Harlem, New York: Supporting Affordable Living and Health Care as Part of State Medicaid Redesign

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East Harlem, New York: Supporting Affordable Living and Health Care as Part of State Medicaid Redesign

Metro East 99th Street is a 176-unit development that offers independent living for persons with mobility impairments or who are chronically disabled. The project combines affordable housing and supportive services to reduce Medicaid-related costs. The development houses former residents of long-term healthcare facilities who do not need full-time care but require some level of supportive services. The $51.8 million development is the first project completed using funds from the state of New York’s Medicaid Redesign Team (MRT).

New York’s Medicaid Redesign Team

MRT was created by executive order in January 2011 after New York Governor Andrew Cuomo found that the state’s share of the Medicaid program, which already exceeded $50 billion each year, was growing at an unsustainable rate and resulting in unsatisfactory health outcomes for beneficiaries. The governor’s executive order created MRT to find methods of improving the quality of care and producing better health outcomes while lowering costs. As part of this effort, MRT examined current Medicaid-related practices and developed an action plan to reform the state’s Medicaid program.

MRT’s research found that the state’s Medicaid system led to an “over-reliance on State psychiatric hospitals, adult homes and nursing homes” because affordable housing is not available for those who do not need institutionalized care and because integrated care in community-based housing is not available for those needing a range of supportive services. In this situation, patients often do not get complete health care addressing their range of needs across medical disciplines and therefore experience poorer health outcomes. Keeping patients who do not require an intense level of care in institutions also increases Medicaid costs. The per-patient cost for institutionalized care is significant; the average annual cost for a patient receiving care in a nursing home in New York City in 2012 ranged from $118,625 for a semi-private room in Staten Island to $179,018 for a private room in Manhattan, according to the U.S. Department of Health and Human Services. Research has shown that expenditures for nursing homes may be up to three times higher than costs for non-institutional long-term care services. Through funding for rental assistance and housing development, MRT is supporting programs that help residents who could live in a community setting to transition from nursing homes to independent living.

Affordable, Accessible, Independent Living

The closing of the Goldwater Memorial Hospital on Roosevelt Island provided MRT with an opportunity to offer alternative housing and care to nursing home patients receiving Medicaid assistance. New York City Health and Hospitals (HHC) selected a 20,000-square-foot parcel in East Harlem near the Metropolitan Hospital Center for redevelopment with affordable housing. HHC collaborated with several other city, state, and federal agencies as well as women-owned developer SKA Marin to create Metro East 99th Street, which was completed in 2014.

As the first fully affordable and accessible housing project in New York City, Metro East 99th Street features a number of design elements and amenities to accommodate residents’ needs. The 10-story building offers 175 studio and 1-bedroom units (as well as a 2-bedroom unit for a superintendent), resident lounges, and a community room. The individual units feature windows set lower on the wall to allow wheelchair users to see outside and roll-in showers with seats; some units exceed the standards of the Americans with Disabilities Act by offering additional doorway clearance and turning radius for bariatric patients.

The site also boasts an outdoor garden with raised beds that permit residents with mobility impairments to participate in horticultural activities, as well as space for a hybrid social model adult day program run by the Carter Burden Center for the Aging. With an individualized care plan to transition to independent living, a resident can choose to participate in the Carter Burden Center’s day program, which offers opportunities for socialization and assistance with health and wellness, nutrition, and education. Residents also have the option to participate in the remote health-monitoring program, which monitors blood pressure, oxygen levels, and other biometrics.

Financing

Several city and state agencies provided permanent financing for the development of Metro East 99th Street (table 1). The city’s Housing Development Corporation and Department of Housing Preservation and Development provided the development’s first and third mortgages, respectively. MRT provided the second mortgage, making the development the first to receive MRT funding. The Department of Housing Preservation and Development provided the 4 percent low-income housing tax credits, which were syndicated by Raymond James Tax Credit Funds.

Ongoing rental assistance for all residents is provided through HUD’s Section 8 Project-Based Rental Assistance program. Funding for the first year of the hybrid social adult day program included a one-year start-up grant from the state Department of Health as well as additional funding from the New York Community Trust. The trust is also providing funds for the adult day program’s second year.

The Benefits of a Community Setting

Because Metro East 99th Street received MRT financing to improve quality of care and health outcomes while reducing Medicaid expenditures, the state’s Homes and Community Renewal agency and Department of Health are tracking expenditures and outcomes for each tenant. The Carter Burden Center is also collecting data to evaluate its remote health-monitoring program and collaborating with the Fordham University Graduate School of Social Service to assess the transition from institutional care to independent living. Dozene Guishard, director of the Metro East 99th Street Hybrid Social Model Adult Day Program at the Carter Burden Center, and William Dionne, executive director of the Carter Burden Center, note that the center is looking forward to contributing to the body of research on such transitions.

Although these studies are ongoing, the evidence thus far suggests that the program is successfully reducing the need for emergency health measures. The Carter Burden Center’s remote health-monitoring participants, including residents at Metro East 99th Street and other individuals served by the center, have experienced a 35 percent reduction in the number of hospitalizations. Guishard and Dionne also cite anecdotal evidence that the combination of independent living and supportive services is contributing to better health outcomes for residents. Since moving to Metro East 99th Street, some residents have reached a healthier weight, including one resident who no longer has to take diabetes medicine. Although the savings to the state’s Medicaid program are not yet publicly available, Sydelle Knepper, founder and owner of SKA Marin, notes that significant Medicaid savings are likely.

Residents of Metro East 99th Street are forming relationships that have the potential to improve their overall health and happiness. Guishard and Dionne note that residents tend to know and check on their neighbors and in other ways create a vibrant community within the development. Outside the development, residents often join other program participants at the Carter Burden Center’s 109th Street location; they shop at local stores and participate in cultural activities, and many volunteer both within the development and in the larger community.

For the state’s Medicaid system, indications are that MRT’s reforms have been successful. Spending per Medicaid recipient has decreased, and growth in overall Medicaid spending in the state has slowed. MRT continues to fund new supportive housing for appropriate populations and has allocated $47 million for the 2015–2016 fiscal year, which can be used to expand the number of supportive housing units for Medicaid recipients with multiple health needs. Because of the combination of affordable living and health care that Metro East 99th Street offers, Affordable Housing Finance magazine recognized the development with the 2015 Readers' Choice Award for Special-Needs Housing.