Louisiana has undertaken a multiyear, comprehensive redesign of its public behavioral health system for children and adults. The redesign has required numerous waivers and state plan amendments, some of which are still to come. Completion of the redesign's components is not expected until 2015 or 2016. Known as the Louisiana Behavioral Health Partnership (LBHP), the new system is structured as a type of managed care organization--a statewide management organization--responsible for coordinating care and managing both Medicaid-funded and state-funded behavioral health programs.
Magellan Health Services operates LBHP, which began enrolling clients who qualify for services covered by LBHP programs on March 1, 2012. Services available from LBHP include a broad array of behavioral health services for children and adults.79 As Louisiana has obtained federal approval for changes in Medicaid-covered benefits, new services have been added. Persons experiencing chronic homelessness or living in PSH who qualify for Medicaid are a small part of LBHP's membership, but the plan's provisions include services that have been structured explicitly to help this group manage their health conditions while achieving and maintaining stable housing.
In Louisiana, this study focused on a group of people with complex health and behavioral health needs who were homeless or formerly homeless and participate in a special program--the Permanent Supportive Housing Program (PSHP). PSHP was established in Louisiana with federal funds in the wake of the 2005 hurricanes Katrina and Rita.80 Most PSHP clients have made the transition to coverage through the Louisiana Behavioral Health Partnership, where they and other LBHP members experiencing homelessness or living in PSH may receive a broad range of health care and behavioral health services. The most relevant of these Medicaid-covered services are Assertive Community Treatment, Community Psychiatric Support and Treatment, and other psychosocial rehabilitation and substance use disorder treatment services.81
In addition to the services provided through the Louisiana Behavioral Health Partnership, different components of the state Medicaid program have been covering other aspects of care. For example, medical care is covered separately. For those who need assistance with basic self-care activities, inhome personal care services are covered under the state's Medicaid Long-Term Personal Care Services program. Participants who qualify for and have applied for 1915(c) home and community-based services are either receiving or on waiting lists for those services. A small percentage of participants are also receiving transition assistance from the state's Money Follows the Person demonstration program.
6.6.1. The Role of Louisiana Behavioral Health Partnership for PSHP Clients
Louisiana's 1915(i) State Plan Amendment
As a condition of transferring PSHP's block grant funds to the State of Louisiana, HUD required the state to commit to continuing funding for the PSHP's service component once the block grant funds ran out. Certain provisions of Louisiana's Medicaid state plan, including new covered services and arrangements to provide these services through the Louisiana Behavioral Health Partnership, are designed to fulfill a good part of that commitment to sustaining services for eligible PSHP clients. Under these provisions, Medicaid reimbursements through the Louisiana Behavioral Health Partnership replace some of the block grant dollars that have been paying for services for many Medicaid-eligible clients. The component of greatest interest for people experiencing chronic homelessness or living in PSH is a state plan amendment under Section 1915(i) that received CMS approval in December 2011 and became effective on March 1, 2012.82 To fulfill its PSHP sustainability obligations, the state will also use other resources for persons and activities that Medicaid cannot cover.
To be eligible for Medicaid-reimbursed services under 1915(i), a person must have one or more of the included psychiatric diagnoses, be enrolled in Medicaid, and also meet 1915(i) functional impairment criteria. These eligibility requirements are similar to the requirements for specialty mental health services in all of our case study sites (see Chapter 5). In the CMS approval letter for Louisiana's 1915(i) (p. 11), a qualifying functional impairment is defined in terms of LOCUS scores on the Risk of Harm and Functional Status subscales and composite/global LOCUS score reflecting a "moderate" level of functioning.83 To reach the final score, many factors are considered during assessment and LOCUS administration, including current functioning, treatment history, availability of supports, housing instability, and similar aspects of a client's situation.
Eligibility for 1915(i) Services
Louisiana's 1915(i) state plan amendment provides home and community-based services for adults over age 18 who meet at least one of the following criteria:
Persons with ACUTE Stabilization (AS) Needs. The person with AS needs currently presents with mental health symptoms that are consistent with a diagnosable mental disorder specified within the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), or subsequent revisions of these documents.
Persons with SMI (federal SAMHSA definition of Serious Mental Illness as of December 1, 2011). The person with major mental disorder (MMD) has at least one diagnosable disorder that is commonly associated with higher levels of impairment. These diagnoses, per the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), include eight psychotic disorder classifications (six for schizophrenia, one for delusional disorder, one for psychosis not otherwise specified, seven bipolar disorder classifications, two depression classifications, and MMD).
An adult who has previously met the above criteria and needs subsequent medically necessary services for stabilization and maintenance. Exclusion: diagnosis of a substance use disorder without an additional co-occurring Axis I disorder.
6.6.2. Services Available Under 1915(i)
The 1915(i) amendment was developed to cover an array of home and community-based services needed by many people with serious mental illness, especially those who are homeless, formerly homeless, or at risk of homelessness. Inclusion of these services furthers the goal of covering the services needed by many PSHP clients that is explicit in CMS's approval of Louisiana's 1915(i) state plan amendment.84 Covered services include: (1) treatment by a licensed mental health practitioner--an individual licensed in the State of Louisiana to diagnose and treat mental illness or substance use disorders acting within the scope of all applicable state laws and their professional license; (2) Community Psychiatric Support and Treatment; and (3) Psychosocial Rehabilitation, and Crisis Intervention (approval letter, p. 17).
A PSH-specific certification is required for agencies offering tenancy support services to PSHP clients through 1915(i), as some of the support services that PSHP clients have received through that program would not otherwise be part of Community Psychiatric Support and Treatment functions. We refer to this combination of certifications and the services provided by these agencies as PSH-Community Psychiatric Support and Treatment.
Many services of great importance to people experiencing homelessness as they move into and live in PSH are explicitly included in PSH-Community Psychiatric Support and Treatment. The Louisiana Behavioral Health Partnership Technical Manual-Service Definitions describes these services as "restoration, rehabilitation, and support to develop skills to locate, rent, and keep a home, landlord/tenant negotiations, selecting a roommate, and renter's rights and responsibilities." The manual goes on to include in these services "assisting the individual to develop daily living skills specific to managing their own home, including managing their money, medications, and using community resources and other selfcare requirements." Habilitation is included in "developing and implementing social, interpersonal, self-care, daily living, and independent living skills to restore stability, to support functional gains, and to adapt to community living." Medicaid will cover activities furthering these goals as long as they are established as medically needed by LBHP members.
6.6.3. How the Louisiana Behavioral Health Partnership Works--Role of Magellan Care Managers and Tenancy Management Specialists
The staffing structure to support care coordination for people with complex and interacting behavioral health conditions within the Louisiana Behavioral Health Partnership is described here in some detail because it provides the best example we encountered of how an MCO's staff are working with community providers to facilitate getting the right care to its more challenging members, including supports to assure housing acquisition and retention. Within the Louisiana Behavioral Health Partnership, Magellan has set up a staffing structure designed to support client case managers and facilitate getting the right care to plan members. Duties are split between health care and tenancy-related needs. Magellan's care managers are staff members who serve as primary liaisons between a member's care provider or team and the LBHP. A second type of staff, tenancy management specialists, takes on housing-related activities to support members as they seek, obtain, and retain housing.
Magellan care managers are a care provider's primary point of contact with the Louisiana Behavioral Health Partnership. They authorize care for plan members and also assure that clients get the care they need. They discuss treatment plans with providers, checking to see whether the Louisiana Behavioral Health Partnership offers services that would benefit the member but that perhaps the provider did not know about or did not ask for (e.g., a detox bed that is open and that the member might benefit from using it). Care management began these services in March 2012 for everyone then enrolled in the Louisiana Behavioral Health Partnership, including PSHP clients receiving Assertive Community Treatment services. PSHP tenants eligible for Community Psychiatric Support and Treatment services began enrolling in the Louisiana Behavioral Health Partnership in 2013, once Magellan was authorized to provide PSH-Community Psychiatric Support and Treatment services as a covered benefit and PSHP clients received the assessment required to establish eligibility for that benefit.
Services for Assertive Community Treatment authorized under 1915(i) are reimbursed on a monthly case rate, while services for other levels of care are authorized as a number of monthly units of care (in 15minute increments). Magellan uses an initial allocation of care units as a checkpoint, not as a ceiling. The reasoning being that the initial allocation might be enough, and before authorizing more they want to see what has been accomplished. But if more care units are needed, Magellan encourages providers to ask for them. Magellan officials figure that over time they will be able to tell whether authorizing more units of Community Psychiatric Support and Treatment or other types of care pays off in reduced use of expensive emergency services as they expect it will. They want to manage costs by improving outcomes and over time will have the data to make this management approach a reality.
Magellan care managers are working to educate providers to ask for more units if the client's circumstances appear to call for them, and the care managers will usually increase the authorization once they have the facts. Magellan describes the relationship of its care managers to client case managers or teams as one of information seeking/provision and consultation; it has not been adversarial.
Care managers also examine quality-related issues for each provider service team in their portfolio. They review staff credentials to assure that they comply with requirements, check for any complaints against particular provider staff (e.g., lawsuits, complaints to medical boards or employers), and perform other quality control functions.
Magellan's tenancy management specialists handle relationships with landlords and property managers for PSHP housing units, increasingly taking over for the agency that administered Housing Choice Vouchers for the program.85 Tenancy managers negotiate with landlords, deal with landlords when tenant issues arise, and otherwise remove the burden of direct work with landlords from the Community Psychiatric Support and Treatment staff. They do not do direct work with plan members, which remains the job of the Community Psychiatric Support and Treatment teams. The housing-related work of the teams includes helping clients find and move into housing and resolve any behavioral issues that threaten their continued tenancy. If landlord-related housing issues arise, the Community Psychiatric Support and Treatment staff can contact their Magellan care managers and tenancy management specialists for help getting the issues resolved.
6.6.4. Relevance of the Louisiana Behavioral Health Partnership's 1915(i) Services to Qualifying PSH Tenants in Louisiana
Services available under Louisiana's 1915(i) provisions are an excellent example of how a state could shape its Medicaid state plan to maximize the program's ability to cover services of greatest value to people experiencing chronic homelessness or living in PSH. When the PSHP began in 2007, the program's state funding and non-Medicaid federal resources were used to pay for services to help clients get and keep housing, provide supportive services, provide behavioral health services (if the level of care was Assertive Community Treatment), and connect to other agencies to meet client needs. At that time, the agencies delivering these supportive services were not Medicaid providers in Louisiana, and thus needed to become certified to offer one or more of the services available through the Louisiana Behavioral Health Partnership once clients transitioned to that plan. Relevant services for PSHP clients and tenants eligible for services under the state's 1915(i) state plan amendment include Community Psychiatric Support and Treatment, Crisis Intervention, Psychosocial Rehabilitation, and Assertive Community Treatment. As described earlier, a PSH-specific certification is also required for agencies offering tenancy support services to PSHP clients through 1915(i), and additional specialized training is required to obtain this PSH certification.
All agencies serving PSHP clients in Orleans and Jefferson parishes, the local focus of this study, qualified to continue offering their services as Medicaid providers in Louisiana. Those delivering Assertive Community Treatment did so as of March 1, 2012, the date that enrollment in the Louisiana Behavioral Health Partnership began. Program participants who qualify for Assertive Community Treatment services also meet the diagnostic and impairment criteria for SSI and most are now enrolled in Medicaid. These participants also meet the eligibility criteria for services covered under 1915(i), so once the Assertive Community Treatment agencies were certified they began enrolling their clients in LBHP. They likewise began seeking Medicaid reimbursement for services delivered after that date.
During the years before the Louisiana Behavioral Health Partnership was established, some participants in Louisiana's PSHP received services from Housing Support Teams, the predecessors to the Partnership's Community Psychiatric Support and Treatment Teams. These teams provided a somewhat less-intensive level of support for people who did not qualify for Assertive Community Treatment. All the agencies that were operating Housing Support Teams and chose to pursue certification also qualified as Medicaid providers and completed the required specialized training to deliver PSH-specific Community Psychiatric Support and Treatment for PSHP clients. With the transition to the Louisiana Behavioral Health Partnership, some additional agencies also qualified and came on board. Service agencies in the program also had the option to seek certification to deliver Psychosocial Rehabilitation and Crisis Intervention services, and all but one are now certified to provide these service to qualifying clients.
Additional behavioral health agencies may seek certification to provide PSH-specific Community Psychiatric Support and Treatment services to clients qualifying under 1915(i) and living in or qualifying for PSH offered through the PSHP; this process is already under way. Officials consider such expansion desirable, as it would increase competition among providers while affording consumers a choice if they live near more than one qualifying agency. To qualify, agency staff would have to have the right credentials, complete the special training for PSH tenancy work, and the agencies themselves would have to be certified for PSH-specific Community Psychiatric Support and Treatment.
Louisiana anticipates that the PSHP will cover more clients as more housing units become attached to the program. The state added 351 units to the program in 2013 through a new Section 811 project (HUD affordable housing for people with disabilities) and expects to add more as opportunities arise. Medicaid could cover the costs of some of the supportive services to tenants in these units if the tenants themselves qualify for 1915(i) services and the agencies providing the services are certified as providers of PSHspecific Community Psychiatric Support and Treatment services.
6.6.5. Home and Community-Based Services Under a 1915(c) Waiver
A 1915(i) state plan amendment is not the only way that Louisiana has structured its Medicaid program to support the housing-related services needed by people with complex health and behavioral health conditions. The state also has several 1915(c) Home and Community-Based Services waivers that give it additional flexibility.
The PSHP is a cross-disability PSH initiative; some participants do not have a serious mental illness and thus do not fall under the purview of the Louisiana Behavioral Health Partnership, although they do have other qualifying disabilities. Many of these individuals can be served under one of the state's four existing 1915(c) Medicaid HCBS waivers for persons with developmental disabilities or for persons, including the elderly, who acquire a physical or cognitive disability after age 22 (generally referred to as the Aging/Disabled population). Louisiana submitted Medicaid waiver amendments to CMS to add tenancy supports for persons served under these waivers, all of which have been approved (see amendment wording below). PSHP participants who currently receive or who qualify and are certified for participation in one of these waivers will have their tenancy supports reimbursed by Medicaid through that mechanism. At the time this research concluded, it had not yet been decided whether claims under 1915(c) waivers would be processed through Louisiana Behavioral Health Partnership/Magellan (for plan members) or be billed directly through the regular Medicaid claims process (for everyone receiving relevant services).
EXHIBIT 6.1. Possible Service Definitions for Two New Housing Services Provided under 1915(c) Waivera
1. Housing Stabilization Services
Service Definition (Scope)
Housing Stabilization Services enable waiver participants to maintain their own housing as set forth in the participant's approved plan of care (POC). Services must be provided in the home or a community setting. The service includes the following components:
- Participate in plan of care renewal and updates as needed, incorporating elements of the housing support plan.
- Provide supports and interventions per the individualized housing support plan. If additional supports or services are identified as needed outside the scope of Housing Stabilization Services, communicate the needs to the Support Coordinator.
- Provide ongoing communication with the landlord or property manager regarding the participant's disability, accommodations needed, and components of emergency procedures involving the landlord or property manager.
- Update the Housing Support Plan annually or as needed due to changes in the participant's situation or status.
Specify Applicable (if any) Limits on the Amount, Frequency, or Duration of this Service
This service is only available upon referral from the Support Coordinator. This service is not duplicative of other waiver services including Support Coordination. This service is only available to persons who are residing in a State of Louisiana Permanent Supportive Housing unit. No more than 72 units of Housing Stabilization Services can be used per year without written approval from the Support Coordinator. No more than 165 units of Housing Transition or Crisis Intervention and Housing Stabilization Services can be used per year without written approval from the Support Coordinator.b
2. Housing Transition or Crisis Intervention Services
Service Definition (Scope)
Housing Transition or Crisis Intervention Services enable participants who are transitioning into a PSH unit, including those transitioning from institutions, to secure their own housing or provides assistance at any time the participant's housing is placed at risk (e.g., eviction, loss of roommate or income). The service includes the following components:
- Conduct a housing assessment identifying the participant's preferences related to housing (type, location, living alone or with someone else, accommodations needed, other important preferences) and needs for support to maintain housing (including access to, meeting terms of lease, and eviction prevention), budgeting for housing/living expenses, obtaining/accessing sources of income necessary for rent, home management, establishing credit and understanding and meeting obligations of tenancy as defined in lease terms.
- Assist participant to view and secure housing as needed. This may include arranging or providing transportation. Assist participant to secure supporting documents/records, completing/submitting applications, securing deposits, locating furnishings.
- Develop an individualized housing support plan based upon the housing assessment that includes short and long-term measurable goals for each issue, establishes the participant's approach to meeting the goal, and identifies where other provider(s) or services may be required to meet the goal.
- Participate in the development of the plan of care, incorporating elements of the housing support plan.
- Look for alternatives to housing if permanent supportive housing is unavailable to support completion of transition.
- Communicate with the landlord or property manager regarding the participant's disability, accommodations needed, and components of emergency procedures involving the landlord or property manager.
- If at any time the participant's housing is placed at risk (e.g., eviction, loss of roommate or income), Housing Transition or Crisis Intervention Services will provide supports to retain housing or locate and secure housing to continue community-based supports including locating new housing, sources of income, etc.
Specify Applicable (if any) Limits on the Amount, Frequency, or Duration of this Service
This service is only available upon referral from the Support Coordinator. This service is not duplicative of other waiver services including Support Coordination. This service is only available to persons who are residing in a State of Louisiana Permanent Supportive Housing unit or who are linked for the State of Louisiana Permanent Supportive Housing selection process. No more than 93 units of Housing Transition or Crisis Intervention can be used per year without written approval from the Support Coordinator. No more than 165 units of Housing Transition or Crisis Intervention and Housing Stabilization Services can be used per year without written approval from the Support Coordinator.
- This wording is attached, with CMS approval, to Louisiana's 1915(c) Community Choices Waiver (in 2013), as well as to its 1915(i) state plan amendment (approved by CMS in 2011). For more information see http://new.dhh.louisiana.gov/assets/docs/OAAS/publications/CCW_Fact_Sheet.pdf and http://new.dhh.louisiana.gov/assets/docs/BehavioralHealth/LBHP/SPA_TN_11-13.pdf.
- This wording refers to limits on units of service used by a particular client, not to limits on the number of clients that may be served.
6.6.6. Services for People with Substance Use Disorders
Many people experiencing homelessness and PSHP tenants who have substance use disorders also have a co-occurring serious mental illness, and they may be enrolled in Medicaid and eligible for 1915(i) services on the basis of their mental illness. But the eligibility criteria specified in Louisiana's 1915(i) state plan amendment do not include people with a diagnosis of substance use disorder who do not also have a co-occurring Axis I mental illness diagnosis.
Medicaid recipients enrolled in the Louisiana Behavioral Health Partnership have access to all the substance use treatment services available within Louisiana's Medicaid program, as well as other state-funded substance use services. Some stakeholders described these benefits and services as limited--a situation similar to that in many other states. Some PSHP participants who do not have a mental illness have one or more chronic and disabling health conditions. If they are eligible for Medicaid as an SSI beneficiary, they may receive other Medicaid services and supports, which are administered separately from the benefits managed through the Louisiana Behavioral Health Partnership. Some of these participants receive benefits available under one or more of the state's home and community-based services waivers. Because Louisiana policymakers have decided not to expand Medicaid eligibility under the Affordable Care Act, it currently appears unlikely that most nonelderly homeless adults whose disabilities are attributable to substance use will be enrolled in Medicaid or eligible for Medicaidcovered services, unless they have another disability that makes them eligible for SSI.
6.6.7. Use of Savings for Services Beyond Those Specified in the Medicaid State Plan
A final important provision of the Louisiana Behavioral Health Partnership is its ability to use program savings to pay for types of service not explicitly included in Louisiana's Medicaid state plan. This ability is authorized under a provision of one of the state's plan amendments--1915(b)(3). In Louisiana these savings will be used to fund children's services, but other states could also request this arrangement, which would allow managed care organizations some flexibility to provide services, such as care coordination and housing supports for high utilizers of expensive services, beyond those specified in the Medicaid state plan.