Business Acumen Webinar: Tools 

for Building Housing and Health 

Care Partnerships

Robyn Stone 

Alisha Sanders 

LeadingAge Center for Housing Plus Services 

Administration for Community Living 

Business Acumen Webinar 

May 15, 2015
Seniors in assisted housing are. . . . 

Poor 

Median income 

= $10,236 

Growing older 

Median age (2006) = 74 

≈ 30% 80+

Median age (at move in) = 70 

≈ 14% 80+

Diverse 

Hispanic = 13%

Black = 19% 

White = 56% 

Other = 19% 

Chronic conditions and functional limitations more prevalent among 

advanced ages, lower incomes, minorities 

Source: Section 202 Supportive Housing for the Elderly Program Status & Performance Measurement; Data is for residents of 

Section 202 housing properties, 2006 
Policy Priorities 

 Expansion of home and community-based 

services 

 Improve coordination and integration of 

health and long-term care services and 

supports 

 Increased focus on dual eligibles 
Bringing It All Together 

Potential 

synergies to 

advance new 

models and 

strategies 

Population trends 

(demographic, health,

economic, housing) 

Desire to age in 

community 

Fair housing allows 

residents to stay 

Few alternatives for 

low-income persons Feds and states want to: 

Enhance community 

options 

Improve health outcomes 

Lower costs 
Value of Housing Plus Services 

 Build on existing infrastructure of housing, health and supportive service 

networks 

 Provides potential concentration of high-risk/high-cost individuals 

(including many dual eligibles) 

 Offers economies of scale; can increase delivery efficiencies for providers 

and affordability for seniors 

 Provides residents easy access to services; may encourage greater 

utilization and follow-through 

 Offer a more regular staff presence on site with residents; can help build 

– Knowledge of resident needs, abilities and resources 

– A sense of trust among residents, which encourages better use of services 

– Early recognition of potential issues before they become costly crises 

 Help preserve seniors’ autonomy and independence
“A Picture of Housing & Health”

Medicare per member 

per month (PMPM) 

HUD Assisted Medicare 

Beneficiaries 

Unassisted Medicare 

Beneficiaries % Difference 

$1,479 $937 57.8% 

Proportion of Medicare beneficiaries dually 

enrolled in Medicaid.

70%

13%

HUD-assisted

(n=180,338)

Unassisted in community

(n=2,843,291)

Proportion of Medicare-Medicaid enrollees 

(MMEs) with 5+ chronic conditions

54.5%

43.1%

HUD-assisted MME

(n=112,045)

Unassisted MME in community

(n=249,490)

Source: A Picture of Housing & Health, found at http://aspe.hhs.gov/daltcp/reports/2014/HUDpic.pdf
HUD-Assisted Medicare-Medicaid Enrollees (MMEs) Spend More: 

Medicare cost and service comparison 

HUD-Assisted MMEs Unassisted MMEs % Difference 

N=112,045 N=249,490 

Average Medicare PMPM $1,222 $1,054 16%

Medicare services utilization 

per 1000 member months 

HUD-Assisted MMEs Unassisted MMEs % Difference 

N = 112,045 N = 249,490

Acute stay admissions 31.4 29.4 6.8%

Hospital readmissions 5.2 4.9 6.1%

Medicare home health visits 581.5 445.5 30.5%

Total emergency room visits 58.4 51.6 13.2%

Physician office visits 1,652.3 1,307.9 26.3%

Ambulatory surgery center visits 14.5 10.0 45.0%
HUD Assisted Medicare-Medicaid Enrollees (MMEs) Spend More: 

Medicaid cost and service comparison 

HUD-Assisted MMEs Unassisted MMEs % Difference 

N = 106,764 N = 227,186

Average Medicaid PMPM $1,180 $895 32%

Medicaid services utilization 

per 1000 member months 

HUD-Assisted MMEs Unassisted MMEs % Difference 

N = 106,764 N = 227,186

Personal Care services 4,512.4 2,149.1 110.0%

DME 380.0 227.7 66.9%

Other HCBS services 3,309.8 1,840.6 79.8%

Other HCBS services includes private duty nursing, adult day care, home health, rehab, targeted case management, transportation and hospice. 
Services Staff, 2008 

69%

26%

13%

25%

Service Coordinator Activity Coordinator Nurse No Staff

SC

44%

SC/AC 

14%

SC/N 

5%

SC/AC/N 

5%

AC

5%

AC/N 

1%

N 

1%

No Staff 

25%
Onsite Services, 2008 

Social activities 74%

Transportation 44%

Congregate meals 33%

Exercise and fitness 49%

Health education 66%

Health screening 64%

Homemaker assistance 31%

Personal care 24%

Medication assistance 19%

Primary health care 10%

Mental health 10%

Dental 3%

Podiatry 27%
Association with Onsite Service Availability 

(preliminary results: do not cite) 

 Increases Decreases 

ER visits per enrolled month, 2008 

(outpatient visit only) 

Exercise 

Odds of having at least one ER visit, 2008 

(outpatient visit only) 

 Service Coordinator 

Acute stays per enrolled month, 2008 Exercise 

Primary Care 

Nurse

Odds of at least one acute stay during 2008 Mental Health 

 

Exercise 

Service Coordinator 

Nurse

Office visits per enrolled month, 2008 Primary Care 

Medicare expenditures per enrolled month 

(medical only) 

 Exercise 

Medicare expenditures per enrolled month 

(Part D only) 

 Primary Care 

Medicaid expenditures per enrolled month 

(among full duals) 

Mental Health 

Exercise 

Service Coordinator 

Medication management 

Non-italicized results are significant (p<.05). Italicized results are borderline (p<10). 
Supports and Services at Home (SASH) 

Program Evaluation 

 Care coordination model anchored in senior housing 

 Interdisciplinary team 

– Housing-based staff: SASH coordinator, wellness nurse 

– Network of community-based providers: home health agency, 

area agency on aging, mental health providers, etc. 

 Linked in with state’s health reform efforts 

– Medical homes supported by community health teams 

– SASH extender of community health teams 

 Statewide expansion supported through Medicare 

MAPCP demonstration 
Supports and Services at Home (SASH) 

Program Evaluation 

 Comparing SASH participants to: 

– Individuals in MAPCP demo, non-SASH properties (in 

VT) 

– Individuals not in MAPCP demo, non-SASH properties 

(in NY) 

 Early results: SASH is bending cost curve 

– Growth in annual total Medicare expenditures was 

$1,756 - $2,197 lower for SASH participants than for 

two comparison groups 

Source: Support and Services at Home (SASH) Evaluation: First Annual Report, found at: http://aspe.hhs.gov/daltcp/reports/2014/SASH1.pdf 
Partnership: Presbyterian Senior Living & 

PinnacleHealth 

 Weekly onsite clinic 

– Staffed by MD, RN, MSW; work with service 

coordinator 

 Care navigation program – clinical and social 

 ID high utilizers 

– Identify barriers to care – navigate through health 

system or help coordinate needed social services 

– Coordinate with PCP (or serve as PCP, if one needed) 

 Utilize Pinnacle’s HIE
Partnership: Presbyterian Senior Living & 

PinnacleHealth 

81

65

41

34

11

57

29

17

13

5 

1/12-6/12 7/12-12/12 1/13-6/13 7/13-12/13 1/14-6/14

ER visits

Inpatient visits
Housing & Health Partnerships: Why Now? 

 Health and long-term care reform efforts at national and 

state level 

 Goal: Better address health care needs of all Americans, 

particularly vulnerable populations 

 Affordable senior housing residents represent the 

vulnerable individuals population-based health reform 

efforts are designed to target 
Housing & Health Partnerships: Why Now? 

 Striving to address population health 

– More effectively managing care of high-need and costly 

patients 

– Early intervention with lower-risk patients to avoid need 

for more expensive care over time 

 Focus on lowering health care costs through 

– Timely, preventative care 

– Improved care coordination & service integration 

– Reduction in over-utilization of expensive services 
Benefits of Affordable Senior Housing 

 Concentrated population 

 Operating efficiencies 

– Streamlined access 

– Programming that reaches multiple individuals 

– Facilitate greater follow-through and compliance 

– More complete understanding of social factors 

 Physical and personnel infrastructure 
Health Care Challenges 

 Affordable senior housing properties can assist by 

helping health care entities 

– Manage chronic illness, both physical and mental 

– Ensure smooth transitions from acute/post-acute settings 

– Minimize avoidable hospital readmissions 

– Address medication complications 

– Increase patient engagement 

– Address social determinants of health 

– Tackle special needs of “super-utilizers”
Housing and Healthcare Partnerships Toolkit 

 Guide: “Housing & Health Care: Partners in Healthy 

Aging” 

– Understanding health care reform 

– Benefits of a housing and health partnership 

– Health care challenges that housing can help address 

– How housing and health entities can collaborate 

– Identifying and cultivating a partner 

– Structuring the partnership 

 Other materials: videos, ROI calculator, resources 

www.LeadingAge.org/housinghealth 
Housing and Healthcare Partnerships Toolkit 

 Guide: “Housing & Health Care: Partners in Healthy 

Aging” 

– Understanding health care reform 

– Benefits of a housing and health partnership 

– Health care challenges that housing can help address 

– How housing and health entities can collaborate 

– Identifying and cultivating a partner 

– Structuring the partnership 

www.LeadingAge.org/housinghealth
Housing and Healthcare Partnerships Toolkit 

 Return on Investment Calculator 

 Videos 

– How housing can help healthcare 

– Healthcare providers on the value of housing 

– Why housing should be interested 

 Other Resource materials 

www.LeadingAge.org/housinghealth 
D I S C E R N 

www.discernhealth.com 23

The Value of Housing in 

Accountable Care Systems 
D I S C E R N 

www.discernhealth.com 

About Discern 

Discern Health is a consulting firm that works with clients across the 

private and public sectors to improve health and health care. Our focus is 

enhancing the value of health care services through quality-based payment 

and delivery 

• Measure alignment and gap assessment 

• Measure selection and strategy 

• Measure implementation and data anal 

• Measure reporting strategy 

• Development of performance-based 

payment models 

• Analysis of payment systems 

• Re-design of care delivery models 

• PCMH transformation and recognition 

coaching 

• Accountable care strategy 

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D I S C E R N 

www.discernhealth.com 

Health Care Is Changing 

25

• Performance measurement, value-based purchasing, 

and health delivery re-design are shaping the future of 

the health care system. 

• Health care providers and their partners need to 

navigate new market demands. 
D I S C E R N 

www.discernhealth.com 

Value-Based Health Care Systems 

26

Characteristics Examples

First Generation

(2000 – present) 

Process and structure quality 

measures; internally-focused; 

“siloed”; volume-based revenue 

with some pay-forperformance

Hospitals, physician practices 

(i.e., “traditional” medical 

providers)

Second Generation

(2010 – present) 

Process and outcome

measures; externally-focused 

on other clinical providers; 

clinical integration; mix of 

volume and value payments

Accountable care 

organizations (ACOs); patientcentered medical homes 

(PCMHs)

Third Generation

(2015?)

Population outcome-focused; 

integrated with community 

resources; global risk-based 

payments

???
D I S C E R N 

www.discernhealth.com 

Defining Value 

• HHS has stated a goal to move most health care 

payment to alternative arrangements by 2018 

• Most alternative payment models define value by: 

• Setting performance benchmarks for defined 

quality measures, such as following care guidelines, 

enhancing patient satisfaction, or reducing 

complication rates. 

• Measuring total cost of care for patients. 

• Health system that meet these goals will earn 

payment incentives 

27
D I S C E R N 

Calculator to Estimate Value 

www.discernhealth.com 

• Discern Health worked with Leading Age to 

develop a calculator that quantifies potential value 

of housing to Medicare ACOs 

• Tool to: 

• Understand ACO quality measures 

• Understand cost of care 

• Assess potential impact of housing 

• Support collaborations with ACOs 

• Focused on Medicare ACOs, but concept apply to 

other accountable care arrangements. 

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D I S C E R N 

www.discernhealth.com 

Medicare ACO Basics 

• Integrated networks of hospitals, doctors, and 

ancillary providers 

• Serve a defined population of at least 5,000 Medicare 

beneficiaries. 

• Are evaluated on patient satisfaction, chronic care 

management, preventive care, and care coordination. 

• Continue to receive fee-for-service payment. Can earn 

“shared savings” if their total population costs are 

below national trend. 

• Shared savings eligibility is tied to quality 

performance. 

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D I S C E R N 

www.discernhealth.com 

Key Questions for Housing Providers 

• How can we impact quality measures? 

• Engaging with patients 

• Facilitating access to needed care 

• Screening for health risks 

• How can we impact costs? 

• Improved well-being and health outcomes 

• Avoidance of ER use, hospitalizations, and 

readmissions 

• Managing the social determinants of health 

30
D I S C E R N 

www.discernhealth.com 

Calculator Demonstration 

31
D I S C E R N 

www.discernhealth.com 

Using the Calculator 

• Understand how an ACO will assess collaboration 

with a housing organization. This can help frame 

the discussion relevant to their quality and fiscal 

performance needs. 

• If the necessary data is available, calculate the 

potential value housing can bring to the ACO. 

• Use as an evaluation framework going forward. 

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