This article appears in the Winter 2018 edition of Shelterforce magazine. Subscribe here.
Petersburg is not the kind of town that jumps off the map when you’re scouting Southern Indiana. Planted in farmland equidistant from St. Louis, Indianapolis, and Louisville, Kentucky, the 2,300-person community boasts coal-fired power and farms as its top industries.
But nestled on a downtown street across from the Kuttin’ Loose hair salon and the Home Building Savings Bank is a different kind of success story, and an example of how community housing and health care are taking a new turn toward the future together.
Downtown Terrace Apartments, which opened nearly three years ago at 611 Main St., offers low-income and senior housing that also includes an on-site health center.
Jointly funded by the National Equity Fund, Indiana Housing & Community Development Fund, and Pike County Progress Partners Inc., the 42-unit complex is part of the new wave of joint programs providing housing and health care in one spot.
“It is a very great thing to have here because a lot of (tenants) do not even drive. We are a senior facility,” says Sherry Riker, property manager for the complex, which is managed by Flaherty and Collins Properties of Indianapolis. Riker said the health center includes both general practitioners and mental health professionals, and serves 50 to 60 patients daily. “We’re a very small town so the outside community uses it, but they give special help to residents, deliver prescriptions for free. They provide meetings for them and classes on eating healthier.”
Related: The Next Step in Supportive Housing
Downtown Terrace is among the recent spate of community housing projects across the U.S. that also include on-site health care centers. According to organizers and government agencies, dozens of health care providers and their community housing counterparts in cities like New York, Chicago, Cleveland, and Phoenix have stepped up joint efforts in just the past few years.
Organizers and housing advocates say that while this may be a natural option for tenants and residents in these communities, the headaches involved in marrying the two services, each with its own regulations, funding sources and, of course, bureaucracies, is what discouraged efforts in the past. They’ve only taken on the double challenge in recent times due to the growing health needs of residents, and the increase in data showing the positive aspects of on-site health clinics.
“My struggle was to get residents to go [to the clinic]. The older community wants to stick with the doctors who have been [treating them] for a long time,” Riker explains. “But when they can’t drive, they ask us to go over there and set up an appointment.”
But while these “co-locations” fill a long-needed void in low-income and homeless housing, veteran managers warn that those developing and managing them need to pay close attention to make sure the funding is there, the services are proper, and the patients are served.
“What’s most important is to see if you can come up with some common goals,” says Eva Schweitzer, health finance director for the Local Initiatives Support Corporation (LISC), which has launched at least 10 such combined locations for housing and health since 2013 through its Healthy Futures Fund (HFF). “This whole movement of combining health centers with other social service providers is that when you operate separately you achieve some impact, but when you work together, you have a greater impact in the community.”
Schweitzer pointed to what is known as the “warm handoff.” Rather than give a patient a referral to a health center elsewhere, staffers can physically [accompany] them to the health center on site for direct access. “That’s one less obstacle for the patient to cross.”
Andrew Ellis, who provides administrative support for the Primary Care Development Corporation—a New York-based health center funding source—agreed.
“There’s a direct correlation between how you are living and how healthful you are,” Ellis says. “It has some relationship to health. That would make perfect sense.”
Schweitzer said HFF began with donations from Morgan Stanley, the Kresge Foundation, and LISC, and has invested more than $158 million in projects nationwide that address the critical social determinants of health, which include education, employment, and housing stability. Several projects are health centers within or adjacent to housing projects and residential communities that serve low-income or homeless residents.
She said HFF’s first project was Lloyd House, an affordable housing rehabilitation project in Menominee, Michigan, which has 44 apartment units and a local community health center operated by Northpointe Behavioral Health. It provides basic health care and exams, as well as mental health treatment and counseling. The financing closed in April 2013 with a $10 million investment and the location has been in operation since 2014.
Another project is Rolling Hills Apartments in St. Paul, Minnesota, which used some $100,000 in grants from LISC and Kresge to help fund the renovation before it reopened with a health center in 2014.
Shai Lauros, LISC’s national program director for health, said the co-location effort took two phases to complete. The first was raising the $200 million needed for the projects. The next challenge was bringing the two different types of organizations—community health and community housing—together.
“Part of it was to encourage folks [who] are involved in health and housing that don’t typically work together to work together on the programs and the developments,” says Lauros. “So they could comprehensively improve the health of the families and residents. Encouraging through the co-location that the programming would have elements of different health care providers coming together.”
This often means going to different entities to show them how a partnership benefits them, says Lauros. Many city and county housing and health departments have taken the initiative to team up and have realized that good health goes beyond the clinic or doctor’s office to include employment, nutrition, safety, and housing.
She added that the immediate questions included, “How could we bring new sources of capital to health clinics at a time when there is such a high need? How could we help them increase the number of patients they could see? How could we expand health care programs and service to tenants of low-income housing who are only financed through low-income tax credits?”
The answers are often simple, but not easy to put into practice.
“On the health side, it depends on the state that you’re in,” says Schweitzer. “It’s an intense time to be a federally qualified health center operator. They receive federal funds to treat the uninsured. Grant funding is going to run out unless they do something, it is a very precarious time. It inhibits health centers from wanting to take on new projects.”
On the housing side, there are community needs assessments, architectural works for preliminary designs, and help needed to evaluate the impact and coordinate it all, Schweitzer explains.
“You have to mitigate risk,” she says. “If a source of funding goes away, you have to know where to fill it in other ways. We either have that expertise or we will work with organizations that do. And bring in consultants and technical assistance providers.
We are able to help people to capture illnesses before it gets to the point where they need emergency room services.
“When it comes to a capital project, partnering with experienced organizations is critical,” she added. “It is the difference between a sustainable project and not. They need partners with experience to navigate and those partners are there.”
When judging whether an organization is right to work with, ask for a “portfolio of previous projects, knowledge of the zoning and permitting processes in a given area, and [find] someone who is local, knows the community, knows the process, and the people involved,” says Schweitzer.
Another success story some 180 miles north of Petersburg is Walnut Commons Apartments in Muncie, Indiana, where 44 apartments have been built for low-income and homeless people, along with a health center operated by Meridian Health Services.
The new development, which opened in June 2015, includes one-bedroom and studio units and subsidized health care.
“We are permanent supportive housing for the chronic homeless. If they come to us, they have been on the street or lived in their car or a homeless shelter,” says Tina Black, the property manager. “We take them and house them no matter what.”
Black said each new tenant receives a $300 package of hygiene and cleaning supplies, bedding, and access to a food pantry. The apartments are furnished, but each person is allowed to bring in “minimal items.” Rent is based on income.
Up Development, of Chicago—which has five affordable housing buildings in the city—oversees the project.
“Some people are not able to cope because it is a tight-knit community and they do not fit in well with others,” Black says. “We reposition people or we have had residents who have gained employment here or received their degrees, gotten married, and moved on.”
She says it’s the health center, which opened in March 2017 and operates with a three-person staff two mornings per week, that has made a major difference.
“The positive is the convenience for sure,” Black says. “Our residents don’t have transportation and because they were homeless, they do not have cars. We are also located in a doctor’s office desert; there are none for a couple of miles.
“The biggest challenge is the insurances. Insurances don’t always cover what they need healthwise,” she says, explaining that a person must have certain disabilities in order to get a subsidized rate for public transportation
Black says it’s vital that health center and housing officials work together if the dual operation is to be successful.
“It’s important for the people who are running the clinic or working inside to communicate with the housing side extremely well,” she said. “There needs to be a collaboration between all sides of the building. You don’t always know who is coming to the community.”
Black cites the use of a case manager who is assigned to each tenant by Meridian Health as an example of keeping the health side and housing side connected. She says the case manager helps reluctant or shy residents make appointments or ask questions of doctors.
Black also says she regularly updates clinic staff about events and the needs of tenants, while also alerting tenants to vaccination sessions, group clinics, or other services offered in the health center.
Something as simple as parking can be an issue with two different operations, says Black. “One of the challenges that we were faced with was in the construction of the building. Our parking lot is on the opposite side of the clinic. When I have an elderly person in a walker or on oxygen, they are having to walk through the smoking area. Keep construction in mind.”
Schweitzer also offers advice for those who might be planning to open co-location sites. Rule No. 1: Scope out the area and see if it will work.
“Early stage planning I cannot emphasize enough in the community you want to expand in,” she says. “Making sure the need is there, that there are not already others there providing the services. You really don’t know until you look into it and do the research. Things like transportation. If there is limited transportation, it might not be a good place to put a center for the residents as well. Zoning is also critical, doing an environmental assessment. Those early stage issues can drive up costs and delay projects.”
Robert Friant, managing director of the Corporation for Supportive Housing (CSH), which has launched co-locations in New York, San Francisco, and Hartford, said even with the challenges, the co-location model is a vast improvement.
“It is affordable housing paired with the essential services that keep people housed,” he says, pointing to the Woodstock Hotel in New York City, a homeless resident housing project that added a health clinic onsite more than 30 years ago. “Just putting a roof over their head does not solve the problems of homelessness. The benefits are proven. As easy as we can make it for those individuals in supportive housing to access these services, the better the outcome. Having access to clinics on site or close by is very important to us.”
Friant points to a study, conducted between 2013 and 2015, that shows a greater increase in the number of patients 50 years and older who use such health centers compared to the general population. CSH’s own health centers saw a 30 percent increase in patients 65 and older.
Friant notes that “The No. 1 issue in terms of having services on site is cost, it is not cheap to offer a full-service health clinic on site . . . expertise is also an issue. Supportive housing providers have great experience in creating and sustaining housing. They don’t have as much experience on the services side.”
Jonathan Chapman, director of community health center advisory services for Capital Link, a national community health center cooperative, says navigating the different funding sources for health and housing is important.
“Housing is a little different, some of the financing options are a little different,” he says. “Initially, everybody has their paths of least resistance. For community health centers, we have four or five funding streams. When we work with housing authorities, they work with a different type of tax credit, the lawyers are different, the jargon is different. A lot of times it is that translation between financing options and construction issues.”
Chapman says Capital Link has partnered with CSH to forge their combined health and housing knowledge in one unified approach that, in many cases, include training others: “It is kind of a new bite for the community health center services to get into. New challenges.
“We know what we’re good at so when we work with CSH and have co-presentations, they will talk about the community housing side. A lot of it requires community engagement and that is a lot of the same people and a lot of the same directive.”
Asked what some of the important areas are for those seeking to create co-location programs, Chapman says: “Health centers need to understand what housing authorities’ goals are. You have to find two personalities that get along as long as they are pointed toward the same goal. Some health centers want to fund financial education, a nutritional kitchen. The housing authority may want the health center on site, but are the type of services you provide different than what you would provide as a standalone? Who are you serving? Mixed families? The elderly? Homeless?
When is it a good, or bad idea?
“There are always red flags. In some cases, you have to look at existing providers. If a housing authority is trying to build something across from an existing health center, that can be difficult. In some cases, it is also finding a partner that is financially solid,” Chapman says. “A housing authority may give you 500 square feet, but if that is not enough to ensure revenue and make it sustainable, it won’t work.”
Chapman says that federal agencies, such as the Health Resources and Services Agency, are urging more overall care at health centers and fewer per-visit fee payments, instead advocating for “value-based reimbursement.”
“There is an encouragement to pull resources together, and that includes housing,” he says. “HRSA provides some funding toward the community health centers and in exchange for that they have quite a bit of input in the type of services they are required to provide. They are asking health centers to report more on the social determinants, which include housing.
“It is about how we stay in touch with your patient and how they take care of themselves when they are outside our offices,” Chapman adds. “You will find it starting to influence everything and everyone understands it is a much more efficient system. Instead of being paid to get them in the door, it is being paid to keep them healthy.
Some health centers provide diet information and help patients shop for healthier groceries at local shops beyond convenience stores. Some locations have even provided monitoring equipment that keeps tabs on a person’s heart rate, blood sugar levels, as well as other vital signs.
Noni Ramos, vice president and chief lending officer for Enterprise Community Partners of Maryland, says the different funding streams for housing and health care must be understood.
“There are very specific finance and funding sources for affordable housing and very specific for federally qualified health centers,” Ramos notes. “Those do not always work well or in a complimentary way. We try to be that intermediary so that you aren’t out of line, and so you can put them side-by-side and they can be in a co-location.
“Housing has its own financing system and it works in its own unique way and on the health side it has only been recently that they have brought in the private capital, it is a newer component of health care. Their primary work is to be health care providers so they are not necessarily real estate development experts. There is a real learning curve.”
Ramos cited the Care Alliance Health Centers that have been in place in or next to several existing public housing complexes in Cleveland through the Cuyahoga (County) Metropolitan Housing Authority.
Carly Hill, interim development director for the Care Alliance Health Center, says there are two clinics inside public housing buildings, and a third located next to several others.
She echoed many of the same views as those in the other co-locations: that the ease of access helps treat and prevent health problems.
“We are able to help people to capture illnesses before it gets to the point where they need emergency room services,” Hill said. “We have our own in-house pharmacy and dental services.”
About 92 percent of the patients are below the federal poverty level and about 40 percent are homeless or not in stable housing, she says. The clinics also see 1,600 pediatric patients per year.
“It is preventative primary care,” Hill explains. “We are focused on well visits and a lot of our patients have chronic illnesses— blood pressure, diabetes—and we have partnerships with the larger hospital systems.”
Adds Ramos: “Part of it is having expertise, bringing in expertise in planning, understanding where folks are, where folks will be able to access the health care, bringing health to where individuals are living . . . and a lot about learning and building relationships. Much of it is starting to learn, each sector learning about each other.”