Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field. 4. Health Centers, Health CARE for the Homeless Programs and Federally Qualified Health Centers

Chapter 4 Highlights

Health Centers, including Health Care for the Homeless programs generally receive federal grants from HHS's Health Resources and Services Administration to provide comprehensive primary care and preventive services to low-income people in underserved communities. These Health Centers can also receive Medicaid reimbursements as Federally Qualified Health Centers. Among case study sites, FQHCs in Chicago, Los Angeles, and Washington are significant providers of health care and other services and supports to people with histories of chronic homelessness and to PSH tenants. They offer models of possible strategies that other communities could adopt.

Health Centers, including Health Care for the Homeless programs, face considerable changes as the Affordable Care Act moves into full implementation. Until 2014, over a third of their patients had no private or public insurance; many of the uninsured will now be Medicaid-eligible in states that expand Medicaid. The Affordable Care Act provided $11 billion in federal funding over five years to expand the Health Center program, with the goal of expanding access to health care services as more people in low-income communities obtain coverage. The volume of Health Center visits increased from 38 million in 2000 to 80 million in 2011, with more than one in six low-income people nationally receiving their care from these centers (Kaiser Commission 2013). Federal funding has expanded the number of Health Center medical staff, as well as staff who provide dental and mental health services.

Most patients of Health Care for the Homeless programs will become eligible for Medicaid coverage based on their low incomes if they live in states that expanded eligibility based on income in 2014. But barriers to Medicaid enrollment will likely persist for some people with histories of chronic homelessness because they lack reliable contact information or required identification documents, or find it difficult to navigate the application and eligibility determination process. In Los Angeles, PSH and homeless assistance providers have worked closely with Health Centers to help uninsured people access Health Center services and, if eligible, to enroll in Medicaid.

FQHCs are paid an "all-inclusive" rate for each visit a Medicaid patient makes with qualified staff. These pervisit rates often appear higher than Medicaid reimbursement fee-for-service rates paid to other types of providers who serve Medicaid beneficiaries, however, because the reimbursement is a bundled rate direct comparisons are not possible.

As many states increasingly rely on Medicaid managed care plans to provide health care for their beneficiaries, many Health Centers have joined these health plans' provider networks.

A growing number of Health Care for the Homeless programs and a few other Health Centers have developed programs to engage and provide ongoing health care and supportive services linked to permanent housing for people with histories of chronic homelessness. To do so they collaborate with numerous partners, including community-based mental health and housing support service providers and sometimes agencies providing rental assistance or PSH units.

Integration of primary and behavioral health care is an important goal, as is consideration of housing status and recognition of the importance of housing stability for health outcomes.

Best practices for serving people experiencing chronic homelessness or living in PSH often do not align with payment structures and requirements for FQHCs. Challenges include obtaining reimbursement for working "outside the four walls," offering "whatever it takes" wraparound services, using techniques such as motivational interviewing to address substance use issues, incorporating unlicensed staff such as peer support specialists into patient care teams, operating in a multidisciplinary team structure, and work aimed at assuring housing stability.

• 4.1. Introduction

  • Health Centers, including Health Care for the Homeless (HCH) Programs, generally receive federal grants from HHS's Health Resources and Services Administration (HRSA) to provide comprehensive primary care and preventive services to low-income people in underserved communities. These Health Centers generally also receive Medicaid and Medicare reimbursements as Federally Qualified Health Centers.³⁴

    In some case study communities, Health Centers are significant providers of health care and other services and supports to people with histories of chronic homelessness and to PSH tenants, often working in partnership with providers of mental health services and housing assistance. They offer models of possible strategies that other communities could adopt. For example:

    In Chicago, Heartland Health Outreach (HHO) is a Health Care for the Homeless program with clinic, satellite, and outreach components, as well as a provider of PSH, mental health, and substance use disorder treatment, and an array of services for people who are homeless. HHO has developed innovative models of integrated care linked to housing for people who are chronically homeless, including Together4Health, an emerging Care Coordination Entity that we describe in more detail in Chapter 7.

    In Los Angeles, JWCH operates the Center for Community Health, which integrates the delivery of primary care with dental, clinical pharmacy, mental health, and substance use services for people who are homeless in Skid Row. For more than a decade JWCH has been providing health services linked to housing for people experiencing chronic homelessness, and it operates part-time "satellite" centers in some PSH buildings. In the past few years, other Health Centers in LA County have gotten involved in PSH partnerships.

    In the District of Columbia, Unity Health Care was founded as a Health Care for the Homeless program and operates as a Health Center serving low-income and underserved people and communities. Unity partners with Pathways to Housing DC to provide primary care services that are integrated with behavioral health services and linked to housing assistance for people who are homeless and have serious mental illness (SMI).

• 4.2. Understanding Health Centers and Federally Qualified Health Centers Medicaid Reimbursement

  • Nationwide, over 1,100 federally funded Health Centers served over 21 million patients in 2012.³⁵ The majority of Health Center patients have incomes below the federal poverty level. Before 2014, more than one-third of Health Center patients were uninsured, and 40 percent of health center patients were Medicaid beneficiaries. Many patients who were uninsured were expected to qualify for Medicaid as of 2014 (if they live in states expanding coverage) or for federally subsidized insurance coverage through the exchanges.

    While Health Centers play a large and important role delivering health care to millions of low-income people, and many Health Centers are now actively engaged in helping people enroll in coverage, they also face significant uncertainty about the ramifications of full implementation of the Affordable Care Act. In expansion states, many of their uninsured patients may gain coverage through Medicaid, and this will increase Medicaid revenues if these patients continue to receive care from the Health Centers. However, these patients are likely to have other choices about where to go for primary care when they gain coverage, and some may select other providers when they get the opportunity to do so. Health Centers are likely to continue to provide care for many people who will remain uninsured because of their immigration status, because of other barriers to enrollment and eligibility, or because they live in states that choose not to expand Medicaid eligibility. In addition, Health Centers' active role in helping people try to enroll in coverage has raised their visibility among uninsured residents in their service areas, which is expected to lead to an increasing number of those who are unable to obtain coverage seeking care at Health Centers.

    The Affordable Care Act provided $11 billion in federal funding over five years to expand the Health Center program, with the goal of expanding access to health care services as more people in low-income communities obtain coverage. The volume of visits provided by Health Centers increased from 38 million in 2000 to 80 million in 2011, and Health Centers serve more than one in six low-income people nationally. Federal funding has expanded the number of Health Center medical staff, as well as staff who provide dental and mental health services. The number of Health Centers that offer some mental health services has grown significantly, from about 40 percent of health centers in 2000 to 75 percent in 2011 (Kaiser Commission 2013).³⁶ While only 20 percent of Health Centers offer substance use disorder treatment services, all Health Centers that receive federal grants to work with homeless individuals are required to provide these services.

    Health Centers vary widely in their capacity for delivering health care services connected to PSH or in tailoring their services to meet the needs of people experiencing homelessness. Some Health Centers are very engaged in delivering services to people who are homeless and to people with significant behavioral health challenges, and may receive federal grant funding targeted for this purpose. In contrast, other Health Centers have been much less engaged in serving these groups of patients. Leaders of some of the centers in the latter group say they face competing priorities as they prepare to respond to the challenges and opportunities related to implementing the Affordable Care Act and other changes in health care delivery systems. They say that they do not have the capacity to deliver the specialized, intensive, and time-consuming care needed by people experiencing chronic homelessness who have SMI or active substance use disorders. Nor do they feel they have the capacity to see people in their homes at a time when they are also seeking to greatly expand capacity in their centers to meet the increased demands for care and provide quality customer service to other newly insured patients. Other Health Centers have strengthened their commitment to serving the most vulnerable people, who are unlikely to receive care that addresses their complex health and social needs in other settings.

    Health Care for the Homeless programs receive 8.7 percent of total federal funding for the Health Center Program. The more than 200 Health Care for the Homeless programs include grantees operating in all 50 states, the District of Columbia, and Puerto Rico. In addition to basic health services, HCH programs must also offer substance use disorder treatment services (directly or through referrals), establish referral linkages for mental health treatment, offer case management services and services that enable people to use other Health Center services (e.g., outreach, transportation, and translation services), and conduct patient education regarding the availability and proper use of health services. In 2012, HCH programs served more than 836,000 patients, almost 90 percent of whom had incomes below the federal poverty level.³⁷

    HCH programs are required to bill Medicaid for covered services provided to Medicaid enrollees, but currently most HCH patients are uninsured. In 2012, 61 percent of HCH adult patients in the United States did not have any public or private health insurance, and 28 percent were covered by Medicaid.³⁸ In states that choose to implement the expansion of Medicaid eligibility under the provisions of the Affordable Care Act, most HCH patients are likely to become eligible for Medicaid coverage based on their low incomes, but barriers to Medicaid enrollment will likely persist for some people with histories of chronic homelessness who lack reliable contact information or required identification documents, or who find it difficult to navigate the application and eligibility determination process.³⁹

    Consistent with national data, HCH providers in the case study communities often reported that, until recently, the vast majority of their patients have been uninsured. As some states expanded Medicaid eligibility and others expanded coverage through Medicaid waivers in the years before the full expansion of Medicaid eligibility in 2014, HCH programs in these states experienced a significant decline in the percentage of uninsured patients, and they are increasingly receiving Medicaid reimbursement for covered services.

    4.2.1. FQHC Medicaid Reimbursement

    Since 2001, federal law has required State Medicaid agencies to pay Health Centers that are recognized as Federally Qualified Health Centers based on a prospective payment system (PPS). Under this system, FQHCs are paid an "all-inclusive" rate for each visit a Medicaid patient makes with certain types of health care providers, including physicians, mid-level practitioners (nurse-practitioners and physicians' assistants), licensed clinical social workers, and clinical psychologists. The rates also include all services and supplies that are "incident to" the services provided by covered providers. Each FQHC's rate is calculated by taking their reasonable costs for Medicaid-covered services during a base period and dividing them by the total number of visits. The PPS per-visit rates that are paid to Health Centers for visits provided to Medicaid patients often appear higher than Medicaid reimbursement rates paid to other types of providers that care for Medicaid beneficiaries; however, the fact that the PPS is a bundled rate precludes making direct comparisons.

    Instead of paying FQHCs under a PPS, state Medicaid programs have the option to pay them using an alternative payment methodology (APM). By law, an APM must result in total payments being at least as high as they would be under a PPS, and each FQHC must agree to receive the APM.

    The intent of the Medicaid FQHC payment methodology is to ensure that the costs of providing covered services to Medicaid patients are not shifted to federal grant funding from the Health Resources and Services Administration. Federal grants and other funding sources cover uninsured patients and activities not covered by reimbursement from Medicaid, Medicare, or private insurance.

    Since 2001 the baseline PPS rate, which was established based on documented costs incurred during 1999 and 2000, is adjusted annually by a standard medical inflation factor. States must also adjust the PPS rate to take into account any increase or decrease in the scope of services provided by the Health Center. When Health Centers establish or expand services, such as when they establish a new team serving people who are homeless or a service site connected to PSH, this change in scope can trigger an adjustment to the Health Center's per-visit rate.

    As many states are relying on Medicaid managed care plans to provide health care for a growing number of people, many Health Centers have become part of these health plans' provider networks. In many cases, the health plans make payments to the Health Centers on a capitated basis, meaning that the Health Centers receive a fixed amount of funding per-member per-month for health plan members who have selected or been assigned to the Health Center for receiving their primary care. States are required by federal law to give Health Centers additional "wraparound" Medicaid payments based on the gap between the health plans' per-member per-month payments and the revenues that would otherwise have been received by the Health Center using the FQHC prospective payment methodology based on the number of FQHC encounters.

    Note that beginning in October 2014, FQHCs will begin receiving payments under a PPS system from Medicare for care provided to Medicare beneficiaries. There are substantial differences between how the Medicaid and Medicare PPS systems will function.

• 4.3. Health Centers, Chronically Homeless People, and Permanent Supportive Housing

  • 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.

• 4.4. Sustaining and Expanding Innovative Programs: Addressing Challenges for Health Centers and Their Partners

  • As part of this case study project, we visited many Health Centers, including some that began as Health Care for the Homeless programs. Among the Health Centers that have been most engaged in serving people experiencing chronic homelessness and delivering services in PSH, innovative programs and integrated services have often been launched with support from time-limited grant funding provided by local governments, foundations, or federal grants. Health Centers involved in these innovations have incorporated some or all of the practices described below:

    • They deliver health services "outside of the four walls" of a Health Center, by sending clinicians or teams to visit people in their apartments or where they are living on the streets or in encampments, and by co-locating satellite clinics in supportive housing buildings, shelters, and treatment programs.⁴⁸

    • They do "whatever it takes" to engage, listen to, and establish trusting relationships with clients who have multiple medical and behavioral health disorders but who may not trust health care providers or seek treatment.

    • They use techniques such as motivational interviewing to help clients recognize and reduce harms associated with substance use, reduce or eliminate problem behaviors that could lead to the loss of housing, and take steps toward recovery, even if the clients are unable or unwilling to enter more structured treatment programs or to make and sustain a commitment to sobriety.⁴⁹

    • They use nurses to make frequent face-to-face visits, to monitor and help clients understand and manage their chronic health conditions, to encourage them to take medications and follow through on recommendations from doctors, and to provide coaching for healthier behavior.

    • They build multidisciplinary teams and collaborations that can integrate the delivery of different types of Medicaid-covered medical and behavioral health services and supports, often using different types of Medicaid payment mechanisms.

    • They include community health workers, peer support workers, and other unlicensed workers as members of multidisciplinary teams.

    • They ensure access to care and continuity of care as people experiencing homelessness and supportive housing tenants are enrolled in Medicaid managed care.

    • They recognize housing as a social determinant of health, and help clients get and keep stable housing as a foundation for accessing and making effective use of health care services.

    The Health Centers involved in these innovations generally have been expected to use Medicaid financing to sustain promising programs and activities that were often initiated with grant funding. Health Centers sometimes encounter challenges when they seek to use Medicaid to sustain and replicate promising practices for delivering services in supportive housing and to integrate primary care and behavioral health care.

    As Health Centers have worked to obtain Medicaid reimbursement using the FQHC payment mechanism, some have reached agreement with state policymakers and Medicaid program officials to ensure that ongoing funding is available to cover the costs of reaching, engaging, and serving people who are living in PSH, as well as those who are still experiencing chronic homelessness. In some cases, however, it has been more challenging to use Medicaid to sustain, expand, and replicate promising practices and programs that include Health Centers.

    The practices just detailed--while important for effectively serving people experiencing chronic homelessness and other high-need Medicaid beneficiaries with complex medical and behavioral health conditions--are not easy to finance using the FQHC payment mechanism. Some Health Centers have found it difficult to cover some of the costs associated with these practices using the FQHC PPS payment mechanism.

    To sustain and expand some of the innovative programs that have been created in recent years, Health Centers, Medicaid program officials, state primary care associations, and other stakeholders are working to clarify policies, to explore payment reform ideas, to continue using grant funding to fill gaps, or to find other solutions. For states, housing and service providers, and other stakeholders seeking to expand the role of Health Centers as providers of integrated primary care and behavioral health services for people who are experiencing homelessness or living in PSH, it will be important to anticipate and recognize these challenges and to collaborate with state Medicaid program leaders in seeking solutions. This may include considering these activities when determining reasonable costs for FQHC services, including services "incident to" care provided by physicians or other clinicians, or exploring alternative payment mechanisms for some promising programs.

    4.4.1. Delivering Health Services "Outside the Four Walls": Addressing Concerns About Productivity

    While states take varying approaches, they may scrutinize some Health Centers that seek Medicaid reimbursement for care delivered "outside the four walls" of a Health Center.

    Generally, the care provided outside of a Health Center must be clearly part of the comprehensive primary care delivered by the Health Center operating under the oversight of the Health Center's medical director. Some Health Center leaders are wary of seeking Medicaid reimbursement for visits provided by their clinical staff when they see clients outside of a Health Center. It is often helpful to clarify state policies and to correct inaccurate information about the availability of Medicaid reimbursement for these visits.

    Even when it is clear that Medicaid reimbursement can be available for visits outside of a Health Center, program administrators and Medicaid officials often have concerns about the productivity of clinical staff members who work on mobile teams or deliver care in satellite Health Center sites in PSH buildings or through home visits. Some Health Centers that have been engaged in delivering health care and other services in PSH have encountered challenges in delivering enough "billable encounters" to produce enough revenue to make these services financially viable and sustainable. Clinicians who work with people who are chronically homeless generally have lower rates of productivity, as measured by the number of visits per hour or day, compared with clinicians who work in busy clinic settings. In part this is because it often takes extra time to establish trust and to communicate with people who have experienced chronic homelessness. They may be distrustful of health care providers, or their thinking and ability to communicate may be impaired by mental illness, substance use, brain injuries, or other disorders. Many people who are experiencing chronic homelessness, and particularly those who have been prioritized for PSH because of their vulnerability, have multiple serious medical and behavioral health conditions, including chronic medical conditions such as hypertension or diabetes, cancer, HIV/AIDS, or the consequences of a stroke or traumatic brain injury. It takes extra time to assess and treat these multiple conditions, and to address complications that may arise when patients are taking medications for both medical and mental health conditions.

    Health Center clinicians who work on teams doing outreach and delivering care to people who are chronically homeless and living on the streets or in encampments cannot complete and document as many reimbursable visits as they might provide in a clinic setting. Teams spend time trying to locate people experiencing homelessness, and with some people who are very reluctant to accept care, the process of engagement may take weeks or months. As Health Center workers seek to establish a person's trust so they can deliver much-needed medical care, they often must take time to listen to the person's story and may need to offer help with immediate practical concerns, such as meals, dry socks or warm clothes, or a bus pass. Eventually after trust is established, the client is often willing to consent to receive medical care and treatment, but the time spent on these relationship-building efforts is usually not reflected in billable encounters.

    Even in site-based PSH settings, it can be challenging to make the best use of clinicians assigned to satellite Health Center sites on a regular part-time schedule. Several Health Centers reported that the volume of billable encounters provided in these settings was less than they had anticipated. This is particularly challenging in buildings with a small number of PSH units, but even in larger PSH buildings a large volume of billable encounters may be difficult to achieve because some tenants are reluctant to manage chronic illness and change behaviors associated with health risks.

    Even if PSH tenants have significant health needs at the time they first move into housing, after a year or two they often need less medical care. Many tenants appreciate the accessibility of on-site health services in PSH or home visits by medical providers, and this access may be critically important for PSH tenants who are unwilling to visit a Health Center or find it difficult to use services in clinics or doctors' offices because of the symptoms of their mental illness. Other people may no longer prefer to see their primary care provider at home and may instead prefer to see the same provider at a Health Center site that serves other community residents, if it is nearby and welcoming. To use Health Center staff more efficiently and to meet revenue targets, satellite Health Center sites located in or close to PSH may also serve other patients from the surrounding neighborhood or former PSH tenants who have moved out to other housing. Health Centers and their partners will need to continue to evaluate the approach to delivering services and the mix of services that are based in Health Center sites or delivered in other settings.

    In some collaborations, Health Center clinical staff accompany teams of service providers on home visits to previously homeless people who live in scattered-site PSH, while in other partnerships the Health Center has determined that home visits are not financially feasible because of productivity concerns. If a scattered-site PSH program also uses an office location where some tenants come to see their case managers or participate in group activities, the Health Center's primary care provider may see clients at that location and also coordinate with other team members without making visits to clients in their own apartments.

    In some states Medicaid officials have raised concern about the productivity of Health Center clinicians and the impact of productivity on the rates established using the FQHC PPS payment methodology. The Federal Government does not provide much formal guidance to states regarding FQHC payment methodology for Medicaid services, and there have been lawsuits and appeals by Health Centers in some states challenging efforts by states to use productivity "screens" or standards to determine whether the per-visit costs reported by Health Centers reflect reasonable costs, and to reduce rates for Health Centers if clinicians have lower levels of productivity. Given the complex needs of people who have experienced chronic homelessness, and the experiences of promising programs that deliver comprehensive health care linked to housing for this group of people, Health Centers interested in serving this population and delivering care linked to PSH might want to open discussions with their state Medicaid office about the costs for these programs and the productivity of clinicians working in these settings.

    4.4.2. Covering the Costs of Unlicensed Members of Interdisciplinary Teams

    When teams do outreach to deliver care to people experiencing chronic homelessness, paraprofessional outreach workers and peers who know where hard-to-serve people sleep or spend time can help to find people, establish trust, and motivate change. By making introductions and a "warm handoff" they can help to make the best use of clinicians' time in the field. Site-based PSH case managers are often very helpful in scheduling appointments and reminding tenants about when health care services will be on-site in their building. Ongoing communication and collaboration among Health Center clinicians and the staff members or partner organizations providing outreach and case management services can help to boost the productivity of clinical team members and to focus their attention on individuals with the greatest unmet needs for care.

    JWCH's Center for Community Health is in the heart of Skid Row. The center is designed to support the delivery of integrated services including medical, mental health, substance abuse, clinical pharmacy, dental, and other services and supports. The building is designed to support interdisciplinary teams working in "pods," so that a primary care provider can walk a client over to a mental health provider for assessment on the same day, and team members can consult with one another. Each team (i.e., each pod) is responsible for a group of patients and uses weekly case conferencing to coordinate care for those with the most-intensive needs. Because California does not provide FQHC payment for more than one visit on the same day, JWCH receives payment for only one visit, even if a patient is seen by two different medical providers or by both a medical and mental health provider on the same day.

    Community health workers, case managers, peer recovery specialists, and other unlicensed staff are frequently essential members of interdisciplinary teams, helping to engage vulnerable people in care and provide the health education, coaching, and case management services that help people reduce risks and better manage their own health. Costs for these staff members are sometimes excluded from the calculation of FQHC payment rates if states do not consider these to be reasonable costs associated with FQHC services. It may be difficult for Health Centers to find sustainable sources of funding for these staff positions.

    Even when multidisciplinary services are delivered by licensed clinicians, many states, including some with sites in this study, do not permit FQHC reimbursement for two or more visits by the same patient on the same day for the same condition. This has the effect of limiting Medicaid revenues for more comprehensive or integrated care provided by teams in some Health Centers. Particularly for people experiencing chronic homelessness and for other people who are distrustful or hard to engage in needed health care services because of symptoms of mental illness or other challenges, "warm handoffs" from one clinician or team member to another are an important strategy for delivering effective care.

    4.4.3. Services for People With Substance Use Disorders

    For residents who have serious substance use disorders and do not seek treatment, motivational interviewing techniques can be effective. Having a member of the service team who focuses on substance use and recovery--or "peer" team members who have personal experience with homelessness, mental illness, addiction, and recovery--can have a big impact on successfully engaging tenants in the services they need. These service interventions can be critically important, helping to solve problems that might otherwise result in serious medical complications, hospitalization because of a mental health crisis, arrest, or eviction and a return to homelessness. In most states, these services are not part of the Medicaid benefits that cover treatment for substance use disorders.

    While Health Centers recognize that substance use has a significant impact on health, and HCH providers are required to deliver services to address substance use, Medicaid reimbursement for services related to substance use problems was limited in the communities described in this report during the study period. Many states had a limited set of optional Medicaid benefits to treat substance use disorders, although some states are expanding coverage for these services as they implement changes required by the Affordable Care Act. For example, California is expanding Medicaid coverage of substance use treatment services that were previously covered only for pregnant and post-partum women; starting in 2014 these services were be covered for all adults.

    State policies may limit the settings in which these covered services can be delivered. In Illinois and California, for example, Medicaid reimbursement for substance use disorder services is available only in designated sites that have obtained certification as treatment facilities. This limitation makes it virtually impossible to use Medicaid to pay for services delivered through integrated, multidisciplinary teams that serve people experiencing homelessness on the streets, in satellite clinics in PSH buildings or program offices, or through home visits. State policies regarding benefit design often require that Medicaid-covered substance use disorder treatment services must be delivered in settings that are certified as treatment facilities, such as residential programs or intensive outpatient programs that require regular participation for a minimum number of structured hours each day or week. States may require Health Centers to exclude the costs of these programs from the FQHC payment methodology, and to operate them as completely separate programs in separate facilities, making it difficult to fully integrate services that address medical, mental health, and substance use disorders.

    Many Health Centers offer some services to address substance use disorders, including screening and brief intervention or counseling services provided by primary care providers or licensed clinical social workers, which may be reimbursed through the FQHC payment mechanism. Some Health Centers offer other substance use disorder services as part of grant-funded programs. Relatively few Health Centers visited as part of this research also operate substance use disorder programs that qualify for Medicaid reimbursement.

    Health Centers that participated in this case study reported that many of the people who are experiencing chronic homelessness or living in PSH are uninterested or unable to participate in highly structured treatment programs. While treatment can be successful, offering a path to recovery for some PSH tenants, others have been through treatment programs several times without being successful in achieving or maintaining sobriety. As a result, some Health Centers that serve many people experiencing chronic homelessness have found it difficult to use Medicaid-covered substance use treatment benefits to finance the engagement and motivational interviewing services that are often most needed to reduce their clients' substance use and related health problems, particularly when the use of alcohol or drugs is a threat to the client's health, safety, or housing stability.

    4.4.4. The Role of Nurses

    The Health Centers and HCH programs that deliver services in PSH and their housing partners often noted that many of the most vulnerable PSH tenants can benefit from services that may be provided by registered nurses in home visits. Registered nurses who work as members of interdisciplinary teams can assess and monitor health needs, educate people about managing chronic medical conditions, help people follow up on doctors' recommendations, and answer questions about medications.

    While the costs of registered nurses are likely to be included in the calculation of Health Center costs and used to set the rate paid for FQHC visits with other medical providers, registered nurses do not provide "billable encounters" that directly produce revenue for the Health Center.⁵⁰ This can make it difficult for a Health Center to add nurses to provide additional services for PSH tenants, because the Health Center does not receive additional revenues from Medicaid reimbursement to cover the added costs for these staff. In several sites we were told that there is significant demand for home visits by registered nurses to PSH tenants, but it is difficult for Health Centers to provide these services without additional, flexible funding.

    Similarly, medical respite services, often staffed by registered nurses, may be a critical link to PSH, providing interim housing for people who are chronically homeless and get engaged in services at the time they are being discharged or diverted from a hospital stay. However, the FQHC payment methodology does not reimburse most of the costs associated with the respite model, per federal regulations.

    4.4.5. Strengthening Partnerships To Deliver Multidisciplinary Care

    Building and sustaining partnerships among PSH providers, other service providers, and Health Centers is not easy. Each partner in these collaborations speaks a slightly different language and responds to the requirements and incentives of different funding streams and government agencies that provide oversight. Billing systems and electronic health records used by Health Centers usually do not integrate or share data with the record-keeping systems used for mental health or other supportive housing services.⁵¹ In part this is because these systems have been designed to meet the requirements of separate systems that manage Medicaid health and behavioral health benefits, and the requirements of these systems have not been aligned.

    Even when the Health Center has made a commitment to assign staff to a satellite clinic, there may be a tendency to pull the clinician from the PSH site when staff vacancies produce uncovered time in the Health Center's busy clinic. Relationships can get strained, particularly when funders have arranged "marriages" between Health Centers and their partners. Regular structures for ongoing collaboration, including frequent meetings to coordinate the delivery of services to shared clients, to plan for improving and sustaining programs, and to share training and learning opportunities can strengthen partnerships and enhance the integration of services.

    4.4.6. Managing Transitions to Managed Care

    In some of the case study communities, Medicaid managed care plans are increasingly responsible for coordinating and paying for health care services for seniors and people with disabilities who are enrolled in Medicaid. When people become enrolled in managed care plans, some Health Centers that serve people who are chronically homeless and those that deliver health services connected to PSH have encountered difficulties.

    We summarize those difficulties and the potential solutions here because many states either already require or are anticipating requiring that this population be served by managed care plans. With appropriate forward planning, other communities may be able to avoid some of the complications we observed and promote the greatest degree of patient continuity of care during transition periods.

    • Know what is coming. Awareness of the nature and timing of state plan requirements to enroll in managed care is critical. During transitions to managed care, people experiencing homelessness and many of those who were recently homeless do not receive or understand notices regarding health plan and provider selection. If they do not respond to these notices, they may be "auto-assigned" to an unfamiliar health care provider instead of being assigned to the Health Center that delivers care attached to a shelter, drop-in center, mental health clinic, or PSH program where the person has been getting care. This can limit access to health care or disrupt the continuity of care, while also making it difficult to sustain partnerships that link Health Centers to PSH or other services for people experiencing homelessness.

      With advance help, service providers in PSH and homelessness assistance or mental health programs can assure that their Medicaid clients know their options and the time frame for exercising their right to choose a provider. It is important for states to make their plans clear in a timely manner and to engage community partners who can reach groups of beneficiaries who lack a permanent address or may have difficulty understanding written notices. It is also important for community-based service providers to have a clear idea of how the managed care enrollment process will likely impact their clients, and what might work best to avoid disruptions in care that occur when someone is assigned to a new and unfamiliar primary care provider and health organization instead of the one the patient knows and trusts.

    • Have a good data system. The data system used by the states and managed care organizations responsible for assigning patients to primary care providers and provider networks needs to have timely and up-to-date information about each Medicaid beneficiary's existing care arrangements. This information would reduce inappropriate provider assignments in the event that people do not make their own choice of provider. In addition, Health Center staff and other care providers need to have a way to see whether their patients have been assigned to them or to another provider or network because if they deliver care to a person who is not assigned to them, the Health Center may not receive payment for these services.

    • Have a good system for switching health plans and/or primary care provider assignments. If inappropriate assignments that disrupt care are made, having a system that makes switching assignment easy would be helpful. To facilitate the efforts by Health Centers to engage and provide easy access to care for some of the most vulnerable and hard-to-serve people experiencing homelessness or living in PSH, health plans and provider networks may need to negotiate arrangements to make these changes effective immediately, rather than having to wait until the next month for them to become effective.

    4.4.7. Competing Demands and Opportunities--and Limited Capacity

    Many Health Centers are not engaged in serving people who are chronically homeless and may not see this population as relevant to their role in the community or consistent with their mission, particularly if the Health Center does not receive federal funding as a Health Care for the Homeless program. During the months leading up to and following full implementation of the Affordable Care Act, Health Centers have been facing many competing demands to expand their capacity to enroll and serve new patients and improve customer service for many existing patients who have other choices once they become Medicaid beneficiaries or recipients of subsidized insurance coverage. At the same time, they must also work to adopt electronic health records and participate in Medicaid managed care arrangements, which often involve multiple plans with different payment systems and procedures for coordinating specialty care and other health services with separate provider networks. Faced with all of this, as well as the impact of state budget reductions, some Health Center leaders are reluctant to focus their limited resources and staff time on people who are chronically homeless--a relatively small group among the many low-income people in their communities--and on unfamiliar potential partners from homelessness assistance, housing, and behavioral health systems.

    As described earlier, Mental Health Services Act funding and additional support from philanthropy have provided critical funding in Los Angeles to cover the activities of integrated mental health teams that cannot be reimbursed by Medicaid. This funding has helped to launch or expand and strengthen collaborations among Health Centers and providers of behavioral health care services. In other communities, these or similar sources of flexible funding have not always been available. Without targeted grant funding or other sources of funding to expand their capacity to provide additional behavioral health services to persons with serious mental illness and co-occurring substance use disorders, many Health Centers have little or no capacity to serve people who do not show up for their clinic appointments, or those who may be disruptive or unable to sit quietly in crowded waiting rooms.

• 4.5. Summary

  • Given their mission to serve low-income people and, in some cases, their Health Care for the Homeless resources, Health Centers can be critical players in linking primary care, behavioral health, and other services and supports to people with histories of chronic homelessness and to PSH tenants. Promising models are emerging, including co-locating clinics in PSH or using multidisciplinary mobile outreach teams, such as those in Los Angeles, as well as special initiatives targeted to frequent users of crisis care, such as those in Los Angeles and Chicago. All require "working outside the walls" of the Health Center.

    Health Centers face uncertainties about the full implementation of the Affordable Care Act. Most of their clients were uninsured before 2014. Some clients may no longer seek care at Health Centers once they become eligible for Medicaid and have other choices for care. Some will still be uninsured because they are undocumented or are in the five-year blackout period after getting residency and before becoming eligible for benefits. Clients may also have trouble successfully completing the Medicaid application/eligibility process.

    As implementation progresses under the Affordable Care Act, discussions among state Medicaid officials and representatives of Health Centers will be vital. It will take good communications for all parties to understand each other's opportunities and constraints, and for strategic frameworks to develop that facilitate the goals of patients, the Health Centers, and state Medicaid interests.

     

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