Addressing the Social Needs of Patients at Cambridge Health Alliance

November 19, 2021

Perspectives in Primary Care (formally the Primary Care Review) features perspectives from practitioners and students representing organizations, practices, and institutions across the country and around the world. All opinions expressed in this article are owned by the author(s).

Housing and food insecurity have always existed in Massachusetts, but the pandemic has exacerbated these issues. Cambridge Health Alliance (CHA), an academic community health system serving Cambridge, Somerville, and Boston’s metro-north region, has witnessed this firsthand and is addressing the nutritional and housing needs of patients by connecting them to community-based support through the MassHealth Flexible Services Program.

The MassHealth Flexible Services Program, part of the Executive Office of Health and Human Services’ MassHealth Delivery System Reform Incentive Payment Program, allows MassHealth Accountable Care Organizations (ACO) to pilot time-limited, evidence-based interventions that address the nutritional and housing needs of patients. ACOs are provider-led organizations that are held accountable and at financial risk for the quality and total cost of patient care. The goal of the MassHealth Flexible Services Program is to improve health outcomes and reduce the total cost of health care for patients in the ACO. As of July 2021, 17 ACOs have partnered with 38 social service organizations for a total of 76 approved programs.

CHA serves 35,000 patients through its MassHealth ACO, which is a partnership between CHA and Tufts Health Plan. We currently offer two programs through the MassHealth Flexible Services Program to serve this population: the Housing Support Program, which launched in February 2021, and the Medically Tailored Meals Program, which launched in March 2020.

Implementing the housing program

CHA partners with Vinfen, a local health and human services organization, to provide comprehensive housing assistance through our Housing Support Program. To be eligible to participate, patients must be experiencing homelessness or at risk of homelessness; be members of the CHA MassHealth ACO plan (Tufts Health Together with CHA); and have one or more health needs, such as a complex physical health need, a behavioral health condition, a high-risk pregnancy, the need for assistance with activities of daily living or instrumental activities of daily living, or repeated emergency department visits.

Patients are considered to be experiencing homelessness if they are living outside, in a shelter, in a car, or continuously staying with different people. Examples of when patients are at risk of homelessness include if they receive an eviction notice, are behind on rent, are in an unsafe living situation (e.g., lack of running water), or are living in an overcrowded space.

Since the launch of the program seven months ago, CHA has referred over 190 patients to the program with 162 patients enrolled as of the end of September. Forty-nine percent of those referred were experiencing homelessness, and 51% were at risk of homelessness. Seventy-nine percent of referred patients have a behavioral health condition, and 48% have a complex physical health condition, with 30% of patients having both. CHA serves a diverse population, and the program reflects that diversity. Of those that were referred to the program, 44% are White, 21% are Latinx, 21% are Black, and 6% are two or more races or other minorities.

Enrolling patients

CHA identifies patients to participate in the Housing Support Program at a variety of entry points across the health system—the emergency department, inpatient settings, behavioral health appointments, and primary care. We also leverage our relationship with our MassHealth behavioral health and long term services and support Community Partners. There is no wrong door.

Patient navigators, case managers, social workers, behavioral health case workers, and physicians all work together to identify and refer patients to the program. We also prospectively identify patients using our social determinants of health screener, claims data, and information from the electronic health record. Once an internal referral is placed, the referral is sent to Vinfen and is assigned to a housing support specialist who then outreaches the patient to conduct an in-depth housing assessment.

Providing housing services

Once patients are enrolled, the housing support specialists assist patients with a variety of tasks depending on the housing situation and goals of the patients.

Pre-Tenancy Support

For patients who want to find affordable housing, the housing support specialists help patients apply for subsidized, public, and affordable market-rate housing and assist patients in addressing any barriers to tenancy. When patients are able to move into housing, the Housing Support Program can support the transition by paying for one-time costs, including first month’s rent and security deposit. Flexible Services does not pay for ongoing rent.

Tenancy Sustaining Support

For patients behind on rent, facing eviction, or having trouble with a landlord, housing support specialists can help patients access rental assistance funds outside of Flexible Services (Flexible Services cannot pay for rent arrears), negotiate with landlords, and connect with legal support in the community. The program can also complete home modifications to ensure patients are living in healthy environments.

Collaborating with the health care system

The housing support specialists regularly communicate with the patient’s care team at CHA, providing updates and receiving insights on the best outreach techniques. For each patient that completes the program, CHA creates a discharge document that is uploaded to the patient’s electronic health record. The discharge document includes goals achieved during the program and housing applications completed, including the usernames entered. The discharge document informs the patient’s care team and establishes continuity for the patient since waitlists for affordable housing can be extremely long.

Assessing results

Obtaining and maintaining housing can improve health conditions and reduce inpatient and emergency department visits. Accordingly, once we have sufficient data, we will examine the change in total cost of care, emergency department visits, and inpatient visits for patients who complete the program. CHA believes primary care is a foundation for health, yet we know that individuals experiencing homelessness have lower engagement with primary care. We will also review the change in missed primary care appointments for patients who complete the program.

Though we do not have robust data to date, below are a few examples of how the Housing Support Program is already helping patients find and maintain their housing.

Example of Pre-Tenancy Work

A patient diagnosed with major depressive disorder and chronic pain was living in a hotel with his wife and three children after unexpectedly being displaced from their home. The patient worked two jobs but was unable to find an apartment the family could afford. The housing support specialist helped the patient enroll in a program through a housing authority that helps with a down payment on a future home. Once the patient was approved for the housing unit, the Housing Support Program funded the patient’s first and last month's rent and security deposit. The housing support specialist also worked with a furniture bank to furnish his new apartment. The patient and his family are enjoying their new home!

Example of Tenancy Sustaining Work

A patient diagnosed with type II diabetes and major depressive disorder received an eviction notice from her landlord after being behind on rent. A housing support specialist helped the patient apply for Residential Assistance for Families in Transition to cover overdue rent payments and also created a housing plan with the patient that resulted in a family member moving in to alleviate the rent burden. In addition, the patient is now on several waiting lists for housing that will fit her budget.

Continuing to address social needs

In addition to our housing program, our Medically Tailored Meals Program has been instrumental in meeting the nutritional needs of patients while reducing food insecurity, total cost of care, and emergency department visits. For this program, we partner with Community Servings to provide patients with weekly deliveries of scratch-made, home-delivered, medically tailored meals, as well as nutrition counseling with a registered dietitian at Community Servings, and this is sustained over six months.

Through our housing and nutrition programs, Cambridge Health Alliance is directly addressing the health-related social needs of the patients we serve and in turn improving the health and well-being of our communities.



About the author

Hallie PhotoHallie Tosher, MPP, is an ACO Program Development Manager at Cambridge Health Alliance where she focuses on developing programmatic solutions to address social determinants of health. She was previously a Program Manager with the Massachusetts Executive Office of Health and Human Services, MassHealth Office of Payment and Care Delivery Innovation, and is Vice Chair of the YWCA Cambridge Board of Directors. She received a Master in Public Policy from the Harvard Kennedy School.


**Feature photo by Emese Pop from Pexels


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