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HUD Housing Policy Updates

AASC National Service Coordinator Conference

August 12, 2019

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Mission

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HUD Housing is Senior Housing• 33% of 1.1M public housing

• 46% of 1.2M Project-Based Rental Assistance

• 23% of 2.1M Housing Choice Voucher

• 325,000+ Section 202 Housing for the Elderly

Of HUD’s 5 million homes, 34% are headed by older adults

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…There Just Isn’t Enough of It

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The Need for Affordable Housing

• 10.8 million renter households nationwide pay more than half of their monthly income on rent, leaving too little for other expenses like health care, transportation and nutritious food

• In order to afford a one-bedroom apartment at the national average fair market rent, a minimum wage worker has to work 99 hours per week

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Lifting Non-Defense Discretionary Spending Caps

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Policy Issues in Affordable Housing

• Preservation of Existing Stock

• Full funding for Renewal of Rental Subsidies

• Expansion of Affordable Housing Options

• Extend Service Coordination into All Senior Housing

• Support Housing and Services Initiatives for community living for seniors

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Policy Issues in Affordable Housing• Preservation

• Preventing opt-out of programs at the end of their contractual obligation

• Modernization funding needed for those that want to remain affordable

• Refinancing almost the only way to support significant rehab of buildings

• Funding for ongoing rental and operational subsidies

• Annual federal appropriations battle• Failure to complete appropriations bills result in funding

gaps for providers

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Support New Funding for HUD

Appropriations for Fiscal Year 2020

$600 million for 4,300 new Section

202 homes

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Speaking of Section 202Housing…

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FY20 Admin. Budget Proposal

• 9% cut requested

• 5% cut to Section 202

• Freeze contract rents

• Rent reform and work requirement proposals

• Keeps Non-Defense Discretionary caps

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FY20 Appropriations in Congress

• House HUD Appropriations Bill• Some new 202 $• Some new Service Coordinator $• Full renewal funding• Language on services financing model• Increased homeless assistance $• Expansion of HOME, CDBG $• Protection of national Housing Trust Fund

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Policy Issues in Affordable Housing (continued)

• Funding for development of new projects• Annual appropriations battle

• Increased development costs and limited resources means fewer units are built each year

• President’s proposed budget undercutting preservation let alone expansion, and raising rents

• State allocation plans (applicable to LIHTC development and important for state priority for elderly projects)

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$30 million for funding for new

Service Coordinators

Full renewal funding for existing Section 202 rental assistance (Project-Based Rental Assistance, Project

Rental Assistance Contracts) and Service Coordinators

Restart HUD’s Emergency

Capital Repair Grants Program

Preserve other existing HUD homes

(PBRA, Public Housing, Housing Choice Voucher)

Support HUD’s new home

modification program

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Policy Issues in Affordable Housing (continued)

• Housing and services initiatives to support community living for seniors

• Section 202 Service Coordinator grant program

• Assisted Living Conversion Grant Program (ALCP)

• Service Enriched Housing

• LeadingAge LTSS Center@Umass Boston• New demos in progress

• Building and expanding the research base

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Expand state LIHTC allocations by 50%

Low Income Housing

Tax Credits Allow 50% basis boost

for communities serving extremely low income households

Low Income Housing Tax

Credits

Fix building purchase rights issues with a purchase option

Low Income Housing Tax

Credits Protect and expand (Fannie and Freddie reform)

National Housing

Trust Fund

Other priorities include:

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Advocacy in ACTION

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Hot Topics in HUD Management

• REAC Physical Inspections and NSPIRE Demo

• Preservation – RAD for PRAC, others

• Rent Reform

• Medical Marijuana

• Research in Housing Plus Services

• Other Topics???

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REAC Inspection Changes

• New format/focus; NSPIRE demonstration

• 14 Notification Live NOW

• Carbon Monoxide Detectors – inspectors collecting data; rulemaking in the offing

• Delays or Database Adjustments

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The Problem

While a significant majority of HUD and HUD-assisted properties are safe and in a quality condition, a new inspection model is needed to expediently address properties that are not. Issues include:

• Inspections do not always identify the extent of health and safety conditions affecting residents • Properties can pass inspection even with poor unit conditions • Scoring model no longer aligns with expectations about housing quality • Some owners preparing for inspections, rather than performing maintenance year-round • Deficiencies are not all Critical to Quality (CTQ)

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CO

Detector

Survey

Wall

Moisture

Inspection Improvements Timeline

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FY2020

Track 2: NSPIRE Standards, Protocols, and Processes

14 Day

Notice

Release

d

Demonstration

Listening

Sessions

14 Day

Notice

Effective

Stakeholder

Outreach

Reverse

Auction

Program

Replacement

Track 1: Changes To Current Process

Initiate

POA Self-

Inspections

Initiate

Contractor

Inspections

First Scores

Generated

Initiate New

Scoring

Model

Final Rule

Standards &

Scoring

Demonstration Execution: Test, Evaluate, Validate & RefineAnalysis & DesignFY2019 FY2021

Start

Demonstration

Stakeholder

Feedback

Demonstration

Notice

Released

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3 In

spec

tab

le A

reas

3 C

ateg

ori

es o

f D

efic

ien

cies

3 Ty

pes

of

Insp

ecti

on

s

NSPIRE Model

NSPIRE Model - Conceptual View3 Types of Inspections – Confidence Increased

• Property Owner/Agent (POA) Self-

Inspections

• REAC Contracted Inspections

• HUD Quality Assurance Inspections

3 Categories of Deficiencies – Resident Focused

• Safety and Health

• Function and Operability

• Condition and Appearance

3 Inspectable Areas – Complexity Reduced

• Unit – Inside - Outside

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Underpinned by 3 mutually supporting components

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RAD for PRAC

• Enables PRACs to voluntarily request conversion to long-term Section 8 Housing Assistance Payment (HAP) contracts.

• Helps older properties access funding to address capital needs – financing necessary recapitalizations, improving conditions for residents

• Ensures continuation of programs, services and service coordination

• Requires new leases and newly executed 50059

• RAD Resident Fact Sheets

www.hud.gov/rad

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Rent Reform Proposals

• Rent Reform

• Eliminate all deductions and exclusions.

• Elderly/Disabled Rent to 30% gross.

• NON-Elderly/Disabled Rent to 35% gross.

• Work Requirements for NON-Elderly/Disabled.

• Change Definition of “Elderly Household.”

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Marijuana – Medical or Otherwise

• Should Housing Providers Permit Use of Marijuana?

• Can residents request a reasonable accommodation to smoke or otherwise use it?

Bottom Line: HUD policies prohibit admission of applicants who admit to using marijuana but allow owners discretion whether to allow continued occupancy of current residents.NOTE: CANNOT be used for medical expense deduction.

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Affordable Housing as a Platform for Wellness and Service Coordination

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What do you think about when you think about

affordable senior housing plus services?

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Simplicity: SCs and wellness nurses, but who pays?

HUD and HHS interagency collaboration: how they

mutually serve an overlapping population.

How can HHS share in the value that affordable, stable

housing provides to healthcare?

Housing Plus ServicesExploring Financing Options for Services in Affordable Senior Housing Communities

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Sustainable financing options to support housing plus

services models.

Explore financing options to support housing plus services.

Need to finance the Service Coordinator, Wellness Nurse,

On-Site Programming, Administrative Costs.

It’s complicated: need for multiple solutions.

Housing Plus ServicesExploring Financing Options for Services in Affordable Senior Housing Communities

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How Housing Matters

• What services are available onsite in HUD-assisted senior

housing?

– Surveyed 2,017 HUD-assisted senior housing properties

in HHS/HUD dataset

– Service staff and services or activities that were

purposely available onsite to residents in 2008

• Does the availability of onsite services have any association

with residents’ health care utilization and spending?

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How Housing Matters - Available Services Staff, 2008

69%

26%

13%

25%

ServiceCoordinator

ActivityCoordinator

Nurse No Staff

SC44%

SC/AC14%SC/N

5%

SC/AC/N5%

AC5%

AC/N1%

N1%

No Staff 25%

Source: Service Availability in HUD-Assisted Senior Housing, found at: http://bit.ly/1RQNE5b

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27%

3%

10%

10%

19%

24%

31%

64%

66%

49%

33%

44%

74%

Podiatry

Dental

Mental health

Primary health care

Medication assistance

Personal care

Homemaker assistance

Health screening

Health education

Exercise and fitness

Congregate meals

Transportation

Social activities

Source: Service Availability in HUD-Assisted Senior Housing, found at: http://bit.ly/1RQNE5b

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Population Health Management

• Greater emphasis on prevention and early intervention

• Consider social determinants (education, income, living conditions, etc.) that also influence health outcomes

• Coordinate care across providers to ensure care is not fragmented

• Engage patients in understanding how to manage their care and to take an active role

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Advantages Affordable Housing Brings

• Concentrated population

• Operating efficiencies – Streamlined access –Programming that reaches multiple individuals

• Physical and personnel infrastructure – Trusting relationships – Monitoring – Facilitate greater follow-through and compliance

• More complete understanding of social factors

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What Service Coordinators Can Offer

• Trusting relationship; know preferences needs and capacities

• Observe living circumstances• Monitor and notice emerging issues • Remind and encourage participation and follow through • Help overcome social determinants/barriers • Availability of service coordinator in senior housing

associated with 18% reduced odds of having a hospitalization in a year (LeadingAge & The Lewin Group, 2015)

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Support & Services at Home (SASH)

• Delivered through panels up to 100 participants served by embedded teams

– 1 full-time SASH coordinator

– 10 hours/week wellness nurse

• 54 panels/118 housing properties across the state; all hosted by nonprofit housing organizations and almost all operated out of housing properties

• Panels serve Site-based participants (any resident in a

participating housing property) and Community-based participants (Medicare beneficiaries in surrounding community)

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Main Evaluation Findings

• Slower annual Medicare growth of $1,467 among urban panels

– Driven by slower growth in hospital, emergency room, and specialist expenditures

• Slower annual Medicaid growth in expenditures for long-term institutional care of about $400 for site-based and rural panels

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Selfhelp Active Services for Aging Model (SHASAM)

• Provided by Selfhelp Community Services in 11 senior communities in NYC

• Service coordinators assist with or coordinate:– Accessing benefits and resources

– Referrals for community-based services (e.g. meals, home care)

– Health and wellness programming

– Educational and recreational programming

– Physical activity

– Social events

• Selfhelp also provides in-home technologies, including motion detectors, telehealth systems that allow residents to check vital signs, and a virtual senior center

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SHASAM Study Results

• Hospitalization rate for Selfhelp residents ≈ 33% lower

• Rate of hospitalization for ambulatory care sensitive conditions ≈ 30% lower

• For residents hospitalized, length of stay ≈ 1 day shorter

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Presbyterian Senior Living & PinnacleHealth Partnership

• Weekly onsite clinic

– Staffed by MD, RN, MSW; work with property service coordinator

• Care navigation program – clinical and social

– Identify barriers to care – navigate through health system or help coordinate needed social services

– Coordinate with PCP (or serve as PCP, if one needed)

• Utilize Pinnacle’s EHR

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Additional Research

• Residents in properties with an onsite service coordinator had 18% lower odds of having a hospital stay during the yearSource: Affordable Senior Housing: What’s the Value?, found at: http://bit.ly/1QqMvpo

• Participants in Staying at Home program (Pittsburgh, PA) significantly

Source: Service-enriched housing: The Staying at Home program, Journal of Applied Gerontology, July 9, 2014.

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Presbyterian Senior Living & PinnacleHealth Partnership

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Integrated Wellness in Supportive Housing (IWISH)HUD Supportive Services Demonstration

Randomized Controlled Trial

40 treatment sites

40+ control sites

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IWISH Goals & Evaluation

• Implement and evaluate a housing-based, person-centered, supportive services and wellness model designed to facilitate successful aging in community by helping residents– Proactively address their health and social needs – Maximize their independence, wellbeing and quality of life

• Independent evaluator will study impact on‒ Healthcare utilization (e.g. emergency department visits,

hospitalizations, re-hospitalizations, etc.)‒ Tenure and unit turnover (e.g. evictions and transitions to

nursing homes and higher levels of care)

• Runs through September 2020

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IWISH Core Components

• Resident Wellness Director & Wellness Nurse Team

• Standardized, comprehensive assessment

• Individual & community healthy aging plan

• Centralized data platform

• Community partnerships

• Evidenced-based programs

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Financing Options for Services in Housing Exploration

• White paper exploring potential financing options for housing plus services models

– Informed by interviews with expert stakeholders (housing providers, health care providers, managed care entities, policy experts, state and federal policy makers)

• In-person convening with experts to assess potential financial options and identify most promising solutions for moving forward

• Identifies next steps to pursue financing solutions

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Potential Solutions

• Creating new housing-based benefits under Medicare Part B, Medicare Advantage, or Medicaid

• Establish umbrella entity to support implementation across housing communities and health care entities

• Create a mechanism that would help ACOs build volume with housing settings

• Allow managed care to establish preferred provider relationships

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CONNECT WITH US

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my.leadingage.orgTailor YOUR subscriptions for

personalized areas of interest, critical news and member-to-member listservs

Your achievement. Your tools. LeadingAge Member Tools & Resources

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LeadingAge’sAffordable Housing Experts

• Linda Couch, Advocacy– lcouch@leadingage.org, (202) 508-9416

• Colleen Bloom, Operations• cbloom@leadingage.org, (202) 508-9483

• Alisha Sanders, Research (LTSS Center@...)• asanders@leadingage.org

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