Overview

CICH targets affordable senior housing residents and low income older adults in a housing site’s surrounding communities. While most individuals served will be dually eligible for Medicare and Medi-Cal, many will have incomes slightly too high to be eligible for Medi-Cal. These individuals are part of the “forgotten middle” – those who do not qualify for Medi-Cal but cannot afford to pay out-of-pocket for in-home services or long-term care. By serving this vulnerable population, CICH provides an opportunity to fill a major gap in California's long-term care continuum. Additionally, a CICH demonstration would use housing as a platform for addressing health inequities in disadvantaged communities.

CICH will serve as an important vehicle to advance California’s Master Plan for Aging (MPA), as its impact is aligned with more than 30 MPA Strategy metrics. These include:

• Increased availability of housing options with health and social care supports 
• Increased health insurance enrollment and coverage
• Increased access to health and social care benefits
• Reduced falls, psychological distress and suicides
• Reduced avoidable hospital visits and stays
• Increased life satisfaction 
• Increased digital equity
• Increased family and friend caregiving support
• Expansion of digital care
• Reduced homelessness and hunger

CICH will also play a critical role in advancing the goals of California’s CalAIM initiative to improve clinical and economic outcomes through California’s current 1115 and 1915 waivers. The purpose of CalAIM is to target resources toward highest need subpopulations, enhance care coordination with a distinct community-based orientation and increase the coordination of community-based supportive services with the traditional healthcare system. CICH directly advances each of CalAIM’s published goals:

• Identify and manage member risk and need through Whole Person Care Approaches and addressing Social Determinants of Health; 
• Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility; and, 
• Improve quality outcomes and drive delivery system transformation through value-based initiatives, modernization of systems and payment reform. 

CICH directly targets these CalAIM populations: 

• Aging Population 
• High Utilizers 
• Behavioral Health Challenged Older Adults and Persons with a Disability 
• People Experiencing Homelessness 

Once implemented, CICH could serve as a statewide template for expansion under CalAIM through a more standardized and efficient approach to bridging affordable housing and healthcare.

We expect to see outcomes comparable to those seen in similar models across the country, including: 

• Improved health outcomes. Participants in SASH® have reported improvement in and better management of chronic conditions, healthier lifestyles and fewer hospitalizations.¹ 
• Costs savings to Medicaid and Medicare. The SASH® evaluation reports Medicare savings of more than $1,450 per urban beneficiary per year and Medicaid savings of up to $400 per beneficiary per year.² 
• Increased access to healthcare for historically marginalized populations. Black, Native American and Hispanic individuals are disproportionately represented in affordable housing.³ The CICH model would provide primary, preventative and mental healthcare, management of chronic conditions and health education for populations that have disproportionately suffered from chronic conditions and decreased access to mental health services.⁴
• Increased access to long-term services and supports for the “forgotten middle.” There are many Californians who do not meet the income qualifications for Medi-Cal but do not have the personal wealth to pay out-of-pocket for long-term care. Creating a demonstration using Medicare eligibility as criteria for admissibility will allow these individuals to better manage their chronic conditions and receive much needed care coordination.
• Reduction in social isolation and loneliness. Each participant will have regular contact with the Community Health Worker and Wellness Nurse forming personal connections and making it easier to recognize when someone needs more engagement. Vermont SASH® participants report improved well-being and reductions in social isolation and loneliness.⁵
• Increased individual participation in their own health care and likelihood of receiving preventative care. Regular check-ins with the CICH team build trust and connections. Having a relationship with the CICH team helps empower people to become more involved in their own care. It also increases the likelihood of a person receiving preventative and mental health care.⁶ 
• Easily adaptable to telemedicine. The CICH model would, by nature, be easily adaptable to telemedicine. The Wellness Nurse can assist with and participate in calls between a participant and their primary care and specialty health providers.

¹Support and Services at Home (SASH) Evaluation: Highlights from the Evaluation of Program Outcomes from 2010 to 2016,” HHS Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy, July 2019. https://aspe.hhs.gov/system/files/pdf/262061/SASH5hl-rs.pdf.
² Ibid.
³ “Racial Disparities Among Extremely Low-Income Renters,” National Low-Income Housing Coalition, Apr 15, 2019. https://nlihc.org/resource/racial-disparities-among-extremely-low-income-renters
⁴ “Health Disparities by Race and Ethnicity,” Sofia Carratala and Connor Maxwell, May 7, 2020. American Center for Progress. https://www.americanprogress.org/issues/race/reports/2020/05/07/484742/health-disparities-race-ethnicity/#:~:text=regardless%20of%20race.%E2%80%9D-,Health%20coverage,health%20insurance%20coverage%20in%202017.
⁵ “SASH Combatting Loneliness and Social Isolation” https://sashvt.org/wp-content/uploads/2018/11/2018-Social-Isolation.pdf
⁶ “Network Success Story: Embedding Mental Health Care in Affordable Housing Sites,” OneCare Vermont. 2019. https://www.onecarevt.org/embedding-mental-health-care-in-affordable-housing-sites/.