# **HSRC Webinar Transcript**

# ***Expanding Access to Service Coordination: Two Models of Braiding Funding***

## January 31, 2024 | 2:00 – 3:00 pm ET

CHARLENE ALLEN: Okay, it's 2 p.m., I would like to say hello and welcome to you all. Welcome to the Housing and Services Resource Center's webinar, *Expanding Access to Service Coordination: Two Models of Braiding Funding*. We're looking forward to our presenters sharing their two different models for using multiple funding streams so people with disabilities and older adults can access service coordination. Our intention is this webinar and a new tool that we'll release next month, will help you start planning to expand access to service coordination in your community. Thank you so much for joining us. Again, the title of the webinar is Expanding Access to Service Coordination: Two Models of Braiding Funding. My name is Charlene Allen, and I am a senior management analyst in the Office for Interagency Innovations, at ACL, which standards for the Administration for Community Living. And we are an operating division within the U.S. Department of Health and Human Services. I will be serving as the facilitator for today's webinar and it's a privilege to have so many of you with us. Your active involvement in this webinar is essential for us to have an engaging discussion. So, let's get started! All right, let's move to slide 3. 

First, there are a few housekeeping items we want to address. This meeting is being recorded. By staying to participate, you are consenting to the recording. Also, all attendees have been muted for audio quality. One hallmark of our webinars, is, active participation from attendees so, please, frequently use the chat to make comments and submit your questions at any time, using the Q&A, feature in the Zoom dash board. Please use the Q&A and not the chat for your questions. Or, you may e-mail a question, or comment, to HSRC@ACL.HHS.gov. We have a very full agenda. But we have reserved time to address your questions, we'll get to as many of them as possible, you can also use the chat or e-mail if you have a technical issue, or a comment for other attendees. Tomorrow, in an e-mail from Zoom, you will get a link to the slides. Once the recording is posted in February, we'll send you another e-mail about how to access it. Next slide.

Today, an ASL interpreter will be visible throughout the webinar. You can enlarge the window of the ASL Interpreter by using the pin feature. Simply click on the ASL interpreter's window, and select the pin icon, to make their window larger. To ensure that ASL interpreters will be invisible -- will be visible in our webinar recording, we have also asked presenters and panelists to limit their own use of camera visibility only to when they are speaking. And for those who want to use a screen reader and want to silence unwanted chatter in the chat, and the Q&A boxes, activate the speech on demand feature, by pressing insert, spacebar, and then, pressing the letter "S" on the keyboard. Next slide. 

So, I'm going to ask our webinar staff, to please launch the participant poll right now. We are asking you to select 1 response and best response to the following QUESTION: How would you describe your organization's primary partner to provide access to service coordination for people with disabilities, and/or older adults? Your options to respond are – 1) we primarily partner with housing owners/managers, or agencies, 2), next choice is we primarily partner with aging and/or disability organizations, 3), we primarily partner with health, or healthcare organizations, 4) none, or we're not involved in service coordination at this time, 5), none, I'm an individual or professional student, or other, (6). If you can please choose one of these options that would be great. 

And while you're responding to the poll, I would like to tell you about the housing and services resource center, or, HSRC, which is a partnership between the U.S. Department of Health and Human Services and the U.S. Department of Housing and Urban Development, also known as HUD. The Housing and Services Resource Center fosters cross-sector partnerships between the organizations, and systems that provide housing resources and homelessness services, healthcare, and mental health services, independent living services, and other supportive services. The HSRC is part of an -- interagency initiative, to streamline, and expand access to affordable accessible housing, and critical services that make community living possible. 

After the webinar, I hope you will look at the HSRC website, At ACL.gov/housing and services. And later in the webinar, we'll share our new HSRC feature on service coordination. This is a tool that we'll expand next month when we release a specific tool on braiding funding to expand, and sustain service coordination for you to use. Okay, next slide.

I think we should close the poll now. And, while and while our webinar team is displaying the results, I want to remind everyone to please use the chat and Q&A function throughout the webinar, we definitely want to hear your comment and questions and it's nice to hear what your other participants are also thinking, all right, so let's look at the poll results. Looks like -- the lion's share of participants today, primarily, partner with Aging and Disability organizations. And then... about a quarter of you partner with housing, owners/managers. And 15% of you partner with healthcare organizations, and about another 20% aren't currently involved in service coordination or have joined us in another capacity. Okay, excuse me. I'm also -- testing out my cough suppressant medicine so please bear with me. Thanks, again, for responding to the poll, and we have a highly-diverse cross-sector audience here, so I'm going to start us off by explaining, what we mean by the term "service coordination", And, that will help set the stage for our presenters. So, for the next slide –

Service coordination, from a broad perspective, assists individuals in finding, selecting, connecting with, and managing the supportive services that they want and need. Some types of service coordination include person-centered counseling, options counseling, care coordination, and case management. Now, exactly what service coordination is, depends on the setting, the provider, the population served, funder requirements, and other parameters. Some of you today may be wondering how this relates to HUD's framework for service coordination that is provided in some HUD-assisted housing? Well, I can assure you that there is much overlap including with ACL's values and priorities. Because the HSRC focuses on the full array of housing in the community, we have been looking at service coordination more broadly, which includes recognizing additional frameworks like person-centered counseling. So many people with disabilities and older adults need a variety of supportive services, such as home-delivered meals, personal care, or transportation, just to name a few. I think we need to be on the next slide. Not quite. That's okay, you can leave it there. 

It can be difficult for an individual to identify the full range of supportive services available to them, in the community. They may find it challenging, to have to compare options, to complete a confusing application process in some cases, and navigate new and complex systems to make arrangements. These types of difficulties can result in people having unmet needs for supportive services, which in turn can contribute to housing instability, and poor health. And that's why having assistance from a service coordinator, can make a real difference in their lives. They get assistance learning about their options, help with applications, help coordinating different providers, and scheduling services. Of course, at times, individuals must be able to choose which, if any, services they want to apply for, or access. This also means that use of service coordination, must be voluntary. It can't be a requirement for obtaining or maintaining housing. 

So, although service coordination is an effective way to support people with disabilities, and older adults with living stably and independently, it is an underutilized approach in many communities. Today you're going to learn about two models that have been expanding service coordination so that it is more readily-accessible. These models are braiding different sources of funding together so that older adults and people with disabilities, have sustained, access, to service coordination. And when we talk about braiding -- you should think about braiding hair, in which, different strands are woven together. When housing and services sectors partner, they are able to braid multiple funding sources, to support service coordination. Different funding streams, are interwoven to support the common goal of providing access to service coordination. And while the goal is shared, the partners have arrangements in which each uses their sources of funding to contribute the trained professionals, communications, data systems, space, and more, to bring service coordination into neighborhoods and across the community. 

So, before I introduce the presenters, we would like you to use the chat to tell us who in your community has the greatest unmet need for service coordination. 

Now that we've done some level setting on concepts and have a clear sense of your backgrounds and interests as an audience, let's dive into the presentations now. It is our privilege today to feature three presenters who will share their models for braiding funding streams across sectors to maximize the use of existing resources and broaden access to service coordination in a sustainable way. And because of their work, more people with disabilities, and older adults, have the supports and housing accessibility, that they need, to live independently, in the community.So, first, we're going to have Andy Chan, strategic advisor for health, at the Seattle Housing Authority, together with Sean Walsh, who is the case management supervisor at the Seattle King County Aging and Disability Services and they will tell us about their thriving housing and service coordination partnership in Seattle, including their funding and braiding strategy. After their presentation, they're going to turn things over to Caroline Bas, chief operating officer at The Kelsey, to learn about how they have figured out a way to bring service coordination into their inclusive housing developments by braiding funding. And that's an innovative model that can help you start thinking about how to expand the reach of service coordination in your community. So, Andy and Sean, the floor is yours.

ANDY CHAN: Thank you, Charlene, Hi, my name is Andy Chan. I am, as Charlene said, the strategic advisor -- sorry, a strategic advisor of Seattle Housing Authority. I work in the housing choice voucher department. Prior to that, I was in, the policy department, and prior to that, I was in the housing operations department. Before I worked at Seattle Housing Authority I did work for Aging and Disability Services. And I also provided quality assurance for the providence Health Housing system which has properties in three -- four different states now. Sean? 

SEAN WALSH: Well, hey, everybody, my name is Sean Walsh and, as noted, I'm a case management supervisor with the city of Seattle Aging and Disability Services. I manage our Seattle Housing Authority Program, and like Andy I have a background in direct service I ran a home care program for about ten years. I've been a case manager in buildings, and have basically been hanging around housing providers and connecting with the residents for a long time, it's great to see everybody here and see all the introductions for everybody around the country. Pretty amazing group! Thank you for having us. 

ANDY CHAN: Next slide, please. So, I wanted to do a bit of a brief introduction to Seattle Housing Authority. Seattle Housing Authority, commonly known as SHA, is a large public housing authority. It houses over 31,000 individuals in over 16,000 households throughout the city of Seattle, Washington. SHA opened the first racially-integrated public housing development in the United States in 1942. Around half the people we house live in properties that we own or manage; and we have properties and partly owned by partner agencies under the housing choice voucher program, which is commonly known still as Section 8. A lot of what we will be talking about today is focused on a subset of our housing -- that is -- in our low-income public housing high-rises, and senior housing. In our low-income public housing high-rises and senior housing around 66% of the people housed are 62 or older. And, an additional 18%, are people under -- under 62, with a disability. So, basically, a lot of people with some degree of functional impairment, be it physical health or behavioral health. 

A couple of other demographics of note, are the in this population, over half are Black, Indigenous or people of color -- so a lot of folks who have experienced generational systemic disparities. The average household income in our high-rise properties, is about 14 and a half thousand dollars a year. And, for context, as a whole Seattle's household area median income is about $115,000 a year. One other thing to note is that SHA is a moving-to-work, or MTW housing authority, and this allows SHA to use funds more flexibly than some traditionally-funded housing authorities. Sean? 

SEAN WALSH: Thanks, Andy. And to speak briefly about aging and disability services -- we're the area agency on aging for king county meaning we're the entity designated by the state of Washington to address the needs and concerns of older adults at the local level. One of our major functions is to manage, the authorization of in-home services like home care, and home delivered meals, and medical alert systems for low-income older and disabled adults to safely live in their community. And countywide we manage about 14,000 residents in home services, specific project that I'm in with the Seattle housing authority serves about 650 residents receiving in home services through Medicaid. Demographically, our clients are 54%, Black Indigenous, or people of color, and about 75% are 62 years or older. Andy? And next slide, please.

ANDY CHAN: SHA has been partnering with ADS since the early to mid-1990s. There were some key things happening around then that provided the impetus for this growing relationship -- some external, and some internal. One of the big factors was the impact of increasing deinstitutionalization in Washington state. A major element of deinstitutionalization, was redirecting people with chronic behavioral health challenges away from congregate care facilities, often into public housing. Another big factor, is the wave of baby boomers. The baby boom generation has an outsized impact, not only because it represents such a large number of people, but also because by and large, their desire has been to age in place. 

These two elements both represent populations that have lived in subsidized affordable housing in growing numbers and both typically have need for supportive services in order to maintain safe and stable tendencies for the long haul. Along with these external factors came internal one at SHA it was the growing recognition firstly, that successful housing means more than just a roof. Secondly, that the people we house were often unable to successfully connect with needed services. And thirdly, though we were great at providing housing, we were ill-equipped to provide supportive services ourselves. 

You probably want to know how this came about, the tendencies of this partnership, however, with a little bit of reverse engineering and benefit of working through several other health and social service partnerships, we can say, that some of the most important factors are, understanding the -- the demographics of the population we work with, having an idea of the systemic challenges or inequities these demographics have faced, talking to tenants to help understand their needs rather than just making assumptions, and not being shy to reach out to city or county governments and healthcare organizations to establish the grounds for partnerships. And you may be surprised about how open they are to this. Next slide, please.SEAN WALSH: Thanks Andy. And these next few slides are going to be about care coordination and braiding in our program. In the extent of our Seattle Housing Authority program, care coordination has two distinct meanings. On the one hand, our team of 12 care coordinators conducts annual long-term care assessments and authorizes services for the 650 residents who are in that program. In the SHA buildings we serve this is a really structured form of care coordination, with a long and complex assessment process and paperwork requirements. And average -- SHA resident enrolled in this program will receive something like 60 to 80 hours of home care services and other support services per month. On the other hand, our staff also provides a more open-end, discretionary type care coordination, Care coordinators have between 4 and 6 buildings, between them, we have 12 care coordinators serving 52 buildings, so each one serves a total of about 350 residents. And within each building each care coordinator holds weekly office hours, so each building has somewhere between 3 to five office hours per week operating in this mode, The care coordinators are doing outreach and responding to residents, seeking them out for assistance, meeting with property management and other providers to connect residents with services. And since the pandemic, we've added another dimension of care coordination using remote meeting tools like this one, making it possible for our service coordinators to convene monthly portfolio meetings with property management, behavioral health providers and other service providers, to share information and updates and staff -- challenging -- excuse me, client situations. Next slide, please. 

So, the braiding-ness of our funding that's what this -- is what we're going to talk about now. We think of braiding as combining sources to support a common goal while maintaining specific program identity for each funding source so within our specific budget 50% of our funding comes from a per month client reimbursement from the long-term care system for doing the care coordination associated with in-home service coordination and assessments.  The other 50% comes from a combination of a grant from the Seattle Housing Authority and that's Andy was alluding to this, having started many, many years ago, that's about 25 years has sort of carried on to the present. The housing authority and city of Seattle manages the housing authority portion, of the -- of the grant, each of those, adding up to about 25% each for our program. So, we have three different funding models and each of them have their own silo of services. This is also reflected in -- in the -- body of work taken on by our care coordinators. Each care coordinator has a caseload that's about half the size of an ordinary case manager, which represents about 40 clients, the other half of their time is doing the discretionary work that’s funded by SHA and the general funds portion of our services. I just want to say another thing, too, listening to the introduction it struck me that braiding also, by combining these two things, sort of opens up some walls between silos between housing authority silo and long-term care silo and the behavioral health. Braiding is one of the ways to sort of get services to fall between those different silos. Next slide.

On impact. So, impact is sometimes, difficult thing to measure, to understand the impact within these communities we have tried to compare access to long-term care services, within, different housing providers, with similarly-demographical clients. And what we found is that within SHA communities between 20 and 25% of its residents are utilizing long-term care services. When we look at other similar communities the number is more like 8 to 12% of its residents using long-term care services. Trying to sort of compute this in terms of dollars is not easy but, you know, the net amount of services received by SHA residents is about 40 million dollars a year, and long-term care services mostly in the form of things like home care. If we were not there, there's about a four or five million dollars’ worth of services that would likely not be in these communities. So, looking at it one way is a return on investment, you know, the $500,000 contributed by SHA results in about four or five million dollars’ worth of services to residents. 

There are a few other less tangible impacts, too -- people having quicker access to new long-term care programs in the state of Washington’s really dynamic long-term care system. We coordinate with emergency service providers and other municipal departments like the fire department, to respond to challenging situations. And coordination around disaster preparedness and response is an important part of our relationship so it's really true during the COVID pandemic where we partnered on extensive COVID vaccination outreach and responding to displacement events like fire or weather emergencies here in Seattle. Next slide, please. And Andy, I think you're up.

ANDY CHAN: Thanks Sean. Yeah, I mean, -- ADS has been the one long-term partner for SHA over the course of over 25 years. We had other partnerships, involving additional things, including, more recently behavioral health. And, going forward, SHA continues to look at ways to leverage more cross-sector funding. A recent example was the introduction of an intensive care coordination program called Foundational Community Supports into our properties. Foundational Community Supports, has sustainable funding through Washington's 1115, Medicaid Transformation Project. But providers are struggling to establish the program in Seattle and not in the least because there were no start-up funds attached to this program. 

So, for a modest investment of $20,000 from the Seattle Housing Authority in seed money, we were able to establish a program that has brought hundreds of thousands of dollars of services to people in our properties who are enrolled. Our interest in the health and housing interconnection has also led to several data partnerships. Really the key one is between Seattle Housing Authority and our regional public health department. This calibration has resulted in several products of value. A health utilization dashboard that, URL -- the URL, for which we have on the slide, they helped us identify which communities or which demographics needed more active outreach during the COVID vaccination efforts. And they led some -- some recent ground-breaking research on health and income outcomes after exiting from federal housing subsidy. Sean? 

SEAN WALSH: Yeah, and in our last minute or two that we have, talking about interesting next steps, one thing we're really excited about trying out that is a function of our relationship with the housing authority -- a major issue, in Seattle, and probably everywhere -- is the supply of caregivers, in our area. Home care workers. We are an expensive city and that's really challenging. And one of the opportunities we're looking at is using housing, as a way of concentrating caregivers also. So that we have a model called "community personal care" or cluster care, that's essentially way of making caregivers more efficient, by locating them in a building or two buildings close together and serving people in smaller increments of time, maybe 15 or 20 minutes or half an hour. Doing tasks like medication reminders, coming back repeatedly during the day, that's not the model of long-term care, as we know it right now. But it is a way, of making caregivers more efficient by serving more people, and guaranteeing longer 8-hour shifts total for caregivers and -- Yeah, something we're really excited about, experimenting with this summer, we've -- we've -- we're looking at this summer later this year, trying -- with the support of our -- our state partners -- putting that project together. And I think that that's the end of our presentation.

ANDY CHAN: I believe -- if we go to the next one. Move -- there you go, yeah, so just -- I think everybody will be getting these slides, eventually, but -- and there will be a Q&A, so don't need to ask questions at this point, I'm sorry, don't need to send e-mail at this point in time but anything that doesn't get answered, feel free to e-mail us directly and now I believe we're over to Caroline! 

CAROLINE BAS: Thank you, I am having trouble starting my video. Says the host -- oh! All right, just got the notification! All right. Great, hello, thank you so much for having me here today. I'm -- as Charlene noted, I'm Caroline Bas, the COO at The Kelsey, and -- and I'm going to give myself, a little bit of grace, where, Charlene said we have figured out -- I would say us as an organization -- we are figuring out how to braid service coordination dollars into the housing that we build. And, but the good thing about us is we are always sharing our learnings and so as we -- as we experiment with our projects, which I'll get into in a little bit, we are so excited to -- to share with you-all what we've learned so far and what we continue to aim to learn, through our approach to service coordination. 

A little bit more about The Kelsey, we are a dual-mission organization, that means we both, develop housing, and, advocate for housing, and the housing we advocate and develop is affordable, accessible, and inclusive. When we say "inclusive" that means for people with and without disabilities. Next slide. 

We really look at our interventions across three different areas. As I noted affordability -- so we have some -- we do some housing finance work. Accessibility -- we have a set of design standards about how you can go beyond code within your buildings. But today, we're talking about inclusivity. What are the resident services that you, or any housing developer or service agencies, or housing authority, or... whomever works within the housing ecosystem -- can integrate within their -- within the homes that they provide to their community? 

And we will be focusing on that today. And, so, my day job is really focusing on the housing finance and development side. However, I come to this work as a lifelong service coordinator for my mother who has significant disabilities and has struggled to live independently. So, it took a lot, just like this learning that I take to my day job every day, all of the work that we've done has been centered on the voices of people with disabilities, on what are the housing needs that they need, and what are the gaps within housing that they have experienced? And how do we design those, those interventions across affordability, accessibility and inclusivity? Next slide. And as the previous speakers noted that there is a -- a history of institutionalization, in -- in the United States. And, so, our -- our role is to -- and all of us on the line today -- is to really create a better integrated future for people with disabilities. The last generation was more within a group home model. And now looking to be even more integrated, and building integrated housing that -- where people with and without disabilities live together, and -- provide, and interdependent, and are valued and supported. And share the same spaces and experiences. Go to the next slide. And we do all this through our -- through our approach through the triangle of community living, you may have seen this, in other -- this is a common framework that folks, adopt a lot. 

And it's important for us to take some time on this as how can folks thrive in that third image of where -- the dots -- all the different colored dots are all integrated together? What are the three different elements that people with disabilities with significant access needs -- need in order to thrive? Living independently? And the three elements of this are services and supports. We've talked about this a lot. What are those formal services and supports that are available?

What is this looks -- is called different things across the United States, but I think we're all familiar with these -- either HCBS services, home- and community-based services or other service systems that enable people to live independently. 

And then we have the housing. As many of us are also familiar with, the affordable housing, both affordable with a capital A, or just attainable housing that -- that people with disabilities on limited incomes can access. And that's incredibly important for this -- for people in order -- for people to be able to live independently. And I will note that the -- that the current affordable housing structure -- was developed when people with disabilities were still in institutions. And so, it was really developed prior, and the structures were -- were in the financing approaches were developed prior to people having the constitutional right to live in community. 

And so that is something -- what we think about every day, of how do we -- how to we work beyond those existing structures? And, modernize them so we can have those integrate dots that we saw in the previous slide. The last part here is community, this is -- so important to everybody, not just, people with disabilities? We here hear our Surgeon General, talking about the loneliness epidemic. We hear -- see all of ourselves thrive through knowing, being connected to our community and seeing really informal support systems, pop-up, during at the beginning of the COVID pandemic. And so, with these three elements, we are intentionally -- by integrating and intentionally thinking about these three elements together within our housing developments -- then, we are -- we are hoping to make, better outcomes for our residents. If you go to the next slide. 

How we do this is just, each of these different roles, is -- is, a coordination, For folks that are -- are, involved in our -- in our housing development so you have your property owners and your management and your housing authorities who are providing the housing -- and the -- and the inclusion concierge that's the role that we call our service coordinators, they're coordinating between them, also the supports and services roles, Of the established Service providers, service providers as well as creating an interdependent community and culture connectedness within the housing that we provide so that community, and informal support networks, can get formed, and defined, even easier (gesturing), so this is -- this is the work that we bring, through our resident services program. I'll switch to the next slide. And the benefits of really looking at this, from a holistic and integrated and intentional way is one, we're bringing resident-centered experience for all of our residents. That you have one resident services manager. Resident service provider -- who -- who is thinking about the service coordination that's needed. Plus, coordinating with all of the different pieces, that somebody needs in order to live independently, and stably. 

As noted before, we're creating a culture of interconnectivity from the very beginning, so thinking from -- we think very intentional, how do we communicate with all residents before they even move in to understand that they are moving in to a supportive and connected community? 

And how do we design spaces in order for people to connect in those places? And, as noted, service infrastructure is really that service coordination role, that this inclusion concierge, about one -- about 50% of their time, is focused on service coordination, for the folks -- with higher service coordination needs who live in the building. We are just getting started. And we have our first two projects under -- under construction, which we can go to the next slide, I'll talk about expected outcomes in the next slide. 

So, we have our first project is just leasing up right now -- our partner is on the line right now, I see -- helping to lease that up. And that will be about 25% of our homes of the 115 homes will be set aside for people, with -- who need supportive services in order to live independently. Same with our San Francisco project, which is under construction, and will be starting leasing up next year. And then we also had a small pilot over the last three years, which we have just -- we don't own this project but we provide services. And through the outcomes that we've seen there is 100% housing retention of really folks that have not been able to stay stably housed in the past because they did not have a strong informal support network in order to continue to live independently. And we've been able to provide that through our service coordination roles. And I think I had one more slide. Go to the next one. So, we'll go back to the last one, a couple more notes on that. 

Is service -- I wanted to talk about the braiding. The cost braiding on each of these, so, what we've done is really taken for these first two projects, taken the operating budget, and making sure there's a very robust resident services budget, within those; and we've done this through a couple of different means. One, we have Section 811 project rental assistance vouchers for both of those first two projects so that we can bring up the mortgage or bring down the mortgage that we need to pay every month. So, we have additional available, for resident services, budgets, so that's how we have done it for both of those, plus braided in housing access service -- housing access services funding that is Medicaid. And Medicaid-funded available through, HCBS clients within Department of developmental services in California, And, and then plus through the Section 11 program having referral partners who are able to bring -- to understand those service needs, prior to folks moving in to the project, and helping to -- to do some of that service coordination, even before they're living independently. I saw some notes in the chat that people need those services prior to living there and, yes, we totally -- -- that is -- that is 100% of what is, what is needed there. And what we're planning to do. So, I will switch it off to Charlene, who is going to kick it off for questions! 

CHARLENE ALLEN: Okay, wow! and I have an ambulance outside my window. I want to thank all of our presenters, in Seattle, and -- and Caroline, The Kelsey, for their fantastic presentation. And these are just two examples of the many ways to operationalize braiding funding, to expand and sustain access to service coordination so that, you know, people are less likely to need to move, enter a nursing home, or end up becoming unhoused.

 So, before we go to the Q&A, please remember to use the Q&A function to ask your questions. We do actually have a fair number of questions. I've been reading them and writing some of them down to try to figure out how we can squeeze them all in. 

Now, before we jump to the Q&A, I want to raise awareness of a new potential source of funding for some of you for service coordination activities. The 2024 physician's fee schedule from the Centers for Medicare and Medicaid services or CMS, has some policy changes designed to address health-related social needs, or HRSN. And, in a nutshell, HRSNs are individual-level adverse social conditions that can contribute to poor health outcomes, such as housing instability, food insecurity, transportation problems, utility health needs, interpersonal safety issues, and many others. so, now, this is a very complicated area, and I would have to spend another five hours on this webinar, to explain it all. But we wanted you to know that, the physician's fee schedule, basically creates new services that support activities that relate service coordination. And just to highlight a few these include person-centered assessment, home- and community-based care coordination, care transition support, social and emotional support, and other services that enable holistic person-centered care. And because there are so many important technical details involved in implementation of these new opportunities, we really want to encourage you to start with the sources, shown on the next slide. 

Into the next slide, we have some links for you and they're also going to be put in the chat. And, you know, these links will help you start to research this. And in a follow-up e-mail tomorrow, we're going to -- in addition to sending the slides, we're going to share these links again. And so -- you know -- you will be able to learn, many of the rest of us on how to implement this and there are some entities including organizations and resource centers at ACL that are helping to explain, kind of how these new building flexibilities actually work so it's an exciting area, for definitely enabling more people to be provided with supports in the community. Okay, so. Thank you for putting so many excellent questions in the Q&A. Thank you for putting so many, interesting questions in the Q&A. and I'm going to do my best to get to them, and have our panelists answer. I guess, let me start with the Seattle team. There were a couple of very specific questions, A couple of people wanted to know more about whether or not your care coordinators any of them live on-site, or, if, they basically engage during office hours in the various locations or other kind of ways that they interact.

SEAN WALSH: Yeah, we don't have an on-site living arrangement. They're actually separate from the housing provider and Seattle housing authority at one time used to have live-in property managers but at this point they just have people coming to spend office hours there, it isn't 24-hour staffing or anything like that.

CHARLENE ALLEN: Okay, and can you say a little bit more about the cluster care model and how that relates?

SEAN WALSH: Sure, maybe we'll come back next year and talk even more about it. It's sort of been around for an idea for a long time and take as basis, where you see clusters together in close proximity taking advantage by providing one, two, three staff, rather than having dozens of people come in. It's fairly complicated because it requires home care agencies, housing providers, and case managers all to be working together. Identifying the people who are eligible for services and then having two or three caregivers going between these folks rather than what's usual. What Medicaid always liked was two- or three-hour shifts of caregivers but we all know that, actually, people needed help in much smaller increments -- 15 minutes, half an hour -- rather than these large blocks of time. So, it's really an effort to get at that. It's been around as a concept for a while in the Pacific northwest, in Seattle. It just hasn't been rolled out at scale, and, you know, as we ponder the shortage of caregivers, that we have, now and are likely to have more in the future, it seems like a good way but one that takes many silos to get together to make work efficient for caregivers, and actually, for clients, too, who would prefer to have people, you know, just for the time that they need them, rather than long blocks of time. Yeah.

CHARLENE ALLEN: Great, thank you, so a question for all three of you. In terms of the way that residents that receive your services are engaged in kind of, you know, participating in how the services are setup, and providing feedback, and input, and, helping kind of steer the approach. How do you facilitate the engagement of the people that you serve, including people with disabilities? 

CAROLINE BAS: Yeah, I can start on that one. So, our service coordinators are front and center in the building so they are, you know, the front desk person you see and you say hello to every single time you come in and out of your home. They're also part of the process, from the very beginning, when you're moving into a building and so there is continuous, conversation and feedback of what of what the person needs, in terms of service coordination. But then, also, we have a resident, advisory board that would be giving feedback to the inclusion concierge, as well as just general feedback to the property management as well. 

CHARLENE ALLEN: Great.

ANDY CHAN: Similarly, Seattle Housing Authority has a joint policy -- two joint policy advisory committees. For older adults, and folks in the low-income public housing high-rises; and -- our contracts people are regularly checking in with the various resident councils in terms of services that are provided and various needs that are being requested. 

CHARLENE ALLEN: Okay, thank you. So, Caroline, I do have a question specifically for you, in terms of the people with disabilities, who are eligible for, you know, the housing and in your model, and to participate in your communities -- People want a little bit of just clarification or just -- can you specify -- does that include people with substance use disorder? Developmental disabilities? Physical disabilities? Like do you have a way that you can summarize sort of who's captured under that umbrella? 

CAROLINE BAS: Very good question, and it's a common question, because, we don't actually prioritize or set -- reserve our 25% set aside for a specific diagnosis. We say people with disabilities who need supportive services in order to live independently. So, this would be anybody who is eligible for HCBS home and community-based services. And this is particularly where we're operating right now -- Is a lot of different diagnosis so both folks that are part of the regional center, which, in California, which is -- people with intellectual and developmental disabilities, or people with mental health disabilities, or people who are living in institutional settings. Nursing homes... other places, who could live independently with additional services. So, depending on the program it covers a lot of different diagnoses. But it's for anybody who needs those services in order to live independently. 

CHARLENE ALLEN: Great, thank you. And, yeah, I'm going to ask this -- another question for all three of you. Now, if you're not really privy to this information, because it's more related to the operational kind of budgeting aspect of it, but there was a question about.... Kind of what -- does it require of your finance team and budget team to successfully do the braiding of the funding? And to kind of manage those different funding streams? Do you have any insights to share on that and additional challenges that poses? And any work-arounds or tips that you have? 

SEAN WALSH: Well, I don't know any tips other than to say it can be a little complicated at the city of Seattle, you know, we have really complex -- budgeting processes, and the big trick -- somebody else had asked I saw in the questions about how -- the big thing that we have to do, is have our staff, track their time in which bucket they are serving, like, are they serving in the bucket of the long-term care work? Or are they serving in the bucket of the discretionary work? And that -- as they just basically do their time sheets that sort of flows into the budgeting for us to allow their time to be allocated in the right way. And the percentage of time sort of varies over years, we do some time studies to determine what it is. And on the back end, it is complicated because, we have a city of Seattle match and, you know, all of those funding streams vary over years, so we go through a process of -- aligning those, and -- you know. I don't know the granular details of it, but there are some things that we do on our side to help make it more possible to braid the funding together. 

CAROLINE BAS: I will say as an independent nonprofit it is really important to have, you know, some general operating support, in order to fund some things upfront. So, a lot of, as we know, the Medicaid services is going to be funded after they are delivered. Whereas we need to be able to know that we can hire these people, full-time, depending on, you know, we don't know who has, who will have how many hours of those services before they move in. And so, us being able to put some support into that project to make sure we can have sufficient staffing in there, even if the Medicaid funding comes up and down. And that's a lot of it, is become -- is coming from, like I said, the operating budget of the buildings. But we as a nonprofit, also support back-stop to some of that Medicaid funding that could come in and out. 

ANDY CHAN: And I mentioned about foundational community supports and how -- what the housing authority had provided, was essentially, front-loaded. So, we paid for the period of hiring and training of the staff so that they could, then, start the services and then -- at that point in time -- could seek reimbursement prior to that. They could not seek any reimbursement. So that's why -- this, you know, -- there is a slow uptake of the services because there are a few providers who are willing to front the money for this. 

CHARLENE ALLEN: Okay, great, thank you. And lastly, if you could just, like, maybe take -- if you have any thoughts, just in, like, 30 seconds each -- What's one recommendation you would make to participants in the webinar who would like to -- can expand their service coordination and kind of get the ball rolling in terms of, you know, your experience? 

SEAN WALSH: Well, I might go first just to say, something Andy said earlier, I think what really caught it for me and it's for housing providers not to be assertive with the entities doing long-term care and support in their communities. Working where I do, I know that doesn't necessarily come from the other direction like these long-term care service providers might not be coming to you as housing providers but if you're initiating, we've had other situations in Seattle where it's really been successful and great housing providers come to the table and say, you know you're coming to the buildings to do the in home services we're doing what we can to support the participation in these programs and writing them in. So, I think that would be sometimes cities and others can be intimidating but as a housing provider, I think that's really helpful. 

ANDY CHAN: I just quickly add part of the communication, would probably be important, communication -- is to ensure that each of the organizations that you approach, understand there is a mutual interest in providing these services. 

CAROLINE BAS: Yeah, I would say -- so as I noted, we're a learning organization, so we share all of our learnings at thekelsey.org/learn. And so, there's a lot of different -- some notes in there about our inclusion concierge program and learnings from other folks who have delivered similar programs across the United States. So, I encourage folks to take a look at that and continue to look back as we learn more and conduct studies on the -- on our population. I'll also say that, you know, -- in terms of resident services. It is something that we've seen in -- and I noted this in terms of the history of the affordable housing finance industry was before people with significant support needs lived independently. And that there is a lot of -- need to uplift the issue of robust resident services budgets within housing developments. And also the need for on-site apartments and manager units to be able to go to resident service coordinators, they are providing, emergency work to the people who live within these units; and so, all of the work that we're doing across the United States, in order to make the -- folks who kind of dole out the funds understand the need for robust resident services budget within new buildings. Is really important for us. All to kind of think about, and elevate when we're talking to our financing partners. 

CHARLENE ALLEN: Absolutely. Great. All right, thank you so much for answering those questions. There are a bunch of other questions that I didn't get to and we've run out of time, unfortunately. Hopefully we will be able to review those, and maybe address them in the future webinar, there were certainly a lot of questions around homelessness that I'm just looking at the clock, I don't think we have time to address right this moment. But we do have a lot of active partnerships with HUD, and SAMHSA and others around homelessness, so I think we'll have additional opportunities to engage, on how, you know, -- service coordination, aligns with addressing homelessness, and, housing-first approach, and other things; so -- more webinars! 

All right, so, again, I want to honor everyone's time, I want to thank our presenters for finding ways to succinctly and effectively share how they are braiding funding to sustain expanded access to service coordination. I think all of us learned about a few strategies, maybe we can act on in the coming weeks and months, and tomorrow, in an e-mail, from Zoom, you will get a link to the slides, and many of the useful links that -- we shared on the screen, and some others -- Also, everyone will get an HSRC e-mail message when the recording has been made available. And, I would like to highlight a few resources for your work.

Again, we're going to post the recording of this webinar and the slides on the HSRC website, which you see the URL there on your screen. And, staff are putting the URL in the -- in the chat as well. And coming up we have a new website feature that will focus on service coordination, it's still kind of in beta mode and we're building it out, but, you know, the staff -- have put the link in the chat as well as showing it on the screen. But we will -- you will be able to go there to find our initial collection of technical resources on service coordination. And in a few weeks, we'll add our first service coordination tool. It, actually, has a written summary about the Seattle partnership and The Kelsey model with a little bit more information. As well as some more funding sources for service coordination. More than we've even had time to discuss today. So, I think you'll definitely appreciate that. And we look forward to sharing it with you. 

If you registered for today's webinar, we're going to send you a notice when the new tool is released as well. So, I want to ask each of you to take a few minutes, if you can, to answer a short feedback form -- it's very short. Staff is putting the link in the chat. There's only 5 questions, so, we want you to rate different aspects of your experience with us today. If you have other comments, you can also provide them. And, please note: We do read the comments, and try to find ways to act upon your input, and your suggestions. And, you know, we learn so much from all of you. 

And, we encourage you to tell us, about your own innovative practices, you can use our HSRC e-mail, which is HSRC.ACL.HHS.gov. Send suggestions to us there and we hope that you will also sign-up for a new set of periodic HSRC e-mails that we'll be sending out in the next few months. And, finally -- I definitely want to thank, everyone that helped put this together. 

We want to thank our New Editions and USAging staff, and -- our ASL interpreters Judith and Luciana, thank you so much, and Anthony, our captioner. Thank you, all, for your role, in producing today's webinar. We're grateful to all of you, who joined us today, and, I want to say thank you, and have a great afternoon

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