Find seats and we will try to get started here. My name is ed howard. I am with the alliance for Health Reform. I want to welcome you on behalf of the board of directors. I want to welcome you to the program on health and housing with an emphasis on the relationship between medicaid policy at the Community Level at the state level and the federal level as well. This is actually a first in a threepart series and we will explore the intersection of social policy over the next couple months. In october, i believe its october 9, you will be looking at how well Health Services correlate with nonmedical home and unity based services. Then in december we will examine some of the emerging issues in connection between health and incarceration, which is is a growing area of concern and activity. There is a connection between health and various determinants and we will look at the strength of that connection during this briefing and the subsequent ones in the theory. You may have seen yesterday the new york city mayor bellagio announced a milliondollar program to connect more Homeless People with Mental Health care. I think just another sign of growing activity at every level to connect the dots that link Better Health and better housing. I hope that will bring a lot of light on that topic. Our discussion will center on how housing stability affects Health Outcomes and healthcare costs. They will look at the role in addressing this program and how much flexibility there is in federal policy to allow states and communities to meld those together. We want to look at what the obstacles might be. What are the biggest obstacles. We are pleased very much to acknowledge the centime corporation. One of americas largest private insurers. They operate in two dozen states. Before we get to the program let me do a little bit of housekeeping. In your packets there is Important Information including speaker biography one page materials and the Powerpoint Presentation in hard copy so you can follow along. There will be a recording of this briefing available on the website on monday followed by a transcript a few days later along with all of the materials in your kit and links to more materials we think would be helpful to you. At the appropriate time you can ask our Panel Questions by filling out one of the green cards in your packet or you can come to the microphones there is one on either side of the room. You can use the health and housing to tweet us questions and if youre watching on cspan to want to ask a question, you can also tweet a question. We will be keeping an eye on that and having them brought to the panel to respond. And at the end of the briefing there is a blue evaluation form in your packet that i would very much appreciate your filling out so we can improve these briefings and target them to the needs of the folks who come and need the guidance. So, enough of that. That. Lets hear from our very wellinformed panelists. We gave them in adequate introductions and ill do it so i wont disrupt the flow of the discussion as we go along. He is the director of policy at the National Healthcare for the Homeless Council. He is also on the healthcare counsel for marilyn. He has a perspective on how to connect and address these problems. Why its important and the opportunities from the state federal and local levels to address it. Then we will hear from the Senior Advisor for housing and services and she will explain the current activities and describe how her agency and others are collaborating health and housing issues. Gretchen will be next. She is director of colorados department of Public Policy and financing and that is colorados medicaid and chip programs. She is going to tell us about the bridge and what gets in the way of those efforts. Our final panelists is a family physician and she is founder of a phoenix nonprofit that brings private and public sectors together to help those experiencing homelessness. They will describe the Innovative Housing model and what gets in the way of this approach. So weve arrived to the part of the program that also has some substance to it. Heres barbara. I really appreciate so many people being here today. I think it really is important about the growing awareness of how healthcare is changing the country and in particular the impact that housing has on health status. The National Healthcare for the Homeless Council represent many Healthcare Facilities and the Homeless Individuals they serve. Over 1 million patients are being seen in these facilities each year. The lack of housing is really an issue not only for the Health Centers but the larger Healthcare System that we are looking to change. One one of the things that might not be intuitive is how housing affects health care. Back in the 80s the institute of medicine did a study looking at that very impact and they found three major relationships. Poor health causes homelessness. Typically what we would see as a spiral of people who had an illness, were unable unable to work and when youre unable to work and you get fired or laid off and you can no longer bring in money. You cant make rent or mortgage so you move in with family and friends and that doesnt work out so you go to a shelter or live on the street. You also hear that homelessness causes poor health. Living on the street or in a shelter is stressful and you are exposed to other illnesses. Without getting hospitalization or Emergency Care that tends to be very high. High blood blood pressure, Mental Health issues alcoholism depression all tend to develop. If you didnt have them before you tend to develop them afterward or they get exasperated. You also think about how lack of housing complicates treatment. We are putting billions of dollars into our Healthcare Industry every year. 2 trillion. None of that funding works well. Nothing that we do as Healthcare Providers works well when someone is living on the seat. Street. Every time we turn someone to a 90 Day Treatment Program it is only to discharge them to the street we have complicated and probably compromise the treatment we just invested. When we discharge from hospital to the street the wound care that we just paid for is now compromise. These are the things that are really bundled up together in health and housing. We need to appreciate how we can rectify that through housing. One of of the things we are seeing, as again we represent the doctors in nurses and addiction counselors and the workforce that goes beyond caring for these patients, and what we see, not surprisingly, is very high rates of acute and communicable diseases. Respiratory illnesses, infections from cuts that you cant keep clean diabetics on the street, the rate in which we replace medication is astronomical because of the rate they are stolen. When you cant keep your medication safe or refrigerated its hard to maintain compliance with your healthcare. How many times as anybody here gone to the doctor and had a prescription given to them that may cause them to visit the bathroom more often . Thats just not possible. No need for show hands. [laughter] thats just not possible when Public Places dont allow homeless to use the public restroom. We have local ordinances increasingly that criminalize that activity so really what we see as Healthcare Providers, our client come in and say i didnt take that medication because otherwise id get arrested or i was afraid of getting arrested or i didnt have any place to go or made meds were stolen or my needles were stolen or its not safe for me to have needles. This is what we hear. We see when we look at the literature it shows people who are homeless get diseases at three to six times the rate everyone else does. Theres still asthma and diabetes and hypertension and high cholesterol and Heart Disease that everybody else has but it still in higher rates. We see a lot of intensive needs and we see both extremes of use of the Healthcare System. We are getting a lot of attention in the frequent user of very high end user were putting a lot of money into a small number of people that we need to stabilize, but we also see people who are living on the outskirts of our society who avoid our Healthcare System that have intensive needs, usually in the Mental Health and Substance Abuse treatment area. How is it that were reaching those people were very fragile and in need of care . Will look at our hospital systems, they are really stressed. They really get it when you are a hospital and you have no safe discharge option for a client that is ready for discharge. It is illegal to discharge to the street but as with anything else we get discharged for rest and recuperation. What do you do for someone who doesnt have any place to go . These are these are the real issue that local Healthcare Systems are facing. What can we do to provide safe and ethical treatment for people question what we see a lot of people wear when they are ill, its difficult to get back out of homelessness. Working on housing and getting a job, if youre fighting an addiction or Mental Health and not in treatment, its very hard to get out of the shelter or off the street. Just one example of in a healthcares situation, people who are homeless have disproportionate high rates of every disease you can imagine. That brings us to support of housing. When we think about what is Supportive Housing, its typically helpful to think about in terms of a traditional model that emphasizes recovery first. Traditionally, in our communities, we required people to get clean and sober. Weve required them to enter into treatment and be successful with that before we get them into a housing unit. Is everyone follows the rules and you continue to follow the rules then maybe one day you can be in independent housing. While while that certainly works for some it doesnt work for people have really serious Healthcare System. Its hard to get clean when youre living on the street. The Supportive Housing slips that model. Its not not timelimited. Its the same lease as anybody in the community. Frankly any one of us can go home tonight and have a drink and its perfectly all right to do in our home. It needs to be an opportunity as well. We need to work with people where they are in the stabilizing unit of housing so weve got that stability. So people have a place for have a place for the medication, they have a place to put an appointment card and keep track of them. Our outreach people people cant find people when theyre shifting around on the street and encampments change a lot. We need to think about how are we supporting housing in this way. A wide range of teambased services is really the key to making this work. When you combine this biz untrans the ability of housing with Healthcare Services, we can can help people be stable in their housing. This is mainstream right now for seniors and people with disabilities. My grandmother has meals delivered to her peerage and have in care help to help her bathe and keep the house clean. All of these things im taking for granted. Speaking about extending that into this population so we are supporting the housing and the services that people need really isnt keeping up with that same theme. I want to talk about our relapses part of recovery. These are things we need to expect. Recovery in Mental Health and addiction doesnt look like black and white and yes and no. It looks like a struggle. When we have we have people who are in zero tolerance housing, even that one slip up advertises your housing and you could be back on the street. Its really important that we are able to work with people and adJust Services if they need that. Again. Again theres no requirement for sobriety and the services are voluntary, but what we have find found his people are very excited when they get into a unit that now so many things were possible that didnt seem possible before. We been evaluating the effects in the peerreviewed literature for about 25 years and consistently, what we find is that housing improves health and it improves Health Outcome and lowers the total cost of healthcare. I think this is really where we need to be in rethinking housing because we are so focused on cost right now, understandably so. We need to think about where is it we can be making a partnership. You can read the slide here. There are consistent findings over all of these issues but again you really want to focus on how is it bringing these two sectors together is really bringing us the things that we need. There is a lot of opportunities at both the federal, state and local level. All of of your states are working on studies to end homelessness and improve health. Were looking at greater determinants of health. One thing that is important in d. C. To remember is we need federal support for the housing piece that goes along to making this work. My colleagues here well talk a lot about what they are seeing in their sectors but again the cuts that are required by sequestration if we dont have the Housing Support to put people in, no amount of our Healthcare Services are going to make this work well. We need these to come together. Another thing i would really recommend are the take away points, for all of you who are health staffers and those of you who are housing staffers, get to know each other because you have a lot in common. A lot of times we are not working together at the federal level like we are asking them to do at the local level. That would. That would be a lot of things i would recommend. What we are doing at the local level is to try to bridge that gap. We are in a rapidly changing environment including medicaid but the system as a whole is changing. We are focused on outcomes and cost we also need to be focused on Vulnerable People and getting them what they need. Nothing works well as a Healthcare Provider if theyre living on the street. We really want to focus on housing as a healthcare intervention. My colleagues will talk about how hard they focus on building this bridge from housing to health is an illustration of how we are trying to Work Together to make this model work and achieve the outcomes we are looking to achieve. I want to point out, my colleague matt warfield, he can take your car to get back to you if you are looking interested in looking into this further. We we really appreciate you being here. Thank you barbara. I am jennifer. I like to joke that means i am the one person that knows the difference between medicare and medicaid every day. You know what im talking about, dont you . My background, actually i spent the first ten years in my career in managed care. Largely medicaid and medicare managed care. It was in that work that i was first brought to the table to consider the relationship between homelessness and health in the impact that the board of housing would have on both Health Outcomes and spending. I have been doing that ever cents for the last 18 years. I want to assure you that there is an unprecedented level of collaboration happening today between hud and hhs. Not just because of my job but because it really is the case. Hud is trying to talk with medicaid almost every day. Were talking to folks at many different organizations. Were no it feels that housing and healthcare are miles apart and no ones talking, but i want to promise you, in this administration, there is an unprecedented level of collaboration. There is a simple fact about how we invest in housing federally that a lot of people dont know because you operate in a world of mandatory budgets. Federal Housing Assistance is not an entitlement. When someone becomes eligible for medicaid or medicare, they get it. If you fill out an application for housing, you get in line. When we asked congress to invest in more affordable or Supportive Housing they worry about the renewal burden. The fact that this increases our total budget in future years something i like to say keeping people in their homes. The conundrum is today, hud pays for a lot of services and housing that medicaid could pay for medicaid has a lot of financial incentives for there to be a lot more affordable, accessible and Supportive Housing and the budget environment is such that were not doing what we know works and not doing anything at the scale that matches the need. That is that is why im excited to be here with you today because your interest in housing could help create the consensus that we need to make the investment that will matter. Thanks for being here and thanks for allowing me to be on this incredible panel. I want to talk about how this plays out in three areas, aging, disability and homelessness. Americans are living longer and the age of 81 will test our commitment between the relationship of housing and health. The ages and equalizer we will be more likely to live alone have chronic Health Issues, less mobility and we grow p