The communities we visited for this project offered excellent examples of collaboration to deliver integrated primary care and behavioral health care services, both among separate organizations and across programs operated by the same organization. Mental health programs and FQHCs can be co-located programs that operate within the same building but use separate staff, documentation, and reimbursement mechanisms. Staff of co-located programs can consult with one another and make warm handoffs to introduce a client to another program operating in the same location. Team-based models may use staff members who are funded separately but work together on a daily basis. Information needed for service planning and care delivery may be shared through integrated electronic records and case conferences, with client permission. Examples we observed during this project are:
Chicago. HHO, an FQHC, has developed a full continuum of homeless-oriented services, including outreach and engagement, primary care, mental health services, and service related to substance use disorder. If a person connects to HHO through any of its many doors (the HCH clinic or one of several outreach programs) and is willing to accept services of any type, HHO completes an integrated intake assessment. The integrated assessment tool gathers the information needed to determine whether the client meets eligibility and medical necessity criteria for a range of services, each of which has different categorical requirements. The assessment tool crosswalks to the rules associated with different types of services or benefits. At a weekly integrated intake meeting, staff review the persons assessment, discuss options for housing and services, and compare them to the persons own stated desires and likely eligibility for benefits that would cover the costs of different options. The meeting works out an offer to the person, with information about waiting times and other relevant facts, and HHO then works with the consumer to find the best fit from what is available.
Alameda County and San Francisco. Bonita House and Lifelong Medical Care in Alameda County and the SFDPH and Citywide Case Management (CCM) in San Francisco have implemented partnerships that integrate the services of an experienced FQHC and an experienced provider of mental health services to serve the same group of people in site-based or scattered-site supportive housing. The FQHC and the mental health service-provider receive Medicaid reimbursement separately. The mental health provider can receive reimbursement for a flexible range of services provided by unlicensed staff (with appropriate training and supervision), but only for persons with SMI and for services and goals related to symptoms of mental illness. The FQHC receives Medicaid reimbursement for medical and psychiatric services, delivered mostly by licensed clinicians, and can get reimbursed for services that address a broader range of health or behavioral health conditions, whether or not a person has SMI. This partnership model is thus able to bridge the gaps in reimbursement rules. Staff members coordinate to deliver integrated care as part of a team, and each provider does what it does best and can get reimbursed for.
PSH residents throughout San Francisco have access to health services provided by the SFDPHs HUH clinic, which sees about one-third of San Franciscos 3,600 PSH tenants each year. In addition to services provided by the HUH clinic, SFDPH contracts with the University of California-San Francisco to operate the CCM program. CCM has several decades of experience providing mental health rehabilitation services reimbursed by Medicaid and participates in programs that target high-users of emergency or inpatient psychiatric hospital services. CCM offers services to supportive housing tenants in 26 buildings. A roving team delivers services to about 125 people every quarter, with a focus on responding to tenants in crisis, and provides services that supplement basic on-site tenant services at the housing sites, including clinical consultation with on-site case managers.
In Alameda County, Bonita Houses HOST works with Lifelong Medical Care, an FQHC. A primary care provider from Lifelong is co-located at the HOST office and works as a member of the HOST team. She provides primary care to HOST clients, participates in case conferences, and makes home visits as needed. Engagement and relationship-building with the HOST program often begins with attention to health problems, because some chronically homeless people are willing to accept care for their significant health problems but will not to accept a diagnosis of mental illness. Because Lifelong has clinic sites throughout the county, HOST can build primary care relationships that can offer continuity of care as people move from homelessness into PSH.
Case Example of Coordinated Care in San Francisco
Client: Mr. Jones (clients name has been changed) was a 64-year-old Caucasian male who lived in a San Francisco PSH building. He was referred to CCM by the property manager when his hoarding and cluttering behavior had led to his failing the Housing Authoritys housing inspection because of safety issues. This meant that he faced potential eviction from the PSH building because he would be unable to pay the rent. The hoarding behavior was related to his diagnosed bipolar disorder and obsessive compulsive personality disorder. In addition, he had diabetes that he did not consistently manage and had received a diagnosis of terminal lung cancer.
Mr. Jones had periods of erratic behavior, irritability, and anger, and frequent conflicts with neighbors. His obsessive compulsive personality disorder also contributed to problems with keeping medical appointments and an inability to make decisions about his cancer-related medical treatment. While confronting end-of-life issues, he was isolated from family and other social contacts, but wanted to reconnect with a son from whom he had been estranged for 20+ years.
The clinical social worker who worked as part of the CCM Roving Team responded to Mr. Joness situation by:
Portland, Oregon. Central City Concern (CCC), which began more than three decades ago to provide clean-and-sober housing to formerly homeless people with substance use disorders, today provides a broad range of engagement, treatment, rehabilitation, recovery support, shelter, and housing services to homeless people. The majority of people served by CCC have co-occurring behavioral and other health conditions. CCC combines services provided under its FQHC and behavioral health clinic licenses and recently renovated a building where both these services are delivered. The primary care clinic is financed through HRSA grants and FQHC Medicaid reimbursement. Services provided in the behavioral health clinic receive Medicaid reimbursement under an Oregon managed care carve-out, and supplemental FQHC reimbursement is wrapped around the behavioral health financing to fill gaps in coverage. To meet separate licensing requirements for primary and behavioral care clinics, the integrated site must maintain separate reception areas. Despite the artificiality of this arrangement, practitioner offices are integrated, and all practitioners use shared medical records.
Housing costs are funded through HUD's Shelter Plus Care and SHP grants, supplemented by Portland City general funds administered by the Housing Authority of Portland. CCCs broader services rely on multiple sources of funding. Detoxification services, for example, are covered by a combination of federal substance abuse block grant funds, Oregon Health Plan treatment slots, and FFS Medicaid reimbursement for those who have Medicaid benefits because of other disabilities. Despite the organizations ingenuity in coordinating a diverse range of financing sources, CCC still experiences gaps in coverage for case management services, outreach and engagement services, and front desk services in PSH.