8
street roots
July 19, 2013
Add it up
Health Share looks at ways to merge
health care and afforable housing
BY AM A N D A WALDROUPE
S T A F F W R IT E R
here’s a lot of money — and lives —
resting on Oregon’s grand experiment
in restructuring health care through
Medicaid. Portland metropolitan area’s
largest coordinated care organization,
Health Share of Oregon, like others across
the state, have a mandate to serve more,
serve better, and do so with less.
With that on their plate, social-service
agencies and advocates are hoping to
compel Health Share’s board of directors to
include in its programs and health services
something that has rarely been part of
conversations about health care: affordable
housing
Ed Blackburn, the executive director of
the social-service agency Central City
Concern, is spearheading the effort. He and
other housing providers and advocates are
making the case that a person’s housing
status can drastically affect a person’s ability
to lead and maintain a healthy life.
“It’s not the job of jurisdictions to
transform health care. It’s not the job of
health care to end homelessness,”
Blackburn says. “When there’s an
intersection of common goals, they can be
more successful by coordinating.”
The opportunities go both ways.
“I’m hopeful that health care becomes a
more prominent element of housing,” says
John Miller, executive director of the
Oregon Opportunity Network, a coalition of
affordable housing advocates, builders and
managers. “There’s a lot more efficient ways
we could be working together.”
Coordinated care organizations, or CCOs,
are the backbone of the state’s newly
overhauled Medicaid delivery system under
the Oregon Health Plan.
Created by the Legislature in the 2011
session, CCOs are charged with coordinating
and integrating the physical, mental and
dental health of Oregon Health Plan
patients. The coordinated model of care is
meant to create a patient-focused system
that efficiently provides more effective and
streamlined health care, but also save
money and stop Medicaid expenses from
rising. Instead of a fee for service structure,
CCOs will have to operate with a capped
budget that they can control — provided they
cut costs.
Health Share of Oregon is one of the two
CCOs serving the Portland metropolitan
area, but it is by far the largest. It comprises
a partnership among 11 health organizations
— including Legacy, Kaiser and Providence
hospitals, Central City Concern, and the
health departments of Clackamas,
Multnomah and Washington counties.
Because of its mandate to cut costs,
Health Share has prioritized a group of
Medicaid patients known as “high utilizers,”
including people who are homeless or
impoverished, have chronic diseases such as
diabetes that go unmanaged, who suffer
from mental health or addictions issues, or
have a high-risk pregnancy and pre-natal
issues.
While such patients represent only about
20 percent of the Medicaid population, they
are most likely to delay primary care, not
prevent their illnesses or conditions from
worsening, use the emergency room as their
primary source of medical care and only use
it when circumstances are dire.
“These populations are very expensive,”
T
Blackburn says. “If you could
\'
address their issues more
' '
effectively, you could save
some money.”
When Blackburn
was asked to
become a
member of
Health Share
of Oregon’s
board of directors, he knew from
experience what was at stake.
Central City Concern is one of
Portland’s largest social-service agencies,
and the organization’s reputation is built
on the strength of its wraparound
services for formerly homeless
individuals: substance abuse treatment,
peer counseling, case management, and
its Old Town Clinic, which provides
primary physical and mental health care
time of day (or at all), eating regularly and
to low-income people.
other tasks regarded as routine become
In 2005, Central City Concern began
difficult. Health problems become
partnering with area hospitals and created
exacerbated and go untreated.
its Recuperative Care Program, which
Before CCOs were created, Oregon
houses low-income and homeless individuals
Health Plan providers were paid by a “fee-
after they’ve been discharged from the
for-service” billing system. There was little
hospital. People in the program also
incentive to emphasize preventive or
continue receiving medical care and are
coordinated care, and like the rest of the
connected with services to help them stay
health care industry, patient interaction was
in housing.
strictly medical.
On average, the program saves
“The way the system is set up is that the
approximately $80,000 per year, per patient
interaction is someone coming into their
in reduced hospitalizations, emergency
office,” Miller says. “They see the part of
room visits, and medical costs. It’s a
someone waiting in their waiting room or
startling amount of money, and Blackburn
office with a particular [medical] need.”
and others say the savings are due to one
All CCOs in Oregon were granted a
simple reason: ensuring those unhealthy
waiver from the federal Medicare and
homeless or low-income individuals are
Medicaid
stably housed.
administrators that
“For these
allow them to use
populations, housing
their budgets more
is critical,” Blackburn H ealth Share of © re f oa
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Blackburn created
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workgroup’s purpose
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illustrated the
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effective health care.
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It’s not clear if
people become
healthy and remain
short-term rent
assistance would qualify under the waiver.
housed.
“There is a limit to what Medicaid can pay
The workgroup met for nine months and
for and what CCOs can do,” Blackburn says.
presented information to Health Share’s
But New York has received such an
board of directors on June 19. In the coming
exception. In 2012, the state received a
months, the workgroup will develop a list of
waiver from federal Medicaid and Medicare
recommended programs and services that
administrators that allowed the state to
Health Share could then begin operating.
direct $86 million of its Medicaid budget
As Traci Manning, the director of
directly toward funding supportive housing
Portland’s Housing Bureau puts it, “If you’re
programs. The state also applied for another
homeless, getting health care is almost
waiver that would generate $150 million
impossible.”
each year that would be used for expanding
People with diabetes, for instance, need
to refrigerate their insulin. That’s difficult, if the availability of supportive housing.
“There is strong and growing evidence in
not impossible, for homeless people to
New York and around the country that a
manage. Because of the stress, mobility and
lack of any regularity in their daily lives,
lack of stable housing results in unnecessary
remembering and getting to medical
Medicaid spending,” the state’s Medicaid
appointments, taking medication at the right Redesign Team wrote in a report.
Closer to home, Health Share of Oregon
received a three-year, $17.3 million grant
from the national Center for Medicare and
Medicaid Innovation (CMMI), which funds
projects designed to provide more effective
health care. Approximately $100,000 is
being used for short-term rent subsidies and
other services that help people remain
stably housed.
Cindy Becker, director of Clackamas
County’s Health, Housing and Human
Services and a Health Share board member
says that the increasing awareness Health
Share has of the connections between a
person’s housing and ability to be healthy is
also an example of how Health Share is
moving toward a model of healthcare that is
not focused exclusively on medical care and
doctor visits.
“We’re still in that education period,” she
says. “People are beginning to understand
that your health is not determined by your
visit to a doctor’s office, but also by whether
you have a place to live? Do you have
healthy behaviors? Are you isolated? Those
things contribute more to your health than
the time you spend in a doctor’s office.”
Blackburn also points out that people
with multiple health needs may have been
seeing a doctor, but not all of their health
problems were being addressed. He gives
the example of someone who has anxiety
and asthma. An anxiety attack can trigger
asthma. If the person is receiving mental
health treatment for anxiety, their therapist
or doctor may not know they have asthma -
a physical health condition — and may not
think to ask.
As part of the workgroup’s work, Health
Share staff conducted a survey at three
properties - the Martha Washington,
Musolf Manor and the apartments above the
Bud Clark Commons.
Between January and March, 171 out of
332 tenants were interviewed. The survey
identified tenants health conditions and
illnesses, identified how many medications
they took and what they are for, the last
time they had seen a doctor, and how often
they use the health care system. The survey
also asked how their life generally had
changed since moving into housing and
specifically if their health had improved.
Sandra Clark, a program manager with
Health Share who worked directly with the
affordable housing workgroup, says the data
is still being analyzed. But she says she
See HEALTH CARE page 9
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