Redesign Medicaid in New York State MRT Affordable

Redesign Medicaid in New York State MRT Affordable Housing Work Group January 10, 2013 - 10 AM to 3 PM New York State Department of Health Metropolitan Regional Office New York City

Goals for Today o o Update the MRT Work Group on the progress of the three Sub Workgroups. ü The 3 Workgroups met in December and January. ü The ideas were developed by Members of the Sub Workgroups. Facilitate discussion on the presentation. ü o 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

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

Program Model and Development Workgroup

Program Model and Development Work Group 1. Identify barriers to moving high-need individuals into supportive housing. 2. Identify New Affordable/Supportive Housing Models. 3. Define “Supportive Housing. ” Medicaid Redesign Affordable Housing Work Group 5

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

Define “Supportive Housing ” 1 o 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. ü Should we include other models or definitions? Medicaid Redesign Affordable Housing Work Group 7

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

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

New Affordable/Supportive Housing Models o Sub-group focused on Individuals with Multiple Health Problems. ü 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

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

New Affordable/Supportive Housing Models o 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. ü Government agency (i. e. HRA) would act as gatekeeper to determine eligibility determined by DOH criteria. ü Health Homes would oversee the referral process and prioritize clients for housing. Medicaid Redesign Affordable Housing Work Group 12

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

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

Funding Workgroup

Funding Workgroup 1. Develop principles for a new supportive housing initiative (to follow NY/NY III). 2. Advise the State on appropriate set-asides and incentives for supportive housing. 3. Advise the State on how to allocate 2013 -14 MRT Supportive Housing funds. 4. Develop a plan to create “social impact investment bonds. ” 5. Identify ways to leverage federal and private funds. Medicaid Redesign Affordable Housing Work Group 16

1. Develop Principles for a new Supportive Housing Initiative o Statewide Supportive Housing Partnership Initiative: ü Build on the success of 3 previous NY/NY City-State supportive housing development collaborations; ü Expand statewide; ü 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; ü Favor residences that mix special needs tenants with low income individuals and families; ü Single RFP for capital, service and operating funds. Medicaid Redesign Affordable Housing Work Group 17

Statewide Supportive Housing Partnership Initiative Key Components: o 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; o Coordination of housing-based services with behavioral health and medical care to decrease Medicaid and other public costs; o Multiple referral sources, including homeless systems, outreach programs and health homes; o Tenant eligibility approvals made by government; o Prioritization for housing determined 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

(continued) Statewide Supportive Housing Partnership Initiative Key Components: o o Adequate service and operating funds: ü Explicit coverage of front-desk security and general case management (OTDA NYSSHP) ü Annual budget adjustment to reflect changes in rental costs ü 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

2. Advise the State on Appropriate Set-Asides and Incentives for Supportive Housing o 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; o Set goal to make supportive housing 25% of all HCR tax creditfunded units produced; o Direct HCR Section 8 vouchers to fund supportive housing for high-cost Medicaid recipients; o Increase OMH and HHAP capital development funds; o Review HCR housing stock to identify underutilized units set aside for persons with special needs. Medicaid Redesign Affordable Housing Work Group 20

3. Advise the State on SFY 2013 -14 MRT supportive housing funds o o SFY 2013 -14 Supportive Housing Fund - $75 million: ü $28 million for SFY 2012 -13 scattered site programs ü $47 million available for new initiatives Additional dollars from hospital and nursing home bed closures. Medicaid Redesign Affordable Housing Work Group 21

MRT Supportive Housing Capital Questions: o How much goes to capital, how much to service and operating? last year: ü $25 million – NYS HCR MRT RFP targeted to NY/NY III high cost Medicaid recipients ü $14. 4 million – NYS OTDA HHAP targeted to upstate o Consensus that MRT capital dollars should not be used to pay for prior capital commitments made under NY/NY III. o Which development agencies are best situated to build effective housing? ü HCR, HHAP, OMH or HPD? Medicaid Redesign Affordable Housing Work Group 22

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

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

Health Homes & Housing Scattered-Site RFP: o Enhanced “housing first” harm reduction, supportive housing model administered by experienced supportive housing providers to house and serve persons referred by Health Homes. o Services will be offered in an ongoing effort to link and transition tenants to community-based care, services and supports. o 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

(continued) Health Homes & Housing Scattered-Site RFP o Key program components include: ü Scattered Site units available to Health Homes across state; ü Funding for operating and services would be RFP’d to housing providers applying in partnership with Health Homes; ü Contracts would be held by housing providers, managed by OTDA; ü Government agency would determine eligibility; ü Health Homes would manage the referral process and prioritize clients for housing; ü 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; ü Population neutral; ü Active, collaborative, real-time evaluation and data collection. Medicaid Redesign Affordable Housing Work Group 26

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

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

Crisis Residence/Step-Down Bed Pilot o 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. o 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. o This model will be less expensive to operate than care provided at inpatient facilities and emergency rooms. Medicaid Redesign Affordable Housing Work Group 29

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

4. Develop a plan to create “social impact investment bonds” o 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 o 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 Medicaid Redesign Affordable Housing Work Group 31

(continued) Develop a plan to create “social impact investment bonds” o o Examples of promising interventions and programs which could be well suited for a Medicaid savings SIB include: ü Housing for undocumented persons in nursing homes, with long hospital stays, or frequent ED and inpatient utilization; ü Implement the FUSE model to reduce crisis health care costs of frequent users of criminal justice and shelter systems; and/or ü 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 Redesign Affordable Housing Work Group 32

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

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

Planning and Service Coordination Workgroup

Planning and Service Coordination Work Group o Improve Interagency Coordination. o Improve the Capital Development Process. o Evaluate perceived barriers to utilization of supportive housing. o Provide advice on overall coordination and implementation of supportive housing policy. o Improve the coordination and timing of the availability of housing. Medicaid Redesign Affordable Housing Work Group 36

Charge of Subgroup Make short/long-term recommendations to the larger group to: 1. Plan to improve interagency coordination of supportive housing policy and implementation. 2. Identify and improve supportive/affordable housing capital development process. 3. Evaluate and provide advice to barriers in utilization of existing SH. Medicaid Redesign Affordable Housing Work Group 37

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

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

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

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

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

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

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

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

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

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

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

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

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

Option 1: Consolidate Development Function into Two Agencies o Option 1: Two Agencies ü Combine unit production functions and dollars of HHAC, “O” agencies, health and aging agencies; ü Work with HCR to leverage other capital sources. Medicaid Redesign Affordable Housing Work Group 51

Pros and Cons: Two Agencies o o PROS ü Retain expertise of human service agencies ü Could build upon existing infrastructure, such as HHAC ü Ensure human service agencies still have ownership of the process and product ü Can tie in with services and operating CONS ü Less constituent agencies ü Housing may become less specialized for particular populations Medicaid Redesign Affordable Housing Work Group 52

Option 2: Consolidate Development into One Agency o Option 2: Consolidate all supportive housing capital into one agency, HCR: ü Create a supportive housing unit within HCR that reviews and monitors any special processes needed for SH. Medicaid Redesign Affordable Housing Work Group 53

Pros and Cons to Development Recommendations o PROS ü o Predictable timeframe, process, standards CONS ü One big roadblock if denied ü Total resources may be reduced Medicaid Redesign Affordable Housing Work Group 54

Pros and Cons to One agency o o PROS ü Know where to go ü Predictable timeframe, process, standards ü Easier to leverage affordable housing resources ü Modeled after effective NYC HPD CONS ü Less constituent agencies ü One big roadblock if denied ü Less SH expertise in HCR ü Could be more competition with for-profits ü Total resources could be reduced Medicaid Redesign Affordable Housing Work Group 55

Charge 3 o Evaluate and provide advice to barriers in utilization of existing SH, specifically: ü State’s interpretation of Section 504 requirements for accessible housing; ü Whether providers are maximizing opportunities for accessible units; ü Whether compliance reviews are included in regulatory agreements and monitored for set aside projects. Medicaid Redesign Affordable Housing Work Group 56

Principles to Utilization of Existing Supportive Housing o No wrong door to SH for high need/cost Medicaid recipient with inappropriate or no housing. o Need constant and predictable intake/placement process that is yet flexible based on location or as target population or needs change. o Solicit tenant feedback. o Promote tenant mobility and choice. Medicaid Redesign Affordable Housing Work Group 57

Barriers to Utilization of Existing SH o Current housing is tied primarily to chronically homeless. o No master data system provides for identification and sharing of high need/high cost persons in need of SH. o No master vacancy list or mechanism to identify. o Supportive housing and Section 504 set aside units are not monitored for compliance in filling vacancies. o Tenant mobility and choice are not fully realized given system rules and capability. o Not all units are accessible. o Accessible units not always occupied by intended tenants. Medicaid Redesign Affordable Housing Work Group 58

Recommendation: Facilitate Targeting High need/cost Medicaid Users o o Create standardized eligibility and assessment process modeled on Money Follows the Person ü Data driven identifying high cost Medicaid users through data matching and/or case finding predictive algorithms that look at multiple years of data; ü Matched with homeless or inappropriately housed; ü Assessment of type of housing needed by person. Assist providers in accepting high need referrals ü Review intake criteria; ü Provide training and resources, as needed. Medicaid Redesign Affordable Housing Work Group 59

Recommendation: Improve Targeting and Intake Process o Create shareable real time master list through data sharing agreements. o Learn from CDIP and MATs programs. o Create single point of entry/eligibility modeled on NYC’s HRA process while ensuring ‘no wrong door’: ü from health homes, clinics and hospitals, shelters and correctional health facilities, nursing homes, adult homes, assisted living, MCOs o Consider use of Patient Navigators and Peer Supports for difficult to engage. o Create incentives for county/regional coordination. Medicaid Redesign Affordable Housing Work Group 60

Recommendation: Track Housing Inventory and Vacancy o o Create web-based master housing and vacancy inventory mechanism at county/regional or major city level for all SH including Section 504 and tax credit units: ü Provides applicant ranked list of housing options by eligibility ü Provides application forms, housing contact information Provides funder notice of vacancy rates. Medicaid Redesign Affordable Housing Work Group 61

Pros and Cons to Targeting Recommendations o o PROS ü Maximizes targeting to intended recipients ü Enables more tenant choice CONS ü Less provider/developer independence in selecting tenants ü Tracking is time consuming Medicaid Redesign Affordable Housing Work Group 62

Next Steps o Further refine proposals based on feedback from Affordable Work Group and subgroups: ü Review in detail effective targeting and data matching strategies; ü Review web based placement and vacancy control systems; ü Conduct thorough analysis of state unit production processes and make specific recommendations for streamlining and consolidating. Medicaid Redesign Affordable Housing Work Group 63

Questions? o Comments or questions? o Goal: Achieve general consensus on a series of policy recommendations for how to move forward on Supportive Housing in Medicaid. o Meeting Schedule: o February 22, 2013 o March (TBD) Medicaid Redesign Affordable Housing Work Group 64