Beyond Housing for Health: Using Flexible Funds to Improve Maternal and Child Health

Abstract

Upstreaming Housing for Health (UHfH) was a pilot program that aimed to improve housing stability and reduce health inequities among people experiencing high-risk pregnancies and their infants. It served 50 families from 2019 to 2020. One critical component of UHfH was an innovative flexible fund, which was originally designed to address housing stability (e.g., rent arrears) but expanded its scope to address material needs that promoted family stability within the context of their housing situation (e.g., housing safety or maternal-infant health while in shelter). Seventy-six percent of families accessed flexible funds for items such as rental assistance, cribs, and breast pumps, with average financial support of $1343 (standard deviation = $625). The flexible fund is an example of a cash transfer policy. Such policies have shown to positively impact family health and well-being in the USA and internationally. Similar funding should be considered as part of future programming to reduce housing instability and homelessness.

Introduction

Homelessness and housing instability are associated with poor health, pre-term birth, low birth weight, developmental risk, and adverse childhood events [1–5]. However, stabilizing housing alone is insufficient to improve these outcomes and reduce family hardship [1, 6–8]; studies show that families need supportive financial, material, and medical supports. Upstreaming Housing for Health (UHfH) was a pilot program designed to improve health outcomes and reduce health inequities by stabilizing housing for pregnant people and their newborns in Boston, Massachusetts. One critical component of UHfH was the establishment of a novel flexible fund to ensure housing stability (e.g., rent arrears) through cash transfers. The purpose of the flexible fund was augmented during the project to address housing stability more broadly (e.g., family stability and safety). We describe the importance of flexible fund to address family material needs that bridge the gap between housing instability, family stability, and health.

Upstreaming Housing for Health

UHfH was initiated by a Medicaid accountable care organization (ACO), Community Care Cooperative (C3), which included 18 federally qualified health centers in Massachusetts. Recognizing the multigenerational health impacts of homelessness and housing insecurity, C3 partnered with the city public health department, Boston Public Health Commission (BPHC), city housing authority, Boston Housing Authority (BHA), and a legal education and technical assistance organization, MLPB (formerly known as Medical-Legal Partnership | Boston), to develop a strategy to address housing challenges among pregnant people.

The partners designed UHfH based on an existing program, Healthy Start in Housing (HSiH), established in 2011 as a partnership between BPHC and BHA to improve maternal and child health through expedited housing access. HSiH participants, who meet BHA’s criteria for homelessness, are provided priority access to city-administered housing units and intensive case management to support housing stability and parental and child health [6, 9]. As of 2020, HSiH has housed over 136 women and their families. While successful in specific ways, HSiH has faced numerous of challenges. Many referred women were ineligible following in-depth screening due to, for example, tenancy-related legal problems or not meeting the formal definition of homeless; the program was unable to stably house women before their infant was born; and program staff could not address material resource needs to support maternal and child health needs and housing stability [6, 9].

Learning from HSiH and with funding from a Massachusetts Office of the Attorney General Social Determinants of Health Partnership Grant, UHfH shifted resources upstream to address housing and social care issues leading to homelessness. UHfH strengthened the multisectoral partnership by convening stakeholders frequently and adding legal education and technical assistance. Staff from C3, BPHC, and MLPB met biweekly for interdisciplinary team meetings. Frontline staff (BPHC public health nurses and community health workers trained as public health advocates), who worked directly with clients, participated in these meetings. The partnership also created an innovative, discretionary fund to help meet families’ immediate housing- and health-related expenses (the “flexible fund”) that were identified in HSiH but which the program was unable to address. The flexible fund is the focus of this report.

Fifty pregnant C3 members who received care at one of six Boston-area health centers were eligible for UHfH during the pilot period from January 2019 through December 2020 (Table 1). The average age of pregnant people was 28.7 years; nearly equal proportions of clients were Black (46.0%) or White (48.0%). The majority of participants were Hispanic or Latinx (54.0%) and spoke English (52.0%). Seventy-four percent of pregnant people had full-term births; 10% experienced pre-term birth; 4% miscarried. The remainder were still pregnant and/or were no longer C3 patients when the pilot ended (12.0%).

Table 1.

Characteristics of participants enrolled in UHfH (n = 50)

	Percent	Number	Mean	sd
Participant characteristics
Age		50	28.7	6.9
Race
Black, African American, or Cape Verdean	46.0	23
White	48.0	24
Other	4.0	2
Unknown	2.0	1
Ethnicity
Hispanic or Latinx	54.0	27
Not Hispanic or Latinx	42.0	21
Unknown	8.0	2
Language
English	52.0	26
Spanish	40.0	20
Cape Verdean Creole	8.0	4
Characteristics at enrollment
Housing status
Housing unstable	76.0	38
Homeless	24.0	12
Pregnancy status/gestation of Baby
Full term birth	74.0	37
Pre-term birth	10.0	5
Miscarried	4.0	2
Still pregnant at end of program or no longer C3 member	12.0	6
Program characteristics
Received flexible funds	76.0	38

sd standard deviation

Methods

We conducted semi-structured in-depth interviews with staff from each partnering organization and triangulated interview data with internal program documentation and email communications among senior staff to gain insight into the program’s components. We also conducted interviews with program participants who spoke English or Spanish. Interviews were conducted by phone or through secure virtual platform and were audio-recorded and transcribed. Initial themes were identified collaboratively and coded independently by two investigators (MLS and FP). Discrepancies were resolved through consensus. Agreement was 98.5%. The Institutional Review Board at Boston Medical Center approved this study.

Results

We conducted 20 interviews with personnel from the partnering organizations: C3 (n = 3), BHA (n = 4), BPHC (n = 11, seven frontline personnel and four senior managements), and MLPB (n = 2). All frontline personnel were female. Three program participants agreed to interviews. Interviews with staff were an average of 50 min long and were an average of 15 min long with clients. Interviews were conducted from November 2020 through January 2021.

The Purpose of the Flexible Fund

As one senior staff stated

The goal of this program, particularly, has been to ensure that housing is one of those determinants of health that is addressed for folks who also have complex health care needs, understanding, as we do, that having secure and stable housing is fundamental to health.

The flexible fund was originally envisioned to address this goal by providing emergency funds of approximately $1000 per family for

housing-stability related purposes including, but not limited to: 1) rent arrears; (2) security deposits; (3) first and/or last month’s rent payments; and/or 4) moving expenses (internal program documents).

Contrary to original expectations, UHfH staff found that securing and stabilizing housing required more than rent and moving expenses. Some families needed more than the allotted $1000 and others needed furniture, such as cribs or appliances, to make housing situations more appropriate for newborns. Frontline workers worked with families to identify resource needs and presented those requests for flexible funds during interdisciplinary team meetings. The evolving scope of requests led senior staff to reconsider ways in which requested items addressed housing stability. In the end, senior personnel agreed that the fund would provide funds for resources that contributed to housing stability (e.g., rent arrears), as well as items that supported family safety and stability (e.g., cribs for safe sleeping) and maternal-infant health (e.g., breast pumps), to make existing housing situations safer and more stable. However, they did not fund items that did not directly address those goals, such as clothing.

How the Fund Worked

Approved purchases and payments were made directly by program staff. For example, rent was sent directly to landlords and other items were purchased by program personnel and shipped directly to clients’ homes. Seventy-six percent of families accessed flexible funds. The average amount of funds among families who received them was $1343 (standard deviation = $625), ranging from $106–$2550. Fifty-one percent of funds addressed rent needs alone, 19.7% paid for rent and furniture and/or infant items, and the remaining 30% were used for infant and/or furniture items, including strollers, beds, and bedding, pack and plays, and bottle warmers and sterilizers.

Outcome of the Flexible Fund

Senior and frontline staffers reported that the flexible fund was key to housing stability and health. Senior staffers described it as “fairy dust” and a “magic wand.” One senior staffer reported that “fundamentally, families need more cash in order to make the math of life add up, period.” Another staffer reported that the flexible fund has “definitely met needs…It’s met needs financially. It’s helped to stabilize moms” who previously would have had to choose between paying rent or other essential costs (e.g., electricity, groceries). Staff also reported that the flexible fund was important because requests could be acted upon immediately; other programs had long waits and complex application procedures. Clients echoed these sentiments during their interviews.

The flexible fund offered an opportunity for partnering agencies to gain insight into patients’ needs that are not strictly medical or housing related but result in high costs to the healthcare system. For example, one senior staffer described a client who requested a stroller due to difficulty safely navigating her highly trafficked neighborhood with her children. A stroller would improve her ability to safely travel to appointments, including her children’s doctor; additionally, it would allow the family to engage more with their community and reduce isolation, ensuring that this affordable urban housing location could be more successful for the family. As the staffer stated.

And you could just see over and over again, how these somewhat, what I will say cheap to the healthcare system interventions, really can make a difference… They have huge… cost saving.

Discussion

UHfH aimed to address the housing needs of 50 pregnant people in Boston, Massachusetts, through a unique package of enhancements possible only through multisectoral partnership. The flexible fund was one enhancement; it was developed based on experiences in existing housing programs regarding the material resources needed for families to be housed stably and safely. The majority of pregnant people in the program received flexible funds to support housing stability.

Using flexible funding to ameliorate poverty-related disparities aligns with cash transfer policies and experiments that have occurred across the globe. Such studies show that cash transfer programs improve infant birth weights and one year survival [10], child weight, and mental health [11]; reduce parental stress and improve mental health [11]; and improve nutrition [11, 12]. There is also some evidence that educational attainment, substance use, and healthcare utilization are improved by cash transfers [11, 12]. Pilot experiments in California and New York have resulted in similar positive outcomes [13, 14]. Based on these findings, it is not surprising that UHfH’s flexible fund was so important to both clients and program staff. Despite its limitations (e.g., dollar amount per family and what items could be purchased), the flexible fund directly addressed a broad range material resource needs identified by clients as essential to promoting both housing stability and safety.

The recognition of the importance of cash transfers to meet families’ material needs as a strategy to promote overall health has gained increasing acceptance over the past several years. MassHealth, Massachusetts’ Medicaid program, received a Sect. 1115 waiver from the Centers for Medicare and Medicaid Services to address health-related social needs of enrollees, implementing a Flexible Services Program (FSP) to provide nutrition and basic housing supports [15, 16]. This program began at the same time as UHfH; results from the first year of the FSP are currently unknown. However, UHfH’s flexible fund provides important data regarding the use of cash transfers that may be relevant to policy initiatives to support housing stability at a larger scale. Based on the experience of UHfH, whose participants were Medicaid enrollees, funding nutrition and basic housing supports may not be sufficient to address the range of material resource needs that promote housing and family stability and safety among low-income families.

Our study has several limitations. We cannot, for example, report on the long-term outcomes of housing stability or health among UHfH participants. In addition, we conducted only three interviews with program participants; thus, our ability to report client perspectives is limited. Nevertheless, our findings support the need for funding arrangements to address unique material resource needs among pregnant people and their newborns in order to promote housing stability, safety, and health.

In conclusion, UHfH enhanced existing housing and health programs through a flexible fund to support housing stability and family safety. This enhancement and the opportunity to revise its original strategy through the collaborative, multisectoral partnership were essential to addressing the upstream factors related to poor health among low-income, marginalized pregnant people and their children.

Funding

This evaluation project was funded by Community Care Cooperative through a grant from the Massachusetts Attorney General’s Office. Fellowship funding (MLS) came from grant number T32HS022242 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this document’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this product as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors have any affiliation or financial involvement that conflicts with the material presented in this product.