At the Intersection of Health and Housing: A Case Study Through New York’s DSRIP Program

Abstract

In line with the growing interest of the medical community in addressing social determinants of health, there has been an outgrowth of collaborative projects between health and housing providers. Healthcare providers have realized that many of their highest utilizers who account for a disproportionately large proportion of hospitals’ spending are unstably housed. This has led to a variety of experimental projects and pilot programs across the nation that attempt to incorporate housing into more holistic models of healthcare.

This thesis will attempt to understand the challenges inherent to these kinds of partnerships by closely examining one such instance of health and housing integration in New York City. It does so by analyzing how the potential for collaborative housing projects has been woven into New York State’s Medicaid Delivery System Reform Incentive Payment (DSRIP) program, and how actors interested in such collaborations have navigated this program. To do so it utilizes qualitative evidence from publicly available documents and reports, as well as interviews with key stakeholders from NYC hospitals, city agencies, DSRIP Performing Provider Systems, community-based organizations, and development corporations. It analyzes this evidence by examining it through the lens of theories and concepts in organizational sociology.

The narrative of this thesis begins with the nearly coincident formations of the Bronx Health and Housing Consortium and New York’s Medicaid Redesign Team (MRT). The former has served as a resource and template for actors pursuing similar work through DSRIP, which was the culmination of reforms passed by the MRT. The avenue that DSRIP has provided for the integration of housing is its requirement that the entities designed to implement DSRIP, Performing Provider Systems (PPS), engage community-based organizations (CBO) within their network. Therefore, although this thesis explores the barriers to integrating housing with healthcare, it also by necessity explores the barriers to integrating community-based organizations more generally.

Ultimately this thesis finds that there is evidence of policy-practice decoupling in PPS engagement of CBOs. This decoupling stems from tensions along organizational and policy boundaries, as well as from the structural challenges of partnering small organizations such as CBOs with large bureaucratic organizations such as hospitals. Difficulties to integrating housing specifically fundamentally stemmed from a lack of affordable housing. The lack of guidance and infrastructure provided by the State for facilitating CBO engagement also contributes to decoupling.

However, while this thesis exposes a number of shortcomings to DSRIP’s hierarchical approach to coordination, it also finds that intermediary organizations, in this case three consortia, function well to facilitate partnerships when policy interventions fail. In sum, DSRIP provided a window of opportunity for greater community engagement and collaborations with housing providers, and associational organizations arose to facilitate that.