This chapter has examined three emerging models for the kind of integrated and coordinated care that evidence shows has promise for people with complex needs and histories of chronic homelessness. The ACO model is based on diverse participating providers addressing needs holistically and sharing savings from improved efficiency and quality of care.
Hennepin Health, Together4Health, and Housing for Health are in the early stages of implementation, but each offers lessons for what it takes to create a provider organization across a large and diverse metropolitan area with differing needs and capacities across the service area. Hennepin Health is countyrun, as is Housing for Health; Together4Health (T4H) is a for-profit company made up of providers. All three examples target users of safety net services and include significant emphasis on the social determinants of health. All include homelessness as one of the social determinants; none limits participation to people with serious mental illness.
All three initiatives are designed to overcome three of the most persistent gaps in care for chronically homeless people with disabilities that we identified during this research.
First, they pay for many of the activities we sometimes call "the glue," the things that help connect people to care and ensure that they get what they need in ways that take the whole person into consideration.
Second, all cover people with and without serious mental illness--although access to specific types of Medicaid-reimbursed behavioral health care will still depend on a consumer meeting the relevant eligibility criteria.
Third, the models include the full extent of services a chronically homeless person or PSH tenant with complex and interacting health and behavioral health conditions might need, from primary care to specialty care to mental health and substance use disorder treatment to social services and housing (although no single source pays for all of these in any of the models).