Mental/Physical Health

20th November
2012
written by naehblog

Today’s guest blog post was contributed by Paul Gionfriddo, a former Connecticut State Representative and Mayor, who also served as a nonprofit CEO for more then fifteen years. Gionfriddo currently works as a consultant and writes a health and mental health policy blog, Our Health Policy Matters.

Many people think that people are chronically homeless because they have serious mental illness or addictions. They are wrong. They are homeless because of the way we treat their behavioral illnesses. Or fail to treat them.

Recently, I argued this point in an essay for Health Affairs that later appeared in the Washington Post. I wrote that the mistakes of an earlier generation of policy makers – a generation of which I was a part – caused so much of the problem.

Many years ago, we emptied our state psychiatric institutions for good reasons. They were often monuments to neglect or abuse. But when we emptied them, we failed to put in place the community-based service delivery system we needed.

Perhaps we had an excuse. We were in over our heads. No one knew much about the importance of behavioral health and primary care integration in the 1970s and 1980s. We had little understanding of PTSD as a debilitating mental illness. We had even less experience with educating children with serious behavioral illnesses in regular schools.

All we did was create a new revolving door, from brief hospitalization to incarceration to homelessness. I learned firsthand about this revolving door when my oldest son Tim entered it when he was just a teenager, after his behavioral health needs were often ignored or neglected throughout his school years.

This revolving door – this system that isn’t – is the reason people like my son become homeless. And, unless our policies change, it is the reason why young men and women like Tim will continue to become homeless.

For Tim and people like Tim, finding housing is not a start; it’s the end of a long process. And policymakers today have no excuse; they know what this process must be.

It should begin in our pediatricians’ offices, by mandating periodic screening of every child for mental illness and its risk factors. It should continue in our schools, by providing every student who has a mental illness with a meaningful special education program (and paying for it, as the law requires) that ensures they will graduate from a high school or vocational school.

It must be carried on by behavioral health service providers in the community, who can offer families all the supports they need when their children are living at home, and who can offer young adults like Tim all the treatment and supports they need when they are on their own.

And we must do everything we can to keep courts, sheriffs, and jails out of the treatment mix. After all, we don’t send people with cancer to jail just because they are symptomatic and noncompliant with their treatment, do we?

Doing these things will help to prevent chronic homelessness. And they will do something else, too – give some people who happen to be homeless today a real opportunity to become well and housed.

It will be a challenge for this generation’s policy leaders. Let us hope that they are up to it.

20th July
2012
written by Steve Berg

We’d like to thank the nearly 1,500 practitioners, public officials and other stakeholders who took time out of their busy schedules to attend our 2012 National Conference on Ending Homelessness. For us in the Alliance, the level of enthusiasm and positivity on display in the plenary sessions and workshops was immensely gratifying. The homeless assistance community has come far, in terms of its overall level of sophistication and focus on implementation in order to get results, and the conference was a great opportunity for people to share what they have learned, as well as for those of us in the community to engage in a discussion about what we still must do to achieve our goals.

In her remarks at the conference’s closing plenary, Alliance CEO Nan Roman touched on a few of the themes that emerged over the course of the three days. I’ll expand on some of those here.

Targeting – The message came through loud and clear: there are a range of interventions to draw upon, but for an intervention to be successful it must be targeted at the right people. Specifically, supportive housing is our most intensive intervention, and it is designed for the most vulnerable population with the most severe disabilities. If such people are screened out in favor of people with fewer challenges, they will live and probably die on the streets.

Olmstead – The Olmstead case reminded us that large programs devoted solely to housing people with severe mental illness are seldom the best way to serve people, and often are not what people in such programs would choose for themselves if they had more reasonable options. In some cases, such programs actually violate civil rights laws. This challenges people who run housing programs for people with disabilities to consider when it might be appropriate to develop mixed-use projects.

Rapid Re-housing – Somebody once said that the only people who believe in rapid re-housing are everyone who’s ever tried it. Now that virtually every sizeable community around the country has tried it, thanks to HPRP, there is a consensus that it’s the right model for moving most people who are experiencing homelessness into housing. With HPRP winding down soon, much of the talk at the conference was about how to maintain funding for rapid re-housing programs. Fortunately, new HUD regulations make it easy for communities to use Continuum of Care and ESG funds for this purpose, and many communities have also identified other funding sources for rapid re-housing.

Youth and youth counts – The homeless assistance community has begun developing a range of ideas about a more systemic approach to ending youth homelessness. A double track of workshops about youth homelessness, as well as increasing collaboration with the federal Administration for Children, Youth and Families and organizations like the National Network for Youth, focused on advancing these ideas. When the January 2013 point-in-time counts roll around, expect a stronger push for a more accurate count of youth experiencing homelessness.

Veterans’ money and leadership – During the conference, VA announced the awards for about $100 million in grants for the Supportive Services for Veteran Families program, which funds community-based organizations that run rapid re-housing and emergency homelessness prevention programs for veterans and their families. This announcement drew attention to the fact that VA now has a full array of programs to address homelessness, and that those programs are on their way to being funded at the scale necessary to end homelessness among veterans.

The struggle over other federal money – It’s clear that federal money for HUD programs has been harder to come by in the past two years, and that this will continue to be the case. Many communities are increasingly turning to the large antipoverty entitlement programs – TANF, SNAP, SSI, and Medicaid, for example – where federal funding has not been cut, while programs for veterans, which are less threatened by budget cuts, must serve as examples of what can be accomplished with the proper funding. Homeless assistance practitioners are also turning to more efficient models like rapid re-housing, which require less money per household. And they are making sure that their representatives in congress, who determine the funding levels, know about the good that their programs do.

Medicaid – The prospect of funding most services and treatment for chronically homeless people through Medicaid appears closer to reality that anyone would have thought possible only a few years ago. The Affordable Care Act will allow states to expand eligibility in 2014, and the majority of states will opt to do so. A lot of work behind the scenes has already gone into ensuring that the right kinds of services will be funded by Medicaid, but it will take new partnerships, particularly at the state level, to make the most of these new opportunities.

Progress – Perhaps the most rewarding part of the conference for us in the Alliance was seeing the resolve of advocates, in the face of enormous obstacles put up by the economy and the political system, to try new options, discard methods that are less effective, and work smarter and more efficiently to develop programs that, for thousands of people, mean the difference between housing and homelessness.

10th July
2012
written by Lisa Stand

What does the Supreme Court decision on the Affordable Care Act mean for communities poised to use new Medicaid funding to bolster their homeless assistance? First and foremost, communities have to engage more intensively with the state policymaking process – this, actually, was true before the ACA ruling came down. And it will be true no matter what the results of elections in November.

Since the decision, we now know that Medicaid will not expand nationally to cover virtually all uninsured people who earn less than $15,000. Therefore, the presumption no longer holds that virtually all people experiencing chronic homelessness will be able to enroll in Medicaid beginning in 2014. But states do have the option to expand in 2014, taking advantage of substantial federal Medicaid subsidies to do so. The ACA cannot require states to expand their programs, but still offers to pay them 90-100% of the cost of covering all uninsured adult citizens who earn around $15,000 or less annually.

Access to health care services – including behavioral health and recovery support – can be a key part of successful housing outcomes for the 107,000 people who experience chronic homelessness on any given night. Without funding for health care, many communities struggle for sustainable solutions – specifically, adequate permanent supportive housing (PSH), which is proven effective to address chronic homelessness. Since Congress passed the ACA in 2010, homeless assistance systems have anticipated the Medicaid expansion – to help individuals and to enhance safety net capacity.

Full Medicaid coverage will not be a “given” in every state. The Supreme Court ruling means additional challenges for the national agenda to end chronic homelessness by 2015. According to the U.S. Interagency Council on Homelessness, 60 percent of the nation’s chronically homeless population is concentrated in six states – California, Florida, Georgia, Louisiana, New York and Texas.  Four of these – California, Florida, Georgia and Texas – were projected to have the highest increases in Medicaid enrollment as a result of the ACA. Only two, New York and California, have indicated an intention to move forward with Medicaid expansion.

To see what might happen in your state, this map and this map from Think Progress are handy starting places.  A note of caution: There are many unknowns about how this part of ACA implementation will actually unfold. To name a few:

  • How many states will take up the expansion, despite what their governors said in the wake of the Supreme Court decision?
  • In the states that do expand, what services and supports will be covered?
  • Will ACA implementation really take place as soon as 2014?
  • Can a state opt in after 2014?

While these and other questions are sorted out, it is more important than ever for homeless advocates to inform state leaders and community partners in the full debate about health care priorities. The necessary policy choices to support communities will be steps that integrate housing, health care, and behavior health/recovery resources at the community level.

  • For chronically homeless populations, permanent housing is the first prescription, with person-centered services and supports to stabilize housing.
  • Opting into the ACA Medicaid expansion will bring federal resources directly to these vulnerable individuals – who otherwise are among the highest users of state and local safety net resources.
  • Failing to opt in means continued pressure on the capacity of state mental health programs and public safety operations.

Further, a number of promising Medicaid provisions remain in effect, including those meant to improve community supports for especially vulnerable enrollees, including those who are eligible because of a qualifying disability. These options were designed to be targeted to those most in need, and they tend to be less politicized. One example is the Medicaid health home. This optional benefit for people with severe mental illness (and other chronic conditions) pays for broadly-defined service coordination.

Several states, including New York, Missouri, Oregon and Rhode Island, have already opted to set up health homes. States can also offer home and community based services (HCBS) without applying for a federal waiver. In a recent proposed rule, Medicaid officials indicated that permanent support housing qualifies as a “community setting” for HCBS. Homeless advocates can join forces with advocates for older and disabled people, to press for their states to adopt these options in a way that adds to the capacity of homeless assistance.

Many states and communities have already embraced health care reform since the ACA passed in 2010. Often, homeless advocates have been at the table with Medicaid leaders, forging new strategies to integrate housing solutions with health care services to address chronic homelessness. The Alliance is paying close attention to successful new approaches and emerging best practices, especially in supportive housing. Speakers with hands-on experience and up-to-date policy knowledge will present on these topics at the July 16-18 National Conference on Ending Homelessness in Washington, DC.

11th June
2012
written by Lisa Stand

Leaders and innovators in supportive housing convened in Chicago last week for a multi-faceted look at integrating housing and health care. The Leadership Forum, sponsored by the Corporation for Supportive Housing, was also the occasion for the release of a “business case” for states to tap Medicaid to pay for key services in permanent supportive housing. The presenters at the day-long conference and the paper on the business case speak to recent innovations with health care and supportive housing — demonstrating what’s possible under the Affordable Care Act, and what’s actually happening in communities where state government and homeless providers are proactive.

Two stand-out ACA provisions enable homeless advocates to persuade state policymakers that supportive housing is a worthwhile Medicaid investment.

 

  • First, the “health home” benefit can be a good vehicle for funding care management and service coordination, services that make supportive housing viable as a strategy to end chronic homelessness. As the Forum audience heard, a Medicaid health home is a unique concept that has to be understood in a health policy context. But once that context is understood, it is easier to bring relevant data and analysis to Medicaid decision-makers. The business case illustrates that if Medicaid pays appropriately for care management via this new benefit, states can expand their service capacity in supportive housing. That’s because Medicaid allows the state to access federal funding to pay a portion of what the state would otherwise have to pay all by itself for a given number of supportive housing units.
  • Second, when Medicaid expands in 2014, states will have new responsibilities to care for very vulnerable people who currently lack coverage and tend to incur very high public costs, especially in hospital emergency rooms. They tend to have severe behavioral and physical health conditions, often co-occurring. And they tend to have unstable housing histories. This is not news to homeless advocates. However, the expanded Medicaid role creates an opportunity to talk to state decision-makers about the value of Housing First for clinical outcomes and managing health care costs.

This is all promising for systems of care addressing chronic homelessness. Safety net systems may always be somewhat fragmented financially, but in any case they need to be integrated and high-performing for the vulnerable people who rely on them. Of course, more needs to be done to finish the job of ending chronic homelessness, and Medicaid in supportive housing is not the answer by itself. As the business case also points out, new strategies should also consider “new processes and/or technologies to identify high-cost, chronically ill clients who could most benefit from supportive housing.” Those who are now experiencing chronic homelessness should be a priority.

The Medicaid proposition for ending chronic homelessness requires advocates to be active in statewide arenas – with Medicaid administrators, of course; but also with their partners – such as mental health directors, hospital systems, and even managed care organizations that deliver on Medicaid contracts. Advocating statewide is the theme of an Alliance pre-conference session on July 16, immediately preceding the start of the National Conference on Ending Homelessness. “Opening Medicaid Doors: State Strategies to Support Homeless Assistance for Vulnerable Populations” is co-sponsored by the U.S. Interagency Council on Homelessness. The half-day program will examine several key facets of how to make Medicaid a stronger partner in programs that house and stabilize people who have been chronically homeless. Space is limited and pre-registration is highly recommended. RSVP at healthcare@naeh.org.

Image courtesy of donbuciak.

14th May
2012
written by Lisa Stand

“States vary” –  a top research finding in virtually every field studied inside the Beltway. When it comes to understanding how Medicaid is relevant to ending chronic homelessness, we would like to be more helpful. True, Medicaid’s relevance to ending chronic homelessness in your community depends greatly on the profile of your state. Still, success in another state is worth looking at, along with assessing what can be borrowed effectively. A pre-conference session for early arrivals at the Alliance’s summer conference will offer an opportunity to do just that.  The half-day mini-conference is co-sponsored by the U.S. Interagency Council on Homelessness. We will examine several key facets of how to make Medicaid a stronger partner in programs that house and stabilize people who have been chronically homeless.

  • Homeless Advocates at the Table. One facet is effective engagement at the right time in state health policymaking. How do homeless advocates get the ear of state health care officials before they make decisions that have implications for addressing chronic homelessness in a person-centered way? New York has an inspiring story of supportive housing stakeholders at the table of statewide Medicaid reform — with results that bolster community-based strategies to end homelessness. In Louisiana, supportive housing is now viewed as a core element in Medicaid’s plans for managing care of behavioral health enrollees. In short, policy gaps have been successfully bridged with stakeholder input at high levels.
  • Benefits and Payment Policy. Another facet is how a state defines Medicaid benefits and payment policies. Do these policies promote housing solutions in a plan of care for homeless people with significant behavioral and other health needs? As federal authorities roll out approved benefits and demonstrations, we are seeing how states embrace new community-based services allowed by the Affordable Care Act (ACA). States like Oregon and New York are doing this with a clear view of supportive housing in the domain of health care, at least for those as vulnerable as chronically homeless people. It may be too soon to know how these approaches succeed, but the state policy pieces are evident and intentional.
  • Federal Policy Implementation. A third facet is coordination at the federal level, such as initiatives led by the Department of Housing and Urban Development (HUD) and various subdivisions of the Department of Health and Human Services (HHS). Which new federal policies and regulatory decisions will have the most impact on ending chronic homelessness by 2015, as the federal strategic plan envisions? Federal Medicaid rules are more favorable to the concept of permanent supportive housing, and HUD is looking for ways to promote access to Medicaid in housing for people with disabilities. Federal policy will continue to drive state and local responses.

These topics will be covered by knowledgeable speakers convening for “Opening Medicaid Doors: State Strategies to Support Homeless Assistance,” on Monday, July 16, in Washington, DC. The half-day session immediately precedes the opening of the National Conference on Ending Homelessness, which takes places July 16-18. Both events are at the Renaissance Washington Hotel. For more information about Opening Medicaid Doors, contact healthcare@naeh.org. Space limited and pre-registration is highly recommended.

30th April
2012
written by Sam Batko

On Thursday, April 26, the U.S. Senate voted to pass S. 1925, the Violence Against Women Reauthorization Act of 2011 in a vote of 68 to 31.  This reauthorization, sponsored by Senator Leahy from Vermont and co-sponsored by 61 bipartisan Members of the Senate, has stronger language to help protect LGBT, tribal, and immigrant survivors which gained the bill its 31 “nays” in the Senate and fairly wide media attention.

Perhaps of more importance in the field of homelessness assistance is another provision of the bill, it would provide particular protections for survivors in a variety of HUD programs.  Current law provides survivors with protections from eviction and the opportunity to transfer in Section 8 and Public Housing.  This reauthorization bill would extend those protections to a variety of other HUD programs, including McKinney-Vento Homeless Assistance grant, Sections 202 and 811, and the Low Income Housing Tax Credit (LIHTC) program, among others.  And, if transfer is not possible, it requires HUD to establish a policy for how a survivor can access a Section 8 voucher instead.

VAWA was first passed in 1994 and since then has created a number of successful programs to help protect survivors of domestic violence, dating violence, sexual assault, and stalking.  One of those programs, the Office of Violence Against Women’s (OVW) Transitional Housing Grants administered by the Department of Justice helps survivors leave abusers and access safe housing with voluntary support services to help the survivor and their family stabilize in housing.  Providers who implement these programs often utilize a transition in place model that provides survivors with the security of permanent housing and a lease in their own name.

Now that the bill has passed in the Senate, it will be taken up in the House where there are three versions of a reauthorization bill introduced all of which have been referred to committee.  A mark-up is scheduled for May 8 for the bill sponsored by Congresswoman Adams (R-FL) which is similar to a Republican alternative to the Leahy bill (S. 1925) that just passed in the Senate.

27th March
2012
written by Lisa Stand

On Tuesdays in March, the Alliance has been blogging about the Affordable Care Act (ACA), which was enacted two years ago and is today (literally, today) the center of attention in the U.S. Supreme Court. As we and our partners have pointed out, the ACA is already helping very vulnerable people, including people experiencing homelessness – for instance, through a limited amount of new funding for community health centers. Other changes are coming on-line this year, such as Medicaid health homes, a state option that can help communities do a better job of coordinating health care and homeless assistance.

Still bigger changes are yet to come. If the key Medicaid expansion is upheld as constitutional, chronically homeless and at-risk adults who do not qualify now will have access to Medicaid benefits, starting in 2014. Even then, the promises of the ACA can fall short, if those benefits are not sufficient for people who need housing stability to recover and improve their health status. It is important for homeless advocates to have a voice in designing Medicaid benefits that make that link with concrete solutions when housing is necessary to complete an effective, person-centered care plan.

There is much work to be done. The ACA offers resources and innovative policies. Whatever the outcome in the Supreme Court, homeless advocates will continue to strive for community networks that seamlessly provide supportive housing, primary care and behavioral health services. We know this approach is necessary to end chronic homelessness.

In closing out this month of blogs on the ACA and ending homelessness, let’s give due notice to how the ACA could touch people experiencing homelessness who fit other typologies besides chronic. Two examples come to mind:

  • At-risk young people – Research shows that children who age out of foster care frequently have significant health care needs, especially compared to other young adults. Under the ACA, states are now required to consider access to health care as part of the transition plan for young adults exiting foster care. Starting in 2014, states will have the further requirement of extending Medicaid coverage to these individuals until they reach age 26.   Advocates for homeless youth have a role to play as states implement this new provision. For more information about access to health care for foster youth, a recent blog at Community Catalyst is a place to start.
  • Vulnerable families – The ACA funds the Early Childhood Home Visiting Program, allowing states to target evidence-based programs for children under age 5. These services may be critical to outcomes for children who have experienced homelessness. Homeless service providers are well positioned to help home visiting succeed by informing strategies to target these new resources, and giving valuable feedback about how the program addresses needs of homeless families.

The Alliance will continue to analyze health care reform and its implications for ending homelessness. For more information about homelessness and health, visit our website or contact us at info@naeh.org.

20th March
2012
written by Lisa Stand

It has been two years since passage of the Affordable Care Act. Next week, key parts of the ACA will be debated in Supreme Court oral arguments. The nine Justices will hear from lawyers on both sides – those who are challenging and those who are defending the law. Yet it could be several months (at least) before we know how the highest court in the land decides.

Whatever happens, there is no denying that the ACA has been helping people, as we noted in our March 6 blog. As we also noted, some of the ACA’s greatest promises are still unfolding for the nation’s most vulnerable people who still lack health care coverage. The Medicaid expansion, for instance, will not take effect until January 1, 2014 – assuming this part of the law is upheld by the Supreme Court. Even so, progress is being made.

For this week’s ACA blog, the Alliance asked some of our national partners how they view the impact of the ACA. Here’s what we heard:

From Barbara DiPietro of the National Health Care for the Homeless Council:

“Homelessness is hazardous to your health.  Poor health causes homelessness, and in many cases, the experience of homelessness creates new health care conditions and exacerbates existing ones.  It is very difficult to become stable in employment or housing when there are untreated health care conditions.

Under the ACA, serving the most vulnerable homeless people will require more capacity in community health centers, especially Health Care for the Homeless (HCH) projects, as the graph below indicates. Nationally, there are currently 1,130 health center grantees that saw 20 million patients in 2010.  Of these, 223 are HCH grantees, which saw 805,000 individuals.”

The ACA allocates $11 billion over 5 years to health centers, with a goal of doubling the patients seen by 2015 to 40 million people. Unfortunately, to date, Congressional appropriations have not fulfilled these goals.  For fiscal year 2011, there was no increase.  In fiscal year 2012, there was a $200 million increase.

Using the modest increases to date, HRSA has issued 67 new access point grants that would create new sites for patients to access—16 of these were specifically to HCH grantees.  In total, these new access grants will facilitate service capacity for an estimated 262,000 new patients, most are very low income.

As the ACA is implemented, the need for health center investments intensifies.  If we can’t expand capacity, those with Medicaid cards won’t have a timely and reliable place to call their health care home. The ACA not only helps people access health insurance, but it also facilitates a growth in non-profit, privately administered, community health care services. Health centers directly employ 130,000 people, but there are many, many indirect jobs as well (contractors who clean buildings, provide maintenance, do contractual services, etc.). In this way, the ACA health center investments help further two national goals:  grow health care capacity and increase employment rates at the local level.

From Peggy Bailey at the Corporation for Supportive Housing:

“Years of living on the streets often leave people battling chronic medical conditions. When they find a home in supportive housing, they can need significant health care service–beyond those available in standard medical benefit packages. Health reform gives states the opportunity to provide comprehensive and integrated benefits to their most vulnerable citizens, giving them access to the breadth of services they need. Thanks to the Affordable Care act, hundreds of homeless people who previously had no health insurance are now Medicaid eligible in DC, CT, MN and WA. That’s progress that improves lives while helping service providers lower uncompensated care costs.”

From Andrew Sperling at the National Alliance on Mental Illness (NAMI):

“One of the four issues that the US Supreme Court will consider next week when it takes up the constitutionality of the Affordable Care Act is whether or not it is within Congress’s limited powers to require states to expand Medicaid eligibility up to 138Q% of the federal poverty level.  This expansion of Medicaid eligibility is a critical provision for homeless individuals living with serious mental illness.  Once Medicaid expansion becomes effective in 2014, in most states these individuals will no longer have to meet the very high eligibility standard for Supplemental Security Income (SSI) in order to qualify for Medicaid.”  (NAMI recently signed onto a “Friend of the Court” brief urging the Supreme Court to uphold lower court rulings rejecting challenges to the Medicaid expansion.  You can view this brief online. )

If the Court upholds these rulings and allows Medicaid expansion to go forward in 2014, NAMI, NAEH and our allies will face a new challenge – convincing states to include appropriate benefits in the “benchmark” plans that will be made available to this new “expansion population” in Medicaid.  For example, it will be critical for these plans to include intensive case management services (including assertive community treatment) and services in supportive housing to ensure that the complex needs of single individuals with mental illness and a history of chronic homelessness are met.

Thanks from the Alliance to Barbara, Peggy, and Andrew – for your thoughts on the ACA and for being great partners, with your organizations, in ending homelessness! Please visit their websites and ours to learn more about how health care reform can change the way you work to end homelessness in your community.

 For information about advocating for affordable, high-quality health care in general, you might visit Families USA and Health Care for America Now. To find out about the ACA in your state, check out these resources from the Henry J. Kaiser Family Foundation. 

13th March
2012
written by Lisa Stand

If you spend your day helping people who have experienced chronic homelessness, you know a lot about “person-centered” care. It means organizing services and supports around the specific needs of an individual – a place to live first and foremost, then recovery supports, medical treatment, supported employment, and so on. In a world of service silos and payment mazes, it also often means a headache of coordination – you braid together programs and accounts, keep an eye on staff resources, manage partner relationships, and try to catch whatever falls off the table before it lands on your client. (You’re welcome). Fortunately, the health care system just might be catching up to you.

There is one area of health care reform that doesn’t draw much partisan controversy. It’s the drive to make the system work smarter with the resources dedicated to people who use the most services. We are all aware of the problem. In health care, the highest share of spending is associated with a small percentage of people who have very complicated health and functional profiles. How much of the costs can be managed better by paying more attention to care management and service coordination? Medicaid policymakers think the answer is “a lot,” and they have gotten behind new strategies to prove it. This is welcome news for homeless advocates.

 

The medical home (or health home) is one of the most promising ways to integrate health care with supportive housing interventions. The concept came to the fore first as a health-care-quality initiative, and later as a possible cost-saver. A medical home is a single provider responsible for organizing a person’s care – especially needed if the care involves many disciplines and practitioners. A qualified medical home provider – like a health center or a doctor’s office — can be paid a certain monthly fee for this service.

Starting this year, Medicaid is paying extra federal funds to states that designate health homes for certain high-need, high-cost populations – including people with mental illness. The Centers for Medicaid and Medicare Services (CMS) has approved health homes in at least three states so far – Missouri, New York and Rhode Island. More health home approvals are in the pipeline. The federal guidelines are clear that Medicaid health homes can be broad in the scope of service – using interdisciplinary teams, emphasizing behavioral health, and providing links for covered enrollees to “community and social support services.”

New York state has clearly made the connection between Medicaid health homes and addressing chronic homelessness. Its application for federal approval explicitly mentions “lack of permanent housing” as an issue to be addressed in its health home population. Housing specialists are considered possible members of interdisciplinary teams in New York and in a number of other Medicaid health home models. All three of the early states have responded to the call for integrating behavioral health with Medicaid health homes. Missouri and Rhode Island are building on their existing infrastructures; community mental health centers will serve as health homes for their Medicaid enrollees with severe mental illness.

This could be good news, and something to watch, for advocates working to end chronic homelessness. However, better service coordination does not have to depend on a Medicaid health home designation. In many communities and service networks, leaders in housing and health care are taking stock and creating betters ways of working together to make supportive housing a sustainable solution. Often, the process begins by getting everyone on the same page about recent changes in policies and programs. Have you had a conversation with your community partners about what’s new in your state? There may be ways to leverage new resources together, to improve how vulnerable homeless people experience their systems of care.

The Alliance is on the lookout for best practices in integrating housing solutions with changes in the health care system. Let us know what’s happening in your community. We are also keeping track of new and improved policy approaches, as the Affordable Care Act is implemented. If you want more information on health homes and related Medicaid strategies, check out the Integrated Care Resource Center and the Safety Net Medical Home Initiative. Take another step: Advocate! Make sure your leaders in state health policy are using this important information as well.

 

6th March
2012
written by Lisa Stand

At the end of March 2012, the Supreme Court will hear oral arguments in the challenge against the Patient Protection and Affordable Care Act. Every Tuesday in the month of March, the Alliance will blog about the impact the ACA has had and can have on preventing and ending chronic homelessness.

March marks the second anniversary of passage of the Affordable Care Act. This national legislation is changing the way communities take care of their most vulnerable residents. For people working to end chronic homelessness, it’s a good time to take note of some important milestones.

At the end of this month, the ACA is going before the Supreme Court. The nine Justices will hear oral arguments for three days about a host of issues raised by ACA opponents. After oral arguments, it could be some time – several months at least – before we know how the highest court in the land decides about upholding this historic piece of health care legislation.

Whatever happens, there is no denying that the Affordable Care Act has been helping people. In its first two years, the ACA has made the most progress in the private sector – making insurance more accessible for people with pre-existing conditions, and young people who age out of family policies.

For low-income populations, there is some good news but still a long way to go. The Affordable Care Act channeled millions more dollars to community health centers, which directly serve 20 million people who otherwise cannot access health care services. There are more than 1,100 such sites across the country today, including 208 projects that specifically serve one million homeless people every year. The ACA gives CHCs a critical role to play in rebuilding a health care system that puts people first. With expanded funding, the safety net has greater reach, with new centers and training programs for community health workers.

For chronically homeless people, the ACA’s biggest promises are still unfolding. Millions of poor and low-income adults still lack access to essential health care services, and many are denied Medicaid even though they have serious and disabling illnesses. The health care safety net remains fragmented and difficult to navigate. From Washington, it’s sometimes easy to think these problems are solved; that’s because we are only seeing federal agencies and states prepare for changes that are yet to come in a meaningful way for people who desperately need them.

But, help is on the way. Medicaid programs in states like Missouri, New York, and Rhode Island are moving ahead with new “health homes.” Health homes dedicate more Medicaid funding to the task of coordinating services and helping people achieve their highest potential for health and independence. (We’ll look more closely at health homes in a blog later in the month.) Other pilot programs are under way to find the best practices, tried-and-true approaches to integrating primary and behavioral health care services. More and more, health care experts are recognizing that housing can be part of the solution. Just last week, the Corporation for Supportive Housing announced $2.8 million in awards to 4 communities that are building out integrated models, capturing cost efficiencies while improving health outcomes.

Finally, Medicaid is getting ready to expand eligibility for basic health benefits, covering as many as 16 million more low-income people – who are uninsured and have not been eligible in the past. This part of the ACA is set to take effect in 2014. It is one of several key aspects that ACA opponents are challenging in the Supreme Court. Meanwhile, advocates are influencing implementation at the federal and state levels. The main task is to see that essential health benefits truly deliver on the promise of access to needed health services for all.

The Alliance will be blogging on the ACA throughout the month of March and paying close attention to the impending Supreme Court case challenges provisions of the health care reform law. For more information about homelessness and health, visit our website. We’ll be featuring these and related resources in later blogs.

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