Housing and Health – Page 3 – The National Academy for State Health Policy

Five States Break Down Interagency Silos to Strengthen their Health and Housing Initiatives

December 17, 2020/in Medicaid Managed Care Illinois, Louisiana, New York, Oregon, Texas Featured News Home, Reports Chronic Disease Prevention and Management, COVID-19, Health Equity, Housing and Health, Population Health, Social Determinants of Health, Special Populations and Services /by Allie Atkeson, Ariella Levisohn and Jill Rosenthal

Guest Blog: Massachusetts Attorney General Issues Recommendations to Address Health Inequities

December 7, 2020/in Policy Massachusetts Blogs, Featured News Home Chronic Disease Prevention and Management, COVID-19, Health Equity, Housing and Health, Population Health, Social Determinants of Health /by Noam Yossefy and Sandra Wolitzky

To showcase what states are doing to address health disparities that the COVID-19 pandemic has laid bare, the National Academy for State Health Policy is highlighting state initiatives through reports and guest blogs, such as this one by Massachusetts Attorney General Office Health Care Analyst Noam Yossefy and Assistant Attorney General Sandra Wolitzky.

A new report, Building Toward Racial Justice and Equity in Health: A Call to Action, released in November 2020 by Massachusetts Attorney General Maura Healey outlines a series of recommendations to address longstanding health disparities and the disproportionate toll that the COVID-19 pandemic has taken on communities of color in Massachusetts.

The report identifies a set of priority areas that are critical to reducing health inequities. The five domains for action include data for identifying and addressing health disparities, equitable distribution of health care resources, telehealth as a tool for expanding equitable access to care, health care workforce diversity, and social determinants of health and root causes of health inequities.

Within each domain, the report offers actionable recommendations, including the following:

Health Care Data

Improve the collection and reporting of data on patient race, ethnicity, geographic and other demographic characteristics to help stakeholders better understand existing disparities and develop targeted strategies to address them.
Establish and measure statewide equity benchmarks to demonstrate commitment to advancing health equity and racial justice.

Equitable Distribution of Resources

Promote equitable health care provider payment rates to ensure that low-income communities and communities of color have access to the same resources available to any other community in order to meet their health needs.
Reduce patient cost sharing during the pandemic for primary care, behavioral health, and prescription drugs for certain chronic conditions so that underserved patients can get the services they need during the COVID-19 emergency.

Telehealth and Clinical Access

Address the divide in digital access by increasing the availability of free and low-cost internet plans and devices and making sure that underserved patients are aware of available resources.
Support coverage and payment parity for telehealth services, including telephonic visits, where clinically appropriate, for the next two years.
Ensure equitable access for individuals with disabilities and limited English proficiency through standardized provider procedures and accommodation services to minimize existing disparities in clinical care.

Workforce Diversity

Expand affordable and inclusive educational opportunities to increase access to health professions.
Include anti-racist and cultural humility training in medical education, licensure, and certification processes.

Social Determinants of Health

Prioritize investments in key social determinants of health — including education, employment, housing, the environment, and violence — in order to address upstream inequities that lead to health disparities.
Explore new models to bring together stakeholders who can apply a health equity lens to regional decisions that affect social determinants of health, such as regional health equity authorities.

While some of the recommendations require legislation, many can be implemented immediately by health care stakeholders changing their policies or practices. “Our health care system works well for many, but the disparate effects of the pandemic provide a somber reminder that our system fails to equitably serve communities of color,” Attorney General Healey explained. “The intent of this report is to advance the urgent work that is needed to address these disparities. COVID-19 has shown us that these actions cannot wait.”

Infographic: Policy Levers to Address Health Equity by Reducing Lead Exposure

October 26, 2020/in Policy Featured News Home CHIP, Chronic Disease Prevention and Management, Health Equity, Housing and Health, Lead Screening and Treatment, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health /by Rebecca Cooper and Elinor Higgins

This infographic highlights how lead exposure and poisoning is a health equity issue, and the role that state Medicaid agencies and other systems play in reducing exposure to improve health outcomes. Additional resources are listed below the infographic.

Additional Resources:

Associations of Maternal & Child Health Programs: Lead poisoning prevention webpage.

NASHP: 50-State Scan of Lead Screening and Treatment Policies for Children and Pregnant Women

NASHP: Medicaid and CHIP Levers to Promote Lead Screening and Treatment: Indiana’s Experience

NASHP: State Levers to Promote Lead Screening and Treatment: Rhode Island’s Strategies

This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UJ9MC31105 – Maternal and Child Environmental Health Collaborative Improvement and Innovation Network (CoIIN) for $849.999. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government. NASHP thanks the Maternal and Child Health Collaborative Improvement and Innovation Network (MCEH COIIN) leadership partners for their review of the infographic.

States Work to Advance Racial Equity in COVID-19 Outcomes and Beyond

October 12, 2020/in COVID-19 State Action Center Blogs, Featured News Home Chronic Disease Prevention and Management, Community Benefit, COVID-19, Health Equity, Housing and Health, Population Health, Quality and Measurement, Social Determinants of Health /by Elinor Higgins

Disparities in states’ COVID-19’s health outcomes have driven home the need for policymakers to reassess their work to advance racial equity and redirect efforts to be more effective. A recent update to the National Academy for State Health Policy’s (NASHP) interactive map, How States Collect Data, Report, and Act on COVID-19 Racial and Ethnic Disparities, reveals that more than half of all states are now actively engaged in advancing equity in their COVID-19 responses and beyond.

States are working to ensure equitable distribution of resources and funding to promote health and safety for all during the COVID-19 pandemic. Some states are also beginning the long-term work of addressing systemic racism and other root causes of the disparities illuminated by the pandemic.

Use this interactive map to learn how each state reports race and ethnicity data on COVID-19 and how they act to address racial and ethnic disparities.

As the pandemic progresses and reveals the disproportionate impact of the disease on people of color, several states have created task forces and workgroups to ensure the equitable distribution of testing, personal protective equipment (PPE), and information about the disease. Some states are funding these efforts to better achieve equitable health outcomes for communities of color.

In Maine, for example, Black Mainers represent about 1.4 percent of the total population, but over 22 percent of the COVID-19 cases whose race is known. Gov. Janet Mills announced that $1 million from the Coronavirus Relief Fund would be dedicated to expanding services like testing, case investigation, contact tracing, and education to help reduce the disproportionately large racial and ethnic disparities in COVID-19.

As the recommendations and findings from the state task forces are published, one theme that emerges is the need for states to engage with communities and prioritize the needs they identify. The examples below underscore a critical lesson that states have learned from COVID-19 – their prior strategies to advance equity were not sufficient and integrating community feedback is essential to forge new and effective strategies. These recommendations reflect the importance of involving communities and people of color in states’ long-term policies:

In New Hampshire, the COVID-19 Equity Response Team released its initial Report and Recommendations in which they described the need for proactive community engagement, working toward an ideal of co-creation and community ownership.
In Oregon, the Equity Framework in COVID-19 Response and Recovery features a commitment to make community-informed policy and forge partnerships by engaging with community leaders who should be an essential part of the decision-making process.
In Washington State, proposed recommendations from the Governor’s Interagency Council on Health Disparities include the provision of opportunities for communities to take the lead in creating information about and for themselves, including through contracts and grants.
In Virginia, Gov. Ralph Northam announced a pilot program in Richmond to increase equitable access to PPE in underserved communities that may be more adversely impacted by the COVID-19. The pilot program includes community engagement events and training on cultural humility and implicit bias for city personnel who engage with the community.

The themes of including communities in decision-making and in the crafting of emergency responses are reflected in state funding streams as well, with some states providing funds to community groups. The Utah COVID-19 Community Task Force created a multicultural subcommittee that oversees the COVID-19 Racial Equity & Inclusion Grant Fund. The fund provides grants up to $5,000 to community-based organizations that provide emergency assistance to multicultural communities. In Michigan, $20 million was made available to the Coronavirus Task Force on Racial Disparities to respond to community needs associated with the disparate impacts the virus has had on communities of color. Community groups were able to apply for the funding through the Rapid Response Initiative, with funds available for a wide range of needs.

As states continue to work towards equitable health outcomes and look for ways to counter a long history of systemic racism, several are focusing on children’s health as a way to address disparities and potentially influence health trajectories in the future. For example:

New Hampshire’s Equity Response Report recommended Adverse Childhood Experiences (ACEs) as an area to explore to continue understanding and serving communities of need in New Hampshire, specifically communities of color, at both the state and local levels.
Ohio’s COVID-19 Minority Health Strike Force Blueprint highlights strategies to improve health outcomes and advance equity for children, including strengthening early childhood education and specifically ensuring that K-12 chronic absenteeism reduction efforts meet the needs of children of color. Ohio’s Plan to Advance Equity highlights how childhood poverty disproportionately affects African American and Latinx children in Ohio. To address this, the governor established the Office of Children Services Transformation within the office of Children’s Initiatives and is investing $675 million to assist students’ wellness and success.

The COVID-19 pandemic is far from over, and the effectiveness of these strategies will be evaluated based on how well they reduce disparities in COVID-19 outcomes and the advancement of health and social equity beyond the pandemic. NASHP will continue to engage states in identifying promising practices and will provide tools and support as states implement their task force and workgroup recommendations and measure change and success over time.

Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.

With a Federal Eviction Moratorium in Place, States Develop Additional Protections for Low-Income Renters

September 8, 2020/in Policy Blogs, Featured News Home COVID-19, Health Equity, Housing and Health, Population Health, Relief and Recovery, Social Determinants of Health /by Allie Atkeson

Last week, the Centers for Disease Control and Prevention (CDC) issued an agency order temporarily halting residential evictions for nonpayment of rent due to COVID-19 through the end of 2020. This unprecedented action, which includes no provisions address landlords’ lost income, identifies housing as a key tool to prevent the spread of COVID-19. Alongside this federal action, states can implement additional initiatives to help low-income renters avoid eviction.

With more than 16 million Americans unemployed, 43 percent of renters were unable to pay their rent at the end of July. It is estimated that 19 to 23 million renters will be at risk of eviction by the end of September. Housing affordability is not a new issue in the United States, but one that is exacerbated by the COVID-19 pandemic. Prior to the pandemic, nearly 21 million renters were cost burdened – spending at least 30 percent of their income on rent. Individuals and families who rent have lower incomes than homeowners and are less likely to have savings to cover unanticipated expenses or emergencies.

Housing is an important social determinant of health, and especially critical now as housing insecurity is associated with an increased risk of COVID-19 infection and mortality.

The $2.2 trillion Coronavirus Aid, Relief and Economic Security (CARES) Act provided essential, one-time $1,200 stimulus checks, enhanced unemployment benefits, and a moratorium on evictions for renters in properties financed by federally backed mortgages. Analysis by the Urban Institute revealed the CARES Act protected 12.3 million renter-occupied, federally financed units, which account for one in four total rental units. The CARES Act eviction moratorium and the enhanced unemployment benefits expired in late July. The CDC eviction moratorium provides more protection for renters than the CARES Act moratorium by covering all rental properties.

The CDC agency order explained, “… housing stability helps protect public health because homelessness increases the likelihood of individuals moving into congregate settings, such as homeless shelters, which then puts individuals at higher risk to COVID-19.” Renters who declare they expect to earn less than $99,000 a year ($198,000 if filing jointly) are protected from eviction until Dec. 31, 2020. Renters will still be responsible for paying rent, including the unpaid “back” rent, after the order expires and can be evicted for other lease violations.

Before the CDC’s action, Moody’s Analytics estimated renters would owe nearly $70 billion in back rent by the end of the year. Moody’s estimate included 12.8 million renter households who would each owe on average $5,400.

While the CDC action protects renters, it creates economic hardship for landlords for whom that lost revenue is significant. A recent study found that over 50 percent of property owners manage four or fewer units, and rely on rent from their units for operating costs and income. A long-term reduction in rental properties could also jeopardize the affordable housing market — there is already a shortage of more than 7 million homes for low-income renters.

Housing and Health Equity

Access to housing is an important driver of health outcomes. Research indicates that eviction can lead to homelessness, housing instability, and increased use of emergency health care services. The threat of eviction is associated with negative mental and physical health outcomes including depression, high blood pressure, and child maltreatment. Eviction prevention can also save states money. In New York, keeping one family in a home saves taxpayers $68,422 per year in shelter costs.

Historically marginalized populations have experienced higher rates of COVID-19 infections and mortality, and are also more likely to be at risk for eviction. These inequalities are driven by structural racism and policies, such as redlining, that created barriers to homeownership for people of color. Today, nearly 70 percent of White residents own their homes compared to 42 percent of Black residents and 48 percent of Latinx residents. Black and Latinx workers are also more likely to be unable to work from home, making it more difficult for them to earn income to pay rent.

July 2020 data from the Household Pulse Survey reveals that more than 40 percent of Black and Latinx households had no or only slight confidence they could pay their rent next month compared to 21 percent of White renters. Additionally, in 17 states, Black women are twice as likely to have eviction notices filed against them as White renters. Eviction filing histories also make it more difficult for renters to secure rental properties in the future.

State Actions

With federal unemployment assistance expired and a federal eviction moratorium set to expire at the end of the year, states are providing additional protections and financial assistance to low-income renters. In March, 43 states and Washington, DC passed eviction moratoria, with more than half expiring by early August. States are now looking at other policy levers to protect low income renters and landlords through leveraging federal funding, executive actions, and legislation. The following states actions outlined below provide protections above the current federal moratorium and some provide landlords with direct financial assistance.

Leveraging federal dollars to support low income renters:

In Arizona, the Department of Housing is partnering with community action agencies to assist renters through the Rental Eviction Prevention Assistance Program. Renters who have lost more than 10 percent of their income are eligible to apply. As of late August, 1,794 households were approved, representing 8 percent of total applications. The program is currently funded by $5 million dollars from the State Housing Trust Fund.
The Illinois Housing Development Authority created the Emergency Rental Assistance Program with CARES Act funding directed to the agency from the General Assembly. The $150 million-dollar fund will provide eligible tenants one-time $5,000 grants paid directly to their landlords for missed rental payments or to cover upcoming rental payments through December 2020. The program is expected to assist 30,000 tenants this year.
Michigan’s Eviction Diversion Program provides $60 million in CARES Act funding for rental assistance, case management, and legal services to support those with eviction filings. Rental assistance is income-based and allows for one-time payments up to $3,500.
Montana used $50 million of its CARES Act dollars to create an Emergency Housing Assistance Program. Financing from the program caps family’s rent or mortgage contributions at 25 percent of their net income. As of late August the program had awarded approximately $2.5 million to reaching more than 830 Montanans with an average of three months of assistance and $2,822 per household paid to landlords and mortgage servicers.
North Carolina Gov. Roy Cooper allocated $175 million federal dollars to support North Carolinians’ economic stability. Federal Community Development Block Grant Coronavirus funding ($28 million) and CARES Act Coronavirus Relief Fund ($66 million) dollars will be used to support rental and utility payments. Approximately $53 million from the federal Emergency Solutions Grant – Coronavirus (ESG-CV) program will be used to support the Department of Health and Human Services’ work on crisis response and housing stability.
Pennsylvania created the CARES Rent Relief Program with $150 million dollars in federal funding. This program provides funding to localities to assist “lessees that became unemployed after March 1, 2020, due to the COVID-19 pandemic, or lessees that are experiencing at least a 30 percent reduction in annual income related to COVID-19.” The program provides funds directly to property owners for rent accrued from March 1 to Dec. 30, 2020. Monthly assistance is capped at $750.
Wisconsin is leveraging $25 million dollars from the CARES Act to assist renters through the Wisconsin Rental Assistance Program. This program is a partnership between the Wisconsin Division of Energy, Housing and Community Resources and the Wisconsin Community Action Program Association. Renters with incomes below 80 percent of the county median income will be eligible for up to $3,000 per individual to cover rental payments and/or security deposits.

Implementing eviction moratoria through legislation:

In California, Gov. Gavin Newsom signed legislation that prohibits evictions before Feb. 1, 2021 “as a result of rent owed due to a COVID-19 hardship.” Tenants must pay 25 percent of rent due to avoid eviction.
In Massachusetts, legislators are considering H4878, which would create a moratorium on evictions and negative credit report filings until 12 months after the State of Emergency declared by Gov. Charlie Baker ends.
Proposed legislation, S8667, in the New York Senate would place a moratorium on evictions for residential and commercial properties. The bill states, “… it is counterproductive to public health and welfare to allow evictions and foreclosures until the COVID-19 pandemic has passed and sufficient time has been provided for communities to recover.” Similar to Massachusetts, the bill extends the moratorium until one year after the public health emergency ends.
In Virginia, the Virginia Supreme Court halted evictions until Sept. 7, 2020. State legislators are currently convening for a special session to consider a proposal to create a $3.3 million dollar Eviction Diversion and Prevention Pilot Program. Lawmakers will also consider a bill to pause evictions until April 30, 2021.

The financial impact of COVID-19 will extend far past 2020, with new research suggesting that 42 percent of recent layoffs could lead to permanent job loss. With the federal eviction moratorium in effect until Dec. 30, 2020, additional measures will be necessary to prevent evictions and housing insecurity for low-income individuals and families. Additionally, if the CDC order is successfully challenged in court, moratoria at the state level will become even more important to prevent evictions.

As states work to prevent evictions, there are a variety of other policy levers available to provide low-income individuals with assistance to find and maintain housing, often with the supportive services they need to maintain housing. The National Academy for State Health Policy Health and Housing Institute works with states across sectors on strategies to improve health and housing for vulnerable populations. Learn more about state work on improving housing and reducing homelessness at NASHP’s Housing and Health Resources for States.

This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.

States Launch Initiatives to Address Racial Inequities Highlighted by COVID-19

August 3, 2020/in COVID-19 State Action Center Blogs, Featured News Home Chronic Disease Prevention and Management, COVID-19, Health Equity, Housing and Health, Population Health, Social Determinants of Health /by Elinor Higgins

COVID-19 has illuminated racial and ethnic disparities across the country and simultaneously created new momentum for state leaders to address the root causes of racial inequity. COVID-19 case data has made the disparities — driven by systemic racism and inequitable economic and social conditions — increasingly blatant. In response to the dual crises of racism and COVID-19, many state leaders are working to address the inequities leading to disproportionate outcomes for communities of color.

A new section of the National Academy for State Health Policy’s (NASHP) interactive map, How States Collect Data, Report, and Act on COVID-19 Racial and Ethnic Disparities, highlights how states are approaching this issue. Eighteen states have activated task forces to address the high rates of COVID-19 cases and deaths in communities of color and their recommendations include:

Additional protections and compensation for employees who are put at increased risk of COVID-19 due to the nature of their jobs;
Additional collection, analysis, and transparent release of COVID-19 demographic data;
Targeted distribution of personal protective equipment (PPE), testing, and treatment resources to communities most impacted by COVID-19;
Formal methods for the incorporation of community-based organizations and community voices into state and local decision-making processes;
Increased efforts to make COVID-19 informational materials multi-lingual and accessible;
Increased focus on affordable and stable housing for those most impacted by COVID-19; and
Increased public health funding and the continuation of services that support and prioritize communities of color.

NASHP will continue to monitor state task forces to identify recommendations that are incorporated into state policy. States are also using new funding streams, implementing innovative technology solutions, and targeting resources to where they are most needed:

North Carolina: The North Carolina Department of Health and Human Services (NCDHHS) awarded grants to five local organizations to help address the disparate impact that COVID-19 is having among the state’s Latinx communities. Additionally, Gov. Roy Cooper issued an executive order to address the disproportionate impact of COVID-19 on communities of color. The order:

- Tasks the North Carolina Pandemic Recovery Office with ensuring the equitable distribution of pandemic relief funds;
- Prioritizes historically underutilized businesses for state contracts and resources for recovery;
- Directs NCDHHS to ensure all communities have access to COVID-19 testing and related health care; and
- Directs the Division of Emergency Management to continue coordinating efforts to protect the food supply chain and support feeding operations at food banks and school systems, and the North Carolina National Guard to assist with mass testing of food processing and migrant farm workers.

Virginia: Gov. Ralph Northam announced a pilot program in Richmond to increase access to PPE in underserved communities . The new Health Equity Leadership Task Force is leveraging data to prioritize areas experiencing disproportionate impacts of COVID-19 and working with the City of Richmond to establish policies and programs that include an equity lens.
Ohio: A new position will be created within the Ohio Department of Health dedicated to social determinants of health and opportunity. This position will build on existing efforts and work directly with local communities on their specific long-term health needs and Ohio’s response to COVID-19. This position will also collect data to inform best practices and assist in implementation of the Minority Health Strike Force’s recommendations.
Illinois: The Illinois Department of Public Health created a multi-departmental COVID-19 equity team to address health disparities. The equity team has launched a COVID-19 text messaging system, which includes an option for Spanish-speakers. Illinois residents can opt-in to receive text messages and obtain the most accurate information about the coronavirus and how to protect themselves.
Louisiana: Gov. John Bel Edwards announced he is making $500,000 from the Governor’s COVID-19 Response Fund available to the Louisiana COVID-19 Health Equity Task Force to examine the causes and possible solutions to the high rate of deaths within Louisiana’s African American community and other impacted populations.
Massachusetts: Gov. Charlie Baker signed a bill into law that requires the collection of vital public health data — information that would provide additional detail about the impact of COVID-19 on minority communities — and establishes a COVID-19 Equity Task Force.
Washington, DC: The Equity, Disparity Reduction, and Vulnerable Populations Committee is part of Reopen DC’s advisory group. The committee assembled a set of recommendations describing how to ensure equity during reopening.
West Virginia: Gov. Jim Justice and the Department of Health and Human Resources also announced a plan to increase COVID-19 testing opportunities for minority populations and other vulnerable populations in counties that have both a large minority population and evidence of COVID-19 transmission.

The disproportionate impact of COVID-19 makes it more clear than ever that racism is a public health issue with implications for state health policy. As states continue to grapple with COVID-19, many, like those in the examples above, are focusing on how to address immediate disparities related to the pandemic.

States are beginning the process of setting in place strategies to address the preexisting racial and ethnic disparities that worsen outcomes for people of color. New positions dedicated to addressing social determinants of health and opportunity; multi-departmental equity teams; enhanced collection and reporting of data; and public health services that support and prioritize communities of color are key strategies to ensure equity issues remain part of states’ agendas. NASHP will continue to track how states approach this work and how they measure change and success over time.

Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation. Thanks to NASHP’s Population Health Team for their contributions to this analysis.

States Craft Collaborative Approaches to House the Homeless and Curb COVID-19

July 13, 2020/in COVID-19 State Action Center Ohio Blogs, Featured News Home Behavioral/Mental Health and SUD, Blending and Braiding Funding, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Equity, Housing and Health, Physical and Behavioral Health Integration, Population Health /by Eliza Mette and Jodi Manz

People with substance use disorders (SUD) who are experiencing housing instability or homelessness are particularly at risk during the COVID-19 pandemic, leaving states challenged more than ever to identify effective housing strategies that can simultaneously address the complex treatment needs of people with SUD while also curbing the spread of COVID-19 in congregate settings.

Addressing the needs of homeless individuals with SUD during the pandemic requires states to involve partners at various levels. Below are some of the collaborative and successful strategies states are taking to protect and support particularly at-risk individuals.

Separate, quarantine, and isolate. Massachusetts, through its COVID-19 Response Command Center, has worked to create sites for socially distanced living and quarantining across the state to minimize the spread of COVID-19 within congregate living settings. The state has also created five Isolation and Recovery (I&R) Sites, which provide a safe recovery space for individuals experiencing homelessness who have tested positive for COVID-19. Individuals recovering at I&R Sites are provided with all necessary services to ensure a safe recovery period, including behavioral health care and other supportive services. Interdisciplinary care teams offer comprehensive services to individuals recovering at the sites and ensure access to needed treatment, including prescriptions. Health care providers are also on-site, and partnerships with local behavioral health providers facilitate the provision of medications for opioid use disorder (MOUD) maintenance, telepsychiatry and counseling, support for self-administered MOUD, and other services.

Establish guidelines for non-congregate housing options. Ohio has published guidelines to assist communities across the state in leveraging hotels/motels for non-congregate housing options during COVID-19. The guidelines make clear that communities planning to establish isolation, quarantine, and specialized arrangements (units for people who are at high risk for poor outcomes or have significant behavioral health needs) must coordinate with local health departments and health care systems. The guidelines also establish procedures for hotels and motels providing housing, including staffing, equipment, and supply guidance. Ohio’s guidelines offer direction on support services, including telehealth for both medical and behavioral health services, case management, safe syringe disposal, assistance with prescription refills, and other supports for individuals with SUD.

Access to affordable, safe housing is a critical social determinant of health.

• People without stable housing experience significantly higher rates of both physical and mental illness.

• Investments in affordable housing programs lead to health care cost savings and better health outcomes.

Substance use disorder (SUD) and homelessness are mutually reinforcing. Underlying risk factors for homelessness can be aggravated by SUD, while people with SUD who lack stable housing have unique barriers to maintaining recovery, including lack of access to transportation to treatment, difficulty receiving and storing medications, and inconsistent social supports.

Reduce shelter density. Maine’s Department of Health and Human Services and State Housing Authority have collaborated to secure contracts with multiple hotels around the state to provide temporary housing for people who are homeless. Although not specifically tailored to individuals with SUD, this state initiative provides shelter to individuals during periods of quarantine and self-isolation. In total, the state has rented 115 hotel rooms at a cost of $7,950 per day. The state response has also resulted in innovative community partnerships with a state university. The University of Southern Maine formed a partnership with Preble Street Resource Center, a local shelter, to open one of its gyms to serve as an overflow shelter. At the beginning of the pandemic, Preble Street reached out to its community in search of additional space to allow for socially distant housing, and the university offered its space and staff to help set-up 50 beds. The state’s efforts have allowed its most populated shelters, which are frequently over capacity, to house appropriate numbers of individuals while keeping them separate from those who have tested positive for COVID-19 or are waiting for a test result.

As COVID-19 continues to sweep through communities across the country, states are being called to action to support their most vulnerable populations – and often those populations are in congregate care settings that pose social distancing and other pandemic-related challenges. States are developing approaches to effectively provide safe housing while treating complex health and behavioral health care issues and are doing so while anticipating significant impacts to their budgets. Investing in collaborative partnerships to implement service-driven models of care and learning from rapidly developed COVID-19 housing interventions can help states provide cost-effective care while working to prevent the rapid spread of COVID-19 within these communities.

States Weigh the Future of Housing Aid in a Post-COVID-19 World

May 18, 2020/in COVID-19 State Action Center Blogs, Featured News Home COVID-19, Housing and Health, Population Health, Social Determinants of Health /by Ariella Levisohn

Aided by an infusion of federal relief funds for housing and other support services, many states and cities are working to provide temporary housing to individuals experiencing or at risk of homelessness to keep them healthy and protected from COVID-19. But with difficult budget decisions ahead, it is important for states to consider the future implications of their short-term, emergency housing measures, and how to maximize government resources in the long-term.

Utilization of Rapid Re-Housing

Now more than ever, when homelessness is associated with high rates of coronavirus infection and renters are increasingly experiencing housing insecurity due to financial instability, housing assistance is critical in order to improve health outcomes and prevent individuals from living on the street or in crowded shelters. One way states are protecting individuals experiencing homelessness is through rapid re-housing, a program that provides individuals with tailored assistance packages and support, including short-term financial assistance, to help them move into housing quickly. Depending on the assistance and funding source, rapid re-housing can last up to two years.

Connecticut’s Department of Housing released guidance for housing providers to help expedite transitions into rapid re-housing. Ohio’s Franklin and Columbus counties also disseminated rapid re-housing guidance, including information on utilizing US Housing and Urban Development (HUD) waivers and providing case management services. Louisiana is using rapid re-housing to move individuals out of temporary hotel units and Rhode Island is prioritizing rapid re-housing for individuals who are currently homeless and awaiting placement in permanent supportive housing.

However, while studies indicate that only 10 percent of individuals in rapid re-housing programs return to homelessness, many do experience rental instability once their rapid re-housing assistance expires. In their guidance to homeless service providers during COVID-19, the Centers for Disease Control and Prevention encourages planning for ways to connect individuals experiencing homelessness with other housing opportunities after they leave temporary housing sites.

HUD’s Emergency Solutions Grant Program (ESG) is a common source of rapid re-housing funding. The Coronavirus Aid, Relief, and Economic Security Act (CARES) provided HUD with $4 billion in ESG funding, which the department began allocating to states in early April, and enables the expansion of rapid re-housing programs, among other housing initiatives.

In addition to ESG, state and local governments have access to a variety of other funding sources, including billions of dollars in allocations from the CARES act, which are designed to address housing needs during the pandemic. Both the ESG and Community Development Block Grant (CDBG) funding through CARES is being distributed in two waves, with the first wave released based on a FY 2020 allocation formula and the second wave, which has yet to be released, allocated to the highest-risk communities.

Encouraging an Equitable Approach to Resource Distribution

In order to guarantee that federal funding reaches the most at-risk individuals and is used in a cost-effective manner, ensuring the money is allocated equitably is critical. Communities of color and senior citizens are disproportionately affected by both COVID-19 and housing instability, and given the link between housing and health, supportive housing and rental assistance can improve health outcomes when used effectively. Because many housing assistance programs are locally run, rather than by the state, many cities are taking the lead and actively seeking ways to equitably allocate federal funding.

The Chicago Continuum of Care (CoC) COVID-19 plan sets aside housing for individuals at high risk of serious illness due to COVID-19, as well as youth, those living on the street, and families. The Chicago CoC is also reviewing data to ensure that people of color are housed in rates proportional to their make-up of homeless individuals in Chicago, rather than by population numbers alone.
In Seattle, the mayor promised to provide equitable access to rent assistance and noted that more than 70 percent of the rent support applications the city received came from people of color. The city is also working to help reduce barriers to housing assistance for seniors and non-English speaking residents.

In addition, HUD recently released a document detailing changes to coordinated entry prioritization for Continuums of Care as they respond to COVID-19. The guidance specifically notes the need to support individuals who are most vulnerable to COVID-19 and housing instability and calls on CoCs to consider the compounding effects of systemic inequities that contribute to high rates of homelessness among people of color when prioritizing housing assistance.

Increased Need for Supportive Services

In addition to using federal funds to support physical housing, states are also finding ways to ensure individuals experiencing homelessness receive other types of support services. Supportive housing combines housing assistance with wraparound services, such as behavioral and mental health services, substance use disorder treatment, and education and employment assistance. In addition to keeping individuals stably housed, supportive housing saves taxpayer money and reduces health care costs. The provision of wraparound services plays a critical role in helping individuals remain housed and healthy.

Given the extent of the public health emergency, there is an urgent need to help people access emergency housing and ensure they are simultaneously receiving critical health and support services. Coordinating case management and support services to ensure medication adherence and access to benefits, such as food stamps and health care coverage, can improve both health and housing outcomes. Some examples of support services that states can and are providing during the pandemic include:

Connecting individuals living in temporary housing with federal nutrition services.
Transitioning to telemedicine for substance use disorders treatment.
Helping individuals released from institutional care, especially prisons, create a housing plan to avoid living on the street or in congregant areas, such as shelters.
Utilizing HUD’s Continuum of Care Program to purchase cell phones and wireless plans in order to help individuals in shelters receive needed support services telephonically.

As states work to provide housing and supportive services to those in need, many questions and challenges arise:

How can states optimally leverage and coordinate federal funds?
How can states ensure that both newly homeless and chronically homeless individuals can access housing and supportive services in the future, after immediate funding and other resources expire?

With more people turning to rapid re-housing during COVID-19, state officials acknowledge that many individuals will require support not only during their transition into housing, but also after their short-term assistance expires, when they may need to transition to more permanent rental resources. Given the unprecedented loss in revenues to state coffers, most states anticipate deep budget cuts, which will make ensuring the sustainability of housing assistance even more difficult. As more individuals move into temporary housing, it will be critical for states to coordinate across health and housing agencies to maximize resources, housing stability, and positive health outcomes. Through its Health and Housing Institute, the National Academy for State Health Policy will continue to monitor and support states during this pandemic and beyond.

States Launch Rapid Response Teams to Curb COVID-19 Outbreaks in Nursing Homes

April 27, 2020/in COVID-19 State Action Center Maryland, Massachusetts Blogs, Featured News Home Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Coverage and Access, Housing and Health, Long-Term Care, Population Health, Workforce Capacity /by Chris Kukka

In several states, nursing home staff and residents make up nearly half of residents who have died from COVID-19, including 55 percent of deaths caused by the coronavirus in Massachusetts. While hospitals’ personal protective equipment (PPE) shortages have been highlighted, less attention has been paid to the critical need for PPE and infection control expertise at nursing homes. In response, states are launching rapid-response initiatives to assess and stabilize patients and provide infection control recommendations and support.

Maryland and other states state are creating teams made up of National Guard members, local health department leaders, and providers reassigned from neighboring hospitals to bolster infection control and testing among nursing home residents and staff. During a recent webinar, Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19, sponsored by the National Academies of Sciences, Engineering, and Medicine and other organizations, experts from Maryland’s Institute for Emergency Medical Services Systems and Johns Hopkins University School of Medicine highlighted their joint efforts to address COID-19 outbreaks in nursing homes.

Read a Q&A with Candace Goehring, director of Washington State’s Residential Care Services, to learn about that state’s response to COVID-19 outbreaks in nursing homes here.

Using a Strike Team Approach

Maryland Gov. Larry Hogan created a strike team initiative in early April that involves Johns Hopkins University School of Medicine experts and providers, the state Department of Health, emergency medicine professionals, hospital system leaders, and members of the National Guard. The private-public partnerships were already cemented by years of hurricane disaster planning work.

The rising number of nursing home COVID-19 cases that required hospitalizations, “made clear we needed in-place infection control practices in skilled nursing facilities as well as the ability to assess and treat these patients in the environment in which they were familiar,” Maryland State Emergency Medical Services Director Timothy Chizmar explained during the webinar.

How Maryland’s strike teams work:

When confronted with a COVID-19 case, nursing homes make requests for assistance to their county health departments, each request is then routed to the state’s emergency operations center.
The center dispatches a health assessment team made up of physicians, nurses, and behavioral health specialists from the Maryland National Guard, supplemented by personnel from the state’s Department of Health and Human Services to assess the needs of the facilities and stabilize patients.
The team triages patients into three categories, those requiring: hospitalization, moderate care provided by the facility, and monitoring of mild symptoms also provided in the nursing home.
A clinical teams from a local hospital assists the facility with treatment and proper infection control.

“We’ve engaged early on with our state and federal partners to form these teams,” Chizmar explained. “Out of these visits, we generate reports that are provided to the state and facility. These records don’t serve as a means to penalize the facility, they’re designed to help reassure the facility and patients and provide recommendations to help the facility continue to care for patients.”

To date, Maryland has averted two large-scale evacuations of nursing homes besieged by COVID-19, according to Chizmar, by stabilizing patients and providing temporary staffing until staffing agencies provide needed resources. “One of our successes has been to prevent patients transferred unnecessarily (to a new facility, which is traumatic for frail and elderly patients) for lack of staffing,” he added. Chizmar pointed out that it remains a challenge to recruit certified nursing assistants and geriatric nursing assistants, even after the state has loosened regulations over job certifications to boost this critical workforce.

The Importance of Universal Testing

Megan Katz, director of Antimicrobial Stewardship at Johns Hopkins Bayview and assistant infectious disease professor at Johns Hopkins University School of Medicine, addressed the toll that limited testing has taken on resource-poor nursing homes.

At the beginning of the pandemic, she noted, regulations set a low threshold for testing residents for COVID-19 – they had to be symptomatic with a temperature of at least 99 degrees F. “(Nursing homes) would wait for supplies from the state, and then waited another couple days to get the results,” she said. In that period, more residents usually develop symptoms. “They were left chasing their tails,” she added.

Working with the state, Hopkins put a team together to develop a new universal testing approach when a facility reported a COVID-19 case. The team would go in and test both symptomatic and asymptomatic residents and staff in a unit or often the entire facility.

The results were shocking, she reported. In cases where one or two positive coronavirus cases were initially reported at a facility, testing of all residents and staff in the entire facility revealed that three-quarters of the entire facility staff and patients were positive for COVID-19, with 60 to 70 percent of them asymptomatic.

“What we’re trying to do is to get many different private hospitals and academic institutions and state and federal partners to work together to expand the ability to test in these facilities, so they can capture asymptomatic residents and staff who are contributing to a lot of this transmission,” she said.

Once infected and uninfected residents and staff are identified, facilities are able to implement targeted infection control practices and identify infected, asymptomatic staff who may be working at several long-term care facilities and spreading the infection, she noted.

Massachusetts has also implemented targeted universal testing, using a mobile testing program that tests both symptomatic and asymptotic residents and staff at nursing homes, rest homes, assisted living facilities, and group homes, staffed in part by the National Guard.

In an effort to expand its nursing home testing reach, the state recently sent 14,000 COVID-19 testing kits to nursing homes, but only 4,000 were returned. State health officials have paused the program and acknowledged that many nursing home staff lack the medical expertise to conduct the tests properly, underscoring the importance of having trained National Guard or health care providers on loan from local hospital systems present in nursing homes to train staff about proper test taking and infection control practices.

Lingering PPE Shortages in Nursing Homes

Even after state “strike teams” work with nursing homes and improve infection control practices, the lingering shortage of PPE can contribute to the continued spread of infection among residents and staff, noted Chizmar. Having the capacity to immediately test residents – instead of waiting for the state strike team to arrive – would help nursing homes identify the infected and enable them to conserve PPEs, so they are used with only infected patients. Webinar participants noted that in addition to hospitals, nursing homes should also be the recipients of masks and other PPE by local community groups.

Webinar speaker and Massachusetts resident Alice Bonner, director of Strategic Partnerships for CAPABLE and adjunct faculty member at Johns Hopkins University School of Nursing, noted that in Massachusetts every nursing home with a COVID-19 case is assigned to a state health officials who calls the facility daily to ask about staffing, PPE, best practices for infection control, and other problems in order for the state to respond to quickly and get the facility the support it needs.

Massachusetts also has a website to recruit nursing home employees, a resource line for nursing home residents and their families to learn more about their facility’s situation, and a weekly call between public health officials and nursing homes to identify problems and solutions.

States Work to Protect Individuals Experiencing Homelessness from COVID-19

April 20, 2020/in COVID-19 State Action Center Blogs, Featured News Home COVID-19, Housing and Health, Population Health, Social Determinants of Health /by Ariella Levisohn

With few places to self-isolate, limited access to disinfectant supplies, and overcrowded shelters that reduce residents’ ability to physically distance themselves, individuals experiencing homelessness are at unique risk for COVID-19. Recent estimates suggest that up to 40 percent of homeless individuals, many of whom have underlying health conditions, may become infected.

As COVID-19 cases increase, states, with federal support, are adopting a variety of approaches to safeguard homeless individuals, including creating temporary shelters and renting hotel and motel rooms.

Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and Department of Housing and Urban Development (HUD) appropriations help states build and operate emergency shelters, provide hotel and motel vouchers, and provide essential services to people experiencing homelessness.

Additionally, some states are requesting authorization under 1135 waivers to use Medicaid funding to assist individuals experiencing homelessness.

Illinois and Oregon have applied for 1135 waivers to create new isolation and quarantine systems for those who cannot quarantine at home.
Massachusetts requested federal funding to use hotels as temporary housing for individuals experiencing homelessness and to help cover the cost of sanitation products to keep the temporary housing clean.
North Carolina asked to use Medicaid dollars to cover housing-related services, including temporary housing, housing application assistance and transfers, and moving expenses for homeless individuals who are ready to be discharged from hospitals.

Other state Medicaid offices are seeking flexibility to waive administrative requirements to address homelessness during the pandemic:

Arkansas submitted an 1115 waiver application asking for the flexibility to use federal funding to cover temporary housing assistance for its high-risk homeless population.
Washington State proposed targeted Medicaid funding to provide temporary shelter for homeless individuals who are currently under institutional care, so that hospitals can discharge these individuals and free up more space for COVID-19 patients.

In addition to using Medicaid authority, states are employing other resources to help individuals experiencing homelessness. In California, with a homeless population of nearly 130,000, Gov. Gavin Newsom dedicated $150 million to support local efforts to house individuals living on the street. In his April 3, 2020 address, Newsom outlined a plan to move individuals experiencing homelessness into temporary shelters, including hotels, motels, and travel trailers. The first phase of the plan, involving sheltering homeless patients testing positive for COVID-19, has already begun, with the state leasing 7,000 of 15,000 rooms needed. As of April 11, 2020, 1,813 of these rooms had been filled.

Washington State, hit early and hard by the virus, is also moving to open additional housing facilities for individuals experiencing homelessness. In mid-March, the Washington Department of Commerce announced that it was allocating $30 million to support the homeless population, with each county receiving $250,000, with the remainder distributed based on the county’s number of homeless individuals. Counties are using this funding to rent motel and hotel rooms and are focusing their efforts on individuals who have tested positive for COVID-19.

Kitsap County in western Washington recently opened two facilities to shelter homeless individuals who test positive for COVID-19 and those awaiting test results. In Seattle, the city’s Human Services Department, in partnership with other local public health departments, is working to expand shelter capacity by finding new spaces, such as the Seattle Center Exhibition Hall, to house residents from the city’s most crowded shelters. The department is also working on deploying hygiene and sanitation resources, such as public toilets and hand-washing stations, throughout the city. The Seattle Navigation Team is providing outreach to high-risk individuals experiencing homelessness to connect them to housing, sanitation kits, and medical treatment.

The Maine State Housing Authority, the Maine Department of Health and Human Services (DHHS), and the University of Southern Maine have teamed up to open a temporary shelter for homeless adults in a university gym. Located in Portland, the new shelter will house 50 individuals and alleviate some of the crowding in the city’s existing shelters to allow for physical distancing during the emergency. Individuals in the shelter are required to be screened for COVID-19 symptoms regularly and they receive food from the university’s food service contractor. Funding for supplies, including beds, comes from DHHS and MaineHousing. The University of Maine System also signed a memorandum of agreement with the Maine Emergency Management Agency that allows the system’s facilities, supplies, and employees to be used as needed to address the pandemic.

As the pandemic response continues to unfold, it will be critical to highlight how states use the flexibility granted under their new waivers, and whether and to what extent these dollars are used to address homelessness. Additionally, though 1135 waivers are only available for the duration of the public health emergency, states may identify new, creative ways to appropriately use Medicaid funding for supportive housing programs that combine rental subsidies with wrap-around services to help people stay stably housed. In California, for example, the governor hopes to continue to provide homeless services at the hotels and motels the state is renting out, and the current agreements allow for individuals to extend leases after the pandemic subsides.

As safe and stable housing clearly promote health, states and the federal government have both invested in programs that help historically disenfranchised individuals find housing and access health care and supportive services to improve equity. Though temporary during the pandemic, current state initiatives may generate new and valuable partnerships between the health and housing sectors. With the rise of COVID-19 and its health and economic consequences, it is more important than ever that health and housing sectors work in tandem to break down siloes and deploy resources in a coordinated way to meet the needs of those who experience homelessness.

States Craft Collaborative Approaches to House the Homeless and Curb COVID-19

States Launch Rapid Response Teams to Curb COVID-19 Outbreaks in Nursing Homes

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