Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field. 5. Mental Health Services and Medicaid as of 2013


Chapter 5 Highlights

Among people experiencing chronic homelessness, those with a diagnosis of serious mental illness may be the most likely to benefit from supports funded in part through Medicaid. This is because they are likely be eligible for Supplemental Security Income (SSI) and be Medicaid-eligible; to come under the aegis of state and county mental health departments, which have responsibilities for their well-being; and to qualify to receive the most effective models of community-based treatment and supports for recovery as identified by extensive research.

Serious mental illness is usually determined by a person's diagnosis, history, and functional impairments. States specify qualifying diagnoses in their Medicaid state plan, virtually always including psychoses, bipolar disorder, and major clinical depression, and sometimes including other diagnoses. In addition, a person's mental illness must "result in functional impairment that substantially interferes with or limits one or more major life activities." Activity areas may include feeling, mood, and affect; thinking; family relationships; interpersonal relationships/social isolation; role/work performance; socio-legal conduct; and self-care/activities of daily living.

Medicaid state plans usually specify how eligibility for mental health services is to be determined. Standardized rating scales are often used, as is consideration of previous psychiatric inpatient admission and utilization. States may also take into consideration other risk factors such as chronic homelessness, repeated arrests and incarcerations, lack of follow-through taking medications, failure to achieve stable housing, ongoing inappropriate public behavior, excessive use of crisis or emergency services with failed linkages, and similar indicators of functional impairments.

Persons with a serious mental illness who are in the public system will most likely qualify to receive community-based mental health services, which usually include services and coordination covered in Medicaid state plans under the rehabilitative and targeted case management options. These approaches are intended to support people who need some level of ongoing assistance beyond what they can get through standard outpatient care in a clinic but who do not need residential treatment or hospitalization, or for whom residential treatment or hospitalization can be averted with appropriate supports delivered in a community setting.

Case study sites used a number of different terms to describe the community-based mental health services that are linked with PSH, including Assertive Community Treatment in Illinois, the District of Columbia, and Minnesota; Full Service Partnerships in California; Field Capable Clinical Services in Los Angeles; Community Support Services or Community Support Teams in Illinois and the District of Columbia; Community Psychiatric Support and Treatment in Louisiana; and Adult Rehabilitative Mental Health Services in Minnesota.

Minnesota makes extensive use of Medicaid targeted case management benefits to provide support and linkages to other services for people living in PSH. Targeted case management benefits are well-suited to helping people who are experiencing homelessness access housing, as covered services include assessment, service plan development, and the referral, monitoring, and follow-up often used to help people get and keep housing.

Public mental health agencies in the case study sites support housing for people experiencing homelessness in several ways: funding the development of housing units (Connecticut, Los Angeles, the District of Columbia); subsidizing rents (Connecticut, Minnesota, the District of Columbia); and participating in partnerships to expand rental subsidy resources (Los Angeles, the District of Columbia).

Several models exist at the provider level for linking health and behavioral health care, supportive services, and housing, starting with outreach and engagement to initiate connections with people experiencing homelessness. Thereafter, models include: (1) one agency that provides housing and services; (2) partnerships in which one agency provides the housing and another provides the behavioral health and other supportive services; and (3) one agency that provides the housing and each tenant is linked to his or her own primary service provider.

Many issues related to payment were common across case study sites. These involved mainly which aspects of the supports needed by people experiencing chronic homelessness and PSH tenants the Medicaid arrangements available during the study period (2010-2012) would and would not pay for.

Medicaid reimbursement often covered community-based rehabilitative services, including services provided in the consumer's home or other community settings, that focus on the individual's recovery and resiliency goals.

Covered services included support for the development of interpersonal and community coping skills, assisting consumers in self-monitoring and managing symptoms of mental illness, and developing strategies and supports to prevent relapse and avoid hospitalizations or the use of crisis public services.

Some services that are important elements of programs that serve people who have experienced chronic homelessness often are not included in definitions of Medicaid-covered mental health services. These may include finding the client, collateral contacts done without the client present and other care coordination activities, teaching people new things (as opposed to restoring previous capabilities), care not specifically related to the mental illness (e.g., wound care, managing diabetes), transporting the client to appointments or to search for housing, and travel time.

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