In many communities, some PSH serves all three groups of chronically homeless people--whether or not people are eligible for or enrolled in Medicaid, and whether or not people have a SMI that makes them eligible to receive specialized mental health services. Before we describe the types of housing and services most often available to members of each group, we will describe some program models that serve chronically homeless people who are in all three groups.
PSH that is available to all three groups of people may be implemented in any of the three housing configurations (dedicated building, scattered-site, and mixed-use) described in the Introduction. It is important to keep in mind that these PSH service-providers rely on other, non-Medicaid sources of funding to pay for services in these programs, and may receive Medicaid reimbursement for only a portion of the services they deliver to some of their tenants. In a study of PSH in six communities in 2007, Medicaid, local public agency contracts, and HUD SHP grants contributed about equal shares to PSH services funding, and still made up only three-fourths of all service funding reported (Burt, 2008a, Table 3.7). It is rather common for PSH projects to assemble ten or more different funding sources to support the services their tenants need.
Agencies that provide PSH to people in all three groups often are not qualified Medicaid providers. If they want to integrate care for their tenants, they need to partner with other agencies to offer the full range of behavioral and primary health care services. Common arrangements include: (1) having strong, well-established partnerships with other agencies to cover all the pieces; and (2) offering the housing as well as very comprehensive services within their own walls. Through these arrangements many PSH providers are able to serve the entire spectrum of homeless and chronically homeless people. For tenants without insurance coverage at first contact, these agencies have become skilled at helping clients qualify for benefits and also for SSI if they are in Groups 2 and 3. Additional details on their services and ability to use Medicaid to cover service costs are available in the second paper in this series, Medicaid Financing for Services in Supportive Housing for Chronically Homeless Persons: Current Practices and Opportunities (Wilkins, Burt, and Mauch, 2012).
3.3.1. Integrating Primary Health Care with Behavioral Health Services for People
One of the greatest challenges for providing the full range of services that PSH residents need is integrating behavioral health care with primary health care. Relatively few mental or behavioral health providers working with PSH tenants offer primary care services through their own staff or through established partnerships with a medical care provider. Instead, these providers refer tenants to local community clinics or other health care providers for primary care. Such arrangements often mean that behavioral health providers do not have information they need about their clients physical conditions or care received for them, despite the best efforts of case managers to get this information when they accompany clients to primary care appointments. Conversely, these arrangements almost always mean that primary care providers do not have sufficient information about their patients behavioral health conditions and treatment that may be affecting their physical health, including prescribed medications that will interact in unknown and perhaps harmful ways with anything the primary care physician may prescribe. None of this is good for PSH tenants.
To address this problem, some PSH service-providers have integrated primary health care with mental health and addictions recovery services to create holistic, integrated service teams. Site visits for this study and other experiences suggest that full (or very close to full) integration is most likely to happen when the same organization employs both medical and behavioral health staff and is able to integrate client records as well as staff across different service departments. The organizations able to establish this configuration are most commonly federal qualified health centers (FQHCs), but sometimes behavioral health service-providers hire primary care staff to be part of these integrated health care teams. Alternatively, FQHCs or other primary care agencies and behavioral health service-providers create partnerships, each hiring staff within its organizations area of expertise and available funding and, working together, they create highly integrated multi-agency health care teams.
Partnership arrangements that provide the various components are unique to each community and depend on agency capacities and interactions developed over many years. Examples visited for this study include both partnerships and umbrella agencies. Organizations participating in partnerships may include two or more of the following:
Housing developers or housing management companies.
Mental or behavioral health agencies.
Agencies that offer primary care such as FQHCs, Community Health Centers (CHCs), and Health Care for the Homeless (HCH) programs. Dental, vision, hearing, and clinical pharmacy services are sometimes also included.
Boston Health Care for the Homeless Program (BHCHP) is integrated both vertically within the health care system and horizontally across the larger world of social welfare, community service, and PSH agencies in Boston. Its primary health care site is at Boston Medical Center, the largest safety net care system in Boston. It also is affiliated with Massachusetts General Hospital and Partners Healthcare System, the largest private health care system in Massachusetts. Treatment and supportive services teams include physicians, physician assistants, nurse practitioners, nurses, case managers, and behavioral health practitioners. Activities and locations cover the range of outreach and engagement, clinical care (at 75-80 locations including the streets and client homes), dental care with on-site laboratory services, pharmacy and lab services, vision services, support for PSH tenants in their own home, medical respite care, and housing. BHCHPs clinical and community support teams (CSTs) helped move over 300 BHCHP clients into housing run by numerous partners offering PSH.
Lifelong Medical Care, a CHC in Oakland serving that city and other parts of Alameda County, California, is an FQHC providing primary care. Over many years Lifelong has developed partnerships with PSH providers and a mental health agency to offer integrated care to PSH clients and homeless people. Lifelong employs staff who work full time or several days a week in site-based PSH buildings. Staff members include a licensed clinical social worker (LCSW) who provides counseling for mental health and substance abuse problems, and social workers or case managers who help tenants with a range of issues related to housing stabilization, access to benefits and social supports, and engagement and linkage to health and treatment services. At some PSH sites collaborating partner agencies provide additional on-site services.
The San Francisco Department of Public Healths (SFDPHs) Housing and Urban Health Clinic (HUH) works with the departments Direct Access to Housing (DAH) program and numerous other PSH providers. HUH is an HCH FQHC. Most of its staff are doctors (including psychiatrists) and mid-level practitioners or nurses; HUH employs relatively few case managers who are not licensed. HUH nurses work at several PSH sites, where they assess and monitor health needs of tenants and help with medication management. PSH sites that are part of the SFDPH DAH program usually also have on-site case managers employed by a partner organization that is a community mental health services provider at some sites and a homeless service-provider at other sites. On-site case managers are funded through HUD supportive-services-only grants and/or county funding through SFDPH.
Community Housing Partnership (CHP) in San Francisco exemplifies a model of a project-based PSH provider that delivers housing and services in its own buildings and sometimes in other buildings in partnership with other housing and/or services providers, and works with other partners to offer specialized services. CHPs primary mission is providing PSH to homeless people. CHP sometimes partners with the SFDPH to provide on-site case management services in PSH buildings that are part of SFDPHs DAH. CHP is just now getting certification as a non-traditional provider of Medicaid mental health services and will begin billing for clinical mental health services for tenants with SMI. CHPs newer PSH projects focus on homeless seniors and people with high levels of medical need. The citys referral process and priorities have resulted in increasing numbers of PSH tenants with very long histories of homelessness and high rates of chronic medical conditions, including cardiovascular conditions, diabetes, and long-term effects of physical injuries and pain. Many tenants have long histories of alcoholism in addition to medical problems, and need medical case management including help to link to primary care, get van service to get to appointments, manage oxygen tanks, and similar issues.
Umbrella agencies supply all the care, having within their organizational structure all the components needed to support PSH tenants. Such organizations create and operate their own housing or arrange for housing in the private market, do integrated behavioral health and primary care, and operate using an integrated team structure that includes housing staff.
Heartland Health Outreach (HHO) in Chicago is an arm of Heartland Alliance, which also has arms that develop affordable housing, provide extensive family supports, help households increase their economic security, and offer legal advocacy. Services of all arms are available to PSH tenants who need them. HHO offers primary health care as an FQHC. It provides mental health and substance abuse services under two different state Medicaid rules, and has developed and runs its own Safe Haven and project-based PSH. It offers health care at dozens of locations, including its own PSH and PSH run by other organizations; conducts extensive street and other outreach including with its medical services; and facilitates its clients applications for SSI and Medicaid.
Community Healthlink in Worcester, Massachusetts is a comprehensive home and community-based services (HCBS) agency affiliated with the University of Massachusetts Memorial care system, working in the greater Worcester and Central Massachusetts area. Community Healthlink provides a full range of services delivered to persons with mental health and substance use conditions through four operating divisions--youth and families, adults, residential services, and homeless services. Homeless services center around the Homeless Outreach and Advocacy Project, which links homeless persons to many Community Healthlink services including health screenings and evaluation, health care counseling, substance abuse detoxification and rehabilitation, the Homeless Emergency Assessment and Response Team, its crisis stabilization units, and referral to other support systems. Community Healthlink integrates the behavioral health care provided through its community mental health center (CMHC) with the primary health care offered at its HCH program and two affiliated FQHCs for families and individuals. The Community Healthlink model of care integrates primary care, behavioral health care, dental care, and case management services.
Being in the same umbrella organization does not always resolve all the challenges of integrated health care. Even when the same organization provides both primary care and behavioral health services, program funding and/or certification rules may require the organization to provide these services in separate programs or components that may have separate eligibility criteria, reimbursement mechanisms, staff and clinical supervision, and sometimes separate locations. In Chicago, for instance, HHO must maintain a specific space that is certified for substance abuse treatment. To be reimbursable under Medicaid, all care related to substance use must occur in that space--even though an integrated team member who usually works in that space could easily walk one block to work with a client in his or her own housing, if that client were unable or unwilling to come to the designated location.
Fully integrated models of health care have some important advantages from the perspective of engaging clients and ultimately being able to address all of their needs. Each component of integrated health care offers a separate access point, some of which may initially be more acceptable to potential clients than others. For example, some chronically homeless people with SMI are initially unwilling to accept a mental health diagnosis or mental health treatment, but will accept care for medical problems such as skin conditions or upper respiratory illnesses, or may be motivated to seek care because of more serious and life-threatening medical problems such as cancer or heart disease. If the person meets a primary care clinician who offers sensitive and non-judgmental care to address medical problems, the essential element of trust can be established and primary care can be the door to treatment for other problems.