Financing Services In Supportive Housing Using Mainstream Resources

Carol Wilkins

Corporation for Supportive Housing

David M. Wertheimer

Kelly Point Partners

Mainstream Services & Funding

More money available from mainstream than in targeted programs

More reliable for sustaining programs after time-limited grants

Make HUD funding available for housing Link tenants and services to Systems of Care

Financing Strategies

Billing for reimbursement under entitlement programs (e.g. Medicaid)

Direct federal grants from programs not targeted to homeless people or people with HIV/AIDS

State or local government decisions to allocate block grant funds for services

Re-investing savings from reduced costs in other systems

Eligibility Considerations

Tenants / Consumers : individuals and family members

Providers : organizations and staffActivities / ServicesDecision-making and oversight

Understand the requirements of potential funding sources

Eligibility determination / verification

Staff credentials and skills required

Service planning Record-keeping Performance

Financial and administrative systems for billing / cost reporting

Frequency of application / grant-writing costs

Cash flow

Service Integration and Systems Integration

Defining service integration: The creation of linkages across multiple

systems at the service delivery level

Defining Systems Integration: The creation of formal linkages across

multiple systems at the structural level

Service Integration: What it Is

Creation of cross-agency/cross-system relationships at the provider level that affords opportunities to construct integrated packages of care for specific clients

Informal opportunities for information sharing, case consultation and cross-training in multiple disciplines

Service Integration: Advantages

Easier to create than systems integration Does not require systematic or strategic

buy-in at senior levels of system Creates useful relationships among

providers across systems Can be highly functional in meeting

individual client needs

Service Integration: Problems

Benefits remain client-specific and do not address systemic gaps and barriers

Is personality-driven Difficult to sustain integration in an

environment with moderate to high staff turnover

Systems Integration: What it Is

Key Components of Systems Integration: Sharing of Information Sharing of Planning Sharing of Clients Sharing of Resources Sharing of Responsibility

Systems Integration: Advantages

Creates structural linkages at the systems level Can be highly functional in meeting individual

client needs Can be highly functional in meeting system

needs (e.g. promoting collaboration) Easier to sustain in an environment with

moderate to high staff turnover

Systems Integration: Problems

Requires stakeholder buy-in at administrative and policy levels

Requires extensive process to mobilize ongoing participation at systems level

Requires formalized working agreements or other linkages to sustain integration over time

Strategies to Access Specific Mainstream Funding Sources

Public Mental Health Services

Public sector mental health services are funded in a variety of fashions:

Fee-for-Service Case Rates CapitationPublic sector services are increasingly being

managed using a managed care paradigm

Mental Health Services: Eligibility

Eligibility is defined in several different ways: Financial eligibility (Medicaid-only systems vs.

other models) “Medical Necessity” (Levels of severity and

levels of need) Diagnostic criteria (e.g. “Axis I” vs. “Axis II”

mental health disorders

Strategies for Accessing Mental Health Services: Service Level

Service Integration Strategies: Forging relationships with mental health

providers Learning the eligibility criteria Knowing what to say and how to say it Quid Pro Quo issues

Strategies for Accessing Mental Health Services: Systems Level

Systems Integration Strategies: Formal working agreements Cross-training in system access and

system issues Prioritization of referrals Contractual obligations Incentive payments

Public Substance Abuse Services

Publicly funded substance abuse and chemical dependency services are usually poorly funded

Access to services is severely limited due to capacity issues

Funding is highly categorical in nature and targets specific populations

Abstinence-only model may dominate

Accessing Substance Abuse Services

Understand the categorical nature of what is funded in your region

Market to the priority population characteristics rather than to your client’s HIV/AIDS status (e.g. IVDU)

Identify range of options that may be more accessible (e.g. specialized self-help groups)

Medicaid

Federal Financial Participation (FFP) matches “state” (non-federal fund) contributions (approx 50/50)

Federal rules and waivers administered by Health Care Financing Agency (HCFA)

State Medicaid Plan : contract between state and federal government

Basic health services + State Options

State Medicaid Plan Defines:

Optional benefits “Medical necessity” Who is eligible to provide services to be

reimbursed under Medicaid Where services must be provided Billing structure requirements

Medicaid Eligibility - Consumers

Generally tied to eligibility for SSI or TANF Low income parents and children are often

eligible even if not receiving welfare benefits – but often they do not apply

New option for states to extend eligibility for people who qualify for SSI (based on disability level) but have earnings from work

Medicaid eligibility issues

Very low income adults without children are usually not covered unless eligible for SSI based on disability level

Adults with disabilities attributable to substance abuse often excluded from Medicaid, in spite of significant health problems

Medicaid eligibility - providers

Federally Qualified Health Centers (FQHC): Health Care for the Homeless programs and Community Health Centers receive cost-based reimbursement under special rules

For other provider organizations and practitioners, eligibility to participate determined by state plan

Managed Care & Freedom of Choice waivers may have exceptions for people with HIV/AIDS or other special needs

Partnering with an FQHC for services in supportive housing

Community Clinic sends a primary care provider (MD or nurse practitioner) to deliver on-site care and health education to tenants, with follow-up at nearby clinic for more complex needs

Mental health services provided by psychiatrist and Licensed Clinical Social Workers employed by (or under contract with) FQHC

Integrated primary care, mental health, health education services are reimbursed through FQHC

Options for using Medicaid to fund services in supportive housing

Rehabilitation Option Targeted Case Management Home and Community Based “Waiver”

Services

Rehab Option

At the option of the state … other diagnostic, screening, preventive and rehabilitative services … for maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level (Federal)

Assistance in improving, maintaining, or restoring … functional skills, daily living skills, social and leisure skills, grooming and personal hygienic skills, meal preparation skills, and support resources, and/or medication education (California)

Rehab Option (cont.)

Most often used for mental health services State plan may define medical necessity differently

for services covered under rehab option State plan may have different requirements for

providers seeking reimbursement under rehab option (e.g. operating under contract with county mental health department)

Requires plan of care reviewed and approved by licensed practitioner

Rehab Option Services May Include (depending on state plan)

Assessment / plan development

Individual or group rehabilitation or therapy

Case management Case management

brokerage

Medication support Collateral Services Crisis intervention Services delivered in a

broad range of settings

Targeted Case Management

Services to assist eligible individuals in gaining access to needed medical, social, educational, and other services

Federal law allows states to limit eligibility for case management services to particular groups of people (e.g. people with HIV/AIDS or other targeted groups)

Requires a separate state plan amendment

Case Management Services Targeted to “High Risk Persons” in California

persons identified as having a need for public health case management services including … persons with HIV/AIDS … and persons with multiple diagnoses

Those who have failed to take advantage of necessary health care services or do not comply with their medical regimen or who need coordination of multiple medical, social and other services due to the existence of an unstable medical condition … substance abuse, or because they are victims of abuse, neglect or violence

Persons with no community support system to assist in follow-up care at home … and persons who require services from multiple health / social service providers in order to maximize health outcomes

Targeted Case Management Services in California

Needs assessment Setting objectives related to needs Individual service planning Service scheduling

Case management services ensure that the changing needs of the person are addressed on an ongoing basis and appropriate choices are provided among the widest array of options for meeting those needs

Home and Community Based Services (HCBS)

Provide broader range of services not otherwise covered under Medicaid plan

Operate under 1915(c) waivers submitted by states and approved by HCFA

Eligibility limited to people who would otherwise be eligible for institutional placement (e.g. nursing home)

Providing housing and services to tenants who meet HCBS eligibility in unlicensed supportive housing may conflict with state licensing laws

Challenges to consider

Many tenants may not be eligible for Medicaid if not receiving SSI

Requires service planning and documentation based on diagnoses and “medical necessity” rather than goals and aspirations of tenant and community

Record-keeping systems must support encounter level data

Skills and credentials required for billing are not the same as those needed for effective engagement and community-building

Federal Block Grants

Temporary Assistance to Needy Families (TANF)

Community Mental Health Services Block Grant

Substance Abuse Prevention and Treatment Block Grant

Social Services Block Grant

TANF

States have significant flexibility to design “welfare to work” programs and services that assist “needy families

Many states have significant surpluses Funding set aside for mental health and substance

abuse services may be under-utilized Some types of assistance subject to time limits Increasing interest in strategies to serve people with

multiple barriers to employment

Community Mental Health Services Block Grant

45% Increase in past two years ($289 million in FY 1999 - $420 million in FY 2001

Go to www.samhsa.gov/funding/funding.html to find your state’s formula grant allocations (for Community Mental Health Services and other SAMHSA grant programs)

Federal law requires Mental Health Planning Council to approve spending plan

States can decide to allocate funds for services in supportive housing