07 | The Flexible Housing Pool: System Coordination to Address Chicago’s Homelessness

07 | The Flexible Housing Pool: System Coordination to Address Chicago’s Homelessness

 In 1991 the United Nations declared housing to be a fundamental human right, and the United States has worked to reduce overall homelessness by over 20 percent between 2005 and 2013.  However, homelessness continues to persist across the country, with the highest concentration in mid-to-large metropolitan areas and disproportionately impacts those living in poverty, people of color and immigrants. 

Those experiencing homelessness also have the highest rates of chronic mental, behavioral and physical disease have significant barriers to health care and affordable housing and a lower life expectancy.  Their use of emergency services for episodic care also leads to higher treatment costs.    

In this episode, I’m talking with Pete Toepfer, Executive Director of the Center for Housing and Health, a subsidiary of the AIDS Foundation of Chicago.  The Center’s mission is to honor every person’s right to a home and health care by bridging the housing and health care systems to improve the lives of Chicagoans experiencing homelessness.  The Center is also the lead agency for Better Health Through Housing collaborative; an alliance of 28 supportive housing agencies across Chicago and Cook County dedicated to collectively working with health care partners.  Most recently, through Pete Toepfer’s leadership, the Center has been selected as the administrator for the FHP. 

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By the most recent report from the Chicago Coalition for the Homeless, in 2017, 86,324 Chicagoans were homeless. 

  • 81% of these homeless residents lived doubled-up in the homes of others 
  • 56% were African American 
  • 28% were Latinx 

Homelessness in Chicago also impacts the working poor, with: 

  • 21% of those experiencing homelessness over the age of 18 are employed 
  • Another 28% attended college or earned an associate’s or bachelor’s degree 

And many Chicago families with children and youth are also experiencing homelessness: 

  • A total of 34,870 families with children experienced homelessness 
  • 86% were doubled-up in the homes of others 
  • 24% were minor children experiencing homelessness 
  • CPS served 16, 451 homelessness students during the 2018-2019 academic year 

This year, the City of Chicago and its partners have collaborated to align funding towards a common goal through the Flexible Housing Program or FHP.  Through FHP, Cook County is able to rapidly house and provide supportive services to some of Chicago’s most vulnerable populations, including individuals experiencing homelessness who cycle through the criminal justice system and utilize hospital emergency rooms for care. 

FHP achieves this through pairing wraparound health and social services with a housing subsidy to support residents experiencing homelessness. The Program focuses on frequent-utilizers of crisis response systems such as hospital emergency rooms, police stations, paramedic calls, jails, and shelters. 

QUESTIONS & ANSWERS

Let’s start with how the FHP is based on a best-practice housing model from Los Angeles.  In what ways did Chicago adapt this model to address our unique challenges in addressing homelessness? 

 

One of the really exciting things that we’ve done is that we’ve expanded the scope of who can participate in the flexible housing pool.  Los Angeles has an incredible and very committed effort on the part of County government.  We’ve gone beyond that to have an inter-governmental response, where we have the Cook County government, as well as the City of Chicago and the Chicago Housing Authority all working together from the public sector.  But we didn’t stop there.  We decided that we wanted to look across all the different stakeholders with an interest in ending homelessness and allow them an opportunity to participate. So with that, we brought hospitals, had conversations with managed care organizations, and we have philanthropy all at the table at the same time, working together towards the same end.  So we are making sure that everybody in this city has a home and decent health care. 

 

On top of that, we have what we call a Governing Board.  So the community and people who are interested in the flexible housing pool have a chance to help guide its direction.  Part of the Governing Board are people with lived experience of homelessness and soon to be people who might actually participate in the flexible housing pool.  They have the same power as any investor who is putting up a million dollars, because we know they are truly experts in what it means to be homeless, and can help us to craft the pool in a way that will be the most responsive and person-centered.   

 

The flexible housing pool also has an explicit racial/equity focus.  We use our data to look at different outcomes to make sure we are, in fact, aligned with serving the population that we’re trying to serve; and that’s in addition to making sure that people have real power at the Governing Board to make decisions about the pool itself.  Finally, we have a pretty unique tool for allowing people to participate.  We have an escrow account that holds all the money that investors put into the flexible housing pool.  Right now the City of Chicago is the holder of the escrow account and the Center [for Housing and Health] receives the funds directly from the escrow account as a way to bring the funds to one place.  That is the “pool” of the flexible housing pool.   

 

And lastly, we are doing amazing work with data.  So our partners at two different homeless management information database organizations; the Suburban Alliance to End Homelessness in Cook County, and All Chicago – along with our partners at Cook County Health have done a data match, where they are able to tell us who are the persistent users across these multiple systems.  Who is ending up in the emergency room or an in-patient in the hospital over multiple years.  Who’s touching the jail, cycling in and out, and who are staying in shelters or out in the streets for the longest periods of time. Those are the folks we’re trying to serve; those who have been failed by our system for too many years. 

 

Tell us more about the administrative role of the Center for the FHP. 

 

The flexible housing pool is really the latest chapter in the Center for Housing and Health and the AIDS Foundation of Chicago’s work to bring together the health care and housing worlds.  It started with a really important research study called the Chicago Housing for Health Partnership in the early 2000s, when we were really demonstrating the efficacy of the Housing First Model.  And that is still one of the most cited research studies around best practices Housing First and programs to end homelessness.  Also importantly, it showed significant reductions in utilization, in-patient hospitalization days, in emergency room visits and in-nursing home days.   

 

So that was in the early part of the story with our role, and the CHIP study was the genesis for the creation of the Center for Housing and Health as a distinct organization.  From there we began to work with our partners around other policy and research projects where we could see how people who were experiencing homelessness were interfacing with multiple different hospitals throughout the region.  How that homelessness is documented in electronic health records and who gets missed because if we’re not able to track who are experiencing homelessness, the chances that we’re going to be able to provide appropriate intervention to them decrease significantly.  And, at the same time, the Center [for Housing and Health] was helping to lead the Better Health Through Housing Collaborative, that you referenced earlier, that was a group of supportive housing providers who came together to say, with one voice, “Health care, we know you need us, but we also need you. How do we work together to make a true difference in our community?  And to show you we are going to be good partners, to build that trust, and to end homelessness for over 100 individuals over the last 4 years.  The Better Health Through Housing Collaborative was also able to reiterate what we knew from the CHIP study and from what we’ve seen from other national studies; that with high quality housing and great supportive services, that people do not use crisis services like emergency department or end up in-patient in the hospital at nearly the same rates.  And, importantly, if you’re making investments that there is a return.  There is cost avoidance and potential cost savings on the part of health care institutions; especially for those who are responsible for being payors.   

 

How does the FHP align with other housing and health initiatives of the Center? 

We recognize that if want to actually end homelessness, we need a bigger tent.  We’ve been biting around the edges and making, in my opinion, modest decreases in the number of people who are homeless in our city for a long time, and it’s not for lack of effort.  But it is for a lack of political power and political will.  As we continue to develop relationships with partners and for us, most importantly, in the health care sector, who have a tremendous impact on our city and the way that they can leverage their economic and political power to say “we understand that we have not just a stake in this, but a passion for it and a role to help end it”.  The Flexible Housing Pool offers that opportunity and also is a way for them to look at some of the folks that come to their institutions on a regular basis, who they don’t have a solution for; who just keep coming back and back and aren’t getting well because they don’t have the dignity of a home.  So the Flexible Housing Pool says “ok, we can help the patients that you have or the members that you have, and you can be part of ending homelessness for those individuals”.  Also, in thinking about this through a collective-impact model, where we’re not just stuck in our own lanes, but saying we all have a commitment to this.  We all want to be working together, and together we’re going to be able to end homelessness and be proud of the city where we don’t have our neighbors living in the streets. 

 

The FHP has already secured investments from non-traditional and cross-sector partners, including local hospital systems and foundations.  Who are these partners, what is the significance of their engagement with the FHP and how do they help to build sustainability? 

 

So the current investors in the pool are the City of Chicago, the Chicago Housing Authority, Cook County Health has made a commitment, the Blue Cross Blue Shield [of Illinois] foundation has made a commitment, Advocate Aurora Healthcare and UI Health have all made commitments to the Flexible Housing Pool to date.  And that’s in addition to a number of philanthropic partners who have helped to support the development and the facilitation of the pool.   

 

Sustainability is a huge question, because if we’re going to put someone in a permanent, supportive housing unit, where there’s a rent subsidy and strong supportive services that are what we like to call the “secret sauce” of the program, if that goes away after one budget cycle or one fiscal year ends, then we are doing a disservice to our community rather than making a true impact.  THe more investors we have at the table, the more stakeholders who are contributing to the flexible housing pool, the better chance that we will be able to stretch our dollars farther, have a multiplying effect with those funds and also have the funds to eventually begin to transition folks to other sources.  So that the Flexible Housing Pool serves as the payor of last resort, if you will, to transition folks to more traditional subsidy sources.  When we have more partners at the table, we have greater buy-in and the stakes become higher, so that any one investor has a little more pressure to stay involved and stay committed. 

 

Since the implementation of the program in March, how many residents have been housed? 

 

To date there are 40 people that have been housed, half of those are in their permanent, supportive housing units where they will likely reside for many years. The other have are in bridge units and have their own safe place to call home but is not the permanent destination. 

 

Help us understand Bridge Units. 

The idea behind bridge units is that we’re often working with folks that are living outdoors, in encampments, under bridges, on lower Wacker Drive.  We want to be able to meet someone, and talk about the Flexible Housing Pool, and then offer them a place to come inside that day.  We’re not quite there yet, to be able to do it exactly in the moment, but the bridge units are generally single room occupancy units where we have people move in for a short period of time so that they’re living in their own space and can conduct a proper housing search rather than coming from living under a bridge, then going to meet with a landlord, and putting in a housing application. 

  

Of those who are housed, do they represent the race, ethnicity, gender and age of those most impacted by homelessness in Chicago? 

That’s correct.  In fact, for folks who are the persistent [and]  frequent users that we’re looking at, there’s even a higher proportion of people of color. The Flexible Housing Pool is looking [to make sure] we’re serving them at multiple time points. So at the time of referral, does that align with the demographics?  And then, are people falling off in the process? Are they making it to housing in the first place so they’re staying housed?  So throughout those different time points, we are consistently serving the demographic that we’re intending.  

 

What, so far, have been the challenges to program implementation and housing placement? 

It is quite an effort,  but I also want to recognize that it is not one that we do alone.  We don’t do it alone because we have a large stakeholder group that has come to the table from the beginning to really vision this project, and that we talk to on a regular basis.  I mentioned the contributers, but I also think it’s important to recognize some of the other partners like the Chicago Department of Public Health, the Chicago Department of Family and Supportive Services, the Corporation for Supportive Housing.  They’re all key members of this group of leaders who are making sure the Flexible Housing Pool works as intended.   

  

And, yet still, we have these housing challenges, Kuliva!  Oh, and I didn’t mention the agencies that the Center for Housing and Health subcontracts with.  We consider them key partners, too.  Housing Forward, located in the suburbs.  Thresholds, Debra’s Place and Renaissance Social Service are part of the folks doing the direct work on the ground, so I’d be remiss if I didn’t acknowledge them, too. 

 

Thank you for acknowledging them! 

And so, what are we collectively still struggling with?  The first is, despite this amazing data match, we still have a hard time locating people.  So we’ve only located about half of all the people who are part of the initial cohort that we identified, and that’s in spite of many still returning to the hospital for care or at different health care sites operated by Cook County Health.  And, you might ask, well why is that?  If they keep coming back, why can’t you find them?  It’s not that we can’t find them, its that we can’t find them, and keep them, or find them again once they’ve been located.  And a big part of that is because folks often end up in the emergency department overnight, and to date we don’t have staff that can respond at 2am, and who can go to Stroger and engage folks.  We are talking about the solutions. We need to adapt to the realities of the lives of the people that we’re serving, so what do we do to stay true to that value of being patient or person-centered. 

 

This is a new program, and as any one who’s started a new program knows, there are hiccups in the way you designed the program, the way that you set up the process, the flow and the way it plays out on the ground.  We’ve experienced some of those growing pains in the first six months of operation, and the team has worked really hard to identify those challenges and then to implement solutions and to test those.  We also haven’t gotten people into houses as quickly as we’d like.  We talked a lot about housing as a human right, and making sure we can bring people to a safe space.  We still have room to grow in making sure we are able to get people into their homes as quickly as possible, and I will acknowledge that that’s a place that [Los Angeles] has a leg up on us to date, but we’re going to be there soon. 

 

What are the established measures of success for the FHP? 

THe first is around housing retention.  That people will stay in housing for at least 12 months from the time that we move them in.  That we can move people in quickly; as I’ve said, that’s an area that we’re still working on.  And that as we have these successful housing placements, and people stay in stable housing, we wrap the services around them, go to their homes to provide services, connect with care-coordinators, [and] that we’re seeing those reductions in crisis care at the hospitals, and that folks aren’t ending up in-patient or in nursing homes.  If we’re reducing the utilization of those services, we’d expect an accompanying decrease in costs. 

 

What can we expect in 2020? 

In 2020, I think first and foremost, you can expect to see every one of the initial referrals housed someplace safe. Whether its with the Flexible Housing Pool or another option they’ve identified.  The second is that we’ve planned to continue to expand, and that we’re not stopping here.  That we bring more health care partners to the table and potentially some other non-traditional partners to the table, so that we are making good on that commitment to looking beyond the traditional players and to engaging partners that maybe have been somewhat interested but not involved in the way that they could. 

Learn More about the Center for Housing and Health: 

Website

Better Housing Through Health 

AIDS Foundation of Chicago 

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06 | The Flexible Housing Pool: Funding System Coordination in Housing and Health

06 | The Flexible Housing Pool: Funding System Coordination in Housing and Health

In 1991 the United Nations declared housing to be a fundamental human right, and the United States has worked to reduce overall homelessness by over 20 percent between 2005 and 2013. However, homelessness continues to persist across the country, with the highest concentration in mid-to-large metropolitan areas, and disproportionately impacts those living in poverty, people of color and immigrants.

Those experiencing homelessness also have the highest rates of chronic mental, behavioral and physical disease have significant barriers to health care and affordable housing and a lower life expectancy. Their use of the emergency services for episodic care also leads to higher treatment costs.

In this episode, I’m talking with Clarita Santos, Executive Director of Community Health Initiatives at Blue Cross and Blue Shield of Illinois. As Executive Director, Clarita advances Blue Cross and Blue Shield of Illinois’ investment strategy in alignment with the Plan’s vision and enterprise imperatives to address critical community health issues, focusing on access to care, health equity and population health.

We’ll be talking today about how the FHP brings value and impact to those served by Blue Cross and Blue Shield of Illinois, and the vision for the health plan on investing in housing to improve population health outcomes.

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By the most recent report from the Chicago Coalition for the Homeless, in 2017, 86,324 Chicagoans were homeless.

  • 81% of these homeless residents lived doubled-up in the homes of others
  • 56% were African American
  • 28% were Latinx

Homelessness in Chicago also impacts the working poor, with:

  • 21% of those experiencing homelessness over the age of 18 are employed
  • Another 28% attended college or earned an associate’s or bachelor’s degree

And many Chicago families with children and youth are also experiencing homelessness:

  • A total of 34,870 families with children experienced homelessness
  • 86% were doubled-up in the homes of others
  • 24% were minor children experiencing homelessness
  • CPS served 16, 451 homelessness students during the 2018-2019 academic year

In March of this year, the City of Chicago and its partners collaborated to align funding towards a common goal through the Flexible Housing Program or FHP. Through FHP, Cook County is able to rapidly house and provide supportive services to some of Chicago’s most vulnerable populations, including individuals experiencing homelessness who cycle through the criminal justice system and utilize hospital emergency rooms for care.

FHP achieves this through pairing wraparound health and social services with a housing subsidy to support residents experiencing homeless. The Program focuses on frequent-utilizers of crisis response systems such as hospital emergency rooms, police stations, paramedic calls, jails and shelters.

In August, Blue Cross and Blue Shield of Illinois was among the first private funders to invest in FHP at the level of $1 million over two years.

 

QUESTIONS & ANSWERS

What was the genesis of the BCBS IL’s decision to invest in the FHP? 

My background is in public health, and I bring that with me as we think about, as an organization, what is it that we do to impact the health of the community.  So when you think about impacting the health of a community, you’ve got to think broader than:  let’s get rid of that bacteria, let’s get rid of that virus, and think about what are some of the things that really impact health.  And as we worked with some of our partners in the community, and also with some of our partners internally – we are an organization of doctors and nurses, case managers and care coordinators, and with our Medicaid business, what are some of the things that we’re seeing in order to address some of the health issues. 

 

Time and time again, whether you look at it from a public health perspective, or the research that you just quoted, Kuliva, and what we see as an organization, it comes down to housing, right?  So we wanted to really understand what can we do in that space, and to really think about addressing health issues, because if you’re coming from an environment of instability,  you’re not in a stable environment where you have housing, how can you then think about taking your medication?  How can you then think about getting a job?  How can you then think about getting self-care when you’re constantly in a state of instability.   

 

How does the FHP align with BCBS IL Community Health Initiatives and the health plan’s population health targets? 

That’s a great question.  We think about our work around community investments and we’re very intentional about using the word “investments”, because we think about how do we build from the strength already in the community.  Or, how do we build upon the strengths already within the system?  And so we looked at the Flexible Housing Pool as a way to leverage all different players, and to think about housing in a different way.  As you mentioned [about] the collaboration that we’re in, it brings together many different entities, right?   So from Cook County Health to Advocate Aurora Health, UI Health and several departments; Department of Family Support Services, Department of Housing and the Chicago Housing Authority.  And then we work in collaboration with the community; the Center for Housing and Health, and they partner with Debora’s House, Thresholds, Renaissance Social Services and Housing Forward.   

 

So what we wanted to do was, the Flexible Housing Pool allows us to fund housing, but also to provide wrap-around services, right?  It goes beyond housing, to what are the other services that we could provide, or supports that would provide stability and address health issues. 

 

There are many ongoing efforts across the City and County to increase affordable and supportive housing for the most vulnerable residents.  Why did BCBS IL invest in this particular housing initiative? 

So, part of it is, as you know, when you work in partnership it’s about who are those partners and who are those organizations that have done the work.  The Center for Housing and Health was one of those partners that we work with, right?  As I talked about with community investments, what we look for is who are the partners or organizations already doing the work, because we see ourselves as “how do we support good work that’s [ongoing].  So what we liked about the Center for Housing and Health through this collaborative was partnering with hospitals.  Particularly, we were noticing as an organization, a lot of individuals who were homeless were presenting in shelters or presenting in the ER.  So one of our natural partners are the hospitals, and so how can we add to that relationship?  You mentioned that we’re the first private investors in this, because we see it as not only good for the community, but also good for business as well.  Our HSCS President, Maurice Smith says that all the time; what’s good for the community is also good for business, as we see this as that.    By looking to stabilize our homeless brothers and sisters, and getting them the services that they need and wrapping around it with case management on the social service and health side, gives the complete picture around what is needed to uplift and to able to adjust health issues.   

 

The current grant is for $1 million dollars over two years.  Beyond the two year investment, how does BCBS IL view its role as a sustainability partner for the FHP? 

We started funding housing in 2017 and the reason that we started doing that was, we had to step back as an organization and, as you know Kuliva, it’s all about what is it we’re looking to do as an organization.  We wanted to impact health, but how do you do that?  So we stepped back and worked on a strategic plan, and we specifically identified housing, and identified housing as a health issue.  As a very large organization, we thought by us saying that, we’re leveraging the assets that we bring as a large organization.  So for us it makes an important point that, as a big organization, we draw a line in the sand that says this is important [and] that housing is a health issue.  What we’re looking to do is extend beyond that, so we’re looking to see what are the lessons learned through this partnership.  As you can see, it’s a partnership model and its looking at building sustainability because it’s not just us.   

 

So one of the things we learned is how to share the knowledge, and you do that by working in partnership. We’re looking to build upon what we’ve learned during these two years.   

 

In what other ways is BCBS IL investing in the social determinants of health? 

The other things we looked at [in the strategic planning process] is violence as a public health issue.  That’s another issue that we’re looking to address as an organization and as part of the system.  We’re also looking at behavioral health, because one of the gaps we see is, even today as we think about health, people are very comfortable thinking about physical health, but really think about our brain as part of our body.  As we think about health, we’ve got to normalize and be comfortable in addressing all parts of our bodies.  So we behavioral health as one of those issues we’re looking to address.   

 

The other issue we’re looking to address is general access to care.  That’s a big bucket, but we also understand that access to care can mean different things.  It can be physical access; do you have access to services?  It can also mean language access; do you have the information you need in order to make decisions around your health care?  As you can see, we have specific issue areas, but then we have a broader one, and that was intentional so that as things come up we can adjust.   

 

What programs and services at the Blue Door Neighborhood Center in the Pullman community addressing the social determinants of health? 

I do want to talk about how we entered Pullman.  I think, a lot of times, the normal way of doing things is build it and they will come.  But how we approached it was very different.  Kuliva, you were there as part of doing the town hall meetings and the research to truly understand and hear from the community, what are the needs and what are the assets within Pullman.  Part of our job is to understand, and I think that comes from a place of humility.  Even the word, understand, means there are some things you don’t know, and to be able to stand, you need to understand what’s going on.  That’s how we present.  We want to understand, and from there, that’s how we have the types of services we have at Blue Door Neighborhood Center.  So, for example, diabetes came up at the town hall meetings and during the one-on-one sessions. And at the Blue Door Neighborhood Center we have health educators there all the time to talk about diabetes, heart disease, asthma.  We also have care coordinators, [who] I think of as your health care concierge.  So, you have diabetes, and you want research on how do I navigate that?  Where do I go?  The care coordinators are there to help you with that.   

 

We also see the Blue Door Neighborhood Center as a way for community members to feel that [its] their center.  We have three community spaces for 501(c)3 organizations to enjoy the company, and to come there and talk about the health issues happening in the organization.  We also have zumba classes.  We also have yoga.  So all these different things that the community has shared with us as:  “these are how you can build upon the assets in Pullman”.  These are the things that you can provide as an organization.  Blue Door, specifically, was about being in the neighborhoods.  We want to be where health is happening.  In the neighborhoods.  In Pullman.  We’re very excited to be able to be part of that.   

And we’re rolling; we’re opening a second Blue Door Neighborhood Center as part of a larger commitment in Morgan Park.  Again, I want to give credit to our HCSC President, Maurice Smith, who had the vision of taking that space, which was a former Target, and turning it into a multi-function, multi-purpose space, which will have some of our customer service lines of business.  So it’s going to bring, like, over 500 jobs to the community.  As part of that multi-purpose center, we’ll have a Blue Door Neighborhood Center, continuing to provide health education, health literacy and care coordination with the community.   

 

What has changed, though, is that we needed a bigger space for our community rooms, so we’re actually doubling our community room space, so that even more community organizations can use that space for the work that they’re doing.  

Learn More: 

Blue Door Neighborhood Center
Blue Cross Investments in the Flexible Housing Pool

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05 | Unintended Consequences: Hospital Consolidations and Women’s Health (Part 2 – The Provider Perspective)

05 | Unintended Consequences: Hospital Consolidations and Women’s Health (Part 2 – The Provider Perspective)

 

As hospitals across the state are consolidating through mergers and acquisitions to gain market share, many Catholic hospital systems have made strong gains based on their financial strength.  As a greater share of Illinois hospitals are operating under the Ethical & Religious Directives for Catholic Health Care Services, a recent University of Chicago report indicates there are unintended consequences for women’s health, and a disproportionate number of low-income women. 

In this episode, we talk with maternal child health researcher and public health lecturer, Janine Hill about the report and the implications for health equity.

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In the backdrop, Illinois Governor J.B. Pritzker signed the Reproductive Health Act in July of this year.  The Act eliminates nearly all restrictions on contraception, sterilization and abortion in the state, and ushered in a law that supports reproductive health care as a “fundamental right”.  Yet, as reported in the Crain’s Chicago Business July 2019 article “Why Illinois’ newly recognized ‘fundamental right’ is getting harder to exercise”, the new law, and the acquisition of regional hospitals by Catholic systems are at odds with one another.  Catholic hospitals operate under a set of rules known as Ethical & Religious Directives for Catholic Health Care Services, or ERDs, which were developed by the U.S. Conference of Catholic Bishops.

ERDs largely restrict access to and the provision of care for contraception, fertility treatment, sterilization and abortion. For women covered by Illinois Medicaid managed care plans in Cook County, this creates a significant barrier to comprehensive reproductive health care access, as the County’s plans are heavily dependent on contractual referral relationships with hospitals newly merged with Catholic hospital systems.  

In this episode, I’m talking with Janine Hill, President of Soar Strategies, Inc., former Executive Director of EverThrive Illinois (a statewide coalition for maternal and child health), lecturer in public health at UIC School of Public Health and non-profit management at Northwestern University, and PhD candidate in community health with a focus on maternal health outcomes.

Janine’s expertise in public health policy, health systems and maternal and child health research brings a unique perspective to this new challenge in Illinois, as the health outcomes for women and their children is largely dependent on broad access to comprehensive reproductive health care services. 

Soar Strategies is a consulting and coaching firm committed to helping leaders and groups in the social good and corporate sectors to share their strengths, create goals, and achieve their professional as well as personal goals through a collaborative process.

We are passionate about teams and individuals. We believe that our diversity in experiences, knowledge, and thoughts are our best qualities, and our goal is to help your special gifts shine at work, school, and home by creating brave spaces for coaching interactions, as well as consulting engagements.

We believe that change is a collaborative process that must be guided by goals. We seek to continuously collaborate with organizations, individuals, and teams to facilitate crucial conversations that lead to transformation.

 

For more on the article “Why Illinois’ newly recognized ‘fundamental right’ is getting harder to exercise”

QUESTIONS & ANSWERS

Reflecting on your research and work, what impact would this have on Maternal and Child health outcomes at the population level?

So, I think this is an important topic, and I think that Illinois really is an outlier in the number of hospital beds we have in our state that are Catholic-owned. So 14.5% of US hospitals are Catholic-owned, as you can see from the research from Dr. Stulberg, it’s even more pronounced in our state, and that does have implications for population health outcomes. So, If I’m a woman going to a facility that is now allowed through ERDs to give me a tubal ligation or IUD or even talk about those types of family planning services, then a couple of things can happen.

Let me back up. One of the most important things that we think about when we have reduced access to family planning methods, which is really what we’re talking about is an increase in unintended pregnancies. So about 5% of women of reproductive age in any given year have an unintended pregnancy, and about half of pregnancies are unintended. So we can logically assume that if we have reduced access to family planning and contraception, we’re going to have increased numbers of unintended pregnancies, and many of those will end in either abortion or in births, right? So, let’s follow that flow-chart.

So if the mom is not able to get family planning services, she gets pregnant, she delivers, the research shows that there are adverse implications for both mom and baby. They include mental health challenges for mom, they include challenges in mother/child bonding when the baby is born, they include things like not getting prenatal care in the first trimester, which is recommended, and increased adverse outcomes like low birth weight and preterm birth. We know that the literature shows us very clearly that, when we have access to family planning, we have less unintended pregnancies, and we have a reduced likelihood of those adverse outcomes like low birth weight, preterm births, [difficulty with] mother/child bonding, etc.

Then, let’s follow the other side of that equation, right? Let’s say that, somehow I was able to get an abortion, we know there’s a very clear link to reduced access to family planning, and increased number and incidence of abortions. So moms may wait later to get an abortion, and that’s a more involved medical procedure. They may, unfortunately, try to access unsafe abortion facilities and practices, and then have a number of medical complications due to that.

So I really do think that there are very clear policy recommendations we can make in this instance, and I think we have to think about what these mergers and acquisitions [mean] in our state and the implications of those at the population and individual levels. This article talks about a woman that’s not able to access family planning services. We know that people who are lower-income, who are Medicaid-eligible, who are in more rural surroundings who are not in the Cook County or Chicagoland area; we know that these women are more likely to be challenged by having one catholic hospital in their network.

In your opinion, how are health care systems impacted by this “consolidation effect”? Specifically, what happens to family planning services across systems of care (i.e., Medicaid managed care, hospital-based care, and primary care)?

I think a couple of things, and maybe I’ll start with the research because that’s where I live. We’d not done a lot of research on the impact of training and [practicing medicine] at a Catholic-based institution earlier, but with these mergers and acquisitions, there are some researchers who are starting to ask those types of questions. There was a 2017 study, published in the Journal of General Medical Education. This was a qualitative study that actually interviewed 31 graduates from seven (7) Catholic residencies between June of 2014 and February of 2015.

What the clinicians reported [were] gaps in reproductive health training that they had to access elective training on their own to get that type of information. And after graduation, they were pretty dissatisfied with their training on family planning. They felt they had delayed competencies in this area, and rightfully so, they thought they had a lack of ability to perform various family planning procedures. They all mentioned that they thought that Catholic programs should improve family planning training by providing routine, opt-out, family planning training opportunities.

So you see this thought at the systems-level and at the provider-level, that the impact of being trained at a Catholic institution, that [providers] reported that is was quite negative in terms of their perceptions of their [own] competencies around family planning. So I do think we have to think about collaborations and what is meant by in-network and out-of-network. If I’m a woman in a rural part of our state, and I have one hospital in-network, and it happens to be a Catholic-owned hospital, is there a way that I could have (for example) access to family planning services in another hospital that would be for the auspices my payment and my managed care plan, be considered in-network for those types of services. It feels to me very unfair to have one hospital that has already stated through the ERDs that they are not able or willing to do certain types of procedures. Yet, as we know, we just passed the reproductive health act. We have decided that each person has a fundamental right to make decisions about reproductive health care, and that includes contraception, abortion and maternity care. A fundamental right is classified as one that the government cannot interfere with, except in certain narrow situations.

So it feels like, if I’m on Medicaid or another type of managed care plan, and I don’t have this access in-network, that feels like interference to me, and so I think we need to think about what that means at the systems-level and systems-level changes that we can provide for these women.

What are the implications for health care equity? Specifically, who is most impacted by this change in the health care delivery system in Illinois?

So, I think we have a lot of different types of data converging here. If I told you the groups that were more likely to have unintended pregnancies, you could overlay the same demographics with the groups that have less access to health care or [within] some of these Catholic-owned institutions. What do I mean by that? We talked about the rural piece, which I think is really important. Really,really important. The other pieces which we have talked about a little bit are, women that are low-income, right? We’ve talked about Medicaid-eligible women a lot in this segment. I would also put women who also have plans that would be considered catastrophic coverage, and don’t have a lot of health care coverage. I would put them in a similar bucket here, because the in-network and out-of-network are pretty tight and there are very clear, large financial implications for selecting a provider that’s out of network. So I would say low-income women, either in Medicaid or other, private, managed care plan. I would say rural women; definitely there are implications for health care equity.

What we haven’t mentioned, but I want to mention here, is that one of the groups that also have high rates of unintended pregnancies are women of color, and in particular, Black women. I know in the article we’re discussing, that was a Black woman. So I think it’s important to think about the converging of those types of demographics on health care equity. It’s going to be the same crew that would have challenges getting family planning anyway. It would be the same crew that would have increased, unintended pregnancies anyway. If we know that from the get-go, and we know that from the research and the data, shouldn’t we be most focused on that population if we really want to see an impact on the reduction of unintended pregnancies? Shouldn’t we be thinking about what can we do for women who may be inside one Catholic-owned, in-network hospital or provider, and what we can do to expand the delivery system and expand their options?

What might be policy-level options to reduce or eliminate the resulting disparity?

That’s a great question, and I have been thinking about this. If I’m the head of the Department of Healthcare and Family Services, or head of the Medicaid Division, what can I do to think about how to address this issue? In some ways, again, I think the wind is in our sails with the passage of the Reproductive Health Act. We have a great opportunity here. The state has said that we have a fundamental right to make decisions about when and where to have children, and when to choose to not have a child.

If we’ve said that, if we’ve passed this public act, then I do think we have a responsibility. I think I should say that first. Some of that might be around the guidance that the Medicaid Division gives to managed care organizations, and this is where I think advocacy could be useful, too – to think about what in-network and out-of-network mean, particularly for family planning and contraceptive services. I honestly think that there should be a statute that says that, if my network is a Catholic-owned institution or hospital, then I should have another option that is a non-Catholic-owned institution to be classified as in-network for me to get my family planning and reproductive health care services. Period.

We could talk about other, less impactful efforts, but I really think we need to think about the classification of in-network and out-of-network, and I should have another option. Because what the ERDs say is that, obviously there should be timely referrals if I’ve decided that I cannot, by virtue of my employer, provide a tubal ligation, or insert an IUD, then I’m supposed to [receive] a timely referral someplace else, right? But timely referral [is something] I almost want to put in quotes, right? If I’m in a rural situation or if it just gets lost in the shuffle, timely ends up not being so timely, and when you’re pregnant, every week matters. And so I don’t think we need to be doing that in the midst of it; like I go and I can’t get an IUD, that plan needs to be set from the very get go. I think there needs to be educated on this also for consumers to understand that, you are enrolled in a plan that actually has as its in-network hospital, a Catholic-based institution. Here’s what they can do, here’s what they can’t do. We actually will give you another period of time if family planning and contraceptive services are important so you can choose another plan, and to choose another in-network hospital.

I bet that if we had a focus group of reproductive aged women in Catholic-based institutions and we asked them: “do you understand that, in your plan, [which is] under an ERD, you cannot get x,y and z at your hospital”. I bet most of them would not know that right now, and they won’t know that until they get into a situation, which I think is unfortunate. So, one – I think we need to do a better job of education on the front-end about health plans and, two – I think we really need to reevaluate what in-network means, and having an in-network option that’s non-Catholic owned for women of reproductive age.

Learn More about Janine Hill and Soar Strategies, Inc.: 

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Janine Hill, PhD(c) MPH

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04 | Unintended Consequences: Hospital Consolidations and Women’s Health (Part 1 – What the Research Says)

The rapid consolidation of hospital systems across Illinois has been dominated by Catholic hospitals, making strong gains based on their financial strength.  With a growing share of hospitals now operating under the Ethical & Religious Directives for Catholic Health Care Services, providers in these systems of care face limitations on the provision of family planning services for their patients and limited options for OB-GYN training as well. 

In this episode, I’m talking with Kai Tao, ND, APN, MPH.

For more nearly two decades, Kai has been in practice as a certified nurse-midwife, Deputy Commissioner with the Chicago Department of Public Health, Senior Policy Advisor for the Director of the Illinois Department of Health and Family Services, and Vice President of Clinical Operations with Planned Parenthood of Illinois. 

 

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As hospitals across the state are consolidating through mergers and acquisitions to gain market share, many Catholic hospital systems have made strong gains based on their financial strength.  With secular and faith-based systems now under their purview, Catholic hospital rules regarding reproductive health care will apply to a greater number of women in Illinois; especially low-income, Medicaid eligible women.

In the backdrop, Illinois Governor J.B. Pritzker signed the Reproductive Health Act in July of this year.  The Act eliminates nearly all restrictions on contraception, sterilization, and abortion in the state, and ushered in a law that supports reproductive health care as a “fundamental right”.  Yet, as reported in the Crain’s Chicago Business July 2019 article “Why Illinois’ newly recognized ‘fundamental right’ is getting harder to exercise”, the new law and the acquisition of regional hospitals by Catholic systems are at odds with one another.  Catholic hospitals operate under a set of rules known as Ethical & Religious Directives for Catholic Health Care Services, or ERDs, which were developed by the U.S. Conference of Catholic Bishops.

ERDs largely restrict access to care and the provision of care for contraception, fertility treatment, sterilization, and abortion. For women covered by Illinois, Medicaid managed care plans in Cook County, this creates a significant barrier to comprehensive reproductive health care access, as the County’s plans are heavily dependent on contractual referral relationships with hospitals newly merged with Catholic hospital systems. 

A recent University of Chicago report indicates there are a disproportionate number of low-income women in health plans served by these hospital systems and that health disparities are likely to increase.  In this episode, we talk with a women’s health provider and women’s health advocate about the rapid consolidations, the report and the implications for patients and providers across Illinois. 

In 2018, Kai launched Juno4Me, a non-profit that provides free IUDs and implants to people in Chicago. Kai’s extensive experience in women’s health, program development, public health policy advocacy, and clinical operations brings a multi-sectoral approach to the challenges of access and equity these recent hospital merges pose to women across Illinois. 

 Juno4Me believes that everyone should be educated and have access to every type of birth control, especially the modern ones such as the new and improved IUDs and Implant. IUDs and the Implant work super well at preventing pregnancy, are considered safer than the typical pill since they don’t contain estrogen, and more importantly, you can forget about it and it’s still doing its a primary job. 

QUESTIONS & ANSWERS

How might this phenomenon impact the number of providers who are willing and able to deliver family planning services across Illinois? 

Dr. Stulberg and I have talked about the data, and for the last few years, the data has been saying that about 1 in 3 hospital networks are either religiously affiliated (often Catholic-affiliated, but could also be non-Catholic, Christian-affiliated) systems, so this data didn’t totally surprise me. I think what was very salient about this data was that, we actually looked at the users of Medicaid from 2015 – 2018, and women from the 15-44 age range, who actually use Medicaid and we saw that women of color were more likely to be enrolled in these programs in Medicaid and thus have the limitations of truly having providers who can provide full access to contraception and reproductive health services.

How might family planning training for providers be different in Catholic hospital settings?

When we think about workforce and pipeline, it is so critical. Not only are we providing evidence, but you want skilled providers who are well trained, and unfortunately for many of these systems that may have some kind of residency, and that could range from family medicine, internal medicine, OBGYN of course, and also for nurses, nurse practitioners, physicians and physician assistants, so it’s not just OBGYN doctors. Their training is really going to be missing a big part of comprehensive care for women.

Will providers have options for patients in need of family planning services that aren’t provided in hospitals newly operating under ERDs?

Full disclosure, I think there’s variation across the system of hospitals that practice under ERDs, in terms of what can or actually cannot happen, as I say, behind the exam doors. We know, within a hospital system, like if you actually practice within an in-patient hospital setting, we believe (and I’ve seen, because I’ve been working in labor and delivery here in Chicago for about 15 years, so we talk a lot to our peers) you really cannot get something like a tubal ligation if a woman says “I’m done with childbearing, I really want to have a tubal ligation”. A pretty simple procedure, especially if you’re already inpatient in the hospital – that cannot happen, right? What happens through ambulatory, so outpatient, affiliated with the hospital? I have to be candid that I think there’s variation. But again, that’s not how good health care delivery should happen; based on if you have a provider who happens to be savvy. We see a lot of people who are going to these religious [affiliated] clinics, and they all have really bad menstrual cramps or they may have severe other issues associated with needing birth control for non-pregnancy reasons.

And can’t access it?
Well, no. That’s how we’re able to access it, because really – under the directive – it’s saying that you cannot use birth control for pregnancy prevention. If you have some real medical indications that has nothing to do with preventing pregnancy, we can most likely help you. Especially in the outpatient setting, and that’s what I’m saying. A lot of young people are saying “I got birth control pills because it’s being prescribed for a medical reason, and not necessarily for pregnancy prevention”.

I also often wonder how often women who are part of these Medicaid managed care plans that now have hospitals in their networks that are operating under ERDs are even aware that, when they signed on to these plans, that there are these restrictions. My guess is, they show up for what they need, only then to discover what the barriers are. Like the woman in the Crain’s article.

Yeah, and the woman in the article found out what the reason is. Most people are just assuming that they’re getting good care, they have coverage, and this is what their provider offered. End of story. My provider doesn’t do this, so I don’t think that’s a procedure I’m going to get, so that’s fine. Most people are not going to question it, and there’s definitely nothing at this point that tells the user when their picking a plan; oh – if you pick this plan, these are the hospitals, and you may not get the full reproductive health services that are based on evidence and science.

That might be necessary for you based on your age and gender.

Exactly.

There are several key objectives in the CDC’s Healthy People 2020 Family Planning Goals, including increasing the proportion of health insurance plans that cover contraceptive supplies and services. These are national goals that set the standard for public health planning at the state and local levels. Reflecting on your extensive work and practice in women’s health, and as an administrator in Illinois and Chicago’s health departments, what impact would these recent hospital mergers have on family planning outcomes at the population level?

I mean, the reality is, there’s a real disconnect when we think about what actually happens from a payor source (the insurance plan) to the experience that an end user may have. Unfortunately, they are often very misaligned. I think, overall, in the United States we’ve seen trends where unplanned, untimed pregnancies are decreasing.

I believe they’re decreasing here in Illinois.

Correct. Nation-wide, consistent with Illinois and even in Chicago, we’ve seen a decrease, which is great. However, like many health outcomes, we see significant disparities. In the city of Chicago specifically, when we look at teen births [from] 15 – 19 years old, we see Black and Latinas having birth rates five times higher than White teens. I always like to say, it’s not because the White teens are having less sex. Right? It’s all about education and access. And so, you know, these goals that the CDC has, they’re nice targets to have, and we’re seeing progressively downward trends. But [at] the end of the day, these disparities are something that are very real, and very evident here in the city of Chicago.

And they are particularly relevant as the majority of the women who are on the 5 to 7 Medicaid managed care plans, for which the dominant hospital systems are now Catholic hospital systems are African American and Latinx women.

Correct, and when we look at national data, who’s most at risk for unplanned, mis-timed pregnancies? We see it in the younger age; 24 and under is the highest. Even though I say 45% of pregnancies are unplanned or mis-timed, in the under age 24, its 80-90% unplanned and mis-timed. What are the other characteristics of women who self-report having an unplanned or mis-timed pregnancy? They are usually cohabitating with someone, and single. They are usually at or below the federal poverty level. They usually don’t have a high school degree, or are still in high school – so never even got out of high school. Those are the main characteristics, and of course, they are women of color. The people who need the services are the ones that, under the ERDs, are being hurt the most.

What might be policy-level options to reduce or eliminate the resulting disparity?

First thing is we have to do more public education, so people know what are their options. What you had in 1980 and what your maternal grandmother told you is not what’s available in 2019. I think more people need to have that education, and with the advent of social media, anything goes. So there’s a lot of misconceptions and myths happening in the world, and in health care in general, and we see it predominantly in birth control and reproductive health. Things that are simply not true, and the evidence has shown us otherwise.

So we need education in the first place, which we can say would be a different podcast. Talking about comprehensive, medically-accurate, age approrpriate K-12 education. But more importantly, people who are on these Medicaid plans; do they know, and do providers know that, nationally, under the Centers for Medicaid and Medicare, there is a freedom of choice provision. Which means that, it doesn’t matter who your primary care physician is, or what network you’re in, or what medical home, you have the right to seek contraceptive healthcare outside and still get coverage. Unfortunately, that is one of those things that most people who know about this say, great, but the end user has no idea. And, of course, many providers have no idea. They would just say, “Well, this is all we offer here, and this is your coverage”.

So I think some policies would be, first, let’s let more people know about this. Let the end user know that she has options. Once she knows what all of her options are, where to go to get these options. That’s the other big piece. And that was just one prong of Juno4me, when we’re talking specifically about IUDs and implants. To help identify some places you can go, and you will get coverage no matter what.

And you will get transportation to get there, which is yet another barrier to care when you are low-income.

Exactly. And then the other piece I often think of, when you asked about policy, Kuliva, is I find it fascinating that in 2019, a public program like Medicaid – which is very big and robust (we have expanded Medicaid in Illinois) – to me it’s almost akin to saying; “By the way, you have no vaccine coverage. Are you ok with that?”. Because we know the data shows 99% of American women between the ages of 14 and 45 have used something other than natural family planning for birth control. This affects a big swath of the population.

More than half.

Right. Exactly. And to know that there’s no coverage for that – that could just never happen. I use the analogy of vaccines, because we wouldn’t make that a health plan. We wouldn’t say that’s ok, but somehow, our long history has allowed this to happen [for birth control].

Learn More about Juno4Me and the Alliance for Health :

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Alliance Health

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07 | The Flexible Housing Pool: System Coordination to Address Chicago’s Homelessness

01 | Collective Impact: On-the-Ground Strategies for Community Engagement

The South Chicago Neighborhood Network uses the Collective Impact model to build a “trauma-informed” community.  Often in community development work, too many organizations are working in isolation from one another, reducing the collective power of resources and networks.  Can the collective impact model provide a structured way to bring people and organizations together to achieve social change?

In this episode, we talk with the Coordinator of the South Chicago Neighborhood Network about how collective impact works on the ground in community development.   

Often in community development work, too many organizations are working in isolation from one another. According to the Collective Impact Forum, collective impact brings people together in a structured way to achieve social change.

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Collective impact: 

  • Starts with a common agenda (coming together to collectively define the problem and create a shared vision to solve it;
  • Establishes shared measurement (agreeing to track progress, in the same way, allowing for continuous improvement;
  • Fosters mutually reinforcing activities (coordinating collective efforts to maximize the end results); and
  • Encourages continuous communication (building trust and relationships among all participants)

It also has a strong backbone – such as a team dedicated to orchestrating the work of the group.

With principles of practice that places a priority on equity, uses data to continuously learn, adapt and improve and includes community members and cross-sector partners, the collective impact model has become a “best practice model” for philanthropy and strategic grantmaking at the community-level.

In this two-part episode, I’ll be exploring the efficacy of the collective impact model from two perspectives:  Philanthropy and Community Development.

Today I’m talking with Tevonne Ellis (of Claretian Associates), who is the Network Coordinator for the South Chicago Neighborhood Network. The South Chicago Neighborhood Network is one of the 10 funded neighborhood networks of United Way of Metro Chicago.  The Network uses the collective impact model, to support the common agenda of creating a trauma-informed community by 2020 and is comprised of over 22 South Chicago community civic and non-profit organizations, leaders, businesses and health partners.

Tevonne and her team convene Network members monthly to review ongoing activities, assess effectiveness, and determine next steps.  The work is led by and coordinated through Committees, and the Committee Chairs convene members and key partners to deploy the planned activities and programs.

QUESTIONS & ANSWERS

How does the SCNN engage the Collective Impact model to support the creation of a trauma-informed community in South Chicago? 

Our goal is to engage youth, between the age of 8-26, to reduce violence in the community. Each of these organizations has a strength to help us engage young people, in particular, around violence. 

How has your funder, United Way of Metro Chicago, guide and support the network in utilizing the collective impact model? 

Our funder provides us with a community engagement officer so they’re basically the boots on the ground in the community from the funder’s office. Really helping, directing and guiding the collective impact process. They were there to help us create our common agenda, our three-year plan as well as looking at our goals and indicators on how we’re meeting our goals in the plan. 

Also, to help us build capacity. They provide an evaluator to look at the concept of the indicators of our plan. I think there is a struggle, I think trauma is a really hard concept to measure so we kind of struggle around data collection and tracking and evaluation. 

What, in your opinion are the strengths and challenges of utilizing the collective impact model in the Network’s effort to create a trauma-informed community? 

One of the challenges is keeping network members engaged and at the table. Another challenge is looking at the topic in which you are approaching. This is a relatively new concept, what is trauma-informed? What does it look like? 

It’s just a really broad topic and I think we struggle with focusing it and really looking at how we can create an impact in using the collective impact model. Rally kind of showing that bc we created a trauma-informed neighborhood, we reduce violence. 

Strength is when you show funders as well as other key partners, that if you’re working collectively to move the needle it’s always powerful to show in numbers vs one organization. Also, I think it creates a movement when you have more than one person at the table around trauma-informed. When one organization hears about it, you start to hear other people talking about it as well. 

Being intentional about making sure we are meeting the needs of collective impact. Common goal, common agenda, having a lead agency and making sure that we are collecting data are some of the key pillars. 

The common goal and the common agenda are always at the head of the conversation. Collective Impact can make a shift and you have to revisit the common agenda and the common goal to make sure everyone is still invested in the key themes. 

What would you share with funders who embrace this model for community-level work? 

People are at different levels of the collective impact model. They may have common goals or common agenda but are they really making an impact in unison. Are you just looking for collaborative work or are you looking at unison where all organizations are working together to make an impact? 

I think you have to be really clear on what you’re looking for when you’re looking at collective impact work. 

Starting from scratch is a very difficult challenge. You have to educate your potential funder what collective impact means to you. It has different definitions for different funders. 

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