Breaking Ground: Using Housing to Reduce Health Care Costs

We speak with Brenda Rosen, the President and CEO of Breaking Ground, about the power and potential of supportive housing.

Images Courtesy Michael Moran

Boston Road is the newest addition to the Breaking Ground family, a New York City-based organization that provides supportive housing (affordable housing with on-site mental health, health care, and job-training services) for both low-income working adults as well as formerly homeless single adults, many of whom suffer from HIV/AIDS or other mental or physical conditions.

Simply put, Breaking Ground employs housing as a strategy for reducing health care costs.Their guiding philosophy is that putting “housing first” infinitely increases the likelihood that an individual can achieve sobriety, live healthier, and contribute actively to society. The philosophy seems to have merit as supportive housing has been proven to be remarkably cost-effective. Between emergency care, shelters, psychiatric hospitals, and jails, the average mentally-ill homeless person costs the city $56,350 a year; the average mentally-ill individual housed in a supportive housing unit costs the city $24, 190 a year.

Equally important to Breaking Ground is that each of their buildings inspires its inhabitants and underscores their value as individuals and contributing citizens. Boston Road, designed by Alex Gorlin Architects and located in the South Bronx, is not just Enterprise Green-Certified (featuring low-toxicity paints and materials, energy-efficient heating and lighting, and a green roof), but also light-filled, optimistic, and oriented towards community. A landscaped courtyard provides space for meditation or congregation; each corridor has windows at the end; the colors are bright and optimistic. As Principal Alex Gorlin explains, “The idea of these buildings is to create a well-designed, dignified residence that people can be proud of.”

To learn more about Boston Road, and the strategy of employing housing to reduce healthcare costs, we spoke with Brenda Rosen, the President and CEO of Breaking Ground.

Vanessa Quirk: Having worked in this space and seeing housing used as a strategy to reduce healthcare costs, what, in your experience, can housing do? What can it accomplish?

Brenda Rosen: I think housing can have a massive positive impact on health, especially for vulnerable populations. We have anecdotally, in this supportive housing field, always felt as though, when you give somebody a stable home and on-site support, that their health and wellbeing is improved. And over the past several years, with numerous studies, more and more documentation shows that that’s true, that people’s Medicaid costs decrease significantly, and people’s health becomes better. I really think that it’s just sensible.

When you’re asking somebody who’s living out on the street to take care of their health, and to manage chronic conditions that have often gone for years undiagnosed, or treated with a “bandaid” time and time again, this doesn’t help anybody’s long-term health, and it’s really really expensive. I figured out that to ask somebody to improve their health by getting sober or off drugs, for example, while they’re struggling to survive on the streets, is really a recipe for failure. When we bring somebody with chronic medical conditions, with somebody that needs to be on medication that’s managed every day, that has medication that needs to be refrigerated, a person that needs comprehensive and consistent care, and we bring them inside and provide that, the impact is just phenomenal.

VQ: Would you mind defining what supportive housing means to you?

BR: Supportive housing, in a nutshell, is affordable housing with on-site support. It’s independent housing, so everybody gets a lease and a key. And all of these services that we offer are voluntary. So you do not get evicted if you do not participate. Having said that, we work very hard to outreach to individuals to engage with them to take advantage of the onsite supports that we have. And they range from primary medical care and psychiatric care to basic case management services to skills building, workshops, and job placement help, and so much more. We feel that we wrap you in whatever the services are that you particularly need to help you become stable and successful and remain that way.

Another component about supportive housing is that no building is 100% special needs. No building of ours is one hundred percent formerly, chronically homeless. Supportive housing, by definition, is a mixed model. So our buildings are anywhere between 60% special needs and 40% low-income, or kind of a fifty-fifty split. And we do that deliberately, because the goal of supportive housing is to help people succeed and to help people to acclimate back into society. And that means living with and among people that are out there and going to work every day and earning income. That is a really successful model. And even across all of our floors, we don’t segregate the formerly-homeless folks and the mentally-ill folks from the people that are coming in through the regular low-income housing lottery.

VQ: And is there ever any kind of friction between these different populations?

BR: Not any more than any other regular building, where you may have a neighbor who plays his or her music too loud. We have twenty-four-seven security, and we do that for a lot of reasons. But one of the reasons is to make sure that if there are issues, we are able to get to them right away. So if your neighbor has relapsed, or has gone off medication, or is having an issue, and his or her neighbor hears, it, we want to make sure that we engage with that person as quickly as possible. Having said that, we don’t have any higher turnover in our low-income units than in our special needs units. So I think that’s a huge measure of success.

VQ: And when you’re evaluating the success of these housing projects, what metrics are you using?

BR: Well, the main metric is staying stably housed and being able to live independently in your own apartment. So in supportive housing, we’re not providing three meals per day, and again we’re not making sure that you are checking in every night and returning to your bed. Having said that, we, when you’re paying your rent, when we’re seeing that you’re able to maintain your apartment, that you’re participating in activities, and engaging in different components of the entire program that we offer, those are all metrics for success.

I will say that success for everybody in supportive housing means a slightly different thing. So for somebody, it can mean that you come in, you get sober, you obviously maintain your housing, and you volunteer in the building. Or you start working. You become a contributing member of society again. For others it means that you are able, again, to maintain your apartment and live independently, and that you take your medicine every day, and that your mental health and case management needs, over time, decrease and you’re able to once again live as part of our community in the building.

VQ: I saw some statistics on the web site that prove the economic value of supportive housing; are there any metrics that keep track of that?

BR: The average cost to remain on the streets is just north of $50,000 a year per person. The cost to be in supportive housing is about $25,000. We know through the data collected on Medicaid savings that people’s Medicaid costs decrease at an average of $10,000 per year per person, so that’s immediate savings every single year. So the economies are definitely there and have definitely been documented. That is because, when you come in off the streets, your reliance on public resources decreases, on using the emergency room as de facto shelter or triaging medical issues. Comprehensive care over time would be less expensive and more efficient and more successful. And other public resources that people on the streets tend to cycle through more frequently, jail and shelter—you don’t use them when you’re in supportive housing.

VQ: Many of the inhabitants suffer from HIV or have other types of special needs or medical needs. Does that change anything in the way that you go about thinking of how to design these buildings?

BR: I don’t know that I’d say that we distinguish, in terms of design, between someone who’s coming in with HIV and AIDS versus somebody who’s coming in with persistent mental illness or substance abuse disorder. But what we absolutely believe is that design elements in general have a huge impact on people’s health and stability. So, we definitely prioritize good design in our supportive housing residences, and when we’re working with our architects, we all are on the same page about having an eye towards elements that are going to help the person feel a sense of pride and dignity about where they’re living.

That’s why when you come into any one of our buildings, you walk in and you’re immediately proud of where you are, because the lobbies are so beautiful. We very much believe in as much natural light as possible coming into the apartments, the common areas, and the hallways; it’s an important component of people being healthy and feeling healthy. And you know, our buildings are either LEED or Enterprise Green and all of those components help people’s health as well.

Interestingly, we recently participated in a study done by Lehman College, where they were funded to look at the impact of people’s housing on their health. They looked at people in older buildings that had been retrofitted and people in new developments that were green. And we participated in that with one of our buildings, and my understanding is that the results showed that people living in LEED Silver buildings fared better than people that were living in the older housing.

VQ: That was going to be one of my questions. Why is it important for you to choose LEED or Enterprise Green? Because you see a direct correlation between those standards and healthy spaces?

BR: Yes. It is also in lots of ways more efficient. Obviously, operating costs are always on our mind, especially as a nonprofit. So we’re also looking for as efficient a building as possible to save money.

VQ: So you’ve found that, by going with LEED or Enterprise Green, you actually see improvements in the bottom line?

BR: Yes. Absolutely.

VQ: And I imagine, also, that it encourages using healthy, non-toxic materials as well, right?

BR: Yeah, all of that combined. We have some older buildings in our portfolio that, as we try to renovate them, we try to put in more efficient systems and green elements, but they’re never going to be what our new construction is like. And because we have this portfolio of old and new, we are able to track the operating costs across the portfolio, and it’s really clear that our newer developments, with a green roof, and condensing boilers, etc., have a direct positive impact on the bottom line.

VQ: One of the things that I was reading on the website was this emphasis on connectedness as a potentially healing aspect of the space. Why is it the connectedness important, and how do the designs themselves inspire opportunities for connecting or community building?

BR: That’s a great question. So, let me give you an example. In most of our buildings, we partner with a social service partner. We do provide some of our own social services and programs, but in most of our buildings, we are the developer and the property managers, and we have a social services provider that does the case management and the psychiatric care, and primary medical care.

In our first couple of buildings (now I’m going back 20-plus years, when we were rehabbing old buildings, not doing ground-up construction), we had our social service provider located on one end of the building and the property manager on the other end of the building. And it worked, but not well…

What we found when we started doing new construction, and we were able to design our own common areas, our own housing spaces, etc., and we were able to connect to those spaces and have one floor that goes in a semi-circle, where you go to the property management office and you move into the suite that has social services, and you may have community rooms and you potentially have the gym right down the hall from there as well, and a multi-purpose room where we have all types of classes and a community computer room, where we do computer classes and allow people to do their resumes, writing, and all sorts of things, we found that bringing those people, the property managers and the social service workers closely together with a lot of community spaces, allowed people to intermingle a lot more, get to know each other a lot more.

One of the things that is kind of a myth about being homeless, people think that because you’re on the street you’re around people all the time. That’s true, except that the other part of it is that people who have been dealing with mental illness and substance abuse disorder have been kind of shunned by society by years on end are very much isolated. And when they come into the housing, one of our primary goals is to help them not isolate, and help them acclimate back into the larger society and a larger community. Having as many opportunities for them to be involved with us and their neighbors, is really, really helpful.

In addition, having both the social service suites and the property management suites next to each other allows for us to manage any issue or problem or concern that comes up in a very fast and coordinated way. Our goal is to never evict anybody. Across our portfolio, we have less than a one per cent eviction rate. And a lot of that is because we make sure that we understand the connectedness: if somebody’s apartment is in disarray and they’re late on their rent, there’s usually a lot more going on than, they just forgot and failed to give us the rent check. We bring issues to our social services partners, and our social services partners bring issues to us right away, so we can sit down and say, ‘all right, what’s the holistic picture and what’s going on in this person’s life? Has he or she relapsed? Is that why all of a sudden we’re not receiving his or her rent payment on time? Is that why he or she hasn’t been coming to computer classes? And again, the design of the space allows us to engage with each other more often, and also allows us to have more eyes on what’s going on at all times.

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