Raising the Roof in Healthcare; Literally!

Brian Urban:                                           
Yes, this is the Healthcare Rethink podcast. I'm your host, Brian Urban, and today we are raising the roof in healthcare, literally. We're thankful to have on our show the CEO of Upside Housing for Health, Jake Rothstein on our show here today. Jake, welcome to our show.

Jake Rothstein:                                        
Brian, it's great to be here. Thanks for having me.

Brian Urban:                                           
This is going to be a lot of fun. We haven't had too much time to get to know each other, so we'll do that in the course of our conversation here. But I'm so excited to have you on, because you are one of many social care tech companies that are addressing age and basic needs, but you've actually showed a notable impact, not just in terms of ROI and value, but societal change as well in the way that healthcare should be addressing housing in particular for the lives they serve. So this is going to be so much fun to get into this. So let's start at the top. Who is Jake and how did you get into this kind of tech? And take us back before you became CEO here.

Jake Rothstein:                                        
Yeah, my pleasure. It hasn't been a perfect A to Z journey I'd say. Started my career... First of all, born and raised in Florida, south Florida. My parents are New Yorkers, but they met down here and I was born and raised here and started my career in sales, in enterprise software sales. Worked at some big corporations, then worked at some smaller startups in selling enterprise SaaS. And then had a problem, a challenge with my own family and it started with my grandfather who developed Alzheimer's. My grandmother had been caring for him, realized that there was this really big gap in alternative caregiving models for older adults, for really for companionship and assistance. And so, started a company based on what we call our own grandfather, Papa. And that got us into, with my cousin Andrew, and that got us into the healthcare space and we started as direct to consumer and then grew in the healthcare world specifically with Medicare Advantage, then it grew from there.
                                                       And then started Upside based on again on a family need. So my grandmother who had been caring for my grandfather, at some point she became unable to really physically and emotionally care for him after he had declined to a certain point. And so she moved him into a traditional memory care facility at a senior living facility and at 87 years old, for the first time in her adult life, found herself completely alone and didn't know how to pay the bills and couldn't navigate the staircase in her house. She had just had knee replacement surgery when this all happened. And then the most important factor, she was paying all this money to support him in this memory care facility, which if you have any experience dealing with these types of communities, they're very expensive and that was unplanned for.
                                                       And so, dwindling away her retirement savings living in this house that was unsustainable. The family got together and we said, "Okay, well we got to sell this house. She's got that equity in the house, we can sell it." So we made the decision, it was a hard one. This is her house, she built this house for her retirement, to move her into a regular apartment, a rental in the neighborhood that she knew and loved and near her doctors and her family and her grandkids. And so we sold the house, we moved her into this apartment nearby and I acted as the helpful grandson. I was there to help her go to the grocery store and help her pay her rent and help her drive her to the doctor. And she used to come over to my parents' house for dinner on Friday nights.
                                                       And so we realized at the time that, wow, 90% of people say that they want to age in place, but at some point due to some trigger event, in this case the trigger event was moving my grandfather out and her finding herself alone, they can't age in place. So, although everyone wants to, it really becomes impractical at some point along the aging journey as a result of one of these trigger events. We've categorized them since into what we call the five Ds; death, downsizing, divorce, disaster and disability. And so it paints this picture of a very broad problem where you have 10% of the population going into traditional senior living, assisted, independent, maybe continuing care retirement, and then you have 90% of people trying to age in place but unable to without the support and without the guidance that really could be necessary.

Brian Urban:                                           
It's amazing. I'm sorry.

Jake Rothstein:                                        
Go ahead. That's the spiel. That's basically who I am and how we wound up here.

Brian Urban:                                           
And it's an amazing story. We speak to a lot of CEOs that are growing an idea based on filling a need and then proving it out as you go. And it just shows that these types of scenarios are extremely complicated. They've existed for a very long time, ever since really we are walking on this planet, and it's impossible to navigate it individually, and you need a helpful family to be able to support you. And we take a look at the next five years, over 90 million people 65 and older. You look at what could support people aging and living in homes safely. Not many models support that. There is the traditional PACE model of course, but that deploys a lot of clinicians in home. So that's not really fiscally sustainable in a lot of ways.
                                                       
But then your model, it's so interesting, because it was based on pure experience and thank you for sharing that. I can absolutely relate in a lot of ways with my family and my wife's family as well. Aging in place is not an easy thing. You need to be able to have a lot of structure behind that. And then if things go wrong, the five Ds you listed, if you're not prepared, then someone has to help you. So, I think it's so interesting. You published something on LinkedIn recently. 2024 is going to be the year housing takes center stage in healthcare. Big question to really start things off here, Jake, why has it taken so long for housing, a basic need, to be center stage in healthcare, specifically for health plans wanting to address this for a lot of reasons, why has it taken so long?

Jake Rothstein:                                        
It's a great question and I don't know if I have a simple answer and I'm not sure it's a complete answer either, but I think that housing, when you think about it, the first thing that you think of is housing is expensive. It's a very big and it's a very expensive problem to tackle. It's also a very complicated problem to tackle. You hear about it all the time, there's a major housing shortage and there's not enough housing and gentrification of cities is causing people to need to move to suburbs. And it just becomes really, really... It's a very challenging problem. And I think that's why it's the last thing that people have tried to tackle. We've talked about food insecurity, we've talked about loneliness and social isolation. We've talked about all of these big trends that we've talked about in the last 5 or 10 years, we're only just now starting to really hear about the gong of housing being mentioned in conversations around health. I think it's because it's hard and I think it's because it's expensive predominantly.
                                                       
You do see some of the bigger health plans, the ones that are really well capitalized, dipping their toes into housing. But from our perspective, it's not anything that's really meaningful. In many cases, it's very good for optics and yes, you can house 114 people, but if that 114 people belong to a health plan of 140,000 people, really what kind of impact are you making? It's very small. And so when we approached this and we started approaching health and we started the business as a direct to consumer company to really learn and then we moved and migrated towards servicing health plans, once we had that knowledge, we think we can take that same dollar that might be spent on building buildings for people and really driving efficiency and using those dollars more efficiently by utilizing existing infrastructure.
                                                       And I think that's where our expertise, it really lies in taking the existing infrastructure that is out there, understanding it better, and then being able to utilize it to meet the needs of a very diverse member population. We started with older adults, because that was our expertise, and we realized in our work with health plans, big and small, that housing is not just a problem for older adults. It's a problem for people that face eviction, or might have a criminal background, or maybe they are dealing with domestic violence. There's a lot of reasons why housing is problematic for people. And the deeper we get into the industry, the more we're learning about how we can be helpful with our really unique model.

Brian Urban:                                           
It's interesting and it seems more highlighted now than ever, and I think what's interesting about your model, it's really straightforward, Jake. It's looking at the individual level, identifying those that might need help based on housing stability, safety, affordability. You screen them and then you rescreen them, you coordinate services along with your network, with the health plan, and then you start the engagement and then you follow through.
                                                       
I think the follow through part is really interesting that I've seen surface level on your model, because you're right, CVS, a great move on their part. Pre-pandemic, I think they invested about $100 million in building new buildings. What's the follow through though? Because if you don't maintain and have a follow through, those buildings you're investing to could go by the wayside. They could have a lot of structural challenges, they could have a lot of affordability challenges. So what's the follow through? I like your model, because it has that. And I'm curious, it has to be powered by really important data that doesn't reside inside the physician's office. So, can you tell us a little bit about the model? Hopefully I got it relatively on the head there, and what's your data strategy within that?

Jake Rothstein:                                        
Yeah, great question. So in terms of the model broadly, we've aggregated a network of 33,000 apartment communities and alternative types of housing across the country and vetted it to meet our standards for safety, for accessibility, for affordability. And then we take that information and we're able to ascertain the real time availability of this network of inventory of apartment communities and do it instantaneously. So this is a very unique thing. This doesn't exist in the regular world and it certainly doesn't exist at the fingertips of the average case manager that works at a health plan that's trying to help his members, especially when there's acute housing need. And so many of the cases that we deal with are very acute and they need to be handled in a timely manner.
                                                       
So I would say, number one, the inherent flexibility and the inherent scale that our model has, because of this existing infrastructure that we're utilizing, is really an important piece of this. I'll say for the data piece of this, you mentioned the follow through, and I think the way we talked about it with our health plan clients and with internal people at the health plan that we work with is about closing the loop. In many cases, health plans work with local community-based operators that are in the housing industry; local housing authorities or affordable housing nonprofits. And these organizations are fantastic, don't get me wrong, but they don't have scale and they don't always have the level of sophistication needed to close the loop with the health plan from a data standpoint. So we can receive a member, a referral from a member, or we can run an outbound engagement with member populations as well, we can understand the true full holistic 360 picture of a person and as it relates to their housing, but also as it relates to these other different social drivers of health and services that they might be able to or they might benefit from.
                                                       We collect all that information and that data and once we place someone and we stabilize someone, either in one of our units or in one of our network of apartments, we're able to report back to the plan on that stability. So it's like, "Okay, you sent us this person that was facing eviction, they're going to be on the street, they're near homelessness. We need to help them figure out a solution for long-term stability. We're going to get them stabilized, we're going to help them apply to this place and this place and that place. We're going to get them under a stable roof and then we're going to report back to you on that." Versus what's happening today in many cases is a referral gets sent to a local community-based operator, and the health plan goes, "Okay, we've done our job. That's on them. Let them figure it out." And a lot of times those cases come back around to the health plan and bite them, frankly.

Brian Urban:                                           
That's what's interesting is it can't be just on one stakeholder in this ecosystem of helping an individual get into an affordable, stable, safe home. It has to have bridge players like yourself. So, it seems like that boomerang effect comes back in a lot of ways, not just with housing, but with other things too; medically tailored meal programs. You can't just stop funding a food program and expect individuals then to carry that behavior on and purchase and then prepare their own food. So it's similar to housing in a lot of ways too, because this is something that's constant and it's probably the biggest financial challenge for a lot of individuals, let alone logistics. So I'm curious of what maybe Upside Housing for Health has in terms of some studies, in terms of any interesting projects you could tease out for us a little bit, Jake. Obviously the ROI is there and societal impact is valid and it's there as well and documented. Any really cool studies you have coming up or initiatives that you could shine a little light on before maybe they happen? Or if they're under wraps, then I'll stop asking questions.

Jake Rothstein:                                        
Yeah, well, we've got a lot of projects underway that are under wraps, because we're under NDAs with our client partners. But what I can tell you is that we're constantly collecting data on the efficacy of this type of programming. And when you think about things like an ROI, when you're talking about it in relation to housing, you're impacting all of these other things that you may or may not have thought about. Fall risk is impacted, which is a big one and it's a measurable one. You're talking about food security. If you're not in an appropriate physical environment, it's very hard for you to get nutritious food. If you don't have a permanent mailing address, it's really hard to get free prepared meals delivered to your door. Or in many cases we talk to people that don't know how to apply for a Social Security number, and so we can help guide them around that, but you can't start those conversations unless you start the conversation around housing.
                                                       
That's what we've found. And one of the things our health plan partners tell us all the time is like, "How are you guys able to get all of this information from these members? We've been working with them for years. We meet them in person, we talk to them three times a week, and we didn't know that they had a problem with their PCP." And so the reality is, is what we're finding, and this was our thesis going into this, is that housing is so foundational. You think of it like Maslow's hierarchy of needs. Housing is so foundational. If you don't have an appropriate home over your roof, it creates all of these other challenges from a social drivers of health standpoint. You aren't thinking about healthy food if you don't know where your next rent paycheck is coming from. You're not thinking about going to your primary care physician if you're hungry.
                                                       
There's all of these things that are completely interrelated that when the industry thinks of the problems, they think of things in terms of point solutions. You mentioned earlier about all of these different social driver of health companies, and they're all targeting a very specific element of a person's life. Okay, grandma is not able to get into and out of the shower easily. She needs an in-home retrofitting, let's get her help. What happens if we send an occupational therapist into grandma's home and there's three feet of mold in the walls and her COPD is acting up as a result of that mold? It doesn't matter how many wheelchair ramps you put into that house, grandma's not really safe to live in that environment. So, if you look at things from a very specific lens, rather than looking at them the way we look at them through this very broad lens all centered around housing, you get a much clearer picture on the problem and you get a much clearer picture on the solution to that problem.

Brian Urban:                                           
It's so interesting that you provided that example, because a very niche model would not pick up something like that, the home being at the center of all things very much so, and I think that's overlooked a lot across the ecosystem. So I'm so glad your company exists, one, and two, the populations you serve, a few moments ago, you mentioned all the different diverse populations, and when I was first looking at your organization and hearing about you many, many months ago, I was like, "Okay, this has got to be Medicaid." Not the case. There's a D-SNP population, very much so, that is fitting for the services that you supply, housing at the center, but then also Medicare Advantage. I did want to talk about this population a little bit more with you, Jake.
                                                       
We have a humongous population that is Medicare eligible, but Medicare Advantage beneficiaries, those buying into some additional support and coverage for their healthcare needs. There's a big SDOH benefit package play now for a lot of big private health insurance organizations, so they're investing and they're starting to track the impact here. Are you seeing more of the growth in terms of the services you supply at a member level on the Medicare Advantage? Or is it equally split across the different populations?

Jake Rothstein:                                        
Great question, and it's a very interesting time. I think over the last three years, there's been a big growth in Medicare Advantage specifically, because of the advent of supplemental benefits and those dollars that have recently become available. I think what we're finding, where we're finding most interest is on the Medicaid and the D-SNP side. We've built our model out to support MA, D-SNP, Medicaid and not even thinking about the commercial side of the business, there's a big opportunity for us working with adult children, the caregivers of older adults, helping them through this journey with maybe their older adult parents or loved ones. And so, we're just scratching the surface where the opportunity is most acute. I think when health plans think about housing, the first thing they think about is affordability. It's my Medicaid groups and these are the people that have the most acute need, these are the people that are calling our case managers and saying, "I'm going to be homeless tomorrow," or, "I'm living in my daughter-in-law's basement," or, "I'm living in the back of my car. I need help."
                                                       
And these are people that shouldn't be living in the back of their... These are just older people that have fallen on hard luck that can be helped if there's someone out there willing to help them. And the reality is, is that the case managers and health plans are overburdened, they're overwhelmed, and they're not specialized in housing. They're specialized in helping people as best as they can with the tools that they have. And so we come and we say, "Hey, we're experts at housing. We have this really unique network that we've built of housing that's already curated and that's ready to go. Let us help, let us step in and help your case managers actually close the loop on these housing challenges."

Brian Urban:                                           
It's so interesting that you say that, and it makes me think of two things. One, the obvious, health plans I think now are starting to actually fulfill a lot of the missions they've had for many decades in which they're actually serving individuals, the person first, and being a true health plan, not just a insurance underwriter of healthcare utilization. I think they're really evolving thanks to a lot of healthcare tech organizations like yourself that address age in home and also social health needs.
                                                       
And the other side of it, which I think is incredible, is the supplemental benefits are truly an investment that you're seeing come from CMS, saying that, "This is a new model that needs to be deployed now more than ever." And you're seeing a lot of different creative programs, all different organizations as well. So it's great that that is where a lot of investment is coming from, from the matrix, but health plans absolutely can't do it on their own. And I feel like you're building trust as currency and putting that back in the health plans court, because to your point where you were saying before, a lot of health plans say, "Hey, we get a lot of self-reported member information." Yeah, but it's difficult to maintain that. But then also when you have a trusted entity working with them, like yourselves, and that trust just gets boosted and then you can really help people. So it seems like that's what you're really starting to see as Upside starts to mature. Would I be right in that assumption?

Jake Rothstein:                                        
100%. We're using housing as a form of engagement. It's, "Let's talk about a problem that you really have, that you're struggling with, that maybe you thought your health plan could help you with, or maybe you didn't think your health plan could help you with it, but your health plan can help you with it, certainly if they have our help to do it. And let's build that trust over time." And the durability of that trust, it gets better the farther along you help someone. And so if you can help someone, something so core to their existence, to their wellbeing, like housing, like the roof over their head, wow, how much better... If your health plan helped you with your housing situation, how many nice things would you have to say about them? So when you think about all of the side effects of... Yeah, sure, it's lower fall risk, it's lower ED visits, it's lower care costs ultimately, and you can build all that stuff into an ROI model. But how about better customer engagement, more meaningful engagement, better HEDIS measure, better star ratings? All of these things that are really important to health plans have a really positive effect down the line when you can start the conversation and the conversation around housing as well.

Brian Urban:                                           
And the thing is, Jake, I can't help but say this, I always care about the individual, the person first, more the philanthropic innovation side of our ecosystem. But in terms of a business, you've put that vision of helping someone into an understandable business model that can be sustained over time across various populations or health plans. And you think about the quality bonus payments, a payment per person per month for a year. That's top line value for a lot of health plans that then can also increase their star ratings, because of that experience survey, the CAP survey that you were alluding to earlier. So it's just, there's so much upside, literally, to Upside Housing for Health. I'm so excited to see your model grow and get to this beautiful utopic vision that we are talking about just before the recording. And Jake, I am curious, what's the goal? Do you want to serve X amount of lives, like 100 million lives you want to impact, or is it X amount of states? Is there a metric in your mind, or is it just one year, one quarter at a time how you're making an impact?

Jake Rothstein:                                        
I think we pull in and we pull out in terms of vision, we want to be the premier, the go-to housing provider, the go-to housing program or platform or company or whatever you want to call it for the health plan world. We think this is, number one, it's an incredible way to help a lot of people. It's an incredible way to make a big impact through the health plan channel, and we believe it's incredibly synergistic. So, health plans want and need to serve their members better, and they also want and need to reduce care costs in order for them to maintain sustainability. We want to impact people's lives. We want to humanize healthcare through housing, and that's what we're really after. And I think the more we get into this and the deeper we get, the more we realize that this human element, this people element of healthcare is what healthcare is. It's how can you humanize healthcare through housing? I think that's our broadest vision yet, and we recently came to that, but we see it every day, our care guides see it every day on the phone with members. And I got to tell you, Brian, going to sleep at night, knowing that even though every one additional person that we can impact and make their lives just a little bit better, that's why we're in this.

Brian Urban:                                           
Wow. I should have led with that question, Jake. I am so excited for the contributions that Upside Housing for Health is going to make, not only in the communities you serve, the lives you serve, but across the entire healthcare ecosystem. I feel personally, just my bias here after 25 minutes, but the standard issue should be addressing housing and it should be done with you all. I'm so excited for what is going to be coming in 2024 for you all. Jake Rothstein, CEO of Upside Housing for Health. Thank you so much for joining our little show here today.

Jake Rothstein:                                        
Brian, thank you so much for having me. This was a real pleasure.

Brian Urban:                                           
And for more exciting excerpts and insights, please visit us at finthrive.com.