MRT Affordable Housing Work Group

1
MRT Affordable Housing Work Group
Redesign Medicaid in
New York State

• February 22, 2013 1000 AM to 300 PMNew York
  State Department of Health Metropolitan Regional
  OfficeNew York City

2
Goals for Today

• Update the MRT Work Group on the progress of the
  sub work groups
• These are ideas developed by members of the sub
  work groups.
• Achieve general consensus on a series of policy
  recommendations.

Medicaid Redesign Affordable Housing Work Group
2
3
MRT Affordable Housing Work Groups

• Program Model and Development Funding
• Ted Houghton, Chair
• Brenda Rosen, Chair
• Tony Hannigan, Co-Chair
• Planning and Service Coordination
• Constance Tempel, Chair
• Kristin Miller, Co-Chair

Medicaid Redesign Affordable Housing Work Group
3
4
Program Model and Development Funding Work Group
5
Program Model and Development Funding Work Group

1. Identify barriers to moving high-need individuals
   into supportive housing.
2. Identify New Affordable/Supportive Housing
   Models.
3. Define supportive housing.
4. Advise the State on how to allocate 2013-14 MRT
   Supportive Housing Funds.
5. Advise the State on appropriate set-asides and
   incentives for supportive housing.
6. Develop principles for a new supportive housing
   initiative.
7. Develop a plan to create social impact
   investment bonds.
8. Identify ways to leverage federal and private
   funds.

Medicaid Redesign Affordable Housing Work Group
5
6
Updates Discussion Items

• Supportive housing definition.
• MRT Supportive Housing Allocation Plan
  Recommendations.
• Model Design Elements of Pilot Programs.

Medicaid Redesign Affordable Housing Work Group
6
7
Defining Supportive Housing

• Supportive housing is defined as affordable
  rental housing operated by non-profit
  organizations, in which all members of the tenant
  household have easy, facilitated access to a
  flexible and comprehensive array of supportive
  services designed to assist the tenants to
  achieve and sustain housing stability and to live
  more productive lives in the community.
• Supportive housing units are intended to meet the
  needs of people with special needs who are
  homeless or would be at-risk of homelessness-or
  cycling through institutional care-were it not
  for the integration of affordable housing and
  supportive services.

Medicaid Redesign Affordable Housing Work Group
7
8
Defining Supportive Housing

• A supportive housing unit is defined by the
  following elements
• The unit is available to, and intended for, a
  person or family whose head of household or
  member is homeless, or at-risk of
  homelessness/institutionalization, and has
  multiple barriers to employment and housing
  stability, which might include mental illness,
  chemical dependency, and/or other disabling or
  chronic health conditions
• The tenant household ideally pays no more than
  30 household income towards rent and utilities,
  and never pays more than 50 of income toward
  such housing expenses
• The tenant household has a lease (or similar form
  of occupancy agreement) in permanent affordable
  rental housing with no limits on length of
  tenancy, as long as the terms and conditions of
  the lease or agreement are met

Medicaid Redesign Affordable Housing Work Group
8
9
Defining Supportive Housing (continued)

• The units operations are managed through an
  effective partnership among representatives of
  the project owner and/or sponsor, the property
  management agent, the supportive services
  providers, the relevant public agencies, and the
  tenants
• All members of the tenant household have easy,
  facilitated access to flexible and comprehensive
  array of supportive services designed to assist
  the tenants to achieve and sustain housing
  stability
• Service providers proactively seek to engage
  tenants in on-site and community-based supportive
  services, but participation in such supportive
  servicers is not a condition of ongoing tenancy
  and
• Service and property management strategies
  include effective, coordinated approaches for
  addressing issues resulting from substance use,
  relapse, mental health crises and medical
  circumstances, with a focus on fostering housing
  stability

Medicaid Redesign Affordable Housing Work Group
9
10
91 Million Allocation Plan Recommendations
Proposed MRT Housing Initiative Spending Plan Approximate NYS SFY 13-14 Funding Amount (in millions) Total Approximate Annual Cost (in millions) Committee Support
Existing Commitments
Continued Funding of SFY2012-13 Initiatives 28.0 28.0 96
NFTD Housing Subsidy 2.5 2.5 93
Total Existing Commitments 30.5 30.5
Total Capital Housing Development 42.5
Pilot Programs
Health Homes Supportive Housing Pilot  5.0 10.0 96
Step-down/Crisis Residence Capital Conversion  4.2 4.2 82
Nursing Home to Independent Living Rapid Transition  2.1 3.6 82/65
OMH Supported Housing Services Supplement  3.0 8.0 74
DHS Homeless Senior Placement Project  2.5 5.0 69
Health Home HIV Rental Assistance Demo Project 1.2 3.6 58
Total Pilot Programs 18.0 34.4
Total Supported Initiatives 91.0    
11
Pilot Program Descriptions
34.4 million Annual Cost18 million SFY 2013-14
12
Health Homes Supportive Housing Pilot
Total Cost 10 million (5 million
SFY2013-14)Per Person Cost House and serve 500
high cost Medicaid recipients at 20,000 each

• Serve 500 rent and service subsidies to
  experienced supportive housing services providers
  to house and serve unstably housed high cost
  Medicaid recipients in scattered-site market-rate
  rental apartments.
• Enhanced housing first, harm reduction
  supportive housing model to house and serve
  persons referred by Health Homes.
• Services will be offered in an ongoing effort to
  link and transition tenants to community-based
  care, services and supports.
• Person-centered, wrap-around services aimed at
  increasing independence and housing stability,
  augmented with Health Home Care Coordination to
  provide a new overlay of assistance aimed at
  helping tenants re-organize medical care to
  reduce use of emergency systems and improve use
  of preventive and primary care.

Medicaid Redesign Affordable Housing Work Group
12
13
Health Homes Supportive Housing Pilot

• Key program components include
• Scattered Site units available to Health Homes
  across state
• Funding for operating and services would be RFPd
  to housing providers applying in partnership with
  Health Homes
• Contracts of 25 to 50 units would be held by
  experienced supportive housing providers, managed
  by OTDA
• Contracts will provide 20,000 per individual per
  year to cover rental costs, service and support
  staff

Medicaid Redesign Affordable Housing Work Group
13
14
Health Homes Supportive Housing Pilot (continued)

• Key program components include
• Government agency (NYC HRA, DOH, OMH SPOA) would
  certify eligibility
• Health Homes would manage referral process and
  prioritize clients for housing
• Health Home care coordination is conducted
  directly by the housing provider, or through
  explicit Health Home-Supportive Housing Provider
  agreements that spell out how care coordination
  will be integrated with housing-based services
• Specific diagnoses will not be a criteria for
  eligibility
• Once placed in housing, tenants will receive
  person-centered, wrap-around case management
  services aimed at increasing independence and
  housing stability
• Active, collaborative, real-time evaluation and
  data collection.

Medicaid Redesign Affordable Housing Work Group
14
15
Nursing Home to Independent Living Rapid
TransitionTotal Cost 3.6 million (2.1 million
in SFY2013-14)Per Person Cost Will serve 200
individuals at approximately 24,000 each per
year

• Offer individuals with mobility impairments or
  other severe physical disabilities an alternative
  pathway to community living.
• Housing subsidies, combined with MLTC enrollment
  or service funding will allow targeted high cost
  Medicaid recipients who live in nursing homes or
  are nursing home eligible to move into an
  apartment in the community.
• Program activities will include educational
  outreach and identification of eligible,
  interested and capable high cost Medicaid
  recipients who are homeless or living in nursing
  homes with physical disabilities. Comprehensive
  assessment relating to living environment,
  transitional needs, and long-term care needs and
  customized retrofitting of apartments will
  follow.
• The individuals move and full transition to
  independent living will be facilitated by the
  support team of staff, funded through the MLTC
  waiver or a relatively modest services contract.

Medicaid Redesign Affordable Housing Work Group
15
16
Step-down/Crisis Residence Capital Conversion
Total Capital Cost  800,000 (one-time cost)One
years operating costs 3 million for twelve
residences with 24-36 beds total (NYC-5 Long
Island-2 Rest of State-5)Per Person Cost 2
week avg LOS 100 high cost Medicaid recipients
in crisis.

• Transition individuals from psychiatric hospitals
  into community settings and divert individuals in
  crisis from use of such services.
• Short-term level of intensive behavioral health
  respite care for individuals being discharged
  from psychiatric hospitals, not quite ready for a
  full transition into the community.
• The designated providers would work in
  partnership with hospitals to identify and assess
  individuals in need of transitional services, as
  well as screen and assess individuals in crisis
  who may require short-term diversionary placement
  services.

Medicaid Redesign Affordable Housing Work Group
16
17
Step-down/Crisis Residence Capital Conversion
(continued)

• This type of pilot program would allow for a
  specified number of existing community
  residential service providers to convert a
  certain number of beds into crisis or step-down
  service units.
• The proposed model would require funding for
  startup costs, including one-time capital
  improvement dollars to reconfigure spaces to be
  able to provide crisis and transitional services,
  and staff training.

Medicaid Redesign Affordable Housing Work Group
17
18
OMH Supported Housing Services Supplement
8 million (3 million in SFY2013-14)Per Person
Cost 1,600 high cost Medicaid recipients at
5,000 each per year

• Supplementary funding to allow nonprofit OMH
  Supported Housing providers to offer a
  time-limited service enhancement to SPMI
  high-cost Medicaid recipients enrolled in Health
  Homes and living in scattered-site apartments.
• The augmented services will supplement the
  minimal services in OMH Supported Housing in
  order to provide necessary day-to-day continuity
  of place-based, wraparound support services
  through a flexible critical time intervention
  approach
• More direct and active engagement to achieve
  successful adjustment and stabilization during a
  flexible12-month transition from institutions
  (psychiatric hospitals, adult homes, shelters,
  street, jails/prisons) to the community.

Medicaid Redesign Affordable Housing Work Group
18
19
OMH Supported Housing Services Supplement
(continued)

• Program elements will include
• A focus on managing the social determinants of
  health that impact tenure in housing.
• Evidenced-based practices delivered in a housing
  context to assist with the adoption of a healthy
  life style.
• Leading and supporting the individual to engage
  in, and follow up with, medical and behavioral
  services, in conjunction with health home care
  coordination.
• Connect the individual to opportunities for
  forging healthy and naturally occurring
  relationships in the community, critical for
  people with SMI who tend to isolation and
  recidivism to shelters and hospitals.

Medicaid Redesign Affordable Housing Work Group
19
20
Homeless Senior Placement ProjectTotal Cost2.5
million/5.0 million Total Per Person Cost 300
individuals at approximately 14,000 per person
per year

• A Housing intervention intended to reduce
  Medicaid spending that is predictive targeting
  a group of individuals who are likely to become
  high Medicaid users rather than those that have
  been in the past.
• Among the current shelter population, there are
  578 single adults age 55 and over and receiving
  SSI who, as a group, are largely defined by these
  characteristics.
• Annual 2.3m in rent subsidy, 1.4m for an
  increased amount of aftercare transitional
  services provided by shelter provider and 300k
  in apartment locator, inspection and placement
  services.

Medicaid Redesign Affordable Housing Work Group
20
21
Health Home HIV Rental Assistance Demonstration
Project Total Cost3.6 million (SFY 13-14 1.2
million )Per Person Cost Serve 200 persons

• Rental assistance for 200 homeless and unstably
  housed Health Home participants diagnosed with
  HIV infection but medically ineligible for the
  existing HIV-specific enhanced rental assistance
  program for New Yorkers with AIDS or advanced
  HIV-illness (AIDS Rental Assistance).
• Provides rental subsidies, apartment locating
  services, brokers fees and security deposits for
  200 HIV individuals
• Administered by Health Home providers as a
  component of Care Coordination
• Available to HIV Medicaid-eligible households
  who have an immediate housing but whose HIV
  disease has not progressed to the point of
  eligibility for the AIDS Shelter Allowance
• The project would employ an experimental design
  to evaluate health care utilization, outcomes and
  costs in the periods before and after receipt of
  rental assistance for the pilot group of HIV
  Health Home participants.

Medicaid Redesign Affordable Housing Work Group
21
22
Additional Considered PilotsSenior Supportive
Housing Models

• Provide stable, affordable senior housing plus
  services to enable low-income seniors to remain
  in the community provide a platform for Medicaid
  Managed Long Term Care and Health Home services
  and support the transition of people from nursing
  homes to the community and independent living.

Medicaid Redesign Affordable Housing Work Group
22
23
Additional Considered PilotsSenior Supportive
Housing Models

• Program Elements Proposed
• Capital grant capital funding would be available
  to incorporate supportive housing features such
  as universal design modifications, renovation and
  reconfiguration including co-location of
  supportive services, gap financing for new senior
  housing pipeline construction, security systems
  and other technologies for residents to maintain
  safety and independence, vehicles to provide
  transportation for residents, or other projects
  as determined by the department of health.
• Supportive services assistance with obtaining
  meals, access to groceries and pharmacy,
  transportation, referral services related to
  resources available in the community,
  housekeeping, and security. Grant funding will be
  limited to funding for the services explicitly
  stated above.

Medicaid Redesign Affordable Housing Work Group
23
24
Planning and Service Coordination Work Group
25
Planning and Service Coordination Work Group

• Improve interagency coordination.
• Improve the Capital Development process.
• Evaluate perceived barriers to utilization of
  supportive housing.
• Provide advice on overall coordination and
  implementation of supportive housing policy.
• Improve the coordination and timing of the
  availability of housing.

Medicaid Redesign Affordable Housing Work Group
25
26
Principles to Improving Planning and Services
Coordination

• Build upon development processes and efficiencies
  that work
• New York has mature supportive housing
  development system with great expertise that
  works well overall.
• New monies (ACA/MRT, Olmstead, and yet
  unidentified) are opportunity for building upon
  and improving what already works.
• Preserve existing successful SH models while
  updating/ creating others with appropriate level
  of services.
• Facilitate growing trend of mixed population,
  integrated housing.

Medicaid Redesign Affordable Housing Work Group
26
27
Principles (continued)

• Ensure an active role for nonprofits
• Create least expensive and quickest way to get
  housing to high cost/need users
• Streamlining process via coordinated requests for
  funding, shared-decision making, and amending
  conflicting development requirements will
• Decrease length of time to get units on line.
• Decrease total costs of project development
  because of duplicative development regulations
  and requirements.

Medicaid Redesign Affordable Housing Work Group
27
28
Current Prototype A 60 unit, 9 LIHTC SH project
_at_ 275,000 per unit
CAPITAL PROGRAM 30 SPECIAL NEEDS 18 High Need 60 SPECIAL NEEDS 18 Homeless, 18 High N NOTES
OTDA/HHAP _ 37,500 18 HOMELESS AT 125,000 PER UNIT
HCR/HOUSING FINANCE AGENCY/MRT 37,500 37,500 18 HIGH NEED AT 125,000 PER UNIT
HCR/HOUSING TRUST FUND (HTF) 40,000 40,000 PROGRAM MAX OF 2.4 MILLION BY 60 UNITS
HCR/DHCR/9 LIHTC 197,500 160,000 19,750 vs. 16,000 ANNUAL CREDIT PER DU. 16,000 IS MORE COMPETITIVE
TOTAL 275,000 275,000  
29
Prototype B 100 units, Bond/As-of-right 4
LIHTC project _at_ 300,000 Per Unit
PROGRAM 30 Special Needs,34 units 60 Special Needs,67 Units Calculation
HFA/4 Tax Credit Equity 150,000 150,000  For project in NYC with 30 Basis Boost. Smaller raise outside NYC. Additional raise if combined with SLIC.
HCR/HFA Loan 35,000 35,000 First Mortgage, self- amortizing.
HCR/HFA Loan 10,000 6,250 Subsidy Loan at 1. HFA has limited capacity for these loans
OTDA/HHAP - 41,250 33 Homeless at 125,000 per unit
HCR/HFA/MRT 42,500 42,500 34 High Need Medicaid Users at 125,000 per unit
Federal Home Loan Bank (FHLB) 10,000 10,000 Subsidy Loan for affordable housing
Deferred Developer Fee 15,000 15,000 42 of Developer Fee paid thru 10 plus years of net income
Total 262,500 300,000  
Gap 37,500   Additional Source of Subsidy Loan Needed
30
Recommendation 1 Streamline SH Capital
Development Function

• Build upon existing HHAC model.
• Create development process that coordinates
  timing of awards and requirements of various
  RFPs, underwriting, design, timetables, legal
  docs.
• HPD SH Loan Program-like model responsible for
  SH capital awards but consults/ties in with
  health human service agencies for operation and
  services.
• Retain expertise of health human service
  agencies.
• Ensure health human service agencies still have
  ownership of the process and product.
• State partners with SH developers and continue to
  share risk of SH development.

Medicaid Redesign Affordable Housing Work Group
30
31
Recommendation 2 Create Funding Council to
Facilitate Integrated Housing

• Create Coordinated Funding Council to assure
  timely awards of capital, operating and service
  dollars from various agencies to individual
  projects
• The Funding Councils impact on SH development
• Retain rolling RFPs yet allow HHAP to inform
  Unified Funding Application determinations for
  early vetting of projects.
• Maintain value of OTDA/HHAP connection to LSS
  districts  CoCs plans.
• Set minimum for on-site service provisions
  quality of services.
• Retain SH underwriting provisions, e.g., larger
  operating reserves, design specifications,
  rent-up provisions.
• Ensure robust asset management capacity.

Medicaid Redesign Affordable Housing Work Group
31
32
Create Funding Council to Facilitate Integrated
Housing (continued)

• Maintain ability to fund different models of PSH
  (without tax credits, very small projects).
• Maintain lead role/ownership of supportive
  housing development for non-profit developers.
• Provide adequate pre-development and acquisition
  funds.
• Maintain set-aside and point preferences for SH
  at HCR.
• Funding Council examples include NJ, WA and CTs
  joint release and review of supportive housing
  funding requests.

Medicaid Redesign Affordable Housing Work Group
32
33
Recommendation 3 Create Targeting Mechanism

• Principles to Targeting Utilization of Supportive
  Housing
• No wrong door to SH for high need/cost Medicaid
  recipient with inappropriate or no housing.
• Constant and predictable intake/placement process
  that is flexible based on location, changing
  target population and/or changing population
  needs.
• Promotes tenant mobility and choice, and solicits
  tenant feedback.

Medicaid Redesign Affordable Housing Work Group
33
34
Targeting Pilot for High Users of Medicaid

• Create standardized eligibility and assessment
  process modeled on Money Follows the Person
• Data-driven identifying high cost Medicaid users
  through data matching and/or case finding
  predictive algorithms that look at multiple years
  of data
• Matched with homeless or inappropriately housed
  and
• Assessment of type of housing needed by person.
• Assist providers in accepting high need
  referrals.
• Provide training and resources, as needed.

Medicaid Redesign Affordable Housing Work Group
34
35
Example DESCs 1811 Eastlake (Seattle, WA)

• Supportive housing for 75 individuals with
  chronic alcohol addiction.
• Tenants identified through County data analysis
  of highest users of county detox and jail
  services.
• Evaluation found decrease in use of detox and
  jail services resulting in a 76 decrease in
  public costs (including 41 decrease in Medicaid
  costs) and significant decreases in alcohol use.

Medicaid Redesign Affordable Housing Work Group
35
36
New York Medicaid Targeting Pilot

• Data match between Medicaid and homelessness data
  systems (e.g. NYC CARES or HMIS (Upstate)) to
  identify homeless, high-cost Medicaid clients
• Begin with Health Home Health Status/Severity
  Groups.
• Match HH groups to homelessness data to identify
  individuals with specific threshold of
  homelessness (e.g. at least 120 days).
• Determine prevalence of homelessness among
  groups.
• Matched individuals become eligible for housing
  unit/subsidy plus care management services
  corresponding to severity/acuity rating.

Medicaid Redesign Affordable Housing Work Group
36
37
Recommendation 4 Create Placement and Tracking
System

• Medicaid High Utilizer Placement System must
• Clearly define process for prioritizing
  populations based on cost and clinical
  appropriateness for housing, not diagnostic or
  population group priorities
• Efficiently identify available supportive housing
  units
• Web-based master list of all housing appropriate
  for supportive housing placements, including
  set-asides
• Track Section 504 accessible units coming on
  line through development and vacancies
• Effectively match people, housing and appropriate
  support

Medicaid Redesign Affordable Housing Work Group
37
38
Placement and Tracking System (continued)

• Transparent feedback loop
• Tracking health outcomes, cost outcomes, and
  process outcomes (e.g., how long the matching
  process takes, comparative performance of
  contracted agencies, satisfaction of individual
  patients with housing and housing stability) to
  drive quality improvement.
• Local systems set metrics at the outset and
  report key data monthly to MRT leadership.
  Regional learning network regularly share
  challenges and innovative solutions to overcoming
  barriers to enable effective and rapid
  implementation.

Medicaid Redesign Affordable Housing Work Group
38
39
Examples of Placement Systems

• CSH Housing Options Tool (HOT)
• Web-based tool that quickly and easily connects
  users with a ranked list of customized housing
  options .
• Currently in use in Chicago, Indiana, and is in
  development in Connecticut.
• Can be used as a universal housing application
  and centralized waitlist.
• Streamlines the process of accessing housing for
  clients, organizations and the system.

Medicaid Redesign Affordable Housing Work Group
39
40
Examples of Placement Systems

• CUCS
• Database that identifies all vacancies in NY/NY I
  II funded units (NYC).
• SPOA Single Point of Access.

Medicaid Redesign Affordable Housing Work Group
40
41
Impact of Recommendations
Coordinated financing and agencies
Targeted identification of tenants

• 
  

Efficient system that best meets individual
tenant needs
Right placements with right services
SH system operated at capacity in real time
Medicaid Redesign Affordable Housing Work Group
41
42
Coordination Next Steps

• Placement and Tracking System Undergo a Needs
  Assessment to determine
• Tracking systems already in place
• Requirements of new system
• Where to pilot the new system.
• Earmark 10,000 - 50,000 for Needs Assessment
  and 50,000-150,000 for programming new system.
• Similar process and numbers for Targeting Tool.

Medicaid Redesign Affordable Housing Work Group
42
43
Next Steps

• March Meeting
• Moving On Initiative
• Salient Education and Training
• Social Impact Bonds

Medicaid Redesign Affordable Housing Work Group
43