09 | Philanthropic Collective Action to Address Homelessness

09 | Philanthropic Collective Action to Address Homelessness

According to the National Alliance to End Homelessness, in 2020, there were over half a million people experiencing homelessness on our streets and in shelters in America.  Seventy percent were individuals, and the remaining 30 percent were families with children.  They lived in every state and territory, and they include people from every gender, racial and ethnic group. 

However, some groups are far more likely than others to become homeless.  In the same year, The U.S. Department of Housing and Urban Development Annual Homeless Assessment Report to Congress revealed that African Americans are overrepresented in the population of people experiencing homelessness compared to their share of the overall US population. 

 

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A recent report by the Chicago Coalition for the homeless found at least 65,000 people were experiencing homelessness in Chicago in 2020, including those who temporarily stayed with others in addition to people living in shelters and on the street. Additionally, similar to national data, although African American Chicagoans make up roughly 30 percent of the city’s population, they represent 70 percent of the City’s homeless.  For housing advocates and activists, ending homelessness is connected to the moral imperative to end racial inequities within our society’s systems, policies, and social practices. 

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Today, we’ll be talking with Emily Krisciunas (Chris-shoe-nas), Director of Chicago Funders Together to End Homelessness.  Incubated at Michael Reese (a public foundation) since 2020, CFTEH seeks to foster a person-centered, ecosystem approach to ending homelessness that reaches across systems and sectors. 

CFTEH is one of several local networks of Funders Together to End Homelessness – a national network of funders supporting strategic, innovative, and effective solutions to homelessness.  CFTEH has more than 30 members and is comprised of a shared table of family foundations, community foundations, corporate philanthropies, and the local United  

Way. The collaborative is guided by a steering committee of four funders and two full-time staff. Collectively, CFTEH members have directed more than $50 million over the last two years towards efforts to prevent and end homelessness in Chicago, supporting more than 200 organizations across the region since 2020. In 2022, CFTEH launched its first pooled fund effort—the Housing Justice Fund—which makes grants to support advocacy, community organizing, and narrative change efforts. 

In our conversation, we’ll learn about how the local philanthropic sector came together to co-create a strategy to end homelessness in Chicago with providers, advocates, government, community partners, and residents with lived experience. 

Welcome Emily! 

QUESTIONS & ANSWERS

1. I’d like to start by having you share with us the origin story of CFTEH.   

Thanks for having me.  Nice to be with you.  I think that CFTEH began as a more informal network of, maybe, 10 or 12 local foundations.  So much of this groundwork was laid long before I came onboard in 2020. And I think that this group grew out of this observation that philanthropy has a ton of resources, and a ton of power to help end homelessness, but that those resources aren’t always well coordinated or optimized.  Both within philanthropy and with partners in the public sector. 

And around the same time, we had colleagues who were connected to the organization that you mentioned in the introduction, Funders Together to End Homelessness at the national level, and were starting to see these local collaboratives pop up in other communities.  There was one really notable one in Los Angeles called Home for Good that I think was particularly influential.  And so this group of funders started to be interested in replicating that collaborative model here in Chicago.  And in order to do that, this group realized that they would need a home, sort of a backbone – administratively and operationally for that work, and we were so lucky that Michael Reese Health Trust was beginning the process to becoming a public charity, which gave them some new resources at their disposal.  They could incubate new initiatives; they could advocate in a different way. So, in 2019, before I came onboard, they raised their hand within the group and volunteered to be the home for CFTEH, which enabled the group to hire their first dedicated staff person, which became me. 

 

2. In 2022, CFTEH created its first strategic plan.  I understand you conducted a series of listening sessions with community and stakeholders to begin the process.  What were the key takeaways from those sessions? 

It’s a great question and felt like an important phase in CFTEH’s work.  There were two big pushes around listening.  The first one came when I started in the role.  As a precursor to strategic planning, I met one-on-one with all of the funders who were participating in the collaborative, and I wanted to get a sense of how they thoughts about addressing homelessness, and what their own grantmaking priorities were, and what their motivations were to be in the group.  I remember this thing that Marianne Philbin, who is a colleague at Pierce Family Foundation kept saying, which was, “CFTEH should be doing things that it can uniquely do as a group that individual foundations can’t do on their own”.   

 And that felt like a recurring theme in all of the conversations that I had with funders.  But what I think wasn’t clear from the beginning was what exactly that “what” be?  What was the unique contribution that CFTEH would have that individual foundations could not do on their own, but that became a guiding set of questions that informed the second round of listening that we did in 2022, which as you said, was focused not within our philanthropic community, but instead on all of our external partners.   

 
So, you’re exactly right.  We did, with your help, interviews and focus groups with at least 50 community stakeholders, and these are people with lived expertise of homelessness, advocates, colleagues in government, policy makers, service providers, and I think there were a bunch of important takeaways from that experience.  They really centered around the role that philanthropy has to play in naming and addressing the role that racism has in homelessness, and drawing that connection a little more clearly.  They wanted philanthropy’s help in promoting this more expansive definition of homelessness, not the often narrow federal government definition of homelessness that is just a person maybe, staying on the street, or in a shelter or on the train, but instead this much more expansive experience of people who are maybe couch surfing, or living doubled-up or under the threat of violence in their home.   

They were really interested in seeing CFTEH think about its power and how it wields it and how it shifts it to communities who are impacted by homelessness.  Partners also had some really helpful critiques, frankly, about the way philanthropy often does grantmaking.  About how arduous and burdensome that process can be.  How inflexible it can be.  That was really something that we saw reinforced in our own grantmaking data that CFTEH reflected on in its strategic planning process where we saw a lot of grants being made just a single year at a time, often restricted.  So, we got a lot of feedback from community stakeholders about the role that CFTEH could play in maybe helping model grantmaking in a different way, and nudging and supporting our foundation members in making their grantmaking processes around ending homelessness as flexible and accessible as possible. 

 

3. I understand that from those listening sessions Emerged a set of “guiding principles”.  Can you share those principles with us that will guide the work of CFTEH for the next three years? 

We landed on four of them, and looking back I can see the way that each of them feels really anchored to the community feedback that I just highlighted for you.  So, the guiding principles in the CFTEH plan are: 

  • To lead with and center racial equity in housing justice in all of the work that we do. 
  • The second one is on Targeted Universalism.  An acknowledgement that homelessness is so disproportionately experienced by communities of color, and particularly Black and African American communities, and so approaches to ending homelessness ideally will benefit all people experiencing homelessness but should really be targeted to the groups and communities who are experiencing it the most, disproportionately.  
  • The third one is around centering people with lived expertise in homelessness and housing instability in all of the decision-making that we do. And we’re exploring all day, every day, different ways to do that in the work of CFTEH.  
  • And then the fourth one is around this idea that, fostering a person-centered, ecosystem approach to ending homelessness, as you mentioned in the intro. This idea that homelessness is this idea that is really simple, in that the solution is housing, but that it is [also] really complex, in that all of these different systems, frankly, are failing people who come to experience homelessness and are often interacting with the justice system, or the employment system or education system, but at the end of the day it is still a person a neighbor who is experiencing homelessness and that we have to keep the person at the center, even though we’re talking about lots of complex systems that are contributing to that persons, perhaps, lack of access to housing.  

 

4.  What can you share about CFTEH’s strategic plan, including goals and objectives? 

Our north star in the strategic plan is for CFTEH, this community of funders, to contribute to a significant reduction in the number of people experiencing homelessness in the Chicago region.  With that focus, in particular on Black communities who are experiencing homelessness most disproportionately.   

In the theory of change that CFTEH has developed for its strategic plan, it suggests that if CFTEH leans into these four big functions that we identified for ourselves as an educator, as an advocate, as a model (as I said earlier for our members) and as a convener, we can help advance these three big categories of change.   

One related to more equitable housing policy, another around shifting power to communities most impacted by homelessness, and the third one is around bringing greater alignment into these often disconnected and disjointed sectors and systems.  To your point you just made, that are often contributing to a person’s experience of homelessness.   

And I love that CFTEH, in its pursuit of these goals laid out in the strategic plan gets to be this sort of lab for new ideas.  We really can be this model for new ways of working.  We learn a lot from other communities that are experimenting in the way that we are, from other funder networks, and communities like New York, LA and Baltimore and the Bay area that are often piloting really different public/private partnerships that we aspire to replicate here in Chicago.  So, even though we have a strategic plan, we’re trying to make it vibrant and useful as is possible in the work that we’re doing every day. 

Tell us more about the Housing Justice “Pooled” Fund and how it ties into the strategic plan. 

Yeah, I’m so excited!  So excited about this effort.  What’s interesting is that we don’t  necessarily set out in the early days of the strategic planning process to have a pooled fund.  It wasn’t really part of the early conversations about what CFTEH would be, and I think the more we got into the planning process, and the more we reflected on what our members are funding currently, and what our stakeholders really wanted CFTEH to do, the more a pooled fund emerged as a really interesting idea that could fill some of the important gaps.   

So the Housing Justice Fund, as you said, is a pooled fund, and what that means is that a bunch of our members, around 15 of our CFTEH members, have collectively pooled funding at Michael Reese, as our fiscal sponsor, to launch this grantmaking effort.  It’s a $2 million dollar pooled fund, and it is specifically focused on advocacy, community organizing and narrative change and public awareness work related to preventing and ending homelessness.    

And the reason we focused on that cluster of things is because we saw that it really wasn’t being funded.  That showed up in a lot of grantmaking data that we looked at from our members.,  We saw that, maybe, 1 or 2 percent of the groups collective grantmaking was supporting that group of things I just mentioned.  I also had a ton of conversations with people working in the advocacy space who talked about how hard it was to find funding for their work and it just started to emerge so clearly as the perfect gap for CFTEH to fill.   

The fund is focused on new and emerging and often small and BIPOC-led organizations that are doing this work.  We really tried to, in the application process, to do outreach to organizations that were not receiving funding from any of our members.  We are trying to build relationships with new organizations who might have had a really difficult time accessing philanthropy in the past. 

The last thing I would say is that we tried to design the process really differently.  The former grant writer in me, my heart sings around this part of it because we, for instance, designed a process where applicants could choose how they made their requests.  They could submit it in writing if that felt like a good fit to them, if they happened to have a grant writer on staff.   And if they didn’t, or if they felt like using their voice and their story to make their request was a better fit they, instead, could hop on a call with CFTEH staff and we would ask them a set of questions and guide then through, essentially, the application.  And then we would, as staff, take on the responsibility of documenting and preparing the group’s application, then sharing it back with them for them to review, approve and finalize.  

We got a ton of takers, first of all, for that kind of format of application, and at least in the first round, a lot of positive feedback about being able to lower barriers to applying.  Especially for really tiny, volunteer-led organizations who may not have a grant writer on staff.  And then, for organizations, they also then were able to have a narrative prepared describing their work that they felt really good about that, ideally, they can use for applications with other foundations as well. 

 

5. So, the pooled fund has started, and you’ve started issuing grants? 

We just announced our first round of grants in December, 2022.  We announced $1.2 million in the first round to 11 partners that we’re so excited about.  They are all doing such incredible work.  Some of them are really focused on policy at the city level or state level, either passing city or state ordinance or enforcing one.  They are, in other cases, focused on tenant organizing efforts, building  the collective power of tenants  in a specific building or a specific neighborhood.  And then others are focused on narrative change aspect of the fund I mentioned.  Trying to challenge conventional narratives about what homelessness looks like, who experiences it and why they experience it, and are using first-person storytelling or art-making or other forms of documentation in order to do that.  So, we’re so excited to be working with that group of partners, and we’re planning to do another round of grant making in the spring or summer of this year.   

 

6. A great deal of growth has happened in 2022. What can we expect from you and your team in 2023? 

If CFTEH is going to do some cool, innovative things, ideally, we’ll do those things and then document what we’re learning about them.  We learned a lot in the first round of the Housing Justice Fund process about what we can do way better in subsequent rounds and so we’re really interested in documenting those learnings and ways to share them, whether its through social media, like you mentioned, or blog posts.  I’m so lucky I’m getting the opportunity later this month to be on a panel at the National Funders Together to End Homelessness conference in California.  I’ll have an opportunity to talk about this work there.  But yes, I think that what we’re trying to do is learn a lot.  Learn and make mistakes and share what we’re learning with our members and partners, both regionally and across the country.  

And, in terms of 2023, it’s an exciting question. I think a lot of things come to mind.  The first is that CFTEH doubled in size last year, which was a thrill to me, so we hired a new colleague, Kathy Neidorowski, who I have to shout out.  She came onboard last year as our CFTEH Program Coordinator and brings this incredible expertise and background as a social worker and a macro social worker, so really thinking about the ways that complex systems interact with each other and impact a person or household experiencing homelessness.  So totally thrilled to think about 2023 and what we can do as a small but mighty team of two.  

And I think the area of growth that I’m most excited about for CFTEH is related to the Housing Justice Fund, in a way because it’s about all of the other resources and power that CFTEH has to advance the collective goals of our grantees through the fund.  Because we have a lot of ways that we can advocate ourselves.  We can join in the advocacy of our grantee partners, and I think in 2023, we’re excited to be a lot more visible, vocal and external in that way, and find other ways to support this cohort of grantee partners through the Housing Justice Fund in lots of ways beyond the funding.  It’s another piece of feedback that we heard a lot from community stakeholders.  It’s like, “Philanthropy, you have relationships!  You can open doors for You can bring us with you to meetings, and then let us do the talking.  When you make a phone call,  someone picks up”. So we’re trying to catalog all of the other many ways that CFTEH has power and relationships in community that can advance the collective goals of our grantees.  So, advocacy feels like it’s very much on the horizon for CFTEH this year and I’m excited with my colleague Kathy to build out the work related to that.

Emily, thank you so much for talking with me today about the role of CFTEH in addressing homelessness in Chicago.  The links and resources Emily provided today will be added to this podcast for our listeners. 

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08 | Flexible Housing Pool: Rapid Expansion to Address Regional Homelessness

08 | Flexible Housing Pool: Rapid Expansion to Address Regional Homelessness

According to the National Alliance to End Homelessness, in 2020, there were over half a million people experiencing homelessness on our streets and in shelters in America.  Seventy percent were individuals, and the remaining 30 percent were families with children.  They lived in every state and territory, and they include people from every gender, racial and ethnic group.   

However, some groups are far more likely than others to become homeless.  In the same year, The U.S. Department of Housing and Urban Development Annual Homeless Assessment Report to Congress revealed that African Americans are overrepresented in the population of people experiencing homelessness compared to their share of the overall US population. 

A recent report by the Chicago Coalition for the homeless found at least 65,000 people were experiencing homelessness in Chicago in 2020, including those who temporarily stayed with others in addition to people living in shelters and on the street.  Additionally, similar to national data, although African American Chicagoans make up roughly 30 percent of the city’s population, they represent 70 percent of the City’s homeless.  For housing advocates and activists, ending homelessness is connected to the moral imperative to end racial inequities within our society’s systems, policies, and social practices.

READ MORE

 The Center for Housing and Health’s unique program, the Flexible Housing Pool, works to address the region’s homelessness through system coordination. Through the Flexible Housing Pool (or FHP), Cook County is able to rapidly house and provide supportive services to some of the region’s most vulnerable populations, including individuals experiencing homelessness who cycle through the criminal justice system and utilize hospital emergency rooms for care.

 

 

 

In this episode, I’m talking with Pete Toepfer, Executive Director of the Center for Housing and Health .

 

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.  We’ll hear more from Pete about how FHP has expanded in the past three years to meet the growing demand for permanent supportive housing and how the organization is centering racial equity in its strategic priorities. 

 

 

QUESTIONS & ANSWERS

Just last week, the Flexible Housing Pool, or FHP, housed its 1,000th resident. Congratulations on this milestone! Can you share more about its significance in the context of serving people in the Chicago region experiencing homelessness?

Kuliva. Thanks so much. As you pointed out, an awful lot has changed since 2019. The least of which was the covid 19 pandemic. For a little context, in the first year of the Flexible Housing Pool, like lots of projects that are starting up, it began fairly slowly. In the first year we housed just under 60 people, and now we’re at 1,000. So as you can tell, the growth has been very, very rapid, but very, very necessary when we’re talking about the tens of thousands of our neighbors who are homeless each year in Chicago. So, for me, the biggest takeaway is that we have dramatically improved the lives of a thousand of our neighbors, and many of those are children. About 350 of those thousand people are minors/children. So those are children who will not have to experience the trauma of living in cars and bouncing between an aunt’s house or grandma’s house, a shelter and that can focus on school, friends and playing. Just like every child should do.

 

One of the stories that I feel is really fitting around the Flexible Housing Pool is one of the first residents who received housing as a result of the Flexible Housing Pool. Her name is Kayla Wallace, and she was actually one of the residents who was at an early press conference talking about the promise that the Flexible Housing Pool could bring. She was also someone who had been bouncing between hospitals, got seriously injured on the job while working as a tour guide on one of the double-decker buses downtown, and was no longer able to pursue her musical career. Fast forward to today. Kayla is now chair of the Flexible Housing Pool governance council. This is essentially the Board of Directors for the Flexible Housing Pool that makes decisions about where we are going as an overall project that brings together all the community stakeholders. She is representing tenants of FHP, and is facilitating the meetings. It really is a full circle moment for her and for the Flexible Housing Pool.

I think that speaks to one of the points that you brought up about how we’re trying to live out the value of racial equity within the Flexible Housing Pool. That, within that governance council, residents of FHP have, per the bylaws, 40 percent of the seats. These are folks who have experienced homelessness and they have the same voting power as someone who put in six million dollars. They are truly the experts in the direction that we need [to go in].

So I think that one of the other things that’s exciting about where we’ve come is that we have two of the largest managed care organizations in the state who are now investors in the Flexible Housing Pool, because they see it as part of their best interest to help their members maintain health, achieve better health outcomes, and as a managed care organization is charged with doing, control costs. It is not a good investment to continue to have someone get hospitalized for conditions that could be better controlled in primary care settings, but that’s very difficult for people to do if they don’t have a stable place to live, and that’s exactly what the Flexible Housing Pool does. So, with CountyCare and Meridian Health Plan, we talk to them regularly about how we are serving their more complex members who really, but for having a safe and stable home, struggle, and cycle through different, high-cost crisis settings.

 

In the past, you’re reported chronic disease conditions, serious mental illness, justice system involvement and undocumented status as housing barriers experienced by FHP participants.  Considering the impact of the pandemic, what other barriers are you and your team working to address? 

 

One of the big ones is that we want to ensure that people joining the Flexible Housing Pool have a meaningful choice in where they want to live. We promote the value of “housing first” along with racial equity and both of those really hinge on self-determination. We want folks to be able to choose the types of neighborhoods they want to live in. That are close to their loved ones, close to transportation, the grocery store, to their health care resources. But what we were finding as we really dug into our data, was that people were being clustered in the same neighborhoods that have historically been red-lined and disinvested for decades and decades in Chicago. We alone as one program aren’t going to solve for that problem but we brought that concern to the larger governance council and the Chicago Department of Housing and said we want people to live everywhere in the city, but we want them to have meaningful choices, and we know that we’re not able to offer the same number of units in certain northside neighborhoods as we are in, say, Austin or South Shore. Continuing to have folks clustered in the same neighborhoods is not ideal. If that’s what people are choosing – wonderful. But we know that without that actual choice, that it isn’t necessarily realistic. So, what we are trying to do is set meaningful and achievable goals for increasing the number of units we have in what we’re calling “opportunity neighborhoods”. Ones that have lower percentages of poverty and lower percentages of violent crime, which generally are also correlating to places that have other types of resources. That’s an effort we have going this coming year, especially as we launch a variety of new programs.

You also mentioned the really disturbing disparity that exists within the homelessness system in Chicago where upwards of 70+ percent of people experiencing homelessness identify as Black, despite only representing about a third of the City’s population.  We’ve been tracking that since day one to ensure that the folks coming to the Flexible Housing Pool are representative of the larger homeless community so that we are starting there but then also throughout their experience in the program that they are not falling off and disparities aren’t developing in different steps in the project.  Like, once we find them, do they actually reach housing?  Do they stay in housing once they enter the program?  And I can say with pride and confidence that we don’t see those disparities developing.  So about 80 percent of participants that we serve that identify as Black or African American, which should be the case based on what we know about the larger demographics of homelessness in the city. 

My understanding is that the program cost is about $125,000 per household per year, which includes:

– Outreach and engagement

– Pre-tenancy supports (e.g., assistance with initial housing assessments and housing applications)

– Tenancy supports (referrals to community-based services, transportation and connect to health and social services)

– A housing subsidy

– FHP Administrative costs

Can you share more on how this represents a return on investment for FHP partners and investors?

 

A quick point of clarification:  so, you’re about $100,000 too high.  It’s only about $25,000 per household, per year.  Which is still a lot, frankly, given what investors often are typically used to paying especially in the health care space.  But that $25,000 per year, as you mention, does cover a really wide spectrum of needed services from the time that someone is identified as being homeless and needing a housing intervention, all the way through helping someone stay housed.  And just to underscore one important thing, once people enter the Flexible Housing Pool, 98 percent remain stably housed for a year or longer. So once they come into the Flexible Housing Pool, they stay and remain stable, which is hugely, hugely important.   

In that sense, that investment is ensuring that a member or a patient or one of our neighbors has housing stability.  To me, there’s no price on that.  And, we know that we live in an environment where need to look at budgets, priorities, and costs.  And so, a way to think about it, especially, let’s say, for one of our insurance company partners, or managed care company partners; what if someone had 3 or 4 hospital stays over the course of the year?  What would those hospital costs average out [to be] for each stay?  What we hear, is that if someone ends up in the hospital, it can average about $10,000, roughly.  Of course, it can depend on medicines, procedures, things like that.  But, just alone, if we’re able to reduce even one or two of those hospitalizations, then the insurance companies have already saved money on that particular individual because they aren’t going to the hospital, especially for something that may not have been necessary in the first place, a condition that got worse because someone was outside on a day when it was -5⁰F with an additional -10⁰F windchill. Someone doesn’t need to have their toes amputated, and instead of being discharged from the hospital back to a tent, this person is going to their home.  And, potentially being discharged sooner because there doesn’t need to be long-term scrambling and planning for where a discharge can happen.  When someone has a stable address, it’s not hard to know where someone is going home to.   

What other positions (moral or fiscal) does FHP take to persuade institutions and systems to pay greater attention to clients they serve who experience homelessness?

To me the clearest answer to that is that housing is a human right. Everyone, no matter who you are, what you’ve done, where you come from, deserves a safe and stable home. To me that is a very clear moral imperative and one that we can’t say enough until we no longer have any of our neighbors sleeping out on the streets, on the el (elevated trains) or on park benches. To me it also speaks to the larger priorities that we have in society. We find money for an awful lot of things. Be it the City-level or at the national-level. To me the fact that we allow, that we tolerate our neighbors experiencing homelessness is part of a moral re-alignment that’s necessary for how we think about ourselves as individuals, but how, more importantly, we think of ourselves in community, and in community with others. Especially those that have been failed by our systems and have faced oppression, racism, and discrimination.

 

So the Flexible Housing Pool is here to say, “Come one, come all.  You are welcome here.  We’re going to help you find a home and we’re going to help you stay there, to help you get healthier, to reach your goals and to reach your potential”. 

 

Tell me what we can expect in scale and scope in 2023? 

 

So, I think there are three things I’m really excited about. The first is that we’ll be launching a Re-Entry Initiative for some of our neighbors who will be coming home from Illinois’ state prisons. These are folks who will be returning to Chicagoland, Chicago and Cook County, are going to need a place to stay and the Flexible Housing Pool is going to help them find those homes and to get back on their feet, and reconnect to people that they care about and to the places that were once familiar to them.

So that Re-Entry Initiative is going to serve between 50-100 people this year, and we’re excited about that opportunity. It includes a workforce component as well, working with the North Lawndale Employment Network, which has a deep history with the North Lawndale community and also working with folks within the re-entry space.  So that’s one thing that’s exciting. 

The second is in partnering with two of the state of Illinois’ Healthcare Transformation projects that are funded through the Illinois Department of Healthcare and Family Services.  Part of their charge is to think about delivering healthcare in a new way.  Those projects have decided that the Flexible Housing Pool is going to help them achieve that charge.  So, Wellness West, based on the West Side of Chicago and the South Side Healthy Communities Collaborative  are both going to be connecting with the Flexible Housing Pool, identifying members in their collaboratives that are going to be the best fit for the Flexible Housing Pool and working with us in the next year.   

Actually, just last week, when (U.S. Secretary of Housing and Urban Development) Marsha Fudge made a visit to Chicago to announce a $60 million dollar investment in homelessness, the Flexible Housing Pool was one of Chicago’s projects and one of the projects that I think helped our local application be especially attractive and competitive as part of the national review.  And so the Flexible Housing Pool is going to be connecting with a federally-funded program through HUD through the HUD Continuum of Care programs for another 100 households, and leveraging our existing experience and some of the resources we have towards this larger end.  So, a lot happening in this coming year, too, Kuliva.  Lots of exciting things and a lot more people to serve.  

Pete, thank you so much for talking with me today about the role of FHP in addressing homelessness, and improving health outcomes for the most vulnerable in Chicago. The links and resources you’ve provided today will be added to this podcast for our listeners.

Links & Resources: 

Center for Housing and Health 

Flexible Housing Pool 

all Chicago making homelessness history 

National Alliance to End Homelessness 

HUD Annual Homeless Assessment Report 

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The New Season of In the Solution Podcast

The New Season of In the Solution Podcast

We return this spring with a podcast reboot and begin with our Healthcare Justice Series with episodes that:

  • Focus on the social determinants of health 
  • And highlight the needs of communities and populations experiencing barriers to health care    

We begin the series with an exploration of The Housing First Model.

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 The Housing First Model 

Housing First for the chronically homeless is premised on the notion that housing is a basic human right, and should not be denied to anyone, even if they are  abusing alcoholor other substances. 

 

The approach offers permanent, affordable housing as quickly as possible for individuals and families experiencing homelessness, and then provides the supportive services and connections (such as health care) at the community-level that are needed to sustain housing and avoid repeating cycles of homelessness.   

 

Housing First is currently endorsed by the U.S. Interagency Council on Homelessnessas a “best practice” for governments and service-agencies to use in their fight to end chronic homelessness in America and has been adapted in many countries across the world.    

 

Join me in the exploration of this health justice model of care as I talk with leaders in the US and abroad to better understand how existing policies drive system integration to support stable housing for the homeless.  

 

Stay Tuned!

 For more information on Housing First in the US, Click Here.

 For more information on Eisenhower Fellowships, Click Here.

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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.

READ MORE

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.: 

Soar Strategies, Inc.

Janine Hill, PhD(c) MPH

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