Lessons Learned Providing Housing Support to SUD Patients in Medicaid
Several state governments are integrating supportive housing into healthcare models and are experimenting with ways to increase Medicaid coverage of services and supports that are fundamental to supportive housing, according to a report from the U.S. Department of Health and Human Services. States emphasized the lack of affordable housing as a key impediment to successfully implementing programs that cover housing-related services and supports, HHS said.
A November 2020 report to Congress required by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act details innovative strategies for providing housing-related services and supports under a state Medicaid program to individuals with substance use disorders (SUD) who are experiencing or at risk of experiencing homelessness, as well as challenges and lessons learned in pilot projects.
The HHS report focuses on five state Medicaid programs—Arizona, California, Maryland, Pennsylvania, and Washington State—in addition to highlighting several local programs across multiple other states.
A number of state program outcomes have shown favorable results: high housing retention rates, reductions in emergency services utilization, reductions in inpatient admissions, increased connection to primary and behavioral health care, and overall reduced health are expenditures for program participants. Several innovative strategies, broadly adopted by all five state programs, were identified: integrated care coordination strategies, peer support models, funding coordination strategies, payment models, and data strategies, among others.
In terms of Medicaid waivers, the report notes that few states have chosen the section 1915(c) home and community-based services (HCBS) waiver program authority to cover housing-related services for individuals experiencing or at risk of experiencing homelessness, because individuals would need to meet an institutional level of care, among other requirements, to qualify. However, states are exhibiting a growing interest in section 1915(i) State Plan Amendments (SPA) which allow states to provide HCBS to individuals who meet state-defined needs-based criteria that are less stringent than institutional criteria and, if chosen by the state, target group criteria. Also, many states are exercising the flexibility through demonstration projects under section 1115 of the Act to test new approaches to providing Medicaid coverage of housing-related services and supports for individuals who are experiencing or are at risk of experiencing homelessness with a focus on HCBS-like services under these demonstrations.
Hospital involvement
Here is an example of how hospitals are participating: Local hospitals in Maricopa County, Arizona, in partnership with FQHCs, fund medical respite programs. Arizona recently participated in the Health Care Innovation Awards (Round Two) awarded by the CMS Innovation Center to the National Health Care for the Homeless Council (NHCHC) to test a model providing medical respite care for homeless Medicare and Medicaid beneficiaries following discharge from a hospital with the goal of improving health, reduce readmissions, and reduce costs.
Medicaid ACOs
Medicaid ACOs adopt strategies to improve integrated care coordination for Medicaid-eligible individuals. The Camden Coalition, a Medicaid ACO in New Jersey, uses “healthcare hot spotting” to identify individuals with frequent hospital use and complex health and social needs. Individuals are referred to community-based care teams comprised of nurses, social workers, and community health workers. The Camden Coalition administers a Housing First pilot program for individuals experiencing homelessness that provides rental assistance and optional wraparound support services. Among Housing First participants, at least 66 percent have a substance use diagnosis. Of those with a substance use diagnosis, at least 31 percent have an opioid-related diagnosis. Rental assistance for this program is not covered by federal financial participation.
Care coordination providers
The programs interviewed for the HHS report adopted integrated care coordination models focused on medical, behavioral health, and social support needs. These models include assessment and linkage activities to connect to primary care, mental health, SUD treatment, recovery support, and other needed services, in addition to providing ongoing care coordination.
For instance, Community Behavioral Health, the Philadelphia Medicaid MCO, employs integrated care teams that share medical and pharmacy data with physical health providers, working to generate joint plans for high-risk enrollees and to flag those who are homeless. The MCO has integrated its care coordination activities into all public health clinics and FQHCs, including satellite clinics. Mercy Care provides care coordination to access services such as transportation, crisis support, peer supports, mentoring, advocacy, and life skills, in addition to physical and behavioral healthcare, MAT, detoxification, supported employment, and supportive housing.
The Camden Coalition Medicaid ACO and two local hospitals developed an arrangement whereby the coalition receives an email of a daily list of patients currently in the hospital with two or more inpatient admissions and/or six or more ED visits in the last six months. The coalition team reviews the daily admissions to identify potential participants for their integrated care coordination program.
Challenges identified
Among key challenges identified, the supply of housing stock to address the continuum of housing needs for low-income households is not sufficient. For instance, federal housing assistance is a limited resource that serves just one out of every four very low-income renter households. To address this issue, Mercy Maricopa in Arizona invested in technical assistance to better understand the affordable housing system and extended this assistance to behavioral health providers within its network. Similarly, Maryland invested in a learning collaborative to help Assistance in Community Integration Services pilot jurisdictions pursue a better understanding of language differences and practices between housing providers, health departments, and other pilot stakeholders.
States also identified challenges related to insufficient provider capacity and lack of experience with Medicaid billing procedures and program requirements. Washington enrolled supportive housing providers and community action agencies that had no prior Medicaid billing or documentation experience. New providers and community-based organizations also did not understand the Medicaid service delivery and managed care system. The state reported that time and resources were needed to reorient business practices to align with Medicaid requirements. Maryland reported similar challenges.
States faced significant challenges in developing data sharing agreements such as Memorandums of Understanding (MOU). MOUs support partnerships between health and housing systems, facilitate needs assessments, and can document justifications for current or future data sharing needs. Matching data from housing IT systems with Medicaid systems was also resource-intensive and often was not technically feasible.
Lessons learned
HHS identified several common lessons learned by state Medicaid programs. Here are a few:
• States partnered with local public agencies, community-based organizations, and local MCOs, allowing these entities to experiment with ways to more comprehensively meet the needs of their communities and to leverage local resources and partnerships.
• States were committed to using health technology and data to improve care coordination and cross-agency collaborations in the delivery of housing-related services and supports. Investing in measurement and reporting helped to inform new state Medicaid reforms.
• States sought to strengthen connections across clinical and non-medical community-based resources that support and enhance housing stability and recovery.
• States experimented with numerous approaches in the delivery of housing services, including payment models, hiring non-traditional health workers to furnish peer supports, and coordinating multiple funding streams to provide access to a full continuum of both Medicaid-covered services and non-Medicaid covered services.
The report concludes by noting that several other states have recently pursued similar strategies. Hawaii offers housing-related services to Medicaid-eligible individuals who meet specified needs-based criteria, such as having SUD and experiencing or at risk of experiencing homelessness under a section 1115 demonstration amendment. In July 2019, Florida and Illinois began piloting programs providing housing-related services and supports to individuals with significant behavioral health needs who are experiencing or are at risk of experiencing homelessness under section 1115 demonstration amendments in certain geographic areas. Hawaii, Florida, and Illinois will implement these programs in coordination with Medicaid managed care organizations.
