Jennifer Colamonico
Welcome to HMA’s Vital Viewpoints on Healthcare. I'm your host, Jen Colamonico, bringing you expert insights and real world perspectives that matter. Our guest today is Maddy Shea, who is a proven champion for health equity with a focus on housing as a key driver of community health. Maddy works with health plans on their strategies to address housing insecurity and safety with affordable housing organizations to finance supports so that residents can age in place and with state and local housing experts to make housing safer, healthier and more accessible.
Maddy previously served at the CMS Office of Minority Health, and since has built expertise in connecting siloed health and social care systems to advance housing as a cornerstone of community health. Maddy, I am really excited to have you with us today. This topic of housing and healthcare is so important. And our HRA conference last fall, we had a fabulous panel on it, and it was a packed house.
And it was really, just an interesting conversation. So there's so much to talk about here. We're really thrilled to have you.
Madeleine Shea
Thank you.
Jennifer Colamonico
So your early years sort of focused on health disparities. Probably before that was as as, big and well understood an issue as we know it is now. How did that take you to focus on housing? Talk a little bit about sort of your journey. And in policy work there.
Madeleine Shea
Work a lot in housing. But, and before I even start, let me just say, thank you so much for helping us bring attention to the opportunities to connect the health and housing sectors, because we can make life better for millions of Americans through better partnerships here. So I'm super excited to be here. Thank you. But I got pulled into the health and housing sector.
Really, the connection between them in a big way. In 2006, when I, was charged to start up a brand new health Healthy homes division in the Baltimore City Health Department in the second port city in America. I was tasked to get funding and resources to make housing, safer and healthier, for children and families across the city that was related to and really address their health needs related to their home environments.
We didn't have any money in the health department, and I was pretty poor at Port City, so I needed to forge public and private partnerships to develop the resources to do these big things. So I got a crash course, as often happens in public health, in what housing people did. You know, I had no idea. Housing developers what they did and how they were incentivized, housing lawyers, what they, you know, cared about as well as what our hospitals cared about.
Clinics. Public health. So, we were able to do really big things together. And since then, I have really, it just propelled me to think about how partnerships between these two sectors can solve problems that I've really encountered over the rest of my career.
Jennifer Colamonico
Everybody loves good public private partnership, so that's an exciting place to start. When we think about housing issues, right, we think about scarcity. We think about affordability, we think about quality. And there's all sorts of different groups of people that that affect. So how are you guys in this, this sort of new initiative at. How are you thinking about, you know, the different areas of problems to solve or people to serve.
How are you kind of segmenting that?
Madeleine Shea
I know for me, and I think for most of my colleagues, we look at where there are aligned interests, interests across both sectors and also where different organizations are all serving the same people. So examples of that would be children with asthma. That's, you know, that's a hit us measure. healthcare organizations care a lot about that. A lot of them don't do very well on that measure of avoidable asthma costs.
And really just people doing well who have asthma. Well, this is also a concern in the housing sector, where, you know, you have organizations that can make those environments better. Similar for, people who have been unhoused and have a real long history of housing instability. healthcare organizations care a lot about them because there's a lot of costs associated with that.
But so do, all the continuum of care housing organizations, community organizations that serve them. So there's opportunities to work together. There's a lot of those. So it's looking at where there's aligned interests is a good place to start.
Jennifer Colamonico
I know, there's a lot of aligned interests perhaps around hospital at home and aging in place. And, you know, we sort of call it different things based depending on which sector we're in. Right. But that is that another area of where there's a lot of aligned interests.
Madeleine Shea
Definitely. We well, there was a big, movement, to help people get out of institutions and into their homes. So when I think of hospital, like home, you know, where people had to go to a skilled nursing facility in the past, now they would be able to have their needs met in their own home, which is for sure what they want, what their loved ones want.
You know, typically there's not a one size fits all, but typically that's what people want. And it's actually more cost effective for the health payers. So that is definitely an area of interest. Supporting aging in place is a little different because that's more preventive. But people with means, all go into assisted living at some point. We all do.
We all need assistance in supports. But if you're very low income and you've had a very hard life and you don't have others to lean on, you might need supports that aren't available there that you can't afford. And, so that's another, another area where I actually do a lot of work.
Jennifer Colamonico
And so thinking just about that issue in particular as an example. Right. So those.
Madeleine Shea
Are.
Jennifer Colamonico
You know, if I'm a housing developer, if I'm building affordable housing, you know, I'm probably I mean, am I thinking about that or is part of what you're doing getting the housing developers to think about, you know, how they construct what what you know, I don't know, technology and physical supports. I mean, are we sort of changing how people are building supportive housing?
Madeleine Shea
Yeah. Or housing in general?
Jennifer Colamonico
Yeah.
Madeleine Shea
We aren't. I mean, there need to be incentives, but we're seeing some great incentives at the state level. I'm working with, an organization that's Virginia based and in Virginia, in order to get points for your tax credits to be able to win these when the tax credits really to develop the property, they needed to show that they could increase access to healthcare.
And so we supported them in their approach to that. And their partnerships so that they could provide telehealth and have a partnership with a, federally qualified health center to meet that goal so that they could actually develop a property. So state incentives are really important here. And of course, the federal government could incentivize that even more.
But it won't happen on its own because the cost of housing is so high, developing properties that putting in things for which there's no incentives is probably unlikely to happen. Sadly.
Jennifer Colamonico
So the incentives have to be aligned. How are those incentives being created? I know some are there some Medicaid waivers that are being utilized? What are the different kind of sources of incentives?
Madeleine Shea
So on building property that's on the housing side, but there are incentives, from Medicaid. Not so much that I know on Medicare yet, to provide services. So we've had rental assistance, services that helps people to get into housing, waivers, that address, really helping people to get into housing to begin with.
So finding it, and, you know, there are pre tenancy deposits, those screenings they have to go through and then another set of Medicaid supports around staying in at once. They're there. There can be communication problems. They help with, you know communications with landlords, things of that nature. And then Medicaid waivers are also paying for housing modifications.
So if someone has a surgery and they can no longer go up stairs or has other mobility issues, Medicaid dollars can be used to make those environments safe and accessible and also for the health of the, for people with asthma or respiratory illnesses.
Jennifer Colamonico
For those modifications, presumably that's cheaper. I mean, even though those stair elevators are not cheap, but they're cheaper than somebody going into, you know, an institution, right. Or assisted living.
Madeleine Shea
Oh, yes. Yes. Significantly, in order to get, approved for a medicaid waiver, OMB had to approve that. There was strong evidence of the cost effectiveness of each intervention was very strong evidence around the, the cost effectiveness of home modifications for people that have accessibility barriers. A fall is very expensive. Jan.
Jennifer Colamonico
Well, right. That's and I'm glad you mentioned that I was going to actually just talk about hospitals. You know, as another kind of interesting partner here. You know, I always think about hospitals as being interested in housing, but you see certain hospitals building housing now, how, you know, how are those opportunities coming about?
Madeleine Shea
Well, in new Jersey, the state incentivized hospitals to expand recovery housing. So that's for people who've been on housed. You don't want to take them from a surgery or some hospital procedure back to the street, because they're going to be right in that door, and the hospitals are going to get penalized for that readmission. So the state actually incentivized hospitals in new Jersey to look at their own.
Lot of times they have a lot of property and, developing, recovery housing or other housing, sometimes workforce housing, on those properties to solve these access issues. And, you know, the quality of care issues. So I see those more at the local level than anything. But housing is very local, as is healthcare.
Jennifer Colamonico
I think it's so interesting because, you know, hospitals have the sort of bricks and mortar problem in some instances, right. As we're looking to transition more care to, you know, lower cost or more appropriate sites of care, the community that would be at at home or clinics or whatnot, you know, they have these big buildings. So it's sort of like you have sometimes you think like, well, could you convert that?
And, you know, are there incentives to convert buildings to other uses that are, you know, relevant and part of the continuum of care, but not necessarily part of a hospital's mission, depending on the system.
Madeleine Shea
That is happening? I don't know as much about it as I wish I did right at the second, but I do know that's happening. I'm pretty sure in Virginia, and some other places and also office empty office space. It might not be there hospital facilities, but some of their administrative facilities as more people are teleworking or, you know, hybrid models, they don't need as much space right now.
Jennifer Colamonico
That makes sense. Innovative, right? I mean, there's a need and there's incentives. And it kind of makes sense. What, you know, talk about, like, what do people need to understand about this opportunity? Like, is there something that you wish more people would understand about, it seems obvious, right? This, these all these things like, well, that's a great idea.
Let's just do more of that. But what what do people to kind of not understand about what it takes to to make these systems work together?
Madeleine Shea
There's completely different language, completely different time horizons. Housing organizations think in terms of ten years and 30 years is when they would have to get the return on their investments. So whereas for healthcare organizations have a very, very short time horizon, and that is one of the difference in language, the difference in, you know, when you've got to show your board or your stakeholders or results is a barrier.
But I think it's one that we at a time, we definitely know how to work through those, those differences. Because what we really need to focus on is particularly on assisted housing, low income housing, those the people, the millions of people in those settings are the same exact people that healthcare organizations are trying to serve.
So we need to keep our focus on these are the same people. How can we do better by them?
Jennifer Colamonico
Yeah. Do you find that data connectivity? I mean, I get when we when we talk about, health related social needs or social determinants of health. You know, housing of course, is always one of those components. And the whole notion of tracking the person, right? Not tracking that sounds Big Brother ish. But, you know, if the same person is frequenting, you know, frequent flier in multiple systems, right?
How are we connecting services in a more efficient way? So do you, do you see progress on that as we keep our eye on that prize of, you know, serving the same people? Do you see, systems improving our ability to do that?
Madeleine Shea
I don't I think that's one of the areas that we really need to delve into now. Particularly on the housing side, they tend not to have the same data infrastructure and data sharing capabilities that healthcare organizations have and demand in their partners. But I, I think that that's we're living in a time where that shouldn't we've got to work through that problem.
I think we can solve for that. It's not even just that there's one healthcare data system. You've got all different ones going on there. So, it's something we've been thinking a lot about. Some of, those of us focused in this area here, and trying to, really put our heads together about solutions. But that is an area that where we need solutions.
Jennifer Colamonico
In terms of, like, demanding, demanding those solutions or generating support for those solutions, maybe talk a little bit about the, the politics of this. I mean, it seems affordable. You know, affordability is one of those words that everybody can agree on, right? As a, as a you hear the language coming from all sides around affordability, crisis and so forth.
And this plays into that. Right. Housing's expensive. It's one of the dynamics that we're, we're sort of struggling with. So when you're talking about these partnerships and these opportunities in communities to do things differently, you know, is it universally well-received? Are there are there sort of different politics that you find in different areas or parts of the country that make this, you know, differently? Complex?
Madeleine Shea
No, I think that this is truly a bipartisan issue. I think it has been, in Congress, particularly support for expanding low income housing, because this does involve public and private partnerships. It's kind of using the levers of government, to make things better for people. People, suffer from lack of affordable housing in every state. Let's look at Alaska versus Hawaii.
You know, red and blue, both have tremendous housing affordability issues, but it's all over. You know, in rural areas of seeing, you know, where a lot of the, their beautiful people want to go. They're on vacation, and a lot of the affordable housing is bought up by Airbnbs and is no longer available for the workforce.
So it's a workforce issue. It's an issue for, you know, just residents of a state or community. So I do see that this is a great area of opportunity moving forward because it's it's truly bipartisan.
Jennifer Colamonico
Are you able to you talked about quantifying the cost savings of certain interventions. And, you know, home modifications, etc.. Are you able to sort of quantify, the, if you will, the wasteful or redundant spending? I mean, it seems like there's sort of a broader case to be made of, of system wide, right, where, creating these better partnerships may save us money.
Are there are you able to pinpoint where money can be saved?
Madeleine Shea
I definitely could pinpoint that the exact cost of the waste. I have never seen an analysis of that, but, when I was at the centers for Medicare and Medicaid Services, we, did an analysis of, you know, in the, program for demonstration projects targeting people who were dually eligible for Medicare and Medicaid services. Was everyone doing as well as each other, like, where were there disparities?
And sure enough, those who had, the greatest needs, you know, who had, due to disability or language access or other reasons, weren't accessing services the most. And in delving into that, those same people had had care coordinators coming in from all over the place, you know, their special needs plan, their public health, their hospital, their, you know, provider, you know, so that that's all a waste.
So what we have is a tremendous amount of providers going after a small number of people. They're not engaging any of them effectively. Whereas if we have more place based solutions, such as working in a community that already has trusted, where the people that are being, you know, our focus, who don't who have these health related needs, can just talk to people they already trust, either in their buildings if they're in, development or, other people they, they interact with frequently and have them be the quarterback or all of that care coordination.
I think the savings could be tremendous. Yeah, that's just mistaken. But I think it could be tremendous now.
Jennifer Colamonico
I mean, it's it makes sense. I love the idea of place based solutions, right? I mean, rather than having 14 different coordinators, it's sort of like an oxymoron, right?
Madeleine Shea
With lots of.
Jennifer Colamonico
Different coordinators coordinating, it's probably not going to be very coordinated. Yeah. That that seems like a again, obvious thing, compelling. But in large complex systems, not always easy. To fix.
So may I ask you our a favorite question? If you had a magic wand, what one thing would you fix that could kind of unleash progress in this area?
Madeleine Shea
So I'm glad I knew you were going to ask me this in advance, because having only one wish, right, is really hard.
Jennifer Colamonico
Tough to pick one. I understand.
Madeleine Shea
But I would make it much easier for housing and healthcare organizations to work together to create the conditions for, vulnerable people, people who need it the most to achieve their highest level of health. And that's different for everyone. I would take out these infrastructure barriers we just talked about. I would create a way where they can talk to each other, so that if someone came in to the emergency room maybe eight times that past two weeks with, a condition that, really seems related to mental health and maybe social isolation, the E.R. could call, you know, could communicate with the place where that person lives, and they could, help
with that. I mean, these are really simple things, but they're very high cost. So, we would, we take out those infrastructure barriers related to sharing data and communicating. I would wipe out the over complexity of accessing health and social care. People really don't even know what they're eligible for, how to access it, and even service coordinators, you know, oftentimes find it dizzying to figure out how to do that so that ordinary people like resident service coordinators or social workers could help people more easily.
And you don't need, you know, weeks of training to understand this complex system. And finally, I would make sure that these partnerships made the conditions for health better to begin with, which means providing more opportunities for social connections, like how a home is a home. It's not a prison cell. You know, health is about our social connections. It's about our social and physical environments.
How can we make those better? So that we can really all be more resilient? Because when it comes down to it, I mean, that's really what we all need. We all saw that in the, in the Covid pandemic. So how can we work together to just make the conditions better for health? Yeah. Well, it kind of.
Jennifer Colamonico
Goes back to where you started, you know, meeting people where they are. I'm struck by a lot of what you just said, right? That some that kind of thing has come up very often when we talk about a host of health related social needs and this kind of emerging awareness over the past couple of years of, you know, the the importance of addressing those health related social needs to to maximize health.
And we talk about meeting people where they are. And, you know, quite obviously and yet not always obvious, like where they are is at home. And so like if that is the place from which, you know, this coordination happens and, you know, it does make a ton of sense. And so as complex and difficult as that may be, you know, does it have to be that complex?
So that's that's a really interesting, kind of a piece of the puzzle, I guess that is has sort of been there, but but, you know, we're really elevating that now is as a, a place to organize from, if you will, or organize around. So, you know, it feels like there is progress. I know there's a lot of momentum.
So, you know, as you think about what you're working on, what you've been working on, you know, what gives you hope? What types of innovations have or accomplishments? You know what? What are the things that kind of give you some hope that we are making progress?
Madeleine Shea
I know there's the will to do this. On both the health and housing sides, I'm hearing more and more, clients who who want help with this and are willing to work through the, you know, the challenges of that. So that gives me hope. And they've all been working on it for a long time. This isn't new.
Jennifer Colamonico
Right?
Madeleine Shea
So people have experience. They're getting better and better. And then the other thing is that, we've created this new health and housing practice group that and we have some terrific new colleagues who are joining forces with us, to help our clients, to work on increasing affordable, accessible, healthy, safe housing. And they're also helping us to expand our solutions to housing instability.
You know, that we see for unhoused people, and people have been chronically unhoused as well as older adults that we talked about people with disabilities, and other vulnerable families. So so that gives me a lot of hope. I think we know what to do. We just want to be doing more of it.
Jennifer Colamonico
Right. How do we scale it? Well, it's exciting. I mean, it seems like in the public policy world when you have, well, I think you said it at the beginning. Right. Where do the interests align? Where do you have a confluence of big, sticky, difficult problems to solve and a lot of focus on that.
And so the focus on affordability right now generally probably helps. So, you know, a good time for, for people to perhaps lock onto this as a way to solve multiple challenges, by working together more closely. So, I'm definitely excited to continue, you know, track what you guys are doing. Welcome our new colleagues to me who are, you know, have been doing this work, as you said, and bringing this group together, is just really exciting.
So, thank you for sharing that with us and sharing your time. And, to be continued.
Madeleine Shea
Thank you. Jenn.
Jennifer Colamonico
This episode of Vital Viewpoints on healthcare is sponsored by HMA Information Services. HMAIS is a subscription based service that provides state level data on publicly sponsored programs like Medicaid from the latest managed care enrollment, market share, and financial performance data to up to date RFP calendars and state by state overviews, HMAIS has all the information you'll need to power your initiatives to success.
This podcast was produced by myself, Jennifer Colamonico along with Tiffany McKenzie in collaboration with our guests. The content is the property of Health Management Associates.
