01/06/2011 Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals Literature Synthesis and Environmental Scan Publisher: US Department of Health and Human Services Author: Martha R. Burt, Carol Wilkins, Danna Mauch

Introduction

This document is the first product of our Environmental Scan, reflecting existing published and unpublished literature on permanent supportive housing (PSH) for people who are chronically homeless. It has a particular focus on the role that Medicaid currently plays in covering the costs of the supportive services that help people keep their housing and improve their health and quality of life. In addition to written material, this document incorporates the knowledge of housing and service configurations and ways that providers have been able to cover the cost of supportive services, garnered over our many years in the field. It also reflects some information we received through telephone conversations preliminary to making recommendations for communities to visit. This version of the literature synthesis will be augmented with the results of site visits and in-depth telephone interviews to form the final Task 4 product.  
 
We know from much research that “supportive housing works” (Caton, Wilkins, and Anderson, 2007). But we also know that it is always a challenge to assemble the resources to sustain supportive housing tenants in their housing, due to their long histories of homelessness and complex health and behavioral health conditions. 
 
Current strategies in the United States for financing the supportive services component of PSH are far from optimal. Ideally, these supportive services would include housing stabilization early in a person’s PSH tenancy, integrated provision of primary care, mental health and substance use conditions care, medication optimization and management, dental care, and overall continuing care management. They might also include supports for entering and sustaining employment, reconnecting with family, and participating in the life of the community. Given all the service elements that need to be coordinated and integrated to reach this ideal, the best programs (those with the best housing and other outcomes for tenants) invest a good deal of time in case conferencing, meetings between landlord/property managers and service team members, and other practices designed to keep tenants stably-housed and adequately supported. 
 
Best practices in integrated care have their challenges, but increasing numbers of PSH housing/service teams are meeting them. One of the biggest challenges is finding the resources to support all the activities that lead to stably-housed tenants. This challenge is amplified by the restrictive eligibility criteria that govern Medicaid, which might otherwise be able to cover many of the costs of PSH services. In addition, there are even more restrictive eligibility criteria for some types of Medicaid-covered services, based on “medical necessity” or “service necessity” in relation to severity of diagnosis or impaired functioning. Medicaid eligibility is slated to expand greatly in 2014 under the Affordable Care Act, but even then there will be challenges similar to many that are observable today that will need to be met and resolved before Medicaid can serve as a more reliable funding resource for PSH tenants. Thus it is important for us to understand today’s challenges in using Medicaid and the ways they are being addressed, so future uses of Medicaid under the Affordable Care Act may be designed to facilitate rather than stymie the use of Medicaid to help chronically homeless and disabled persons leave homelessness and sustain housing. 
 
Funding for homeless, behavioral health and other health care services currently being used for supportive housing tenants is often fragmented across many public sector programs and agencies and the non-profit service providers they support. Funds flow from different state and county agencies, through different entitlement and benefit programs governed by their own regulations and mandates. This complicated picture includes state and county appropriations (homeless, mental health, substance abuse, criminal justice, public health) and federal programs and funded entities (Department of Housing and Urban Development (HUD), Medicaid, Medicare, Substance Abuse and Mental Health Services Administration (SAMHSA) Block Grants and program grants, and Health Resources and Services Administration (HRSA) Primary Care Block Grants, Federally Qualified Health Centers (FQHCs), Community Health Centers (CHCs) HealthCare for the Homeless (HCH) Programs, other sources of funding for homeless programs, and Ryan White Grants). From the prospective enrollee’s point of view, 
program rules often conflict or leave large components of service need uncovered. 
 
Finding the resources to support specific service elements such as primary care, mental health treatment, or dental services is difficult enough. The hardest element of care to fund, though, is “the glue” that holds them all together in the service of providing PSH tenants with holistic care. “The glue” includes: 
  • Early activities to induce prospective tenants to accept housing and stabilize new tenants in housing and to engage them in the services and supports that will address their health, mental health, and addictions problems. 
  • Care coordination, including planning, involving staff able to offer all the different services needed, assuring regular consideration by team members of the tenant’s well-being and challenges to it, and, most of all, establishing a relationship of trust, openness, and support with each tenant. 
  • Team-building with support staff from multiple disciplines, training, and agency affiliation, independent of handling individual cases, including cross-training. Making this happen often requires external influence to bring the relevant parties together and keep them together. 

The Office of the Assistant Secretary for Planning and Evaluation’s (ASPE’s) primary interest in this project is in learning as much as possible that will help it shape the most useful possible demonstration and, ultimately, structure access to Medicaid and appropriate care once Affordable Care Act provisions render most people who are homeless eligible for Medicaid in 2014. ASPE is already convinced that PSH works, and has recognized that the Department of Health and Human Services’ (HHS’) primary resource to support PSH, Medicaid, is less widely used to pay for needed services than might be the case. A good bit of this underuse occurs because a relatively small percentage of people who are chronically homeless are eligible for Medicaid and an even smaller percentage are actually recipients, either before or during PSH residence. Many people who are chronically homeless will qualify in 2014 under the Affordable Care Act, or earlier for early implementer states, do not qualify now, but it is also true that many who could qualify now are not beneficiaries because the hurdles in the way of establishing eligibility are many and high.  

Other factors contributing to underuse include insufficient provider capacity, administrative/ bureaucratic barriers to expanding the provider base, and inadequate opportunities at the state and local levels to match Medicaid expenditures as required by law. State and local budget limitations are particularly important, because most of the services that could be financed by Medicaid in PSH are covered as optional Medicaid benefits. States have considerable flexibility in deciding whether to cover these benefits and how to tailor provider qualifications and reimbursement rates as well as medical necessity criteria governing their use. Many states facing budget shortfalls have reduced coverage for optional benefits under Medicaid or are considering significant reductions that could limit opportunities to use these benefits to reimburse new service providers or to expand the availability of Medicaid-covered services for PSH tenants. 

Despite these challenges, some communities, and some provider agencies, have developed ways to help people who are chronically homeless establish eligibility, just as they have developed ways to use Medicaid to cover a variety of treatments and services, delivered by several different types of agency. To support ASPE objectives in planning for the evaluation of the PSH Voucher Demonstration, this document summarizes existing published literature, unpublished program documents, and information obtained from telephone conversations with key informants, to: 

  • Provide evidence of how much benefit derives from PSH, in terms of avoiding crisis health care costs and enhancing the health and well-being of PSH tenants. The authors address this in Section 1 of this synthesis. 
  • Describe the basics of housing options for people who are chronically homeless and how supportive services currently complement them and identify the ways that Medicaid is currently being used as one source of funding for supportive services in PSH. We do this in Section 2 of this synthesis. 
  • Identify the most effective practices currently in use to increase Medicaid enrollment among people who are chronically homeless and formerly homeless, through both categorical eligibility (via Supplemental Security Income (SSI)) and other mechanisms, and to get current Medicaid beneficiaries among those who are chronically homeless into PSH. We do this in Section 3 of this synthesis. 

In Section 4, we preview how the implementation of health care reform could affect Medicaid funding of services in PSH. Finally, in Section 5 we summarize what we have learned in this first stage of the environmental scan. The authors discuss the implications of findings, including how the results of a demonstration of PSH could contribute to creating the most effective possible Medicaid Program in 2014 under the Affordable Care Act.

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