Can Innovative Financing Move The Needle On Health Equity?
2025; Project HOPE; Volume: 44; Issue: 1 Linguagem: Inglês
10.1377/hlthaff.2024.01471
ISSN2694-233X
Autores Tópico(s)Community Health and Development
ResumoEntryPointHealth Equity Health AffairsVol. 44, No. 1: Medicare, Medicare Advantage & More Can Innovative Financing Move The Needle On Health Equity?Jessica Bylander AffiliationsJessica Bylander ([email protected]) is a deputy editor and correspondent at Health Affairs, in Washington, D.C. This article, part of a series on paying for health equity, is being published with the support of a journalism grant from the NIHCM Foundation.PUBLISHED:January 2025Free Accesshttps://doi.org/10.1377/hlthaff.2024.01471AboutSectionsView PDFPermissions ShareShare onFacebookXLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits Abstract Communities and health organizations are testing novel ways to fund costly initiatives to advance health equity.TOPICSHealth equityHousingSystems of careFoodSocial determinants of healthPublic goodOrganization of careOlder adultsMedicaid managed careMedicaidMeals: Staff from TRIO Community Meals, in Cleveland, Ohio, prepare meals for Benjamin Rose's traditional Meals on Wheels recipients as well as clients of a new medically tailored meal program for food-insecure older adults called Nutrition Solution. The latter is financed through a new, collaborative financing mechanism that brings in funding from many sectors.Photograph by Jessica Bylander Donna Dozier hops into the back of a boxy white delivery truck, filling a refrigerator with plastic-wrapped trays of cold food, cartons of milk, and a brown paper bag labeled with a green "R" for "renal disease." In smaller containers, she stacks trays of hot food, some regular meals and some "medically tailored" for clients with a range of chronic conditions and medical needs. A narrow freezer is stacked with boxes, each filled with a week's worth of frozen meals. Around 9:00 a.m., Dozier pulls out of the lot behind the Margaret Wagner Apartments, in Cleveland, Ohio, to start her route, delivering food for Meals on Wheels and a new medically tailored meal program called Nutrition Solution. Retired from a career as a lieutenant in a local house of corrections, Dozier now works part time for the Benjamin Rose Institute on Aging, a nonprofit that serves about 10,000 meals per week in Cleveland through both of those programs. "This is sometimes all they have," Dozier says. "A lot of them depend on this." On a warm day in October, Dozier is driving "route 10," which she knows by heart, delivering meals to about forty people on the west side of Cleveland. Hers is one of ten trucks on the road today. Most of the drivers are retirees, including Anthony Bolden, who has been delivering meals for almost ten years. "You get to meet a lot of interesting people," Bolden says. "A lot of them just want to talk for a few minutes to somebody. A lot of them don't have any family members coming over. Some people really, really appreciate what we do here." While Meals on Wheels is funded in part through the Older Americans Act, the new Nutrition Solution program is made possible through a completely novel enterprise. In 2020, eleven organizations in Cleveland—three health systems, five health insurers, two foundations, and the Western Reserve Area Agency on Aging—came together to share in the cost of getting this program off the ground by confidentially identifying what they were willing to pay toward the intervention and then pooling their funds to make it happen. The model that made this possible is called the Collaborative Approach to Public Goods Investing, or CAPGI, and it's being piloted in several cities across the US to fund a variety of health equity interventions, from COVID-19 vaccine access to complex case management for families with behavioral health–related social needs.1 "Rather than kind of rehashing the debate about should health systems pay for it, should community organizations pay for it, should health insurers pay for it, this was a way to take seriously what we all know, which is that many players benefit simultaneously, and as a result, many players should pay some minority amount," says Lauren Taylor, an assistant professor in the Department of Population Health at the NYU Grossman School of Medicine, in New York City, and cocreator of the CAPGI model. CAPGI is just one of several innovative financing mechanisms designed to launch health equity– or social determinants of health–focused interventions that would not otherwise be funded or funded at the scale necessary to have the greatest impact. The goal of these various experiments is to solve the inherent challenges of trying to fund interventions that improve the social determinants of health far upstream of the health care system. Generally, the farther upstream you go, the longer it takes to realize an intervention's benefits. And along the way, many more individuals and communities are likely to see some of those benefits even as very few can, or want to, pay the hefty price tag.Nutrition Solution In the basement of the Margaret Wagner Apartments, a subsidized housing complex for low-income older adults that Benjamin Rose owns, staff from a national company called TRIO Community Meals prepare the day's meals. An assembly line of employees in white aprons, hairnets, and baseball caps preps tray after tray of nutritious food. Today it's grilled chicken, mixed vegetables, and mashed potatoes for many of the medically tailored meal recipients. Nutrition Solution began as a visionary reach for Dabney Conwell, vice president of health and wellness at Benjamin Rose. In 2017, Conwell received a fellowship from the Sisters of Charity Foundation of Cleveland, which asked for big ideas to combat poverty in the city. Conwell's proposal to create a medically tailored meals program was given the green light. Nutrition Solution is targeted at Medicaid-eligible people with heart disease, hypertension, diabetes, or kidney disease (or some combination), age fifty or older, who are food insecure and were admitted to the hospital for treatment and discharged home. Participants receive ten meals a week developed by a dietitian for their medical condition. They also get nutrition education information and an option to do "wellness calls." The program is designed to decrease hospital readmissions, reduce health care costs, and address food insecurity and social isolation. "We were seeing lots of older adults on our existing home-delivered meals program go on and off the program, and it wasn't clear as to why," Conwell says. "When I dug down into it a little bit, I found that oftentimes they were admitting into the hospital." At the same time, she was learning more about the link between chronic diseases, poor nutrition, and hospital readmission, she says. Lisa Weitzman, director of strategic partnerships at Benjamin Rose, joined Conwell about three months into the work of developing Nutrition Solution. Part of Weitzman's job is figuring out how to work with health care providers and payers to address issues around health equity, including increasing access to services and finding a sustainable model for funding them. "So often right now the model is…you apply for a grant," Weitzman says. "And when that grant period is over, even if you're doing great work and you really have moved the needle, if the priorities of the funder change, then poof, the program is gone." In February 2020, Conwell and Weitzman learned that the creators of the CAPGI model were interested in piloting it in various cities, applied, and in July 2020 were selected to take part in the model. They aren't sure how the program would have been funded otherwise. "CAPGI for us was a lifeline," Weitzman says. The first round of the Nutrition Solution program lasted six months, although there was enough funding left over to provide three additional months of "bridge meals" to people who wanted to stay on the program longer. In the first round, the program served 80,000 meals to food-insecure older adults in Cleveland; 404 participants initiated services, and 217 participants received at least three months of meals.2 The collaborative is now in the second cycle of the program. The model was ideal for a health equity intervention with proven results such as medically tailored meals, from which many entities benefit, according to Conwell and Weitzman. "It says, let's identify a problem, everyone put their dollars in the one pot, and we distribute it out to get to the root cause of the problem that's happening," Conwell says. "That doesn't happen in our world."Collaborative Financing Over the course of a day, Dozier delivers meals to squat bungalows, mobile homes, Tudor-style brick houses, modest apartment complexes, and senior living housing. The residents are effusively grateful for the deliveries. "God bless you," a short older woman with gray hair says as she takes her bags of food through her cracked-open front door. These recipients are not aware of the complex funding model that made some of these deliveries possible, but they and others stand to benefit from innovations such as these.The CAPGI model is designed to address the fact that many social determinants of health interventions are "public goods." Introduced by Taylor and Len Nichols in 2018, the CAPGI model is designed to address the fact that many social determinants of health interventions are "public goods," in that they benefit different people and sectors, including those who don't pay directly for them. Although upstream social determinants interventions can reduce health disparities, Nichols and Taylor argue that they are rarely pursued by health care organizations because of this issue of misaligned benefits. Additional challenges include figuring out which health equity interventions to invest in and who should deliver them.3 Nichols describes his meeting Taylor at a Princeton conference in 2016 as a coming together of diverse academic interests: Taylor knew social determinants of health, and Nichols knew economic theory. Together, they adapted an economics model from the 1970s to create a financing model that solved some of the problems they'd identified with social determinants of health investing. There was an overwhelming interest in their model, which Nichols chalks up to a confluence of three factors: Medicaid expansion under the Affordable Care Act, which put homeless people on the rolls of health plans for the first time; hospitals' concerns about readmissions penalties, which began in 2013; and the opioid crisis, which also begged for upstream solutions. Decades ago, conventional wisdom said that the government would have to step in to solve public-good problems, but that hasn't sat well politically. "The economists are sort of historically determined to find a way for the private sector to solve problems without government," says Nichols, a nonresident fellow at the Urban Institute and a professor emeritus at George Mason University, in Fairfax, Virginia. Nichols and Taylor received funding to pilot CAPGI with several communities across the US, including Cleveland. Based on their evaluation of data from the first year of the CAPGI project in Cleveland, they found that one investor saved significantly more than the program cost them, while others had small but not statistically significant savings. They are not yet authorized to share additional results, but Nichols says that, tellingly, most of the investors opted to participate in a second round of the program. Key to CAPGI's success in a community, Nichols says, are strong existing partnerships with local organizations that genuinely want to collaborate, even with their competitors. Just as important has been the presence of an entity on the ground to serve the crucial role of "trusted broker." In the CAPGI model, the trusted broker convenes the stakeholders, receives their bids, and provides oversight and quality assurance, among other duties. In Cleveland, that role was played by United Way of Greater Cleveland. Jennifer Kons, community investment strategic initiatives director at United Way of Greater Cleveland, oversaw the CAPGI work when it first started in the city. She learned of the model in 2018 after inviting Taylor to speak with United Way's advisory board on another topic. "We understood that there were things that were insufficiently funded and needed investment," Kons says. "[There was] this growing sentiment at the federal level, at [the Centers for Medicare and Medicaid Services], that we needed to find ways to save costs.… One of those main ways might be by addressing health-related social needs…so [we] wanted to figure out how to do that." Choosing between Nutrition Solution and a permanent supportive housing project, the investor group voted in 2020 to fund Nutrition Solution. "By the time we got to…those eleven investors who were at the table, they were really committed," Kons says. "We're gonna learn together. We're gonna share the data. We're still a little cagey around what we share about our process, but they were invested in learning together overall." The main caginess showed up when it came time to share confidential data with each other, including with the trusted broker and competitors. "For some folks, that's a hard sell to share the data," Kons says. During 2020–21, armed with worksheets provided by Nichols and Taylor, the investors calculated their potential return on investment from the intervention and built their bids around those estimates. The initial round of bids fell short of funding the intervention. With a second round of bids, they had nearly $800,000—enough to fund the initiative. "We learned what worked and didn't work for participants," Kons says. "And then that enabled Benjamin Rose to have some data to guide their decisions on how they might modify the intervention to make it more effective." The investor that saw the most substantial cost savings was MetroHealth, the safety-net health system serving Cuyahoga County. Although the data for all parties were deidentified, the health system was willing to reveal itself and help others learn from their process. "We were taking on a large burden for the patient population that could most benefit from social programs like this," says Kristen Matlack, Community Health Advocacy Initiative manager at MetroHealth's Institute for H.O.P.E., which screens for and addresses social determinants of health for the health system. "There's a lot more interest…[in] talking about different ways to fund social drivers of health–related projects, knowing that this is something we have to do in order to really move the needle on health disparities," Matlack says. The health system recruited participants with higher health care use, who tended to have at least two of the target chronic conditions. "They were overutilizing the system," she says. "These are patients that are sicker, coming to the [emergency department] more often, having longer admissions than they should." MetroHealth theorized that providing nutritious food to counteract the chronic conditions that were causing these patients the most trouble would improve their health. MetroHealth also screened for food insecurity and social isolation. In coming up with its bid, MetroHealth considered what was fair to pay for the service that was provided, instead of attempting to estimate what the cost savings would be and basing their bid off of that. Ultimately, MetroHealth patients who participated in the program had a cost savings of $1,532 per participant per month, more than 70 percent of which was attributed to the intervention. "It was pretty compelling with our small group of participants, and [we're] hoping to repeat that in the second cycle," Matlack says. "Then we'd have a better sense of investing going forward…on how much it's worth to us." The health system has doubled the number of patients who will be served in the second cycle of the program, from thirty patients in the first cycle to sixty-five in the second cycle, and hopes to make it a permanent offering. Matlack notes that MetroHealth will likely opt to partner one-on-one with collaborators from this process instead of pursuing the CAPGI process again. Nevertheless, she credits CAPGI as a way to try a new intervention with less up-front investment than MetroHealth would have had to provide if they'd done the project alone. She adds that the process laid the groundwork for additional collaboration between the three health systems involved in the first round of the intervention. "Now there are other conversations, not even about medically tailored meals, but where all three major health systems in the county are at the table together or were part of collaboratives that involved payers and providers as well," Matlack says. "It really opened up that door." Among the five health insurers involved in the CAPGI project was the UnitedHealthcare Community Plan of Ohio, a Medicaid managed care plan. In a statement, CEO Scott Waulters told Health Affairs that the plan saw CAPGI as an effective way to reduce health inequities and improve health outcomes, given that 80 percent of what affects an individual's health can be attributed to factors that happen outside of the doctor's office. The plan hoped to improve outcomes for their members and decrease health care costs. Waulters said the health plan is determining what the next phase of these efforts will look like in Ohio. Another factor that will likely help spur collaborative health equity investments in Ohio is that Medicaid managed care organizations in the state must now partner together and reinvest a portion of their annual proceeds—around 3 percent to 5 percent—into community-based programs.4 As of 2022, Arizona, California, Nevada, and Oregon Medicaid managed care contracts also require managed care organizations to invest a percentage of their profits into the local community.5 "It's not a large percent, but it's a sizable amount of money," United Way's Kons says. "When you add it all together across the various [managed care organizations]…there's a pot, and now they're deciding how they're going to make those investments." After the second round of Nutrition Solution, United Way of Greater Cleveland is stepping out of the trusted broker role. "We didn't need to sit in the middle of that, long term," Kons says. "This was a way to test [return on investment] created…and then really hand the relationship off to Benjamin Rose."Other Financing MechanismsCAPGI is just one of several innovative financing mechanisms designed to get health equity interventions off the ground. CAPGI is just one of several innovative financing mechanisms designed to get health equity interventions off the ground. Other models include social impact bonds, impact investing, and a new federal government program aimed at improving the health of a whole population by paying stakeholders for outcome improvements. In 2024, the Advanced Research Projects Agency for Health (ARPA-H), a funding agency created inside the Department of Health and Human Services by the Consolidated Appropriations Act, 2022, launched the Health Care Rewards to Achieve Improved Outcomes (HEROES) program. Under the program, public health entities and collaborators will work to improve the health status of their communities for specific patient populations through community-based interventions. If they succeed, ARPA-H and other investors will pay them.6 "For the first time…we are creating a market to buy a public health outcome at scale," says Darshak Sanghavi, the program manager at ARPA-H who pitched the idea that became HEROES. Sanghavi says that the HEROES program steps in where value-based payment and underresourced entities such as the Centers for Disease Control and Prevention and public health departments fall short. The health areas targeted in the launch of HEROES are maternal health, heart attack and stroke risk, opioid overdose, and alcohol-related health harms. The specific health outcomes they're seeking include a reduction in the rate of perinatal and postpartum severe obstetric complications and a reduction in the number of emergency medical service calls for fatal and nonfatal opioid overdoses. Participants, referred to as "health accelerators," choose a health outcome for anywhere from half a million to up to five million people, and an entire high-need geographic region to target, with the expectation that they'll generate at least a $60 million value to society (across health care, productivity, and social service costs) over three years by improving trends in that region compared with the US as a whole. ARPA-H will pay up to $15 million for each of the initiatives, and it expects "outcome buyers," such as health plans, hospitals, employers, and philanthropies, to contribute at least as much. While ARPA-H provides some up-front funding for administrative work, the health accelerators are responsible for finding their own capital and delivering services. Sanghavi explains that HEROES is essentially an advance purchase agreement. "We're the market that will purchase the outcome if you deliver the result," he says. "If you deliver it, you get paid; if you don't, you don't get paid." Health equity is an important goal of the program, which aims to improve the health care of all Americans in a population, regardless of insurance status, income, race, ethnicity, gender, age, or other factors. "We can all agree that we think people should get the best care regardless of who they are, where they happen to go," Sanghavi says. "Fundamentally we are trying to refocus from the way we pay for health care." For too long, he says, health care has been "paying for widgets and…highly medicalized interventions…instead [of] requiring a view of what is the health of the whole population." ARPA-H solicited solution summaries through the end of June 2024 and invited a subset to submit a full application by December 10. Contracts are anticipated some time in 2025, the agency says. Social Finance, a national impact finance and advisory nonprofit, is providing technical assistance to ARPA-H in setting up the financing mechanism. Historically, Social Finance implemented financing tools such as social impact bonds, also known as pay-for-success contracting, but has broadened its efforts with the overarching goal of better linking payment to results within the social sector. "There are some fairly substantial problems that exist within the social sector that stop us from being able to expand really effective programs and help them reach more people," says Jake Segal, managing director of the impact advisory and public sector practice at Social Finance. These include the "wrong pockets" problem; a focus on short-term wins versus long-term outcomes; and the high level of uncertainty and risk within the social sector, including uncertainty about what interventions will work, for whom, and in what context. Investors solve the latter two problems, Segal says. "They solve time and risk problems with money." Segal notes that social impact bonds are not actually bonds but outcomes-based contracts. But they can be difficult to implement within the uncertainties of the social sector, and they work best in places with a history of having high-quality data, measurement planning, outcomes definition, contractual sophistication, and referral and collaborative pathways. "Impact bonds are tremendously demanding versus the status quo," Segal says. In 2016, Denver, Colorado, successfully established a social impact bond program to address homelessness by providing housing and supportive case management to homeless people who frequently used the city's emergency services, including police, jail, courts, and emergency departments. The city estimated that it cost $7 million a year to provide these safety-net services to 250 people experiencing homelessness in Denver.7 The first social impact bond, which ultimately placed 285 people in supportive housing, led to fewer shelter stays, fewer days in jail, more time in stable housing, and less use of detoxification services.8 Participants also had more psychiatric visits, more prescription medications, and fewer emergency department visits.9 In 2022, Denver launched a new round of the project, which involves an $11.75 million investment from private funders and up to $5.5 million in the form of a Social Impact Partnerships to Pay for Results Act grant from the Department of the Treasury, to fund supportive housing for another seven years.10 The Colorado Health Foundation was among the investors in both rounds of the housing bond. Currently the foundation is also working on a career paths impact bond in partnership with Social Finance, four other philanthropies, and training providers across Colorado. The bond offers students of color an alternative to traditional student debt, explains Ben Bynum, the foundation's senior director of impact investing. "If you don't get the job that you were promised, the school pays a little bit of it," he explains. "If you're not getting as much in wages, the employer pays a little bit. If you don't graduate, philanthropy steps in and pays the bill." Impact investing is another avenue the foundation is using to leverage financing to improve health equity. It involves making investments for social as well as financial gains. At the foundation, impact investments are expected to be repaid, potentially with a small amount of interest but usually not, and health impact metrics are expected to be met. "For us, that impact agreement includes health equity–type metrics," Bynum says. For instance, the foundation has made agreements where clinics commit to enlisting a board and staff whose race and ethnicity resemble those of the patient population. "Those equity milestones are part of the partnership, legally," he says.Promises And Challenges Experts agree that these innovative financing models hold both great promise and important challenges. Glen Mays, chair of and a professor in the Department of Health Systems, Management, and Policy in the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus, in Aurora, leads a research program called Systems for Action, a big part of which is evaluating innovative financing models to sustain interventions around social determinants of health and health equity. "The financing piece is a critical area," Mays says. "[There is] still a lot of experimentation and no clear solutions yet in terms of a way to actually finance particularly upstream types of interventions that can address the health challenges associated with the social determinants of health."It's critical to find a way to pay for these strategies if we want to improve health in the US. But it's critical to find a way to pay for these strategies if we want to improve health in the US. In addition to innovative financing, Mays notes, it will take new governance, workforce, and data information sharing models to improve health and health equity as well. "Ideally, we like to see interventions that are touching in all four of those spaces," he says. Systems for Action is funding a study in Minnesota that looks at a novel type of social impact bond meant to address the challenges of using bond financing with a larger number of stakeholders and making impact bonds work over a longer time horizon. The bond allows multiple health plans in Minnesota's Medicaid program to invest collectively in a fund that finances interventions targeted at issues such as food insecurity, housing instability, transportation, and structural racism.11 "There's a lot of good experimentation going on," Mays says. All of this experimentation, however, will also result in fragmentation and duplication, much as has been seen in the health care system writ large, he says, which can erode effectiveness and efficiency. "Some of that, hopefully, will wash out as we do strong research and evaluation around the experience," he says. "Hopefully the research and evaluation can help…eventually to reduce some of the fragmentation and waste that is going to crop up into these models." As for CAPGI, Nichols and Taylor both note that the type of public-good investments that the model is best suited for—upstream social determinants interventions with diffuse benefits but concentrated costs—have been less of interest to investors than quasi-medical interventions such as medically tailored meals, which affect upstream social determinants of health but whose cost benefits are more easily tied to individuals and their interactions with the health care system. "Housing is the one we wish we could have gotten to and were not successful," Taylor says. Plans to use the model to fund the construction of new affordable housing in Maryland fell through as a result of competing demands during the COVID-19 pandemic. "It's fair to say everybody wants to solve housing," Nichols says. "A lot of people think housing is beyond their capacity. In my opinion, it's not beyond the collective capacity of the community at large, but it is beyond the financial capacity of the organizations that are most focused on it today. We gotta build…a constituency that believes it can get the right combination of financial and nonfinancial return over time. I believe it's doable, but…that's a three-year process, not a six-month process." The CAPGI experience also taught Nichols and Taylor that in many cases, what they thought were financial problems were actually governance problems. "As much as there has been talk…about wanting to do things collaboratively, when you look under the hood of these local coalitions and collaboratives and cooperatives, they are tenuous," Taylor says. Their hope is that some organization will invest time and resources into making the collaborative aspect more uniform and streamlined so that organizations could "plug and play" their investors and investment into the model without as much burden.Back On The Road Dozier delivers the brown paper bag labeled with an "R" to a woman on the upper floor of an old brick apartment building who has been diagnosed with renal disease. When the delivery was delayed longer than expected, the woman's daughter called Dozier anxiously, underscoring the importance of these meals to those who receive them. For all of the complexities and challenges underpinning this collaborative financing initiative in Cleveland, it's worth noting just how meaningful it is as a direct and tangible intervention: People are getting meals that they otherwise would not—meals they need to stay well and keep chronic conditions in check. In two days, Dozier will be back on the road, delivering almost fifty more meals—most of them Nutrition Solution meals—to neighbors in need. "I have compassion for their situation," she says. "You have to have it, or there's no sense [in] you doing this job."NOTES1 Urban Institute. Current implementations of CAPGI [Internet]. Washington (DC): Urban Institute; 2021 Sep 22 [cited 2024 Nov 22]. Available from: https://capgi.urban.org/index.php/2021/09/22/implementations-of-capgi-so-far/ Google Scholar 2 Taylor LA, Nichols LM. Insights from implementation of a community-based model for collaborative public good investing. Health Aff (Millwood). 2024;43(1):72–9. Go to the article, Google Scholar 3 Nichols LM, Taylor LA. Social determinants as public goods: a new approach to financing key investments in healthy communities. Health Aff (Millwood). 2018;37(8):1223–30. Go to the article, Google Scholar 4 Ohio Department of Medicaid [Internet]. Columbus (OH): The Department. Press release, The Ohio Department of Medicaid, in partnership with Ohio's Medicaid managed care entities, is providing more than $6.5 million to Ohio communities through a new grant program; 2024 Jun 12 [cited 2024 Nov 19]. Available from: https://medicaid.ohio.gov/news/press-release/odm-grant-communities Google Scholar 5 State Health and Value Strategies. Addressing health-related social needs through Medicaid managed care [Internet]. Princeton (NJ): Robert Wood Johnson Foundation, SHVS; 2022 Oct [cited 2024 Nov 19]. Available from: https://www.shvs.org/wp-content/uploads/2022/11/Addressing-HRSN-Through-Medicaid-Managed-Care_October-2022.pdf Google Scholar 6 Advanced Research Projects Agency for Health. HEROES: Health Care Rewards to Achieve Improved Outcomes [Internet]. Washington (DC): ARPA-H; 2024 Apr [cited 2024 Nov 19]. Available from: https://arpa-h.gov/sites/default/files/2024-05/HEROES%20Public%20Deck%20Focused%20Rev%204-19-24.pdf Google Scholar 7 Urban Institute. Denver Social Impact Bond Program [Internet]. Washington (DC): Urban Institute; 2016 Jan 25 [cited 2024 Dec 2]. Available from: https://pfs.urban.org/pfs-project-fact-sheets/content/denver-social-impact-bond-program.html Google Scholar 8 Cunningham MK, Hanson D, Gillespie S, Pergamit M, Oneto AD, Spauster Pet al. Breaking the homelessness-jail cycle with Housing First: results from the Denver supportive housing social impact bond initiative [Internet]. Washington (DC): Urban Institute; 2021 Jul 15 [cited 2024 Nov 22]. Available from: https://www.urban.org/sites/default/files/publication/104501/breaking-the-homelessness-jail-cycle-with-housing-first_1.pdf Google Scholar 9 Hanson D, Gillespie S. "Housing First" increased psychiatric care office visits and prescriptions while reducing emergency visits. Health Aff (Millwood). 2024;43(2):209–17. Go to the article, Google Scholar 10 Hanson D, Gillespie S, Oneto AD. Denver Housing to Health (H2H) Pay for Success Project: evaluation design [Internet]. Washington (DC): Urban Institute; 2022 Jul [cited 2024 Nov 19]. Available from: https://www.urban.org/sites/default/files/2022-07/Denver%20Housing%20to%20Health%20%28H2H%29%20Pay%20for%20Success%20Project.pdf Google Scholar 11 Systems for Action. Social bonds as a pooled financing mechanisms to address social drivers of health equity [Internet]. Aurora (CO): Systems for Action; [cited 2024 Nov 19]. Available from: https://systemsforaction.org/projects/social-bonds-pooled-financing-mechanism-address-social-drivers-health-equity Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 6 January 2025 Information© 2025 Project HOPE—The People-to-People Health Foundation, Inc.PDF download
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