SAFE LANDING HOUSING PROGRAM EVALUATION€¦ · SAFE LANDING HOUSING PROGRAM EVALUATION ... know-how, partners, policy leadership and investments to multiply the impact of local affordable

SAFE LANDING HOUSING PROGRAM EVALUATION

ENTERPRISE COMMUNITY PARTNERS

Evaluation of a two-year pilot designed to illustrate how shallow rental assistance can lessenthe risk of a family losing their home in the face of a short-term health issue.


GENEROUSLY FUNDED BY AND PRESENTED TO: Collins Foundation, FamilyCare, Meyer Memorial Trust, and Providence Health

PRESENTED BY: Enterprise Community Partners, Inc.

DATE PREPARED: October 1, 2018



ABOUT ENTERPRISE COMMUNITY PARTNERSEnterprise is a proven and powerful nonprofit that improves communities and people’s lives by making well-designed homes affordable. We bring together the nationwide know-how, partners, policy leadership and investments to multiply the impact of local affordable housing development. Over 35 years, Enterprise has created nearly 470,000 homes, invested $28.9 billion and touched millions of lives.

This report represents a joint effort between the National Health and Housing Initiative and the Knowledge, Impact and Strategy team at Enterprise Community Partners. Thanks to the many partners who made the Safe Landing Housing Program possible, and to Fran Weick and Holly Vander Schaaf at Human Solutions who provided background interviews and the initial data analysis for the report. In addition, thanks to the Enterprise staff who contributed to this report, including Mary Ayala, Bethany Boland and Stephany De Scisciolo. And a very special thanks to our former Enterprise colleague, Amanda Saul, for leading Enterprise’s involvement from initial idea to pilot implementation.

Designed by Aaron Geis.

Join us at www.EnterpriseCommunity.org

© 2018, Enterprise Community Partners, Inc. Permission is granted to copy and distribute this document under the CC BY-ND license with EXCEPTIONS listed in the Terms of Use on our website, www.EnterpriseCommunity.org.



INTRODUCTION: HEALTH THROUGH HOUSING

Quality, stable, affordable housing is a key driver in maintaining good physical and mental health. The impacts of housing on health are well documented, and include improved chronic disease management, mental health, and children’s health along with reductions in the prevalence of infectious disease, asthma, injuries, exposure to toxins, and drug and substance use.1 Additionally, the affordability of housing is directly connected to the availability of household resources for use on other health-promoting needs, including preventive healthcare, prescriptions, and healthy food.

Too often a health crisis can have a devastating effect on household income, which can jeopardize the ability of a family to maintain their housing because of high medical expenses or an inability to work. With the lack of adequate social safety nets, family supports, and healthcare coverage in the United States, even a short-term health issue can create significant challenges for low-income families and put them on the brink of homelessness. In a 2016 study on the financial capability of families in the U.S., two-thirds of respondents indicated that they would not be able to come up with $2,000 if an unexpected need arose.2 Women, younger respondents, those with lower income and education levels, and African-American and Hispanic respondents are more likely to have difficulty handling a short-term unexpected expense.

Thus, for low-income families, a health crisis can easily lead to

homelessness.3 The implications of homelessness are vast and severe, particularly on children, and often result in school changes that can lead to learning disadvantages and lower levels of engagement, an increase in stress and the risk of food insecurity, and toxic tradeoffs between healthcare and other necessities.4 Studies have shown that a single experience of homelessness can cost $10,000 to $150,000 per person, per year depending on the level of services the person receives.5 Medical services represent the largest share of these costs. For example, in Washington County, Oregon, seven out of every ten dollars in services for homeless persons is made up of medical costs.6 Given these societal costs, as well as the long-term adverse effects of homelessness, healthcare payers and providers are looking at innovative ways to provide short-term supports for those at risk of losing their homes due to a health crisis.

THE SAFE LANDING HOUSING PROGRAMLike many states in the U.S., Oregon has been grappling with a dual crisis: rising healthcare costs and a growing number of individuals and families lacking stable, affordable housing as rents rise across the country. Oregon is unique, however, in how it has chosen to combat increased healthcare costs. Sixteen Coordinated Care Organizations (CCOs) now operate across the state. These umbrella networks are made up of diverse healthcare providers who have agreed to work together in their local communities to serve people who receive healthcare coverage under Oregon’s Medicaid health plans.

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1 Maqbool, Nabihah; Viveiros, Janet; Ault, Mindy. The Impacts of Affordable Housing on Health: A Research Summary. Insights from Center for Housing Policy. April 2015. URL: https://www.rupco.org/wp-content/uploads/pdfs/The- Impacts-of-Affordable-Housing-on-Health-CenterforHousingPolicy-Maqbool.etal.pdf

2 FINRA Investor Education Foundation. Financial Capability in the United States 2016. July 2016. URL: http://www.usfinancialcapability.org/downloads/NFCS_2015_Report_Natl_Findings.pdf

3 O’Flaherty B. What shocks precipitate homelessness? New York: Department of Economics, Columbia University; 2009. (Discussion Paper No. 0809–14)

4 U.S. Interagency Council on Homelessness. “Ending Family Homelessness, Improving Outcomes for Children.” July 2016. URL: https://www.usich.gov/resources/uploads/asset_library/Impact_of_Family_Homelessness_on_ Children_2016.pdf

5 Portland State University. “An Analysis of Homelessness & Affordable Housing Multnomah County.” 2018. URL: https://pamplinmedia.com/documents/artdocs/00003616728975-0644.pdf

6 Portland State University. “A Study of Emergency Service Provider Costs for Chronically Homeless Persons in Washington County, Oregon.” January 2013. URL: https://pdxscholar.library.pdx.edu/cgi/viewcontent. cgi?article=1017&context=nerc_pub



Oregon’s 1115 Medicaid waiver allows these CCOs to use Medicaid dollars to pay for non-medical services, which may include housing supports and services. This set of services is known as flexible services and the dollars associated with these flexible services will be referred to as flexible funds in this report.7 In 2016, a group of community stakeholders, including Enterprise Community Partners (Enterprise) and other members of the Oregon Health and Housing Learning Collaborative, were interested in learning the impact of short-term rental assistance, as a potential flexible fund use, on health outcomes and medical expenses. A two-year pilot, known as the Safe Landing Housing Program, was launched in 2016 to illustrate how shallow rental assistance (less than $500 per month) and other services can lessen the risk of a family losing their home in the face of a short-term health issue. The pilot was also designed to develop a scalable model for the use of flexible funds in this way.

The pilot program targeted Multnomah County transition age youth (age 15–25) and their families experiencing a housing and health crisis due to physical or mental health challenges. Rental assistance

was available for up to 12 months and funds were provided through private grants and the flexible funds of one Oregon Medicaid health plan, FamilyCare Health (FamilyCare).

This report will detail the multi-partner process that was developed to identify participants in need of this assistance and to deploy the funds, the results of the data collected, the challenges that arose in developing and executing a flexible funds model, and the lessons learned to assist the development of future models that unite the health and housing sectors to provide additional supports to families in need.

The success of the Safe Landing Housing Program in terms of promoting housing stability among the program participants suggests a need for policy changes that would allow states more flexibility in using their Medicaid dollars to enable recipients and their families to better cope with the tangential effects of a health crisis. The relatively small amounts of money spent on shallow rental assistance are more than offset by the benefits of averting even one case of homelessness.

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7 Oregon Housing Authority. Oregon CCO Housing Supports: Survey Report. September 2016. URL: https://www.oregon.gov/oha/HPA/HP/docs/OHA%208440%20CCO-Housing-Survey-Report.pdf



METHODS

At the outset of the pilot, very few CCOs were using Medicaid flexible funds to cover any sort of housing supports, including short-term rental assistance. Without other models to work from, one of the first steps taken by the program partners was to define the roles and responsibilities of each organization and develop the model for delivering short-term rental assistance as a form of flexible services. The model included the creation of participant selection criteria, a screening tool for clinicians and service providers to identify participants, a service delivery model, a tracking methodology, and an evaluation tool to demonstrate cost savings and health outcomes.

PARTNERSSeveral community organizations comprised the partner group that oversaw the design and execution of this pilot, including Enterprise, Human Solutions, FamilyCare, Home Forward, Oregon Health Authority, and Providence Health & Services. Funders included FamilyCare, Meyer Memorial Trust, Providence Health, and Collins Foundation. Below is a description of the roles and responsibilities of each partner organization.

• Enterprise served as the group’s convener, ensuring that monthly meetings were held. Additionally, Enterprise led the grant funding process for the pilot; pursued policy changes, including proposed language for Oregon’s Section 1115 Medicaid waiver, to allow for additional housing supports to be covered by Medicaid; and produced this report that describes the results of the program.

• Human Solutions (1) developed the selection criteria in partnership with Enterprise and FamilyCare; (2) defined a pathway for identifying high-need participants experiencing a health issue with the potential to jeopardize their ability to stay housed; (3) developed a screening tool and a referral process; and (4) created the service delivery model.

Human Solutions also developed relationships with the referral clinics, including Kaiser Permanente’s Rockwood Medical Office, the Wallace Medical Concern, and the Rosewood Family Health Center. Once participants were referred to the program, Human Solutions coordinated a series

of intake documents, connected participants to a variety of services if needed, and collected health and housing surveys from participants. Human Solutions also compiled, performed initial analyses, and provided deidentified survey and participant data to Enterprise for further analysis.

• Project Access Now (PAN) managed all Safe Landing Housing Program grant funds. PAN tracked grant dollars from various funding sources and dispersed funds to landlords. PAN also tracked participant demographics and created reports.

• FamilyCare, one of Oregon’s Medicaid providers, led the development of outcome metrics and a methodology to track spending that would allow health outcomes and cost savings to be measured.8 As part of the participant recruitment, FamilyCare placed a program referral form on its website and alerted providers to the pilot and the process by which they could refer their patients. FamilyCare used flexible funds to provide rental assistance to its members who were enrolled in the pilot based on the agreed upon selection criteria.

Many of the outlined roles were new to the partners and required the development of untested systems of referral and payment to allow for the coordination of patient needs and program payments between traditional healthcare partners (FamilyCare, referral medical clinics) and housing-focused organizations (Human Solutions and landlords).

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8 After 30 years, FamilyCare’s Medicaid arm was discontinued at the end of 2017. Although all participating FamilyCare members were provided rental assistance prior to this discontinuation, the unexpected closure prevented the inclusion of any data that would have been derived from participant Medicaid claims.


ENTERPRISE COMMUNITY PARTNERSENTERPRISE COMMUNITY PARTNERS

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PILOT PARTICIPANT SELECTION CRITERIAHuman Solutions, Enterprise, and FamilyCare worked together to develop selection criteria for the participants. Th e partner organizations agreed that the program would off er short-term rental assistance to transition age youth or to households with a transition age youth present in Multnomah County, Oregon. Th e decision to center the pilot around transition age youth was made in response to FamilyCare’s interest in this demographic. Youth in this age bracket often do not access the healthcare system, and FamilyCare wanted to better connect with this population. Additionally, Oregon does not allow transition age youth in family shelters, so they often end up in alternative housing situations (e.g., friends’ houses, foster care, homeless).

The selection criteria considered the nature of the participant’s housing and health issue as described below.

• Health issue: Th e qualifying health issue had to include a medical condition, as defi ned by a medical professional (e.g., physician, nurse, community health worker, patient navigator), that was expected to be resolved or stabilized within a one-year timeframe. Th e partner organizations considered developing a list of conditions or circumstances; however, initial conversations revealed that the number of circumstances would be too vast and too varied to capture. Additionally, the partners had to consider the legality of specifying certain diseases given that Medicaid fl exible funds were going to be used. Th e selection criteria did not require that participants demonstrate how the health issue was going to impact their income and housing situation.

• Housing: Th e medical professional had to justify that stable housing would positively infl uence the participant’s health outcome for the qualifying health issue. Participants were not required to demonstrate that they were about to lose their housing because of their medical condition.

Th e Safe Landing Housing Program took place over two years. Enrollment into the program was open for one year and the duration of assistance was limited to one year. Th e length of time for which assistance was provided to a program participant was determined through conversations between the participant and their referring medical provider. Assistance was adjusted based on changes to participant circumstances—if the participant was able to return to work earlier than expected, the assistance period was reduced; if he or she was unable to return to work when expected, the assistance period was extended (no more than one year).




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1. HEALTH ISSUEProgram participants would be selected based on the existence of a health issue which would be positively infl uenced by stable housing (that was threatened by high medical expenses, inability to work, or other reasons).

2. REFERRAL TO PROGRAMTh e participant would then be connected to the program through a medical professional referral. Th e referrals were facilitated through the referral clinic partners and FamilyCare and Human Solutions.

4. CONNECTION TORENTAL ASSISTANCEOnce a participant was accepted into the Safe Landing Housing Program, there were two pathways for receiving rental assistance – one for FamilyCare members and one for uninsured participants or participants insured through another payer. FamilyCare members’ requests were sent to a FamilyCare service coordinator who recommended members for approval to the Medical Director who provided fi nal approval. All other participants’ requests were fulfi lled through private grant funding. For all participants, the rental assistance was paid directly to the landlord, and the participant was notifi ed via a letter at the beginning of their assistance. Landlord communication and rental assistance payment was managed by Project Access Now.

3. ELIGIBILITY REVIEWAND INTAKE

Based on the referral, Human Solutions would hold an eligibility appointment that included going through the program checklist, verifying the health and housing referral from the health professional, obtaining a Declaration of Housing need, collecting demographic and initial survey data, obtaining permission around confi dentiality of data and grievance, and collecting information on the participant’s landlord for payment processing.

5. RENTAL ASSISTANCE PROVIDEDRental assistance was then provided for the amount and length of time that was agreed upon at the time of intake. Th e maximum amount of assistance was $2,500; however, a few exceptions occurred during program implementation based on need.

In designing the program, the partner organizations developed a pathway for identifying participants in a medical setting, enrolling them into the program by a third party, and making payments directly to landlords to guarantee housing stability. Th e fl ow of the pilot program is illustrated below:

Safe Landing Housing Program Design



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DATA COLLECTION

HEALTH AND HOUSING SURVEYAs noted in the process outlined above, an initial health and housing survey, as well as a 3-month and 6-month follow-up survey, was administered or was attempted to be administered to every participant receiving assistance. Human Solutions developed the survey instrument which consisted of 27 questions with sections on the participants’ health, healthcare, housing, education, employment, and their children’s health and healthcare (if applicable). A copy of the survey is included in Appendix A.

The initial survey was administered verbally by a Human Solutions’ staff member at the time of program intake. Human Solutions staff then attempted to reach every participant by phone both 3 months and 6 months following their last rental assistance payment. It is important to note that the survey was administered to the person who attended the Human Solutions intake and eligibility review appointment and was not necessarily the household member experiencing the health issue.

Pilot participants were not required to complete the initial intake survey or either of the follow-up surveys.

MEDICAID OUTCOMES DATAIn the original program evaluation design, FamilyCare planned to provide Medicaid cost and utilization data on the participants enrolled in the pilot. Unfortunately, FamilyCare’s Medicaid arm was discontinued with little notice at the end of 2017. Although all participants were provided assistance by this time, Enterprise was unable to access the participant cost and utilization data for the evaluation. Alternative options for obtaining the Medicaid outcomes data were explored, including outreach to the Oregon Health Authority. However, after considering several options, participant privacy protections and other issues prevented this data from being collected or analyzed. Thus, we are unable to report results related to Medicaid costs and utilization.

INTERVIEWS WITH PARTNERSIn addition to analyzing responses to the health and housing surveys, Enterprise interviewed key staff members from Human Solutions after the pilot was complete to gather additional information on program implementation, data collection, and lessons learned.



RESULTS

SAFE LANDING HOUSING PROGRAM PARTICIPANTSIn total, 69 participants enrolled in the Safe Landing Housing Program between August 2016 and August 2017. On average, participants received a total of $2,028 in rental assistance over a three-month period.9 Th is result diff ers from the program design which was premised on the expectation that participants would need a smaller amount of assistance for a longer period of time.10

SUCCESS STORIES: TERRANCE Safe Landing provided rental assistance for fi ve months while Terrance recovered from surgery. He is no longer at risk for homelessness. Safe Landing was a perfect fi t for this case.

Participants were referred to the pilot program by a variety of partner organizations that used discretion in defi ning a “resolvable health crisis,” since a list of qualifying conditions or circumstances for the program was not created. As a result, participants, or a member of their household, experienced a wide range of health issues. Th e majority of participants (75 percent) who attended the rental assistance appointment and completed the health and housing surveys were also the household member experiencing the health issue. Th e remainder of participants reported that their child (21 percent) or their spouse (4 percent) was experiencing the health issue. Information presented in this report comes from the individual who attended the intake appointment and completed the health and housing surveys and does not necessarily refl ect the perspective of the individual experiencing the health issue.

Over 50 percent of verifi ed health issues were related to an injury or limited accessibility; nearly a quarter (22 percent) were related to a mental health condition; and the remaining health issues were related to pregnancy, cardiovascular disease, diabetes, cancer or respiratory health. Several participants were enrolled as a result of a health issue related to a chronic condition, such as diabetes or cancer; however, the medical provider indicated that a stable housing situation would positively infl uence the participant’s health outcome. Appendix B further details the specifi c health issue experienced by the participant or an individual in the participant’s household.

In addition to a wide range of health issues, participants also varied in terms of health insurance coverage. Nearly half (42 percent) of participants were FamilyCare members and the non-FamilyCare participants held either OHP Health Share, Open Card, CAWEM, commercial insurance coverage or were uninsured at enrollment.

Th e variety of referral sources and the discretion used to assess eligibility led to a varied participant group in the Safe Landing Housing Program. Exhibit 1 presents the characteristics of the pilot participants and their households.

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9 Rental assistance amounts ranged from $375 to $6,000 over a one- to ten-month duration.

10 The program design called for rental assistance of less than $500 per month for no more than 12 months.

Exhibit 1. Characteristics of participants and their households at program intake

79% 44% 68%84% 50%Had at Least One Child

Completed High School or

Equivalent

Had SomePost-Secondary

Education or Training

Employed Income of <$1,000 Per Month



The majority of participants were female (73 percent) and generally in their mid- to late-30s. Nearly half of participants were Black Non-Hispanic; one-third were White Non-Hispanic, and 10 percent were Hispanic/Latino. Over three-fourths (79 percent) of participants had dependent children and the remaining 21 percent of participants were transition age youth.

The pilot supported individuals with diverse educational backgrounds. At enrollment, most participants had a high school diploma or equivalency certificate. Nearly half (44 percent) had some post-secondary education or technical school training, and 10 percent had a 4-year college degree. In addition to educational attainment, 50 percent of participants were working when they enrolled in the pilot.

As expected given the pilot’s intent, Safe Landing participants had very low household incomes. Over two-thirds (68 percent) of participants reported monthly incomes of less than $1,000, and over a quarter (27 percent) reported incomes of less than $500 per month. These monthly income levels are significantly lower than the median household income of Multnomah County residents which was $57,449 annually in 2016.11

As noted above, prior research on financial capability of U.S. families found that women, those with lower incomes and education levels, as well as African-Americans and Hispanics, are particularly

vulnerable when faced with an unexpected short-term expense.12

The Safe Landing Housing Program successfully targeted rental assistance to households with these characteristics.

FINDINGS FROM THE HEALTH AND HOUSING SURVEYSThe feedback provided by participants through the health and housing survey yielded valuable insight into their experiences and perceptions during the pilot (see Exhibit 2). The initial survey was administered in-person during the rental assistance intake appointment. Of the 69 households that received rental assistance, 53 households (77 percent) completed the initial survey. Nearly all respondents to the initial survey were very concerned about their ability to pay for housing. Sixty-two percent of respondents described their overall health as poor or fair, although 26 percent of survey respondents reported that their child or spouse was experiencing the health issue.

A majority of respondents (81 percent) reported feeling highly anxious and unable to stop or control worrying, and over half (51 percent) were diagnosed with anxiety and 47 percent were diagnosed with depression at enrollment. Feelings of anxiety and depression have also been found in prior research among adults who worried about their housing costs as they are often forced to choose between healthcare and other needs.13 In fact, most (87 percent) noted that a health condition limited their ability to work.

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11 Oregon Demographic by Cubit. URL: https://www.oregon-demographics.com/multnomah-county-demographics

12 FINRA Investor Education Foundation. Financial Capability in the United States 2016. July 2016. URL: http://www.usfinancialcapability.org/downloads/NFCS_2015_Report_Natl_Findings.pdf

13 Liu, Y., et al. (2014). Relationships between housing and food insecurity, frequent mental distress, and insufficient sleep among adults in 12 US States, 2009. Preventing Chronic Disease. URL: https://www.ncbi.nlm.nih.gov/ pubmed/24625361

Exhibit 2. Participant-reported perceptions of health and housing

97% 81% 84%62% 87%Very Concerned

About Ability to Pay for Housing

Poor or Fair Overall Health

Unable to Stop or Control Worrying

Health ConditionLimits Ability to Work

Able to Access Needed Healthcare



Th e State of Oregon maintains a strong Medicaid program and expanded Medicaid eligibility under the Patient Protection and Aff ordable Care Act (ACA).14 Th is coverage contributed to a high level of healthcare access among participants with 84 percent of respondents reporting being able to access the healthcare they needed. In fact, pediatric healthcare access was reportedly universal for participants whose child experienced the health issue. While children had greater access to care, they received medical care at the same providers as their parents. In general, participants usually received medical care at a private doctor’s offi ce, a public clinic, or a service provider in their building.

To fi nd out whether participants experienced any changes in their health or housing status following the rental assistance, Human Solutions administered follow-up surveys at 3 months and 6 months after the last rental assistance payment. Of the 69 participants that received rental assistance, 36 participants (52 percent) completed both the initial survey and the 3-month follow-up survey. Only nine (13 percent) participants completed all three surveys – the initial survey, the 3-month follow-up survey, and the 6-month follow-up survey. Given this low response rate, the following section only discusses key fi ndings from respondents who completed both the initial and 3-month follow-up survey.

SUCCESS STORIES: TATYANA Safe Landing provided mortgage assistance to Tatyana’s family for two months. Th e main breadwinner could not work due to surgery. Th e assistance provided the bridge that they needed in order to keep their home. Th is was a perfect match for the Safe Landing Program. Th e family is thriving.

Th e 3-month follow-up survey contained the exact same series of questions as the initial survey. One set of questions in the survey asked respondents about their perceived health status. Th e results presented in Exhibit 3 suggest improvement in the participants’ overall health and mental health from intake. At intake, two-thirds of respondents reported fair or poor health compared to less than half at the 3-month follow-up. Respondents also reported feeling less anxious and depressed as illustrated in Exhibit 4. For each question on mental health, between 23 percent to 30 percent fewer participants reported feelings of worry, anxiety, and depression at the 3-month follow-up compared to the initial survey.

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14 Henry J Kaiser Family Foundation. “Medicaid Expansion Enrollment.” 2016. URL: https://www.kff.org/health-reform/state-indicator/medicaid-expansion-enrollment/

Exhibit 3. Respondents reported improved health

In general, how would you rate your overall health?

Excellent

Very Good

Good

Fair

Poor

27

34

78

149

108

Initial Survey 3-Month Survey



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29 16

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Another set of questions asked participants about their employment and housing status. Overall, there was no change in the employment status of participants, however, the number of participants reporting increased income nearly doubled between the initial survey and the 3-month follow-up. Additionally, Exhibit 5 suggests a decrease in participants’ limitations or inability to work as a result of physical, mental or emotional problems. At intake over 80 percent of respondents reported being limited in their ability to work due to physical, mental, or emotional problems compared to 55 percent at the 3-month follow-up. Importantly, responses revealed a 42 percent decrease in the number of participants very concerned about their ability to pay rent.

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Exhibit 4. Respondents reported improved mental health

During the past two weeks, about how often have you been bothered by the following?

Not being able to stop or control worrying

Feeling nervous, anxious, or on edge

Feeling down, depressed, or hopeless

Little interest or pleasure in doing things

3224

3021

2317

26


Exhibit 5. Respondents reported less medical limitations to employment

Does a physical, mental, or emotional problem now limit your ability to

work at a job or business?

Yes No


20



These results are indicative of the short-term nature of the health issues facing participating households—providing further support that low-income families may avert a housing crisis if they are able to access relatively small amounts of resources over a short period of time to assist them with the non-health-related impacts of a health crisis.

SUCCESS STORIES: ROMI Safe Landing provided Romi with rental assistance while she recovered from surgery. In addition, the Program provided her with information regarding no-cause evictions, helping Romi remain stably housed during her convalescence. ESTIMATED COST SAVINGSParticipants in the Safe Landing Housing Program were provided the stability of living in their home while their families addressed an acute health issue. Given the evidence base around health shocks precipitating homelessness, it is reasonable to assume that some of these families could have faced homelessness as a result of the financial and job limitations caused by their qualifying health issue.

If this program was not available and these families instead experienced homelessness, the public costs, such as emergency room visits and shelters, would far exceed the amount of rental assistance provided to participants.

For example, if half of pilot participants (34 families) had experienced homelessness, the costs to society in the first year would have been a minimum of $680,000.15 Much of the public spending associated with homelessness (70 percent) is driven by individuals and families accessing medical services and the remaining 30 percent represents the public costs of emergency shelters, mental health services, and law enforcement.16

Contrast these estimates with the total of $140,000 in rental assistance provided to all pilot participants and the savings ($540,00) are obvious.

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15 Note: The public cost of homelessness figure assumes a very conservative estimate of $10,000 per person, per year multiplied by 68 (34 two-person households). URL: https://pamplinmedia.com/documents/ artdocs/00003616728975-0644.pdf

16 Portland State University. “A Study of Emergency Service Provider Costs for Chronically Homeless Persons in Washington County, Oregon.” January 2013. URL: https://pdxscholar.library.pdx.edu/cgi/viewcontent. cgi?article=1017&context=nerc_pub



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LIMITATIONS

The shift toward improved physical and mental health and ability to work and pay rent among the Safe Landing Housing Program participants are important findings of this pilot. However, some participants continued to report fair and poor health, feelings of anxiety and depression, and an inability to work or pay rent due to a health condition at the 3-month follow-up. This could be a result of several limitations of the study, including:

• Survey respondents were not always the household member with the qualifying resolvable health issue. In future evaluations of such programs, survey results comparing health status should reflect the individual experiencing the qualifying health issue.

• While detailed information about the acute health issue was collected, no information on pre-existing co-morbidities (i.e., additional chronic conditions) amongst qualifying participants was provided for the evaluation. As a result, participant results may have been influenced by the effects of these conditions, causing them to report fair or poor health and feelings of anxiety and depression. Future evaluations of these types of programs should control for the existence of one or more chronic conditions (in addition to the qualifying resolvable health condition). The potential impact of a short-term intervention, such as shallow rental assistance, should also be considered within the context of an individual’s total care needs.

Additionally, health expenditure and outcomes data were not collected as part of this evaluation due to the unforeseen closure of FamilyCare’s Medicaid program. This limited our ability to assess the cost effectiveness of using flexible funds for rental assistance and

its impact on health outcomes. Research with clear cost and outcomes results will encourage the uptake of many housing or community-based solutions targeting improved health. Pilot projects, such as the Safe Landing Housing Program, are critical to building the evidence base necessary to convince policy makers and other stakeholders of the benefits of making upstream investments on both individual and population health outcomes and to scale innovative approaches, such as flexible Medicaid funds, that will allow vulnerable families to remain stably housed during a health crisis. Both sectors should look for future opportunities to work together to further define the health costs and outcomes associated with these types of pilot programs.

Lastly, more specific qualifying criteria may have strengthened the results. The qualifying criteria for the Safe Landing’s Housing Program was intentionally broad. Based on the partner interviews, much of the motivation around establishing broad criteria was to ensure that those in need would be able to access the resources available through the program. However, after launching the pilot it became clear that more specific criteria are necessary to ensure that the intervention offered will prove beneficial to the eligible household. Without more specific criteria, the variety of health and housing issues addressed led to confusion among medical professionals on who to refer into the program, slow adoption of the program by these professionals, and difficulty in evaluating the effectiveness of the program on improving health outcomes and housing stability.



LESSONS LEARNED

Increasingly partners from multiple sectors are working outside the clinical setting to address the complex issues that impact health and well-being. With the significant impact housing has on health, developing new models for health and housing partnerships is essential to this goal. The lessons learned from the Safe Landing Housing Program highlight the many challenges that arise in developing new pathways for referral and payment delivery between the historically disconnected systems of healthcare and housing.

These lessons learned suggest the value of flexibility in healthcare resources and the importance of addressing not only acute healthcare needs, but also their tangential effects.

While short-term interventions, such as the Safe Landing Housing Program, are helpful, practitioners in both the healthcare and community development fields must come together to drive the systems change work that is necessary to ultimately create a healthier population.

SHORT-TERM HOUSING ASSISTANCE OFFERS AN INDIVIDUAL SOLUTION; SYSTEMS-LEVEL CHANGES ARE NEEDED TO IMPACT POPULATION HEALTHThe need to deliver the appropriate level of care in the right setting at the least cost is a familiar issue to the healthcare industry. Similarly, as health is increasingly treated with housing solutions, a similar balance between level and setting of care will need to be defined for housing solutions to health issues. Housing-based health solutions may span both individual- and population-level solutions. Rental assistance may be an appropriate individual intervention, while access to housing stabilization services, legal supports, and other service-based solutions may offer improved population-level health outcomes.

Additionally, this pilot illustrated the positive effects of a short-term intervention targeting a resolvable health issue; however, low-income populations in the United States face a significant set of challenges that would best be addressed at the systems level. Within the spectrum of housing solutions geared to improving health, the healthcare and housing sectors should work collectively to address the systematic gaps individuals experiencing both health and housing crises are facing, including the availability and accessibility of affordable housing.

SUCCESS STORIES: MISTY Safe Landing provided Misty with rental assistance while she was pulled away from work to care for her son. The housing security that Safe Landing provided Misty allowed her time to find the right care program for her son, who continues to have healthcare needs, without the added worry of losing their home. Today she reports that they are both doing well.

SYSTEMS CHANGE REQUIRES NEW PATHWAYS TO BE DEFINEDWhen the Safe Landing Housing Program was developed, the partners embarked on the process of creating a new pathway for healthcare delivery. Unlike the process of filling a drug prescription, which has a clear pathway from origination to delivery, a prescription for housing requires the recipient to navigate a fractured and poorly defined system involving numerous touch points and unclear outcomes.

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The Safe Landing Housing Program considered shallow rental assistance to be another type of “prescription.” However, the pathway for delivering this intervention did not exist. A new system of referral, in-take, delivery, and payment had to be defined. The success of the program highlights the need for changes to our current healthcare delivery system if we are to realize the full potential of addressing both the medical and non-medical needs of low-income families experiencing a healthcare crisis. This was a lesson highlighted during a partner interview. Human Solutions noted the difficulty of defining these pathways at the organization level, particularly the difficulty of developing referral relationships, which were critical in the uptake of this program.

SUCCESS STORIES: TINA Safe Landing offered Tina rental assistance for five months. This provided Tina the ability to stay housed while undergoing breast cancer treatment. Tina is still undergoing breast cancer treatment and remains at risk for homelessness.

Additionally, Human Solutions and Project Access Now played the role of a connector between the organizations in the healthcare sector and housing sectors.

This role is most akin to the pharmacy or pharmacist if applied within the context of the typical prescription. It is an essential role to delivering the “prescribed” intervention from the medical provider. The connector allows for the individual sectors (provider and landlord) to make only small changes to their processes; because the connector takes on much of the excess work around outreach, payment processing, and applicant review. As this solution is scaled to the systems level, defining the organization or organizations to serve in this essential role will be important because it is critical to streamlining the process across payers, providers, and participants.

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CONCLUSION

The Safe Landing Housing Program demonstrated the positive impact that a relatively small amount of rental assistance can have on the physical and mental health of individuals and families who are facing a short-term health issue that can jeopardize their ability to pay rent. While program participants required more rental assistance per month than originally anticipated, they received that assistance for far fewer months than expected. In addition, while we were unable to document healthcare utilization, it is safe to assume that relieving the anxiety around paying rent positively contributed to the overall health and well-being of the household and perhaps accelerated the healing process for the ailing family member.

These findings support the need for short-term supports around housing when health issues arise for low-income families. The cost of the rental assistance provided for all participants was minimal compared to the cost of just one family becoming homeless. If we were to assume that the program prevented homelessness for

10 percent of the enrolled families (a conservative estimate given the precarious circumstances of low-income Americans), then the return on investment is even more pronounced.

Overall, the Safe Landing Housing Program illustrated the value of having flexible healthcare resources available to support both the healthcare and housing needs of low-income families experiencing an acute health crisis. Programs such as these need to continue to be developed and shared, evaluated for their impact on health expenditures and outcomes, and adopted at the systems-level for larger impact and scale.



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APPENDIX A:HEALTH & HOUSING SURVEY

YOUR HEALTH01. In general, how would you rate your overall health?

q Excellentq Very goodq Goodq Fairq Poor

02. Does a physical, mental, or emotional problem now limit your ability to work at a job or business?

q Yesq No

03. If you’re pregnant, are you receiving regular prenatal care?

q Yesq No

04. Would you like to become pregnant in the next year?

q Yesq No

05. Have you been told by a doctor or other health professional that you currently have any of the following?

Diabetes or sugar diabetes: q Yes | q No

Asthma: q Yes | q No

High blood pressure: q Yes | q No

Heart disease: q Yes | q No

High cholesterol: q Yes | q No

COPD: q Yes | q No(Chronic Obstructive Pulmonary Disorder)

Depression: q Yes | q No

Anxiety: q Yes | q No

Post-traumatic Stress Disorder q Yes | q No(PTSD)

Addiction issues: q Yes | q No

Another ongoing health issue: q Yes | q No



06. During the past two weeks, about how often have you been bothered by the following problems?

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Not at all Several Days Over half the days Nearly every day

Little interest or pleasure in doing things?

Feeling down, depressed, or hopeless?

Feeling nervous, anxious, or on edge?

Not being able to stop or control worrying?

YOUR HEALTH CARE07. Where do you usually go to receive medical care? Mark only one.

q A private doctor’s office or clinic

q A clinic or provider in my building

q A public health clinic, community health center, or tribal clinic

q A service provider in my building

q A school based health center

q A hospital emergency room

q An urgent care clinic

q Someplace else (tell us):

q I don’t have a usual place

q I don’t know

08. If you needed medical care in the last 12 months did you get all of the care you needed?

q I got all the medical care I needed

q I got some but not all needed medical care

q I got no medical care at all

q I didn’t need medical care in the last 12 months

09. If you needed dental care in the last 12 months did you get all the care you needed?

q I got all the dental care I needed

q I got some but not all needed dental care

q I got no dental care at all

q I didn’t need dental care in the last 12 months

10. If you needed prescription medications in the last 12 months, did you get all of the medications you needed?

q I got all of the medications I needed

q I got some but not all medications

q I got no medications at all

q I didn’t need prescriptions in the last 12 months

11. In the last 12 months, if you needed treatment or counseling for a mental health condition or personal problem did you get all the care you needed?

q I got all the care I needed

q I got some but not all care I needed

q I got no mental health care at all

q I didn’t need this kind of care in the last 12 months

12. In the last 12 months, if you needed treatment or counseling for your use of alcohol or any drug, did you get all the care you needed?

q I got all the treatment I needed

q I got some but not all needed treatment

q I got no treatment at all

q I didn’t need this kind of care in the last 12 months



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13. Overall, how would you rate your ability to access the health care that you need?

q Excellent

q Very good

q Good

q Fair

q Poor

YOUR CHILDREN’S HEALTHAnswer the questions in this section only if you have one or more children under the age of 18 living with you at least two days per week. If this does not apply to you, go to question 20.

14. In general, how would you rate your children’s overall health?

q Excellent

q Very good

q Good

q Fair

q Poor

15. Have you ever been told by a doctor or other health professional that your children have any of the following? Mark all that apply.

q Diabetes or sugar diabetes

q Asthma

q A behavioral or mental health diagnosis (such as depression, anxiety, or ADHD)

q A developmental delay or learning disability

q Another ongoing health condition

(tell us):

q None of the above

YOUR CHILDREN’S HEALTH CAREAnswer the questions in this section only if you have one or more children under the age of 18 living with you at least two days per week. If this does not apply to you, go to question 20.

16. Where do your children usually go to receive medical care? Choose only one.

q A private doctor’s office or clinic

q A clinic or provider in my building

q A public health clinic, community health center, or tribal clinic

q A service provider in my building

q A hospital emergency room

q An urgent care clinic

q A school based health center

q Someplace else (tell us):

q They don’t have a usual place

q I don’t know

17. If your children needed medical care in the last 12 months did they get all the care they needed?

q They got all the medical care they needed

q They got some but not all needed care

q They got no medical care at all

q They didn’t need medical care in the last 12 months

18. Overall, how would you rate your children’s ability to access the health care that they need?

q Excellent

q Very good

q Good

q Fair

q Poor

19. Do you or your child(ren) receive his/her recommended regular checkups? (at 1 , 2, 4, 6, 9, 12, 15, 18, 24 and 30 months then annually from 3 – 21 years old)

q Yes

q No



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YOUR EMPLOYMENT20. About how many hours per week, on average, do you work at your current job(s)?

q I don’t currently work

q Less than 20 hours per week

q 20-39 hours per week

q 40 or more hours per week

21. Has your income improved in the past 12 months?

q Yes

q No

YOUR EDUCATION22. What is the highest level of education you have completed? Mark only one answer.

q Less than high school

q High school diploma or GED

q Vocational training or 2-year degree

q 4-year college degree or more

YOUR HOUSING23. How concerned are you that you will be unable to pay for your housing in the next 90 days?

q Very concerned

q Somewhat concerned

q Not very concerned

q Not at all concerned

24. At any time in the last 6 months have you slept in a place not meant for human habitation (such as a vehicle, garage, etc.) or in a shelter?

q Yes

q No

25. At any time in the last 6 months have you stayed at a location that you consider unsafe because you did not have a home of your own?

q Yes

q No

26. Altogether, how many people currently live in your home? Count adults, and children under age 18.

Me, plus _______ adults, and ________ children.

27. How many times have you moved in the past year?

q 0

q 1

q 2

q 3

q 4

q 5+

STOPThank you very much for completing this survey.Contact Shawna Hoffman at 503-907-2152with any questions.



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APPENDIX B:SELECTED RESPONSES TO THE HEALTH AND HOUSING SURVEYS

Summary of Flex Fund Assistance # of Households PercentageGrant AmountLess than $1,000 10 14.5$1,000 to $1,499 4 5.8$1,500 to $1,999 13 18.8$2,000 to $2,499 19 27.5$2,500 to $2,999 20 29.1$3,000 or More 3 4.3DurationOne month 10 14.5Two or three months 41 59.4Four or more 18 26.1

Health & Housing Characteristics and Perceptions # of Households PercentageHousehold Member with Health IssueSelf 50 72.5Spouse 3 4.3Child 14 20.3nonresponse 2 2.9



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Types of Health Issue Experienced by Participant or Family Member in the Household

DSM Code

Injury and accessibility (51% of participants)Low back pain M54.5Migraine without aura, not intractable, without status migrainosus G43.009Injury of spleen 865.01 Displaced subtrochanteric fracture of unspecified femur V54.15Local infection of skin and subcutaneous tissue L08.9Obstructive sleep apnea G47.33Schistosomiasis 120.9Chronic pain syndrome; migraine with aura G89.4Syncope and collapse R55Child maltreatment syndrome 995.5Intracranial injury of other and unspecified nature CM854Presence of other functional implants Z96Fracture of unspecified bones 829Other intestinal obstruction K56.69Acquired absence of other specified parts of digestive tract Z90.49Acquired absence of cervix and uterus Z90.71Chronic sinusitis, unspecified; J32.9Polyp of nasal cavity J33Stress fracture, unspecified ankle M84.373ARetained foreign body fragments, unspecified material Z18.9Unspecified motorcycle rider injured in collision with two- or three-wheeled V22.2Gastro-esophageal reflux disease without esophagitis K21.9Cerebral Vascular Accident I63.9Cellulitis of unspecified finger L03.019Spontaneous rupture of flexor tendons, unspecified lower leg M66.369Nonfamilial hypogammaglobulinemia D80.1Other specified disorders of cornea, bilateral H18.893Hyperkalemia E87.5Acute kidney failure, unspecified N17.9Fracture of metatarsal bone(s) S92.3



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Types of Health Issue Experienced by Participant or Family Member in the Household

DSM Code

Mental Health (22% of participants) Generalized anxiety disorder F41.1Major depressive disorder, recurrent, unspecified F33.9Major depressive disorder, single episode, unspecified F32.9Post-traumatic stress disorder (PTSD) F43.1Separation anxiety disorder of childhood F93.0Obsessive-compulsive disorder F42.8Panic disorder [episodic paroxysmal anxiety] F41.0Pregnancy (9% of participants) Supervision of high-risk pregnancy, unspecified, unspecified trimester 9.9Pregnancy, childbirth and puerperium 000-09AEncounter for supervision of other normal pregnancy, third trimester Z34.83Cardiovascular disease, diabetes, or obesity (7% of participants) Acute systolic (congestive) heart failure I50.21Long term (current) use of insulin Z79.4Hypertensive heart and chronic kidney disease with heart failure I13.2Essential (primary) hypertension I10Type 1 diabetes mellitus E10.1Cancer or health outcomes related to toxin exposure (6% of participants)Intraductal carcinoma in situ of breast D05.1Asthma or respiratory health (5% of participants) Pneumonia due to Klebsiella pneumoniae J15.0Cough R05Whooping cough, unspecified species without pneumonia A37.90Pneumoconiosis due to other inorganic dust 503



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Health & Housing Characteristics and Perceptions # of Households PercentageHealth Insurance CoverageOregon Health Plan - FamilyCare 28 40.6Oregon Health Plan – Health Share 25 36.2Oregon Health Plan – Open Card 2 2.9Oregon Health Plan – CAWEM 2 2.9Commercial 5 7.3I don’t know 2 2.9None 3 4.3nonresponse 2 2.9SexMale 18 26.1Female 49 71.0nonresponse 2 2.9Age Less than 34 years 22 31.934-44 years 22 31.945+ years 21 30.4nonresponse 4 5.8Race and Ethnicity Hispanic/Latino of any race 6 8.7Black/African American, non-Hispanic 30 43.5White/Caucasian, Non-Hispanic 23 33.3Other (includes Native Hawaiian/ Pacific Islander & Declined), Non-Hispanic

2 2.9

nonresponse 8 11.6Dependent Children None 14 20.3One or two 49 71.0Three or more 4 5.8nonresponse 2 2.9Educational AttainmentLess than high school 9 13.0High school diploma or GED 23 33.3Vocational training or 2-year degree 19 27.54-year college degree or more 6 8.7nonresponse 12 17.4



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Health & Housing Characteristics and Perceptions # of Households PercentageCurrent EmploymentFull-Time 20 29.1Part-Time 12 17.4Not currently working 32 46.3nonresponse 5 7.3Monthly Household Income DuringLess than $500 17 24.6$500 to $999 25 36.2$1,000 to $1,500 7 10.1More than $1,500 9 13.0Unknown 4 5.8nonresponse 7 10.1Currently Diagnosed ConditionDiabetes or sugar diabetes 13 24.5Asthma 17 32.1High Blood Pressure 15 28.3Heart Disease 4 7.5High Cholesterol 6 11.3COPD (Chronic Obstructive Pulmonary Disorder) 1 1.9Depression 25 47.2Anxiety 27 50.9Post-traumatic Stress Disorder 14 26.4Addiction Issues 6 11.3Another Ongoing Health Issue 23 43.4Able to Access Needed Health Care Excellent 12 22.6Very Good 17 32.1Good 14 26.4Fair 5 9.4Poor 3 5.7nonresponse 2 3.8



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Health & Housing Characteristics and Perceptions # of Households PercentageMedical Care Provider A Private Doctor’s Office or Clinic 22 41.5A Clinic or Provider in My Building 7 13.2A Public Health Clinic, Community Health Center, or Tribal Clinic

14 26.4

A Service Provider in My Building 0 0A School Based Health Center 0 0A Hospital Emergency Room 3 5.7An Urgent Care Clinic 1 1.9Someplace Else 1 1.9I Don’t Have a Usual Place 3 5.7I Don’t Know 0 0nonresponse 2 3.8

Outcomes of Focus (N=36) # of HouseholdsInitial Survey

# of Households3-Month Survey

SurveyPerception of Overall Health Excellent 2 7Very Good 3 4Good 7 8Fair 14 9Poor 10 8Health Limits Ability to Work Yes 29 20No 7 16



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Outcomes of Focus (N=36) # of HouseholdsInitial Survey

# of Households3-Month Survey

SurveyRecent Feelings of Anxiety or Depression Excellent 2 7Very Good 3 4Good 7 8Fair 14 9Current Employment Full-Time 5 7Part-Time 13 12Not currently working 15 16nonresponse 3 1Income Improved in the Last 12 Months Yes 6 11No 27 24nonresponse 3 1Ability to Pay for Housing in Next 90 Days Very Concerned 31 18Somewhat Concerned 1 8Not Very Concerned 0 5Not at All Concerned 0 3nonresponse 4 2



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