Subsidized Housing as a Platform for Better Health

Housing is increasingly recognized as an important “social determinant” of health. Researchers and policy makers are making the connection between having a secure, affordable, accessible and quality place to live and improving or maintaining our health. This is especially true for people with disabilities who want to live in the broader community, older adults who want to avoid moving to nursing homes, and individuals who experience chronic homelessness.

Abt is at the forefront of evaluating initiatives to coordinate subsidized housing with community-based, voluntary services and supports, and we use multi-disciplinary research teams that bring together our expertise in housing and health to do so.

Lessons from our work can inform efforts to refine and scale innovative approaches that combine housing and supports for better health and sustained community living. For example:

• The current supply of affordable housing is not sufficient to meet the demand among people who qualify for and need it. This has been a significant challenge when transitioning people from nursing homes and other institutions to the community settings they prefer.
• The majority of low-income people with disabilities and older adults who need affordable housing are eligible for Medicare, Medicaid, or both. These programs can be leveraged to provide needed supports, particularly following Medicaid expansion efforts nationwide, but there are barriers.
• Offering and funding subsidized housing in new ways can be difficult: systems are not agile, owners are wary, securing units takes time.
• At the program level, finding the right unit for the right person at the right time is very difficult, both for people transitioning from institutions and for those experiencing homelessness or housing instability.
• Working across the housing and services systems brings challenges – different languages, different incentives at the systems level – that require state efforts to build formal partnerships across health and housing agencies.

Recent efforts--including federal and private sector support for integrating health services and housing--are helping bridge the gaps.  Abt’s rigorous evaluations of these efforts and our work to link key cross-agency data sources are identifying successful approaches to addressing challenges. Our current and completed work, both at the systems and program level, includes:

1. Using Medicaid to Fund Permanent Supportive Housing

As Medicaid expansion was taking effect, the Department of Health and Human Services’ (HHS) Assistant Secretary for Planning and Evaluation contracted Abt to explore the roles that Medicaid, Community Health Centers, and other HHS programs might play using the Permanent Supportive Housing (PSH) program to provide services linked to housing for people who experience chronic homelessness. Abt researchers explored how the government and its PSH partners can leverage Medicaid to fund services in PSH, what kind of systems change this would require, and which program models are most cost-effective and likely to be sustainable. The study included an environmental scan, case studies, and a primer for Medicaid officials on how Medicaid-funded services can support people in PSH.

2. Section 811 Project Rental Assistance Program

The Department of Housing and Urban Development’s (HUD’s) Section 811 program aims to expand the supply of supported housing for very low-income people with disabilities. Its Project Rental Assistance (PRA) program provides rental assistance funding to state housing finance agencies, which work with state human services and Medicaid agencies to create supportive housing in the community. Abt supported a Phase I evaluation of initial PRA implementation, and is currently leading a comprehensive second phase evaluation of grantees’ implementation experiences; PRA’s impact on participants' quality of life, housing, and service utilization; and the costs of housing and supportive services provided to participants, including a cost–benefit analysis.

3. Fostering Partnerships between State Medicaid and Housing Agencies through the Innovation Accelerator Program

Abt is evaluating the Medicaid Innovation Accelerator Program (IAP), a Centers for Medicare & Medicaid Services’ initiative designed to build state capacity and to support ongoing Medicaid innovation. IAP provides targeted technical support to states’ delivery systems reform efforts, including promoting public and private partnerships between their Medicaid and housing systems and helping states create action plans for additional community living opportunities for Medicaid beneficiaries. We’re assessing the results of this support, documenting the knowledge gained and the results of efforts to build partnerships, match health and housing data to better focus reform efforts, and expand housing options for Medicaid beneficiaries who have disabilities or are experiencing homelessness.

4. Supportive Services Demonstration

Research suggests that Americans prefer staying in their homes and communities as they age. HUD’s Supportive Services Demonstration (SSD) is a three-year effort that funds service coordinators and wellness nurses in HUD-assisted housing developments serving older adults to support successful “aging in place.” Abt is evaluating the implementation and impacts of the intervention, including analyzing healthcare utilization and housing outcomes for the more than 13,000 residents living in 40 “treatment” properties, as well as 84 “control” properties that will maintain their usual approaches to resident wellness services and programming.