In recent years a growing number of Health Care for the Homeless programs and a small number of other Health Centers have developed programs designed to engage and provide ongoing health care and supportive services linked to permanent housing for people with histories of chronic homelessness. To implement these programs, Health Centers work in collaboration with numerous partners, including providers of community-based mental health services and housing support services. They may also partner with providers of housing assistance that may be administered by public housing authorities (PHAs) or available in PSH operated by nonprofit housing organizations.40
4.3.1. Examples of PSH/Health Center Partnerships
In several case study communities, a few Health Centers were very actively engaged in expanding their roles in providing services linked to PSH, and other Health Centers were considering or planning to do so.
In Los Angeles, expanding the role of Health Centers as service delivery partners in PSH builds on the experience of Skid Row's Center for Community Health run by JWCH, the largest Health Center serving a predominantly homeless population. JWCH has a decade of experience providing services in PSH. Other Health Centers that serve a large number of people experiencing homelessness include LA Christian Health Center in Skid Row and Venice Family Clinic, both of which are now collaborating with providers of mental health and homeless services linked to site-based or scattered-site PSH. Several additional Health Centers have more recently participated in partnerships to engage and link housing and services for some of Los Angeles County's most vulnerable people, including people who are chronically homeless.
Los Angeles County's Department of Health Services designates most of the Health Centers that serve people who are homeless as "community partner clinics."41 This designation allowed the centers to receive reimbursement at the FQHC rate when they serve people enrolled in coverage through Healthy Way LA, the Low Income Health Plan established under the terms of California's Medicaid waiver.42
These Health Centers played a significant role in assisting thousands of uninsured people who have experienced homelessness to get enrolled into coverage through Healthy Way LA before 2014, and are playing a similar role to encourage enrollment into Medicaid now. The Health Centers hired staff to help people obtain documentation and complete the application and to navigate the eligibility redetermination processes. Although it has been a bumpy road, the Health Centers are now receiving reimbursement for a much larger share of their previously uninsured patients, including a larger share of the tenants in PSH.
For at least a decade, JWCH has been delivering services in PSH for people who are chronically homeless. Initial involvement came through JWCH's partnership with the Skid Row Housing Trust in the Skid Row Collaborative that was funded from 2003 through 2007 under the federal HUD/HHS/VA Chronic Homelessness Initiative.43 Project 50, which Los Angeles County launched in 2008, built on relationships begun during the Skid Row Collaborative, including a satellite clinic in a site-based PSH project developed by Skid Row Housing Trust. A JWCH primary care provider works in partnership with Skid Row Housing Trust case managers to deliver services to PSH tenants, many of whom were chronically homeless and prioritized for access to available housing units because of their vulnerability.
To obtain Medicaid reimbursement for health services provided by clinicians who go to streets or encampments to see people experiencing homelessness, make home visits in scattered-site PSH, or staff satellite clinics that operate for a few hours each week in shelters and in site-based PSH, JWCH and other Health Centers include a description of these services and locations in the project scope information they provide to HRSA in conjunction with their federal grant funding. The clinic location is used as the billing code for these services.
In addition to receiving HRSA Health Center grant funding and Medicaid payments as an FQHC, JWCH's multidisciplinary teams often rely on other sources of funding, including grants or contracts from Los Angeles County and other sources to provide some mental health and substance abuse services. JWCH also has become certified to provide some Medicaid-covered mental health and substance use treatment services outside of the FQHC Medicaid reimbursement. During the case study period, JWCH also began receiving Medicaid reimbursement for Medicaid-covered services provided in a residential treatment setting that serves some women who are homeless. Medicaid reimbursement is also available for some outpatient substance use treatment services, but JWCH has found it challenging to use this as a funding source for services to people who are chronically homeless and for PSH tenants.44
In Minnesota, Catholic Charities of St. Paul and Minneapolis developed Higher Ground, a seven-story building that combines overnight emergency shelter on the first two floors, 74 single-room occupancy (SRO) supportive housing units, and 11 affordable efficiency units on the top floor. The Higher Ground Clinic located on the ground floor of the building, staffed by the Hennepin County Human Services and Public Health Department's Health Care for the Homeless program, opened in June 2012.
The clinic operates three days a week, mostly during evening hours when people are at the shelter. It serves people using shelter services at Higher Ground or other nearby facilities, as well as the PSH tenants living in the SRO and efficiency units on the upper floors of the Higher Ground building.
The Higher Ground Clinic is the first site where Hennepin County's HCH program is delivering services to PSH tenants. It was designed to accommodate and offer assistance to the most vulnerable people in the community, including people who are chronically homeless. When selecting people to move into the PSH units, Catholic Charities prioritized those who had been homeless the longest, including those who had made the greatest use of shelter services and people engaged through street outreach efforts that focused on serving the most vulnerable people experiencing homelessness. The clinic manager reports that the tenants at Higher Ground are "the sickest people we serve" and that many tenants have serious and complex health needs, including people in wheelchairs and those recovering from a heart attack or stroke.
4.3.2. Models for Integrating Primary Care and Behavioral Health
In two case study communities, Health Centers partner with other providers to integrate primary care and behavioral health services.
Unity Health Care/Pathways to Housing Partnership in the District of Columbia
With funding from a SAMHSA grant to support the integration of primary medical care and behavioral health services, Pathways to Housing-DC and Unity Health Care have formed a partnership. Pathways-DC operates a scattered-site PSH program for people experiencing homelessness who have SMI. HUD Shelter + Care certificates subsidize most tenant rents for the privately owned apartments that program participants occupy throughout the community. Unity Health Care is a Health Center that began as a Health Care for the Homeless program and retains that focus within its now-expanded role as a Health Center.
For the service integration partnership serving formerly homeless PSH tenants, Unity Health Care added primary care providers to the Pathways Assertive Community Treatment teams that deliver services for PSH tenants. Unity clinicians deliver services at the Pathways office, where PSH program participants may come to meet with their case managers. In addition, a Unity nurse-practitioner accompanies Assertive Community Treatment teams during home visits and street outreach. Unity Health Care has a homeless outreach component to which this nurse-practitioner is formally attached, so the services he or she delivers can be billed under Unity's FQHC auspices.
Virtually all of Pathways-DC clients are Medicaid beneficiaries, mostly because their mental illness qualifies them for SSI. Some people contacted through outreach who are not yet beneficiaries would qualify for Medicaid because the District of Columbia expanded coverage in 2010 to people with incomes below 200 percent of the federal poverty level, and the enrollment process is relatively easy and quick. In the past year the more than 500 clients of Pathways-DC have made almost 1,000 Unity clinic visits, increasing the health care engagement of this very vulnerable population. Most of these people used health care infrequently before the Pathways-Unity partnership was established.
Integrated Mobile Health Teams in Los Angeles County
The Los Angeles County Department of Mental Health has funded five Integrated Mobile Health Teams using funds set aside by California's Mental Health Services Act for testing innovative care models. The team model is designed to serve people with SMI who also have other vulnerabilities, including advanced age, many years of homelessness, co-occurring substance use, or other physical health conditions that require ongoing primary care such as diabetes, hypertension, cardiovascular disease, asthma or other respiratory illnesses, obesity, cancer, arthritis, and chronic pain.
Each multidisciplinary team is staffed from 1-2 mental health service providers and a Health Center. As specified in Department of Mental Health contracts, the vision is for staff from these partnering organizations to work together "as one integrated team to provide mental health, physical health, and substance use services" and "operate with one set of administrative and operational policies and procedures and use an integrated medical record/chart to ensure integrated and coordinated services." Team services are intended to increase immediate access to housing by using a housing-first approach that incorporates harm reduction, motivational interviewing, and access to housing without requirements for treatment, sobriety, or "housing readiness." Each team partners with a PSH developer(s) to have housing units dedicated to the team's clients. Except for a few administrative activities and medical procedures that require an established setting, virtually all team services are delivered in the field, including engaging people experiencing homelessness on the streets and making home visits to people in PSH.
For outreach and engagement work, the team's mental health and medical staff go together to the streets, encampments, and other "hot spots" to engage potential clients and talk to social workers at shelters and hospitals. The team tries to find highly vulnerable people who have not been well-connected to mental health services. Providers report that the people they serve through these Integrated Mobile Health Teams are sicker, more vulnerable, and have more severe and untreated mental illness and/or substance use problems than the people their agencies usually serve. Nearly all have co-occurring substance use disorders and most are uninsured at the time of enrollment.
Medicaid and Integrated Mental Health Team Services
Although many of the people served by the teams were uninsured when they first became clients, the teams have helped about half of their clients to enroll in Medicaid. Before 2014, the remaining clients were either enrolled in Healthy Way LA, the county's program offering coverage under California's Medicaid waiver, or uninsured. The teams worked to help their uninsured clients to enroll in Healthy Way LA, often doing so in conjunction with helping them gather the documentation needed to complete applications for housing assistance. Much of the documentation needed to establish eligibility (identification, proof of citizenship or residency, proof of income) was the same for both housing assistance and health coverage under the waiver. Thus, the teams worked with a client to gather the documentation once and used it for multiple applications. Most people who enrolled in Healthy Way LA became eligible for Medicaid in 2014.
Mental Health Services Act funding administered by the Los Angeles County Department of Mental Health for the Integrated Mobile Health Teams provides the nonfederal matching funds to leverage reimbursement through Medicaid. The service funding for the teams also leverages other resources for program participants, including housing assistance funded by other programs. The service providers are expected to use the Mental Health Services Act funds for costs that cannot be reimbursed through other funding sources. As of early 2013, only a fraction of the teams' costs were being covered through Medicaid reimbursement--usually half or less. The Department of Mental Health expects that Medicaid reimbursement will cover an increasing portion of project costs and contribute to the financial sustainability of these program models in the future. In addition to the flexible Mental Health Services Act funding administered by the county, several of the teams have also received grant funding from foundations to build their capacity and cover a portion of staff salaries and other costs for services that are not covered by Medicaid.
The vision of fully integrated teams, with shared procedures and records, is ideal for people who experience chronic homelessness. Payment mechanisms and bureaucratic procedures, however, still have some catching up to do, as the providers working to implement the model must still meet separate state and county agency requirements for documenting and billing for Medicaid reimbursement. Service providers reported that the billing mechanisms for FQHC and mental health services are completely separate and different, and that the separate payment mechanisms were not designed or modified to support or accommodate integrated care. This has created some frustration for team members and a learning curve for their organizations as they build collaborative partnerships without being able to fully integrate record-keeping and billing systems.
Example: The Exodus Recovery/LA Christian Health Center Team45
This Integrated Mobile Health Team partners with Skid Row Housing Trust for the PSH that its clients use. The trust set aside 50 apartments in one of its new PSH projects to provide permanent housing for people experiencing homelessness who are eligible to receive mental health services, including tenants who are served by this team (other units in the building are for low-income residents but are not designated for people experiencing homelessness or people with disabilities). Skid Row Housing Trust case managers work with building tenants and are integrated into the team's activities.
Because a PSH unit may not be immediately available when the team has a client willing to accept housing, the team tries to get people into interim "safe harbor" housing on the same day that they complete the assessment and enrollment process. Providing interim housing if needed reduces the chances that the team will lose the client while gathering the documentation needed to complete the application process for a housing subsidy and finding or waiting for a permanent housing unit. Arrangements to move into a permanent unit are made as soon as a unit becomes available and the client has been approved for a housing subsidy. The team establishes a coordination plan with each client from day one, which it updates after 3-6 months. The plan is flexible and can be adjusted based on new information and new goals.
Formal and informal opportunities for team members and clients to interact are plentiful. Health Center medical staff hold clinic hours every Thursday on-site at the PSH building, and also come to the building every day to participate in a morning meeting with other team members. Each day one of the team's case managers "patrols" the building, making the rounds, knocking on doors, and checking on tenants to ask how they are doing. This provides a chance to ask people if they are taking their medications and if they have any complaints or concerns. There is a cooking group and, at the end of the group meeting, an "ask the doctor" session with the team's medical provider and a mental health clinician from Exodus Recovery.
Exodus has long been a Medicaid provider through its contracts with the county's Department of Mental Health. Its primary care partner on the team, the LA Christian Health Center, became a Healthy Way LA provider in late 2012, qualifying it for the first time to receive reimbursement for care provided to Healthy Way LA members. The Exodus/LA Christian Health Center team reported that about 20 percent of its clients had Medicaid at the time of enrollment in services; the team was able to increase this proportion to about 50 percent over a period of eight months. The team includes a staff position that focuses on benefits, filled by a couple of people who are familiar with the SSI application process. The team also asked the state to designate staff for processing SSI applications from program participants to increase the speed and success of the application process and thereby also qualify more people for Medicaid by reason of being SSI recipients.
4.3.3. Models for Serving Frequent Users of High-Cost Care
In both Los Angeles and Chicago, Health Centers participate in collaborative partnerships that work to identify, engage, and deliver services and housing to people who are chronically homeless and have frequent and avoidable hospitalizations and emergency room visits. These projects seek to improve health outcomes and housing stability for program participants while also significantly reducing the high costs associated with the avoidable use of crisis services.
In Chicago, Heartland Health Outreach and the AIDS Foundation of Chicago (AFC) are partnering in a Medicaid Supportive Housing Project that uses HUD grant funding for 48 units of scattered-site supportive housing and intensive case management services, and leverages Medicaid reimbursement and other funding obtained by Heartland Health Outreach for services it provides to program participants.
The project serves people experiencing homelessness who have been identified as high users of Medicaid-reimbursed services. The Illinois Medicaid agency analyzed service use and cost patterns of its Medicaid beneficiaries and divided the population into deciles representing shares of Medicaid service costs. The state has calculated the average Medicaid costs for each decile and found that the top three cost deciles (accounting for 30 percent of the costs) include only about 1 percent of people enrolled in Medicaid.
The project targets people experiencing homelessness whose Medicaid use falls in the top six deciles.46 As project staff identifies homeless individuals at hospitals and other locations, they conduct initial assessments and then submit prospective client names to the state Medicaid office to see which cost decile the person is in. This allows AFC to estimate participants' presupportive housing Medicaid costs (based on the average for persons in that decile) without obtaining the details of each person's actual service utilization history or costs. Using average annual costs for the deciles of the first 49 people served by the program, AFC estimates that their total annual presupportive housing Medicaid costs were more than $50,000 per person per year, or at least $2.5 million for the group.
Nearly all the project's clients were chronically homeless, and nearly all have a serious mental illness or substance use disorder--usually both. Most have spent time in jail or prison, usually as a result of drug-related charges. As program implementation continues, the project will give its partners the opportunity to better understand the differences among Medicaid users with the highest costs, and between that group and those with costs that are still significant but in lower deciles, including differences in needs, characteristics, and success in supportive housing.
Case managers funded by the project's HUD grant devote most of their time to helping clients get and keep housing. This often includes working with clients to address substance use issues. Case managers coordinate with primary care providers at Heartland Health Outreach and with other health care services, and they help program participants keep appointments and follow through on the medications and recommendations they receive from their health care providers. For PSH tenants who receive care from Heartland Health Outreach, the case managers have access to electronic health records, with client consent, and this makes care coordination easier and more effective.
In Los Angeles, the Corporation for Supportive Housing and the Economic Roundtable are collaborating to support the implementation of partnerships that involve 17 hospitals, seven Health Centers, and more than a dozen organizations that provide housing and social services navigators, permanent supportive housing, interim housing, benefits advocacy, and other supports. Seven collaborative projects have been developed through the Corporation for Supportive Housing's Frequent Users Systems Engagement (FUSE) Program, funded through several foundations and federal grants, and a Social Innovation Fund (SIF) grant from the Corporation for National and Community Service. Each project seeks to engage high-need people experiencing homelessness who have been identified by participating hospitals as "frequent users."
When potential participants are identified--usually when a person who is homeless is receiving inpatient care at the hospital or making repeated visits to the emergency room--hospital social workers contact FUSE project staff to determine whether the person is likely to be among the most costly 10 percent of people experiencing homelessness and using crisis services. FUSE staff make this determination using a triage tool developed by the Economic Roundtable that identifies homeless people likely to be in the tenth cost decile. In 2012 the Economic Roundtable revised the triage tool to use data that is likely to be available in hospital settings, using diagnostic information, demographic characteristics, and other information that people experiencing homelessness themselves can provide.47
Most of the direct services offered by the FUSE/SIF projects are delivered by the partner organizations in each collaborative that take responsibility for social services and housing navigation. These providers (known as navigators) use grant funds to pay for a team that delivers an array of flexible services, including case management; assistance with applications, including those for SSI, Medicaid, and housing assistance; and interim housing and connections to permanent supportive housing. The navigators also facilitate rapid connections to medical care at the partnering Health Center as well as mental health and other behavioral health services as needed.
The navigators help program participants get to their appointments at the clinics and work to solve problems related to engagement in and access to health care and other services. Sometimes the offer of temporary or interim housing and help to access permanent housing makes the FUSE project very attractive to people who might not otherwise be willing to engage in services, while other people may be ready to try a residential treatment program after a serious health crisis serves as a "wake-up call" about the health consequences of alcohol or drug use and life on the streets.
In most cases the Health Center partner in these collaborative projects is receiving little or no grant funding to support FUSE or SIF project implementation, and many of the participating Health Centers have not made significant changes in their approach to delivering medical care to the people experiencing homelessness served by these projects.
Instead, the navigator is responsible for helping FUSE project participants get connected to care at the Health Center and may help the participant get to appointments and communicate with medical providers. While some of these Health Centers have a long history of serving people experiencing homelessness, others have little such experience, and even less experience serving chronically homeless people with challenging behavioral health issues. Participation in a FUSE project is increasing awareness at these Health Centers of the needs of frequent user patients with behavioral health problems and those who are experiencing chronic homelessness, but in general these centers have not changed their practices to deliver care through home visits or in other settings, or to assign Health Center clinicians to work as members of interdisciplinary teams.