A Primer on Using Medicaid for People Experiencing Chronic Homelessness and Tenants in Permanent Supportive Housing. 8.1. Making Changes, From Small Steps to Comprehensive Redesign


People experiencing chronic homelessness or living in PSH are part of the larger group of Medicaid beneficiaries with the most complex co-occurring health conditions. They are the most vulnerable to negative outcomes and most likely to incur avoidable costs for crisis services if they receive inadequate and uncoordinated care. People with histories of chronic homelessness have added difficulties with building trust and engaging in services, and the added need for a strong focus on housing acquisition and stability. In thinking about changes to a state's Medicaid program to facilitate delivery of appropriate services to this group, it would be important to plan for the needs of the larger group of people with chronic and disabling health conditions and co-occurring behavioral health disorders, with special attention to housing and engagement for those who are or have been chronically homeless. With appropriate modifications to Medicaid state plans, Medicaid could cover the costs of many of the services needed for this group of beneficiaries. In turn, effective integrated services linked to housing for people who have experienced chronic homelessness could help to achieve savings to the Medicaid program by reducing avoidable hospitalizations and facilitating more appropriate use of other Medicaid-covered services.

For the group of people who are or have been chronically homeless, positive outcomes have been demonstrated by approaches that link medical care, behavioral health care, and supports to housing stability. These approaches focus on engaging and building trust with the most vulnerable people to help them get and keep housing and receive the care they need to manage their health needs. Effective program models incorporate recognition of housing as a social determinant of health. Efforts within Medicaid programs to align benefits, eligibility requirements, qualified service delivery personnel, service delivery sites, and payment mechanisms would promote integration by making it easier for providers to be paid for serving this population and removing current obstacles to integrated care. Risk adjustment and other incentives may be needed to make it feasible for health plans and provider networks to focus on the most high-cost, high-need individuals, for whom there are the greatest opportunities for achieving savings and improving outcomes.

To help state Medicaid officials working toward a more aligned system and greater integration, the Center for Integrated Health Solutions, co-funded by SAMHSA and HRSA, identified a set of promising approaches to integrating physical and behavioral health care that range from small steps to major system change.108 The Kaiser Commission on Medicaid and the Uninsured has released an issue brief based on that report, highlighting five promising approaches ranging from those that are relatively simple to adapt to more ambitious levels of system redesign.109 Most of these approaches are being used in one or more case study sites, as reported earlier in this Primer.

The five approaches described in the Kaiser Commission brief that are currently being modeled in Medicaid case studies aimed at better integrating physical and behavioral health care, are described below:

  1. Universal Screening. Integrated care begins with screening patients for conditions in addition to the ones they present for. A number of evidence-based tools are available for primary care providers to use to easily screen for behavioral health disorders. Routine screening for common medical conditions among adults with behavioral health conditions can be accomplished by providing behavioral health practitioners with basic equipment like a scale, a blood pressure cuff, and a stethoscope, along with training in how to use them. Early identification of conditions helps to prevent or mitigate their progression.

  2. Navigators. Even when individuals get screened for other conditions and referred for care, obtaining the recommended services can be challenging. Some state programs or managed care plans are deploying a new cadre of "navigators," who may be nurses, social workers, or trained paraprofessionals, to help beneficiaries navigate the health care system. Navigators' functions can range from simply helping individuals to seek care, to interacting with their health care providers on their behalf, to improving home and community-based support for their clients. Navigators also foster patient engagement.

  3. Co-Location. Geographic distance between physical and behavioral health provider settings can itself be a significant barrier to coordinated care. Some Health Centers and community behavioral health service providers are leaders in the "co-location" of physical and behavioral health care. Medicaid's system of prospective, cost-based payment for Health Centers supports this model because the costs of licensed behavioral health practitioners can be included in the calculation of Health Centers' prospective rates.

  4. Health Homes. A growing number of states are using the Medicaid "health home" option, established by the Affordable Care Act, to advance the integration of physical and behavioral health care for Medicaid beneficiaries with SMI. Health home services, which are eligible for a 90 percent federal match for two years (100 percent for those who enrolled under the expansion of Medicaid eligibility), include comprehensive care management, transitional care, referral to community and social services, and other services to foster integrated care for people with complex conditions and needs. Community mental health centers are one natural choice to be designated health home providers for Medicaid beneficiaries with SMI.

  5. System-Level Integration of Care. System-level integration of services and fiscal accountability underpins truly person-centered, holistic care and represents the most advanced model on the integration continuum. A fully integrated system for Medicaid beneficiaries is one that directly provides and is at financial risk for the entire complement of acute physical and behavioral health services covered by Medicaid.

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