Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field. 7.1. Introduction


This chapter looks at three innovative models for care coordination for individuals experiencing chronic homelessness. Two of the examples are initiatives to create Accountable Care Organizations (ACOs) or ACO-like models--Hennepin County, Minnesota's Hennepin Health and Chicago's Together4Health (T4H). These initiatives are led by providers from the nonprofit and public sectors working to organize the local health and behavioral health care delivery systems to meet the needs of the community's most vulnerable, extremely low-income members. Both have an explicit focus on those with chronic patterns of homelessness, and both include housing as part of the picture. A third example is Housing for Health, Los Angeles County Department of Health Services' ambitious program to link housing, health, and behavioral health services for the same population through linkages with housing providers and its own network of county hospitals, clinics, and contracted service providers.

The Accountable Care Organization (ACO) concept is fairly new, first appearing in 2007. The Kaiser Commission on Medicaid and the Uninsured describes an Accountable Care Organization as, "…a provider-run organization in which the participating providers are collectively responsible for the care of an enrolled population and also may share in any savings associated with improvements in the quality and efficiency of the care they provide" (Kaiser 2012).

The first ACOs were created to serve Medicare patients. The Affordable Care Act contains provisions that recognize Medicare ACOs; it also authorized a demonstration project for pediatric ACOs and provided authority for the Centers for Medicare and Medicaid Innovation to test new models of care delivery and payment reform. Several states have launched initiatives to develop and implement similar models in Medicaid that aim to reduce costs and increase quality, most of which are in the early stages of development. Both T4H and Hennepin Health are examples of efforts to create ACO-like entities in Medicaid.

The three initiatives featured here--Hennepin Health, T4H, and Housing for Health --differ in some ways while working toward similar goals.

  • Hennepin Health. Hennepin Health is one of the pilot projects selected by the State of Minnesota to develop ACOs to serve people enrolled in Medicaid. It has been designed to enroll and deliver care to adults who are newly eligible for Medicaid under the Affordable Care Act.86 It is county-run, with the county's health care and human service systems playing key early roles. Its goal is to integrate medical, behavioral health, and human services in a patient-centered model of care. A central premise of Hennepin Health is to promote the integration of care across fragmented service systems and to address social determinants of health as a strategy for improving health outcomes and lowering costs for the most complex and highest-cost Medicaid enrollees. Hennepin Health is expected eventually to serve more than 10,000 people and had 8,774 people enrolled as of July 2014.

    Hennepin Health was a "work in progress" during the study time frame; experiences during its first year illustrate some of the challenges ahead for such efforts, as well as some of the opportunities for connecting an emerging ACO to supportive housing and other services and supports to address social determinants of health.

  • Together4Health (T4H). T4H is a new for-profit company comprising a network of providers covering the city of Chicago. The Illinois Medicaid office selected T4H as one of six Care Coordination Entities (CCEs) following a competition offered by the Illinois Department of Healthcare and Family Services (of which the Medicaid office is a part) in conjunction with the governor and three other state agencies. T4H members include five hospital systems (including Cook County), eight Federally Qualified Health Centers, and numerous mental health, substance use, behavioral health, and permanent supportive housing providers, as well as advocacy organizations. T4H and the state settled a contract for the program in late fall 2013, and T4H began enrolling clients in December 2013. While not currently a full-risk managed care organization, it anticipates working toward that status over the next few years.

Los Angeles County's Housing for Health is similar to Hennepin Health in that it is a county-run program seeking to integrate health and behavioral health care and stable housing. It negotiates directly with housing providers, seeking to obtain housing units dedicated to the clients of the Department of Health Services' many hospitals, clinics, and community partners in exchange for covering the cost of supportive services to help people retain housing.

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