From Home-Sharing to Housing Stability: The Evolution of Upside with Jake Rothstein

Jake Rothstein: Housing stability is not binary. It’s not you’re unhoused and now you’re gonna be housed. It’s you’re unhoused.

You’re probably unhoused for a number of reasons. What are those reasons and how are we solving for those in order to get you on a path towards stability and long-term stability?

Keren Etkin: We usually think of housing and healthcare as two separate industries, but providing housing stability can actually improve health outcomes. In this episode of the AgeTech podcast, Jake Rothstein, CEO and founder of Upside Breaks Down how they built a network that gets health payers to invest in housing stability without laying a single brick.

Jake, welcome to the show

Jake Rothstein: Thank you. Thank you for having me back.

Keren Etkin: So this is the second time you’ve been on the show.

I think the first time was during COVID, so quite a long time ago. And a lot

Jake Rothstein: Wow.

Indeed. I can’t believe it’s been that long. Wow. That’s crazy.

Keren Etkin: it, it has. So could you give us a, a recap of sort of the, the arc, the story arc of, of upside from five years ago until today

Jake Rothstein: Yeah, totally. I, it’s a long story, so I’ll shorten it for, for listeners. Perspectives. We started based on a personal need, right? My grandmother found herself alone at the age of 87. After having cared for my grandfather for a long time with Alzheimer’s. She wound up moving him to assisted living to memory care specifically, and found herself at 87 in this two story house that she could no longer maintain or afford or navigate.

She couldn’t walk up and down the stairs. She had recently had knee replacement surgery, and so. The impetus for Upside came from helping her with family got together and we said, okay, well she can no longer stay in this house. It’s not sustainable. She has equity in it, so let’s sell the house. Let’s take the equity, let’s move her to a rental apartment, and I’ll step in as the grandson.

That’s, you know, the closest by and. Help her out with the things that grandmothers need, help with transportation and groceries, and shop, you know, doctor’s appointments and things like that. And that’s what, what we started upside on that premise. We said, we’re gonna build the biggest senior living community in the world without laying a single brick.

And we’re gonna do that by utilizing existing apartment infrastructure, vetting it to ensure quality and accessibility and affordability for older adults specifically. We’ll create these great intergenerational communities because, you know, these buildings are inherently intergenerational. And you know, eventually we will work towards finding distribution through payers.

And that, that’s what we had done at Papa, and that’s what the intention was with upside. And so we started that like that and we started placing older adults

Keren Etkin: All.

Jake Rothstein: really all across the country, in in communities and apartments that we were, that were vetted by us. And so we started collab, you know, conglomerating, this network of vetted apartments, right?

And a couple years into it I think sooner than we anticipated, we started kind of loosely talking to payers. Medicare Advantage specifically. Medicare Advantage organizations and leaders started telling us like, well, this is an incredible concept and if you can build this national network of apartments, you can create housing stability programs and all this stuff.

But it was weird. It was weird timing. It was 2023 and there was a major pullback in supplemental benefits, which was the payment mechanism that we were gonna utilize to support the program specifically as it related to Medicare Advantage. And one thing led to another and we started wound up talking to a lot of Medicaid managed care organizations.

And so. When you’re talking to these big payers, right, they’re, they have managed care Medicaid, they have Medicare advantage organizations, they have commercial lines of business. So we hadn’t, at the time, in 2023, hadn’t had any real experience with vulnerable, lower income folks, Medicaid population.

But we said. You know, we’re willing to, we’re willing to try and see if we can use this kind of systematic way of understanding the real time pricing and floor plan and unit mix of all these apartments that are in our community and vetted as it relates to the populations that we serve. And so we had a conversation with one big national payer, and they had a state in Virginia, they had a, a health plan in Virginia where they said, well, we’ve got really challenging populations specifically in these three counties in this state, and we can find you some money and, you know, we can maybe put a, a put a pilot together.

And so in January of 2024, we launched our first payer pilot with a Medicaid managed care organization in Virginia. And within three months using this network of apartments that we had curated and vetted and sort of tailored to this Medicaid population that we knew we were gonna be serving we started stabilizing people housing, stabilizing them in a.

Within a three month period at rates that the health plan had never seen before. And in doing so, we had convinced, kind of along this journey, we had convinced the health plans that it made sense for them. To help get these members into stabilized settings and to pay for that because there was a clear and tangible ROI associated with it in, and the way that translates is to reduction in hospitalizations and reduction to fall risk, and reduction to, you know, emergency department visits and hospitalization, length of stays and medication adherence, and all these things that impact medical costs down the road.

And so that pilot wound up expanding across now seven states with one big national payer. We are working with all of the big national payers now over the course of the last two and a half years, the team has grown by, I can’t, we were, we started the year at nine, people we’re at 45 people. And it’s just been a, it’s been a wild journey and we’re just getting started.

Keren Etkin: Wow.

So I, I already knew that housing or housing stability was part of the social determinants of health, but I didn’t realize that payers were able to actually measure that. How long did it take you to show ROI? So

Jake Rothstein: So the way it works with payers is they need to be able to understand ROI from a theoretical or hypothetical standpoint at the launch of a program. But every payer also wants to understand the ROI as it relates to their specific population. Not a sample population, not a population that looks like their population, but their actual population.

That happens kind of over time and it’s continuing to happen with us. But what we did at the onset was we said, okay, well there’s all of these housing studies out there and that articulate and that show meaningful cost savings to the health to the healthcare system, to medical costs as a, as a result of stabilizing certainly the most vulnerable people, but even those that aren’t as vulnerable.

And what we found was that. S housing stability applies and is prevalent in a lot more people than we thought it was. For example, in Medicaid, 40% of members that we interact with have housing instability or we, we interact with a hundred percent of ’em. 40% of Medicaid members are flagged positive for housing instability.

Medicare,

Keren Etkin: Medicare, Medicare

Jake Rothstein: Medicare Advantage has almost similar numbers, and what we sort of realized was that the breadth of this problem is much bigger than we thought. And housing stability manifests itself in so many more ways than we thought it was. When we first started in Medicaid we were under the impression that housing instability is, you know, you’re homeless and you’re living under a bridge, or you’re you’re an addict, or you might have a, you know, a mental health issue.

The reality is, is that. People that are victims of abuse could have housing instability because they can’t stay where they’re at. Or maybe they’re living on their friend’s couch for the last three years

years

because they’ve had to move for medical reasons. Or maybe they’re they lost their job and they’re, they already got another job, but they don’t

but they

know where they’re gonna go in between.

And so they’re temporarily homeless. And so

so

the amount of reasons for that cause housing instability, the triggers for housing instability are, are very varied and the list is very long. It’s in the health plan’s best interest because they share the risk or they own the risk, they carry the risk for these patients to ensure that housing stability ensure it quickly and in and for the long term.

And so

so

we made that case with very clear and articulate, actuarily backed ROI modeling.

on

and we continue to make the case with identification of members that we help pulling claims in relation to those members and understanding over time how our program actually reduces claims.

Keren Etkin: I have a question that could be provocative or it could be just ignorant because I’m not American. Doesn’t it work better in the payer’s interest if the person becomes homeless and then they drop out of being a member?

Jake Rothstein: Not really. So the, the, the payer wants to keep the member the payer wants to keep the member because they get a capitated rate from the federal government in Medicaid. That’s how it works too. And a Medicare advantage, it works Similarly the Medicare Managed Care organization receives a payment for that member and for all of their members.

For every month that they’re in the system and they’re in their, you know that they’re under their care. And so, you know, these people are typically remaining in Medicaid or they’re remaining in Medicare Advantage, but their medical costs are reduced. Reduced. And so the idea is, let’s go upstream.

Let’s get ahead of. Claims because the only time that health plans really without programs like this, the only time health plans really see problems is through claims. And so they only see a problem after it’s already happened. So we go to them and we say, okay, we can survey members for housing instability.

You can survey them, whoever you want to survey. We can understand people that have any housing instability and capture rising risk within your population and nip those, those challenges early on. So that. You can find out about them before they wind up in your, you know, in your claims box. And before you incur major $40,000 hospital admissions for those members.

And so it is in very much alignment with the health plans, revenue goals, and profit goals to get upstream of so many of these. You know, kind of housing related issues that could potentially arise from housing instability, like I mentioned, fall risk and ED avoidance and all this stuff. So that’s why, and that’s why we’re getting a lot of you know, so much traction on the program.

Keren Etkin: That is wonderful. what did you have to change about the product when you Expanded your reach from not just Medicare, but to also serve Medicaid

Jake Rothstein: It’s a great question. So the type of housing that might be suitable for an older adult is different than the type of housing that might be suitable for someone that’s low income or someone with a disability. And so what we do is we take a very fine tooth comb and we understand the inventory in our network.

And our network spans now across the country, all 50 states and 33,000 apartment communities, plus a variety of. Different types of housing. We include section eight in our in our inventory. We have group homes in our inventory for people that have special, you know, specific, specific types of circumstances that might require that.

And so we’ve had to add a lot of types of housing that. Aren’t just suitable for older adults, but for all of these people, and you know, especially where it’s interesting is where the older adult and the lower income population coincide. These dual eligible, dually eligible members for both Medicare and Medicaid, those are really vulnerable members.

They’re very high cost to the health plan. And as a result, they’re very you know, hot. Are very hotly interested by the health plan to help stabilize from a housing perspective. So we’ve been really successful there as well in terms of the actual physical inventory, you know, for us. The process is very similar, so we’re running the same process on understanding and determining what inventory is suitable for an older adult or suitable for a Medicaid recipient.

It’s just a matter of, you know, filtering out one thing or another, dependent on the member’s specific needs. And everything’s very individualized that we do, and thankfully we have technology as a backbone of this that allows us to do this really quickly. And so what, what really is our secret sauces?

This proprietary network of inventory that we have real time visibility into that can provide these most vulnerable members among us access and advocacy to get them housed really quickly. Because if they’re walking off the street trying to find an apartment, you know, the, the kind of the knee jerk reaction from all of our clients at the very beginning of our interaction with them as well, there’s not enough affordable housing.

And what we say is, well, there’s also not a, a. You efficient utilization of the housing that exists. And the reason there’s not an efficient utilization of the housing that exists is because everything’s very pigeonholed. Everything’s very narrowly focused. The local section eight housing authority only sees what’s in their purview.

The local mom and pop landlord that has a multi, you know, multi-tenant apartment complex, they only see the availability in their purview. The case manager that works at the health plan that’s assigned to these members. Only has the ability to go apart to apartments.com or Zillow and see what’s locally available, if that’s even up to date.

And who knows if it meets the standards of that Medicaid member that has a low credit score or a criminal background or a mobility challenge. And so there is no to, until us, there is no centralized place to find real time information on inventory that relates to specific healthcare populations. And that’s what we’ve really done.

And, and that’s changed the game.

Keren Etkin: So how does it work in practice? Are you the, the landlord and the person is renting from you and then Medicare pays them? Or does Medicare or Medicaid pay you directly?

Jake Rothstein: Medicare, Medicaid pays us directly. And we’re not the landlord. We don’t actually carry risk on any of the apartments. There’s, you know, there’s an argument to be made where there’s an opportunity for us to do that, maybe down the road. But what we said is, let’s utilize this existing infrastructure.

Let’s be the facilitator, the advocates, the. The eyeballs, the eyes and ears to what’s available, and get these people the most vulnerable people into the most available housing near them, that’s affordable, that’s sustainable and let’s do that more efficiently and more quickly than anybody else can do it, including the health plans themself.

And so we are kind of that glue that, that keeps the whole system together and that allows the most vulnerable members to be most vulnerable members to be housed really quickly. The second part of that and, and I think the reason we provide a lot of value to our customers is the data piece. We track everything.

We track everything from the first interaction with our member to until the time that they’re housed, and then beyond the time that they’re housed to, to ensure that they stay housed long term. ’cause that’s a really. Also a really big problem. You can house someone and you might be able to house ’em temporarily, but the recidivism rates on becoming unhoused again for someone that’s housing unstable is are, they’re very high.

So they need consistent touches, they need consistent interactions, and they, those interactions need to be appropriate. They need to be timely, and they need to be relevant to the, to the member that we’re serving. And so. We can, you know, we can do that and we can provide the data back to the health plan that says, okay, here’s the justification for this program.

Here’s the reason. Here’s the kind of realtime ROI that you’re experiencing as a result of this missed DR visit or this primary care visit that happened as a result of our engagement with them. And so that data layer is a really important element of all of this that sits on top of the actual housing infrastructure.

Keren Etkin: Is retention. A big part of the incentive for Medicare Advantage, at least to work with you because if someone is on a specific Medicare Advantage plan and they have their housing paid for, and then maybe if they switch to another plan, they don’t work with you, so they have to find another apartment.

Jake Rothstein: Yeah, I, and I will let, I’ll clarify one point. We’re not actually, Medicare’s not paying for the rent. They’re paying for everything that’s ancillary to rent in some cases. In Medicaid specifically, we utilize what they call flex fund dollars. And flex fund dollars are dollars that sit at the health plan level, at the state level, at the health plan that are to be used, that are allowed to be used on things that are ancillary to rent.

Things like security, deposit assistance, things like rental payments and arrears, things like utility assistance. What we learned doing this is that, that so many of the barriers to stability for, for vulnerable members and for vulnerable people are those security deposits, right? Like, I can afford the rent, I can afford to make rent.

’cause my job, I barely can make it, but. I don’t have any money saved for a security deposit. I need $2,000. And the health plan historically has not been good at distributing those dollars. They don’t wanna give it to the member themselves because there’s, you know, trust issues there, and they don’t have the relationships with the landlords that we do.

So we become the fiduciary, the intermediary for those flex fund dollars. To the landlords themselves. And as a result of that, we unlock so many people from instability to stability by facilitating that those transactions and efficiently utilize those dollars that are just sitting on the sidelines, either unutilized or underutilized.

Today. So it’s a really important you know, it’s a really important element of our success and we see that applied through, you know, throughout, you mentioned retention, retention’s, incredibly important. Acquisition’s important on Medicare Advantage from a marketability standpoint. Using this program as a marketable asset for older adults that specifically know they’re coming into a period of their life where they might have to downsize or they might have to s look for an assisted living facility or a, some sort of senior living facility.

Those are really important selling points, but like you said, once they have the help with something that’s so important as housing from you know, an entity that’s associated with their health plan, stars ratings go up. H DDIs scores go up on the Medicaid side. Retention increases as long as we’re keeping them in the population, in the, you know, the plan area and the coverage area, which most of the time happens because we work to make that happen.

Yeah, all those things are a factor.

Keren Etkin: Is brilliant. so. What happens when someone sort of grows older? They’ve, they’ve been on Medicaid and now they’re older and they’re, they’re now they’re dually eligible. do they sort of check with you before they transition into Medicare to see the, whether Medicare works with you so they can stay in their current housing?

Jake Rothstein: Typically because the, because the member is paying the rent themselves, there typically isn’t an issue with that. So if they’re transitioning from straight Medicaid to being coming a dual eligible, their benefits only increase and they’re able to stay where they’re, when you know where they’re located.

So that’s typically not an issue where we do see interesting kind of transitions. And where we help with this is the transition from acute long-term for, from skilled nursing from an acute type of injury or recovery back to independent or more independent living situations. We work with a big payer, a big national payer in Florida.

On a transition from long-term care program. And essentially what that means is they have a population of older adults predominantly, that lives at, or has lived in a skilled nursing, A SNF facility for six months or more. And as you know, those skilled nursing facilities are incredibly expensive to the system that could be $3,000 a day for a very high level of care.