PROVIDENCE – Much of the debate around the current crises in health care, in affordable housing policy, and in government spending has revolved around how resources should be spent to address homelessness in Rhode Island – and its interconnectedness with the social determinants of health.

The debate has produced a volatile mixture of competing visions of how best to provide “support” services to an increasing number of Rhode Islanders who have found themselves outside in the cold, “unhoused” during the current coronavirus pandemic – and with it, competing political arguments about how best to direct and invest state resources.

On one side of the political equation has been state Sen. Cynthia Mendes, running as a candidate for Lt. Governor in 2022 under the R.I. Political Cooperative flag, who led a tent city protest, as she and her supporters slept in tents outside the State House, demanding that money be directed to prevent Rhode Islanders from freezing on the streets.

On the other side, Gov. Dan McKee and the R.I. General Assembly leadership, who resisted the idea of spending $1.1 billion in American Rescue Plan federal funds without an orderly plan to do so -- even as emergencies kept cropping up around the shutdown of Early Intervention services, and the apparent warehousing of patients in hospital beds with behavioral health conditions, because of a lack of community residential treatment facilities.

Much of the hubbub centered around the chronic failure of the R.I. Medicaid program to increase its rates of reimbursements for providers, a problem that has been detailed at length in a series of hearings before a Senate legislation commission looking at the future organization of the R.I. Executive Office of Health and Human Services.

Medicaid program scaled up
Lost in the policy divide, however, has been the scaling up of a pilot program by the Integra accountable entity, a division of the Care New England health system, in a partnership funded through the R.I. Medicaid office, featuring the investment of $250,000 in a partnership between Integra and the House of Hope, focused on providing housing options for as many as 30 patients/clients, in order to help “vulnerable people secure and maintain safe housing.”

“Housing has a vital impact on everyone’s health,” the Dec. 27, 2021, news release said, in announcing the new working partnership, explaining the rationale behind the program. “We all need a safe, decent and supportive place to live in order to maintain our health and wellness. But nearly 1,300 Rhode Islanders on a given night are living on the streets, in shelters, or places not fit for human habitation—a 14 percent increase from the previous year. And many more are housing insecure, at risk of eviction, couch surfing.”

The focus of the Integra Medicaid accountable entity program, according to Dr. Joe Diaz, the program’s medical director, is seeking to extend the concept of care beyond the four walls of the clinic. “The impact of adverse social determinants of health – which include poverty, racism, homelessness, substance use, interpersonal violence, poor nutrition, and many others – are felt throughout Rhode Island communities,” Diaz said, in the news release.

In turn, Bill Stein, House of Hope’s clinical director of training and development, talked about the importance of “focusing on housing and homeless through a community health lens,” in order to ensure positive outcomes for individuals experiencing homeless and housing instability.”

To get a better understanding of how the new scaled-up program worked, ConvergenceRI recently interviewed Dr. Joe Diaz, the medical director of Integra’s Medicaid Accountable Entity Program [see first image], and Matthew Harvey, the senior director of government programs and grants for the Integra Community Care Network [see second image].

ConvergenceRI: Can you explain how the program works?
DIAZ: We recognize the importance, really, of all social determinants of health, in addressing the health of the patients. Paramount among them is stable housing for the patients. For anyone without stable housing, it is hard to be healthy.

We began a small pilot program in 2020-2021, identifying a handful of patients with unstable housing, and then identified opportunities to match them with housing, working in partnership with the House of Hope and the R.I. Coalition to End Homelessness. We had some success with that initial small cohort of about half-a-dozen patients, who we were able to find housing for.

Now, we are expanding to serve a larger group, with the goal of serving around 30 individuals. We want to address the underlying causes of poor health, those being the social determinants of health with housing being really critical among all those.

HARVEY: That is exactly it. Integra is a Medicaid accountable entity, and we received funding from the state to support that work. One of the conditions of that funding is that we dedicate a portion of that to partnerships with community organizations. What we realized, early on, is that we wanted to partner with organizations who not only could do good work to help our patients, but also teach us how to effectively partner with them. And, that is how we landed with the House of Hope.

Health care is an incredibly confusing and complicated space; it turns out that so is housing, and we wanted to be humble enough to recognize that we didn’t know what the right answers were or how to go about finding them.

ConvergenceRI: How does the partnership change the way that care is delivered? Does it require a need to think about the concept of wrap-around services?
DIAZ: When you think about the social determinants of health, they are very broad. And, in thinking about what services are out there, whether it is transportation, interpretation, food insecurity, or safe neighborhoods, it requires a 360-degree perspective. It is a different way of thinking about providing health care.

HARVEY: Anybody who is participating in this program is getting housing support from the House of Hope. But they are also getting a full spectrum of medical care management through Integra’s care management team.

In addition, there are the House of Hope caseworkers that have the expertise around housing issues, and the Integra community health workers and social work team to address all those other social needs Dr. Diaz was talking about.

When you talk about wrap-around services, it depends on where you are standing. So, the 360-degree metaphor is the best way to think about it.

ConvergenceRI: How are the community health workers involved in the program?
DIAZ: Integra employs six community health workers, but they work all across the state. When someone is identifying as being eligible for this program, or indeed, for any Integra program, the community health worker is almost always the first point of contact with the patient.

They will do an initial outreach, explain the services and supports that we can offer; they will conduct an initial screening to identify all of the social needs that that patient might have.

And, after they are enrolled in the housing program and are receiving House of Hope services, the community health worker will continue to follow up with them to provide those other social wrap-around services and supports, as part of the Integra team.

ConvergenceRI: So how is Integra progressing, over all? It was an innovative approach to design a system of primary care affiliated with a health system. What have been the areas of growth?
HARVEY: Let me take a stab at answering that, Joe, and then I would love to hear your take on it.

My first answer is that Integra is doing extremely well. We just closed out our numbers for 2021, which was a challenging year for us. And, I think we are doing really well, no matter how you measure it.

We have been successful in the terms that the state wants us to be successful. Which is to say, we are improving the quality of care for our members’ health, we are improving the health outcomes, and we are reducing the amount of avoidable care being provided, and therefore, helping to manage the costs.

So, that is one sort of quantifiable success. And, what has been a real success has been our ability to continue to grow this kind of partnership we have the House of Hope.

The House of Hope partnership was started in 2020-2021; it started with six patients, and we were able to successfully house them, all of whom, as far as we know, are still successfully housed.

And, for at least two or three of them, I know that we have helped get them employment. We have an incredible list of anecdotal evidence about the work we are doing.

But the fact that the House of Hope said to us, let’s scale this partnership up together, that feels like a success. So now, we are going to tackle helping up to 30 or more folks.

And, we are taking this model of working with community organizations, who have the expertise and the domain, and we are trying to take it to other areas.

We are [pursuing] partnerships in the food space, we have partnerships in the healthy housing space, we are thinking about what we can do around transportation or home-delivered meals, and trying to continue to grow the portion of supports and services that we can offer the patients. It is exciting, and it is innovative, and this is the kind of thing that Medicaid is hoping that accountable entities will do, to look outside of the four walls of the clinic, so to speak, and bring in partners who have the expertise and the resources to support us.

DIAZ: I totally agree with what Matt [Harvey] just said. And, from the perspective of being inside the four walls of the clinic, having the resources has been tremendous, having a patient that is an Integra patient and knowing that there is a team that can support that patient. It is one of the things that make me the most excited and optimistic about primary care. This is going to change the way that things are done

ConvergenceRI: How are you tracking the data from this program?
HARVEY: We track basic measures. One of the tools that we use as an accountable entity is to look at levels of health care utilization. Do we see, for example, that for a patient who has been included in this program, does the housing have an impact on their health downstream? Does the pattern of utilization improve?

One of the challenges is that the scale is pretty small right now. We have only successfully served six people, so it is hard to do high-powered studies on a population sample that small. Anecdotally, we have seen that when patients are housed and employed, and more stable, their health improves.

Our hope is that within a few months, we will have that data assembled that we can use to draw a picture, before and after.

ConvergenceRI: You have received $250,000 from Medicaid to expand the pilot program. Is that enough money for a program like this? Is the program sustainable?
HARVEY: For this year, we are adequately funded. We probably have the funding to do this for another year. But we want to be a program that is sustainable, even in the absence of that state-funding stream.

The way that a program like this becomes sustainable on its own is when it can produce the kinds of outcomes that I was just talking about, that it can demonstrate that it reduces unnecessary utilization of high-cost medical services that improves quality and outcomes. If we can demonstrate that this program pays for itself.