Innovative Financing Mechanisms to Address Vulnerable Populations: Lessons from a Medical Respite Intervention 2019 Medicaid Health Plans of America Conference

September 19, 2019 Innovative Financing Mechanisms to Address Vulnerable Populations: Lessons from a Medical Respite Intervention 2019 Medicaid Health Plans of America Conference Quantified Ventures is an outcomes-based capital firm that drives transformational health, social, and environmental impact. Our Solutions ▪ We cultivate trusted partnerships across sectors and involve agencies, investors, private and nonprofit institutions, philanthropies and community groups that share our vision to be at the forefront of creating healthy people and planet. ▪ To make positive health, social, and environmental outcomes both financeable AND profitable, we leverage the strengths of all sectors. ▪ We help to build robust, accountable, and sustained structures that bring needed resources to solve stuck problems. Benefits of Outcomes Based Financing ▪ Transfer performance risk of innovative projects to investors ▪ Access new sources of flexible investment capital ▪ Showcase partners and their projects, attracting internal and external support ▪ Engage diverse and new stakeholders benefiting from projects ▪ Measure and track outcomes through embedded performance evaluation ▪ Establish external accountability structures that foster commitment and support sustained partnerships Courtesy of WEF We commit to: Driving positive impact Linking financial results to proven outcomes Expanding access to capital Building a sustainable outcomes-based financing marketplace Investor Repayment Option: Performance Contracting ▪ Limits contracting complication, with familiar performance contract between payor and service provider ▪ Fewer regulatory or compliance risks (real or perceived) for payors ▪ Intervention sustainability by not having termed contract with payors ▪ Solves double capitalization issue by removing need for escrow Expansion of Medical Respite Can Help Break Homeless-to-Hospital Cycle ▪ For the first night after hospital discharge: ▪ In these settings, individuals can’t heal (i.e. simple cuts become infected) and get sick enough to require further hospitalization …Without a safe place to recuperate, they are more likely to return. 75% 11% go to a shelter end up on the street Individuals experiencing homelessness are more likely to be hospitalized and… Individuals experiencing homeless are: 4x 5x more likely to present in the emergency department more likely to be hospitalized Expanding Medical Respite Capacity in the District of Columbia ▪ Project Goal: To increase the number of beds in the District for AmeriHealth Caritas DC members experiencing homelessness and housing insecurity ▪ Outcomes: ▪ Address DC Medicaid’s top priorities related to acute care utilization (3 P4P Measures) ▪ Reduce total cost of care to AmeriHealth Caritas DC ▪ Connect individuals experiencing homelessness to permanent supportive and other (non-shelter/street) housing solutions ▪ Program Model: Health and Human Services Case Study Respite services include: ▪ Clinical care ▪ Case management Permanent supportive housing ▪ Room and board ▪ Peer support Temporary housing, other social services Hospital/ED Medical Respite Housing Support States are Increasingly Demanding More of Medicaid Managed Care Sample State Managed Medicaid RFP “…Meet health related needs of members, including : • Housing instability • Homelessness • Nutrition • Other social services…” States are Struggling With: • Affordable housing crises • High rates of homelessness and housing insecurity • Chronic shortage of funding available to support many human and social services The Envisioned Medical Respite program will be comprised of 3 phases, each with distinct levels of medical, behavioral health, and social support services Phase 1: Temporary for Medical Necessity Phase 2: Temporary for Transition Phase 3: Permanent Medical Behavioral Health Socialization Hospital Discharge Medical Necessity 90 Days Transition of Case Management Maintenance Assessment Engagement Active Care 11 Phase 1 – Hospital Discharge until End of Medical Necessity Facility • Temporary Housing – Medical Respite Facility • Meals – Catering Service Medical Care • Active Medical Treatment including screening & assessment Behavioral Health Care • Behavioral Health Engagement including MAT Social Supports • Socialization Assessment including Adult Needs & Strengths Assessment and Service Prioritization Decision Assistance Tool (SPDAT) or Vulnerability Index (VI-SPDAT) • Applications for disability and other benefits as needed On-site staff Staff : Client Ratio FTEs Needed (per facility) Day Shift - Monday – Friday (9am – 5pm) APRN 1:24 1/3 RN 1:8 1 LICSW 1:8 1 Behavioral Health Staff PRN Paid by CSA Weekday Evening (after 5pm) & Weekend (24hrs) LPN 1:8 3-4 Security 1:8 3-4 Visiting staff As per medical necessity (dental, OT, PT) PRN PRN 12 Phase 2 – Transitional for up to ~90 Days Facility • Temporary Housing – Step Down Unit • Meals 1. Communal with staff support 2. Catered Medical Care • Medical Monitoring Behavioral Health Care • Active Behavioral Health Treatment Social Supports • Socialization Engagement including follow-up Adult Needs & Strengths Assessment Staff : Client Ratio FTEs Needed (per facility) Day Shift - Monday – Friday (9am – 5pm) Community Support Worker 1:8 1 Behavioral Health Staff PRN Paid by CSA Weekday Evening (after 5pm) & Weekend (24hrs) Community Support Worker 1:8 3-4 Security 1:8 3-4 Individuals will transition to Phase 2 if their treatment plan includes moving towards Permanent Supportive Housing. 13 Phase 3 - Permanent Housing Facility • Permanent Housing • Flex funding to assist with household essentials Medical Care • Medical Monitoring Behavioral Health Care • Behavioral Health Monitoring Social Supports • Active Socialization including follow-up Adult Needs & Strengths Assessment Staff : Client Ratio FTEs Needed Day Shift - Monday – Friday (9am – 5pm) Community Support Worker 1:8 Paid by CSA Behavioral Health Staff PRN Paid by CSA AmeriHealth Case Manager/Care Coordination For Discussion Anticipated Partnerships Pilot Pay for Success HOMELESS MEN Pay for Success HOMELESS WOMEN Pay for Success PREGNANT WOMEN Volunteers of America Unity Health Pathways to Housing Volunteers of America Unity Health Pathways to Housing Volunteers of America Unity Health Pathways to Housing Volunteers of America Mary’s Center Pathways to Housing Patients who enter the Medical Respite program after an inpatient admission will flow through the program in different pathways depending on their medical acuity and treatment plan. Partnership with hospital partners will be essential to the correct identification and referral of homeless individuals to the medical respite program. Considerations: When Does This Work? ▪ Is there a new intervention or partnership model perceived as too risky? Or a proven intervention that should to be scaled? ▪ Do stakeholders have aligned interests / value the same outcomes but need incentives to work together? ▪ Can these outcomes at least partially be achieved within 3-7 years? ▪ Are there easier, cheaper, or faster ways to finance this work? ▪ Is the potential deal size big enough to warrant this form of financing? ▪ Are any stakeholders driven by regulatory requirements and/or policy pressures? Considerations: Stakeholders and Measurement ▪ Stakeholder Buy-in Questions: ▪ Is there a champion willing to fight for innovation? ▪ Is there a revenue source that can be allocated to repayment? ▪ Is there at least one clear outcome that will interest investors? ▪ Measurement & Monitoring Questions: ▪ Can the desired outcomes be measured quantitatively? ▪ With what data sources and over what time period? ▪ Can those outcomes be valued financially? To which parties does that value accrue? Key Data and Evaluation Questions ▪ Where is the best starting point to determine the right target population(s)? ▪ What other factors inform site selection? ▪ How big are you trying to scale? ▪ What data are available to assess eligibility / impact potential of the population? ▪ Who can contribute resources to that analysis? Or provide data for 3rd party? ▪ What data use or other agreements would need to be established or modified? ▪ At an institutional level, what data are contractually prohibited to share? ▪ What, if any, IRB considerations need to be addressed (i.e., is it TPO, QI, “Big R” Research?) 20 The Envisioned Medical Respite program will be comprised of 3 phases, each with distinct levels of medical, behavioral health, and social support services