To increase the integration of health and housing in New York by scaling The Bronx Frequent Users of Hospital Systems (Bronx FUSE) Initiative, which helps communities identify and engage super utilizers of public systems and place them into supportive housing to break the cycle of repeated use of costly crisis health services, shelters, and the criminal justice system. This grant will support the creation of a roadmap for establishing health plan and housing partnerships and cross-systems data-sharing to facilitate replication of the FUSE model across the City and State.
Deliverables will include:
• Cross-systems Roadmap for Establishing Partnerships and Sharing Data to Reduce High Medicaid Utilization. Designed for hospitals, other health care providers, health plans, housing providers, and government officials, this “how to” manual will utilize the data and operational details of the Bronx FUSE initiative to develop a framework for how other communities can create similar programs. The Roadmap will provide detailed instructions on utilizing existing Medicaid claims, electronic medical record, and Homeless Management Information Systems data to identify and understand the medical, behavioral and social needs of Medicaid high utilizers. It will also discuss the logistics of forging meaningful partnerships between health, housing and other sectors to ensure delivery of the most appropriate health and social services once individuals are housed.
• "Are You Ready" training series to design housing and health services that meet high Medicaid utilizers’ needs. As new resources to build supportive housing units become available, this series provides an opportunity to inform stakeholders about the health and social support needs of Medicaid high-utilizers that may be destined for these new units. "Are You Ready" will share best practices from the Bronx FUSE to develop and disseminate two webinar and online training modules (bi-monthly webinars for each module) for hospitals, housing providers, and other stakeholders on how to best serve the frequent utilizing Medicaid population.