Cross-posted with permission from Health Affairs Forefront.

[Original Post: Kathleen Noonan, Mary Naylor. Building A Longitudinal Community Supports Model, Health Affairs Forefront, November 5, 2024, https://www.healthaffairs.org/content/forefront/building-longitudinal-community-supports-model, Copyright © 2024 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.]

Increasingly, states are adopting Section 1115 waivers that allow Medicaid to address health-related social needs (HRSN) such as food insecurity, housing instability, and lack of transportation. Ten states now have received approval to cover HRSN services such as housing-related services and nutrition supports, allowing them to waive longstanding bans on using Medicaid to pay for room and board. As states implement these waivers, significant questions remain about who will manage these benefits and how these social supports will be delivered. Will they be distributed with a transactional, piecemeal approach, rather than as part of an integrated model of care? In states with Medicaid managed care, how will managed care companies handle these new benefits that straddle the health and social service sectors?

There is reason to be concerned, given the challenges experienced by Medicare Advantage (MA) plans in implementing nonmedical supplemental benefits. To date, only a small proportion of MA plans are taking advantage of the more complex benefits, the geographic reach of these benefits is limited, and rarely are newly available health and social supports aligned to meet the individualized and continually evolving needs of vulnerable older adults. The primary approach to MA plans’ nonmedical supplemental benefit delivery is a transactional model that is often costly, inefficient, and disruptive to the lives of people who depend on such services on a continuing basis. Intentional investment in alternative models is essential to ensure that the implementation of states’ 1115 waivers does not follow this path.

Two models have dominated service delivery for high-needs populations: institutional care and community-based alternatives. Institutional settings have largely fallen out of favor because they are expensive, carceral, and offer little autonomy. While they have certain virtues—chiefly stability in housing and treatment or, in today’s lexicon, “one-stop, place-based services”—government and society have looked to community-based alternatives because they tend to be less costly and dehumanizing than large institutions. Additionally, there is growing awareness that community-based options align with people’s preferences for living and aging in place.

Yet, community-based alternatives often lack the physical and organizational infrastructure needed to coordinate ongoing health and social supports and the stabilizing capacities of traditional brick-and-mortar institutions. Thus, there is good reason to suggest that community-based solutions will continue to rely on individual service providers or require participants to make their own arrangements to take advantage of health-related social supports under Medicaid 1115 waivers.

Therefore, while individual autonomy and freedom of choice are important values to uphold in community-based care, implementing these new 1115 waiver services might be even more challenging to navigate than the conventional medical services provided by the complex and fragmented health care system. And, although most of these waivers include some type of care management services, such support is intended to be time limited. Yet, a growing number of people need ongoing support; they require the stability and consistency of services characteristic of institutions but now offered in a community context. (The federal government has recognized these challenges, and this year launched a “Housing and Services Partnership Accelerator” to help states to develop or expand innovative housing-related supports and services for Medicaid-eligible people with disabilities and older adults who are experiencing or at risk of homelessness. Eight states and the District of Columbia will participate in the year-long technical assistance program.)

To effectively address health and social needs in the current ecosystem, we need a different paradigm, one that is more than a transactional, point-in-time service. The reality is that the rapidly growing number of high-needs adults require more support than just meals being dropped off, a ride voucher, or short-term, intensive care management. Because their situation changes frequently and often unexpectedly, these individuals require ongoing monitoring and just-in-time interventions. They both need and deserve a more dynamic care model where the right type and amount of support is provided at the right time and over time.

Effective alternative approaches that capture the best features of both models exist. Here, we will share insights from organizations with which we are affiliated, Camden Coalition and NewCourtland.

For the past decade, the Camden Coalition has run a Housing First program, which houses people who were “chronically homeless” (defined by the Department of Housing and Urban Development as being unhoused for at least two years). Over the past 10 years, this program has housed 95 people. Approximately 63 percent of participants have a mental health or substance use issue, and 58 percent have two chronic physical health conditions. This program provides not only stable housing but also a more open-ended and flexible approach to care coordination and community living support. Clients have a standing connection with a community health worker (CHW) who checks in with them at least monthly in their home to provide a holistic assessment of their social lives, living situation, tenant obligations, and any health issues—using a “whole health” perspective based on the Camden Coalition’s care management model. This model considers physical, behavioral, spiritual, and socioeconomic well-being as defined by individuals, families, and communities and focuses on self-care, skill building, and support. Current participants have been housed an average of five years. What we have found is that at any point in time about 20 percent of the program participants need help with something that is more time-sensitive or urgent. The needs of most program participants are episodic and cyclical. If there is an acute situation, the larger team can step in to provide help. In the two-year period before moving into housing, Housing First participants averaged 7.6 hospitalizations and 28.1 emergency department visits per 1,000 days at risk (alive and not in the hospital). After being housed, a 32.0 percent reduction in hospitalizations to 5.2, on average, and a dramatic 71 percent drop in emergency department visits to an average of 8.1 per 1,000 days at risk were observed.

Similarly, NewCourtland, an organization that has been serving at-risk populations in the Philadelphia, Pennsylvania, area for more than 150 years, launched the Housing with Supportive Services program in 2019. It combines the general Housing First model and intensive case management to address the unique needs of older adults who are experiencing homelessness and complex medical conditions. This program provides community housing with health and social services coordinated by social workers in an environment that prioritizes residents’ goals and trust. Similar to the Camden Coalition model, the NewCourtland model uses a “whole health” approach that relies on social workers, guided by an interdisciplinary team, who interact with residents at least monthly to identify needs and address them early. The program onboarded an average of four residents per quarter for the first two years, serving 45 residents since its inception with an average length-of-stay of 2.5 years. With an estimated resident capacity of 40 housing units (funded by NewCourtland), the program currently supports 28 residents. Of the 17 past program participants, nine moved to alternative housing (four to nursing homes), three died, and five were involuntarily evicted. Preliminary qualitative data suggest that as trust builds with the care team, residents are more likely to keep scheduled health visits and comply with prescribed medications (unpublished data).

While we do not yet have formal cost-effectiveness analyses on these programs, the unpublished estimated costs per participant are sustainable: in Camden, New Jersey, $15,500 per year (not including a housing voucher) and in NewCourtland, $10,000 per year (not including housing). For context, New Jersey’s Medicaid program spends approximately $56,000 per year for each person to provide similar services to participants in its Program of All Inclusive Care program. Looking at costs on a program level, NewCourtland’s annual program budget of $400,000 supports a staff of a social worker, registered nurse, and housing coordinator, as well as resident transportation and management administration.

To realize their potential, community supports designed to enable high-needs individuals to live and age in place and promote their well-being need to be:

Evidence-based: Many studies have shown the benefits of the Housing First model, whether it is used for people whose primary issue is substance use, a mental health condition, or a chronic physical illness. While the model has fallen out of favor for some because of its connection to “harm reduction,” its primary goal to stabilize people who have been unhoused and then address their physical, mental, and substance use needs remains a desired outcome. More rigorous evaluations of hybrid models such as Camden’s and NewCourtland’s are essential to understand what works and what doesn’t and to demonstrate impact on their cost-effectiveness.

Grounded in relational continuity: Because the US medical model responds to diagnosis and illness, services are provided only when and for as long as someone is “sick.” It is reactive and transactional. In the past, however, the expectation was that a person’s primary care doctor or “internist” would remain constant, which is why they sought “privileges” to be allowed into hospitals to visit their patients. This is no longer the case. As small clinical practices disappear and clinicians are more likely to be employed by large corporate, nonprofit, and for-profit systems, health care operates on the assumption that sick care does not require (or cannot depend on) relational continuity. Shift workers, from environmental services to doctors and nurses, are less likely to know their clients and vice versa. Both Camden’s Housing First and the NewCourtland model are built around the concept and expectation of relational continuity. This relational continuity means workers know their clients and vice versa. It is important to note that both of these programs are staffed by full-time employees who receive generous benefits packages and wages that are very attractive.

Focused on “whole health,” which includes housing: Camden’s Housing First and the NewCourtland model focus on strengths first, and not deficits. This may sound pithy or fall into the “easier said than done” category, especially for programs that are addressing the needs of people who have previously been unhoused or have multiple chronic health conditions, but both programs view this as a core tenet of their approach. This requires finding out what is important to participants and helping with that, perhaps while also addressing other critical health issues. It also means supporting connections with family or friends. For example, the Camden Coalition asks participants to prioritize among a set of domains in their life—from housing to health to family relationships to employment status and legal issues—to determine what is most important for them to address. Given the mounting public health crisis of isolation and loneliness in our country, support that is ongoing and stable seems critical.

Integrated into a well-coordinated, place-based longitudinal care model: A critical element of a new social care model that sits between institutions and community-based services is the idea that the services are long term. With the exception of care management, many of the new health-related social need benefits coming online through 1115 waivers are intended to be short term and tied to a particular diagnosis. For some people, this will be sufficient, offering a new supply of safety-net resources to people at a time of need. But our programs’ experiences have shown us that some people could benefit from more enduring care that includes consistent monitoring and clearly defined lines of communication between this type of embedded community support and health care teams. In both the Camden and NewCourtland models, participants have had the same CHW or social worker for years.

Adaptable/flexible in response to individuals’ changing needs: The Camden Housing First and NewCourtland models are built on the assumption that an individual’s needs will change, and that there will be higher and lower periods of intensity of services. In addition to the monthly in-person and in-home check-ins, sometimes there are daily check-ins if there is an acute medical or other challenge. The models are staffed with a primary resource—for the Camden Housing First program it is a CHW, and for NewCourtland it is a social worker—but both models are built around teams so that if a CHW or social worker is out or unavailable someone else knows and can respond to the client’s needs. While the models do not provide 24/7 “awake” care, they do strive to ensure that the needs of participants are met during waking and working hours so that crises can be minimized. The reduction in emergency department use by Camden Housing First clients illustrates the program’s focus of helping participants get the care they need before an urgent issue arises.

As our nation ages, with the need to address more mental health and loneliness challenges than ever, it is time to design new place-based care models that capitalize on the strengths of our old-style institutional care and current approaches to community-based services. We need models that engender trust and create relationships with the people we serve and provide ongoing, place-based support, not just when people are sick but also when they are well—to ensure they stay well.

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