ARCH: Setting Strategic Priorities with TJACH
Advancing Resilience and Community Health (ARCH) is a project to help the burgeoning relationships between healthcare institutions (payors and hospital systems) and community-based organizations (CBOs) get off the ground successfully and at a scale that will make a difference. NFF has been partnering with three networks – EngageWell IPA (New York), Metropolitan Alliance of Connected Communities (Minnesota), and Thomas Jefferson Area Coalition for the Homeless (Virginia) – to explore what it takes for networks of CBOs to come together and partner with healthcare. NFF prepared a blog series for each network to share reflections from staff involved with ARCH (Lisa Thirer, Deirdre Flynn, Sophia Raday, Meadow Didier, Elise Miller, and Martin Lenarz-Geisen) to share what we’ve learned from defining scopes of work and delving into strategic priorities for each network. Though each network has a unique set of characteristics, all captured in this network snapshot, there are actionable takeaways that anyone can apply no matter the structure, size, or other characteristics that might define a network’s approach.
TJACH is a collaborative of community providers and funders in the Charlottesville, Virginia, area. TJACH is committed to improving health outcomes and housing stability for people experiencing homelessness or housing instability, and to reduce inappropriate use of local emergency departments through supportive housing services. Some of TJACH’s network characteristics are that it is regional, issue-specific (homelessness), and multi-service.
Goal and Vision: TJACH’s vision for the future is to make homelessness in Charlottesville a rare and brief occurrence by: building capacity within the community to provide services beyond housing, particularly supportive services (Housing Navigation & Case Management), helping housing and service providers to take advantage of Medicaid Expansion across Virginia, and creating community urgency around housing as healthcare. A related goal is to find new funding sources to close current funding gaps in rental subsidy and supportive services in Charlottesville.
How the network’s operating environment influences its strategic priorities
Growing understanding of the current impact of historical racism, coupled with the events of the “Unite the Right” rally in August 2017, have spurred increased funding and effort to address homelessness in Charlottesville.
Charlottesville has a major anchor institution – the University of Virginia – with vast influence on healthcare and affordable housing availability. However, the UVA health system is still reimbursed by volume from the state, which limits the incentives to contract with CBOs. Like many payors who are committed to working with their local community but operate in a heavily siloed system, their interest in addressing social determinants of health is largely focused on areas where there is a “business case” to be made. Many individuals at UVA are clearly committed to social justice; however, translating that to an institutional priority in such a context is tough work.
“UVA gets reimbursed at a higher rate for homeless patients than what their cost is. That’s a dysfunctional state policy that’s working against value.” – Lisa Thirer
Virginia expanded Medicaid as of 2019 and TJACH and its members are interested in exploring whether Medicaid reimbursement for some of the services they provide would help allow them to expand services. They want to be ready for (and potentially help shape) the State’s Medicaid expansion program. However, it’s still unknown if or how the state will roll this out to Charlottesville.
“We are trying to establish if the cost-benefit of potential Medicaid reimbursement for small CBOs is worthwhile to invest in the infrastructure to bill, and if the revenue would allow them to expand and meet the demand.” -- Lisa Thirer
In earlier days, TJACH – among other things – provided direct service to people who are homeless. As a HUD-designated Continuum of Care lead, it currently coordinates funding-related services in the community. Through this history along with stable and trusted leadership, TJACH has tremendous social capital within the community. TJACH has its finger on the pulse on what organizations in housing and homelessness are doing and can bring a “systems lens” to this work. Finally, TJACH’s singular focus on homelessness has enabled identification of very clear steps to reach its goals.
“Part of TJACH started out providing direct services and so there’s an emotional connection to the work and also credibility that comes from that genesis.” – Sophia Raday
Challenges to manage when setting network priorities
1) Given limited capacity, how can TJACH take on more leadership/coordination responsibilities?
- TJACH has one person on staff, and he has never charged for his role in leading and coordinating collaborative projects such as contracting with healthcare. NFF is helping TJACH’s leader identify the full costs of TJACH’s strategic role as the intermediary so he can negotiate contracts armed with that knowledge.
2) How do you bring a systems lens to a complex problem, yet avoid “intellectualizing” a problem that is a crisis for fellow human beings?
- NFF is providing financial support through ARCH for TJACH to work with the Corporation for Supportive Housing to do a “systems map” of the many providers to identify bottlenecks in the system. NFF, TJACH, and TJACH collaborators have discussed the benefit of coupling data with stories that illustrate the impact of their services from a human perspective.
“TJACH’s history – working as a direct service provider, plus coordinating funding for most of the homeless services in the area – allows it to look system-wide but with ground-level empathy.” –Meadow Didier
- One of TJACH’s priorities is to educate the community on the role of housing in health. NFF is working with TJACH and its collaborators to estimate the resources necessary to bring homelessness to functional zero (in services and dollars) and host a convening of key community leaders and funders to present its findings.
3) How do you prepare for Medicaid billing when you don’t know what the roll-out will look like?
- TJACH and its collaborators believe that Medicaid billing may provide additional funding for their existing work, potentially freeing up dollars for expanded services. But little is known about the details of the program, or when and how it will be rolled out across communities in Virginia.
- TJACH and NFF teamed up to host a convening which included a primer on the healthcare landscape and the basics of Medicare expansion.
“If you want to play in the healthcare sandbox, an understanding of healthcare language and norms and priorities – what value-based payments are, and the basics of Medicaid – is critical.” – Deirdre Flynn
- NFF is also working with TJACH and its collaborators to model growth by making documented assumptions about unknowns, as well as identifying the unit cost of their work to be able to advocate for a sufficient Medicaid reimbursement rate.
Other actionable takeaways for CBO networks
- A charismatic leader who inspires trust is a wonderful accelerator to this work; however, it can also be a risk if that person should leave. Work to build not only trust in one leader, but to leverage that trust to build a web of connection across stakeholders.
- Quantify the work of coordination and include it in your full cost (see how EngageWell is approaching this).
- Healthcare is complicated ‒ both state and federal policy have a huge influence on what is even possible. Payors and systems are so diverse in what they can do, or are interested in doing when it comes to social determinants of health. A big part of the work of a network is understanding the political and policy context in your area, and advocating for the changes needed to effectively serve the populations you care about.