Service Coordination Models and Sustainability | Transcript 1

Service Coordination Models and Sustainability

Transcript from 2nd Ohio Office Hour on 1/25/22

Presenters: 

• Duana Patton, CEO, Ohio District 5 Area Agency on Aging, and Board Member, Ohio 

Association of Area Agencies on Aging

• Joseph Recchie, CEO, Community Building Partners and Praxia Partners

• Justin Moor, Vice President of Planning and Program Development, Area Office on 

Aging of Northwestern Ohio

• Calvin Thomas, Vice President, Accord Management

Facilitator: Alicia Anderson, Administration for Community Living

>> Hello, thank you for joining. 

I see we have about 23 participants. 

As I go through the general introductions, I know others will be joining. 

Thank you. 

This is our second office hour of the year. 

I'm really excited to bring this to you. 

If you are here, engaging with us we have deep appreciation. 

If you are viewing this, please know you can always get in contact with us. 

Welcome, my name is Alecia Anderson. 

I'm a management and program analyst with the office of interagency innovation here at 

ACL. 

If you are not familiar with ACL, I encourage you to visit our website at ACL.gov. 

Thank you, we are so excited to bring this to you. 

We are here to support your work. 

This is the second of a three-part series featuring partnerships in Ohio between the housing 

sector and aging and disability networks. 

As our partners in Ohio, which will find throughout this hour is the information can be used 

where you are located. 

Share with us where you are located in the chat so we have a sense of relatability and can 

gauge the reach. 

These collaborations are expanding options for older adults and people with disabilities to 

live in their communities with access to services. 

In this session, and the next hour what you can expect is a close look at service 

coordination models and sustainability. 

Before we do that, I have to go through instructions resume. 

This is being recorded. 

For audio options we ask that you use your computer speakers or dial in using the phone 

number and the registration email. 

Please stay needed unless called upon. 
Service Coordination Models and Sustainability | Transcript 2

Chat, please actively use the chat throughout the meeting. 

Whatever you want to put into the chat to call for engagement throughout this next hour. 

If you have a question and you want to direct to a particular presenter, the format will be 

questions for Duana and then you will ask a question. 

Raise your hand -your summa hand. 

We are actively monitoring the chat. 

We will definitely see you. 

If any point time that you raise your hand, we will stop to make sure we engage with you. 

Intention is for this to be an engaging hour. 

We are asking for you to support that. 

If you haven't heard, and I'm sure many of you have, we launched a website in December. 

We launched a housing of services and resource Center in December and made a website at 

that point in time. 

Please visit our website in the chat. 

HS RC is not just website. 

It's intended to facilitate the federally coordinated approach to providing resources, program 

guidance, training and technical assistance to the disability aging network associations, 

state Medicaid agencies, mental health and substance use disorder dividers, homeless 

shelters, public housing authorities and private housing providers. 

The goal of HS RC is to coordinate and leverage technical assistance, training and resource 

efforts with HUD and our HHS partners. 

It's to reach a broad audience of aging, disability, housing and homeless networks and 

stakeholders. 

We ask you to help us spread the word. 

It facilitates state and local partnerships between housing and services systems. 

It assists communities in the Virginia housing and service resources putting those from the 

American rescue plan and build back better. 

What to expect for the next hour? 

You can expect an engaging conversation. 

You can expect to listen directly and ask questions directly to presenters and learn about 

how they are working to expand affordable housing. 

You can expect to receive practical tips and real-world examples and you can expect 

participants pulling to help inform the next session on February 10. 

How will this work? 

Our presenters are going to give you a short presentation and we will follow that by along. 

Where you can engage in questions and discussions. 

Feel free to post questions in the chat and raise your hand. 

We want this to be engaging. 

Thank you. 

I will hand the conversation to Duana for introductions. 

>> Thank you for being here with us this afternoon. 

Myself and my fellow Ohio colleagues I'm really excited to be here with you today. 

We are looking forward to sharing information with you, but we are here for you. 

Therefore, we encourage you to participate in the chat. 

Raise your summa hand if you have a question and certainly at the end, we will have time 

for some Q&A. 
Service Coordination Models and Sustainability | Transcript 3

Let's jump right in with the next slide. 

For those of you that were with us at our last office hours or conference we talked a lot 

about housing. 

Let's be honest, housing is more than bricks and mortar. 

What happens under an individual's roof is just as vital as the structure itself. 

We believe a service coordinator or the activity of service coordination can make a big 

difference. 

Service coordinators work with clients to ensure quality service and ensure that clients get 

the service that they need. 

In order to really successfully do that service coordinator needs to build strong relationships 

with community partners and service providers to ensure clients receive the best care 

possible. 

We will dive into both of those things with the next slide. 

Service coordination is a function. 

It's important to understand that service coordination is a function. 

Basically, that means that is a function the title may differ across different organizations. 

It's an active and ongoing process to assist individuals to get the services and support that 

they need. 

We look at the model here in this particular slide you see different things such as 

homeownership and counseling, medical, educational programs, childcare. 

We do more than just senior housing in our area, we do service coordination and 

multifamily facilities as well. 

Basic service coordination is a function. 

When deployed appropriately it can provide value to those that have access to it. 

It does have funding challenges. 

We will talk a little bit about how we might overcome those funding challenges. 

The service coordinator is the individual, the professional who is performing the role. 

We consider them a facilitator, investigator, and advocate, and educator or someone who is 

a networker. 

You can see how service coordination isn't driven by position or by title. 

It can be anybody in an organization who is doing this type of work. 

The role might not be service coordinator with their providing service coordination. 

A little bit about our model here at the area agency district 5 in Richland County we serve 

nine counties. 

We have been providing service coordination and low-income housing properties for over 20 

years, probably going on 30. 

We have three locations all of which are senior housing. 

That is us connecting with the seniors in these particular facilities. 

Connecting them with transportation, perhaps they need assistance in finding a physician or 

even scheduling a doctor’s appointment. 

Or even preparing them for a successful appointment with the doctor. 

Coaching them on how they might ask questions. 

It is everything to meet their needs so that they can remain independent in the place that 

they reside. 

We have two locations where we do service coordination. 

One of which is the multifamily. 

We have young families, individuals over the age of 60. 
Service Coordination Models and Sustainability | Transcript 4

I will turn to Joe, and we will talk more about how that structure works. 

>> I'm happy to share this with you. 

When a developer wishes to have service coordination within their facility, they can pay for 

it out of the operating budget. 

The Federal Home Loan Mortgage in many of the state housing agencies on projects using 

the tax credit limit that service coordination amount that is allowed to be in the budget at 

$250 per unit year. 

That's not a whole lot for service coordination. 

However, the developer can pay for it from its developer fee or deferred developer fee on an 

unlimited basis if they chose. 

They are actually in that instance sharing some of their development fees with the nonprofit 

in order to enhance the service coordination. 

The benefit of doing so however is investors since it is part of the eligible basis for the tax 

credits, investors are paying from 50-90 percent of that service coordination fee. 

It's a very valuable way to enter a project long term and receive a large service 

coordination fee that is not borne by the residents in the form of rent, but simply added to 

the basis of the property and used for tax credits. 

I'm happy to answer questions about it. 

It's going a little bit in the weeds. 

It's an alternative that I feel strongly it can be successful. 

Duana ... 

>> We believe there is a lot of value from a previous slide we talk about housing is more 

than bricks and mortar. 

It's really about the people who lived there. 

We have had some really great conversations with the developers that we work with in 

providing the individuals with the service coordination is just as important as the layout of 

their unit or the appliances that they use. 

I know Calvin is going to talk about this and I won't steal his thunder, but we also find that 

when there's a service coordinator in place the success of the individual to remain in the 

unit that they live in is more likely. 

I will stop there because I know Calvin will talk about that later. 

For our agency there is more. 

We did something really exciting and took our team of service coordinators and elevated 

them by certifying them as community health workers. 

If you go to the next slide this gave us the ability to expand the reach of funding we 

receive. 

We talked about the grants we get from our state unit on aging. 

Joe has talked about the development fees and operational budget of the property. 

When we elevated our service coordinators and certified them as a CHW we were able to 

benefit from payment from third-party payers. 

A community health worker is a trained individual who acts on behalf of the communitybased organization but in a manner where they are bridging between health and social 

services of the individual they are working with and the community. 

It does require an Ohio minimum of 100 classroom hours, hundred and 30 clinical hours. 

It is also a certification that is submitted and approved to the Ohio Board of nursing. 
Service Coordination Models and Sustainability | Transcript 5

That may be different in other states. 

That's something you might want to look into. 

For us, definitely elevated our individual, give them additional training and they couldn't be 

more excited to have a certification behind their name and on the resume as well. 

Next, when we work with the CHW gave us another opportunity. 

By having the CHW was it allowed us to work with our local HUB which allows us to do 

pathways. 

They are the organization that is contracted with these third-party payers. 

Namely managed care organizations. 

When we received the CHW certification our staff and could get referrals from our HUB. 

They come in the form of an individual who is a member of any of the respective managed 

care organizations or contract with the local HUB. 

Our service coordinator CHW then conducts we call a pathway. 

When that pathway is completed, the HUB gets payment from the MCO and ultimately, we 

get a share. 

It then brings in another level of reimbursement. 

You can see here there are not HUBs across the country. 

There are many pockets in Ohio because I think that is where some of the worker got 

started. 

A couple in Wisconsin and Texas and up in Washington. 

This implies that this is a great place to start. 

You can also see where we are actively looking to have certified [Pathway Community] 

HUBs. 

It's important to look at your community. 

If you are in a state where you don't see any color perhaps asking others around the area in 

your circles about the potential of having a HUB. 

Anybody can become a HUB. 

When we do service coordination and we utilize it qualified CHW and we have a contract 

with the HUB can get reimbursement from insurance carriers, managed care organizations, 

Medicaid and Medicare depending upon how the HUB is set up and what contracts they 

have. 

This will show you a little snapshot of a 12-month period for the woods which is a senior 

housing complex where we deploy our community health workers, service coordinators. 

These are unduplicated numbers. 

These represent pathways. 

May have an individual that comes to our service coordinator with housing issues, whatever 

that might be. 

They also might need some personal care or homemaker services. 

Each one of those represents a pathway. 

Our community health worker may complete one or more of those. 

Each time that they do it is submitted to the HUB for reimbursement. 

Service coordination when done -remember service coordination is a function. 

That does not have to be a service coordinator. 

I know there are some organizations who perhaps do the CHW HUB work from their aging

and disability resource networks. 

Maybe the referral department, may be another care management function. 

When service coordination is incorporated with the CHW and there is a contract with the 

HUB it does result in additional revenue streams. 
Service Coordination Models and Sustainability | Transcript 6

Connecting with the client, completing pathway the agency can receive payment from the 

MCO. 

I am really excited to turn the next part over to Calvin who is going to talk about the 

importance from a property management standpoint. 

>> In my years and working in multiple senior facilities and multifamily and access of the 

service coordinator is invaluable. 

We found working closely with them it provides that third-party mediator/ advocate that is 

able and a senior environment help them with health services. 

Which is very important to seniors. 

We found in certain instances where seniors are needing extended care or even short-term 

rehab where the service coordinator can step in and facilitate making sure the rent gets 

paid, the apartment stays in the proper condition for them to be able to come back home 

after their short-term rehabilitation as opposed to leaving this place. 

We want everyone to be aging in place the standard facilities. 

To piggyback off of what Duana said, it's more than just brick-and-mortar. 

The resident relations portion for any property manager -there are people in this group who 

know that you will have many one-on-one relationships with several residents. 

You need the intermediate or person who can come in and take the burden off. 

Also, given that tenant kind of relationship that they need to interpret bills and take them 

through access endpoints for Medicaid and Medicare in preparing for doctors’ appointments 

like Duana had mentioned. 

This can get confusing for them. 

One slipup could lead to a loss of income which some of these residents are on fixed 

income. 

They don't have the money to lose which makes our service coordinator all the more 

important. 

As I think about it, even in small counties where you really don't have those access points 

to say I can just go to point a to get the particular financial assistance or if I need a ride to 

the store or to visit a husband I will sign the household - having that service coordination 

can get a person into that kind of -they make a house a home for a senior in a sense. 

It has been a great source for me in my career. 

Going forward -I will also be able to answer any questions in regard to the property 

management piece. 

Thank you. 

>> Thank you, Calvin, for sharing that. 

Any questions please put them in chat. 

Calvin will be with us through the rest of the session. 

I would like to turn it over to Justin. 

He'll talk about the work being done in the area of office aging of Northwest Ohio. 

>> Thank you Duana. 

Before I jump in, I see that Julianna put a question in the chat for Joe. 

I will read that aloud. 
Service Coordination Models and Sustainability | Transcript 7

Joe mentioned developers using a basis boosting tax credit. 

>> I answered that in the chat. 

The development fees are quite generous. 

In Ohio the maximum fee is about $1.7 million for an average project size of about 50 units. 

The sharing of that fee for service coordination enhances the project viability and 

sustainability seems appropriate. 

>> Thank you, Joe. 

Looking at where organizations that individuals are here already making varying levels of 

knowledge and experience with housing and affordable housing development for older 

adults in particular. 

I don't want to assume knowledge. 

I know I am learning a lot and affordable housing about myself. 

Sometimes having a bit of background information is helpful. 

There are four main roles with housing development. 

We can quickly outline those to make sure everyone is understanding those potential roles 

reorganization of housing. 

As a development partner you can get a portion of those development fees and play an 

active role with the development process of affordable housing. 

The second is as a potential owner or partial owner. 

The third is with management. 

The fourth rule is housing service coordination which we are taking a deep dive here today. 

In terms of this question of how we are leaving in case management to service 

coordination. At the risk of oversimplifying, I have heard the role of the housing manager as 

getting the individual to move into the apartment where there is a vacancy in place in the 

housing service coordinator's role is helping them stay there. 

Hoping that resident ages in place where they are. 

That's a big focus of our care management. 

A risk oversimplifying it. 

We focus our case managers attention on helping individuals feel like they are not 

prematurely getting forced into a nursing home. 

We realize there's a time and place for a nursing home. 

We want people to file their prematurity having to go into a nursing home if they want to 

remain in their own home and it is safe for them to do so and get the same services brought 

into their own home to help them age in place. 

Similarly, we want to make sure that people are not unnecessarily being admitted to the 

hospital. 

That's one of the reasons why working with health plans, CR rolling helping with bathing 

and dressing. 

Getting home delivered meals etc. They see how our case management can help individuals 

in the healthcare field and avoid any unnecessary admissions to the hospital. 

Avoiding going to the nursing home. 

In many ways the case management works with service coordination. 

It's an extension of the coordination or agencies are providing. 

Those case managers who pre-COVID might have done a home visit once per month the 

individual or maybe once per quarter depending on needs, what is even better than that is 
Service Coordination Models and Sustainability | Transcript 8

having somebody that has daily eyes and ears on that. 

For example, the individual that we are providing case management services for has 

congestive heart failure. 

Having that coordinator be under the same roof as the individuals day in and day out to 

keep an eye out on things like today have some unexplained swelling? 

Maybe they had too much sodium? 

That way the case manager can do a necessary intervention. 

To prevent an unnecessary escalation and in this case management and service 

coordination work hand in glove with each other. 

Service coordination is an extension of the care manager role but tends to be a licensed 

social worker or registered nurse with or agencies. 

The health plans again realize the role we are uniquely positioned to be able to play 

providing case management and service coordination as an extension of that case 

management. 

In terms of how the model can be improved in the future, with future housing development 

were having conversations internally with our different care management programs. 

We have basically different flavors of case management. 

One that is done with the Ohio Department of aging, Medicaid, 

Each of those has a different approach to case management want us to take. 

I think there is a real opportunity for example, Senior apartment complex is let's say but 

with 100 individuals in it. 

It's a 13 of those individuals are working with the health plan managed plan A. Another 10

or with healthcare plan B and five with health plan C. 

There is an opportunity for us to have the individual that knows residents and members call, 

or the medical transportation, instead of that being someone that they are calling out our 

corporate office, there is an opportunity for us to combine that service coordination role and 

have the individual be under the same roof as the individual resident who has those kinds of 

needs. 

It would be responsive and however today to build the relationship. 

Put a face with the resident and vice versa. 

I think that is an opportunity for improving the model. 

The future is looking at ways we can combine some of those activities historically have been 

telephonically and -- we are working to meet the growing needs of aging adults. 

Our CEO has been a leader nationally in developing affordable senior housing. 

It started off 35 years ago in a rural communities. 

We partner with the management company to handle the management aspect of those 

facilities. 

We help directly with our role as a direct service provider of services like case management 

wishes are core service or when put on there as a funder and working with several 

organizations, medical transportation providers, etc. We are serving 36,000 individuals per 

year.

We are able to offer is a menu of services that is a little or cost to the individual but have 

value to the residents living in these facilities. 

The value is in the form of giving them the necessary support to help set them up for 

success and aging in place where they want to be in their own home. 

Evidence-based health and wellness workshops like diabetes self-management program, 

both women who ask that service coordination that I mentioned and many other services 

and programs. 
Service Coordination Models and Sustainability | Transcript 9

We really think that service coordination has tremendous value and allows us to take a 

deeper dive into having more touch points with individuals that we are serving. 

Having a more meaningful relationship with them we are able to get who they should call 

when they need help. 

That provides tremendous peace of mind individuals who are residing in the senior 

apartment complex is to know that if they need something they know who the person is to 

contact. 

That person is someone they can trust, and they built up a rapport with the individual over 

the years. 

They are able to get a timely response to their needs. 

We view this as a great opportunity for us to be able to do more in this area of housing. 

The vast majority of healthcare we can help them make healthy choices and access services 

that are beneficial to them. 

That's helping further our agency's mission it's an opportunity for us to get some increased 

revenue as well as flexible revenue that we can reinvest in services in rooms we mentioned 

earlier. 

The vast majority of people who live long as they can in their homes. 

As long as it is safe. 

The services are critical way of us setting those individuals up for success in meeting their 

outcomes being their own home as far as possible. 

Avoiding unnecessary hospitalizations. 

We owe the last 35 years of developed of helping individuals to do this. 

>> John Sorensen asked this question and underscores your use of the word options. 

We want to know if this is mandatory with the housing. 

It's independent living and not set up as an assisted living model or controlled model. 

>> Absolutely. 

This is an invitation if you will. 

The day of moving they know what is available to them if they choose to pursue any of 

those. 

It's a real easy access for them to pursue any of those options. 

We are not in a position to force-feed anybody. 

This is a menu of services and programs available. 

It's not a complicated process to navigate accessing those. 

It's a matter of stopping by the office there in the housing facility or picking up the phone 

and calling the individual who is there on a daily basis. 

>> I think Calvin made this point as well. 

The service coordinator is there is much for the residents as for the management company. 

We recently had an instance where the individual is going to be evicted based upon the 

manner in which they maintained their unit. 

There were health and safety issues that were exiting beyond their four walls. 

The management company needed to do what they had to do but then could refer the 

individual to the service coordinator who could then help the resident overcome whatever 

the barriers were to keeping his unit in the way it needed to be maintained. 
Service Coordination Models and Sustainability | Transcript 10

Lo and behold we were able to the service coordinator to reduce the risk of homelessness. 

I think the value proposition is not just for the resident but as others alluded to it was for 

the management company as well. 

>> It helps as one third party. 

Having a discussion on a disciplinary side is one thing. 

We have to come and see the principal and then you are the bad guy that told Ms. Jones 

that she can have all this stuff. 

Any of those particular instances. 

You have one third party it eases it. 

It creates an atmosphere where this person has your back is supposed to they are bad 

principal. 

They work with him in the situations. 

I joke when I see residents and tell them as younger man, I need them to keep the services 

around when I get old. 

Seniors get all the stuff. 

I need that. 

>> With any position nowadays, there is inevitable turnover that exists. 

It is also true with the property management rule. 

What we have seen especially property managers that often times are splitting their fulltime hours across multiple buildings, there's something to be said for having service 

coordinator as that consistent person that is there to cover some of those gaps when there 

is that turnover with the property manager. 

I know sometimes the quickest way to double the size of a problem is to turn your back on 

it or for it to be neglected. 

If a resident has an issue that is a small puddle in the shoe annoying issue there is no 

property manager to help talk about the issue, sometimes it provides peace of mind and 

goes a long way toward improving resident satisfaction. 

>> Also, as mentioned early on in the presentation that it is important to Justin's point in 

the service coordinator is a knowledgeable individual. 

That knows what is going on in the community and property managers need to deal with all 

the rules and regulations of leasing and maintaining buildings. 

The service coordinator knows the latest and greatest and where funds are available. 

Keeping the service coordinators, CHW's informed of what's happening in the community is 

really important. 

Before we go to Q&A I did also want to mention a couple of things that we as an 

organization to make sure that our service coordinators have the latest and greatest and 

have access to resources. 

We rely on them. 

There are great resources out there from a national perspective that can help provide best 

practices and insight and access to national resources as well. 

With that, I think next slide. 

It is everybody else's turn. 
Service Coordination Models and Sustainability | Transcript 11

We are looking forward to your questions and comments. 

>> This is Alicia. 

I'm saying that we have some huge players in the space in the chat. 

I won't call them out, but it would be good if we could hear from them. 

>> I agree. 

>> While we wait, quick question. 

If someone asked the question you can bypass my question. 

Continue to say it's more than bricks and mortar and he repeated that several times. 

I have a question for you, and I think Justin can contribute as well. 

Looking at where did you start developing your reports knowledge and interest in housing 

issues in you can talk about that process would be great. 

>> We talked about service coordination and our conversation started realized that we 

could do more than service coordination. 

We were able to really play in the space of development because it became more than just 

providing services and support. 

Over the last few years, it's been where are these people going to live? 

We began having conversations from the perspective of what are the pain points in their 

respective communities and where do we already have variance and knowledge and how 

can we do more? 

>> I have been learning the hard way at times with the Board of Education process. 

Part of this is our CEO 35 years ago abilities Senior complex departments. 

We continue to own those properties and make enhancements to them. 

We are removed from the day-to-day operations because the contract out the management 

of those properties. 

A lot of our new report members really had not much in the way of training or education on 

this affordable housing development. 

As our agency now is hitting back into the affordable housing development area there is a 

need to train board members and new on this whole topic. 

Get a feel of how engaged they want to be in the process and how deep dive they want to 

get an education. 

We have had a few weeks or months ago for an information session on this housing topic. 

We brought in different speakers that are experts in this area did to help with the education 

process. 

That went a long way toward increasing the comfort level that her agency is getting back 

into a more active role with affordable housing development. 

I see also that Laurie asked a question about where the funding stream sources that can 

support service coordination is something we plan on pursuing as well. 

Just to be really concrete about it with the tax credit applications in the past many times we 

had developers knock on our door as an afterthought right before they click the submit 
Service Coordination Models and Sustainability | Transcript 12

button for the tax credit applications to say we sign this letter of support for affordable 

housing. 

We would sign off on it and they would say thank you very much. 

They would get the tax credits and we would never hear from them again. 

That makes our expectations clear about our desire if they do get tax credits if they bill that 

we want to be a service partner and we want to specify in there a good faith effort will be 

made by both parties to enter into a service agreement where they are paying us a certain 

dollar amount for us to provide our employee is a service coordinator on-site in their facility. 

With the Medicaid to be specific about the, right now there is that case manager role that 

our funding in our agency. 

The individual doing the home visit once per month or once per quarter. 

There's also a second role of the case manager assistant who is that person that individuals 

call if they need a home health aide replacement. 

Those contracts are also finding that position. 

>> Just yesterday we submitted along with an area agency proposal to the city of Toledo 

for two products totaling 178 units that a senior housing the service coordination. 

In that is built-in thousand dollars per unit year of service coordination fee index 3.5 

percent to cover inflation over a 15-year period. 

Between those two products is the dedication derived internally from the project economics 

itself. 

I will add another variation on this, something that Duana has done without tax credits and 

investor she simply competed for local funding home funds for small projects which lowered 

the amount of financing required. 

Produces a surplus and can recycle those income dollars back into her service coordination. 

That's a model available in any small community in the country because of the ARP funds 

being distributed for that purpose. 

>> With a high specific there's also some senior community services line-item funding that 

can be used for this purpose. 

There's a possibility of older Americans act in Ohio there's lots of County Senior services 

levy funds. 

That's another possible use for some of the service coordination activities. 

A lot depends on the geographic area and what options might exist. 

There are a variety of different funding sources that could be used for this purpose. 

>> I noticed also in the chat here Julia had a question indicating they had been alarmed by 

the amount of HUD and service coordinators. 

It's definitely underfunded. 

I'm looking forward to seeing what will happen in the future because we see an uptick 

during COVID and the need for our service coordinator is to be present and available for 

individuals. 

We are not just navigating normal day-to-day stuff but now COVID and pandemic and all 

the things that came there. 

I'm anxious to see what advocates can do in the future to advocate for policy change, 

funding changes that increase the importance of service coordination and therefore 
Service Coordination Models and Sustainability | Transcript 13

hopefully in turn there is funding that will support the important role that service 

coordinators play. 

She asked specifically are you working with the HUD team to increase investments in this 

area. 

I'm not aware of anything formally, I will look to my peers here and people out there if you 

are aware of anything please share that. 

Raise your hand or include something in the chat. 

Maybe we need to do a little homework. 

>> I am spoiled at having service coordination at all of my sites throughout my career. 

I can't imagine not having them. 

Should be more widespread. 

The seniors have more one-on-one interaction. 

There need to have somebody in the corner, especially as they get older, the younger spry 

seniors will push you out of the way. 

They don't need to talk to you. 

As you get up in age and 80 or 90 years old, we have residents that are 96 or 98 or 99 

years old. 

Every day is valuable to them. 

The older they get the more help that they need. 

It has to be more than just us. 

We play service coordinator. 

We like to dress up and say we have all the resources and everything else. 

We don't know it all. 

You guys have the latest and greatest. 

There are a lot of residents. 

Even new building construction they have -they deserve access to these programs as well. 

>> One thing I want to put in is that HUD is a partner with HHS, and we will forward this 

question to HUD and provide you with a written response. 

We don't want to speak for HUD because we know this is a HUD program and we want you 

to know that we expect to pass that forward. 

You can expect to see it on a website. 

>> I also see a question here from Patty. 

Can you comment on how you think the new HUD appraisal guidance clarify the criteria for 

services as being part of the fair market rent would impact the ability to put together 

financing for complexes that provide enhanced service? 

>> I can respond to the question. 

The service component that is part of the operating budget affects the appraisal. 

However, all of this housing and market studies and research is based on independent 

living. 

Service coordination is actually added to. 

The housing itself is its own evaluation. 
Service Coordination Models and Sustainability | Transcript 14

By separating those two service coordination is on. 

The underwriting for the HUD financing. 

>> Jody thank you for your patience, Jodi's question was, is the CHW the only certification 

for service coordinators? 

I would have to say no. 

Referring to the American Association of service coordinators is a great place to start if 

you're not familiar with CO RES that is a certification for organization that does 

development or provide service coordination as a part of development. 

I also know there is a Marriott of training. 

If you look at some of those resources, there are certifications that are available and that 

also depends on what your service coordinator is doing. 

I know some of our coordinators who are in our ADR and are AIRS certified. 

There is a myriad of certifications. 

I would say CHW is not the only opportunity. 

The CHW is the pathway that gets them into getting reimbursement from the MCO's. 

>> I saw question from John Ballard who is worth the center of independent living asking if 

the developers seek out most or if we recruit them or investors? 

Show you may want to weigh in on the investor part of it. 

From the development standpoint think it depends on where you are at with your 

involvement with housing. 

The more you make it known in the community that you are actively engaged with this 

whole affordable housing development space think the more likely you are to get those 

knocks on the door from developers and have them reach out to you in some other way. 

If you are newer in the space, I think need to be more active in reaching out to some of the 

developers in your area about your interest in being a service partner or being a 

development partner or being involved with having an ownership stake. 

I don't know if you have anything to add onto that? 

>> Both of your organizations have done a really good job of what I would call soft 

marketing. 

It's very low-cost marketing announcing to the communities in which you are serving that 

you are quite interested in the issue of housing and how to support it. 

That alone generates interest from parties that might come to the city and ask for help or 

seek direction to find affordable housing opportunity. 

Developers will find their way to your door. 

The other part of this, people asking for the MOU at the late date. 

My suggestion is to prepare for the with a yes and response. 

Always say yes you are happy to do it, and these are the circumstances under which you 

can do it. 

The front, have a plan for that which is that service coordination? 

Were the standards he set? 

No Duana did a great job of laying out the standards in a concrete proposal. 

It has a dollar amount attached to it has to be a long-term contract so there is no fluff in it 

from the standpoint of being asked to participate in ignored later. 
Service Coordination Models and Sustainability | Transcript 15

Those things when you are prepared to respond in the soft marketing by announcing to the 

communities your vital interest in housing and supportive services and seeing what 

happens. 

>> We have a question from Melissa Harris. 

The service coordinators in the Pathways HUB model working in HUD funded properties? 

Without taking it too deep of a dive into the HUB model and how that works basically the 

answer is they don't have to be. 

Our service coordinators actually will take referrals from her HUB pathway regardless of 

where the individual lives. 

The bonus is if the individual lives in a facility where we are doing service coordination with 

a certified community health worker. 

They are conducting a pathway for an individual who is with an MCO member tied to the 

HUB we get reimbursement. 

The great thing about being contracted with the HUB is they may call us and say we have 

got a member who is in need of housing or is in need of transportation. 

We would like to refer them to complete that pathway. 

It becomes another referral source. 

If our community health worker has the capacity to take that referral they will. 

That's where I was indicating that the CHW certification does not have to be tied to service 

coordination. 

It can be tied to anybody in the organization who has the skill set and ability to do those 

pathways. 

That's what we do in community-based organizations. 

We take referrals and we help people identify what all their needs are and help them get to 

the result of meeting that need. 

That is a pathway. 

If we can get paid to do that, we want to get paid to do that. 

We will take any referral from the HUB and work to complete that pathway and get paid 

when we do. 

I hope that answers your question. 

>> We have three more minutes to go. 

I think we can probably get to one last question. 

This can be directed to Calvin, Duana or Justin. 

What are ways property management can work with service coordination programs? 

>> Do you have any closing remarks before I wrap this up? 

>> On behalf of all of us and everybody here on this call and in the session thank you so 

much for your interest in the topic. 

We are always here if you have questions. 

>> Thank you. 

I consider you guys rock stars. 
Service Coordination Models and Sustainability | Transcript 16

You bring so much rich information and your willingness to share is powerful. 

Just a plug for what's coming up next, cross sector partnerships to expand options for 

housing. 

Thursday, February 10 from three-4 PM. 

That will be the last of the three office hours we planned in the series. 

If you have not registered, please do so. 

We will put the link in the chat. 

If there was something that you would like to see as we move forward, please email us. 

If you have questions, please email us and let us know what you need to support your work. 

We are here to move you forward. 

Thank you for joining us. 

We look forward to connecting with you again in February. 

Thank you.