Years after the end of a nationally prominent and innovative effort to combine housing and health services in Portland, local leaders hope people around the country learn lessons from the project’s demise.
Housing with Services LLC operated for five years in Portland with support from a mix of public and nonprofit organizations before ending its work in 2018. Its focus: to address the broad spectrum of problems facing low-income seniors and adults with disabilities living in publicly subsidized housing.
Now, with a different presidential administration in place, the pandemic potentially fading, and attention focused on addressing social determinants of health such as housing, lessons from the project are resurfacing. Dan Valliere, CEO of Reach Community Development in Portland and former Chair of the program’s board, is among the local officials hoping the shuttered project can foster a new round of efforts to “bend the cost curve” and improve residents’ health.
“A lot of good was done,” he said. “We had a lot of good learning, so we wanted to share it.”
Valliere and other project participants recently released a study finding the project had mixed results, along with recommendations to improve such efforts in the future. The study was completed just as the global pandemic had begun, at a time when public agencies were consumed with COVID.
“Everyone was focused on emergency response,” he said, so the study was shelved. Now, however, the lessons of the pandemic are driving renewed interest — to the point where project leaders including Valliere presented information about the effort at a national conference, held by NeighborWorks America last month.
As a result of the inequities the pandemic highlighted, “I think people just know and see the reality of why there needs to be more strategy around connecting the systems of health care with the systems of housing in ways that aren’t super-expensive, but are, like, really durable and relational at the community level,” Valliere said. “And that’s what we were trying to do in a microcosm.”
Nonprofits, Agencies Worked With Residents
When Housing with Services moved into Harsch Investment Properties’ 1200 Building in downtown Portland in 2013, Darlene Eckert was a natural choice for its resident building representative.
Eckert had lived there since 2007. She was 56 and a wheelchair user after a childhood case of Polio paralized her from the waist down and she could no longer use forearm crutches after they had damaged her shoulders. She also had a master’s degree in social work from Portland State University and work experience helping seniors.
She was a perfect fit for the new subsidized housing program aimed at helping seniors and people with disabilities.
The project provided care coordination, peer support and preventative services to more than 1,400 residents. It included 11 buildings and numerous public and nonprofit partners: Cedar Sinai Park, CareOregon, Home Forward, REACH Community Development, Asian Health and Service Center, Family Care Health, Jewish Family and Child Services, Sinai In-Home Care, Cascadia Behavioral Health and LifeWorks NW.
Building representatives like Eckert volunteered their time to help participating agency staff better understand needs at the buildings. In regular meetings, “we would talk about what we wanted to see happen and what was going well and what wasn’t,” Eckert said.”
Many residents found counseling the most important service, Eckert said. Regular visits from nurses were a big help. The program also tackled food insecurity.
“The food bank would come and bring food and it would be all on this big table. And we would have to divide it into four piles. And then we took it to the (other Harsch) buildings,” she said.
The “Share and Care” program worked as a localized sharing economy for residents of the program’s buildings.
“If you had a dog you needed walked and I needed somebody to go to the store with me, we traded services in our building,” Eckert said. “I thought that was just marvelous.”
Eckert said that it took residents a while to gain trust in the program because of nearly ubiquitous bad experiences with the medical field among seniors, especially low-income seniors.
“It was just catching on, and then left. And so I think that was very unfortunate,” she said. “It was just such a good program.”
Mixed Evaluation Showed Challenges
But the project faced challenges, too. In addition to contributions from the various partners in the program, it was supported by grants from Meyer Memorial Trust, FamilyCare, the Harry and Jeannette Weinberg Foundation, the HedcoFoundation, Enterprise Community Partners and Providence Health Systems.
But funding shriveled in late 2016, and then again after a major funder, FamilyCare Health, closed down in connection with a rate dispute with the state. In 2018, the project shut down.
Sponsors, including REACH, had asked a think tank, the Center for Outcomes Research and Education at Providence Health & Services, to track and evaluate the project. Analysts there worked on issuing a report, released in February 2020. The report used Medicaid and Medicare claims and enrollment data, administrative housing data and program data from the program’s partners to assess its impact between its creation in September 2013 and when it was dissolved nearly five years later.
The evaluation measured the program’s impact on resident health care utilization and cost. It found that while residents used program services, no positive impacts were evident in four of the six health care outcomes assessed, noting this may be due to factors including the funding cuts mid-way through the program’s life.
Among the findings:
- Residents went to the dentist and accessed outpatient mental health care more frequently than peers who lived at buildings not involved with Housing with Services.
- The increased access to care did not reduce emergency department utilization, and the use of services and total health care costs went up. The report attributed this to residents of the buildings having more access to services than they did before.
- The program’s goals of improving health equity by providing culturally specific services to residents were at least somewhat successful. Residents of both buildings participating in Housing with Services and peer buildings were significantly more racially diverse than the population of Portland at large.
The report authors noted other analyses of the program as well as outside factors that may have affected results.
An earlier evaluation of the program from the Providence Center for Outcomes Research and Education found residents in program buildings felt they had more access to care and better care. Meanwhile, a 2016 evaluation of Housing with Services by Portland State University’s Institute on Aging, conducted before funding was cut, found program participants had greater food security and were more likely to use preventative services.
Dr. Paula Carder, director of the Institute on Aging and an author of its 2016 report, said that while the program design may have had room for improvement to achieve certain outcomes, “what’s kind of amazing to me is that we did see some effects in a short period of time.”
To her, the lasting relationships are a major success.
“Some of these relationships between housing providers, social service providers and health care providers didn’t exist before, and now they still do,” Carder said. “It didn’t cost that much. I mean, it was one social worker and another person, a project manager.”
In an email to The Lund Report, Dr. Hannah Cohen-Cline noted that reforms in 2014 under the Affordable Care Act and a new coordinated care system for Oregon Health Plan members may have affected the measurement of outcomes against statewide baselines because new financial incentives had sparked health system improvements around the state.
Cohen-Cline was a primary author of the report on the project and serves as program director at the Outcomes Research and Education Research and Evaluation. This could “explain why use of health care increased over the study period for both the (Housing with Services) and the control group,” she said.
What’s Next
Housing with Services has remained a priority for some local housing advocates despite the pandemic.
Valliere and former project director Howard Klink released the report two months ago, along with “key takeaways” about how to improve on such efforts in the future. (Klink, long the public face of the program, is married to Lynn Knox, who joined The Lund Report’s Board of Directors last year. The board has no control over news content.)
The two were asked to present virtually on the program, the report and lessons learned at a NeighborWorks America event on Feb. 8. About 60 housing officials and advocates attended and “some of them were really excited,” Lavalliere said.
Valliere said the timing was good in part because federal health officials and other organizations are showing renewed interest in such programs. He said the big difference is not increasing spending on services, but co-locating them in one place so people can work together.
Because that takes organization and cooperation, such programs remain too rare, he said.
“I work in housing day-to-day,” he said. “There’s a lot of challenges that people have. And we can only be successful if we're partnering and connecting with other resources in the community.”
