In 2014, most homeless people will become Medicaid-eligible under the Affordable Care Act (ACA) of 2010 based on their low incomes. Many homeless people have complex physical and behavioral health conditions for which they seek care through frequent use of emergency rooms and inpatient hospitalization, at considerable cost in public resources.
With appropriate supportive services, inappropriate use of crisis health services can be avoided. Medicaid reimbursement is an important source of funding for many of the health, care coordination, and recovery support services that help homeless people succeed in housing and stop such inappropriate use. Among the best indicators of Medicaids potential usefulness to homeless people once they become beneficiaries are the ways that todays providers have been able to use Medicaid to cover health care and behavioral health care for people who have been chronically homeless and are now living in permanent supportive housing (PSH).
In October 2010, the Department of Health and Human Services (HHS), Assistant Secretary for Planning and Evaluation (ASPE), contracted with Abt Associates Inc. for a study to explore the roles that Medicaid, Community Health Centers, and other HHS programs might play in providing services linked to housing for people who experience chronic homelessness through PSH. Permanent Supportive Housing provides a permanent home for formerly homeless people with disabilities, along with the health care and other supportive services needed to help tenants adjust to living in housing and make the changes in their lives that will help them keep their housing. It differs from group homes, board and care facilities, and other treatment programs in that most tenants hold their own leases, and keeping their housing is usually not contingent on their participating in services or remaining at a certain level of illness.
Because Medicaid is implemented through partnerships between states and the Federal Government, every states Medicaid program is different. Medicaid is only one component of strategies that communities use to create and sustain supportive housing. It does not pay for housing costs, and Medicaid reimbursement is available only for services that address health-related issues. This study focuses on communities known to be using Medicaid to provide integrated health, mental health, and substance use services combined with housing for chronically homeless people. Other states and providers will develop new models of service delivery and reimbursement in the coming years.
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The Study's First Phase: Literature Synthesis, Environmental Scan, and Site Visits
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The chronically homeless people on whom this study focuses have multiple, complex, and interacting physical and behavioral health conditions. Achieving the best results for these clients and the public institutions and systems from which they get care requires effective engagement, service delivery, and care coordination. To understand how this care is currently being delivered, the research team reviewed both published and unpublished literature and drew on team members extensive knowledge of successful programs and agencies. The result was Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Literature Synthesis and Environmental Scan (Burt, Wilkins, and Mauch, 2011). This report documents the evidence on the rationale for linking housing assistance with Medicaid-funded health services--specifically, that these services are more clinically effective while also being less expensive than avoidable emergency room use and hospitalizations.
The research team then conducted site visits to see how housing and supportive services worked together in practice. The team identified the relatively few communities in the United States with experienced providers that integrate housing with health, mental health, and substance abuse services. The team conducted site visits to three of these communities--the San Francisco Bay Area, Chicago, and the Boston-Worcester area. The communities visited are not representative; rather, they are examples. Their experiences may be helpful to policy makers and practitioners alike, as they illustrate both what can be accomplished and the many challenges and barriers that must be overcome along the way. A growing number of communities are starting to implement similar approaches.
The research team then produced four issue papers on promising practices linking health, mental health, and substance abuse services to housing assistance for the target population of chronically homeless people:
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Paper 1--describes three subgroups of the people experiencing chronic homelessness, and the services and housing configurations currently supporting them. Health, Housing, and Service Supports for Three Groups of People Experiencing Chronic Homelessness. Cambridge, MA: Abt Associates Inc., 2012. M.R. Burt & C. Wilkins. [http://aspe.hhs.gov/daltcp/reports/2012/ChrHomls1.shtml]
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Paper 2--describes the ways that Medicaid is being used now and might be used in the future under provisions of the ACA to serve chronically homeless people. Medicaid Financing for Services in Supportive Housing for Chronically Homeless People: Current Practices and Opportunities. Cambridge, MA: Abt Associates Inc., 2012. C. Wilkins, M.R. Burt, & D. Mauch. [http://aspe.hhs.gov/daltcp/reports/2012/ChrHomls2.shtml]
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Paper 3--describes innovative approaches to establishing Supplemental Security Income (SSI) eligibility. Establishing Eligibility for SSI for Chronically Homeless People. Cambridge, MA: Abt Associates Inc., 2012. M.R. Burt & C. Wilkins. [http://aspe.hhs.gov/daltcp/reports/2012/ChrHomls3.shtml]
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Paper 4--looks at innovative ways that public housing agencies (PHAs) are supporting housing for formerly homeless people in the communities the researchers visited. Public Housing Agencies and Permanent Supportive Housing for Chronically Homeless People. C. Wilkins & M.R. Burt.
Core information about health, housing, and supportive services found in the Literature Synthesis and Environmental Scan is not duplicated in the briefs. Likewise, Papers 2, 3, and 4 do not repeat the information on subpopulations found in Paper 1. Each brief refers to the others or to the Literature Synthesis and Environmental Scan as needed.
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Second Phase: Case Studies of New Strategies
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The second phase of this study involves case studies of six communities that are on their way toward early implementation of the ACAs Medicaid provisions or other Medicaid-related policies and practices designed to deliver care to chronically homeless people. The study will follow the six communities through fall 2012, watching as they design and implement different strategies that involve Medicaid waivers, state plan options, and other approaches. Future reports will describe these strategies and the progress communities are making.
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Introduction to This Paper
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This Issue Paper focuses on the roles that PHAs can play in expanding opportunities for chronically homeless people to move into housing, including the participation of PHAs in expanding the supply of PSH. A November 2011 HHS/ASPE Research Brief presents the findings of another ASPE project, in that case focusing on homeless families with children rather than on chronically homeless people (http://aspe.hhs.gov/hsp/11/FamilyHomelessness/rb.shtml). That brief documents promising practices among programs that work with PHAs to help serve homeless families by linking human services and housing supports.
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