Depending on the state, public mental health services may include a wide range of services that vary in intensity and duration, from medications and medication management at an outpatient clinic (low intensity, varying duration depending on need), through crisis stabilization (very intense but usually lasting a few days at most), and inpatient hospitalization (intense but usually short). For mental health system clients who are Medicaid beneficiaries, Medicaid may be able to pay for services if federal Medicaid requirements are met.
Our focus in this chapter is on care for 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 that are delivered in a community setting. Generally, we found that the mental health services likely to be linked to housing assistance as part of PSH for people with serious mental illness who are chronically homeless incorporate the following characteristics:
- Services providers have frequent face-to-face contact with clients, and mental health workers or teams have relatively small caseloads. Service providers often meet with clients several times a month, and can see clients more frequently if needed.
- Services are often delivered in a range of community settings outside of clinics or program offices, including home visits.
- Service providers reach out assertively to engage with clients, particularly during a crisis, relapse, or transition (e.g., from homelessness into housing, or after a hospitalization).
- Services are individualized and flexible, based on the needs, strengths, and goals of the client.
- Services are expected to continue for many months, or for years, to support ongoing recovery and stability, while the frequency of contact and the client's goals or focus of service interventions may change over time.
- State and local mental health systems use different terms to describe these models of service, which are generally more-intensive than other community-based mental health services.59 The five case study sites that used Medicaid to cover community-based mental health services for people experiencing homelessness or living in PSH during the study period gave the following names to their program or service models that are most often linked to PSH:
- Assertive Community Treatment teams in Illinois, the District of Columbia, Louisiana, 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.
- Adult Rehabilitative Mental Health Services in Minnesota.
- Community Psychiatric Support and Treatment in Louisiana.
The states of interest in this chapter all provide coverage for some or most of the costs associated with these service models using state or county funding. For Medicaid recipients, the states have used the Medicaid Rehabilitative services option to a greater or lesser extent to cover part of the cost, depending on the alignment between the service models and covered services in the state's Medicaid plan.60 Some states may also cover targeted case management services under their Medicaid state plan.
In some cases, states use a specific model, such as Community Support Teams, whose services the state may choose to cover under the Medicaid state plan rehabilitative services benefit or as optional home and community-based services some states have established specific eligibility criteria for an individual to receive each type of service. Among our case study sites, the District of Columbia, Illinois, and Minnesota have all done this.
In other cases, the state's Medicaid state plan does not specify coverage for services such as Assertive Community Treatment, and definitions of covered benefits or service models may not have been updated to align with recognized evidence-based practices. In such cases, the state may choose to fund some aspects of the newer program models with its own resources, while using Medicaid reimbursement to pay for some of the Medicaid-covered services described in the Medicaid state plan. California is the primary example in our study of this pattern.
California state regulations governing funding provided through the Mental Health Services Act defined the service model as Full Service Partnerships, and Los Angeles County's Department of Mental Health added its own definition of Field Capable Clinical Services. The mental health benefits contained in the state's Medicaid state plan include some of the services that comprise these models. However, the Medicaid service definitions have not been updated to incorporate the approach to services described in the Full Service Partnership or Field Capable Clinical Services models, with the consequence that some aspects of those models are not covered by Medicaid. These include attention to co-occurring substance use disorders and a focus on delivering the flexible supports people with mental illness need to achieve housing stability and to reduce homelessness, hospitalizations, and involvement in the criminal justice system. Thus, Medicaid reimbursement covers the services delivered by providers when they implement these service models that are included in the state plan, while funding from other sources is used to pay for the costs of supportive services that are important components of the service model but not reimbursed by California's Medicaid program.
We next provide some detail about the ways these service models and Medicaid benefits are used in California (specifically in Los Angeles), the District of Columbia, Illinois, and Minnesota.
5.3.1. Assertive Community Treatment and Similar Models of CareLinked to PSH
Assertive Community Treatment is an evidence-based model that offers an intensive, individualized, and integrated package of treatment and supportive services provided in community settings for persons with SPMI or co-occurring mental illness and substance use disorders.61 Interdisciplinary Assertive Community Treatment teams include members who are trained in the areas of psychiatry, social work, nursing, substance use disorder treatment, and vocational rehabilitation; the teams provide these services as needed, 24 hours a day, seven days a week, 365 days a year. The Assertive Community Treatment model's comprehensive services, which are available to clients in their homes or other "natural" community settings, include treatment, rehabilitation, and support services.
- Treatment includes psychopharmacologic treatment, including new atypical anti-psychotic and antidepressant medications; individual supportive therapy, mobile crisis intervention, and substance use disorder treatment for those with a co-occurring disorder.
- Rehabilitation includes behaviorally oriented skill-teaching, including structuring time and handling activities of daily living, and support for employment or resuming education.
- Support services include support, education, and skill-teaching to family members; collaboration with families and assistance to clients with children; and direct support to help clients obtain legal and advocacy services, financial support, supportive housing, money-management services, and transportation.
The District of Columbia began using Assertive Community Treatment in the early 2000s, when it invited Pathways to Housing to establish a local presence. Pathways to Housing-DC provides services linked to housing for people who are chronically homeless with SPMI through several Assertive Community Treatment teams of 7-8 people each; teams handle caseloads of 75-85 clients.
The Department of Mental Health expanded its Assertive Community Treatment commitment about five years ago, adding nine teams and going from about 375-1,200 people as part of its efforts to help people move into the community from St. Elizabeth's Hospital, as well as to provide the service to more people experiencing homelessness. All people receiving Assertive Community Treatment services are Department of Mental Health clients, who first go through the department for assessment (using the LOCUS) and then are referred to the appropriate level of care.
Minnesota uses Medicaid to provide coverage for Assertive Community Treatment. Some of the Assertive Community Treatment teams are linked with housing programs, through which they serve homeless persons with serious mental illness experiencing chronic homelessness or living in a variety of community-based housing situations. Housing options could be rent subsidies for scattered-site apartments or site-based PSH for people experiencing homelessness. In addition to the Assertive Community Treatment teams operating in many parts of the state, Hennepin County also has one "homeless Assertive Community Treatment team" that specializes in serving people with severe and persistent mental illness who have lived for more than a year on the streets (although the program will consider someone in shelter for the same length of time who might meet the diagnostic criteria). About 95 percent of participants also have co-occurring substance use disorders.
California's Full Service Partnership service model is similar to Assertive Community Treatment. Full Service Partnerships fall within the domain of the state's Mental Health Services Act, which has made a significant investment in transforming the delivery of services and supports to people with mental illness since passage of a voter-approved initiative in 2004. The terms of the voter initiative increased taxes on incomes above $1 million a year and allocated those revenues for specific purposes. State regulations require that counties devote a significant portion of the funds available through the Act to implementing Full Service Partnerships for persons who meet specified eligibility criteria.62 For adults, eligibility criteria include SMI with substantial functional impairments.
Consistent with state requirements, Full Service Partnership services are targeted to people who have been unserved, underserved, or inappropriately served in the mental health system. In addition, they must be homeless, at risk of homelessness, involved in the criminal justice system, a frequent user of hospital or emergency room services as the primary resource for mental health treatment, or at risk of institutionalization or involvement in the criminal justice system.63
Full Service Partnerships are the most-intensive level of care offered by Los Angeles County's mental health system outside of a hospital, residential treatment, or crisis stabilization facility.64 They use a multidisciplinary team model to do "whatever it takes" to provide very flexible, client-centered care for people who have not been engaged or effectively served by more traditional mental health services and treatment programs. These resources have often been used to engage and serve homeless people with SMI. The programs have demonstrated positive outcomes, including reductions in homelessness and costs associated with hospitalizations and incarcerations. Medicaid reimbursement covers the costs for state plan rehabilitative services delivered by Full Service Partnership programs, while Mental Health Services Act or county funds pay for the balance for costs that are not specified in the state's Medicaid state plan.
As with Field Capable Clinical Services, described below, California's Medicaid state plan service definitions and service eligibility criteria were not updated to align with the Full Service Partnership model or eligibility criteria. Counties and service providers are encouraged to use Medicaid reimbursement and other non-Mental Health Services Act funds to cover the costs for services within the state plan, but it is not always easy to do so for a variety of reasons.
5.3.2. Other Moderately Intensive Levels of Service Linked to PSH
In addition to programs that use the Full Service Partnership Model, the Los Angeles County Department of Mental Health has created a program model called Field Capable Clinical Services, offering a somewhat less-intensive level of support than the Full Service Partnership mode. Teams of professionals provide these services, which they often deliver through visits to a client at home or in other community settings (i.e., in the field). Though less-intensive, Field Capable Clinical Services incorporate many of the practices that have been developed through Full Service Partnership programs that receive funding under California's Mental Health Services Act. Some of the services delivered by these teams are covered as Medicaid benefits, but the state does not define the team service model itself as a Medicaid benefit.
The District of Columbia Department of Mental Health provides funding for Community Support Teams, which deliver Medicaid-covered rehabilitative services for persons with SMI who need a moderately intensive level of rehabilitative supports that are considered essential for achieving rehabilitation and recovery goals.65 Community Support Services focus on building and maintaining a therapeutic relationship with the consumer. Activities include: (1) working with the consumer to develop a service plan; (2) providing assistance and support for the consumer in stressor situations; (3) providing mental health education, support, and consultation to consumers' families or their support system; (4) providing individual mental health service and support interventions to regain interpersonal and community coping skills, including adapting to home, school, and work environments; (5) assisting the consumer in symptom self-monitoring and self-management to identify and minimize the negative effects of psychiatric symptoms that interfere with the consumer's daily living, financial management, personal development or school or work performance; (6) helping the consumer to increase social support skills and networks that ameliorate life stresses resulting from the consumer's mental illness or emotional disturbance and are necessary to enable and maintain the consumer's independent living; (7) developing strategies and supportive mental health interventions for avoiding out-of-home placement or use of crisis public services; and (8) developing mental health relapse prevention strategies and plans.
Illinois also provides Medicaid coverage under the rehabilitation option for rehabilitative services delivered by Community Support Teams. These services are often used to help people with serious mental illness who are experiencing chronic homelessness by assisting clients recover the functional, interpersonal, coping, and community living skills they need to become stably housed. To receive Community Support Team services, consumers must be enrolled in Medicaid and meet medical necessity criteria established by the state Department of Mental Health. These criteria include severe and persistent mental illness and several indicators of need that often characterize the experience of persons with mental illness who are homeless, including repeated arrest and incarceration, inconsistent self-management of medications, excessive use of crisis or emergency services with failed linkages, inability to achieve stable housing, and chronic homelessness. Community Support Teams provide recovery and resiliency oriented, intensive, community-based rehabilitation and outreach services. They include mental health rehabilitative interventions and supports necessary to help the recipient achieve and maintain rehabilitative, resiliency, and recovery goals. Community Support Teams are intended to meet the recipient's educational, vocational, residential, mental health, co-occurring disorders, financial, social, and other treatment support needs. Interventions are provided primarily in natural settings, including a person's home, and are delivered face-to-face, by telephone, or by video conference with individual recipients and their family or significant others as appropriate. Community Support Teams assist in regaining optimal developmentally appropriate community living skills, and in setting and attaining recipient-defined recovery and resiliency goals. The team is available 24 hours a day, seven days a week.66
Minnesota covers some of the services in PSH as Adult Rehabilitative Mental Health Services. Services include rehabilitation to support independent living and community integration, and medication education. Areas that can be addressed by covered services include regaining skills such as interpersonal communication, relapse prevention, budgeting, shopping, healthy lifestyle skills and practices, cooking and nutrition, mental illness symptom management, household management, and employment-related skills. The focus on rehabilitation provides reimbursement for services that help to restore functioning that has been impaired by mental illness back to a predisability baseline. Service providers report that the availability of these services to people who meet SMI criteria but not the criteria for severe and persistent mental illness is a significant advantage, as it makes the service available to many more of those who are chronically homeless. The services can be highly creative, as long as goal-setting and case notes comply with requirements to show linkages to goals in a person's plan related to reducing impairments. Reimbursement is provided based on the number of units of service, and for most types of services a unit is 15 minutes. An initial authorization covers a high number of units; additional units are possible with prior authorization. Targeted case management services, described further below, also provide a moderate level of support for many PSH tenants with severe and persistent mental illness. Some provider organizations use team models that incorporate both adult rehabilitative mental health services and targeted case management, with different staff members providing services that can be reimbursed as one or the other to avoid any possibility of duplicate billing.
5.3.3. Step-Down Requirements for the Most-Intensive Medicaid Mental Health Services
Assertive Community Treatment teams provide a very intensive, and therefore expensive, level of services, giving the mental health agencies that fund them an incentive to use them only for people who need them. Most of our case study impose restrictions on continuing receipt of Assertive Community Treatment services, with the District of Columbia offering the exception.
Maintaining client trust while stepping down the level of service can be very tricky. Throughout our case study site visits to providers who work with people experiencing chronic homelessness, we were impressed with the difficulties of engaging people who are chronically homeless and persuading them to participate consistently in mental health care, particularly for people who have co-occurring mental illness and substance use disorders. The process of engagement and persuasion is time-consuming, laborintensive, and relies on building relationships and, above all, on establishing trust. These trusting relationships are not easily expanded or shifted to other providers. The danger of step-down requirements, if lower levels of care do not provide the individualized support and home visits offered by Assertive Community Treatment or other more-intensive service models, is potentially having the client become resistant to care. For formerly homeless people that may also mean that they will not be able to sustain housing, because they will not be receiving the supportive services that help them maintain stability with respect to their mental illness and reduce harmful or disruptive behaviors associated with substance use. As a consequence, people can have greater problems meeting their obligations as tenants when services are withdrawn.
Most state definitions of Assertive Community Treatment service eligibility include wording to the effect that, even if a client appears stable, eligibility may continue if it can be persuasively argued that withdrawal of the current level of services would result in significant deterioration of client functioning. Assertive Community Treatment providers in both Louisiana and the District of Columbia noted that, while their Assertive Community Treatment clients are pretty stable, it has taken them 1-2 years to reach that stability, and clients rely on continuing contacts to help them through situations that might otherwise have destabilizing outcomes.
Illinois has published guidance that defines medical necessity criteria for initiating and continuing to receive or terminate Medicaid-covered mental health services. The criteria generally require that an individual's severity or complexity of symptoms and level of functional impairment can only be successfully remediated by the specific type and intensity of covered service (e.g., Assertive Community Treatment or Community Support Team). Continuing service eligibility criteria generally require that a person's severity of illness and resulting impairment continue to meet the level of service criteria to maximize functioning and sustain treatment goals. An alternative criterion for continuing services is that the individual's support network is insufficient to allow for independent living and sustaining treatment gains without ongoing support at the same level of intensity. If a consumer's circumstances improve enough that she or he is no longer eligible for Assertive Community Treatment or Community Support Team services, the consumer may transfer within the same provider if the provider offers the less-intensive service. Rarely, however, do the same clinical staff offer both levels of service. The advantages of transferring are that care is still within the same organization and can be tapered off to meet the reduced level of client need while still providing some services.
The disadvantage is substantial, however, because the consumer has to switch from the team he or she likes and trusts to a single clinician attached to the lower level of care. Many do not want to do this, as they are comfortable with the current team. As most Assertive Community Treatment and Community Support Team clients have histories of alienation from mental health services, and their current level of participation is due to long-term nurturing and relationship development by their current providers, there is some realistic concern that stepping them down, with its switch to different staff, will cause client setbacks or, worse yet, dropping out of care.
In Los Angeles, clients are expected to transition to lower levels of care as they stabilize. For example, people who are chronically homeless with serious mental illness are often engaged and served by Full Service Partnership programs, which may be linked to housing vouchers or site-based PSH. As people achieve some stability, they may transition to less-intensive Field Capable Clinical Services provided by another team, and/or receive ongoing mental health services from an outpatient clinic or peer-run wellness center. Currently, only the Full Service Partnership and Field Capable Clinical Services are mobile, providing services to clients in their own homes, including PSH. Clients who no longer qualify to receive these services must visit a clinic or wellness center to receive ongoing treatment and support services--an arrangement that has failed for many Full Service Partnership clients in the past. It can be challenging to re-establish eligibility for Full Service Partnership if a person has transitioned to less-intensive services but later experiences more severe symptoms of mental illness and needs to return to more-intensive services. This sometimes creates problems with accessing needed services for PSH programs and tenants.
The District of Columbia alone among our case study sites has been using Assertive Community Treatment as a continuing service, reasoning that the level of support a client is receiving contributes in a major way to that client's stability, and to reduce or withdraw that support would threaten the client's mental health and housing status. The Department of Mental Health is starting to think about "graduating" people if they no longer need that level of care to reduce costs and make the slot available to someone else who needs it. Most agencies in the District of Columbia offering Assertive Community Treatment also offer Community Support, and providers say it is relatively easy to adjust levels of care, as long as the change is justified with a LOCUS assessment or its equivalent.
5.3.4. Targeted Case Management
Medicaid's optional targeted case management services include assessment, developing a service plan, referral and linkage to other needed services, and monitoring and follow-up services. Case management consists of services to help eligible beneficiaries obtain medical, social, educational, and other necessary services, which could include linkage or referral to housing assistance. Targeted case management is restricted to specific populations. States may target populations by disease or medical condition or by geographic regions, such as a county or a city within a state. Targeted populations could, for example, be individuals with HIV/AIDS, tuberculosis, chronic physical or mental illness, or developmental disabilities. Targeted case management is an optional service that states may elect to cover and for which they must get Centers for Medicare and Medicaid Services (CMS) approval through state plan amendments. Targeted case management services are defined as services furnished to assist individuals eligible under the Medicaid state plan to gain access to needed medical, social, educational and other services. Targeted case management includes the following assistance:67
- Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include:
- taking client history;
- identifying the individual's needs and completing related documentation; and
- gathering information from other sources, such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual.
- Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that:
- specifies the goals and actions to address the medical, social, educational, and other services needed by the individual;
- includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual's authorized health care decision maker) and others to develop those goals; and
- identifies a course of action to respond to the assessed needs of the eligible individual.
- Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services, including:
- activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan.
- Monitoring and follow-up activities, including:
- activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual's needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met:
- Services are being furnished in accordance with the individual's care plan.
- Services in the care plan are adequate.
- Changes in the needs or status of the individual are reflected in the care plan.
- Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.
When used to assist Medicaid beneficiaries who are chronically homeless, targeted case management can help link or refer the beneficiary to housing programs or services that are identified as a need in the care plan. Minnesota uses targeted case management as a significant source of funding for services to persons who are in PSH programs to help them access needed services. Minnesota's use of targeted case management seems to offer an approach available within Medicaid that is a good fit for some of the service needs of people who are chronically homeless, including services that help people obtain housing assistance and other benefits and to find and keep housing in the community. California also covers targeted case management services as a component of mental health services, which may be targeted to groups of Medicaid beneficiaries, some of which include PSH tenants.
Minnesota has two Medicaid targeted case management benefits, one for people with severe and persistent mental illness (MH-targeted case management) and the other for vulnerable adults and people with developmental disabilities (VADD-targeted case management).
To be eligible for MH-targeted case management services, a person must have a current diagnosis of SPMI (within 180 days) and qualify for services based on a functional assessment, which must be performed every 36 months. For providers who serve only people with severe and persistent mental illness, MH-targeted case management can pay for the services they provide to help their clients connect to services and benefits they need to avoid returning to homelessness. MH-targeted case management is somewhat less useful to PSH providers who serve people without a serious mental illness but who are chronically homeless and have a range of other health and behavioral health problems. Some of these providers report that as few as 15-20 percent of their clients meet SPMI criteria.
To receive Medicaid reimbursement for MH-targeted case management services, providers in Minnesota must have a contract with the county or Medicaid managed care plan for services provided to a person enrolled in managed care. Providers do time studies annually to determine the proportion of program staff time associated with targeted case management-eligible activities. The time studies are used to exclude costs associated with ineligible activities, which are direct services such as teaching or improving client skills, providing transportation, monitoring medications, or accompanying a client to court appearances or for other contact with the legal system. The time study results and information about program costs are used to establish monthly MH-targeted case management rates, which are negotiated between each county or managed care plan and service provider. The monthly rates usually range from $400 to $500 per person. Some providers and health plans have negotiated a tiered rate-structure, with higher rates paid for clients who need more frequent and intensive services and lower rates for clients who need less case management.
While the MH-targeted case management payment methodology is attractive to many service providers because it reduces the need to document time spent on every separate service, it also creates some challenges. In Minnesota, targeted case management services are paid at a monthly rate, while Adult Rehabilitative Mental Health Services are paid based on 15-minute units of service. It can be difficult for providers to demonstrate that they are not getting paid twice for the same program costs, even though it is understood that people who are chronically homeless and PSH tenants need both types of services. The state will not reimburse for the two types of services "unless the activities are separate, clearly defined and documented, and billed separately." As a result, some providers have created teams with designated staff members performing case management functions and other team members delivering Adult Rehabilitative Mental Health Services, while other PSH service providers have stopped requesting Medicaid reimbursement for Adult Rehabilitative Mental Health Services because of the complexity of managing two different payment mechanisms.
To be eligible for targeted case management services in Minnesota as a vulnerable adult or person with developmental disabilities, a person must be age 18 or older, must be receiving medical assistance, must have significant functional impairments, must be in need of service coordination to attain or maintain living in an integrated community setting, and also must be "a vulnerable adult in need of adult protection or an adult with a developmental disability or an adult who lacks a permanent residence and who has been without a permanent residence for at least one year or on at least four occasions in the last three years." (The last description in the quote is the HUD definition of chronic homelessness.) The county where a person needing VADD-targeted case management resides must assess the person and determine that she or he is eligible.
Thus, the current VADD-targeted case management criteria make people who are chronically homeless eligible for services if they also have functional impairments and a need for service coordination, which appears to make this benefit a good match for the people who need and live in PSH. However, Minnesota requires a county desiring to offer these services to provide the nonfederal match, and many counties have not allocated locally controlled funds to do this. Thus VADD-targeted case management was rarely used for PSH tenants and people who are chronically homeless at the time of our case study, although at least one county was potentially interested in opportunities to use VADD-targeted case management to help finance services to assist people experiencing homelessness to get and keep housing. County human services agency staff are wary about committing to offer these services for this population because they are not certain which funding sources they could use as a match, and they do not yet have a structure of VADD-targeted case management contracts for programs that offer PSH. Some stakeholders also reported concerns about the risk of significant audit disallowances or payback requirements by Medicaid and suggested that counties would like to have more guidance about how to define medical necessity for these services.
California's Medicaid program also has a targeted case management component as part of covered mental health services and a separate targeted case management program that is administered by counties for designated high-risk groups. California covers some targeted case management services under Medicaid as part of the benefits available to people with SMI, and some mental health service providers obtain reimbursement for services that help connect clients to other benefits and housing. These targeted case management benefits are considered part of the package of specialty mental health services that Medicaid covers and county mental health departments administer. The payment mechanism for these services is usually integrated into a county's system for managing Medicaid claims by and payments to contract agencies.
California uses targeted case management services for other designated populations as well, including persons served by county public health agencies, adult probation departments, and other public systems. Counties administer these benefits, drawing down federal funds to match county spending on covered services. Local government agencies are the only qualified providers for these services, and the funding mechanism for these benefits is not well understood by community providers. As a result, these targeted case management benefits are not widely used in PSH in California. So far, people involved in efforts related to ending homelessness have not been able to figure out how to get reimbursed for targeted case management services for people experiencing homelessness who do not have a serious mental illness. This may be explored in future years but it is not a current strategy.