MRT Affordable Housing Work Group

1. Redesign Medicaid in New York State MRT Affordable Housing Work Group January 10, 2013 - 10 AM to 3 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 three Sub Workgroups. • The 3 Workgroups met in December and January. • The ideas were developed by Members of the Sub Workgroups. • Facilitate discussion on the presentation. • Encourage Members to provide comments and questions throughout the presentation. • Gather Feedback which can be incorporated into final Sub Work Group recommendations. Medicaid Redesign Affordable Housing Work Group 2

3. MRT Affordable Housing Work Groups • Program Model and Development • Brenda Rosen, Chair • Tony Hannigan, Co-Chair • Funding • Ted Houghton, Chair • Planning and Service Coordination • Constance Tempel, Chair Medicaid Redesign Affordable Housing Work Group 3

4. Program Model and Development Workgroup

5. Program Model and Development Work Group • Identify barriers to moving high-need individuals into supportive housing. • Identify New Affordable/Supportive Housing Models. • Define “Supportive Housing.” Medicaid Redesign Affordable Housing Work Group 5

6. Define “Supportive Housing” • Adapted from “The Seven Dimensions of Quality for Supportive Housing” by CSH. • Intended to represent all populations w/o specifying individual groups. Medicaid Redesign Affordable Housing Work Group 6

7. Define “Supportive Housing1” • Supportive housing is defined as affordable rental housing operated by non-profit organizations, in which all members of the tenant household have easy, facilitated access to a flexible and comprehensive array of supportive services designed to assist the tenants to achieve and sustain housing stability and to live more productive lives in the community. Supportive housing units are intended to meet the needs of people with special needs who are homeless or would be at-risk of homelessness-or cycling through institutional care-were it not for the integration of affordable housing and supportive services. • Should we include other models or definitions? Medicaid Redesign Affordable Housing Work Group 7

8. Barriers Moving High-Need Individuals Into Supportive Housing • Limited housing stock to accommodate individuals with mobility impairments. • Lack of flexibility in service delivery: • Residents eligible to “move on” require/want minimal services, but services tied to units not individual. • Transitional support needed for individuals moving from institutions to community settings. • Residents need enhanced services at specific intervals during tenancy to maintain housing and avoid institutions. Medicaid Redesign Affordable Housing Work Group 8

9. (continued) Barriers Moving High-Need Individuals Into Supportive Housing • Current funding limits to “head of household” • Fear of admittance of having mental illness, SA issues etc. (i.e. victims of DV). • At-risk of becoming high need users do not currently qualify. Medicaid Redesign Affordable Housing Work Group 9

10. New Affordable/Supportive Housing Models • Sub-group focused on Individuals with Multiple Health Problems. • Wide range of recommended target populations. (seniors “aging in place”, individuals transitioning from nursing homes, disabled individuals that are not “head of household”, chemically dependent individuals not ready for abstinence, etc.) Medicaid Redesign Affordable Housing Work Group 10

11. New Affordable/Supportive Housing Models • RFP Directly Linking Health Homes to Housing • Covers services and rental subsidy in scattered site setting; Capital funding for congregate in this year's round w/ operational and services funding attached. • Funding for operating and services would be RFP’d to housing providers applying in partnership with Health Homes. • Contracts would be held by housing providers. • RFP needs to provide flexibility with regards to who should deliver care coordination. Medicaid Redesign Affordable Housing Work Group 11

12. New Affordable/Supportive Housing Models • Care coordination either conducted directly by the housing provider, or through explicit agreements spelling out how care coordination will be integrated with housing based services. • Government agency (i.e. HRA) would act as gatekeeper to determine eligibility determined by DOH criteria. • Health Homes would oversee the referral process and prioritize clients for housing. Medicaid Redesign Affordable Housing Work Group 12

13. New Affordable/Supportive Housing Models • Promote flexibility of services and adjustment to dollar amounts (i.e. flexible contracts, etc.). • Focus on prevention of future high-cost users. • Refine categories to include individuals with undocumented health problems (i.e. victims of DV who may lose child custody if diagnosed). • Explore various models for seniors “aging in place”. Medicaid Redesign Affordable Housing Work Group 13

14. Next Steps • Profile senior populations not served/included in current supportive housing models. • Discuss what supports essential for this senior population. • Follow up discussion based on feedback from larger group; finalize supportive housing definition. • Define models “not” targeted to Individuals with Multiple Health Problems. • Develop a “Moving On” Initiative. Medicaid Redesign Affordable Housing Work Group 14

15. Funding Workgroup

16. Funding Workgroup • Develop principles for a new supportive housing initiative (to follow NY/NY III). • Advise the State on appropriate set-asides and incentives for supportive housing. • Advise the State on how to allocate 2013-14 MRT Supportive Housing funds. • Develop a plan to create “social impact investment bonds.” • Identify ways to leverage federal and private funds. Medicaid Redesign Affordable Housing Work Group 16

17. Develop Principles for a new Supportive Housing Initiative • Statewide Supportive Housing Partnership Initiative: • Build on the success of 3 previous NY/NY City-State supportive housing development collaborations; • Expand statewide; • Broaden target population to include both high-cost Medicaid recipients, as well as other homeless, vulnerable and at-risk individuals and families who require support to remain housed; • Favor residences that mix special needs tenants with low income individuals and families; • Single RFP for capital, service and operating funds. Medicaid Redesign Affordable Housing Work Group 17

18. Statewide Supportive Housing Partnership Initiative Key Components: • Broader, more flexible target population categories, high-cost Medicaid recipients; homeless individuals with behavioral health issues; homeless and at-risk families with special needs; homeless and at-risk youth; • Coordinationof housing-based services with behavioral health and medical care to decrease Medicaid and other public costs; • Multiple referral sources, including homeless systems, outreach programs and health homes; • Tenant eligibility approvals made by government; • Prioritization for housingdetermined by Health Homes (for units reserved for high-cost Medicaid recipients) and local homeless service agencies (other pops). Medicaid Redesign Affordable Housing Work Group 18

19. (continued) Statewide Supportive Housing Partnership Initiative Key Components: • Adequate service and operating funds: • Explicit coverage of front-desk security and general case management (OTDA NYSSHP) • Annual budget adjustment to reflect changes in rental costs • Service funding levels to reflect needs of new MRT populations; • The Health Homes & Housing Pilot Program evaluation will inform model principles and implementation strategies. Medicaid Redesign Affordable Housing Work Group 19

20. Fully fund HCR’s QAP NOFA $4 million set-aside for supportive housing projects that designate at least 30% of units for people with special needs; Set goal to make supportive housing 25% of all HCR tax credit-funded units produced; Direct HCR Section 8 vouchers to fund supportive housing for high-cost Medicaid recipients; Increase OMH and HHAP capital development funds; Review HCR housing stock to identify underutilized units set aside for persons with special needs. 2. Advise the State on Appropriate Set-Asides and Incentives for Supportive Housing Medicaid Redesign Affordable Housing Work Group 20

21. SFY 2013-14 Supportive Housing Fund - $75 million: $28 million for SFY2012-13 scattered site programs $47 million available for new initiatives Additional dollars from hospital and nursing home bed closures. 3. Advise the State on SFY2013-14 MRT supportive housing funds Medicaid Redesign Affordable Housing Work Group 21

22. How much goes to capital, how much to service and operating? last year: $25 million – NYS HCR MRT RFP targeted to NY/NY III high cost Medicaid recipients $14.4 million – NYS OTDA HHAP targeted to upstate Consensus that MRT capital dollars should not be used to pay for prior capital commitments made under NY/NY III. Which development agencies are best situated to build effective housing? HCR, HHAP, OMH or HPD? MRT Supportive Housing Capital Questions: Medicaid Redesign Affordable Housing Work Group 22

23. MRT Supportive Housing Capital Questions: • Which developers? • How to speed development? • Acquisition & pre-development funds • Operating funds available for underwriting Medicaid Redesign Affordable Housing Work Group 23

24. Proposed New Pilot Programs: • Health Homes & Housing Scattered Site RFP • New Senior Supportive Housing Model • Deinstitutionalization Demonstration Initiative • Crisis Residence/Step-down Bed Pilot Medicaid Redesign Affordable Housing Work Group 24

25. Health Homes & Housing Scattered-Site RFP: • Enhanced “housing first” harm reduction, supportive housing model administered by experienced supportive housing providers 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 25

26. Key program components include: Scattered Site units available to Health Homes across state; Funding for operating and services would be RFP’d to housing providers applying in partnership with Health Homes; Contracts would be held by housing providers, managed by OTDA; Government agency would determine eligibility; Health Homes would manage the referral process and prioritize clients for housing; Health Home care coordination is conducted directly by the housing provider, or through explicit agreements that spell out how care coordination will be integrated with housing-based services; Population neutral; Active, collaborative, real-time evaluation and data collection. (continued) Health Homes & Housing Scattered-Site RFP Medicaid Redesign Affordable Housing Work Group 26

27. Flexible grant project to fund capital and services projects that will save Medicaid dollars. Eligible applicants are nonprofit entities that operate public or publicly assisted multi-family housing projects administered or regulated by HUD, HCR or HPD. Targets low-income seniors (62 years or older) who are high-cost Medicaid users, and/or at risk of institutionalization paid for by Medicaid. Can be used to fund a resident services advisor, security, transportation, meal planning, technology, entitlements advocacy and other non-medical services. Funding can also cover capital renovations not funded through the Access to Home program, which can be coordinated with this funding. Funded projects must address gaps in service or financing, and would not replicate existing services. New Senior Supportive Housing Model Medicaid Redesign Affordable Housing Work Group 27

28. Transition individuals with mobility impairments and chronic illness now in nursing homes into accessible, affordable apartments. Key program components include: Outreach component to nursing homes; Comprehensive assessment plan; Customized services that are person-centered to meet each individual’s needs; Some funding available for accessibility modifications; after maximizing other options; Ongoing rental assistance. Deinstitutionalization Demonstration Initiative: Medicaid Redesign Affordable Housing Work Group 28

29. Hospital stays (psychiatric & medical) could be significantly shortened or avoided if individuals could transition or be diverted to a short-term residential program enhanced with clinical staff and peer supports. This program can be a “step down” from inpatient services in a secure setting to crisis and prevention programs to reintegrate individuals into the community and avoid costly admission and readmission to hospitals, enhanced staffing patterns and designated residential treatment slots. This model will be less expensive to operate than care provided at inpatient facilities and emergency rooms. Crisis Residence/Step-Down Bed Pilot Medicaid Redesign Affordable Housing Work Group 29

30. Crisis Residence/Step-Down Bed Pilot: Options • Convert some number of existing community residences to crisis/step-down/hospital diversion beds: • Requires some one-time capital for renovation to downsize the beds and reconfigure the spaces; • Requires some recurring supported housing to replace lost beds; • Requires recurring dollars to pay for enhanced staff including psychiatry and nursing; or • Set aside some beds in a number of CRs around the state for crisis/step-down/hospital diversion: • Requires recurring dollars to pay for enhanced staff including psychiatry and nursing; • Pay providers at a minimum level to hold the beds even if vacant. Medicaid Redesign Affordable Housing Work Group 30

31. Recommendation: Set up a subcommittee to identify where Social Impact Investment Bonds (SIBs) have potential to add value and recommendations for a pilot program targeted at high-cost Medicaid users SIBs, also known as “pay for success” contracts, are a tool for scaling up the social interventions that have potential to result in considerable cost savings to government 4. Develop a plan to create “social impact investment bonds” Medicaid Redesign Affordable Housing Work Group 31

32. Examples of promising interventions and programs which could be well suited for a Medicaid savings SIB include: Housing for undocumented  persons in nursing homes, with long hospital stays, or frequent ED and inpatient utilization; Implement the FUSE model to reduce crisis health care costs of frequent users of criminal justice and shelter systems; and/or Provide technology-driven, housing-based services to seniors to improve their health outcomes and allow them to successfully age in place. SIBs are currently being tested in a number of applications in NY State, New York City, elsewhere in the US, and abroad.  The MRT Affordable Housing Work Group should continue to investigate this promising tool for bringing private investment to bear in bending the cost curve on Medicaid. (continued) Develop a plan to create “social impact investment bonds” Medicaid Redesign Affordable Housing Work Group 32

33. 5. Identify ways to leverage federal and private funds • Redirect State and local Section 8 Resources to high-cost Medicaid recipients. • Maximize bed closure dollars. • Leverage local capital contributions of HOME, CDBG, McKinney-Vento and other resources. • Ensure that Health Home Care Coordination dollars can flow to, and be integrated with, housing-based services. Medicaid Redesign Affordable Housing Work Group 33

34. Next Steps • Finalize Details of Allocation Plan • Finalize Model Design Elements of Pilot Programs • Explore SIB possibilities Medicaid Redesign Affordable Housing Work Group 34

35. Planning and Service Coordination Workgroup

36. 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 36

37. Charge of Subgroup Make short/long-term recommendations to the larger group to: • Plan to improve interagency coordination of supportive housing policy and implementation. • Identify and improve supportive/affordable housing capital development process. • Evaluate and provide advice to barriers in utilization of existing SH. Medicaid Redesign Affordable Housing Work Group 37

38. Charge 1 • Plan to improve interagency coordination of supportive housing policy and implementation. Medicaid Redesign Affordable Housing Work Group 38

39. Guiding Principles for Interagency Coordination • Coordinate around a person, not an agency. • No wrong door to SH for high need/cost Medicaid recipient with inappropriate or no housing. • Build upon MRT inclusive and constructive process. • Coordinate/streamline state policy and resources among agencies. • Need constant and predictable intake/placement process that is yet flexible based on location or as target populations or needs change. • Capture learning and make mid-course corrections. • Solicit tenant feedback. Medicaid Redesign Affordable Housing Work Group 39

40. Recommendation: Create State Coordinating Mechanism • Purpose: • Coordinate statewide planning, policy development and implementation. • Maximize state resources and expertise targeted to high need/cost Medicaid recipients that are inappropriately housed/institutionalized/homeless. • Ensure implementation based on advancing policies and plans created through the MRT process. Medicaid Redesign Affordable Housing Work Group 40

41. Mechanism’s Responsibilities • Implement housing and services plan, budget and timeline. • Coordinate housing development process. • Consolidate tenant identification, assessment and placement system. • Monitor and evaluate annual goals, benchmarks and outcomes. • Commission ad hoc work groups to advise on implementation issues. Medicaid Redesign Affordable Housing Work Group 41

42. Option 1: Council • Option 1: Create Interagency Coordinating Council • Executive Order/Legislature creates Council • Members including Governor’s Office, DOB, “O” agencies, health, housing, corrections, aging • Memorandum of Understanding signed by all member agencies • MRT Affordable Housing Work Group representatives monitor for accountability and oversight Medicaid Redesign Affordable Housing Work Group 42

43. Pros and Cons of Council Option • Pros • Governor’s authority and priority • Creates a spotlight and priority on needing to work together • Agencies have equal standing and accountability • Could create both policy and implementation • Cons • May create another bureaucracy that is not nimble • May not be as results-oriented Medicaid Redesign Affordable Housing Work Group 43

44. Option 2: Implementation Work Group • Option 2: Formalize State Agency MRT Implementation Work Group on Supportive Housing • Governor’s Office creates and leads; • Joint agency design, review, and sign-off processes and projects; • Transparency in reporting; • Others brought in if issues arise to make mid-course corrections. Medicaid Redesign Affordable Housing Work Group 44

45. Pros and Cons of Work Group Option • Pros • Leaner, less layers • More implementation-focused, tactical • Governor’s office still leads, so still a priority • Modeled after successful NYC NY/NY 3 coordination • Cons • Less high profile • Staff still need to go “up the ladder” for final signoffs • Goes against national best practice of creating interagency councils Medicaid Redesign Affordable Housing Work Group 45

46. Charge 2 • Identify and improve supportive/affordable housing capital development process Medicaid Redesign Affordable Housing Work Group 46

47. Principles to Improving Development Process • Build upon development processes and efficiencies that work • Preserve SH models that work while updating/creating others with appropriate level of services • Ensure an active role for nonprofits • Create least expensive and quickest way to get housing to high cost/need users • Process needs to facilitate leveraging federal, state and local resources and reinvest Medicaid savings into SH Medicaid Redesign Affordable Housing Work Group 47

48. Challenges to Development Financing • Several state agencies currently finance SH/AH: • HCR – capital and tax credits • HHAP – capital for homeless or at-risk often in combination with other capital and tax credits • OMH – capital, operating and services for mentally ill only often in combination with other capital and tax credits • OASAS – operating and services tied to capital • OPWDD – capital, operating and services • Various sources for assisted living Medicaid Redesign Affordable Housing Work Group 48

49. Challenges to Development Coordination • Difficult to coordinate funding streams into one integrated project because each agency has: • Own application; • Own timetable for receipt of application, review and award; • Different underwriting standards; • Different point system for awards; • Different design standards; • Different construction documents, requirements, processes. • Difficult to leverage federal resources • Conflicting eligibility requirements Medicaid Redesign Affordable Housing Work Group 49

50. Recommendation: Consolidate Development Function • Consolidate State unit production that creates SH. • Create standardized development processes including RFPs, underwriting, design, timetables, legal docs. Medicaid Redesign Affordable Housing Work Group 50