Expanding Access to Service Coordination: 

Two Models of Braiding Funding 

January 31, 2024 

Webinar 
 

 

Welcome 

Webinar is hosted by the 

Housing and Services Resource Center (HSRC) 

Facilitator 

Charlene Allen, Senior Management Analyst, Office for Interagency 

Innovations, Administration for Community Living (ACL) 

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Instructions for Zoom 

Audio Options 

• Use your computer speakers, OR dial in using the

phone number in your registration email.

• All participants are muted.

Questions and Comments

• Please actively use chat throughout the meeting,

especially for your comments.

• To ask a presenter a question, please use the Q&A

function.

Or, send your question or comment via email to 

HSRC@ACL.HHS.GOV 

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This event is being recorded.
 

 

Accessibility 

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• Request speech on demand: 

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Poll 

What is your organization’s primary partner to provide access 

to service coordination for people with disabilities and/or older 

adults? (choose 1) 

• We primarily partner with housing owners/managers or agencies. 

• We primarily partner with aging and/or disability organizations. 

• We primarily partner with health or healthcare organizations. 

• None—we're not involved in service coordination. 

• None—I'm an individual professional or student. 

• Other 

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Poll Results 

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What Is Service Coordination? 

Service coordination is a broad term encompassing 

similar activities that assist individuals with 

identifying and connecting to services and 

supports they want and need. 

Some types of service coordination include: 

• Person-centered counseling 

• Options counseling 

• Care coordination 

• Care management 

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Service Coordination Improves Housing Stability 

Service coordination improves access to and use of supportive 

services. 

• Supportive services provide assistance with everyday activities and help 

make it possible for many people with disabilities and older adults to live in 

their chosen housing environments and participate in their communities. 

• Examples: nutrition services, benefits enrollment, personal care, 

transportation, and assistive technology. 

Unmet needs for supportive services can contribute to housing 

instability and risk of poorer health outcomes. 
 

 

Braiding Funding 

"Braiding" involves lacing together funding sources to 

support a common goal while maintaining the specific 

program identity of each individual funding source (which 

often can only be used for a unique set of activities). 

Braiding maintains the specific program identity of each 

individual funding source. 

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Chat Question 

Who in your community has the 

greatest unmet need for service 

coordination? 
 

Presenters 

Andy Chan, PhD 

Strategic Advisor for Health, 

Seattle Housing Authority 

Sean Walsh, MPA 

Case Management Supervisor, 

Seattle-King County Aging and 

Disability Services 

Caroline Bas, MBA 

Chief Operating Officer, The 

Kelsey 

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SHA/ADS 

PARTNERSHIP 

DEVELOPING AND FUNDING SUPPORTIVE SERVICES FOR LOW-INCOME 

TENANTS OF PUBLIC HOUSING 

Sean Walsh & Andy Chan January 2024 
 

 

 

 

 

 

 

 

 

 

THE PARTNERS 

Seattle Housing Authority (SHA) 

 Public Housing Authority 

 Houses over 31,000 people with very low incomes 

 Around 1⁄2 live in SHA owned/managed properties 

 In Hi-Rises and Senior Housing: 

 About 66% are 62 or older 

 About 18% are people with disabilities under 62 

 About 51% are BIPOC 

Aging & Disability Services (ADS) 

 Area Agency on Aging (AAA) for King County 

 Care Coordination Provider for 12,000 residents 

 Contract manager for Medicaid Long-Term Services 

& Supports (LTSS) In-home Care programs 

 Demographics 

 54% are BIPOC 

 75% are 62 or older 
WHY HAVE A PARTNERSHIP? 

ADS & SHA have partnered since the early 1990s 

Why? 

 De-institutionalization 

 Aging in Place + Baby Boomers 

 Recognizing successful housing = more than 4 walls and a roof 
 

 

 

CARE COORDINATION 

 Provides annual or as needed assessment process for eligibility for services such as 

Home Care, Medical Alert, or higher levels of care (i.e. Adult Family Home/Assisted 

Living) 

 Building trust through on-site presence and community involvement 

 Hands-on approach to connecting tenants to needed services 

 Maintaining contact with tenants (and often providers) to ensure service 

relationships endure 

 Problem-solving landlord-tenant issues 
 

 

BRAIDED FUNDING 

 2024 Budget:Approx. $2.1 million funding 12 Care Coordinators and 1 Supervisor 

 Funding Model: 

 Seattle Housing Authority Grant 25% 

 City of Seattle General Fund Matching Grant 25% 

 Medicaid Case Management Fee for Service Funding 50% 
 

 

IMPACT 

 Increased Access to LTSS Service: per 2020 estimate 2-3x more likely to enroll in 

LTSS services 

 Resulting in $40 million worth of services flowing into communities 

 Better access to new programming: Medicaid Transformation Projects 

 Multi-sector health and housing coordination i.e., SHA Care Network, Monthly 

Portfolio Meetings, Coordinated Personal Care 
NEXT STEPS 

 Leverage more cross-sector funding 

 Provide seed capital 

 Continue to build health and housing partnerships 

 ...including data partnerships 

(https://kingcounty.gov/en/legacy/depts/health/data/health-housing) 
CONTACT 

 Sean Walsh sean.walsh@seattle.gov 

 Andy Chan andy.chan@seattlehousing.org 
 

 

The Kelsey 

We pioneer disabilityforward housing 

solutions that open 

doors to homes and 

opportunities for 

everyone 

Today’s Overview: 

Our Inclusion Concierge Program 
The Kelsey solves 

for three gaps in 

housing. 

•Affordability: for all incomes, from the 

lowest up to market rents. 

•Accessibility: support diverse access 

and more person-centered design 

Today’s 

•

Discussion

Focus 

Inclusivity: where people with and 

without disabilities share an 

interdependent, connected community 

© 2020 The Kelsey® 22 
© 2022 The Kelsey®

Anchored in inclusion.

People with disabilities are segregated in: 

• Hospitals

• Institutions

• Congregate Settings

• Homeless Shelters

• Disability-specific housing developments

People with and without disabilities live in the same 

building physically but with barriers to full access, 

separate lives and experiences, and no community 

connections

People with and without disabilities share 

community together, diversity is valued, 

interdependence is supported, and people 

have access to the same spaces and 

experiences.

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Triangle 

Community 

Living 

Housing 

that is 

accessible, 

affordable 

across a range 

of incomes, and 

meets personal 

preferences 

Community 

with connections, 

recreation, 

spirituality, joy, 

meaningful work, 

and relationships 

Supports & 

Services 

including medical 

services, in home 

supports, and 

therapies 

designed to meet 

individualized 

needs 

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●

Team 

Based 

Approach 

Resident Services 

Natural Supports 

(unpaid) 

Partners/Agencies 

(paid) 

Community 

with connections, 

recreation, 

spirituality, joy, 

meaningful work, 

and relationships 

Neighbors; family members 

●Community based 

organizations 

●Community Volunteers 

●

Housing 

that is 

accessible, 

affordable 

across a range 

of incomes, and 

meets personal 

preferences 

Property Owners and 

Management 

●Housing Authorities, Housing 

Finance Agencies, and other 

Voucher Providers 

● Supports & 

Services 

including medical 

services, in home 

supports, and 

therapies 

designed to meet 

individualized 

needs 

In -home service providers 

●Medicaid Service 

Coordinators/ Case 

Managers 

●Local ILCs 

Inclusion 

Concierge 

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Benefits & 

Outcomes 

Benefits of Inclusion Concierge Program 

Resident 

Centered 

Experience 

Inclusion Concierge 

facilitates a teambased approach to 

coordinated support 

for each resident 

from fostering 

inclusion, promoting 

connections, and 

delivering a quality 

resident experience 

Culture of 

Interconnectivity 

Through fully 

accessible, thoughtfully 

planned Inclusion 

Hours, the Inclusion 

Concierge engages 

each resident to 

experience the value 

and joy of being with 

community; Inclusion 

Concierge also sets a 

culture from the start as 

a healthy, 

interdependence space 

Services 

Infrastructure 

Through building 

trust, circles of 

support, and 

community supports, 

the Inclusion 

Concierge supports 

the building’s high 

quality, effective 

services for residents 

that leads to 

reduction of 

interrupted services 

and avoidable issues 

Expected 

Outcomes* 

●Increase resident 

housing success

●Increase resident 

satisfaction and 

reduce vacancies

●Avoid resident-related 

issues before they 

occur 

●Save staff time on 

responsive work 

*Longitudinal studies to be conducted 

in The Kelsey Civic Center 

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The communities we build prove new, replicable models of inclusive, accessible housing and provide 

homes to people who need them most. 

The Kelsey Ayer Station, San 

Jose 

Leasing Up Now: 115 homes; 

30% of units priced at 

<$500/month; spaces designed 

to foster informal support 

networks 

The Kelsey Civic Center, San 

Francisco 

Under Construction: 112 homes; 

mixed income, from extremely 

low income to moderate; 25% 

homes set aside for people with 

disabilities that use HCBS 

services 

The Kelsey at Atlas, Oakland 

A pilot community in a market 

rate building; our Inclusion 

Concierge enhances services, 

builds community, and has 

supported a 100% housing 

retention rate since lease up in 

2020 

© 2022 The Kelsey® 27 
 

 

 

 

CMS 2024 Medicare Physician Fee Schedule Rule 

• Beyond setting payment rates for physicians, other professionals, the annual 

schedule includes policy changes. 

– The rule is effective as of January 1. 

• The schedule offers new contracting opportunities for aging, disability, health, 

other community-based organizations for reimbursement for services that 

assess and address health-related social needs (HRSNs). 

• HRSNs are individual-level adverse social conditions that contribute to poor 

health outcomes, such as: 

– Housing instability, food insecurity, transportation problems, utility help needs, 

interpersonal safety, etc. 
 

 

HRSN Services 

Examples of HRSN service reimbursement: 

• Person-centered assessment,

• Home and community-based care coordination,

• Care transition support,

• Social and emotional support, and

• Other services to enable holistic, person-centered care
Learn More: Physician Fee Schedule 

• CMS Fact Sheet: Calendar Year (CY) 2024 Medicare Physician Fee 

Schedule Final Rule 

• Code of Federal Regulations: https://publicinspection.federalregister.gov/2023-24184.pdf 

• Aging and Disability Business Institute webinar: Data, Billing and Coding: 

What CBOs Need to Know: New CMS Rules on Health-Related Social Needs 

Screening 

• Partnership to Align Social Care on-demand webinar: The Medicare 

Physician Fee Schedule Includes Codes to Address HRSNs...What Happens 

Next 

 

 
HSRC Website 

acl.gov/HousingAndServices 

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Call to Action 

Learn more about service coordination at 

acl.gov/HousingAndServices/Service-Coordination 

Use our forthcoming tool on braiding to plan 

how to expand service coordination in your 

community. 

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Help Us Improve 

Please complete our short feedback form at 

https://www.surveymonkey.com/r/HSRCjan31 

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Stay Connected 

1. Send your innovations and suggestions to us 

at hsrc@acl.hhs.gov 

2. Sign up for periodic HSRC emails 

at https://cloud.connect.hhs.gov/acl-subscriptions 

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Acknowledgment 

This presentation was supported by the U.S. Administration for Community Living through a contract with New 

Editions Consulting (Contract number H47QRAA19D003X) which subcontracted the work to USAging. The views 

expressed do not necessarily represent the positions or policies of the Administration for Community Living / 

Department of Health and Human Services.