For the most part, people living in institutional settings are not homeless, although a growing number of older and vulnerable homeless adults are entering nursing homes or other long-term care facilities, often after a period of inpatient hospitalization for an acute medical and/or psychiatric crisis.
North Carolina provides an example of how 1915c waivers are being used in PSH. The state has a partnership between its Housing Finance Agency and HHS that generates hundreds of housing units supported by rent subsidies for people with disabilities. Residents of this housing receive case management and mental health services from community-based service-providers. Some of these services are financed through a 1915c HCBS waiver. Although many residents of these supportive housing units were not homeless when they moved in and may have no history of homelessness, many others came from homelessness--which makes the units they occupy PSH in the nomenclature of homeless service systems.
In Chicago, the Chicago Housing for Health Partnership Study,32 which enrolled homeless people hospitalized for a chronic medical condition, found that 19 percent of the intervention group and 27 percent of the usual care group had at least one stay in a nursing home during the 18-month follow-up period. The intervention group that was offered respite and PSH had more than 40 percent fewer total days in nursing homes, compared to the usual care group.33 These homeless people would presumably meet service necessity criteria for HCBS waiver services.
In San Francisco, the Department of Public Health gives priority for admission to its long-term care facility, Laguna Honda, to people who are homeless or who cannot be discharged from a hospital because they do not have a place to live and would thus become homeless. Again these formerly homeless people likely would meet the criteria for HCBS services in PSH. SFDPH currently is attempting to obtain a 1915c waiver to provide the resources to pay for services in PSH that would help people move out of Laguna Honda and live in the community or avoid the need for nursing home care for very disabled homeless people (see text box).
As described above, the State of Louisiana worked with CMS to obtain approval of a Medicaid SPA to provide optional HCBS (1915i) that will include ACT and other team-based models of care to PSH tenants with mental illness or other disabling health conditions. Technical assistance is being provided to help PSH service-providers meet requirements to become qualified as Medicaid service-providers and develop the administrative capacity to obtain Medicaid reimbursement. The expectation is that Medicaid reimbursement will cover the full range of services currently funded through state contracts, including outreach and engagement and the glue functions such as integrated team meetings and care coordination.