Bronx FUSE
Background
For low-income individuals and families with complex medical and behavioral health needs, homelessness and housing instability are all too often both the cause and result of poor health outcomes. The extreme instability and lack of resources associated with homelessness make coordinated care and chronic condition management extremely difficult, resulting in households that tend to receive sporadic treatment in expensive emergency settings. In the ensuing cycle of shelter, street, and hospital stays, these households easily fall through the cracks of the fragmented and siloed systems they touch. Such individuals are known as the ‘5:50 Population’ - the 5% of Medicaid beneficiaries who account for 50% of the system’s costs. Health experts are increasingly recognizing that in order to bring down overall costs and improve health outcomes for these individuals, the healthcare sector must proactively address the pressing social needs (including homelessness or unstable housing, unemployment, and social isolation) of the most vulnerable and highest cost individuals.
In tandem with ongoing efforts across the country to improve healthcare access and costs, New York ushered in a series of reforms through the Medicaid Redesign Team (MRT) in 2011 to effectively change how services are delivered and paid for under Medicaid. Guided by the Triple Aim of reducing unnecessary and avoidable Medicaid costs, improving quality of care, and improving health outcomes, the State implemented the Delivery System Reform Incentive Payment (DSRIP) program to reduce avoidable hospitalizations within five years. Achieving this ambitious goal required a set of comprehensive solutions to bend the healthcare cost curve for some of Medicaid’s most vulnerable and high-cost members: homeless frequent users of hospital systems. Within this context, the Bronx FUSE program launched to help address homelessness as a social determinant of health by building a data-sharing infrastructure and robust partnerships between key stakeholders in the health and housing sectors.
About the Bronx FUSE Program
With funding from the Altman Foundation, United Hospital Fund, and Bronx Health Access Performing Provider System and in partnership with the Corporation for Supportive Housing (CSH), the Bronx Regional Health Information Organization (Bronx RHIO), several managed care organizations, and the New York City Department of Homeless Services, Bronx FUSE was a borough-based data-matching initiative that identified homeless high utilizers and prioritized them for a housing placement. This initiative is modeled on CSH’s national FUSE initiative, which helps communities break the cycle of homelessness and crisis among individuals with complex medical and behavioral health challenges who are the highest users of emergency rooms, jails, shelters, clinics and other costly crisis services.
By establishing data sharing agreements with MCOs and the NYC Department of Homeless Services (DHS), the initiative matched detailed housing and Medicaid claims data to better understand the medical and behavioral health complexities of frequent ED/IP utilizers experiencing homelessness in the Bronx. This unprecedented data sharing allowed MCOs and supportive housing providers to form unique partnerships to engage households in need and provide supportive housing, ultimately promoting health and stability while reducing potentially avoidable costly systems use.
The Bronx FUSE program’s main goal was to show how integration between historically siloed systems––health and housing––can enable data sharing to coordinate care for their shared patients or clients. Furthermore, the program aimed to explore opportunities and ultimately serve as a guide for how healthcare can invest in housing as a crucial social determinant of health. Specifically, the project achieved the following:
facilitated the secure transfer of Private Health Information (PHI) data from four Bronx-serving health plans on each of their top 150 high-need, high-cost Medicaid recipients in 2016 and 2017 to the Bronx RHIO,
implemented a homeless system data-match of the high-cost, high-need Medicaid members to identify a study group representing the borough's homeless highest utilizers of emergency departments and inpatient hospitalizations,
supported the analysis of the de-identified data on the Bronx frequent utilizer population,
convened regular housing and health plan stakeholder workgroup meetings to facilitate health and housing collaboration, including points of access for data-sharing, streamlined care coordination, and opportunities for value-based partnerships,
cultivated partnerships between four participating health plans (MCOs) and three community-based supportive housing providers to prioritize and place individuals into available housing settings with the most appropriate level of support,
provided each partnership with a $15,000 “Barrier Busting” grant to the housing provider to assist with the costs associated with locating, accessing, and stabilizing in supportive housing,
moved six individuals in five households into supportive housing, and
measured ED/IP utilization 1 year pre- and post-supportive housing intervention.
The lessons learned throughout the course of this program demonstrate the need for further investment from government, private healthcare and housing organizations to effectively address housing as a social determinant of health, specifically for the households with frequent utilization of emergency healthcare services.
The Bronx FUSE Roadmap describes the key steps needed to implement a data-driven and partnership development project. Each step provides an overview of the implementation process by the Bronx FUSE team, describes some successes and challenges, and offers key takeaways to help others in the implementation of a FUSE model in their community.