Low-income or disadvantaged people are often isolated in neighborhoods where affordable housing is not aligned with public transportation and where they are disconnected from employment opportunities, child care, education, recreation, health care, and quality food resources. For many, this disconnect has been devastating to personal well-being, life chances, and life expectancy.
However, a small number of housing providers are working to reverse these conditions by linking critical services to the physical place provided by affordable housing developments, and by fostering regular face-to-face interactions between residents and staff.
Their experiences are indicating that connecting residents of affordable housing with needed supports—such as educational resources, asset building tools, or health services—can enable low-income families, seniors, the chronically homeless, people with disabilities, and other vulnerable populations to achieve a better quality of life.
But these efforts to weave a range of related but distinct programs together with housing support will not reach scale until there are sufficient data and evidence of success to encourage providers to adopt proven practices and persuade policymakers to provide more resources and relax the housing, health care, and other regulatory restraints that make it so difficult to bring multiple programs together to enable residents to improve their lives.
There is as yet relatively little sound evidence that connecting housing to services results in positive outcomes for vulnerable populations. In an effort to strengthen the evidence base, Stewards of Affordable Housing for the Future (SAHF), with active support from The Kresge Foundation, has launched the Outcomes Initiative to gather consistent data across the housing portfolios of its members. The data will measure the effect of access to supportive services on important life outcomes of affordable housing residents.
The members of SAHF expect that the initiative will enable them to engage and serve their residents in a more integrated, effective, and cost-effective way. Of equal importance, they anticipate that the data will help make the case for additional resources and, with time, move government policy toward more integrated approaches.
Given the need for varied and integrated supports to improve quality of life for vulnerable populations, it is important to identify a place to bring various resources together in support of an individual or family. It seems intuitive to use the place where people live as a base for providing and connecting them with the array of resources they may need to improve their condition. A number of housing providers who have experimented with the approach are seeing that it makes a difference in people’s lives. However, the evidence—and underlying data—needed to persuade policymakers to alter program design, resource allocation, and regulations to support this approach is currently very limited.
Numerous historical, political, programmatic, and regulatory reasons explain the lack of this evidence, not least of which is the relatively few integrated approaches from which to collect supporting data. Indeed, the design of public programs and regulatory frameworks is tied to old models or assumptions that are resistant to the funding and operating flexibility required to support better integration and service delivery. As result, the various programs and institutions charged with delivering services remain disconnected. Government housing subsidies, for example, seldom provide resources to address the additional health and human service needs of most families in subsidized housing. Likewise, health care Medicaid funds cannot generally be used to build housing or pay for its operating costs, even when it is clear that poor-quality housing can exacerbate health problems and even though health care subsidies routinely pay the far greater costs of room and board in nursing homes for the elderly than for aging in place.
In the housing world, herculean efforts are required to move beyond providing basic shelter to enable residents to address the multiple other factors affecting their lives. To access and coordinate other, non-housing services, nonprofit housing owners typically must assemble limited, short-term funding from multiple local government and charitable sources. In some cases, owners can use the cash flow from property operations to fund some services, but often that cash flow is unreliable and its use for services risks starving the property of the resources needed for maintenance or weakening the financial sustainability of the owner.
Even where these efforts have been successful, the quantity and quality of available data are limited. Nonprofit owners generally lack resources to track how residents are faring. As a result, the data collected by providers are often simply the basic information required to satisfy funding sources. Too often, the data measure only activities rather than outcomes. Without measuring outcomes, property owners have no way to tell whether they are making a difference beyond providing shelter or how to change their approach if they are not. This void limits the utility of the data to support program design and policy change. Even if sufficient data are collected, there are few resources for data analysis.
The data that exist vary in quality and consistency. Different reporting requirements from different funders result in a mishmash of data that make aggregation across owners nearly impossible. As a result, lessons are not transferrable. Moreover, isolated data have little or no impact on policy or social investment and are of limited use in demonstrating impact to potential partners in sectors important to resident success, such as health care and education.
As a result of these shortcomings, analyzing data collected from properties is difficult, even in the rare circumstances that providers have the necessary resources. Funders rarely aggregate or analyze data on the impact of housing connected to services in any methodologically sound manner, or regularly consider whether the data collected tell them what they need to know to improve policy and programs. The evidence that does exist supporting policy change and increased investment in the housing platform has come from a quite small base of studies often focused narrowly on particular populations (e.g., homeless people, seniors) or housing types (e.g., permanent supportive housing, public housing).
The SAHF Outcomes Initiative
The dearth of data on how residents fare in settings where housing is linked to services prompted SAHF and its members to embark on an effort to gather consistent, aggregated data across members. The Outcomes Initiative aims to:
- Develop baseline data on the impact that having stable, affordable housing has on the lives of residents;
- Develop baseline data on housing connected to services (e.g., key services, the commonly accepted definitions of those services);
- Show which program-delivery mechanisms have the greatest effect on an individual’s quality of life;
- Develop measures that matter to social investors, foundations, and those who control the resources in related fields such as health and wellness and education;
- Gather evidence to make the case with policymakers for additional resources to support integrated housing and services efforts, and to create a public policy environment that can stimulate more extensive private grantmaking and investment.
A planning group of SAHF and four of its members began by sorting through current approaches and identifying common outcome measures across five areas important to residents:
- Health and wellness;
- Work, income, and assets;
- Housing stability;
- Children, youth, and education; and
- Community engagement.
The planning group began by reaching consensus on a list of interim outcome measures across all five fields. Through this process, the group worked to balance the desire for standardization with the competing reality that each member has its own internal structure and is at a different point in its data collection efforts. The members were able to agree on 30 measures that they either were already collecting or would be willing to begin collecting. The measures include, for example, the percentage of students who advance to the next grade level, percentage of households with a checking or savings account, and number of emergency room visits in the prior year.
The group also worked to develop an aggregation process that would allow members to use their current collection methods (such as annual resident surveys) while still achieving the consistency needed for aggregation. In the end, the measures adopted are clearly defined, flexible for different staff resources and resident populations, and of high value to residents, members, and potential funding partners.
This is an ongoing process. These measures may well be adjusted following the deeper dives described below. Members will move forward with collecting and aggregating data across their portfolios to the extent feasible in early 2015.
SAHF is drawing on specialized expertise to inform the continued outcomes data work and to explore effective strategies to serve residents in each of the five domains noted above. These “deeper dives” into specific focus areas enable the group to better understand the evolving landscape in each of these fields and understand the types of metrics that would resonate with and assist in bridging to potential partners. The planning group chose health and wellness as the first area of focus because of its promise for housing-based approaches that both improve health and reduce costs, especially in the Medicare and Medicaid programs.
The Affordable Care Act’s Medicaid expansion, the act’s funding for innovation, and health care reform more generally are changing health care quickly. SAHF retained Health Management Associates (HMA), a national health care consulting firm, to help navigate the complex health care landscape. HMA determined which outcome data are substantiating in the health care field and how to agree on a common set of measures, and identified the opportunities for accessing funding for services or capital from health care payers such as state Medicaid programs, managed care organizations, and insurance companies. The firm strongly recommended that SAHF: 1) pay close attention to indicators that are used to evaluate the performance of health care providers and payers, and 2) build a business case that supporting housing with services can help them meet industry and regulatory quality standards more effectively and cost-effectively than they can by providing all services themselves.
Following this planning effort, SAHF engaged all interested SAHF members in the discussion. The larger group identified services of high value to health care payers and target properties where members could document value. SAHF also undertook an initial exploration of a second area of focus: children, youth, and education. Specifically, it identified: 1) the outcome measures educators and others in the child development field find useful, and 2) evidence-based programs supporting these outcomes that are based in or linked with affordable housing. The initiative will later focus on work, income, and assets; community engagement; and housing stability.
Challenges and Solutions
Even among motivated housing providers, determining how to collect outcome data in a consistent manner posed challenges.
First, each SAHF member had its own starting point. The populations SAHF members serve are diverse in their needs and aspirations, ranging from seniors and families with children to people with disabilities and formerly homeless individuals. Some members had collected only data about participation in activities—logging attendance at meetings or classes and contacts with residents. Others had tracked only information relating to specific services they have offered, often in a format designed to satisfy a government funder or foundation. Even when members measured the same concept, some collected information at the household level while others collected it at the individual level. Similarly, some members collected information only about adults; others, about children as well. In some cases, groups asked the same question, but response categories differed. For example, all members measured “type of lease violation,” but grouped the responses in different categories. Finally, most members had not aggregated any data across properties.
Working together requires not only a commitment to outcomes and consistency, but also a willingness to surrender approaches that have been developed at significant expense in staff time and consulting fees. It also requires engaging with staff at sites across a member’s portfolio. With sustained discussion and negotiation, the participating SAHF members came together around a tentative list of outcome indicators across the five areas, all to be tested and honed based on experience. For example, they decided to collect the percentage of households reporting increased net assets, the percentage of students who advanced to the next grade level, the number of emergency room visits in the prior year, and the number of lease violations.
To ensure consistency in the data, the planning group created a data “dictionary.” With respect to lease violations, for example, they agreed to disaggregate response categories and added “damage to property” and “criminal activity” to “nonpayment of rent” as separate categories.
A second challenge in improving data collection is competing demands on already busy senior staff to engage in the design process and property staff to gather and record the data. Both groups already have more than a full array of responsibilities. Properties owned by mission-driven nonprofits often operate in the red or with limited or no operating margins, making it almost impossible to hire staff to focus on data collection and analysis. Although some large properties have significant staff, and many properties, especially senior properties, have service coordinators, most SAHF member properties have only a property manager and janitorial staff. The average property size is small, in the range of 65 apartments, and many have only 20 or 30 apartments.
Accordingly, it made sense to start the data collection process by looking at what data could be gleaned from the annual income recertifications required for residents of HUD-assisted housing, expand somewhat the information gathered in that process, and supplement that data with resident surveys. But even this level of data collection requires significant training and staff time, and therefore was not feasible for understaffed properties. Rather than await additional resources, the initiative focused first on properties with service coordinators.
A third challenge is the time and expense required to aggregate and analyze data. In a perfect world, an external IT vendor would provide an inexpensive platform for aggregation. As it turns out, the available vendor technology is expensive, having been designed for intensive assessment of specific programs at properties rather than the overall life success of residents. Rental-assistance programs do not provide resources for this work, and one-time funding could create a data strategy that would turn out to be unsustainable. To address the aggregation problem, the team adopted the interim solution of using common Excel spreadsheets that can easily be aggregated across members. Using this simple approach will likely help build toward the next stage of technology.
Other challenges are institutional barriers to existing data. Institutions in other sectors, such as managed-care organizations, hospital systems, community clinics and school systems, gather and often analyze extensive data about residents of affordable housing. Health care payers, for example, often know who are the high-cost users of health care and why. The data they collect would provide a richer sense of how an individual is faring in terms of health. Similarly, school systems have data about school attendance, grade progression and, often, personal development.
But the institutional barriers to accessing those data for the residents of even one property, much less across a portfolio, are daunting. They begin with the difficulty of getting the attention of senior officials in the other sectors. Privacy laws compound the problem and often provide an excuse for inaction. The team is addressing these issues first through dialogue with “coalitions of the willing” in the other sectors. Owners can request that residents waive their rights so that data can be shared with their housing members, and schools and health care systems can share data that have removed individual identifiers. Over the longer term, as it becomes clearer that well-intended restrictions can defeat efforts to serve the “whole” person, policy change will likely be required to facilitate data sharing.
A final challenge in collecting and using data is that even data collected widely and consistently may not always meet academic or “evidence-based” government standards. Moreover, outcome data alone are generally not sufficient to establish cause and effect; the housing provider cannot control all the factors that affect resident well-being.
Nonetheless, the data will enable better decisions, and housing owners and managers can craft stronger programs. Moreover, institutions in related sectors, such as health care payers, are not bound by academic standards of evidence and will instead be able to use their business judgment to engage housing providers based on a combination of these data and their own data. Social impact investors may conclude that the data are strong enough to warrant investment. Finally, the data may persuade policymakers to redesign existing programs that lack data support. More methodologically sound data, even though short of academic standards, may be sufficient to support changes in programs or policies.
Broad-scale data collection can also spawn pilots and demonstrations to test the effectiveness and cost-effectiveness of specific interventions, and the evaluator of those demonstrations will collect and analyze more detailed data. For example, a demonstration of the ability of housing providers to increase access to primary care or improve chronic disease management will generate detailed data on health impact and cost. Potentially, basic outcome data can be correlated with in-depth data and the basic indicators, possibly modified with experience, can become affordable proxies for the in-depth data.
Spreading the Idea
This SAHF initiative was launched at an opportune time for both its focus on data-driven approaches to social problems and its ultimate goal of enhancing resident success.
In 2013, the Bipartisan Policy Center’s Housing Commission released “Housing America’s Future: New Directions for National Policy.” The report’s recommendations were the culmination of a 16-month process of roundtable discussions and regional housing forums.
The report included a focus on outcomes-based performance,
[A] focus on outcomes, rather than process. We propose establishment of a performance-management system that measures resident outcomes across all rental-assistance programs, focused on creating incentives for greater efficiency and improved housing quality, as well as ensuring that rental assistance meets its full potential to serve as a platform for the achievement of other social outcomes.
Of even greater significance is that the public sector was beginning to appear receptive to integrated services. In 2010, when HUD released its 2010–2015 strategic plan, it included a new goal: to “utilize housing as a platform for improving quality of life.” For those in the housing field who have been connecting housing and services for years, this was by no means a new idea. But the fact that HUD elevated this concept to one of its five strategic goals signaled new attention to this important link between housing and services and how the physical “place” of housing can serve as a hub for needed services. The secretaries of HUD and Health and Human Services have recognized that their departments are serving essentially the same people and have sought to work together to better connect their programs and policies.
Building momentum will require enlisting other affordable-housing owners in the effort. With that in mind, SAHF and the Council of Large Public Housing Authorities convened a meeting at which SAHF presented its tentative list of outcome measures and the council, the Housing Partnership Network, and NeighborWorks® America outlined their own approaches.
The End Game
Accessing resources from multiple systems (e.g., housing, health and human services) can be a challenge for even the most committed and knowledgeable providers. As noted, the challenges include the absence of direct funding for services in assisted housing, inadequate space for on-site services in assisted housing, regulatory limits that create barriers to accessing or aligning certain services, and lack of resources for service coordination.
Not every individual or family needs a full range of services; nor does every housing provider need to provide comprehensive supports. But where needed, access to the right services at the right time can make all the difference in creating stability and fostering a path to the economic mainstream.
Kresge and SAHF anticipate that the Outcomes Initiative will identify services that have the most impact on improving well-being and could open up opportunities for approaches that provide a payback over time. That payback would come through reduced system costs stemming, for example, from less use of the emergency medical system, improved academic performance, increased employment in living-wage jobs, and improved health.
Once positive effects are identified, the policy and systems barriers to integrating these services with housing can be addressed. The Kresge Foundation and SAHF further expect that the initiative will uncover opportunities for third-party “pay for performance” investments that enable residents to achieve improved outcomes and control or even reduce costs. These have the potential to lead to significant policy changes once results are proved.
SAHF and its members, with active support from Kresge, have embarked on a long journey, but a journey that will enable them both to serve residents better and to work effectively with new partners using approaches shown to make a difference.
 SAHF is a consortium of national affordable housing nonprofit organizations. Its members are BRIDGE Housing, Homes for America, Mercy Housing, National Church Residences, National Housing Trust/Enterprise, Preservation of Affordable Housing, Retirement Housing Foundation, The Community Builders, Evangelical Lutheran Good Samaritan Society, NHP Foundation, and Volunteers of America. The consortium serves more than 106,000 households (families, seniors, the formerly homeless, and people with serious disabilities) in affordable housing across the country. The Kresge Foundation determined early to invest in this effort because of its dual interests in identifying and applying evidence-based approaches for improving outcomes for vulnerable populations and in policy and systems change to facilitate the funding and implementation of proven practices.
 J. Krieger et al., “Housing and Health: Time Again for Public Health Action,” American Journal of Public Health 758 (May 2002). Also see R. Cohen, “The Impacts of Affordable Housing on Health: A Research Summary.” Insights from Housing Policy Research (Washington DC: Center for Housing Policy, May 2011).
 D.J. Rog et al., “Permanent Supportive Housing: Assessing the Evidence,” Psychiatric Services, 65(3) (March 2014). Also, see wide-ranging research on impact of housing and services funded by the John D. and Catherine T. MacArthur Foundation at http://www.macfdn.org/press/article/how-housing-matters-research-briefs/.
 SAHF retained the Urban Institute, a national nonpartisan research organization, to explore the education landscape and build the connection to affordable housing.
 Bipartisan Policy Center, “Housing America’s Future: New Directions for National Policy” (Washington, DC: Bipartisan Policy Center, February 2013), p. 97, available at http://bipartisanpolicy.org/library/report/housing-america%E2%80%99s-future-new-directions-national-policy. The report also noted SAHF’s efforts in this area (p.98), ensuring that affordable housing is a platform for delivering services.
 U.S. Department of Housing and Urban Development, “HUD Strategic Plan FY 2010–15” (Washington, DC: HUD, May 2010), p. 11, available at http://portal.hud.gov/hudportal/HUD?src=/program_offices/cfo/stratplan.
 U.S. Department of Housing and Urban Development, “HUD Secretary Donovan, HHS Secretary Sebelius Discuss Housing, Health, Education, Economic Outcomes of Low-Income Families,. HUD No. 11–259. (Washington, DC: HUD, 2011), available at http://portal.hud.gov/hudportal/HUD?src=/press/press_releases_media_advisories/2011/HUDNo.11-259.