Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field. 8. Challenges and Opportunities


Chapter 8 Highlights

Olmstead. In 1999, the Supreme Court issued a decision in Olmstead that prohibits the unjustified segregation of people with disabilities. This decision was made based on an appeal of a case brought on behalf of two women in Georgia who alleged that their rights under Title II of the Americans with Disabilities Act (ADA) were violated.

The ruling creates a mandate for states and other public entities to reduce the isolation and segregation of people with disabilities in institutional settings and instead provide community-based services. It requires that people with disabilities be housed in "a setting that enables individuals with disabilities to interact with nondisabled persons to the fullest extent possible."

Lawsuits brought based on Title II of the ADA and Olmstead are stimulating Medicaid and other state agency officials to re-balance their long-term care systems and expand the availability of home and community-based services linked to housing and employment for people with disabilities who were institutionalized or at-risk of institutionalization.

Depending on the alleged violations and rulings, states are typically obligated to expand housing resources for the affected class. This presents significant challenges to states. These challenges include: (1) the sheer availability of supportive housing units, which may not be sufficient to meet the level of demand created by Olmstead in addition to the needs of people not covered, including individuals experiencing homelessness; and (2) the requirement that new resources be developed in the most integrated setting possible.

Despite the challenges, states and community providers have been working hard since Olmstead to develop financing strategies for delivering the services and supports called for by the court decision. Medicaid's home and community-based services are often an essential part of these strategies, including waiver services authorized under Section 1915(c) and state option services authorized under 1915(i).

Efforts to meet the requirements of Olmstead can be reasonably well-aligned with efforts to reduce chronic homelessness, or they can be separate efforts that reflect competing visions and values. Two case study sites, Louisiana and the District of Columbia, have followed the first path, while three others--California, Minnesota, and Illinois--have followed the second. In these latter cases, approaches to financing and organizing housing and services for people with disabilities coming from homelessness and those living in institutional settings are not well-aligned.

Workforce Capacity. As expanded eligibility swells the Medicaid rolls, newly eligible people may find it difficult to locate a provider or get care in a timely manner, due to a shortage of primary care providers as well as providers of specialty medical services. To translate coverage into meaningful access to care will require not only more medical providers in some communities, but also changes in the ways that health care is delivered to improve efficiency and the quality of care.

Team models using personnel such as nurses and community health workers as "care extenders" are likely to be important strategies.

Training, skill development, upgraded credentials, and increased supervision are likely to be needed to safely respond to some people's complex medical and behavioral health conditions. Movement to begin these processes is already under way in many places.

Increasing emphasis on care coordination and multidisciplinary team approaches create another challenge, as even highly trained clinicians rarely learned to work across disciplines or as members of teams.

Gaps. Current gaps in services include the need for more flexibility in services to address substance use disorders, alone and in the context of co-occurring medical and mental health conditions; and the need to address challenges in serving "dual-eligibles"--those who receive both Medicare and Medicaid. These challenges lie primarily in aligning the very different payment mechanisms and covered services between the two programs.

New Opportunities. Health homes under the Affordable Care Act, with federal funding at 90 percent for the first two years of operation, offer an important new opportunity to incorporate care coordination services for people with complex health needs into Medicaid state plans. Some states are also working with CMS to find a way to include housing stabilization services as a covered benefit.

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