By Martin Lenarz-Geisen
Last year, we selected the Housing to Health Initiative to be part of our first cohort of subgrantees receiving Social Innovation Fund funding to support Pay for Success transaction structuring efforts. In partnering with the project development team over the past year, we have learned about the impetus for the project, broader project goals, and challenges encountered along the way. Following the February launch of the project, we had the opportunity to visit and talk with the two service providers in this project, Mental Health Center of Denver (MHCD) and Colorado Coalition of the Homeless (CCH), to better understand how Pay for Success participation fits into their work and missions.
These two organizations are tasked with providing supportive housing for 250 individuals over a period of five years. The individuals to be served have been identified by the City of Denver as frequent users of both criminal justice and emergency medical services. Beyond providing individuals with supportive housing units, both organizations will employ assertive community treatment (ACT), a team-based model of care that includes services which are tailored to fit the client's individual needs. Services are designed to: (i) help address barriers to housing stability; (ii) manage mental illness; (iii) reduce interaction with the criminal justice system; and (iv) improve health outcomes. Participants are provided intensive case management, crisis intervention, substance use counseling, mental health treatment, peer support, skills building, connection to primary care, and various other services identified as appropriate to the client’s goals. The goal is to provide individuals with the stable housing that provides a platform for stabilizing and maintaining health.
A lot of attention is often focused on the innovative financial and contracting mechanisms that are at the core of Pay for Success projects. But, NFF believes that the role of service providers in these projects is central to project success, and that there are many valuable lessons to be learned from the service providers in early Pay for Success projects. Here we summarize what we observed of MHCD and CCH that suggests that they are well-positioned to deliver on the project’s goals, as well as what we heard from them about the benefits and opportunities of the Pay for Success model.
Organizational Expertise and Commitment
The deep expertise and reach that CCH and MHCD have developed in the Denver community were immediately clear. Collectively, they serve more than 60,000 individuals experiencing homelessness and mental illness each year. Both organizations are experienced at providing integrated housing, healthcare, and supportive services, and operate more than 30 housing developments combined. We were struck by the level to which both organizations reflected this expertise and commitment in the design of their state-of-the-art medical and housing facilities. Design elements such as collaborative work stations for integrated care teams, and light-filled supportive housing units, demonstrate the organizations’ intention to create welcoming and accessible environments for their clients to access care and improve their own well-being.
The core competencies both of these organizations have developed over decades of experience allow them to be flexible and partner with the City of Denver for this project. CCH’s experience developing affordable housing developments meant that 25 new housing units at North Colorado Station (shown above) were available at project launch, and both organizations bring to the project a pipeline of both newly developed and available existing housing units to house individuals throughout the duration of the project. Both organizations also have well-developed data collection systems and internal evaluation departments. These position them well in the Pay for Success context, which relies on ongoing performance management and evaluation in order to demonstrate intended program impact.
The project’s design and evaluation mandates that both service providers locate and engage with specific chronically homeless individuals identified by the Denver Police Department as frequent utilizers of the City’s criminal justice and emergency room services. In their initial outreach, CCH found that the individuals identified were largely disconnected—that is, not on the radar of or receiving services from CCH, MHCD, and its peer social service providers. Additionally, the service providers learned that some of the individuals identified were not English speakers. This prompted CCH to build out an outreach team with new language competencies and to employ new techniques in order to be able to identify and engage with specific individuals. For example, the Denver Police Department has provided CCH outreach staff with mug shot photos of clients who were identified as part of the project’s target population. In turn, CCH has also begun providing local police officers with laminated cards with pictures and basic information of clients they are trying to locate. These new tools and partnerships will help to keep service provider’s outreach robust and strengthen their collaboration with police and other Denver social service agencies for the benefit of Pay for Success clients and beyond.
Historically, both organizations have been funded primarily from federal sources such as HUD, Medicaid, SAMHSA, and HRSA. While this project leverages $15 million in federal resources in the form of Medicaid billing for services providers, it also presents a new opportunity for the City and County of Denver to address their broader policy objectives and achieve greater efficiency or value in the allocation of local resources. The Pay for Success contract provides an opportunity for the City to target its financial resources and human capital toward achieving an ambitious goal of housing 250 people with intense needs and challenges. They also realize some efficiencies by securing multiyear funding for delivery of supportive services, at the same time that they secure support for the actual housing units themselves.
Demonstrating Impact and Building Evidence
Supportive housing and assertive community treatment are both considered evidence-based interventions and have been studied in a range of communities and with different populations. But, by participating in this Pay for Success project, these service providers have an opportunity to have the impact of their services, validated by outside researchers in a randomized control trial. The study will also provide evidence of the effectiveness of these two interventions provided together. These organizations may be able to leverage this evidence as they seek support and resources for their services beyond Pay for Success contracts, and make the case for funding that covers the full cost of combining this integrated service model.
Early discussion about the potential of Pay for Success contracting centered on its potential to scale proven interventions, but the first generation of projects in the United States have shown that Pay for Success can also be used more broadly than this, and have benefits beyond what is measured by the project. Our conversations with CCH and MHCD underscored this.
In particular, the Housing to Health Initiative is providing an opportunity to advance innovations in service delivery; align public resources with the goals of different stakeholders; and build the existing evidence base for social service innovations. Thus, while the number of people that CCH and MHCD will serve through this project is relatively small compared to their organizational footprints, the impact of this project on the organizations themselves, and the Denver community, has the potential to be much greater.
Finally, CCH and MHCD reinforced that Pay for Success is another way in which organizations can work towards achieving their missions. As CCH President John Parvensky says, “CCH is committed to proven solutions to homelessness, providing affordable housing and health care to improve the lives of those we serve. We are excited to be a part of this creative and innovative new approach to bring permanent supportive housing to those who need it most. It is programs like these that help us build strong, caring communities.”