A Primer on Using Medicaid for People Experiencing Chronic Homelessness and Tenants in Permanent Supportive Housing. 8. Putting the Pieces Together


As this Primer has frequently noted, people experiencing chronic homelessness and those who have spent years living on the streets and in shelters before moving into PSH often have complex co-occurring health conditions. These include chronic medical conditions as well as mental health and/or substance use disorders. Some have cognitive impairments that result from brain injuries, substance use, or other health conditions, and many have experienced trauma and toxic levels of stress that have had significant long-term health consequences. Their circumstances call for mechanisms that coordinate and integrate care for physical, mental, and substance use conditions and incorporate links to housing and coordination with staff that can provide the supports that help people maintain that housing.

Many Medicaid beneficiaries who have not had the misfortune to be homeless also experience this complex pattern of health conditions and would benefit from similar coordinating and integrating mechanisms. Attention to housing circumstances as part of the package is not misplaced for this larger group of beneficiaries with complex conditions, as their housing circumstances could change in ways that would put their health and health care at risk. Some beneficiaries could leave institutional care in nursing facilities or IMDs once they are able to access supportive housing in the community; others could lose a caregiver or no longer be able to maintain independent living. Care coordination and service integration will have the greatest impact if it includes a commitment to assure housing stability with supports as needed to maintain and improve health conditions.

The approaches described earlier in this Primer are primarily mechanisms for coordinating and integrating care for physical, mental, and substance use conditions. Development of these mechanisms has been spurred by the increasingly widespread recognition that, for people with complex needs, such integration is needed. Integrated care helps lead to better health outcomes, better care experiences for patients or clients, and care that is more cost-effective. The current state of the issue can be summed up as follows:

  • Many useful approaches are being pioneered; using Medicaid to serve people experiencing chronic homelessness and PSH tenants is complicated, but it can be done.

  • Medicaid will not cover everything, but it can support various services needed by PSH tenants.

  • Many types of Medicaid providers--managed care organizations, FQHCs, behavioral health providers, and ACOs--are playing important roles.

  • Conditions are ripe for improving care coordination and services integration, but achieving these goals will take the work of many parties. Some communities are already seeing the benefits from Medicaid expansion, both from Medicaid covering individuals who are homeless and from local resources being freed up to fund PSH programs.

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