Good afternoon, everyone.
Thank you so much for joining us.
We're really excited to have this presentation today and to see this incredible audience.
I see housing advocates.
I see health care advocates.
I see individuals who've experienced homelessness.
And I see people who want to build more affordable housing.
I see folks in the audience who've been advocating for health care for all and folks who want a regional health plan so that everyone has access to health care.
Today, we're combining these two topics of both housing and health, two of the issues that are usually in my committee, the Housing, Health, Energy, and Workers' Rights Committee.
We've created an extra special conversation today for us to have a lunch and learn.
I'm glad to see some folks have brought their lunch so that you can both feed your brain as well as you feed your bodies.
We want to walk out of here full, full of information about how we can better care for those who are the most vulnerable and who've been left out for far too long.
Whether it's left out of the housing stability that everyone has the right to, or left out of access to healthcare, which everyone should have.
We also know that today is an extra special day for those in the press, and we thank you for being here with us today because they are covering this important topic of homelessness here in Seattle.
One important takeaway that I hope all of us have heard in the last few months and, frankly, the last few years as we've been talking about the crisis of homelessness and housing is that many individuals who've experienced homelessness, who are experiencing homelessness, have had a health complication that has either led them to being housing unstable or economically unstable, and thus they are dealing with a health care crisis while they are homeless.
We also know that we can prevent homelessness if we can also help individuals have access to the health care that they need to prevent individuals from becoming economically unstable or housing unstable.
These are the two issues that we know inherently.
Too often, housing is decoupled from health.
And today we'll have a conversation that I hope will be the first of many.
Actually, we've talked about this before in our committee.
a continuation of our conversation around how we can better couple health services with housing services.
Here in the city of Seattle, we have begun doing a better job of making sure that those who are now finding homes or shelter also have supportive services that come with healthcare services.
We want to build more housing that is coupled with permanent supportive services because we know that it's not just a door or a bed or a roof that many people need.
It is the ability to access medications, case management, know that you can go somewhere for preventative health care or ongoing health care.
And today we're going to have a conversation about what we can learn from other cities and what we've done here in our city as well.
I think that this is an incredible opportunity for us to hear from some national experts who've been doing some great work, but also from you.
We will share a few minutes or save a few minutes at the end if there are questions from the audience for folks to line up as well and ask some questions from the audience.
So thank you all for joining us and for turning out and for being present.
And frankly, for already making sure that healthcare is always coupled with housing and that we treat folks in the humane and holistic way that folks deserve.
I appreciate that Councilmember Bagshaw has joined us today for this Lunch and Learn.
And before I begin any more, I would love for folks to introduce themselves at the table so that we all know who's up here before we get started.
Council Member Bagshaw, did you want to introduce yourself as well?
I'm Sally Bagshaw, and I have, over the past few years, been deeply engaged in human services and housing, not just as a council member, but across the street in the Prosecuting Attorney's Office, where we've really focused on pairing the mental health, physical health with housing, knowing so well that they're critical and they are entwined.
And if we're going to have a healthy community, it means that people have to have a roof over their head and they have to have access to just basic health care.
Wonderful.
Why don't you introduce yourself and then I'll make a few more introductory comments.
Hello, everybody.
I'm really pleased to be here.
My name is Lisa Chan Son and I'm the principal and CEO of Transform Health.
And we do systems transformation work across the nation.
And hello, I'm Jessica Kendall.
I am the director of stakeholder engagement with Transform Health.
Excellent.
So we do have some copies of the PowerPoint presentation that are on the table up here.
If you haven't yet had a chance to grab one, we want to make sure that this is an accessible conversation.
And we will keep the slides going at the front up here as well.
In one of the first committee meetings that we had in the Housing, Health, Energy, and Workers' Rights Committee was to talk about the integration between these policy topics that are all too often siloed.
We actually know that what makes us healthy as individuals, you think that it's health insurance, but actually health insurance is only about 5% of what makes us healthy.
What makes us healthy as individuals, as families, as community, are the social determinants of health.
Do you have access to affordable housing?
Is it healthy housing free of mold and toxins?
Do you feel in your work that you can speak up and be free from retaliation and intimidation?
Do you have the ability to voice your concerns?
fight for a union, talk about if you've been experiencing wage theft.
In the community, do you feel like you've been under stress because you've been living in poverty?
All of these issues affect our health and health outcomes.
We in our committee have talked a lot about how your zip code or your race and ethnicity should not determine your health outcomes or the life expectancy of you or your family members.
Yet far too often, our race, our ethnicity, our zip codes determine our health outcomes and our quality of life.
So with that in mind, our committee and I think the council as a whole has been fighting to make sure that we actually build the housing, that we invest the capital dollars necessary to create housing so that individuals who are experiencing homelessness or those who are on the cusp of falling into homelessness actually have a place to live.
And in doing so, we also recognize that they will only be able to maintain housing if their healthcare needs are met.
We've heard multiple examples of cities throughout the country who have done a really great job of making sure that individuals not only get a place to sleep at night where their materials are safe, where they feel like it's a place of their own and they don't have to get kicked out at 6 in the morning, but that they also have the healthcare services that they need.
That includes connecting the mind, the body, and the mouth, making sure everyone has access to mental health services, physical health care, oral health care, making sure prescriptions are readily available, and that access to treatment and counseling is also available.
It means also recognizing the whole body and making sure people have access to case management services so that they can maintain jobs.
Because let's be clear, many individuals who are homeless also have jobs.
And making sure that they can maintain their employment or find employment is something that's critically important for maintaining housing.
Today we'll be talking about Sacramento's example.
And what I want to put into context is in Sacramento we will hear about ways in which the city and advocates have used innovation waivers, the federal 1115 waiver which was made available under the Affordable Care Act as one revenue tool to help provide additional healthcare services to those who are very low income, those who are experiencing homelessness and those who are on the cusp of falling into homelessness.
But we'll also talk about how this safety net could be replicated in a place like Seattle.
So while we might be using 1115 waiver dollars, we also know that we have a deep need for additional revenue in our city.
As we've heard over the last two to three months, This region is lacking about $200 million in what is needed annually to invest in the housing needs of our city.
The report that was put out, financed by the Chamber of Commerce themselves, said that we need in this region about $410 million a year in King County to provide housing to those who are unsheltered.
And Councilmember Baxter and I have been working very hard to make sure that those are coupled with the healthcare services that are needed.
So while we don't currently have the revenue stream like you see in Sacramento's 1115 waiver, we do know that we need a revenue stream that is secure, that is stable, and that is allocated to housing and health services.
And we also know that there's some really innovative ways, which we'll talk about at the Board of Health meeting at 1.30 in case folks want to go across the street.
we can talk about ways that we can expand access to health insurance.
And while health insurance does only make up 5 to 10 percent of what makes us actually healthy, it is critical for preventative health care, for making sure people have access to prescriptions and regular screenings.
And in the Board of Health meeting, we will continue this conversation about how we in this region, in King County, could potentially replicate a regional health plan, much like what we see in San Francisco, much like what we see in LA and New York and some of the other places that I know you guys have expertise in as well.
And so I want to be clear that this is a conversation about how we care for the most vulnerable.
Today we'll be talking about how we provide health coupled with housing.
And later this afternoon at the Board of Health, let's think upstream.
Let's get healthcare for everyone.
Let's treat healthcare as the human right that it is and really fight for a regional health plan.
That's what we'll be talking about this afternoon.
Yeah.
So any additional comments before we get started?
Okay.
Great.
Awesome.
So let's go ahead and get started.
Wonderful.
Thank you.
Pull this real close, okay, Jessica?
Yeah, this slide.
Real close?
Yeah, there you go.
All right.
Well, thank you, Council Member Mosqueda and Bagshaw.
I appreciate the opportunity.
We appreciate the opportunity to come, be able to share the work that we are doing in Sacramento, and hopefully it can help spur some ideas to think a little bit outside of the box.
I can definitely say that although we're talking about Sacramento, I am a Washington resident and I have definitely been witnessing the crisis that's been unfolding over the last handful of years.
And there is an incredible opportunity to make some transformative changes at the local level and at the state level because we have some really pressing needs right now to address the needs of our most vulnerable in the state.
So what I want to do is go through, real brief, who is Transform Health and why are we actually here and talking to you about this.
Discuss the intersectionality of health and housing, which Council Member Mosqueda definitely touched on, but I think it's a point that many of us realize, but we really need to drive home and keep talking about because too often those two topics are siloed.
And I'm going to give a brief overview of what California is doing, although you guys can come up with other creative funding streams.
and then go into a deep dive of what we're doing in Sacramento and the promising approaches.
And please, council members, interrupt at any point with questions.
So Transform Health, we are a full-service, mission-driven firm, and we're focused on customized solutions to transforming systems of care.
But really what that means is majority of us, and we're a very small team, are consumer advocates and have come from a long career of doing consumer advocacy.
And all of us are committed to fighting for the most vulnerable, and that's the focus of our firm.
We have a deep expertise in health systems transformation, which is really critical to what needs to happen in My opinion in this region and in other regions around the country, if we want to actually transform the way care is delivered and received, we also have a lot of expertise in stakeholder and community engagement and health policy analysis, outreach and enrollment, right?
We need to be reaching out to the most vulnerable.
to be able to get them interacting with the programs and have those programs interacting in a way that actually works for all of the different systems and the folks that are using them.
So at baseline, looking at this at the national level.
Housing is a health care issue.
So nationally, and I apologize, we don't have the Seattle statistics.
We do know over half a million people on any given night are sleeping on the streets.
Nearly a quarter of them are children.
And nearly 50% have some kind of chronic illness.
Almost 40% have mental health problems, and over a quarter have issues with addiction and drugs.
So when you're talking about the homeless population, we automatically have to shift the conversation to be talking about health.
When you think about it from a systems perspective and a financial perspective, the annual health care costs per homeless person on average nationally is $35,000 to $150,000.
To house those folks, and granted, it's going to be different depending on the city that we're talking about, but to house them is $13,000 to $25,000 a year annually.
Where this really shows up, and I think this is where in Sacramento this conversation was driven by health systems, is if you look at emergency visit and hospitalization rates, a homeless person is 9 to 12 times high, has a higher likelihood, they're showing up, excuse me, they're showing up in the ER and getting hospitalized 9 to time, 12 times higher for a homeless person than for somebody who's housed, for a housed patient.
So if you are homeless, what this means is that you're ending up in our ERs, you're engaging in a lot of times, especially for the most vulnerable of the homeless, interacting with our police department, our fire department, our emergency systems, which has a huge cost on our regional systems, but then it also has a significant cost on the individual, both of which we want to be addressing.
Not only that, we're finding and we've learned that the homeless is an extremely complex population and that there are subpopulations, which many housing advocates are very aware of.
When we think about the chronically homeless, we often talk about the trimorbidities of mental health, having physical health conditions and addiction issues, but many of this is also driven by trauma, by poverty.
estrangement from family and friends.
And, you know, when we look at when they present within the ERs, it's often with pain, intoxication, withdrawals.
Average life expectancy for this population is 47 years.
But this is a population that we all know, that the police know by face.
Many folks in the room also know who they are, where they are currently living.
They're an extremely complicated population.
And when we drill down further, we know that this population is also growing because of many other issues around housing, availability of housing, rental rates.
For example, in Sacramento, we've had a significant increase in the homeless population because rental rates have gone up 60% over the last five years.
Many cities nationwide are facing similar issues.
And because the homeless population is not always the same, they're changing.
We're seeing new entrants that have very specialized needs.
So, for example, we are starting to see within the program that we're talking about in Sacramento, over 50% of our enrollees are over the age of 50. And we're finding that it's because there are a lot of seniors on fixed incomes who are being pushed out of their homes because of rising rental rates.
And so all of this is to say there's a huge budgetary and a personal impact for people living within cities that will continue to drive emergency room costs, housing costs, and also has a significant impact on the quality of life.
So housing is an incredibly important social determinant of health.
Without housing, there are clear limits to what we can do within the health care system to drive improvements in health outcomes.
Without a doubt, housing first is a best practice.
But, you know, let's talk about the elephant in the room.
There are a lot of cities where land and ability to build more housing is not always readily available or it is extremely costly.
And so when you have a situation like that, you really need a multi-pronged strategy to support and address the needs of this population.
And I think for the rest of this presentation, as we talk about what is happening in California, specifically what we're doing in Sacramento, we really want to acknowledge, obviously, having housing available and shelters available is crucial.
However, we also really think that addressing the health needs and looking at the system holistically is essential for the long-term health of our community.
So as we transition into talking more about health, I don't want it to come across at all like we are not seeing housing as a big issue across the country.
So, Council Member Mosqueda mentioned this earlier, whole person care in California, what we're doing is using an 1115 waiver.
Basically, that's what Washington has decided to use to create accountable communities of health, your ACHs.
This is one model creating other funding sources is something that I think should be discussed.
What California is doing is using Medicaid dollars to have pilots run little test sites across the state.
Most of them are being run by counties.
In Sacramento, it's being run by the city.
And it's trying to look for innovative solutions to help the most vulnerable of the population.
excuse me, the most vulnerable of the populations.
So if you hear us talk about whole person care, it's because that's what the state of California has deemed this project, whole person care.
In Sacramento, we personalized it and we've called it Pathways to Health and Home.
But in case whole person care comes up, that's because that's what the state has called this.
So in the city of Sacramento, what they're doing to address homelessness is a multi-pronged approach.
Lisa will be discussing some of the other components of it throughout the presentation, but the majority of it for Pathways, we have the mission to improve the health, quality of life, and housing stability for Sacramento's most vulnerable individuals experiencing or at risk of experiencing homelessness through an integrative system of care.
What this really means is our pilot targets the most vulnerable of the homeless population, those that are interacting on a regular basis with emergency rooms, that are interacting with the fire department, that are in what we have a triage shelter, which Lisa will be discussing in a moment.
These are the high utilizers and most oftentimes they have multiple health conditions and they have been chronically homeless.
So they've been homeless for a number of years.
Now, in order to launch this program, Sacramento, the city of Sacramento, really is trying to think through a new way of addressing this.
And so they've brought together a variety of different players to actually partner together in a proactive way for systems change.
Now, because it's in a different city, a lot of the names that you're seeing might not mean much to you, but what you're looking at is the city, an organization that did navigation services to enroll folks into public programs, health systems, health centers, housing folks, homeless shelters.
It's trying to get everybody at the table to think through how we can streamline our efforts to target the most vulnerable of the population.
And our approach really was focused on bringing everybody who was within the healthcare sector as well as the housing sector and within different city services, bringing them together to create a common table where we can discuss the issues that various homeless populations face as well as the way these organizations can work together and to build a new model for this program.
We'll be drilling down into the way that we brought people together and how the different organizations are engaging at different levels.
But I want to say that one of the key things that we did when we started this project was to start with an environmental scan because we wanted to understand what are all the resources and components that are trying to serve this population, what programs are being funded, and what were the results of those funding.
We learned that there were many organizations, many resources, but not all of them were connected, and many organizations were trying to serve the same population, but really lack coordination.
And there were different so organizations would use similar terms like case management or care coordination but it would mean something completely different in the housing sector versus the housing sector the health sector.
Yes.
Who hired you to do that.
What was the scope of work.
How long did it take.
So my team was hired by the city of Sacramento because this is an 1115 waiver pilot.
We helped the city write the application and design the application and then were asked to run and bring up the entire program.
And so the lead entity is the city.
But as part of this effort we were able to bring and reached out to a wide swath of partners because it was incredibly important to have everybody at the table recognizing just how complex addressing homelessness is.
So the way we think about this program and as we built our model, we wanted to keep in mind two critical functions that our program had to meet.
We looked at it from the client level, where we were trying to provide services at the right place and at the right time, and also support their individual ability for self-sufficiency.
There's no time definition or limits for how long people can be in our program, but we want to continue to encourage and support them in the best way possible and in the way that they need those supports.
We also looked at the system level, where we looked at how organizations can come together to better serve this population.
And so we focused on building a common table to have to address issues and create buy-in.
We also created opportunities for linkages and coordination of services across organizations.
And a key component of this is building out the IT infrastructure that allows for shared care planning and care coordination so that if individuals within different organizations are trying to serve the same individual, they're seeing the same care plan and understand and know what their partner organizations in this effort are doing.
By doing it and designing our model, keeping the focus on both the patient and the organization level, that allowed us to use more of a collective impact model to achieve the system change that we're trying to do.
We wanted an opportunity to make sure that everyone's voices are heard, and all those organizations that you saw on the prior slide are engaging in very different ways.
This is our governance model.
All of our partners, their leadership sits at the steering committee level where we talk about progress to date, what we're doing in the program, they provide feedback to how we've built the model and how we are evolving the model.
We also have IT and service delivery committees where the programmatic leadership of these various organizations come together and the IT leadership comes together because we need, we wanted to make sure that we were building out the IT system that would support this effort and would actually support efforts even after our funding is over and after this pilot is over.
By using a collective impact model, we're driving systems change across all of the sectors involved and bringing the right people to the table to make the, you know, to provide input and to help create buy-in and create, a model that we can continue to evolve and tweak to make sure that we were getting the outcomes that we want.
And so that's one of the nice features of our program is our model continues to evolve based on what we're learning on the ground.
And we also have a learning community for all of the frontline staff who are providing these services so that they can come together and talk about the barriers and issues and challenges that they are facing when they're trying to provide services as well.
I just want to pause really quickly here.
I want to welcome Councilmember O'Brien.
Thank you for joining us.
Councilmember Lorena Gonzalez as well has tuned in and is watching, and I believe Councilmember Juarez as well is watching from home.
So I just want to say thank you for joining us.
I want to underscore that point that you just made, which I know a lot of us in the audience have been committed to as well, which is shared governance.
And we talk a lot in our committee about how we invite those who've had the lived experience of the policy issue that we are trying to affect change to the table so that they can be part of the policy solutions.
And what I hear you saying is that you've created a forum so that those who have the lived experience of needing housing or needing health services are truly informing how you can improve the policies and practices and programs.
Absolutely.
That's a critical part of what our work is trying to achieve.
In addition to this governance model we also have focus groups of the patients that we're serving and we also have an individual who was formerly homeless who we were recently able to house and who also actually sits on our steering committee because we want to make sure that that voice is captured.
Maybe you've already addressed this, but in Sacramento and in the associated county, what was your point-in-time count most recently?
Our most recent point-in-time count was a little over 3,000, but that was a significant jump from the prior point-in-time count.
We had, I want to say, like a 30-some percent increase.
Was that people who were unstably housed or folks that were completely unhoused?
And that was completely unhoused.
Great.
And was that at the county level or within the city of Sacramento?
That was at the county level.
Okay.
Just by way of reference, we here in King County in our 2018 King County point in time count revealed that there were over 12,000 people who were experiencing homelessness.
We know that about three quarters of them live within the city of Seattle's borders.
We also know from that report that about 98% of survey respondents said that they would move into safe and affordable housing if it was available, and that around 90, over 90% said that they had previously lived, housed in the city and county.
So these are individuals who are our neighbors, they're our friends, they're workers here in our community.
And I appreciate you giving us that number and also underscoring the urgency in which we here in this region need to look to successful models like that that you're sharing.
Absolutely.
So I'm going to go over our model at a high level.
The way we've approached our program, because it is a high utilizer program, this is one tool in the toolbox for the city of Sacramento and pairs with other housing strategies and interventions.
We partner with the city fire police team, the winter triage shelter, which is a specialized shelter, which we will talk about in just a few minutes, as well as hospitals, clinics, health plans, our homeless organization partners, all the organizations that touch this population and these organizations are providing referrals into the program.
Individuals are determined eligible and enrolled and because this is funded through Medicaid 1115 waivers they have to maintain their Medicaid eligibility.
So part of this process is ensuring and helping them maintain that eligibility, running monthly eligibility checks, helping them maintain all of their documentation.
As we find individuals who are being referred in, if they're not eligible for the program, we still provide them warm handoffs and connection to other services and programs that they are eligible for.
And once they're enrolled, they're activated and motivated by CHWs and navigators.
These navigators are constants for them, where they're assigned to them, they provide a number of supports, they're field-based, and they meet the patient where they are, so they'll go out to encampments and wherever the individual patient is, and they will make sure that their services are met.
They'll provide encouragement and coaching.
One example I can give you, in Sacramento, if you have, if you're taking mental health medications, you're only given medications a week at a time if you're homeless.
And so our navigators will check in on the patient every week?
Do you have your medication?
Do we need to make arrangements for transportation to the pharmacy?
Making sure that they are coached and that they're getting the supports that they need.
The Navigator is supported by a care team where they're connecting enrollees to needed services and our care teams are very different because our care teams are individuals from multiple organizations who are trying to coordinate care and services to the enrollees.
And our goal is to both stabilize enrollees, to support them towards self-sufficiency, and then when they are ready, then they graduate from the program.
And all of this is enabled and supported by a data sharing infrastructure that will allow all of our partners who are providing services to coordinate around a shared care plan.
And I'd like to just ask, yeah, please.
Quick question here.
I noticed you have fire.
You don't have police as a referral, so.
The impact team is a specialized unit within the police department in Sacramento, specifically trained to serve and work with the homeless.
So does everybody in the little dotted corner here, do they share information equally so that you would provide the same information to the navigation team so that a police officer could have it?
How do you protect if people are concerned about that?
So we don't share all information with referring organizations, but organizations that are part of the care team do get to see the totality of the care plan.
You're absolutely right to bring up HIPAA and 42 CFR.
We have had to do a lot of work providing supports to our housing partners to understand HIPAA and what those challenges are and what those requirements are.
And so we built it into the system.
And the shared care plan is a cloud-based system that is workers that are out in the field can look up and do work in like on their iPads.
And so there it's a multimodal opportunity to
Did you create the software yourself, or is there something off the shelf that could be modified?
So believe it or not, we actually took a Salesforce database and built it out in Salesforce.
I'm sorry, what?
Say that again.
We used Salesforce as a, it's a database, an online cloud-based database.
All right.
And we were able to modify it and that's what we're currently using.
But there are other options as well.
That's great.
To jump in, because I think, and y'all probably may have experienced this, hospitals can't often talk to each other, can't talk to the police.
You have all of these different departments and what we found is You know, if Lisa's the person who's living under the freeway, she might interact with all of these different departments and they, you know, with the housing authority, with all these different groups, and they can't talk to each other.
So how can Lisa's information live in one place?
And how can all of our, one, how can we make sure we have all the right people at the table, right?
Who's going to come in contact with Lisa?
How can they all be at the table?
And how can all of Lisa's information stay with her?
And that information shared and the shared information is the information that benefits Lisa.
So I completely concur.
And this is something we've been working on seriously for years to get this to work.
Frustrating that we still haven't.
Congratulations to you for having figured out a way to make that work.
One quick question about medicines.
So if you've got someone who's going out and talking with a particular individual, what is the extent of their authority to offer medications?
These are navigators, CHWs, they're paraprofessionals, so they are not authorized to issue prescriptions.
They would work with the care team and clinical professionals and the physicians to do that.
So if an individual has multiple medications, are those brought to the individual or how does that work?
No, the navigators will help support and arrange for transportation so that our patients and enrollees can get to the pharmacy to get the medications.
Any consideration about a mobile medical van?
We have not done the mobile medical van yet.
We have clinical partners who are FQHC clinics that actually have field-based street teams, so they have nurses that go out into the field.
We're also working with our dental health plan partners, so they provide mobile dental vans out in the field as well.
One point about the health information exchange and sharing IT, that's why we had the IT committee because we needed, it's incredibly hard to bring partners together to share data in the healthcare setting.
When we layer on other organization, it becomes more complex.
And so through the IT committee, we can work through a number of issues.
We also leverage a lot of best practices and other models so that we can understand what is possible and what isn't.
So would you say you've been successful at that?
I mean, are you at the point where you could say, and I'm looking at my friends in King County across the way, The folks that are in the King County Department of Health and Human Services, the information they have to be able to work with the city, to be able to work with police and fire, you guys have accomplished that.
You are my heroes.
I wouldn't say we're 100 percent there.
We have a model that we're taking baby steps and so we're taking one step at a time.
We're starting with the shared care plan and one centralized platform that the program is providing.
But our next phase is building out a hospital notification pilot so that When our enrollees show up in ERs and emergency rooms, then we'll get notifications.
And so we're taking this one bite at a time, helping our partners get comfortable with sharing data.
A number of the other pilots that are also doing similar work also have that experience.
That's why the environmental scan was so important because we really dove into what is the existing IT infrastructure as well and what can we build upon and where different organizations' appetites and experiences would allow us to go.
Thank you so much for everything you've shared so far.
I know you have some lessons learned slides too.
I'm just taking a look at the clock and I'm thinking if it's okay with our council members and we have this space, maybe we'll try to go to 115 so we can get through your slides and see if there's a few questions in the audience.
We also have Jeff Sakuma who has run a very similar program and efforts here in our city.
Yes, and we will also ask him if he's interested to join us at the table when there's questions as well in case we want to kind of do a little inquiry into what we're currently doing.
So let's go ahead and keep going through your slides, and then we will see if we have any questions from our friends in the audience.
And due to the time crunch, I just skipped the guiding principles for model development.
We have touched on it, and you guys have it in your slide deck.
Jessica, get a little closer to that microphone.
Here we go.
So this slide hopefully paints the vision of what we were discussing, the multidisciplinary, multi-organization, community-based care teams.
Go back to Lisa being my example.
She's interacting with so many different systems.
How can you have one person be her point?
Right, so I become her navigator.
I am the person that's making sure she's getting her medications on a weekly basis.
Does she need anything?
I'm working with her on this on her shared care plan.
And then I'm also bringing in either the dental union or the behavioral health specialist or if she has drug and addiction issues, the counselor.
So you have one person, you have the patient at the center, and then you have all of the other systems that they would engage with, creating a bubble around that person to help them get their lives stable.
And what's different about our care teams is we also embed a housing navigator onto the care team because we know that the housing support services are incredibly important.
And the distinction that I would make between that We actually have to house people and the housing subsidies, the vouchers are, will enable us to actually pay for the actual housing.
But the housing support services are the services like working with landlords, finding units in the built environment, supporting the individuals.
We had one patient where, you know, they weren't comfortable being housed or didn't know how to, And we needed some coaching around paying rent every month, how to be a good neighbor, providing those types of ongoing supports and adjudication was incredibly important.
And so by embedding the housing navigator on the care team, the CHW can share with the housing navigator, they're having this challenge, these are the things that, you know, are coming up, can you help with the landlord?
Are there other things that you can do so that we can build the right intervention?
So just to clarify, are you using 1115 waiver dollars from Medicaid and the Affordable Care Act to help individuals get into housing?
Or are you using those dollars to help those who already have housing get the health care services that they need or other supports?
We're using, so Medicaid, where federal policy is at is Medicaid dollars cannot be used to pay for the actual housing.
And a number of the pilots are built, have the whole person care pilots paired with a housing pool to be able to pay for the housing.
But the Medicaid will, we can use Medicaid dollars to pay for housing support services.
So they'll pay for the housing navigator.
Great, okay, thank you.
And where this is part of the work that the city of Sacramento is doing is this really is targeting the most vulnerable of the homeless.
Not all homeless people need this much support, but we are targeting specifically those that are chronically homeless, have other health issues that really need this level of care in order to be able to stabilize their lives and get into housing.
So just to paint a picture of what the experience looks like for an individual in our program, we use assertive outreach techniques when we are doing initial outreach and enrollment.
We want to support them.
We do eligibility verification.
We initiate engagement and care planning as well as goal setting.
And once they're enrolled, we do a lot of work in terms of activation and engagement of the individual.
helping them connect to the right set of services, both on the healthcare side and the housing side, and fund a lot of the care coordination and follow-up across the organizations that are serving them.
Our goal is to really provide the right level of intervention.
So during this phase, it's very high touch, whereas once they're stabilized, it becomes a lower touch intervention.
But I would say the biggest distinction between activation engagement and stabilization is under activation engagement, the CHW and our care teams are doing a lot of work.
They're proactively going to the individual, asking them, coaching them.
you know, trying to provide the interventions that they need, whereas when an individual is stabilized, they're the one initiating for services.
And our goal is, of course, to when a client achieves stability and self-sufficiency, they are permanently housed, that's when we graduate them.
And there are certain circumstances where we do disenroll, for example, at a client's request.
And I'm going to skip the population-specific approach because the details are there.
So for pathways to sustainability, Lisa was just talking about graduation.
You know, one of the examples that really resonated with me was this couple who were chronically homeless.
They got housed for the first time.
They had worked with this care team and one of the housing navigators, one of the housing folks who built a relationship with the landlord got a call a month in and the landlord wanted to know where rent was.
So one, the success in that is that rather than the landlord evict them, the landlord reached out to the housing navigator to figure out what was going on.
And what came out of it is that the couple, you know, How do you save money throughout the month?
What does that look like?
Where do they put that money?
They don't have a checking account.
What is this whole process?
When do you pay rent?
I mean, there's so much that goes into being able to pay rent on a monthly basis.
So the housing navigator was able to intervene, help the couple, moving forward, figure out how to put that money aside and where to put it on a monthly basis, and also work with the landlord to be able to keep them in housing.
So it's not just, here's your house, you've graduated, goodbye.
It's how do we actually help stabilize people's lives, get them into housing, and do whatever it takes, do what they need.
So at the individual level, it's not like our care teams are going out on the street and people are pushing the way in to get this help.
You know, there's a lot of fear from the folks that we are working with.
There's a lot of doubt that we're going to stick around.
And I think that there's also a lot of shame that goes with using the program and what does that mean and how do they actually stay connected to it.
So our navigators are continually out on the street as a public face building these relationships, going back to these same folks, you know, these folks that are the high utilizers of the systems and trying to figure out how can I best support you?
How can I be here for you?
And we're doing that on the individual level day in and day out to the folks that we're seeing as the most vulnerable.
And at the organizational level, we're also providing a lot of supports to our partner organizations.
I mean, changing systems is hard, and it just requires a buy-in at multiple levels, not only at the leadership level, but at the program design and even at the front line.
We're also learning that, you know, There's a tendency to say, this is my patient.
But we're trying to reframe that dynamic and create a space where it's our patient that we are collectively serving.
And we had to really understand the limitations of funding as well as local politics to be able to bridge the language gap and to be able to bring organizations together and create that space where they're willing to commit to actually doing things differently.
And supporting frontline staff is absolutely critical because They're the ones trying to provide the support, and they're bringing back a lot of lessons learned.
And so in our learning community, as they bring these lessons learned, we do constant quality improvement cycles, and we elevate that learning back to our committees so that we can have a discussion with our service partners and all the partners at the table about, do we want to evolve the model?
And just as we're transitioning to some of the results to date, I just want to thank Representative Nicole Macri, who's also watching from afar, a huge champion for housing and caring for those who are homeless, who just reminded me that the $11.15 in Washington can be used for outreach and security deposits for eligible beneficiaries to get folks into supportive housing, and that we're in the infancy of this program here, and perhaps we'll learn a little bit more as well if there's questions about what we're doing in Seattle.
Great, so results to date.
So I wanted to put a human face to who we are serving, and this is Catherine Wall.
Ironically, she was actually originally a resident of Washington.
And she is 61 years old.
She became homeless 30 years ago.
And the reason why she became homeless was because she had an arrest warrant for a misdemeanor offense.
And so she'd been homeless for 30 years.
And she was very despondent and initially refused help.
Our outreach workers, continued to engage her, didn't give up on her.
And once we were able to begin, we started building trust with her and were able to finally convince her to enroll into the program.
One of the things that we did is work with the police impact team to address that warrant because it was preventing her from getting access to services.
And once that was cleared up, we were able to get her on Medicaid, we were able to get her on Social Security, and to get her a number of services that she needed.
Initially, we were able to pair with the city's winter triage shelter.
The city funded multiple shelters, but they reserved one for high utilizers who had special needs.
And so she was able to get into that shelter because she had chronic health conditions that we were trying to address.
And by clearing up her documentation, we first got her sheltered through the triage shelter, started addressing her healthcare needs, and ultimately were able to get her housed by working with our housing agency, and now she is permanently housed.
And so, you know, these are unfortunate events and hard choices that led many of these individuals to their life circumstances.
And being able to address them was incredibly important.
But now she has her own apartment, she's getting her healthcare needs addressed, and her life is fundamentally different.
And we're happy to share the article if that would be of interest.
And, you know, this is, we're still in an early phase of the program.
This is some of the results to date.
We officially launched the program actually last November, and as from November to now, we've had enrollments of You know, we've enrolled about 476 people, but we currently have 345 enrolled.
We do lose some individuals, lost a follow-up, or they move out of the county.
But we are really tracking through what type of services they need.
And as you can see here, there's a lot of care coordination service, but a lot of the services that we're providing is just getting people ready for programs and supporting them to stay in programs.
We get a number of referrals through the city police and fire teams.
We also get referrals from hospitals and plans.
We didn't open it up for just a batch number of referrals.
Our referral process is a little bit different because we use a warm handoff process.
So when they show up in hospitals then we get we're notified and we can deploy somebody or we know where to find them.
We also work and track closely our health plan assignments and our clinic assignments so we know where to go.
Many health plans have chronic case management programs and so we begin coordinating with them.
so that we have better access to specialists and create additional pathways to services.
Just to really begin to unpack and really work with our partners to create new avenues for engagement and linkages to services.
What I think is interesting about this slide here on the top right corner is that the vast majority of people who you are serving are eligible for health insurance, and it sounds like with that warm handoff and the case management type focus that you have, you are getting folks enrolled in health insurance.
I think what we'll talk about later this afternoon at the Board of Health is what to do for the remaining folks who are not qualifying for health insurance and how we provide that safety net.
But I think this is an important takeaway that if we were to do more case management and coordination with this navigator-like approach, we can actually get folks not only enrolled but into the services that they need and potential medication or treatment that they might need.
Jessica?
And one of the really interesting things I think about what's happening in Sacramento is the group and their logos at the top, Sacramento Covered, the group that has been the hub of all of this and is doing so much work, it's a local nonprofit.
They're also the nonprofit in Sacramento that was doing all of the outreach and enrollment to get folks into Medi-Cal, which is the Medicaid program.
So we partnered with the organization that's already on the ground doing this work.
And then they're partnering with housing organizations who are doing this work from another angle.
And I haven't seen that model in other places.
You know, King County had an incredible outreach and enrollment campaign to get people enrolled in health insurance.
So you have experts that are used to going and finding people.
And tapping into that, I think, was incredibly valuable in Sacramento.
Absolutely.
These are trusted messengers.
And I would also say that for the health plan assignment, Sacramento is really interesting because their Medicaid model is a managed care model and so all of Medicaid enrollees are put into Medicaid managed care plans but we still have a number who are in fee-for-service or we find that they're actually enrolled in another county's Medicaid plan and so we do a lot of work with our other county partners as well.
Just to give you a little snapshot of, on the housing side, what we were able to do, to date we've housed roughly 20% of those who have come through our program.
And this is in an environment where we were not able to build new housing, and we're not funding actual housing subsidies.
And so we paired this program with and worked with the housing redevelopment agencies, worked with the local continuum of care, and looked at what are the available vouchers in the community.
We worked in the built environment.
and really provide us supports to address barriers to housing and staying in housing.
But to note, you know, the homeless community, the homeless population is evolving.
Like even in our program where it is the most vulnerable of this population, we still see You know, we run across those who are veterans, families, pregnant women.
And so just to remember that, you know, this is an evolving population.
And I want to be mindful of time, so we'll do these real quick, and then we do have some acknowledgments.
Many of you know that homelessness is an extremely complicated issue.
I will, because we are short on time, I will leave with that.
It's incredibly important what we've learned, not only from our experience in Sacramento, but working with and looking at other pilots across California and in other states.
The tools that you need in your toolbox vary and the interventions need to vary depending on who you're trying to reach within the population.
And so thinking about, you know, as Seattle crafts its approach to homelessness, thinking about what type of tools, how do you pair those tools together to create the right synergies is incredibly important.
We're very fortunate in Sacramento to have a number of partners at the table, partners who are willing to not only provide service supports but monetary supports to provide the local match because this is a Medicaid 1115 waiver program.
And so being able to bring everybody together and put all the resources at the table and really think about how to use them in a different way was incredibly important to this effort.
Your numbers here on the, I don't think your slides are numbered, but this one, that was a health engagement, it was about two or three back.
And you say you've gotten 345 enrolled, and that was 7,144 touches, so essentially everybody was touched more than 20 times by average to get them in.
What is your goal for 2018?
Oh, this is actually the touches is how often we're engaging the individual.
So this is across services.
I understand.
I'm just like doing a quick mean that if you were able to enroll 345 people into this and it took 7,144 touches, I don't mean to at least be crass here.
I'm looking at the amount of of time, effort to get people enrolled?
What is your hope and expectation for 2018?
Double that so you can get 700 in or?
Our target is to serve 1,000 people at any given time, knowing that as people graduate, you know, we'll be able to create additional capacity and serve more.
A point of clarification though, the 7,000 touches includes touches for services after enrollment.
Okay.
So how many of these folks were you able to find housing, units, roofs, you know, warm places for?
We've provided housing for 20%.
Okay.
And this is a combination of permanent and transitional housing.
And then an additional 46% we were able to find shelter options for.
Okay.
And 33% remain unhoused.
And that's partially because of the limitations on how an 1115 waiver dollar can be used.
And so you needed to partner with permanent supportive housing advocates, agencies, the city who works on housing folks.
But even though you had the limitation, you were still able to assist with getting folks the services that they need.
Okay.
So it's truly that partnership that probably is a much bigger number.
I don't know if that's possible to crunch that number at some point, but to see not only your 20% plus the folks you got into shelter, but the 20% plus those in the city that you've been able to facilitate getting into housing would be helpful.
I know we're close to that last slide, acknowledgments.
So I just want to acknowledge that this effort would not be possible without the leadership of the city.
They, you know, in California, healthcare is run by counties at the local level.
And so they did take an incredible risk here.
We also were able to bring together an incredible team of experts, subject matter experts, operational program experts together.
And I just wanted to take a moment to acknowledge Desert Vista, Intrepid Ascend, and Health Management Associates, which were incredible partners at the table and on our consulting team helping bring this program to life.
And as Jessica mentioned Sacramento covered is that local CBO nonprofit entity who provided incredible support and was able to actually bridge a number of gaps because they were already working with a number of health care partners.
They understood the Medicaid program and it was actually their database that we leveraged to build out our shared care plan.
Amazing.
Great.
So thank you so much for having us today.
And I did talk to some folks earlier.
We would love your feedback.
I mean, especially folks in the audience after this or after the next meeting.
You know, if you are homeless, I would love to hear how you think this would work for you.
These kind of programs only work if they actually They need to work for the people that we're targeting.
So all feedback is welcome.
And what we hope in Sacramento is that we're able to make these changes in the system overall and in how the city does business and how partners work together and that it becomes sustainable.
We want to make sure that this isn't just a pilot, that we actually make change and improve the overall health of folks there.
So thank you.
Well, before we take questions, a huge round of applause for our special guest today.
Thank you.
And you're going to the Board of Public Health meeting, right?
It will be special featured guests at 1.30.
Thank you.
I am going to have to excuse myself to get to a sound transit meeting, unfortunately.
Normally, I would be right by my colleague here in the Board of Public Health, so I apologize.
for not being able to join you.
And Mr. Sakuma, I would love after this, if you and I could get together, you could tell me what did you hear and where are the gaps that are different from what we're doing now?
So if I, I don't want to put you on the spot now, but I would really like to follow up with this.
Maybe we can have that as an agenda topic on one of our agendas that is a little lighter this late summer, fall.
We can do a quick comparison.
And Jeff, if you'd like to join us at the table, we might have questions for one slash two questions, if folks can keep them short.
We'll put a minute time on the timer so that we can make sure to be succinct in our questions.
I know that this is really exciting.
It's also probably what you have been living and fighting for every day.
So it might not be brand new information, but it's very nice to see it played out and how it's been successfully packaged in Sacramento.
If you do have a question, please do come to the podium at the center here, and we're happy to take your question.
And Jeff, if you want to introduce yourself for the record.
Sure.
My name is Jeff Tsukuma.
I work for the City of Seattle, the Mayor's Office, and I'm the health integration strategist.
And in that role, I also hold the City of Seattle's seat on our 1115 Medicaid waiver project, which is called Healthier Here.
And we will have a presentation I think on healthcare here just to make sure that you have the chance to respond to some of the questions, identify maybe where our data aligns and what we might be doing similar or slightly different given the funding sources.
We have two people lined up to testify.
I'm going to ask folks to cut off the line there just for time.
So thank you for jumping right up and we're happy to have you.
Introduce yourself for the record please.
Hi, my name's Angelicia Castro.
I grew up in Elk Grove, California, south of Sacramento.
I'm on the King County Youth Advisory Board for Youth Homelessness.
As somebody with lived experience, I wanted to know how you guys have been working on not having the police be as instrumental in your model.
Great, thank you for your question.
So we actually involved the police right up front because what the city realized even before they got this waiver is, you know, there is engagement with the EMS services.
We don't work with the entire police department.
We work with the, specifically with the impact team, which is designed specifically to work with the homeless and uses very different interventions.
And really it's to provide the right supports.
Their goals are to help connect the homeless to services as well.
And so we, find that they're actually a really fantastic partner.
And because they have sort of frontline knowledge of what's actually happening on the ground, they're actually giving the program information that is very useful to really understand where to target our efforts.
Thank you so much.
Welcome.
Hi.
My name is Matthew Lang.
You were talking about how if someone is ineligible for Medicaid, that there are some services that can be provided, whereas a lot of them cannot.
I'm wondering about someone who perhaps is enrolled in the program already and then becomes ineligible.
Perhaps they gained employment.
Unfortunately, the Medicaid requirement, it still is a poverty-level requirement.
So, you know, I think it's $15,000 a year in California.
that you can make, so I guess I wonder how you deal with that issue.
So because this is funded through an 1115 waiver, we have to ensure all enrollees in the program are in Medicaid and maintain that eligibility, but for when we do find folks who become ineligible, we still, there are a number of other programs that provide a number of different services.
One of the key things we're doing through this program is providing leverage points and connections.
Because we are bringing everybody to the table, our goal is this is creating a system change in the way the organizations actually work together.
And so we'll be able to maintain these connections and these new ways of working together, you know, even outside of the program.
One of the things that we talk about a lot in Sacramento is silos of excellence, and we're really trying to break down those silos.
There's a lot of people who are doing really good work, and they've been doing them in silos for years.
So when somebody becomes ineligible, hoping that we can tap them into these other partnerships and that those silos, you know, moving forward in the future, that those no longer exist or at least are reduced.
Thank you.
Matthew, thank you for your question.
It also tees up our discussion later about what to do for those who are not eligible for existing health programs.
And so again, a plug for the King County and Seattle Board of Health meeting that starts at 1.30 where all our guests will be joining us with Northwest Health Law Advocates.
Jeff Sakuma, do you have any other additional few closing thoughts before we turn it over to our friends?
Yeah, I would just say that 1115 waivers vary widely from state to state, and the state of Washington's waiver is a very different waiver.
It's basically sort of the whole state is on a very similar program, if you will, and each of the nine regions, King County is one region.
has to do specific things that are statewide, and then we have what are called our transformation projects that the regions get to select those transformation projects.
So real briefly, the four transformation projects here in King County, is whole person care, and that's the integration of behavioral health and physical health.
That's a mandated one.
There's opioid disorders, expanding access, and that's, again, a state mandated one.
And the two optional ones that this county is doing is transitions of care.
And that's making sure that people who are transitioning, particularly out of jails and hospitals, get continuous care.
And the other one is chronic conditions.
And that's focused on people with disabilities, our elderly folks, and other folks with chronic conditions who their, our goal is to make sure that their care is very holistic and that, again, that the care is continuous from place to place.
Thank you.
Are there any additional comments before we wrap up?
Thank you very much for having us.
Yes.
Thank you.
So can we give Lisa and Jessica one more huge round of applause?
Thank you to Jeff for a preview of a conversation I know we will be having in the health committee soon.
And again, thank you all for joining us today at this Lunch and Learn.
We will continue this conversation, learn from other cities and states, and we will continue to break down those silos and actually house folks with the healthcare services they need.
Thank you all for joining us today.