofte by attractig private capital that has egaged i housig or health, but ot ecessarily the two combied. Housig developers are more tha willig to itroduce ew health parters to the itricacies of our atio s agig housig policy framework. EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 11

26 Orgaizatioal Priorities A focus o immediate istitutioal eeds ca spur orgaizatios to look toward aother sector to address housig as a social determiat of health. Three cases i our research were motivated i part by a orgaizatio s iterest i expadig its facilities ad catchmet area. Natiowide Childre s Hospital i Columbus, Ohio, was udergoig a hospital expasio i 2007, ad as part of this expasio, leaders had coversatios with the city ad other local stakeholders about the eed for local eighborhood improvemets. After the city challeged the hospital to do more to positively affect the surroudig eighborhood through the expasio, the hospital proactively egaged with commuity stakeholders ad city leaders to develop a iitiative focused o the health ad well-beig of idividuals livig i the surroudig eighborhood. Similarly, the motivatio for the Coway Ceter i Washigto, DC, grew out of a mutual eed for expasio amog the two key parter orgaizatios. Social service ad affordable housig provider So Others Might Eat wated to develop 1,000 ew uits of retal housig ad icrease its employmet traiig services. Uity, a Federally Qualified Health Ceter, wated to double its capacity. The motivatio for the Vita Health & Welless District i Stamford, Coecticut, grew out of the public housig authority Charter Oak Commuities madate to improve its housig through redevelopmet, as well as the Stamford Hospital s desire to icrease its impact area ad expad its primary ipatiet facility. Commuity Needs I additio to orgaizatios beig motivated by iteral busiess iterests, some orgaizatios came to uderstad the itersectio betwee health ad housig by learig more about the eeds of the populatios they already served. I Austi, Texas, Foudatio Commuities established a formal health program after employees oticed that may of their residets livig i permaet supportive housig had poorly maaged chroic diseases, such as diabetes, HIV, ad hypertesio. I additio, their residets had high rates of metal illess, which threateed their ability to be live idepedetly i a commuity with others. To help these residets be more stable i their housig placemets, Foudatio Commuities leadership realized they had to icrease residets access to metal health ad chroic care maagemet ad thik more holistically about the supportive services that allow people to thrive. Similarly, UitedHealthcare s work i state ad local cotexts has highlighted that housig istability ca egatively cotribute to health care costs, as patiets who are homeless or otherwise ustably housed ted to be higher users of emergecy care. Aroud 2010, UitedHealthcare leadership recogized there was o way to improve health outcomes for may Medicaid erollees without 12 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

27 addressig the housig eeds of the medically uderserved populatios, ad they bega ivestig more directly i housig itervetios. Seekig Allies Mega Sadel, a pediatric doctor at the Bosto Medical Ceter, remarked whe asked about the first steps toward addressig residets housig ad health eeds, Every commuity is differet, but it s a importat first step to thik about atural allies. May types of local health care ad housig orgaizatios ca coalesce aroud a commo desire to address the itersectio of health ad housig (table 3). TABLE 3 Housig ad Health Care Players Health care orgaizatios Hospitals, particularly childre s hospitals Federally Qualified Health Ceters Catholic health systems Maaged care orgaizatios Local public health departmets Uiversity medical schools or public health schools Housig orgaizatios Commuity affordable housig developers Supportive housig developers Local public housig authorities Commuity developmet corporatios Commuity developmet fiacial istitutios Homeless service providers Shared Missio ad Goals May orgaizatios seek parters who share a iterest i a specific place. Hospitals ted to focus o improvig the health i specific service areas. These achor istitutios large ad relatively fixed i place ca be powerful egies for reivestmet i their surroudig commuities (Norris ad Howard 2015). Hospitals across the coutry particularly childre s hospitals because they have a specialized populatio ad ofte have a missio-based approach are icreasigly motivated to improve idividual ad populatio health i their backyard. Similarly, respodets poited to commuity developmet corporatios (i.e., oprofit, commuity-based orgaizatios focused o developig affordable housig) ad local public housig authorities as examples of istitutios that are also rooted i place, motivated to improve the well-beig of their residet populatio through housig developmet ad supportive service provisio. EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 13

28 All the parterships i these case studies have a commo geography that allowed them to establish shared goals early. I some cases, such as So Others Might Eat ad Uity s joit work o the Coway Ceter, the orgaizatios had bee servig the same populatios before their partership, creatig a atural opportuity to collaborate. Natiowide Childre s Hospital had a specific ivestmet i the surroudig eighborhood ot as a direct service provider, but because of its role as a achor istitutio. It partered with local oprofit Commuity Developmet for All People because they had a shared iterest ad because Commuity Developmet for All People already had direct coectios i the commuity. Eve UitedHealthcare, which operates atioally, foud that solutios required developig place-based parterships i the commuities where their Medicaid members live. Committed Leadership Across the case studies, iterviewees oted that successful local cross-sector parterships require strog leadership o both sides ad cotiuous egagemet betwee the parters. Leaders provided the visio ad chose to ivest the time, eergy, ad resources ito developig ew strategies that were ot ecessarily guarateed success. A ogoig commitmet to health ad housig work etails frequet meetigs, combied ivestmet i the itervetio, ad missio-drive leadership. Leadership also eeded to be committed for the log haul, as the challeges beig addressed (e.g., affordable housig developmet ad eighborhood revitalizatio) ofte require sigificat time before improved outcomes ca be achieved. Willigess to Traslate across Sectors Although there are myriad opportuities to tailor health ad housig work to local eeds through crosssector parterships, oe mai challege people ecouter is the laguage barrier betwee the oftesiloed health field ad housig field. Termiology used by each sector ca be urecogizable to the other, ad both fields have complicated fiacig structures, policy eviromets, ad o-the-groud service delivery practices that ca be challegig to uderstad without formal traiig. I most of the case studies, the health ad housig parters had ot previously worked together o ay programmig, ad respodets emphasized how difficult it was to get o the same page iitially because of their distict vocabularies. As oe respodet oted, whe settig iitial goals ad desired outputs, health care orgaizatios speak i people, but housig orgaizatios speak i uits. To overcome this challege, some parterships, such as UitedHealthcare s work with local housig orgaizatios, relied 14 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

29 o traslators, people or orgaizatios kowledgeable about both fields who ca be a liaiso i the early stages of partership. Attractig Resources Oce health ad housig parters have established commo goals, they brig together their expertise to idetify possible strategies ad how to fud them. I the case studies, parters leveraged public ad private fuds from the housig ad health sectors to iovatively fiace their cross-sector itervetios. I all the case studies, parterships relied o braided fiacig, which brigs together fudig from multiple sources, idetifyig ew ways to leverage fudig from the health ad housig sectors to maximize impact. Table 4 highlights fudig sources parters use to fiace their iitiatives. TABLE 4 Fudig Sources for Health ad Housig Iitiatives Fudig source Local foudatios Regioal ad atioal foudatios Commuity developmet itermediaries Private ivestors Iteral operatig fuds Govermet housig fuds Local govermet health fuds Fudig type Bosto Coway Foudatio Ceter Commuities Philathropy X X HNHF Philathropy X X Philathropy/ Public Private X X X X Uited- Healthcare Vita District Private X X X X Public X X X X X X Public X Note: HNHF = Healthy Neighborhoods Healthy Families. EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 15

30 Fidig Fuds from Withi Orgaizatios are lookig iterally at their operatig resources ad directly ivestig i their ow itervetios. Hospitals have sigificat edowmets they ca use to fud these iitiatives, ad isurace compaies maitai reserves they ca ivest. Parters i these case studies were ofte ivestig some of their portfolio i geeral real estate ad realized that some of these ivestmet dollars could be allocated for these more targeted iitiatives. Natiowide Childre s Hospital ivested $9 millio ito the Healthy Homes iitiative through its ivestmet portfolio ad leveraged savigs from its accoutable care orgaizatio work. Similarly, the Stamford Hospital leverages its edowmet to make ivestmets i the medical ceter, which is oe piece of the commuity-focused iitiative kow as the Vita Health & Welless District. O the housig side, the Bosto Housig Authority uses the operatig fuds it receives from HUD to implemet its Itegrated Pest Maagemet program i partership with the Bosto Public Health Commissio. These direct ivestmets ofte allow for more flexibility, makig them appealig for log-term itervetios. I additio, direct ivestors (e.g., hospitals ad payers) are ofte willig to accept a lower retur o ivestmet tha traditioal leders (e.g., baks). Lastly, direct ivestmet allows for more cotrol over the iitiative by havig fewer fuders ad potetially coflictig program criteria to follow. Raisig Fuds All the health ad housig iitiatives i this report rely o public fiacig resources from HUD ad state ad local govermets. Health parters ca use the Low-Icome Housig Tax Credit to directly ivest i housig, as UitedHealthcare s Treasury Departmet does, ad public housig authorities ca leverage their operatig fuds as the Bosto Housig Authority did to implemet Itegrated Pest Maagemet withi its stadard maiteace practices. Charter Oaks, the public housig authority i Stamford, leveraged HOPE VI public housig revitalizatio fuds ad the Low-Icome Housig Tax Credit to help create 12 mixed-icome revitalizatio developmets withi ad aroud the Vita Health & Welless District. The Coway Ceter will tap ito DC s local Housig Productio Trust Fud. Local foudatios, which kow commuity cotexts well ad have a special iterest i promotig local well-beig, ca play a valuable role i supportig this type of work. These fuders ca be easier to approach for place-based projects tha large foudatios, as they are ofte familiar with the health ad housig orgaizatios i the city ad ted to have a less resource-itesive proposal process. I Bosto 16 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

31 ad Austi, local foudatios are puttig sigificat resources toward uderstadig, evaluatig, ad improvig the itersectio of health ad housig i their cities. I additio to local foudatios, larger regioal ad atioal orgaizatios ca provide substatial fiacial support to these iitiatives. Because these orgaizatios are ot or focused o a particular local cotext, it is importat to fid oes that alig i goals ad missio to what the local partership is tryig to achieve. The Coway Ceter received $14 millio from the Healthy Futures Fud, a $200 millio effort fuded by the Local Iitiatives Support Corporatio, the ivestmet bak Morga Staley, ad The Kresge Foudatio. The Healthy Futures Fud primarily leverages New Market Tax Credits, the Low-Icome Housig Tax Credit (which i the case of Coway was sydicated separately), ad grat ad loa capital to cultivate commuity developmet projects that combie housig ad health services, which directly aligs with the Coway Ceter s missio. Although these fuds that seek out local iitiatives at the itersectio of health ad housig are ascet, they exemplify how local parterships ca tap ito grat opportuities from larger orgaizatios to provide fiacial support for their itervetios. Private doors ca make sizable cotributios to local health ad housig itervetios, addig stability to the fiacial portfolio ad further diversifyig fudig sources. Foudatio Commuities raises a average of $1 millio at a aual fudraisig evet ad puts $100,000 of this toward its health programmig. The Coway Ceter parters received a sizable doatio from Bill Coway, a local Washigto, DC, philathropist, to develop the colocated housig, employmet, ad health services property i Northeast DC. Although private doatios are ofte oe-time fudig sources with limited optios to reew, they ca provide sigificat resources to local iitiatives ad ofte require less capacity to write grats ad execute the deals. Fudig Challeges Despite these opportuities, sigificat fudig challeges udermie the potetial impact of health ad housig itervetios. First, as Low Icome Ivestmet Fud chief executive officer Nacy Adrews said, The itersectio of housig ad health is well uderstood from a kowledge poit of view, but from a practice poit of view, these two sectors are quite siloed i their fudig. Siloed fudig streams at the federal ad local levels ca make it difficult for orgaizatios to fid fiacial resources for cross-sector iitiatives. For example, despite recogizig that ustable or uhealthy housig ca have direct implicatios for Medicaid recipiets health ad well-beig, Medicaid is ot set up to pay for ogoig direct housig costs such as ret. Recet chages i Medicaid policy permit payig EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 17

32 for some trasitioal costs, such as first moth s ret whe a perso is movig from a istitutioal settig. I a era of isufficiet affordable housig subsidies, fidig steady fudig sources to pay for housig solutios poses a challege to sustai targeted itervetios that aim to get chroically ill, lowicome people stably housed. Sigificat efforts must be made to braid fudig to pay for housig ad health-related services while respectig programs parameters. I additio, specific iterests (e.g., health or housig, but ot both) ofte drive foudatios. It ca take time to covice private ivestors or fuders that addressig housig will directly beefit residets health because there has bee limited research o the cross-sector beefits of these parterships. But this challege of appealig to foudatios with specific missios has bee overcome i places like Austi, where the board of the health-focused St. David s Foudatio came aroud to the idea of housig as a social determiat of health ad is ow a primary fuder for Foudatio Commuities health work. I additio to siloed fudig streams, showig retur o ivestmet for health ad housig itervetios is challegig. Because the savigs are ofte cross-sector, the retur o ivestmet ofte caot be traced to a sigle source. Although our highlighted cases seemed to have overcome the wrog pocket problem, where oe orgaizatio ivests i a iitiative but a differet orgaizatio experieces the cost savigs, these are still the exceptio rather tha the rule. For those with a eye toward fiacial savigs, it remais challegig to uderstad the fiacial payback of cross-sector parterships. Commuity Egagemet Experts from various fields at the itersectio of health ad housig agree that egagig program participats ad local commuity members i every step of a joit iitiative results i programs better suited to commuity eeds, but this is ofte challegig for istitutioal stakeholders i both sectors. Commuity egagemet ivolves a collaborative, ogoig relatioship betwee commuity members ad local orgaizatios to address issues affectig the citizes well-beig. At its core, commuity egagemet is grouded i the priciples of commuity orgaizatio: fairess, justice, empowermet, participatio, ad self-determiatio (Natioal Istitutes of Health 2011). Research shows that whe commuities idetify health eeds ad collaborate or are cosulted to desig more appropriate itervetios, the itervetios ted to have better health outcomes tha whe commuities are ot egaged (O Mara-Eves et al. 2015). Furthermore, egagig citizes i the itervetio process 18 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

33 icreases the likelihood that projects will be widely accepted, empowers ad itegrates people from differet backgrouds to come together i the commuity, ad icreases trust i commuity orgaizatios ad local goverace (Bassler et al. 2008). Commuity Egagemet i Actio Although proactive commuity egagemet is ot a cetral piece of most programs i this case study research, respodets oted that they wat to icorporate it, ad they some had successful efforts. Residet educatio. To esure a itervetio s sustaiability, some parterships educate residets about how to maage the potetially adverse effects of poor housig quality o health. I Bosto, residet educatio is a vital compoet of their Itegrated Pest Maagemet approach, where they teach public housig residets about how to keep their homes pest free. The Vita Health & Welless Collaborative developed a Parets as Co-Educators program, which focuses o childre of immigrat parets livig i the Vita district ad uses family egagemet strategies to improve childre s educatioal outcomes ad access to quality educatio. Similarly, residet educatio is a strog compoet of the Coway Ceter s missio. A job traiig facility o-site at the Coway Ceter will teach people about health-sector jobs ad aim to equip them with the skills to be ecoomically self-sufficiet. Participat feedback. Formal, iformal, ad frequet opportuities for participats to egage with program leaders ad offer feedback are importat aspects of successful egagemet. The case studies i this research used participat feedback to shape ad improve their programs. At Foudatio Commuities, residets complete surveys after pilot programs to provide feedback o how to alter the program. I additio, every three moths, commuity health workers meet with residets to ask them what their eeds are i the short term ad desig programmig based o their resposes. I Bosto, public health urses lead coversatios over luch to give cliets a opportuity to share their opiios ad feedback o the program. Direct participat egagemet i itervetio developmet. Providig a space for program participats or other commuity members i the iitiative s orgaizatioal leadership creates more egraied commuity egagemet ad ca help esure the itervetio meets commuity eeds. At Foudatio Commuities, the two seior health specialists who oversee family properties ad Permaet Supportive Housig properties are both Foudatio Commuities residets, so some residets directly oversee strategy ad programmatic EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 19

34 discussios. The leader of Foudatio Commuities Healthy Livig Iitiative, Adrea Albalawi, oted, this really helps itegrate the work to make sure the eeds of their residets are beig met. Commuity Egagemet Challeges Despite these early forms of commuity egagemet, most of the health ad housig itervetios explored through this research ted to reflect top-dow approaches with limited formal iput from affected commuity members. Oe challege associated with commuity egagemet is that it takes sigificat time ad resources to weave feedback ad aveues for egagemet ito the itervetio s fabric. Participats ofte have competig priorities (e.g., rigid work or child care schedules) that prevet them from participatig directly i program desig ad implemetatio. Some participats, such as the chroically homeless ad people facig physical ad metal health issues, face additioal barriers to egagig i commuity developmet. I additio, program participats ad orgaizatioal leadership poited to buildig commuity trust as a challege. Some participatig orgaizatios had to work hard to gai the trust of commuities with which they were previously at odds. For example, i Columbus, Ohio, Natiowide Childre s Hospital had to overcome a history of ot takig commuity eeds as seriously as they could have i past expasio projects. But whe local commuity-based orgaizatios are egaged as parters, their participatio may be a bridge betwee istitutios ad residets. I the Healthy Neighborhoods Healthy Families iitiative, Natiowide Childre s Hospital sought a partership with Commuity Developmet for All People, a oprofit commuity developmet orgaizatio, to be a liaiso with its surroudig commuity. Evetually, the housig iitiative was formally structured as a partership betwee these two orgaizatios. Data Itegratio Icorporatig data whe desigig ad implemetig a health ad housig itervetio ca lead to targeted ad more effective iitiatives. But data are collected ad used differetly i health ad housig orgaizatios, ad stakeholders i oe sector may be uaware of isights available from the other. 20 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

35 The Power of Local Data Local orgaizatios ca use local data to see clustered health problems, or patiets of certai types, ad better coect health data with people s housig eviromets. The Bosto Public Health Commissio added a questio to the Behavioral Risk Factor Surveillace System survey, which is ru by the Ceters for Disease Cotrol ad Prevetio ad admiistered by state health departmets, to determie whether residets lived i public housig. They foud that the city s public housig properties were home to may of Bosto s households with the most sigificat health challeges, motivatig them to parter with the Bosto Housig Authority ad desig a itervetio focused o betterig public housig residets health. Sharig Data with Parters I additio to leveragig oe orgaizatio s data sources to desig itervetios, housig ad health orgaizatios ca eter data-sharig agreemets that allow them to lik health ad housig datasets to evaluate where there are overlappig issues. Homeless service orgaizatios, for example, may lik their data with health isurers membership data to help idetify Medicaid members ad coect them to their maaged care orgaizatio, like Austi s Edig Commuity Homelessess Coalitio did with UitedHealthcare. These opportuities to itegrate data ca promote more precise ad effective itervetios ad make it easier to evetually assess programmatic outcomes. Data Itegratio Challeges Limitatios of preexistig data sources ad difficulty matchig housig ad health data i a compliat maer pose challeges for leveragig data to desig or ehace a itervetio. Medical data systems are ot ofte coected with housig assistace ad homeless maagemet iformatio systems, ad orgaizatios eed to lik these systems to uderstad where there is importat overlap i populatios. I additio, covered health care orgaizatios are required to protect the cofidetiality of idividual-level health data accordig to federal law (Health Isurace Portability ad Accoutability Act), ad egotiatig data agreemets must take these rigorous rules ito accout. The homelessess maagemet iformatio system protocol ca also stymie the ability to share data because of its ow set of security protocols. Although these protocols are desiged to beefit patiets ad providers, they ca prevet targeted itervetios from blossomig. Locally based orgaizatios, such as Foudatio Commuities, are implemetig Health Isurace Portability ad Accoutability Act compliat EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 21

36 protocols to safeguard health data that may iform health itervetio desig to better meet residet eeds, but the resources ad time this process takes ca be a impedimet, posig challeges for replicatig this process at smaller orgaizatios. Outcome Measuremet ad Evaluatio Measurig outcomes ad evaluatig a itervetio s effectiveess is a key step toward betterig the iitiative, replicatig the work elsewhere, ad expadig it to have a greater impact. The fidigs allow parters to modify their programs for icreased efficiecy or effectiveess ad help make the case for the itervetio. Most of our case studies are ewly focusig o trackig outcomes (as opposed to solely trackig outputs), but some parterships have show early success through outcome measuremet. UitedHealthcare s work that targets the chroically homeless populatio i oe city caused a iitial spike i health care use, followed by a log-term decrease. The spike is likely explaied by the pet-up demad for health care services that a homeless perso could access through their program, ad the resultig log-term tred shows the positive effects of maitaied cotact ad prevetive care that ca be assisted with stable housig for this populatio. I additio to use-related outcomes, programs are thikig about how to track housig outcomes, health ad well-beig outcomes, ad self-sufficiecy outcomes to assess program effectiveess. Uiversities as Outcome Measuremet Parters For orgaizatios that caot coduct full evaluatios of their programmatic activities, local istitutios such as uiversities or research orgaizatios ca provide valuable evaluatio assistace. Bosto Uiversity worked with the Bosto Public Health Commissio to evaluate its Healthy Start i Housig program. This mutually beeficial process provided ivaluable feedback to the program s leadership ad allowed Bosto Uiversity researchers to cotribute to the academic literature o health ad housig itervetios. Similarly, Foudatio Commuities has worked with the Uiversity of Texas School of Public Health to better uderstad the outcomes associated with Foudatio Commuities after-school program. 22 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

37 Outcome Measuremet ad Evaluatio Challeges Challeges with outcome measuremet ad evaluatio ofte prevet orgaizatios from evaluatig their iitiatives. First, isolatig the impacts of a housig itervetio aloe o health outcomes is difficult, as it is oly oe social determiat of health ad ofte cocurret with other chages i the lives of program beeficiaries. It ca also be difficult i strategies such as those i Columbus, Ohio, or Stamford, Coecticut, where the housig itervetio is oly oe prog of larger commuity revitalizatio focused o residets health ad well-beig. I additio, may of these iitiatives are ascet ad have ot baked evaluatio ito their framework. This is largely because of limited fudig i the health ad housig space that forces orgaizatios to prioritize maagemet ad admiistratio over evaluatio. Some itervetios are addig evaluatio compoets. Ca Cross-Sector Parterships Be Expaded? While housig is ot a direct health care itervetio, it ca be more powerful tha access to a really good doctor. If 80 percet of health outcomes are dictated by what happes outside of the walls of a cliic, where else do [people] sped their time? Houses ad eighborhoods. Kimberly McPherso, St. David s Foudatio (Austi, TX) Our expert iterviews ad case studies highlight iovative parterships betwee health ad housig stakeholders that focus o leveragig quality affordable housig as a importat compoet of idividual ad commuity health ad well-beig. Health care orgaizatios have take o diverse roles i these ew collaboratios: a catalyst for a iitiative, a ivestor brigig ew fuds to the table, or a parter coectig residets with health services supportig housig stability. These iitiatives have bee shaped by iteral istitutioal priorities ad shiftig exteral policy eviromets. The result has bee a ew appreciatio amog health care stakeholders for the importace of housig itervetios as part of their toolbox for achievig better health outcomes. Although these ew parterships have bee eye-opeig for the housig ad health orgaizatios ivolved, they do ot represet a stadard way of doig busiess i either sector. Sustaiig, expadig, EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 23

38 ad replicatig iovative cross-sector parterships requires a fudametal shift i priorities ad recogizig that parterig meas workig withi each sector s laguage, istitutios, ad chagig policy eviromets. They also require a willigess to ivest i strategies that may require time to bear fruit. Oe iformat oted, The chages are ot goig to be immediate. What you will see are measurig thigs that are more closely tied to the ivestmet. Are people/families feelig more stable? Do they have more hope? Are they less stressed? These are the thigs that will be helped i the short term, ad the public health people kow that this is what will reduce chroic health problems. The fear is that health care will oly look at cost savigs, but they might ot see this right away. Orgaizatios are itegratig health ad housig through cross-sector parterships, may of them with goals of buildig upo successes ad teachig others how to do the same. There is still a lot ukow, however, ad several areas to moitor i developig future iitiatives that try to address health through housig. The chagig policy cotext. Cotiued progress is icumbet o health ad housig stakeholders ability to be flexible amid chagig policy. Some iovatio has advaced through programs that are at risk i the curret fudig eviromet, icludig Medicaid expasio ad housig subsidies. It is uclear how curret parterships would advace or how ew parterships could form aroud this work i the face of dimiished health ad housig program resources. Threats to publicly fuded resources whether as reduced health isurace coverage, less housig assistace, or decreased resources for commuity developmet fiacial istitutios will icrease the pressure o private-sector resources. Although successful parterships leverage both public ad private resources, udue pressure o publicsector resources will slow progress ad limit iovatio. The importace of uderstadig place i ew ways. Although health care providers have typically worked withi catchmet or service areas that defie the patiet populatios with which they iteract, place takes o a differet meaig whe the goal is addressig social determiats of health. I this cotext, attedig to place requires focus o the health of a etire commuity (ot just people who preset for care) ad egagemet with the eviromet that shapes commuity well-beig. Similarly, stakeholders iterested i housig have to iclude health impacts i their defiitio of shelter ad cosider how the lack of quality affordable housig is a impedimet to larger goals for commuity health ad well-beig. The role of cities as a exus for both sets of stakeholders. Cities are egaged i activities ad policymakig that cross both sectors ad play a role i shapig icetives to foster collaboratio. Decisios about lad use, health ad housig code eforcemet, ad resources allocated to public 24 EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING

39 health ad housig agecies exhibit cities leadership at this importat itersectio. Expadig parterships withi ad across commuities is possible through city visio ad collaboratio. I additio, cities ca provide critical feedback o state ad federal policies that ca help or hider progress at this itersectio, such as the optios states pursue uder Medicaid or the role of housig assistace i health ad housig parterships. They may also be key players i testig ew fiacig mechaisms, such as pay for success strategies that leverage potetial savigs i public-sector programs as ivestmets i iovatio. The eed for istitutios that ca bridge worlds. Health ad housig orgaizatios are likely to eed the expertise of orgaizatios who uderstad how to address commuity eeds ad structure complex fiacial trasactios. Commuity developmet fiacial istitutios may be ufamiliar to health care stakeholders but are well-established parters for those iterested i commuity-coscious developmet. I additio, both health ad housig orgaizatios eed to grapple with the importace of commuity iput, ot just as patiets or as residets, but as people who have multiple idetities ad are essetial parters i achievig better outcomes. Commuity health workers, teats rights advocates, public housig residet represetatives, ad grassroots commuity-based orgaizatios offer various ways to support authetic egagemet with people at the ceter of the itersectio. EMERGING STRATEGIES FOR INTEGRATING HEALTH AND HOUSING 25

40 Notes 1. For past reports ad a curret database, see State ad City Fuded Retal Housig Programs, Natioal Low Icome Housig Coalitio, accessed Jue 21, 2017, 2. Istitutig Smoke-Free Public Housig, 81 Fed. Reg., (December 5, 2016). 3. Healthy People 2020: A Opportuity to Address Societal Determiats of Health i the Uited States, US Departmet of Health ad Huma Services, July 26, 2010, 4. Medicaid Beefits: Home ad Commuity-Based Services Waiver, Kaiser Family Foudatio, accessed July 12, 2017, D. 5. Sectio 811 Project Retal Assistace (PRA) Program, US Departmet of Housig ad Urba Developmet, accessed July 12, 2017, 6. Medicaid Icome Eligibility Limits for Adults as a Percet of the Federal Poverty Level, Kaiser Family Foudatio, Jauary 1, 2017, 7. Sara Rosebaum, Additioal Requiremet for Charitable Hospitals: Fial Rules o Commuity Health Needs Assessmets ad Fiacial Assistace, Health Affairs Blog (blog), Jauary 23, 2015, 26 NOTES

41 Refereces Bassler, Alla, Kathy Brasier, Neal Fogle, ad Ro Tavero Developig Effective Citize Egagemet: A How-To Guide for Commuity Leaders. Harrisburg: Ceter for Rural Pesylvaia. Bo sher, Luke, Sewi Cha, Igrid Gould Elle, Bria Karfukel, ad Hsi-Lig Liao Accessibility of America s Housig Stock: Aalysis of the 2011 America Housig Survey. Washigto, DC: US Departmet of Housig ad Urba Developmet, Office of Policy Developmet ad Research. Briggs, Xavier de Souza, Susa J. Popki, ad Joh Goerig Movig to Opportuity: The Story of a America Experimet to Fight Ghetto Poverty. New York: Oxford Uiversity Press. Cuigham, Mary K., Sarah Gillespie, ad Jacquelie Aderso Rapid Re-housig: What the Research Says. Washigto, DC: Urba Istitute. Cuigham, Mary K., Mike Pergamit, Marla McDaiel, Maeve E. Gearig, Simoe Zhag, ad Bret Howell Supportive Housig for High-Need Families i the Child Welfare System. Washigto, DC: Urba Istitute. Day, Kriste Active Livig ad Social Justice: Plaig for Physical Activity i Low-Icome, Black, ad Latio Commuities. Joural of the America Plaig Associatio 72 (1): De Leo, Erwi, ad Joseph Schillig Urba Blight ad Public Health: Addressig the Impact of Substadard Housig, Abadoed Buildigs, ad Vacat Lots. Washigto, DC: Urba Istitute. Dwyer-Lidgre, Laura, Amelia Bertozzi-Villa, Rebecca W. Stubbs, Chloe Morozoff, Joah P. Mackebach, Frak J. va Lethe, Ali H. Mokdad, et al Iequalities i Life Expectacy Amog US Couties, 1980 to 2014: Temporal Treds ad Key Drivers. JAMA Iteral Medicie. Fairbaks, Robert B. From Better Dwelligs to Better Neighborhoods: The Rise ad Fall of the First Natioal Housig Movemet. I From Teemets to the Taylor Homes: I Search of a Urba Housig Policy i 20th-Cetury America, edited by Joh F. Bauma, Roger Biles, ad Kristi M. Szylvia, Uiversity Park: Pesylvaia State Uiversity Press. Gillespie, Sarah, ad Susa J. Popki Buildig Public Housig Authority Capacity for Better Residet Services: Lessos from HOST. Washigto, DC: Urba Istitute. Gubits, Daiel, Marybeth Shi, Michelle Wood, Stephe Bell, Samuel Dastrup, Claudia D. Solari, Scott R. Brow, et al Family Optios Study: 3-Year Impacts of Housig ad Services Itervetios for Homeless Families. Washigto, DC: US Departmet of Housig ad Urba Developmet, Office of Policy Developmet ad Research. James, Julia Noprofit Hospitals Commuity Beefit Requiremets. Priceto, NJ: Robert Wood Johso Foudatio. Istitute of Medicie ad Natioal Research Coucil US Health i Iteratioal Perspective: Shorter Lives, Poorer Health. Washigto, DC: Natioal Academies Press. Joit Ceter for Housig Studies The State of the Natio s Housig Cambridge, MA: Harvard Uiversity. Marmot, Michael The Health Gap: The Challege of a Uequal World. New York: Bloomsbury Press. Musumeci, MaryBeth, ad Hery Claypool Olmstead s Role i Commuity Itegratio for People with Disabilities uder Medicaid: 15 Years after the Supreme Court s Olmstead Decisio. Washigto, DC: Kaiser Family Foudatio. Natioal Istitutes of Health Priciples of Commuity Egagemet, 2d ed. Bethesda, MD: Natioal Istitutes of Health. REFERENCES 27

42 Norris, Tyler, ad Ted Howard Ca Hospitals Heal America s Commuities? All i for Missio Is the Emergig Model for Impact. Clevelad OH: Democracy Collaborative. O Mara-Eves, Aliso, Giy Bruto, Sady Oliver, Josephie Kavaagh, Farah Jamal, ad James Thomas The Effectiveess of Commuity Egagemet i Public Health Itervetios for Disadvataged Groups: A Meta-Aalysis. BMC Public Health 15. Riis, Jacob How the Other Half Lives. New York: Charles Scriber s Sos. Rosebaum, Sara, Mauree Byres, ad Nikki Hurt..d. Commuity Beefit ad the ACA: A Brief History ad Update. Washigto, DC: George Washigto Uiversity. Schwartz, Alex F Housig Policy i the Uited States, 3rd ed. New York: Routledge. Shirk, Cythia Rebalacig Log-Term Care: The Role of the Medicaid HCBS Waiver Program. Washigto, DC: George Washigto Uiversity ad Natioal Health Policy Forum. Spillma, Breda C., Pamela Blumethal, Nicole Cafarella Lallemad, Josh Leopold, Eva H. Alle, ad Emily Hayes Housig ad Delivery System Reform Collaboratios: Evirometal Sca. Washigto DC: Urba Istitute. Sturtevat, Lisa, ad Jaet Viveiros How Ivestig i Housig Ca Save o Health Care: A Research Review ad Commet o Future Directios for Itegratig Housig ad Health Services. Washigto, DC: Natioal Housig Coferece. UitedHealthcare Commuity ad State Why Does a Health Care Compay Care about Housig? Uderstadig the Itersectio of Housig ad Health Care. Mietoka, MN: UitedHealthcare. Vartaia, Keri, Maggie Weller, ad Amada Saul Health i Housig: Explorig the Itersectio betwee Housig ad Health Care. Washigto, DC: Eterprise Commuity Parters. World Health Orgaizatio Closig the Gap i a Geeratio: Health Equity through Actio o the Social Determiats of Health. Geeva, Switzerlad: World Health Orgaizatio, Commissio o the Social Determiats of Health. Zuckerma, David Hospitals Buildig Healthier Commuities: Embracig the Achor Missio. Baltimore, MD: Democracy Collaborative. 28 REFERENCES

43 About the Authors Coriae Payto Scally is a seior research associate i the Metropolita Housig ad Commuities Policy Ceter at the Urba Istitute, where she explores the complexities of iteragecy ad cross-sector state ad local implemetatio of affordable retal housig policy, fiace, ad developmet. Her areas of expertise iclude federal, state, ad local affordable housig programs ad parters, coverig topics from policy developmet ad advocacy to program fudig ad implemetatio to o-the-groud developmet ad operatios. Through extesive case study research, iterviews, ad surveys, Scally evaluates how well the affordable retal housig system serves vulerable populatios, icludig low-icome households, people with disabilities, ad the elderly. She is a former associate professor of urba plaig at the State Uiversity of New York at Albay ad a former oprofit affordable housig developer. Scally received her BA i iteratioal affairs ad MS i urba plaig from Florida State Uiversity ad her PhD i urba plaig ad policy developmet from Rutgers Uiversity. Elaie Waxma is a seior fellow i the Icome ad Beefits Policy Ceter at the Urba Istitute. Her expertise icludes food isecurity, utritio ad the food assistace safety et, the social determiats of health disparities, ad other issues affectig low-icome families ad commuities. Before joiig Urba, Waxma was vice presidet of research ad utritio at Feedig America, where she oversaw research o food isecurity, the itersectio of huger ad health, ad the circumstaces ad experieces of people seekig charitable food assistace. She also helped develop commuity-based itervetio models to address the eeds of lowicome, food-isecure families. From 1999 to 2009, Waxma worked o a series of liked research projects at the Uiversity of Chicago o low-wage work ad the challeges facig low-icome workig families. Waxma has coauthored umerous research ad policy reports ad articles i scholarly jourals, icludig Applied Ecoomics Perspectives ad Policy, Health Affairs, Social Sciece Review, Joural of Huger ad Evirometal Nutritio, Joural of Family ad Ecoomic Issues, ad Joural of Food Law ad Policy. She holds a MPP ad a PhD from the Uiversity of Chicago, where she is a lecturer. ABOUT THE AUTHORS 29

44 Ruth Gourevitch is a research associate i the Metropolita Housig ad Commuities Policy Ceter. Her curret research projects iclude a evaluatio of the DC Promise Neighborhood Iitiative; a evaluatio of the Strog Cities, Strog Commuities Natioal Resource Network; ad a research study o emergig parterships i the health ad housig sector. I additio, she assists o projects related to mobility from poverty, promotig ecoomic iclusio, ad uderstadig the effects of eighborhood chage o residets. Before joiig Urba, Gourevitch participated i iterships at New York Uiversity s Furma Ceter for Real Estate ad Urba Policy ad Brow Uiversity s Aeberg Istitute for School Reform. She graduated with hoors from Brow with a BA i urba studies. sade adeeyo is a research associate i the Metropolita Housig ad Commuities Policy Ceter. She works primarily with the Program o Neighborhoods ad Youth Developmet team, focused o buildig multigeeratioal, place-based itervetios i public housig commuities. She is part of the Promotig Adolescet Sexual Health ad Safety project. Before joiig Urba, adeeyo worked at the Black Wome s Health Imperative. She has cosistetly held positios that advocate for equitable public health ad the housig stability of wome ad commuities of color. adeeyo holds a BA i comparative wome s studies with a mior i public health from Spelma College ad a MPP with a cocetratio i wome s studies from the George Washigto Uiversity. 30 ABOUT THE AUTHORS

45 S TATEMENT OF I NDEPENDENCE The Urba Istitute strives to meet the highest stadards of itegrity ad quality i its research ad aalyses ad i the evidece-based policy recommedatios offered by its researchers ad experts. We believe that operatig cosistet with the values of idepedece, rigor, ad trasparecy is essetial to maitaiig those stadards. As a orgaizatio, the Urba Istitute does ot take positios o issues, but it does empower ad support its experts i sharig their ow evidece-based views ad policy recommedatios that have bee shaped by scholarship. Fuders do ot determie our research fidigs or the isights ad recommedatios of our experts. Urba scholars ad experts are expected to be objective ad follow the evidece wherever it may lead.

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