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.