A Primer on Using Medicaid for People Experiencing Chronic Homelessness and Tenants in Permanent Supportive Housing. 5.7. Integrating Primary Care and Behavioral Health Services


A growing number of states and health care providers are involved in efforts to integrate the delivery of primary care and behavioral health services. Efforts to support the integration of primary care and behavioral health services are gaining momentum across the country. In some states, planning or implementation is underway to use new approaches to Medicaid financing to facilitate the integration and coordination of care by using Medicaid Health Home benefits or by organizing networks of health care and behavioral health providers into Accountable Care Organizations (ACOs) or other organized delivery systems. People who have experienced chronic homelessness, including those now living in PSH and those still living on the streets, can benefit greatly from the integrative approaches being developed by health homes as well as other innovative care coordination strategies. Many have the health and behavioral health conditions commonly found among people who have the highest utilization rates for expensive emergency room or hospital care. Experience has shown that inappropriate use of these facilities can be substantially reduced with appropriate models of care coupled with housing.71

In many states, providers are using existing benefits that cover primary care and behavioral health services to work toward service integration. Medicaid financing may be used most frequently for integrated care when services are delivered through partnerships that involve two or more organizations, usually community behavioral health service providers and Health Centers that receive Medicaid financing as FQHCs. In some cases a single organization may operate as both an FQHC and a behavioral health service provider, but these services may function as separate programs within the same organization. For Medicaid financing to support integrated care, it is important that definitions of covered services include activities related to contacts among team members through case conferences or other direct communications to coordinate care for shared clients, as described in Chapter 4. Health home services, which are optional Medicaid benefits described in Section 4.6 of this Primer, can also facilitate the coordination or integration of primary care and behavioral health services.

Integrated care is particularly important to improve health outcomes for people with mental and substance use disorders. For people experiencing chronic homelessness--who often have co-occurring chronic medical conditions, mental health, and substance use disorders, as well as unmet needs for primary and preventive health care--integrated care can be particularly important. When communities and PSH providers work to prioritize access to housing for the most vulnerable people who are experiencing chronic homelessness, primary care and behavioral health services are often integrated in PSH.

5.7.1. Challenges to Integrated Care

State policies that define Medicaid benefits are not always aligned with emerging models of integrated care. States adopt Medicaid program rules and requirements that determine which services or procedures may be provided by individuals, programs, and organizations with specific types of credentials or certification. In most states these definitions of covered services and other requirements related to Medicaid primary care, mental health, and substance use disorder services were developed separately, and these requirements often did not anticipate or provide for integration in the delivery of services by a multi-disciplinary team or through a partnership involving more than one provider coordinating care for the same group of consumers. The lack of consistency in these requirements can create barriers to the delivery of integrated care.

In some states, Medicaid managed care plans are responsible for managing Medicaid benefits for some behavioral health services as well as primary care and other medical care. In other states, Medicaid benefits for primary care, mental health, and substance use disorder services are defined and administered separately, and may be delivered through separate managed care plans or provider networks. Provisions in the contracts between the state and managed care plans may require or help to incentivize collaboration and formal agreements to facilitate coordinated or integrated care, particularly for Medicaid beneficiaries with disabilities or chronic health conditions and co-occurring behavioral health disorders. The example below describes a recent innovative approach to service integration for people experiencing chronic homelessness in Los Angeles County. The approach integrates housing as well as medical and behavioral health services.

To facilitate progress toward integrated care within the Medicaid system, SAMHSA and HRSA, the latter of which administers federally funded community Health Centers, created and support the Center for Integrated Health Solutions to promote the development of integrated primary and behavioral health services.72 The Center promotes integrated care from several perspectives, including integrating primary care into behavioral health settings, integrating behavioral health into primary care settings, examining the promise of health homes under the Affordable Care Act to promote integrated care, and focusing on the needs of specific populations. The ability of providers to be reimbursed for the coordinative aspects of delivering integrated care is a primary concern. The Center provides tools and resources to help states structure integrated care in ways that support Medicaid reimbursement for integrated care, including worksheets that have been developed for each state.73 Each Interim Center for Integrated Health Solutions Billing and Financial Worksheet has been reviewed by the specific state's Medicaid office. With continuing changes in health care financing, states continually review and update their Medicaid state plans and programs. The Center also offers a variety of trainings, one of which is discussed below in relation to peer support specialists.

Integrated Mobile Health Teams: Housing, Medical, and Behavioral Health Services
The Los Angeles County Department of Mental Health has funded five Integrated Mobile Health Teams using funds provided by California's Mental Health Services Act. Each multi-disciplinary team includes staff from 1-2 community-based mental health service providers and a Community Health Center. Staff work as one integrated team to provide mental health, physical health, and substance abuse services. The partner agencies are working to establish one set of administrative and operational policies and procedures and use an integrated medical record/chart to ensure integrated and coordinated services for people served by each team. Each partner agency obtains Medicaid reimbursement separately for covered services, including FQHC services provided by the Community Health Center and specialty mental health services covered under the rehabilitation option and TCM.

The Integrated Mobile Health Team program model is designed to serve people with SMI who also have other vulnerabilities, including age, years of homelessness, co-occurring substance abuse and/or other physical health conditions that require ongoing primary care (such as diabetes, hypertension, cardiovascular disease, asthma or other respiratory illnesses, obesity, cancer, arthritis, and chronic pain). The teams use a vulnerability scale to identify and serve the most vulnerable individuals among those people experiencing homelessness who have a SMI. The team may engage identified individuals through outreach to the streets, encampments, and other locations where many people experiencing homelessness congregate. The team tries to find and engage people with a high level of vulnerability who have not been well-connected to mental health services.

Integrated Mobile Health Team services are intended to increase immediate access to housing by using a housing first approach that incorporates harm reduction, motivational interviewing, and access to housing without requirements for treatment, sobriety, or "housing readiness." Each team partners with a PSH developer(s) to dedicate housing units to clients served by the team. With the exception of some administrative activities or medical procedures that require a clinic setting, all team services are delivered in the field, including engaging people experiencing homelessness on the streets and making home visits to people in PSH.


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