TIPs Research Report 2021

TIPs Research Report 2021 communityopportunityfund.org

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Community Opportunity Fund TIPs Research Report 2021

Telehealth Intervention Programs (TIPs) Final Report Table of Contents Executive Summary 5 1. Introduction 9 2. TIPs Overview 11 3. Impact of COVID-19 15 4. Wrap Around Services Summary

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5. Resident Anecdotes 25 6. Financial Sustainability 29 7. PAM Survey Summary 31 8. Analysis 35 9. Conclusion and Future Plans

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Appendix Exhibit 1. 48 Appendix Exhibit 2. 49

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Community Opportunity Fund TIPs Research Report 2021

Executive Summary Community Opportunity Fund (COF) was awarded a contract through the Fannie Mae Sustainable Communities Innovation Challenge: Healthy Affordable Housing in May 2019 to deliver the Telehealth Intervention Programs (TIPs) at Grace West Manor, Newark, New Jersey, a 429-unit Section 8 senior and family property.

Fannie Mae’s Sustainable Communities Innovation Challenge collaborates across sectors to support innovative projects that are tackling the challenges of delivering stable, healthy, and affordable housing.

TIPs is a multi-award-winning, affinity and congregate setting, multi-disciplinary, intergenerational, high-tech/high-touch, remote patient monitoring program enhanced with wraparound social services programs targeting low-income, high health risk, underserved communities.

This report sets out the progress made during the course of the 2-year Fannie Mae contract, with key results and achievements.

PROGRAM DESCRIPTION

The TIPs Classic model was based on a congregate setting program. In-person sessions were held twice-weekly on site, in the Grace West Senior Community Room and in the Community Center that serves the Townhomes.

After a successful pre-launch awareness and marketing campaign and detailed consultation with resident groups, TIPs was launched in September 2019. The program was extremely popular with residents, and the target of 200 enrollees which had been set for the entire 2-year program was achieved within a few months. The telehealth screenings were supported and enhanced by multiple health-related social programs.

Executive Summary

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IMPACT OF COVID-19

The COVID-19 pandemic fundamentally altered the delivery of the project. Our model was predicated upon a congregate setting with vitals screenings and wrap around social services being delivered to groups of residents. Many of the participants in the program are elderly and/or suffer from multiple chronic conditions and therefore fall into the highest risk categories for COVID-19. The TIPs Classic model was suspended on March 11, 2020.

Our service pivoted through multiple variations of the TIPs Classic model in response to the changing COVID conditions through 2020 and 2021. The following models were all implemented: •

TIPs in Touch – telephone wellness checks

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TIPs Classic Outdoors – outdoor, face-to-face vital signs screenings in accordance with strict COVID protocols when COVID conditions allowed.

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TIPs at Home – in-home vital signs monitoring equipment provided and readings collected by phone.

COVID-19 VACCINE CLINICS AND ANALYSIS

Jonathan Rose Companies (JRCo) ran multiple COVID vaccine clinics through the CDC Pharmacy Partnership program during the early part of 2020 at Grace West and other properties in their portfolio.

We analyzed participation rates at Grace West and compared rates for those enrolled in the telehealth program and those not enrolled in the telehealth program. The vaccine rate for TIPs participants at Grace West was 68%, compared to 30% for non-TIPs participants.

We also analyzed the participation rates in vaccination clinics across the JRCo portfolio and explored whether the presence of a Resident Services Coordinator (RSC) relates to vaccine take-up rates.

The presence of an RSC was associated with a 6.5 percentage points increase in vaccine rates.

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Community Opportunity Fund TIPs Research Report 2021

WRAP AROUND SERVICES

The provision of health-related wrap around services has always been foundational to the successful implementation of the TIPs program. The overarching goal of the program has been to build a holistic culture of health at Grace West.

Wrap around services were co-created with residents to meet their needs and wants.

During the pandemic, the wrap around services focused on food security, maintaining telephone contact with residents and ensuring medical needs were met.

The positive impact on residents’ lives can be seen in multiple resident anecdotes in the report.

FINANCIAL SUSTAINABILITY

Efforts to establish a route to financial sustainability have been difficult to achieve due to the suspension of the program for much of the pandemic period. Much has been learnt about the criteria required for reimbursement. A TIPs at Home Tech Pilot is now proposed for the forthcoming year. This should provide insight into the process of Centers for Medicare and Medicaid Services (CMS) billing and reimbursement.

ANALYSIS OF HEALTH IMPACTS

In addition to multiple anecdotal reports where TIPs participants reported improvements in health, we also evaluated changes in health care usage, self-reported health, and potential cost-savings stemming from the change in health care usage. For health care usage, there was little evidence of a change in hospital visits, but a considerable decrease in readmissions to the hospital within 30 days. This change persisted over the course of our intervention. For self-reported health, we saw sizable improvements for TIPs participants in their physical and mental health. The emergence of COVID-19 likely had an influence on these outcomes. In terms of cost effectiveness, we calculate that TIPs provided a savings in total health care expenses of $26,388, which amounts to 16 percent of the total costs from delivering TIPs. Since health care usage only reflects one component of health, this estimate likely understates the total benefits; the improvements in self-reported health, COVID vaccine take-up, and other unmeasured outcomes also likely contributed to cost savings.

Executive Summary

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Community Opportunity Fund TIPs Research Report 2021

1. Introduction Community Opportunity Fund (COF) was awarded a contract through the Fannie Mae Sustainable Communities Innovation Challenge: Healthy Affordable Housing in May 2019 to deliver the Telehealth Intervention Programs (TIPs) at Grace West Manor, Newark, New Jersey, a 429-unit Section 8 senior and family property.

Fannie Mae’s Sustainable Communities Innovation Challenge collaborates across sectors to support innovative projects that are tackling the challenges of delivering stable, healthy, affordable housing.

In underserved communities, affordable housing and health outcomes of residents are inextricably linked. This project brings telehealth and health-related wrap around programming into an affordable housing setting, aiming to help residents manage chronic health conditions, improve general health and wellbeing and helping to build a culture of health in the community. The TIPs program aims to analyze whether preventative health care services at a large affordable housing community can improve the health and wellbeing of residents and reduce health care costs.

The project aims to leverage telehealth services to improve health outcomes for the residents of Grace West Manor in Newark, NJ. It addresses the deep health and racial inequities that exist in our country.

People of color face higher rates of diabetes, obesity, stroke, heart disease and cancer than do whites.

Grace West is a community of color, with approximately 87% of residents identifying as Black or African American. The telehealth program is a critical component of the racial and health equity work being carried out at Grace West. The program is, by design, a social justice program with wrap around services being coproduced with residents. The telehealth program offers residents a voice in their own health.

1. Introduction

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2. TIPs Overview 2.1 PROGRAM DESCRIPTION

TIPs is a multi-award-winning, affinity and congregate setting, multi-disciplinary, intergenerational, high-tech/high-touch, remote patient monitoring program enhanced with wraparound social services programs targeting low-income, high health risk, underserved communities.

Using on-site telehealth equipment, Telehealth Technician Assistants (TTA’s) check vital signs, ask behavioral health status questions that are predictive of hospitalization and/or counsel participants and caregivers on available assistance. Telehealth equipment includes HIPAA-compliant Bluetooth blood pressure, blood oxygen, and weight scale connected to Wi-Fi. Information transmits to an electronic database dashboard, which a Registered Nurse reviews and uses to provide follow-up to the participant, primary care physician, and/or caregiver. Social programming, co-produced with residents, is delivered on-site to support and enhance the telehealth services.

The TIPs model has proven that cost-efficient, long-term weekly remote patient monitoring (RPM) of basic vital signs and behavioral health status, along with “wraparound” social services is an early warning preventive strategy enabling participants to remain in community, significantly improve individual and community health, prevent hospitalization/ER incidents, and reduce individual and health system costs.

2.2 PARTNERSHIP

Community Opportunity Fund partnered with The Westchester Public/Private Membership Fund for Aging Services (WPPP) and Jonathan Rose Companies to launch Telehealth Intervention Programs (TIPs) at Grace West. Our project team also includes Professor Matthew Neidell from the Columbia University Mailman School of Public Health, whose role is to analyze the data and draw conclusions on cost savings in the health care system as a result of the preventative care being delivered through TIPs.

2. TIPs Overview

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2.3 GRACE WEST MANOR - PROPERTY PROFILE

In June 2013, the Rose New Jersey Green Affordable Housing Preservation Fund acquired Grace West Manor, a 429-unit, affordable Section 8 property in Newark, New Jersey.

The property consists of a 12-story senior tower with 325 units, and family townhomes with 104 units.

Grace West benefits from a long-term project-based Section 8 Housing Assistance Payment (HAP) contract. 100% of units are reserved for households earning below 50% of Area Medium Income. Between 2013 and 2018 approximately $4M of upgrades were undertaken, including modernized elevators in the senior tower, new energy-efficient boilers in the townhomes and a new community center. In October 2018 the property was refinanced using Low Income Housing Tax Credits, enabling further capital improvements.

Physical improvements included upgrades to resident units as well as community spaces. The Community Room with the senior tower was modernized, and an all-season room was added to the senior tower community room to increase useable space and create a cohesive flow between the indoor and outdoor community areas. A fitness room and a consultation room were also added to the senior tower. These additional community spaces are part of Rose’s mission to build a culture of health at all Rose properties. The consultation space has been used for health screenings and benefits consultations.

Grace West benefits from two full-time Resident Service Coordinators (RSCs), one working primarily with seniors, and the other focused on the families and youth. The RSCs work with residents and community partners to coordinate programs and events, make referrals, and support resident wellbeing through case management. The rapport built between the RSC’s and Grace West residents was pivotal in the successful recruitment for and launch of the TIPs program.

In addition to two full time service coordinators previously in place prior to the launch of TIPs, an additional part-time service coordinator, specifically dedicated to the TIPs program, was hired in July 2019. This RSC assisted with recruitment of participants, raising awareness, and generating excitement about the Telehealth program. Upon the launch of screenings in September 2019, she also worked with community partners to coordinate wrap around services, continued to build rapport with residents to ensure their regular participation in the program, and is essential to the continued recruitment of new participants and in supporting and coordinating many aspects of the TIPs program.

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2. TIPs Overview

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3. Impact of COVID-19 The emergence of COVID-19 had a significant impact on the program. We had to alter our delivery model many times in response to the changing COVID conditions. Set out below is a summary of the impact of COVID on the program and the way it was delivered.

3.1 TIPS CLASSIC

After a successful pre-launch awareness and marketing campaign and detailed consultation with resident groups, we launched the TIPs program in September of 2019. The program was extremely popular with residents, and we quickly achieved the target of 200 enrollees which had been set for the entire 2-year program. The telehealth screenings were supported and enhanced by multiple health-related social programs which gathered residents for activities such as eyesight and hearing screenings, chronic disease management classes, walking clubs, Zumba classes and more.

The classic TIPs model was based on a congregate setting program. In-person sessions were held twice-weekly on site, in the Grace West Senior Community Room and in the Community Center that serves the Townhomes.

The COVID-19 pandemic altered the project in some fundamental ways. Our model was predicated upon a congregate setting with vitals screenings and wrap around social services being delivered to groups of residents. Many of the participants in the program are both elderly and/or suffer from multiple chronic conditions and therefore fall into the highest risk categories for COVID-19. We took the difficult decision to suspend what we now call the “TIPs Classic” program on March 11, 2020.

3. Impact of COVID-19

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3.2 TIPS IN TOUCH

Within 2 weeks of the suspension of the program, we had implemented a “TIPs in Touch” telephone screening service, whereby our Telehealth Technician Assistants (TTAs) used enrollee lists to call all participants in the program. They asked standard behavioral health status questions that were in use as part of the telehealth screenings pre-COVID to check on residents’ general health and to enable us to continue to collect consistent data.

The system used responses to these questions to trigger health alerts, which were followed up by the remote nurse. Additionally, the social services wrap around programming shifted away from group programming and took the form of telephone wellness checks and ensuring consistent delivery of essential food and medical supplies to residents.

3.3 TIPS CLASSIC OUTDOORS

During a late summer window of opportunity when COVID cases in the region were dipping and the weather was agreeable, we launched a COVID-compliant TIPs Classic Outdoors service, in addition to the TIPs in Touch telephone wellness checks.

Through a carefully scheduled appointment system and strict COVID protocols, we were able to resume in-person vital signs readings in an outdoor setting, which minimized COVID transmission risks. These ended in October 2020 when a second wave of COVID infections began to materialize across the country.

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3.4 TIPS AT HOME

Even during the TIPs Outdoors period, we were planning for a return to lockdown conditions, when we would not be able to hold in person sessions. With the agreement of Fannie Mae, we diverted funds within the contract towards the purchase of in-home vital signs monitoring equipment to enable residents to continue to manage their health from home. We knew this was important to residents, not just to collect vital readings but also to help counteract the social isolation and boredom that lockdowns brought with them.

By mid-November 2020, we had begun a phased rollout of in-home monitoring devices to a total of 60 enrollees. Residents were then able to collect their own vital readings as frequently as they wanted to and reported them to the TTAs during their weekly TIPs in Touch calls.

3.5 RETURN TO TIPS OUTDOORS AND TIPS CLASSIC

In April 2021, with lower COVID transmission rates and a return to warmer weather, we restarted the TIPs Outdoors program, offering face-to-face screenings for the first time since the Fall. In-person wrap around services have also begun to take place. As restrictions around the country relax, and vaccination rates increase, we plan to move back to our TIPs Classic model and recommence screenings and group wrap around services, making use of the community facilities at Grace West.

3.6 GENERAL IMPACT OF COVID-19

The COVID pandemic has underscored the overwhelming pattern of inequality and racial health disparities that exist in our country. It has called attention to the long-standing inequalities that pervade the health care system and society at large. We see these gaps as having potentially widened during COVID, making this program even more vital for residents.

3. Impact of COVID-19

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With the easing of COVID restrictions, we will be reviving resident focus groups to learn more about the impact of the pandemic. We intend to re-engage with residents in the co-production of the remainder of the program. Their leadership and their role as ambassadors are an important ingredient for the success of the program.

COVID has also significantly affected our ability to collect consistent data from the program and has affected the economic analysis that evaluates the impact of TIPS on health outcomes and usage.

3.7 COVID-19 VACCINE CLINICS AND ANALYSIS

Although the spread of COVID and the ensuing lockdowns led to a halt in the delivery of services, it also created a new opportunity to explore how our program may have influenced vaccine take-up. The race to vaccinate against SAR-Cov-2 is essential for halting the spread of COVID-19.

Jonathan Rose Companies successfully applied to be part of the CDC’s Pharmacy Partnership Program which delivered vaccines initially to elderly and vulnerable sections of the population, at a time when vaccines were very scarce. RSCs at Grace West worked in partnership with Walgreens to provide on-site COVID-19 vaccine clinics in January and February 2021. 175 Grace West residents were vaccinated as part of this program.

Despite the availability now of multiple, effective vaccines, hesitancy is a major hurdle for reaching socially desirable levels of immunity. The hesitancy is particularly notable for African Americans, who not only suffer disproportionately from COVID but also indicate a lower willingness to obtain a vaccine. Lack of trust, stemming from centuries of historical maltreatment, is a major reason for this.

Access to “trusted messengers” who deliver clear, transparent messages regarding vaccine safety, effectiveness and availability may help increase take-up for this group. Other studies have suggested that religious leaders and other community leaders can serve as trusted messengers for increasing vaccine take-up. We believe that the frequent interactions with residents suggest that the involvement in TIPs, especially with the presence of an RSC, may serve as another venue for creating a trusted messenger.

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Community Opportunity Fund TIPs Research Report 2021

To assess this, we proceeded in two steps. First, we compared the mean vaccination rate of TIPs participants to non-TIPs participants at Grace West. Three COVID-19 Vaccination Clinics were held at the senior tower at GW in January and February 2021 as part of the CDC’s Pharmacy Partnership Program. The vaccine rate for TIPs participants at GW was 68%, compared to 30% for non-TIPs participants. When we later surveyed 31 TIPs participants about vaccination beliefs, 52% indicated that participation was helpful in that decision.

Second, to explore whether these results may hold more generally, we explored whether the presence of an RSC relates to vaccine take-up rates. We gathered data on vaccine rates, presence of an RSC, and demographic characteristics of the residents from 47 properties managed by JRCo (including GW), all of which ran three COVID-19 vaccine clinics through the CDC’s Pharmacy Partnership Program as well. We performed a multivariate linear regression of vaccine rates on an indicator for RSC presence, adjusting for demographics, with results shown in Appendix Exhibit 1.

Summary statistics indicate that approximately 51% of the 10,219 residents across all properties had been vaccinated. 51% of the properties had an RSC present. The regression analysis indicates the presence of an RSC was associated with a 6.5 percentage points increase in vaccine rates. We found higher vaccine rates for older populations (41.6 percentage point increase), consistent with vaccine rollout policy, and lower vaccine rates for African Americans (10.7 percentage point decrease).

We recognize important limitations in this analysis. As an observational analysis, confounding is a possibility. Participation in TIPs is voluntary, opening the possibility of selection bias whereby factors correlated with TIPs participation may explain the difference in take-up. Similarly, despite the inclusion of several control variables, properties with an RSC may differ along other, unobserved dimensions that explain the higher vaccine take-up rate.

Nonetheless, given the timeliness of the issue and the need to act on limited knowledge, our study suggests that connections formed through place of residence may aid in creating trusted messengers who encourage vaccine take-up, further supporting the notion that trusted messengers is one strategy for increasing vaccine uptake to improve public health and the fight against COVID.

3. Impact of COVID-19

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4. Wrap Around Services Summary The TIPs team has always considered wrap around services to be foundational to the successful implementation of the TIPs program. The overarching goal of the program has been to build a holistic culture of health with our residents, and to do that we had to first understand the health status of the participants.

As TIPs launched, data was gathered during intake indicating that most participants were managing multiple chronic health conditions, such as COPD, diabetes, asthma, etc. With this in mind, education around the management of chronic health conditions was an important first step in setting the stage to build a culture of health. The on-site Resident Services Coordinators engaged with Essex County Division of Senior Services and the NJ Division of Aging Services to run a six-week workshop series called “Take Control of Your Health”, aimed at managing chronic health conditions. Also, as a result of the intake data, the RSCs partnered with a local hospital used by many Grace West residents to run a diabetes education workshop.

The team also discovered two unexpected challenges for participants as a result of the program intake process. First, it was observed that many of the residents were squinting or having trouble reading the intake form, even when wearing their glasses. Free vision screenings were organized by the RSCs at the same time as the telehealth screenings were taking place, to give residents updated prescriptions and advice. The second unanticipated barrier to the program was that many residents did not have working phones or phone numbers. Because telephone follow up from the nurse is an important part of the TIPs program, lack of phone access was a significant barrier to health. To address this, the on-site Resident Services Coordinators partnered with Assurance Wireless to sign participants up with free phones. This service benefitted both the townhome families and the seniors.

Additional programming to build a culture of health at Grace West included nutrition programs to promote healthy eating and Zumba classes to promote movement. Fitbits were also distributed to a sample of participants to track steps taken and further motivate participants to include movement in their daily lives.

In March 2020, TIPs had to pause its in-person programming due to the COVID-19 pandemic. The team had to reimagine ways to monitor and support participants in their health without being able to physically see them. Resident Services Coordinators (RSCs) and Telehealth Technician Assistants (TTAs) began contacting participants by phone to ask the five standard telehealth screening questions that had traditionally been asked at the start of each health screening. By doing this, resident well-being could be monitored, and the telehealth nurse would be able to follow up with residents to provide support and advice. Later, in a pivot to address the new challenges posed by COVID 19, the TIPs team began a pilot of “TIPs at Home.” With this program, a subset of 60 participants was provided with a blood pressure machine and a pulse oximeter that they can keep in their apartment. TTAs continued to call residents and ask not only the five screening questions, but also the vital sign readings participants were taking on their devices. With this new model, the team had a better understanding of participants’ health at home. Additionally, these readings were able to be entered into the telehealth system, to gather data and trigger alerts for the remote nurse to follow up on, thereby ensuring that residents were getting the health support and advice they needed.

4. Wrap Around Services Summary

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An important aspect of well-being is social connectedness. During this challenging time, on-site staff has worked to ensure that residents feel connected and supported. With isolation necessary due to COVID, community-wide activities were planned that allow residents to have a sense of community while still maintaining distance. A property-wide door decorating contest was hosted, and for the Thanksgiving Holiday, the RSCs organized a “gratitude” tree. Residents were given leaves on which they could write what they are grateful for. They dropped them off in the RSC office so they could be added to the tree in the lobby. Residents were able to view what their neighbors were grateful for. In addition to activities designed to decrease social isolation, RSCs have also been working with community partners to distribute food to children, families, and seniors.

On-site RSCs supported children and families in the shift to remote learning by providing homework help over video chat and coordinating with school districts to ensure that all Grace West students had access to remote learning devices. RSCs also assisted families in finding childcare so parents could continue to work.

As highlighted above, in January of 2021, the Rose Social Impact team was able to coordinate COVID-19 vaccination clinics for Grace West Manor and other Rose properties.

With a successful rollout of vaccinations, and parts of the country beginning to reopen, the team has once again implemented outdoor TIPs sessions, and has been incorporating wrap around services such as gardening, Occupational Therapy consults, and vision screenings.

Looking forward, the team is focused on helping participants with emerging needs that have developed over the past year of COVID-related lockdowns and other restrictions, such as decreased mobility and poor nutrition. Wrap around services will focus on behavioral health and social connection to address the emotional impact of the pandemic and will be co-produced with residents. To address physical health, the team is focused on mobility, nutrition, and exercise.

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4. Wrap Around Services Summary

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5. Resident Anecdotes The impact of the telehealth program on peoples’ lives can clearly be seen when looking at resident case studies and anecdotes. A selection of resident stories is set out below.

Ms. W (60s, female, African American) •

Ms. W shared with the RSC that she learned from the nurse that dehydration can impact blood pressure, and when her BP is high, the nurse has suggested she drinks more water.

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Ms. W “loves” the nurse and closely follows her advice.

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She also spoke about how the program can create a sense of community because it sparks conversation about health amongst friends that they might not otherwise be having.

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She mentioned the friendly competition she and her friends in the program engage in, which encourages them all to have better habits and talk about their health.

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Ms. W reports continued weight loss toward a healthier weight with improvements in her diet and movement.

Ms. H (60s, female, African American) •

Ms. H. spoke about how the TIPs program can help you age in place, as it can be an early warning sign for health issues that, if left unchecked, could potentially lead to the need for a higher level of care.

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The program is a great reminder to take medication - the nurse’s advice is helpful in controlling high blood pressure.

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She also discussed how the program can help you “take control of your health” which can lead you to taking control of other areas of your life and forming better habits.

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Ms. H spoke about how it can make you want to “stay home where you have control” and about the importance of being independent as you age.

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Ms. H participated in the COVID-19 vaccinated clinic that was held at Grace West and is fully vaccinated.

5. Resident Anecdotes

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Mr. A (Early 60s, male, Hispanic) •

“Helps me to do something about my weight”.

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He has been exercising more regularly (utilizing the Grace West gym) thanks to TIPs.

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Mr. A has lost 7 lbs. since beginning the TIPs program.

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He also shared that he always takes his TIPs sheet with his vital readings on it to his doctor’s appointments so that he and his PCP can have a fuller discussion about his health.

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Mr. A participated in the COVID-19 vaccinated clinic that was held at Grace West and is fully vaccinated.

Ms. R (60s, female, African American) •

“Telehealth has made me mindful of watching my weight and I have been eating more fruits and veggies and healthier foods.”

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“The nurse will follow up with me to address any concerns, and then I can bring it up with my personal doctors. It’s like having a second eye on my health.”

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She has lost weight and been exercising more thanks to the program.

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Ms. R participated in the COVID-19 vaccinated clinic that was held at Grace West and is fully vaccinated.

Ms. M (70s, female, African American) •

Says TIPs has helped foster a sense of community in that people get to know one another and can look out for each other more.

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As an example, she shared that when they were all down in the Community room as a group, they noticed that one of the residents did not look well. He ended up needing an ambulance called, which people might not have realized.

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Also says that seniors don’t always go to the doctor as much as they should and having a regular screening right in the building is convenient and helps people.

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Ms. M participated in the COVID-19 vaccinated clinic that was held at Grace West and is fully vaccinated.

Ms. B (70s, female, African American)

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Nurse checkups help her improve her habits to monitor and treat her high blood pressure.

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Ms. B participated in the COVID-19 vaccination clinic that was held at Grace West and is fully vaccinated.

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Currently, she is a consistent participant in the TIPs at Home program. She received her own equipment and checks in weekly with the TTA over the phone and follows the nurse’s advice on any alerts.

Community Opportunity Fund TIPs Research Report 2021

Mr. G (67, male, African American, male) •

Manages diabetes, hypertension, and asthma.

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Original member of TIPs Classic and one of the 60 residents with in-home monitoring devices through TIPs at Home.

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He checks his BP and Pulse Ox every day. He wasn’t feeling well on a weekend and decided to check his BP and Ox levels. Ox level was low. He called an ambulance and was taken to ER. The Dr. told him that having the pulse ox reader at home saved his life. The resident came and personally thanked the TIPs staff.

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He participated in the COVID vaccine clinic and had vision screenings as part of the original wraparound services.

Ms. M (66, female, African American) •

Manages COPD, Coronary Artery Disease, and has suffered a stroke.

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Original member of TIPs Classic and one of the 60 residents with in-home monitoring devices through TIPs at Home

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Received a Fitbit through the TIPs program and has walked over 1 million steps.

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She completed nutrition classes and Chronic Disease Self-Management classes through the TIPs wraparound programs.

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She joined the Zumba classes, that were also part of the wrap-around programming.

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Since enrolling in TIPs, the resident reports that she is more mindful of her health, has started to walk more and now always takes part in educational and health-related programs offered at Grace West.

Ms. S (50’s, female, African American) •

Ms. S in an active participant in telehealth.

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During the first few sessions she participated in, her high blood pressure was generating alerts through the telehealth program. Recently, it has been more under control which she attributes to these regular readings.

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Although she works, she always tries to come to the in-person sessions.

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She has a Fitbit which she shares is very helpful in increasing her physical activity. She has been working to increase her daily step count.

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She was vaccinated on-site in January.

5. Resident Anecdotes

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6. Financial Sustainability Financial sustainability has been a goal of the Fannie Mae TIPs project at Grace West since its inception.

CPT codes exist that permit billing for services provided via remote patient monitoring. In theory, the codes could provide revenue to offset some of the costs of the Remote Patient Monitoring hardware and software and ongoing monitoring costs.

However, there are some challenges: • Services must be provided by a doctor or a qualified health professional.

• Individuals MUST provide 16 (or more) remote patient monitoring readings (blood pressure, pulse/ ox, and weight) within a 30-day period.

• An entity that is familiar with CMS billing codes and procedures must do the billing.

For the past two years, we have explored these options. We have learned a great deal about what could work, and what will not work. The opportunity is there, but there are some definite challenges, which are outlined below: Challenges: • Remote patient monitoring readings in a congregate setting, once or twice a week (i.e. – our “TIPs Classic” model), are not currently eligible for reimbursement. This model would NOT yield the requisite 16 times per month number of readings (individuals typically show up once or perhaps twice each week).

• And TIPs in a congregate setting is NOT set up for a doctor’s supervision. The individuals who participate in TIPs do not all have the same primary care physician.

There are, however, potential opportunities in continuing to explore the potential for finding a reimbursable model for telehealth through a TIPs at Home Tech pilot. Such a pilot would involve providing a subset of telehealth enrollees with a full suite of Bluetooth enabled vital monitoring devices, as well as a tablet for transmitting readings. We would use the pilot to test the reimbursement potential of a version of the TIPs program.

We expect that a TIPs at Home Tech pilot will yield a great deal of information, and some revenue, that can be used to partially offset the cost of the TIPs program at Grace West.

6. Financial Sustainability Report

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7. PAM Survey Summary Patient Activation Measure (PAM) surveys have been conducted periodically between November 2019 through April 2021 with participants in the TIPs program at Grace West Manor and Townhomes. The Patient Activation Measure (PAM) is a well validated instrument measuring health-related confidence, engagement, behaviors, and lifestyle used extensively to establish baseline health engagement and change over time and circumstance.

PAM was initiated in November 2019 with monthly measures taken through March 2020 with quarterly follow-up anticipated. At that point, the COVID-19 crisis imposed serious disruption in both program vital signs monitoring for all 200+ enrolled participants in the program and PAM data gathering for those participating in this measure. PAM surveys were re-established on a limited basis in March 2021.

The program “pivots” in services from “TIP Classic” with congregate group services, to “TIPs in Touch” telephone-based services without vital signs monitoring at the outset of COVID-19 restrictions, to “TIPs at Home” with limited participation to selected elderly high-risk participants, was instrumental in maintaining health related activities and services during this time.

The following sections present a summary of two measures of the overall effects of the program, particularly on the four levels of patient activation which the PAM survey measures (Level 1: Disengaged and Overwhelmed; 2: Aware but Struggling; 3: Taking Action/Gaining Control; 4: Maintaining Behaviors and Progress). The overall results include general trends and changes in levels of PAM scores among residents who were consistently participating in the program from initiation through April 2021 and who had completed at least two PAM surveys during that time. The sample included (n=49) is smaller than the number of participants in the program but offers a reasonable framework for assessing the program effects on participant health activation.

7. PAM Survey Report

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I. TRENDS

This section presents the overall comparison of PAM baseline results at implementation through contract completion and reflects changes in the initial levels of patient activation with those of the most recent levels.

There has been a noticeable increase in the number of participants in Level 3 (D= +6) and comparable decrease in Level 2 (D= -7). While there is also no significant difference in the baseline average PAM score (58.8) with the program final average score (58.5), individual changes within levels does indicate a relatively dramatic increase in this higher level of health activation.

II. CHANGE WITHIN LEVELS

There is continued observational evidence that the circumstances of the COVID-19 crisis have continued to impact specific items measuring health confidence and behaviors, especially with concerns related to items such as, “I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising.”, “I know how to prevent problems with my health.”, and “I am confident that I can figure out solutions when new problems arise with my health.”, and additionally in more recent surveys , “I am confident that I can maintain lifestyle changes, like eating right and exercising, even during times of stress.” attesting to the impact of Covid 19 stresses and uncertainties on health issues.

The changes within levels observed further illustrates the generally positive effects pattern from participation in the TIPs program, despite the stresses imposed by COVID-19 restrictions on social interaction with friends and family, reduced access to services, and uncertainties about vulnerability and transmission. Noticeable gain scores for Level 1 and Level 2, in this case the average score gains are +6.44 (14%) and +9.65 (19%) respectively with 80% of the group experiencing improved scores. The declines among Level 3 (-11.5%) and Level 4 (-18.3%) are also notable in view of the general stability expected for those groups. While many aspects of the interaction within and between the intervention and health activation scores remain to be examined in depth, there are certainly clear and consistent indicators suggesting considerable improvement in participants embracing a more active role in their health behaviors and attitudes through participation in the telehealth program.

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Community Opportunity Fund TIPs Research Report 2021

7. PAM Survey Report

33

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Community Opportunity Fund TIPs Research Report 2021

8. Analysis In this section, we provide the details and results of our analysis of the impact of TIPs on participants’ outcomes. After providing background information about TIPs enrollees, we provide evidence of the impacts on health care usage and self-reported health, followed by a cost-effectiveness analysis. We performed these analyses at three stages: February, 2020, November, 2020, and May, 2021.

8.1 SUMMARY STATISTICS

Details about the number of participants enrolled in TIPs over time, separately for the senior tower (Grace West Manor) and the townhomes, are displayed in Exhibit 1. Enrollment grew steadily during the first few months when the program began, and then began to plateau by the end of 2019. After the interruptions caused by COVID-19, enrollment remained flat for over a year. This is not surprising since during COVID we concentrated efforts on delivering services to existing enrollees, rather than on recruiting more participants. Enrollment picked up again once we resumed outdoor, in-person sessions, through natural means as a result of carrying out readings outdoors, in the middle of the Grace West campus. It is important to note that not all of the enrolled participants were consistently active with TIPs the entire time. By the end of May 2021, 51 participants from the Manor were considered inactive and 20 from the Townhomes. Inactivity could be due to several factors, such as relocating to another residence or loss of interest in the program.

During April and May 2021, individuals who had become inactive in the TIPs program were surveyed. We were interested in better understanding why they had become inactive, and what factors might cause them to return. 32 individuals were interviewed by phone. Of the 32 individuals who were interviewed, 28 (88%) said that they had found the TIPs program to be somewhat or very helpful. As well, 28 (88%) individuals said that they were somewhat or extremely satisfied with the program. When queried about why they had become inactive in TIPs, 18 (56%) individuals cited Covid-19, and 16 (50%) said that they preferred meeting in person (which was no longer possible during the pandemic). When asked if they planned to return to TIPs once the program restarted, 19 (59%) individuals said yes. Those who said that they were not planning to return to TIPs offered an array of reasons, including wishing that the program could be offered on different days or times, that the program would offer more gifts and raffles, that they might like to have reminders about when to attend, that they would prefer to have TIPs in their homes, and that they would return when/if TIPs was once again offered as a group activity.

8. Analysis

35

Exhibit 1: TIPs Enrollment over Time

180 160 140 120 100 80 60 40 20

Grace West Manor

1 /2

02

1 31 5/

31

/2

02

20 1/

11

/3

1/

20

20

20

0

1/

10

/3

/2

02

0 31 8/

/2

02

0 5/

31

/2

02

0 26 4/

/2

02

0 29 2/

1/

31

/2

02

19 20 0/

/3 11

9/

30

/2

01

9

0

Townhomes

Notes: The first solid, vertical line indicates when in-person sessions ceased due to COVID restrictions. The second solid, vertical line indicates when in-person sessions resumed.

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Community Opportunity Fund TIPs Research Report 2021

Characteristics of the people enrolled as of May 31, 2021, are displayed in Exhibit 2. Participants from the Manor have an average age of 66, compared to an average age of 40 for Townhome participants, consistent with the age requirements for each site. Over two-thirds of the participants from the Manor are on Medicaid, a government insurance program for low-income adults. At the Townhomes, roughly half of the participants receive Medicaid. The lower rate at the Townhomes probably reflects that these residents are more likely to be working, making them ineligible for Medicaid. Most participants in the program are female (61.6% for the Manor and 73.8% for the Townhomes), likely reflecting high life expectancy for female seniors and increased caregiving responsibilities for females.

Exhibit 2. Characteristics of Enrolled Participants Site Number Enrolled Age (average)

Grace West Manor 159

Townhomes

Total 65

224

66

40

53

68.6% (109)

49.2% (32)

62.9% (141)

Female (%, N)

61.6% (98)

73.8% (48)

65.2% (146)

Hospitalized Prior 12

20.1% (32)

6.2% (4)

16.1% (36)

9.4% (3)

0% (0)

8.3% (3)

53.5% (85)

87.7% (57)

63.4% (142)

Medicaid (%, N)

Months (%, N) Re-hospitalized 30 Days Prior 12 Months (%, N) Chronic Conditions 0 1

17.6% (28)

7.7% (5)

14.7% (33)

2 or more

28.9% (46)

4.6% (3)

21.9% (49)

Notes: Data collected on participants through 5/31/2021. Chronic conditions consist of Hypertension, diabetes, and COPD.

Consistent with their older age, enrollees from the Manor have poorer health status, as indicated by hospitalization rates and chronic conditions, than do enrollees from the Townhomes. Over 20 percent of enrollees from the Manor had been hospitalized during the past year (at the time of TIPs enrollment), compared to only 6.2 percent for the Townhome residents. Nearly half of the Manor enrollees have a chronic condition, with 28.9 percent having two or more. Only 13 percent of Townhome enrollees have a chronic condition.

8. Analysis

37

8.2 ANALYSIS OF HEALTHCARE USAGE

Over the course of the TIPs program, we analyzed the change in hospitalization rates and 30-day readmissions for TIPs enrollees. During our weekly sessions, we asked participants if they had been hospitalized during the past year and readmitted to the hospital within 30 days. Since we collect these data at our initial intake survey, the first response to these questions reflects the “pre-TIPs enrollment” period.

Questions asked at later stages, after TIPs enrollment, are annualized to reflect the “post-TIPs enrollment” period. To assess the impact of TIPs, we compare the outcomes in the pre- and post-TIPs periods, with results summarized in Exhibit 3.

Exhibit 3. Hospitalizations and 30-Day Readmissions over Time Grace West Manor Feb, 2020

Townhomes

Nov, 2020

May, 2021

Feb, 2020

Nov, 2020

May, 2021

A. Hospitalizations in Past Year pre-TIPs enrollment

23%

21%

20%

6%

6%

6%

post-TIPs enrollment

45%

23%

22%

11%

6%

6%

impact of TIPs

22%

2%

2%

5%

0%

0%

B. 30-day Readmission in Past Year pre-TIPs enrollment

10%

9%

9%

0%

0%

0%

post-TIPs enrollment

2%

3%

3%

0%

0%

0%

impact of TIPs

-8%

-7%

-6%

0%

0%

0%

Notes: All data are reported in percent. Post-TIPs enrollment percent for data through February 2020 are based on estimated annualized outcomes.

For hospitalizations at Grace West, there was an estimated 22% increase in hospitalizations for Grace West residents as of February 2020 compared to the pre-TIPs period. Although the increase was at first a surprise result, it improved over the course of the program, changing to a 2% increase in both November 2020, and May, 2021. A similar trend for hospitalizations was observed for townhome residents, though at a lower scale. In February 2020, there was a 5% increase in hospitalizations. This improved to no change in November 2020, and May 2021. We interpret these results to suggest that there was no overall change in hospitalizations.

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Community Opportunity Fund TIPs Research Report 2021

For 30-day readmissions, we found a more consistent and sizable impact for Grace West residents.

The decrease in 30-day readmission rate hovered around 6-8% across the three waves, suggesting an enduring impact of TIPs on readmissions. We found no change for Townhouse residents; in fact, there were no 30-day readmissions at all for these residents.

We note that COVID hampered our ability to consistently collect data from all participants. Subjects that we were able to contact more recently were more likely to be in worse health. Those in worse health potentially have more health care encounters, biasing our analysis to finding a spurious increase in health care usage. Moreover, our conversations with Beth Israel Hospital, which most residents use when hospitalized, to verify the reliability of these self-reported data, was derailed by the pandemic.

COVID may have also changed health care encounters in at least two important ways: 1) participants may have been infected with COVID-19, thus requiring a hospitalization they may not have otherwise had; and 2) participants may have reduced their use of health care services more generally in an effort to reduce their exposure to COVID-19. The first factor biases our estimates toward a spurious increase in care due to TIPs, while the second biases our estimates toward a spurious decrease. We do not suspect that issue (1) is particularly relevant because only 1 person (out of 95 surveyed) reported having contracted COVID-19 and going to the hospital as a result. Nonetheless, the precise impacts of COVID-19 on this analysis are unknown.

8. Analysis

39

8.3 ANALYSIS OF SELF-REPORTED HEALTH

While hospital admissions are one metric of interest, they may only represent the tip of the iceberg. To assess whether TIPs impacted other health outcomes, we explored the impacts of TIPs on physical and mental health, focusing solely on the Grace West residents since their health status at the start of the project was much worse on average. To measure health status, we asked three questions, all derived from the Behavioral Risk Factor Surveillance System run by the CDC: 1. “During the past 7 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?”

2. “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 7 days was your mental health not good?”

3. “Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 7 days was your physical health not good?”

These measures were only taken after TIPs enrollment, so there is no pre-TIPs measure. We took the first and last measure for each outcome and noted the length of time between the outcomes. Results are shown in Exhibit 4.

Exhibit 4. Changes in Self-reported Health over Time Feb, 2020

Nov, 2020

May, 2021

early

late

diff

early

late

diff

early

late

diff

usual activity

0.36

0.14

-0.21

0.42

0.08

-0.34

0.40

0.07

-0.33

mental health

0.42

0.16

-0.26

0.41

0.07

-0.34

0.43

0.07

-0.36

physical health

0.49

0.09

-0.39

0.49

0.16

-0.33

0.47

0.13

-0.34

Notes: All outcomes are measured in days per week. ‘early’ reflects the first measurement of each outcome, ‘late’ reflects the last measurement, and ‘diff’ reflects the difference between the early and late measures. As of February 2020, there were 76 enrollees with an average of 8.2 weeks between measures.

As of November 2020, there were 143 enrollees, with an average of 30.5 weeks between measures. As of May 2021, there were 148 enrollees, with an average of 45.7 weeks between measures.

Measures of physical and mental health showed considerable improvements over the course of the study.

For example, in response to “the number of days physical health was not good during the past 7 days,” enrollees improved from an average of 0.49 days to 0.09 days over the 8 weeks between measurements, resulting in an improvement of 0.39 days per week. These improvements persisted over time, as shown in the results from the November 2020 and May 2021 waves.

While this trend is encouraging, it is important to keep in mind that, like the hospitalization data, this also relies on a self-report. For these data, however, there is no clear way to verify their validity.

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Community Opportunity Fund TIPs Research Report 2021

8.4 COST-EFFECTIVENESS ANALYSIS

We conducted a cost-effectiveness analysis (CEA) to succinctly summarize the cost impacts of TIPs. We calculated the annual costs of the TIPs program to Grace West residents based on internal estimates of the cost to deliver services plus any relevant line items in the JRCo budget. We monetized the changes in healthcare utilization based on the changes in outcomes measured from the healthcare usage analysis.

Any such analysis is always filled with limitations, and unique circumstances due to the COVID pandemic even further that. We outline several of these caveats below.

I. COST OF TIPS PROGRAM

To estimate the cost of TIPs, we used existing estimates for “TIPs-classic” for one full year. Since the TIPs program was interrupted due to COVID, annual numbers may overstate the full costs. The TIPs costs include the costs of a nurse, TTA, travel, hardware, software, licensing, and other administration tasks.

Given that TIPs as delivered at Grace West involved additional costs (involvement of a residential service coordinator, promotions, and other activities to recruit participants, and a security guard) not included in the TIPs classic estimate, we also included costs from the JRCo budget for these items. Exhibit 5 reflects the overall costs to deliver TIPs at Grace West.

Exhibit 5. Estimated Costs to Deliver TIPs program at GW TIPs costs to serve 50 participants (in first year)

$60,000

TIPs costs per additional 50 participants

$25,000

Number of participants at Grace West

150

Additional budget items Total costs

$59,886 $169,866

We did not include the cost of wrap-around services since some already existed absent TIPs, and many were secured at no cost. We also did not include indirect costs associated with the project team to coordinate and analyze TIPs. These costs center on establishing TIPs as a viable service and providing proof of concept. That is, these are costs that are not necessary for establishing a new TIPs program and would not be part of the calculus for assessing financial sustainability.

8. Analysis

41

II. HEALTHCARE SAVINGS FROM TIPS PROGRAM

To measure healthcare savings, we focus on 30-day hospital readmissions as our measure of healthcare utilization. This outcome improved for TIPs residents and is readily monetizable using estimates of the cost of hospitalizations. We used outcomes measured from the November 2020 wave because it reflected roughly one year of services, which corresponds with the timeframe of the cost measurements.

Exhibit 6 reflects the monetized healthcare savings from TIPs.

Exhibit 6. Estimated Monetized Healthcare Savings from TIPs at GW Reduction in 30-day hospital readmissions Hospital charge per readmission

a

Costs to charge ratiob Total healthcare savings a

2 $64,952 0.203 $26,388

Calculated from NJ State Inpatient Database from readmitted patients over 65 years of age from the ZIP

code 07108. b

Calculated from CMS files for all hospitals located in Newark.

c

The inpatient database reports hospital charges, which is the value provided on the initial bill submitted

to the insurer. Insurers pay a reduced amount based on negotiated rates. Therefore, we adjust the hospital charges above by the “cost to charge ratio” (CCR) to approximate the final costs to insurance for the health care provided.

We recognize that using changes in only this outcome reflects a partial accounting of the full range of impacts for participants because it does not monetize all of the potential benefits to participants. At least three items are not included. One, the hospital costs for readmissions do not reflect the full costs to residents, such as the role of any caregivers and the pain and suffering of the patient. Two, we also found evidence that the program improved health-related quality of life measures, which represents an additional benefit not readily monetized. Three, there may be other benefits to participants that we did not measure, possibly because they have yet to accrue.

An example of an additional health benefits that TIPs enrollees might benefit from is improved COVID outcomes because of the higher COVID vaccination rates (described in Section 3.7). We can combine this finding with information on background COVID rates and vaccine effectiveness to provide an approximate estimate of the number of COVID hospitalizations and positive cases avoided (details of the calculations are provided in Appendix Exhibit 2). We approximate that, because of the improved vaccination rates attributable to TIPs, we avoided 0.26 hospitalizations and 1.90 positive cases of COVID. If we value the change in hospitalizations at current reimbursement rates, this would contribute an additional $6,342 to the healthcare savings, which is roughly 24 percent of the savings shown in Exhibit 6. We recognize these as speculative measures only meant to be suggestive of the potential additional savings We also note that our estimate of the improvements in readmissions is subject to uncertainty. The pandemic hampered our ability to consistently collect data from all participants and may have changed healthcare encounters in important ways. Unfortunately, there is no readily available solution to address these issues.

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Community Opportunity Fund TIPs Research Report 2021

III. COST-EFFECTIVENESS ANALYSIS

Bringing the cost and savings together, we can calculate how much the reduction in healthcare costs offsets the cost of TIPs. Based on costs of $169,886 and healthcare savings of $26,388, we project that 16 percent of the costs of TIPs has been recouped through these healthcare savings. Given that we have erred on the side of overstating the costs and understating the benefits, this is a conservative estimate that likely understates the true percent of costs recouped. We know from resident anecdotes that other health care interventions may have been avoided as a result of TIPs but it is difficult to quantify the benefit due to the qualitative nature of the information.

8. Analysis

43

44

Community Opportunity Fund TIPs Research Report 2021

9. Conclusion and Future Plans Health care is a constantly changing field, and the telehealth revolution is no exception. For populations with limited access to care, bringing care to the patients at their place of residence has the potential to alter the culture of health. This report indicates promise for TIPs as a telehealth program to improve the lives of those who participate. We consistently delivered services to residents at their place of residence. Despite the challenges posed by COVID-19, we were able to modify TIPs on-the-run to ensure that participants received the intended services. The provision of the telehealth service, together with wrap around services, helps to begin to address the health inequities that exist and delivers a meaningful and valued health resource to this underserved community.

Although hospitalizations were largely unchanged, we saw considerable improvements in 30-day readmissions, self-reported measures of physical and mental health, and increased COVID vaccine take-up. Initial assessments indicate that the TIPs program has the potential to become cost-effective, and the increased ability to receive reimbursements from insurance for telehealth services will only bolster that potential.

TIPs is an ongoing program. Participants continue to attend weekly sessions, receive alerts, and have access to wrap-around services. We will continue with the above analysis to assess if the impacts persist over time. Further analysis will also let the dust from the pandemic settle so that our analysis is not confounded by any changes in health behaviors or outcomes because of COVID. Since hospitalizations are an extreme outcome and TIPs has the ability to transform participants’ health in many ways, we seek to explore the myriad ways in which health may be affected. The improvements in self-reported health and COVID vaccine take-up are encouraging signs of the wide range of possible effects from telehealth services. To further assess other health outcomes, we will explore additional outcomes such as medication adherence, primary care visits, and confidence about health status and the degree to which individuals feel that they have some control over their lives.

9. Conclusion and Future Plans

45

Preserving wellbeing and creating a culture of health may assist residents beyond their health to affect economic outcomes, such as maintaining their housing situation. By improving their management of health conditions and reducing the need for hospitalizations and/or emergency care, residents will save money on co-pays for medical treatment and/or transportation costs to access medical services. Through participation in TIPs and access to an RSC, residents will have access to greater levels of resident services and program offerings, such as Benefits Checks and help accessing utility supplements and rebates.

Providing residents with ways to improve their financial stability and increase disposable income will assist in housing stability. In future analyses, we plan to investigate the impact of TIPs and the associated wraparound services delivered by Resident Services Coordinators on housing stability and housing affordability.

If the TIPs program is able to improve health outcomes and housing stability, it has the potential to create opportunities for new sources of funding for telehealth services. Health systems that experience reduced expenses for hospital admissions and re-admissions may benefit from subsidizing telehealth services.

Property owners who experience lower resident turnover and higher on-time payments may choose to invest in telehealth services. Such investments have the potential to further spread telehealth services to improve the health and economic well-being of affordable housing residents.

Preserving wellbeing and creating a culture of health may assist residents beyond their health to affect economic outcomes, such as maintaining their housing situation. By improving their management of health conditions and reducing the need for hospitalizations and/or emergency care, residents will save money on co-pays for medical treatment and/or transportation costs to access medical services.

Through participation in TIPs and access to an RSC, residents will have access to greater levels of resident services and program offerings, such as Benefits Checks and help accessing utility supplements and rebates. Providing residents with ways to improve their financial stability and increase disposable income will assist in housing stability. In future analyses, we plan to investigate the impact of TIPs and the associated wrap-around services delivered by Resident Services Coordinators on housing stability and housing affordability.

If the TIPs program is able to improve health outcomes and housing stability, it has the potential to create opportunities for new sources of funding for telehealth services. Health systems that experience reduced expenses for hospital admissions and re-admissions may benefit from subsidizing telehealth services.

Property owners who experience lower resident turnover and higher on-time payments may choose to invest in telehealth services. Such investments have the potential to further spread telehealth services to improve the health and economic well-being of affordable housing residents.

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Community Opportunity Fund TIPs Research Report 2021

9. Conclusion and Future Plans

47

Appendix Exhibit 1.

Summary Statistics and Regression Results for COVID Vaccine Analysis 1 mean/SD

2 Regression

0.511

0.065*

0.505

[0.007 - 0.122]

0.361

0.015

0.090

[-0.332 - 0.362]

0.128

-0.131

0.116

[-0.417 - 0.154]

RSC present % Male % Married % Hispanic % Asian % Black % Over age 62 % Income < $10,000 % Vaccinated

0.093

0.109

0.152

[-0.044 - 0.262]

0.099

-0.105

0.215

[-0.261 - 0.052]

0.328

-0.107*

0.372

[-0.197 - -0.017]

0.672

0.416*

0.278

[0.327 - 0.505]

0.229

-0.039

0.144

[-0.254 - 0.177]

0.505 0.152

R-squared

0.669

Notes: SD = standard deviation. There are 47 properties in the analysis. * indicates p<0.1. 90% confidence interval in brackets. The regression and all percent variables are weighted by the number of occupants per property. The regression also includes a constant term. The coefficients are interpreted as a percentage point change in vaccine take-up. For example, .065 indicates a 6.5 percentage point increase in vaccine take-up.

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Community Opportunity Fund TIPs Research Report 2021

Appendix Exhibit 2.

Estimated Reduction in COVID Hospitalizations and Positive Cases Attributed to Increased Vaccine Take-up Cumulative Cases Percent Risk Cases Avoided Medicare Payment to Hospitals Healthcare Savings

Hospitalizations

COVID Positive Tests

3603

24521

0.98%

6.64%

0.26

1.80

$24,012 $6,342

Notes: Vaccine clinics occurred in January and February of 2021; we assume maximum immunity obtained in March. We calculate the cumulative number of cases for Essex County from March through May of 2021 (data from https://www.nytimes.com/interactive/2021/us/covid-cases.html). Percent risk is the age-adjusted cumulative number of cases divided by the population of Essex County, which is 799,767 as of 2018. Age adjustment is derived from the CDC COVID Data Tracker (https://covid.cdc.gov/covid-datatracker/#datatracker-home); we calculate the rate of COVID cases from March through May of 2021 for those over 65 relative to all, which amounts to 2.17. The 38-percentage point increase in vaccine take-up amounts to an additional 28.5 TIPs enrollees having been vaccinated. Cases avoided is measured as additional vaccinated people*vaccine effectiveness of 0.95*percent risk. Medicare payment to hospitals is taken from https://www.healthcarefinancenews.com/news/hospitalized-care-covid-19-averages-3466245683-varying-age.

Appendix

49