Access to safe transitional supportive housing is a key determinant in stabilizing chronically ill super-utilizers of health care.  The availability of stable and affordable housing should also include support services which will allow discharged patients to stabilize in the community setting instead of re-admitting to the hospital.

The Affordable Care Act (ACA) has expanded opportunities for home and community based services, including supportive housing and innovative models such as Medical Respite for a wider range of Medicaid members.

FLPPS undertook a multi-pronged stratgy to maxibize these opportunities, in support of DSRIP outcomes and system transformation.

Stakeholder Engagement and Advocacy
FLPPS has proactively worked as a convener of multi-sector stakeholders related to housing and homeless challenges, and the impact of these on health outcomes and system costs. An advisory workgroup of FLPPS netsork partners, incliding representatives from health systems, public housing authorities, non-profit housing developers, government agencies, and HUD Continuum of Care entities, was convened from 2015-2017 to help inform and shape the design and implementation of FLPPS’ Housing strategy. FLPPS co-chaired the Health and Housing Sub-committee of the Monroe County Homeless Continuum of Care from 2016-2019..These and other stakeholder convening efforts led to multiple successful applications for both permanent supportive housing programs and Assisted Living Program beds throughout the Finger Lakes region, dramatically expanding the availability of long term housing options for vulnerable community members.

Best Practice Dissemination
FLPPS has presented at multiple regional, state and national conferences, including the 8th Annual North American Housing Conference: Housing is Health Care, co-organized by the Center for Supportive Housing (CSH) Connect the Dots: State and Regional Initiatives Integrating Housing and Health Care, hosted by the Center for Budget and Policy Priorities (CBPP) in 2017. FLPPS has also promoted promising practices in housing and health through contributions to a 2018 United Hospital Fund Medicaid Institute Brief “Stable Housing, Stable Health: Addressing Housing Insecurity through Medicaid Value-Based Payment.”

System Transformation through Clinical to Community Integration Initiatives
As the only Performing Provider System in NYS to administer the Transitional Supportive Housing project, through its network partners, FLPPS was able to leverage DSRIP funds to increase access to housing for high-risk Medicaid enrollees and eligible individuals, monitor the impact of housing as a key service within an Integrated Delivery System, and evaluate the cost-benefit of housing interventions to improve health outcomes and system utilization.

In 2019-2020, FLPPS partnered with several hospitals and community-based organizations to design and implement an innovative program to develop transitional supportive housing and medical respite type services in emergency shelters in Monroe County. By developing a more person-centered care pathway and enabling hospitals to share information directly with emergency shelters, the project helped improve discharge planning for homeless individuals and better enabled emergency shelter staff and peer service providers to support patients in stabilizing both their health and housing once in shelter.