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Waiver and State Plan Amendment Options – State Examples

These three states are highlighted as examples of different models for carrying out housing as health care programs using Medicaid.

  Example 1: Massachusetts Community Support Program for People Experiencing Chronic Homelessness52
Implemented in 2005
Example 2: Louisiana Permanent Supportive Housing53
Implemented in 2011
Example 3: California Health Homes and Housing59
Scheduled Implementation of July, 2017
Example 4: California Medi-Cal 202060 Scheduled Implementation of November, 2016
Example 5:California Community Transitions
Implemented in 2007
Target
Population

Chronically homeless individuals (U.S. Department of Housing and Urban Development [HUD] definition) with a diagnosis of a MH or SUD

People with substantial long-term disability (includes physical, BH, SUD, developmental disability or disability related to chronic health conditions);
prioritizes chronically homeless and institutionalized individuals or households with disabilities

High-cost Medi-Cal members with chronic conditions and those experiencing homelessness

High utilizers, nursing facility discharges, those who are homeless or at risk of homelessness

Nursing facility discharges, recipients of long-term inpatient care and those who are homeless or at risk of homelessness

Medicaid Authority

1115 waiver

Multiple 1915(c) waivers, Mental Health Rehabilitation under 1915(i) replaced with Mental Health Rehabilitation under state plan effective Dec. 1, 2015

Health Homes State Plan Option (pending approval)

1115 Waiver

Money Follows the Person

Services Covered

Housing Supports

  • Identify and triage potential participants
  • Assist individuals with housing search
  • Assist individuals in obtaining permanent housing
  • Assist individuals in enhancing daily living skills: may include tenancy skills support (bill payment, housekeeping, lease observance, etc.)
  • Provide crisis planning, prevention, intervention

Health Services

  • Coordinate service and linkage to BH and physical health
  • Link/refer to recovery supports
  • Schedule, transport, and accompany clients to medical appointments

Social Supports

  • Link/refer to social supports
  • Assist with obtaining entitlement benefits
  • Assist in enhancing daily living skills, which may include nutrition and time management skills building and support

Pretenancy and Tenancy Supports

  • Provide pretenancy assistance in viewing and selecting units, obtaining necessary documents to complete housing and voucher applications, seeking reasonable accommodation when needed and entering into lease agreements
  • Assist with apartment setup and move in, identify transportation resources and routes, orient to neighborhood
  • Provide tenancy skills support (bill payment, housekeeping, lease observance, getting along with neighbors)
  • Provide tenancy preservation and maintenance including assistance in obtaining entitlement benefits, building social connections, accessing primary and other health care, and support for voluntary compliance with treatments
  • Assist in crisis planning/eviction prevention

Other

  • Transition services
  • Environmental accessibility adaptations
  • Personal care attendant
  • Skilled maintenance therapies (physical therapy, occupational therapy, etc.)
  • Nursing
  • Support coordination
  • Home delivered meals
  • Caregiver respite
  • Employment support and training
  • BH services, including for SUD, by licensed practitioners
  • Adult day health care
  • Transportation
  • Personal emergency response systems
  • Assistive technology, specialized medical equipment and supplies
  • Provide comprehensive care management
  • Provide care coordination
  • Assist the member in navigating health, BH and social services systems, including housing
  • Engage in health promotion
  • Provide comprehensive transitional care
  • Assist in planning appropriate care/place to stay post-discharge, including temporary housing or stable housing and social services
  • Provide transition support to permanent housing
  • Link/refer to individual and family support services
  • Link/refer to community and social supports
  • Link to individual housing transition services, including services that support an individual's ability to prepare for and transition to housing
  • Link to individual housing and tenancy sustaining services, including services that support the individual in being a successful tenant in their housing arrangement and sustaining tenancy
  • Provide housing-based care management
  • Provide tenancy supports, including outreach/engagement, housing search assistance, crisis intervention, application assistance for housing and other benefits
  • Allows health plans flexibility to provide non-traditional services such as care coordination, discharge planning
  • Allows health plans and other participants to contribute to shared savings pool with county partners that can be used to fund other housing-related supports and services, and to form regional integrated care partnership pilot programs to more effectively leverage state, federal and local dollars
  • Arrange for the transition to home- and community-based services
  • Encourage local care coordination organizations work directly with willing and eligible individuals to transition them back home or to the community
  • Combines with HUD Section 811 grants to create more affordable rental units for the disabled population
Outcomes
  • In an analysis of 137 members of the Community Support Program for People Experiencing Chronic Homelessness (CSPECH), there was a net savings of $10,249 per person annually, and a total estimated annual savings of $1,404,11354
  • Examining the top 10 emergency department (ED) users in fiscal year (FY) 2009, nine out of 10 had a decrease in ED use after enrolling in CSPECH; these extreme high users of the ED decreased their ED use by 73 percent, from 300 visits in FY 2009 to 166 ED visits in FY 2010 and 80 ED visits in FY 201155
  • 24 percent reduction in Medicaid acute care costs (2011–2012)56
  • 96 percent housing retention rate57
  • 61 percent increase in household income58
TBD TBD TBD

Local Innovation: Los Angeles Department of Health Services

The Los Angeles Department of Health Services (DHS) recently launched the Housing for Health61 program to house homeless DHS patients who have complex physical and BH conditions. Notably, they have successfully done so without additional county dollars. The county approved a reallocation of $4 million in existing DHS funds from services to housing, allowing DHS to pay the rent for formerly homeless individuals. DHS secured the reallocation of funds by demonstrating that they would be offset by significant reductions in ED and inpatient utilization. In addition to rent subsidies, DHS provides individuals with intensive case management that includes tenancy support services. Initial results of the program include a 77 percent decrease in ED visits, 77 percent decrease in inpatient admissions and 85 percent reduction in inpatient days.62