Building on CalAIM's Housing Supports Strengthening Medi-Cal for People Experiencing Homelessness AUGUST 2023 AUTHOR Sharon Rapport, JD Corporation for Supportive Housing About the Author About the Foundation Sharon Rapport, JD, is the director for California The California Health Care Foundation (CHCF) state policy at the Corporation for Supportive is an independent, nonprofit philanthropy that Housing (CSH) and works to advance a state policy works to improve the health care system so that agenda for solving homelessness. all Californians have the care they need. We focus especially on making sure the system works for Rapport has worked in collaboration with col- Californians with low incomes and for communities leagues to offer technical assistance to California's who have traditionally faced the greatest barriers Departments of Health Care Services, Housing and to care. We partner with leaders across the health Community Development, and Social Services. care safety net to ensure they have the data and She works in partnership with other advocates resources to make care more just and to drive and co-led efforts to establish the Bring California improvement in a complex system. CHCF informs Home Coalition and the Coalition for Solutions to policymakers and industry leaders, invests in ideas Homelessness Among Older Adults. She served on and innovations, and connects with changemak- the Housing California Board for six years, where ers to create a more responsive, patient-centered she was elected president of the board from 2017 health care system. to 2018. She has served on multiple councils, includ- ing an appointment to Governor Newsom's Council of Regional Homeless Advisors. About Corporation for Supportive Housing CSH works to advance solutions that use housing as a platform for services to improve the lives of the most vulnerable people, maximize public resources, and build healthy communities. CSH is a national champion for supportive housing, demonstrating its potential to improve the lives of very vulnerable individuals and families by helping communities create more than 385,000 real homes for people who desperately need them. Building on 30 years of success developing multiple and cross-sector partnerships, CSH engages broader systems to fully invest in solutions that drive equity, help people thrive, and harness data to generate concrete and sustainable results. By aligning affordable housing with services and other sectors, CSH helps commu- nities move away from crisis, optimize their public resources, and ensure a better future for everyone. Learn more at www.csh.org. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 2 Contents 4 Executive Summary 6 Foreword: Bob's Story 7 California's Potential to Address Homelessness Part 1. Background: Homelessness Complicates Care Part 2. Opportunities for Funding Housing Support Services Through Medi-Cal Part 3. Challenges for Enrollees, Providers, and Managed Care Plans Part 4. Recommendations: Seven Steps Toward Greater Person- Centered Care 32 Conclusion 33 Appendix A. Acknowledgments 34 Appendix B. Housing for People Experiencing Homelessness 38 Appendix C. Trauma-Informed Housing Support Services for People Experiencing Homelessness 44 Appendix D. What the Federal Government and Other States Are Doing to Fund Housing-Based Services 48 Appendix E. Additional Challenges with CalAIM Implementation 51 Appendix F. Achieving the CalAIM Goals 52 Endnotes Executive Summary While the health care system cannot by itself Black and American Indian / Alaska Native peo- solve homelessness, it has a crucial role to play ple being significantly more likely to experience in providing access to services critical to the homelessness.3 Decades of racism in housing welfare of people experiencing homelessness. and institutional policies contribute to these Across the state, organizations and communi- disparities, leading to untreated chronic health ties help people exit homelessness every day. conditions and other behavioral and physical But the story behind each success is often a long health problems that contribute to chronic pat- journey through layers of administrative barri- terns of homelessness and early mortality. ers and siloed programs. Navigating access to meaningful care by people experiencing home- The primary driver of homelessness is a lack of lessness, who are already facing trauma and affordable housing. Part 2 describes opportu- struggles to survive, requires a person-centered nities in CalAIM, in the Providing Access and approach to care. Transforming Health (PATH)4 initiative, and in the Home and Community-Based Services California's Medicaid program, Medi-Cal, is Spending Plan5 to fund housing support services undergoing an ambitious transformation known that connect people to housing and help keep as CalAIM (California Advancing and Innovating people stably housed. This section also includes Medi-Cal).1 A key focus of this transformation is explanations of CalAIM's Enhanced Care removing barriers to care for populations who Management benefit (PDF)6 and Community struggle to access services, including people Supports (PDF),7 seven of which specifically experiencing homelessness. A critical goal of focus on people experiencing homelessness. CalAIM is a more person-centered approach to publicly funded health care. Despite the promise of CalAIM and related programs, CalAIM's impact has been limited to This paper rests on a foundation of exten- date. Part 3 describes the challenges providers sive research and examines the successes, and managed care plans face in implementing challenges, and opportunities in providing CalAIM and the provision of housing support person-centered care to people experiencing services. Health care and social service providers homelessness. In Part 1, the authors describe offering services under CalAIM must navigate in detail how homelessness undermines a per- differing reimbursement rates - which may son's health. When people live outdoors or not be enough - and differing requirements without reliable shelter, existing health issues set by each managed care plan, even among are made worse, and people develop new ones. plans operating in the same county. Managed Californians experiencing homelessness die in care plans may not know how best to identify large numbers from causes directly related to and reach people experiencing homelessness, their lack of housing. Homelessness cuts lives and to connect people to housing and housing short: People experiencing homelessness die support services. Meanwhile, people who are on average 20 to 30 years younger than their unhoused must still find and access the care and housed counterparts.2 Homelessness also exac- services they need by navigating complex sys- erbates existing racial health disparities, with tems of care and fragmented provider networks. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 4 Recommendations The substantial research cited in this report These recommendations can help advance our highlights the need for a well-designed Med- health care system toward evidence-based, Cal benefit for housing support services that comprehensive, person-centered care that can would make the integration of housing and sup- help people with the most complex needs find port services funding possible and sustainable. and access housing, obtain needed care, stabi- lize, and thrive. The report offers these seven recommendations California policymakers can take now to imple- ment Medi-Cal housing supports and achieve person-centered care for people experiencing homelessness: 1. Seek federal approval by the end of 2024 for a housing support services Medi-Cal benefit to provide a comprehensive range of services to all Medi-Cal members experiencing homelessness. 2. Set provider rates that adequately support hous- ing-related services, covering the full costs of evidence-based programs. 3. Fund evidence-based homeless outreach and engagement strategies through sustainable funding sources. 4. Build the capacity of community-based organiza- tions to implement housing-related services. 5. Develop a plan for integrating inter-agency health and housing policies, aligning funding models and resources effectively. 6. Establish equity benchmarks to address health disparities and reset eligibility criteria based on need. 7. Create a process for referrals that begins with the homeless response system, allowing for smoother access to housing support services. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 5 Foreword: Bob's Story Unable to manage his diabetes and clinical depres- together, Maria found Bob a small apartment and a sion after a difficult divorce left him unable to subsidy from the local housing authority that priori- afford rent, Bob sought emergency treatment at tized Project RESPECT clients. Oakland's Highland Hospital about 12 times a year. Bob said he felt "human for the first time In his 50s, Bob had nowhere to shower or store his medication. Following a healthy diet was almost in years." He was able to remain in his own impossible. He spent most days hunkered in De apartment for about five years, when he Lauer's, a downtown Oakland newsstand, in an died from his chronic illnesses. effort to stay safe. He could not rest because the shelters were noisy and the streets dangerous. As After Bob moved to his new home, Maria con- Bob focused on day-to-day survival, his conditions tinued to work with him to improve his health. worsened. Like many Californians experiencing Eventually, he stopped visiting the ED, no longer homelessness, Bob qualified for Medi-Cal cover- used drugs, reestablished relationships with his age, but he did not know his insurance plan, had no kids, and even began volunteering at a veterans' primary care physician, and lacked transportation. hospital. He said he felt "human for the first time in years." Bob was able to remain in his own apart- On one visit to Highland's emergency department ment for about five years, until he eventually died (ED), Bob met Maria, a social worker with Project from his chronic illnesses. RESPECT, a "Housing First" program providing intensive case management services8 to people fre- Meaningful access to health care is elusive for peo- quently visiting hospitals due to acute conditions. ple experiencing homelessness, like Bob. People Project RESPECT had partnered with the hospital like Bob bear the burden of navigating administra- to identify and provide outreach to people expe- tively complex and uncoordinated health, housing, riencing homelessness and visiting the ED. Maria and social services systems, leaving them to access began establishing a trusting relationship with Bob. care in acute care settings or not at all. The result She worked with him to plan for his care and make is relentlessly poor outcomes and unnecessary sure he got what he needed: medical care, mental suffering for those affected, as well as the grossly health treatment, new teeth, and assistance find- inefficient use of resources. ing a place to live. After a few months of working Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 6 California's Potential to system operates (Figure 1). In a person-centered approach, the person drives their care, and systems Address Homelessness coordinate to meet the person's needs. In responding to homelessness and its health ramifi- cations in California, the Department of Health Care This report provides research findings and back- Services (DHCS) is taking a leading role (described ground on the current system, opportunities, and in detail in Part 2 of this report) through the follow- challenges associated with integrating housing and ing programs and initiatives: health care systems, and specific recommendations for creating a housing support services benefit that $ California Advancing and Innovating Medi-Cal does the following: (CalAIM) $ Reliably funds evidence-based services to $ Providing Access and Transforming Health (PATH) help people access housing and remain stably $ Home and Community-Based Services (HCBS) housed. Spending Plan $ Coordinates and aligns with housing and home- less response systems. Importantly, state leaders are working to make Medi-Cal an integral component in solving $ Includes people with lived experience in all homelessness through bridging two major sys- aspects and components of the health care sec- tems - housing and health care - with a goal of tor, including policymaking, program design, creating a person-centered approach to receiving delivery system, service delivery, financing, and care. A person-centered approach seeks to accom- research. modate the unique needs of the person, rather than $ Increases access to people with the greatest bar- requiring the person to accommodate the way the riers to receiving care. Figure 1. Current Systems-Centered Approach to Care vs. Person-Centered Approach to Care SYSTEMS-CENTERED APPROACH PERSON-CENTERED APPROACH Housing Health support Behavioral services health care Primary Enrollee System care accommodates accommodates Enrollee Needs system needs of requirements enrollee Social Help with Housing Housing activities of Services daily living Sources: What Is People-Centered Care?, World Health Organization, YouTube video, June 21, 2017; and "Person-Centered Care," Centers for Medicare & Medicaid Services. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 7 Part 1. Background: Homelessness Homelessness exacerbates existing racial health Complicates Care disparities. In California, Black people are more than five times more likely to experience home- lessness than the population as a whole, while How Homelessness Undermines Health American Indian and Alaska Native (AIAN) popula- For Californians without housing, the traditional tions are over four times more likely.18 Decades of approaches to health care fail under any typi- racism in housing and institutional policies underpin cal measure - access to care, health outcomes, today's housing inequities,19 which are consistent equity, or costs.9 The consequences are often with health disparities seen in Black and AIAN lethal; every year, thousands of Californians die populations with regard to preventable hospitaliza- from causes directly attributable to homelessness.10 tions, hospital readmissions, and untreated chronic A literature review showed that people experienc- conditions.20 ing homelessness die, on average, 20–30 years younger than housed people with similar health conditions.11 An Alameda County study revealed Although California spends two to three that the health conditions of people without hous- times more on people who are unhoused ing were akin to those of housed people 25 years than on other Medi-Cal members, people their senior.12 experiencing homelessness still have far A relatively small number of Medi-Cal members worse health outcomes. experience homelessness - an estimated 273,500 Californians, or less than 2%13 - but their needs Homelessness is also costly to public health care are complex. People experiencing homelessness systems. Although California spends two to three encounter a combination of health risk factors, times more on people who are unhoused than on such as exposure to communicable disease, other Medi-Cal members, the former have far worse extreme temperatures, unsanitary conditions, health outcomes. For the costliest 10%, the public poor nutrition, sleep deprivation, physical and health care system spends more than $75,000 per emotional trauma, and long periods of standing person annually,21 often because hospitals keep and walking. They face extreme danger of physi- people longer than medically necessary when they cal and sexual assault and are far more likely to be lack a safe and stable place to recover. Also, peo- victims of violence than people who are housed.14 ple without housing are often admitted to nursing They develop a more complex array of medical homes for conditions that could be managed at and behavioral health conditions while homeless. home with nursing support.22 They are more likely to suffer debilitating skin and foot conditions, as well as heart and lung dis- Housing Affordability ease.15 The stress of homelessness can bring on A lack of affordable housing for people with the low- or exacerbate behavioral health conditions such as est incomes is the leading driver of the homelessness complications from stimulants (which many people crisis in California, where renters need to earn almost use to stay awake and vigilant), major depres- three times the state's minimum wage to comfort- sion, anxiety, or post-traumatic stress.16 Further, ably afford the average rent for a two-bedroom research shows that people cannot significantly apartment,23 and people with the lowest incomes improve their health without housing and that, in pay a far higher portion of their income for housing fact, health conditions continuously worsen during than is sustainable.24 Substantial research points to episodes of homelessness.17 the critical role of housing in solving homelessness Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 8 when said housing does not limit length of stay The Role of Housing Subsidies in Supporting ("permanent housing")25 and is affordable to some- Someone to Exit Homelessness one in deep poverty.26 Health and social services are People with little or no income often require "afford- far more effective when provided to a person living able housing," which is made possible through in housing rather than to someone living in a shelter, subsidies. "Tenant-based" subsidies allow a person a vehicle, or on the street.27 When people experi- to rent from a private-market landlord; "project- ence homelessness, they are focused on survival: based" subsidies help developers of affordable where to sleep or how to stay awake so as to avoid housing pay for the costs of operating an affordable abuse, how to access food and water, how to store or supportive housing project (in a project, tenants medication or access medication, how to avoid the do not take the subsidies with them if they move). elements. This instability does not allow people to Subsidies include the following: recover from or evade illness. Health stability is only possible with housing stability.28 $ Capital funding. The federal government, the state of California, and local governments offer Data show that people who have experienced capital funding for developers of affordable homelessness and complex health challenges can housing to build a project that offers apartments thrive with housing and services offered through affordable to people with low incomes. a "Housing First" approach.29 Grounded on $ Operating funding. The federal government American psychologist Abraham Maslow's hier- funds "project-based" subsidies to pay the costs archy of needs30 theory of human motivation, of operating new affordable or supportive hous- Housing First is a recovery-oriented model devel- ing developments. The subsidy amount is the oped about 30 years ago to address the needs difference between the cost of operating and of people experiencing both homelessness and maintaining those apartments and 30% of the serious and persistent behavioral health condi- tenants' income. California sometimes pays the tions. Housing First programs result in high rates up-front operating cost for new projects through of housing stability,31 decreased emergency room a "capitalized operating subsidy reserve" that visits and inpatient hospitalizations,32 reductions in developers can draw from over time. incarceration,33 and reduced substance use.34 $ Tenant-based rental subsidies. The federal gov- This evidence-based model shows that people ernment and some counties in California offer must have a safe and stable home before they tenant-based rental housing subsidies, which can improve their health conditions.35 The federal pay a private-market landlord (or a nonprofit that government36 and the state of California37 now has leased apartments from private-market land- require almost all housing and service programs lords) the portion of rent the tenant cannot afford receiving homelessness services funding to adopt to pay. The best-known and largest housing the Housing First core components, which include subsidy program is the federal Housing Choice harm reduction and helping people move into Voucher program, also known as "Section 8." permanent housing as soon as possible without $ Public housing. The federal government also preconditions. Housing First uses a voluntary ser- owns and operates "public housing," afford- vice approach that does not condition housing on able apartments all in a single project (though participation in a program or services.38 CalAIM's California has little remaining public housing). Community Supports, discussed in this report, also adopt these core components of Housing First. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 9 Two Definitions Housing Versus Shelter Tenancy-Sustaining Services "Housing" is distinguished from temporary places to Tenancy-sustaining services help people adjust to liv- stay (often referred to as "shelter" or "interim hous- ing in housing and address behaviors that could lead ing"). In this report, "housing" refers to a place to to eviction. People receiving voluntary services who live without time limits ("permanent housing"). Such are paired with assertive engagement - the process housing is: of using interpersonal skills and evidence-based practices to engage someone who is distrustful - $ A permanent structure, usually with a foundation are more likely to participate in services, to receive and access to what makes a home healthy, such as treatment,* and to be satisfied with their services than running water and a bathroom in the unit. people in programs that require them to participate $ A decent, safe, healthy place to live, typically an in services or "comply" with a program.† apartment or rental home, with the requirements of * Min Hwa Lee and Mi Kyung Seo, "Perceived Coercion of Persons an apartment in California (i.e., hot water, electric- with Mental Illness Living in a Community," International Journal of ity, and heat). Environmental Research and Public Health 18, no. 5 (Mar. 2021): 2290; Angela A. Aidala et al., Frequent Users Service Enhancement 'FUSE' $ Subject to the same landlord-tenant protections Initiative (PDF), Columbia Univ. Mailman School of Public Health, 2014; and Daniel Gubits et al., Family Options Study: 3-Year Impacts of and laws as other California renters. Housing and Services Interventions for Homeless Families, US Dept. of Housing and Urban Development, October 25, 2016. $ Not a licensed setting. † Evaluating Your Program: Permanent Supportive Housing (PDF), Substance Abuse and Mental Health Services Administration (SAMHSA), 2010. "Supportive housing" is affordable housing with to stay (non-congregate shelters) and to build new intensive tenancy-sustaining services designed to permanent housing projects. Yet the scale of fund- help people with disabilities remain stably housed ing needed to build projects offering permanent (see more information about evidence-based ten- housing is nowhere near what it would take to allow ancy support services below). Such housing is most even 15% of California's homeless population to exit appropriate for people with multiple disabilities homelessness.39 What's more, waiting lists for fed- and is strongly associated with reductions in acute eral rental housing subsidies, like Housing Choice care use and costs. Tenancy-sustaining services are Vouchers (Section 8), in California can be 10 years critical to the success of supportive housing. long or closed altogether, as demand for subsidies is far higher than supply, with only four in 10 house- Resources for Housing Subsidies holds eligible for a rental subsidy receiving one.40 California has recently increased investments to local governments and to developers to build hous- However, several programs prioritize resources ing and temporary/interim stays in shelter or other for people experiencing homelessness, and many temporary settings. California does not directly housing authorities establish preferences that allow invest in rental housing subsidies for people expe- them to more quickly access federal housing rental riencing homelessness, but some counties have subsidies such as Housing Choice Vouchers. When recently created programs that pay subsidies for a household no longer needs a subsidy, that sub- rental apartments in the existing private market. sidy "turns over," and housing authorities, which run most federal rental subsidy programs, can pri- The state has invested in capital funding to convert oritize people experiencing homelessness for these existing structures into housing or temporary places turned-over subsidies. Even with these preferences Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 10 and some local funding for rental housing subsi- the homeless response system, such as help access- dies, people experiencing homelessness typically ing housing vouchers, help completing housing wait nine to 12 months (or longer) before receiving applications, and some help moving into housing a subsidy. (pre-tenancy, housing navigation, or housing transi- tion services). California has homeless response systems covering every county (often serving people across multiple Some people require intensive, individualized counties) that homeless Continuums of Care navi- tenancy-sustaining services in supportive housing. gate, working within or alongside a county agency Organizations managing rental housing subsidies or agencies, and sometimes city agencies funding or developers creating supportive housing projects housing. These entities often collectively control partner with homeless service providers to offer resources for housing, though they do not always services to tenants, preferably at provider-to-tenant coordinate effectively. ratios of between 1:10 and 1:20.41 People needing supportive housing include people with disabilities See Appendix B for more information on housing or major long-term health care needs, those expe- and housing resources. riencing long-term (chronic) homelessness, and people who have significant barriers to housing Housing Support Services stability, such as those who cycle between institu- Housing support services include finding and tionalization and homelessness. engaging people experiencing homelessness, helping people move into housing, and offering The Corporation for Supportive Housing (CSH) has individualized attention and services to stabilize created a Supportive Housing Services Budgeting people in housing. Services begin with meeting Tool42 to help agencies, communities, and project people where they are - often outside, in vehicles, planners estimate costs for supportive housing ser- or in shelters - and building trusting relationships. vices. It includes common evidence-based service Services continue through an individual's tenancy. models, along with ideal staffing for team-based Most individuals need "light" services to navigate and individual case management. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 11 Assertive Engagement: Vikki's Story Vikki is a case manager in Los Angeles who was formerly unhoused. She shared her story: "A truly caring outreach worker, Darren, rescued me from homelessness. He would stop by and try to engage in conversation with me, but I did not want anything to do with him. This went on for two years because I was so distrustful of anyone saying they wanted to help me because of my previous experience of being forced to take medication that almost killed me. When I became very ill from a respiratory infection, Darren offered me bus tokens and information about the Rose Family Clinic. Something inside me said, 'OK, you need the doctor.' About a month into antibiotic treat- ment for my respiratory infection, when I was living in an emergency shelter at Daybreak for Women, Dr. King of Rose Family Clinic referred me to Edelman Westside Mental Health. It took another 11 months before I was referred to permanent supportive housing. My case worker in supportive housing was so incredible! Believe it or not, I could not fill out forms. She went through housing applications with me, line by line, question by question, and completed forms with me in this way. Thanks to her real caring, when I was given the opportunity to be a resident at the Downtown Women's Center, I accepted. Today, I am a case manager for people who are elderly and disabled in South Central Los Angeles for the Aging and Disability Resource Center. I no longer need help paying for my housing." California has a network of effective homeless service $ Transitioning people from living outside to providers highly skilled at assisting people experi- tenancy in their own apartment, often with encing homelessness. They offer a range of services: support from peers with lived experience of homelessness. $ Meeting people wherever they are located $ Offering case management or tenancy-sustaining and asking them what they need, then working services to those needing supportive housing. toward meeting those needs. These "outreach Such services help people plan to meet goals, and engagement" services include returning to avoid behaviors that may lead to eviction (like see people, again and again, and building trust hoarding), shop for groceries, pay rent, navigate over months or even years, using evidence- relationships with neighbors and landlords, coor- based techniques of assertive engagement. dinate and advocate for tenants' health care, and $ Helping people access the local homeless connect tenants with community services. response and Coordinated Entry System (PDF)43 to complete applications for housing and hous- Multiple studies show that tenancy-sustaining, ing subsidies, as well as benefits, if eligible, and housing navigation, and outreach and engagement to connect them to treatment. services significantly improve the stability of people after they are housed.44 For some specific study $ Recruiting landlords willing to take housing findings, see Table 1 on page 13. subsidies. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 12 Table 1. Findings from Eight Studies on Housing and Support Initiatives STUDY LOCATION METHOD FINDINGS Daniel Flaming et al., Getting Home: Outcomes Los Angeles Pre-/post-housing one-year analysis of costs and People receiving outreach, engagement, and from Housing High Cost Homeless Hospital outcomes among 163 of the costliest 10% of tenancy-sustaining services reduced hospi- Patients, Economic Roundtable, September 1, homeless hospital patients tal costs by 72% and reduced the days they 2013. spent in the hospital by over 65%. Maria C. Raven et al., "An Intervention to New York City Pre-/post-housing one-year analysis of costs and People receiving housing navigation and Improve Care and Reduce Costs for High-Risk outcomes among hospital patients identified as tenancy-sustaining services decreased their Patients with Frequent Hospital Admissions: A high-risk for readmission hospital admissions by 37.5% on average, Pilot Study," BMC Health Services Research 11 with 73.3% of patients having fewer hospital (Oct. 13, 2011): 270. admissions in the year after the intervention versus the prior year. Debra Srebnik, "Begin at Home": A Housing King County, Comparison between high-cost chronically People connected to supportive housing, First Pilot Project for Chronically Homeless WA homeless adults who received supportive services receiving tenancy-sustaining services, had Single Adults: One Year Outcomes (PDF), in housing and those who did not, one year after 74% fewer hospital admissions than a compar- King County Dept. of Community and Human tenancy ison group receiving usual care. Services, October 15, 2007. Alvin S. Mares and Robert A. Rosenheck, Multiple cities Pre-/four-years-post-placement evaluation of 734 Formerly homeless tenants receiving tenancy- "Twelve-Month Client Outcomes and Service chronically homeless people sustaining services were able to decrease their Use in a Multisite Project for Chronically mental health crisis services costs by 79% and Homelessness Adults," Journal of Behavioral were able to decrease their total health costs Health Services & Research 37, no. 2 (Apr. by 73% after moving into housing. 2010): 167–83. Daniel Flaming, Patrick Burns, and Michael Los Angeles Los Angeles County public agency costs among Homeless GR recipients incurred county costs Matsunaga, Where We Sleep: Costs When 9,186 General Relief (GR) recipients experiencing of $2,897 per month versus $605 per month Homeless and Housed in Los Angeles (PDF), homelessness versus 1,007 people who formerly for people now living in housing and receiving Economic Roundtable, 2009. experienced homelessness and are now receiving tenancy-sustaining services. housing subsidies and services Laura S. Sadowski et al., "Effect of a Housing Chicago Randomized control-group study of 405 chroni- People receiving housing and services had and Case Management Program on Emergency cally ill, chronically homeless adults receiving 29% fewer hospital days and 24% fewer ED Department Visits and Hospitalizations Among housing with services versus similarly sized group visits within 12 months than control group, Chronically Ill Homeless Adults: A Randomized receiving usual care and 46% fewer hospital days within 18 months Trial," JAMA 301, no. 17 (May 6, 2009): 1771–78. than control group. Mary E. Larimer et al., "Health Care and Seattle Randomized control-group study of chronically People receiving services in housing incurred Public Service Use and Costs Before and After homeless people with alcohol use disorder receiv- $2,449 less in Medicaid costs per-person Provision of Housing for Chronically Homeless ing intensive case management, using harm per-month than control-group participants Persons with Severe Alcohol Problems," JAMA reduction in housing, versus control group receiv- after six months. They had 45% fewer arrests, 301, no. 13 (Apr. 1, 2009): 1349–57. ing usual care 42% fewer jail days, and a 60% decrease in alcohol and substance use, compared to the group receiving usual care. David Buchanan et al., "The Health Impact of Chicago Tenants of housing receiving intensive case Tenants receiving services lived longer and Supportive Housing for HIV-Positive Homeless management for people with HIV/AIDS compared were 63% more likely to have normal immune Patients: A Randomized Controlled Trial," to control group receiving usual care systems than the control group. Amer. Journal of Public Health 99, suppl. 3 (Nov. 2009): S675–80. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 13 Homelessness is a traumatizing experience.45 socially isolating) and may not have these relation- People who are unhoused often also have past ships. Medi-Cal also funds personal care services experiences of trauma such as these: through a number of programs intended to allow people to live independently if they are at risk of insti- $ Involvement in the foster care system as children46 tutionalization, such as the Program of All-Inclusive Care for the Elderly (for people 55 and older), the $ Adverse childhood experiences, including physi- Assisted Living Waiver, the Home and Community- cal and sexual assault47 Based Alternatives Waiver, the Multipurpose Senior $ Experience of domestic or dating violence48 Services Program, and Community-Based Adult Services.51 However, people who are unhoused $ High rates of previous accidents, severe inju- struggle to access these services because of their ries, and traumatic or life-threatening health homelessness status; they are often not eligible conditions49 because of requirements to literally receive services in a home. Most supportive housing does not offer Trauma can cause fear, hopelessness, isolation, and help with personal care services. As a result, enroll- disempowerment. It can impact the survivor's ability ees who need help with activities of daily living have to trust others.50 no choice but to live in licensed settings, putting California at risk of violating federal law requiring Housing First service models offer trauma-informed states and local governments to offer housing in the care (TIC), an evidence-based approach both least restrictive setting.52 health care services and social services providers use. Housing First–oriented services incorporate A person's need for tenancy-sustaining services six TIC principles: (1) safety, (2) trustworthiness and help with activities of daily living tends to be and transparency, (3) multidisciplinary support, cyclical, not linear. Someone who has experienced (4) collaboration and mutuality, (5) empowerment homelessness for years is likely to need two to and choice, and (6) cultural, historical, and gender three years of intensive, more frequent services to understanding. These principles are described in overcome long-term trauma before stabilizing into detail in Appendix C. a lower level of services. They may need intensive housing-related services again when experiencing Some people with disabilities cannot live indepen- stressors, such as the loss of a family member or dently without regular services that help them with a deteriorating health condition. Some supportive cooking, cleaning, dressing, or other activities of housing tenants need services for the rest of their daily living. Once housed, people can access these lives due to the acuity of their conditions. Crucially, services through the In-Home Supportive Services a person who loses services is at risk of losing hous- (IHSS) program, a Medi-Cal program to aid people ing, and a formerly homeless tenant who loses with disabilities to find help with these tasks. In housing often faces greater challenges getting most counties, IHSS enrollees must find their own rehoused. A tenant's ability to achieve and maintain IHSS workers, who can also be friends or relatives. successful outcomes is therefore directly related to Many enrollees elect to have someone they know their service continuity, and whether those services provide IHSS services to them; however, finding a are available for as long as or whenever the tenant worker can be more challenging for someone who needs them. has experienced homelessness (as homelessness is Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 14 received CMS approval to fund housing for up to Supportive Housing Services: Emily's Story six months for people experiencing homeless- Emily, who was formerly unhoused, shared her ness or leaving institutional settings.54 California's story about receiving supportive housing services recently approved state budget similarly includes where she currently lives: funding for up to six months of rental assistance or "At the apartments where I live, I have social temporary housing for people exiting institutional services I would not receive in a conventional settings through a CalAIM Transitional Rent Waiver apartment. Some of these services include sub- Amendment.55 stance abuse programs, healing arts, cooking, gardening, and health care. I have a doctor and See Appendix D for more information on federal social worker from the Department of Mental and state action to fund housing support services. Health who come to my apartment biweekly. Recently, I suffered a financial setback. Without the CalAIM - Intended to Offer a Whole- support of the supportive housing services and Person Approach to Care staff at my apartment complex, I may have found CalAIM seeks to build and expand on the successes myself in an institution or back on the streets. You and lessons of two previous programs, the Whole may think this will never happen to you, but it hap- Person Care (WPC) Pilot and the Health Homes pens to thousands of people every day." Program (HHP), with the goal of creating something more robust, permanent, and statewide. Part 2. Opportunities for Funding CalAIM's goals include shifting the state's Housing Support Services Through Medicaid program toward a more whole-person- Medi-Cal oriented approach, integrating Medi-Cal benefits Several states, including California, have been with social services, improving the outcomes for looking to Medicaid to fund services to address enrollees with complex or high levels of need, and health-related social needs. In its 2015 Informational standardizing and making more equitable services Bulletin on Coverage of Housing-Related Activities funded across the state. For people experiencing and Services, the federal Centers for Medicare & homelessness, CalAIM programs offer the follow- Medicaid Services (CMS) indicated that states can ing services: use Home and Community-Based Services (HCBS) and demonstration programs to support Medicaid $ Outreach and care coordination, including refer- recipients to obtain and maintain housing stability.53 ral for social services, through a new Enhanced Since then, states have begun funding services for Care Management (ECM) benefit administered people experiencing homelessness. CMS recently by managed care plans (MCPs). ECM is designed approved three states' Section 1115 Medicaid to support people with multiple conditions and waivers to include funding for housing support ser- complex needs in navigating multiple health vices for people experiencing homelessness. While and social service systems. People experienc- California's managed care plans can currently offer ing homelessness or at risk of homelessness are posthospitalization housing for up to six months among eligible populations for the ECM benefit. for people discharged from hospitals and other MCPs receive an additional capitation payment institutional settings, Arizona and Oregon recently for ECM services.56 Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 15 $ Community Supports - provided through a $ Recuperative care for short-term residential care Medicaid regulatory tool, In Lieu of Services - and medical monitoring62 allow MCPs to cover services that address $ Day habilitation services, including training in health-related social needs, in an effort to decrease daily living skills, help moving into a home, set- preventable expensive acute care services such tling disputes with landlords, managing money, as emergency room visits, hospitalizations, and and connecting to community services63 nursing home stays. These nontraditional services must be medically appropriate and cost-effec- $ Sobering centers, providing 24 hours of a tive. MCPs may include the costs of Community safe environment for people who are publicly Supports in their reported medical costs, requir- intoxicated64 ing the state to consider these costs when it sets MCP rates in the future. Unlike ECM, MCPs do However, MCPs are not required to offer all 14 not receive increased payment for the ongoing Community Supports, resulting in a patchwork of costs of providing Community Support services Community Supports across counties and even to their members, unless the MCP was offering within counties with multiple health plans that pro- those services prior to CalAIM. vide Medi-Cal coverage. If DHCS chooses to, it may ask that CMS allow DHCS to make a Community In addition, MCPs have begun receiving payments Support a Medi-Cal benefit, which would in turn under the DHCS Incentive Payment Program (IPP) if make that Community Support available to all and when they achieve specific outcomes defined Medi-Cal members regardless of the MCP they are by DHCS in their ECM and Community Supports enrolled in. programs.57 These IPP payments will be available to MCPs over a 30-month period in part to help With the combination of the ECM benefit and the plans with additional costs incurred from providing optional Community Supports, CalAIM is a pathway Community Supports before new rates that include for MCPs to offer services in new ways to members them go live. experiencing or at risk of homelessness. CalAIM identifies 14 preapproved Community PATH - Building Provider Capacity Supports, including seven that specifically focus on The Whole Person Care (WPC) Pilot, which pro- people experiencing homelessness: vided county-administered services for high-cost, high-need populations, ended in December 2021. $ Housing navigation and transition services to To avoid service gaps during the transition from help people access and move into housing58 WPC to CalAIM, and to provide the up-front fund- ing and capacity building for community-based $ Housing deposits to pay for onetime costs of organizations and county agencies to become moving into housing, such as security deposits59 providers, when they have not worked with Medi- $ Housing and tenancy support services to help Cal managed care in the past, DHCS created people maintain housing stability60 the Providing Access and Transforming Health (PATH) program. Approved under CalAIM, PATH'S $ Short-term posthospitalization housing, provid- purpose in regards to people experiencing hom- ing an interim bed for people exiting a treatment lessness is twofold: facility61 Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 16 $ Ensure continuity of care for people receiving county-led Whole Person Care services Opportunities for Using PATH or IPP Dollars to Strengthen Provider Networks $ Build administrative capacity among providers $ Hiring staff to meet requirements of Medi-Cal who have yet not contracted with MCPs or who billing, administration, or oversight, including are contractors but need to strengthen capacity, a quality improvement manager, a compliance including their capacity to serve people experi- officer, or additional quality improvement staff encing homelessness $ Federal HIPAA (Health Insurance Portability and Accountability Act) and whistleblower and Med- The PATH Capacity and Infrastructure Transition icaid fraud prevention training Expansion and Development (CITED) (PDF) ini- $ Acquiring software and licenses for electronic tiative is aimed at building county and local health records, and/or software for Medicaid government, public hospital system, tribal, and billing and for email and data encryption community-based provider capacity specifi- $ Funding training for staff on working with MCPs cally for ECM and Community Supports.65 PATH or training for health center staff on working with funding - which will total $1.85 billion over five homeless service providers who offer trauma- years - offers an opportunity to build a network of informed and evidence-based housing support homeless service providers that can bill Medi-Cal services or coordinate smaller providers to work with or cre- $ Creating a regional entity providing support ate an entity that can bill Medi-Cal.66 PATH funding to multiple community-based organizations in eligibility is limited to organizations actively con- receiving payment from the Medi-Cal program tracted with MCPs or that have an attestation from for the provision of housing support services an MCP they intend to contract. MCPs are not eli- gible to receive funds. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 17 HCBS Spending Plan - Connecting Services and Housing Opportunities for MCP Investments Using HHIP Incentive Dollars The Home and Community-Based Services (HCBS) $ Capitalized services reserves like an account Spending Plan is California's plan to use sav- holding 15 years' worth of tenancy support ings achieved under the federal American Rescue services that could be dedicated to funding ser- Plan's enhanced federal match for Medi-Cal HCBS vices in affordable or supportive housing units services. California's HCBS Spending Plan offers within projects serving MCP enrollees additional funding for PATH to build provider $ Capitalized reserves for housing navigation capacity to serve people experiencing homeless- offered to county agencies or homeless Con- ness. It also includes $1.3 billion for the Housing tinuums of Care to help MCP enrollees connect and Homelessness Incentive Program67 (HHIP) to Coordinated Entry Systems and move into to provide MCPs incentive payments for making housing investments and progress in addressing homeless- $ Capitalized operating reserves to pay for costs ness and achieving specific DHCS benchmarks. of operating a housing unit set aside for MCP MCPs that opt in must show how they intend to enrollees invest their incentive dollars and identify the gaps $ Staff time of housing authority, county agency, or in health access they intend to address for people Continuum of Care staff to establish preferences experiencing homelessness they intend to address. for federally or locally funded housing vouchers, Once an MCP earns an incentive by meeting spe- plus landlord recruitment and incentive funding cific HHIP benchmarks or milestones, the MCP may to help MCP enrollees move into private-market use these funds flexibly.68 housing $ County and Continuum of Care staff and MCP time to develop data-matching process to iden- tify MCP enrollees experiencing homelessness Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 18 Part 3. Challenges for Enrollees, capture the ROI of housing-related services that Providers, and Managed Care Plans take longer to materialize, considering the housing scarcity in California (see Figure 3 on page 25). Challenges for Enrollees To achieve ROI for housing supports, MCPs report Housing support services are not universally avail- they have been narrowing eligibility to prioritize able under CalAIM. DHCS has acknowledged their members with recent histories of high-cost or that housing support services are a cost-effective frequent hospitalizations. Some MCPs are funding intervention. However, an enrollee's access to hous- only one or two of the housing-based Community ing support services under Community Supports Supports rather than a more comprehensive pack- depends on whether their assigned MCP decides age of services and are limiting the time period to fund these services. members can receive services. Members face the following challenges in accessing Community In July 2023, DHCS issued an updated Community Supports: Supports policy guide (PDF)69 that will require all MCPs to align eligibility and service definitions Time limits. While DHCS guidance does not restrict with DHCS guidance by January 1, 2024. This how long members can receive housing navigation critical guidance will significantly expand access to and tenancy-sustaining services, in the first year of Community Supports. In the first years of CalAIM, CalAIM, MCPs have signaled that they are likely to MCPs have narrowed eligibility for housing sup- fund services for a set duration, such as 12 or 18 port services out of concerns about demonstrating months (in addition to authorization periods), again, return on investment (ROI). The guidance promises to ensure MCPs are ensuring ROI or minimizing risk to end differences in eligibility criteria between for ongoing costs of services. Some MCPs also set MCPs. six-month reauthorization periods, with reauthoriza- tion requiring a higher level of documentation than Though MCPs are not required to demonstrate initial authorization. People with complex health con- the cost effectiveness of housing support services, ditions may need services for multiple years or over they report setting policies, like narrowed eligibil- multiple episodes. Someone who needs services ity, based on their ability to achieve ROI due to the and does not receive them may return to homeless- upfront costs MCPs invest in services. MCPs have ness, putting their health at great risk. shared concerns that they will not meet all incentive payment requirements, and their upfront payment Lifetime limits. DHCS guidance states that a mem- for services to all eligible members may exceed the ber may receive tenancy support services for a incentive payments they will receive. These con- single duration in their lifetime, with an option to cerns may increase as eligibility for these services approve the provision of those services one addi- expands under the new DHCS guidance. MCPs tional time.70 This might mean that a person exiting have further shared that the Community Supports chronic homelessness could lose services after six (services provided "in lieu of" other, more expen- months if their MCP decides they no longer need sive services) approach to showing cost avoidance those services. Should they need services again, may work well for programs like recuperative care they might not qualify. However, research shows or sobering centers, as the plans can realize ROI that people typically need services cyclically, with quickly by avoiding hospital admission or readmis- varying intensity over time. sion. However, they may not be able to adequately Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 19 Black and Indigenous people are less likely to be Potential Impacts of Lifetime Limits to admitted to hospitals, visit emergency departments, Services: Lisa's Story or be admitted to nursing homes - all of which are Lisa successfully moved into housing after experi- high-cost services.72 In fact, Black and Indigenous encing years of chronic homelessness and received people experiencing homelessness in California tenancy support services to help her stay housed represent a lower share of hospital emergency for a period of time. After six months of stability, department patient encounters relative to their over- Lisa needs tenancy support services again and risks losing her housing without them. However, Lisa's all representation in the homeless services system.73 provider can no longer offer Lisa tenancy support services via Community Supports because Lisa In July 2023, DHCS updated its policy guide to has met her lifetime limit. Although DHCS allows standardize eligibility and ensure MCPs authorize the managed care plan to offer a second addi- Community Supports equitably. People who were tional period of service delivery, the provider must previously denied by MCPs should have the oppor- show that the second round of services will be tunity to receive Community Support services in "more successful" than the first, a high standard 2024, necessitating provider and enrollee educa- when Lisa's first round of services already resulted tion or notification. in good outcomes - housing placement and stabilization. Without being able to show a more Siloed ECM and Community Supports. Studies successful outcome, the service provider will not show that care coordination for people who are be able to offer Lisa a second round of services. homeless is not effective at improving care or Lisa, like many others, may continue to need inter- decreasing costs until they are stably housed.74 mittent tenancy support services for many years The ECM benefit funds outreach and relation- beyond what is currently available. ship-building engagement services. Community Supports fund services that the homeless- Limited eligibility. DHCS guidance on eligibility ness sector provides in tandem, like housing for housing supports is not restrictive. However, in navigation/transition services and tenancy-sus- the first year of implementation, many MCPs have taining services. In practice, providing services prioritized their highest-cost members for housing- like enhanced case management, housing navi- related support services. This approach overlooks gation, and tenancy-sustaining services in a members with high levels of need who do not incur piecemeal way presents barriers to efficient ser- high health care or public costs. Two studies review- vice delivery and adds administrative barriers and ing deaths of people experiencing homelessness in costs for providers. San Francisco found that a subset of them were not accessing care at their time of death:71 In addition, different provider types and organiza- tions may offer the ECM benefit and Community $ Only 32% of those who died were among the Supports. A person's primary care provider is likely top 5% most frequent utilizers of urgent or emer- to offer ECM, whereas community-based homeless gency health services in the city. service providers primarily offer most of the hous- ing-related Community Supports. Behavioral health $ 24% had no health care utilization in the year providers, Federally Qualified Health Centers, before their death (this increased to 36% during vocational or life skills service providers, county the pandemic). agencies, public hospitals, social service agencies, $ 10% had no health care or social services utiliza- and affordable or supportive housing providers tion in the year before their death. may also provide these services.75 Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 20 To add further complexity, an MCP may contract (it convinces people it is safe for them to accept with multiple Community Support service providers, and access services). Providers should receive com- some of which may offer only housing navigation pensation for the time and effort that goes into this and some of which may offer only tenancy-sus- work, as engagement and homeless outreach ser- taining services or housing deposits. In addition, vices are part of an essential package of care.77 members may have other case managers through different programs, exacerbating existing mem- Misaligned funding for supportive housing devel- ber complaints that they need a "case manager to opment and services. A person may be eligible manage their case managers" as they struggle to for services (e.g., ECM or Community Supports) understand the role of each. Though DHCS encour- but not for a housing program, which would be an ages ECM providers to work with Community added barrier. Housing programs providing capital Supports providers, the siloed programs may subsidies to developers to build supportive hous- require a member to work with more than three ing typically require the developer to identify and providers, in addition to their primary care provider, secure long-term funding commitments to cover to receive a full array of services. service costs before the developer can access the capital subsidies. A service provider could not make Members have remarked that they need those long-term funding commitments by rely- ing solely on ECM and Community Supports, so a "case manager to manage their case developers could not count on Medi-Cal services managers" as they struggle to understand to cover service costs for tenants in newly built sup- the role of each. portive housing. Capital subsidy programs also typically require a staff-to-client ratio of at 1:20,78 "Noncompliance" label. Language in DHCS which Community Supports may also be unable to guidance for Community Supports suggests that guarantee. providers or MCPs may terminate or not offer ser- vices to members considered "noncompliant" or Only the ECM benefit can fund outreach, unresponsive.76 However, many people experienc- engagement, and care coordination services, ing homelessness appear to be unresponsive or noncompliant because of their entrenched distrust and only Community Supports can offer of health care systems and providers. Some have housing support services. experienced forced treatment, had health issues long ignored, or been misdiagnosed or mistreated Challenges for Providers in health care settings. Some have been victims DHCS has worked to reduce barriers to community- of crime and other violence while homeless and based organizations (CBOs) interested in providing therefore are distrustful of strangers in general. The homeless services under Community Supports. proven approach to people perceived as "services DHCS has focused many of these efforts on mak- resistant" or "noncompliant" is to use continuous ing contracting with MCPs easier for providers engagement techniques (i.e., reaching out again who have not been Medicaid providers in the past. and again), consistently and reliably asking and pro- For example, DHCS took steps to guide providers viding what people report they need. Over time, through obtaining a National Provider Identifier this active engagement helps providers develop (NPI) that is typically required to receive reimburse- trusting relationships. This longer-term engage- ment under Medi-Cal. DHCS also directed MCPs ment approach may take months to bear results to allow providers who normally do not have a Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 21 state-level pathway to credentialing to nevertheless of MCPs. Although PATH and the HCBS Spending contract with them, even if the provider does not Plan can help providers build capacity, they may have an NPI.79 Also, DHCS received CMS approval be unable to invest time and money in becoming to fund provider capacity building through both Medi-Cal billers without assurance of funding for PATH and in the HCBS Spending Plan. And finally, services enrollees may need on an ongoing basis, DHCS has required MCPs to pay provider claims and without knowing the number of referrals they within 30 days, which is particularly important for may receive from MCPs. smaller providers that operate without substantial reserves.80 Insufficient rates. Many providers report challenges negotiating adequate rates to pay for services pro- Despite these mitigation strategies, CBOs face vided to people with complex needs. In the first significant challenges participating in CalAIM as year of implementation, many plans have asked Community Supports providers. Community-based ECM providers to provide ratios of care manager to homeless service providers may be reluctant to enrollee of 1:25 to 1:50. That ratio is insufficient to engage with MCPs for a number of reasons, includ- provide the type of assertive engagement strategies ing those described below. often required for people experiencing homeless- ness, particularly among people with complex Steep learning curve for contracting with MCPs. health conditions. For people who recently exited Homeless service providers are typically less expe- homelessness, ideal case management ratios are rienced at billing Medi-Cal for services and may typically between 1:10 and 1:20.81 In addition, pro- lack the technical capacity and infrastructure to viders widely regard rates DHCS has suggested transition to a retrospective billing system (see in Community Supports Pricing Guidance82 as too Figure 2). Billing and reporting requirements for low, based on a review of a range of case manager Community Supports may be too daunting and salaries.83 Though DHCS suggested generous rates expensive for many homeless service providers for housing deposits, and rate guidance accom- to meet. While some access Medi-Cal funding modated potential costs of travel time to meet through county behavioral health systems, most enrollees where they are, pricing guidance rates did homeless service providers do not have sufficient not take into consideration the intensity of services reserves to wait to receive reimbursement well after required to achieve the outcomes the state believes service provision and lack cultural understanding it can achieve. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 22 Figure 2. Administrative Differences Between the Nonprofit Grant World and the Health Care Financing World HOW THE NONPROFIT GRANT WORLD WORKS Get the Write the report Write the grant Do the work award/paid to funder HOW THE HEALTH CARE FINANCING WORLD WORKS Provider enrollment/ Do the work, including Get paid agreement with MCPs submitting claims Source: Stuart Butler and Marcella Maguire, "Building Connective Tissue for Effective Housing-Health Initiatives," Brookings Institution, May 3, 2022. Administrative burdens. Each MCP may admin- trust and provider continuity,85 and may dissuade ister and offer ECM and Community Supports additional providers from forming contractual rela- through different contracting requirements, rate tionships with plans. structures, staffing plans, data sharing platforms, and programmatic structures, even across plans DHCS published third-quarter ECM and Community within the same county. Navigating these differ- Supports data that show that about 26,000 ent structures and requirements is a significant Californians at risk of or experiencing homeless- undertaking for a community-based provider. This ness had enrolled in the ECM benefit. The data also burden is particularly true for providers that have showed that 23,000 Californians received at least not previously billed Medi-Cal and already juggle one housing-related Community Support service by programmatic requirements for different sources the end of September 2022.86 of funding. Many providers have never reported encounter data,84 and most receive monthly pay- ment for services through other programs. To offer For more insights into CalAIM people the full range of services they need, provid- implementation so far: ers may have to submit multiple requests (for each $ Diana Crumley, Kelsey Brykman, and Matthew separate Community Support). Also, in the first Ralls, Launching CalAIM: 10 Observations About year of CalAIM implementation, providers report Enhanced Care Management and Community low referral rates from MCPs, frequent denials of Supports So Far, California Health Care Founda- authorization requests, and delays in payment. The tion, May 2022. administrative burden coupled with authorization $ How It's Going: Local Insights into CalAIM (PDF), denials or delayed payments may lead to delays Insure the Uninsured Project, 2022. in the provision of services, interrupting member Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 23 Challenges for Managed Care Plans Even among MCPs that have been working with MCPs and many of their contracted providers Continuums of Care for some time, data matching have long faced challenges identifying and effec- has remained challenging due to lack of interop- tively serving people experiencing homelessness. erability between data systems and differences California's recent experience with the Health in privacy standards.91 Other ways of identifying Homes Program (HHP) demonstrated this chal- people experiencing homelessness - through lenge. DHCS staff and contractors, philanthropies, shelter addresses or ICD-10-CM (International and the Corporation for Supportive Housing spent Classification of Diseases, 10th Revision, Clinical over four years and millions of dollars prepar- Modification) Z codes in the electronic medical ing MCPs for HHP, including providing extensive record - are not always fully reliable.92 MCPs may trainings, and facilitated collaboratives between explore additional direct data collection strategies MCPs and homeless service providers, meetings such as adding housing or homelessness questions, with regional groups of stakeholders, and techni- or both, to member intake surveys. However, add- cal assistance on providing housing navigation and ing such questions alone does not guarantee an tenancy-sustaining services to members experi- accurate or timely reflection of members experienc- encing homelessness. Despite the effort, the final ing homelessness. Who asks these questions, and UCLA evaluation of HHP showed that only 8.2% how the questions are asked matters, since many of the 90,045 participants had experienced home- people often answer "no" when asked if they are lessness at some point during enrollment, even homeless, even though they meet the formal defini- though people who are unhoused were a priority tion of homelessness. population under HHP.87 Researchers noted incon- sistencies in reporting homelessness/at-risk data Calculating return on investment. Almost all due to providers' struggles identifying housing sta- MCPs in California decided to offer one or more tus. The majority of homeless enrollees received housing-related Community Support services. only one type of housing support service, usually Though DHCS does not require MCPs to docu- housing navigation/transition services, and only 6% ment return on investment, MCPs could find these of HHP participants who were unhoused had exited services yield an ROI through a reduction in expen- homelessness by the last reported quarter.88 HHP sive acute care services after members move into participants were among the first group to transi- housing and can achieve health stability. However, tion to the ECM benefit.89 The Whole Person Care achieving a positive ROI through housing sup- (WPC) Pilot, administered by counties, in contrast, ports may take significantly longer than MCPs offered services to over 124,000 consumers experi- expect (see Figure 3 on page 25). For example, encing homelessness.90 people receiving housing navigation often wait well over a year for a housing subsidy. While wait- In the first year of CalAIM implementation, MCPs ing, those suffering from complex, chronic health are experiencing the following challenges: conditions may see their conditions worsen and will continue to need frequent hospitalizations. Member identification. MCPs do not have reliable Although once housed, their health conditions ways to identify members experiencing homeless- may begin to stabilize, reductions in costs may ness. Though MCPs have begun partnering with not be immediate. Often, these members begin some homeless Continuums of Care to identify eligi- long-delayed medications, treatment, and other ble members, creating data use agreements can take high-cost interventions for a year or longer after years, and timely data matching remains difficult. they move into housing.93 Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 24 Figure 3. Possible Scenario Timeline for an MCP's Return on Investment in Housing Supports Based on the Frequent Users of Health Services Initiative Final Evaluation Report End of Year 1: Year 3 or 4: Services and high High services need and health costs lower health costs Months 1–6: Months 13–24: Months 49–72: Meeting the person, Months 7–12: Accessing long- Months 25–48: Service intensity engaging them to Housing navigation, delayed treatment or Person stabilizes; decreases, with only participate in eventual referral to medication; high costs decrease with occasional need for services (assertive a home health costs continue intensive services intensive services engagement) (or increase) End of Year 2: High services need and higher health costs Source: Karen W. Linkins, Jennifer J. Brya, and Daniel W. Chandler, Frequent Users of Health Services Initiative: Final Evaluation Report (PDF), California Health Care Foundation, August 2008. Adverse selection. MCPs operating in counties with enrollment and look back on authorizations and more than one MCP may offer different Community claims from other plans, it becomes difficult to Supports or have limited data documenting eli- ensure continuity of coverage and to make decisions gibility, potentially resulting in confusion around about eligibility for ECM and Community Supports. referrals and adverse selection, as providers will likely help people change MCPs to plans offering A deeper look at challenges can be found in longer-term, more comprehensive, or higher-paid Appendix E. housing-based services. Adverse selection can lead to an atypical distribution of healthy and unhealthy people signing up for one CURRENT REALITY MCP's coverage. Part 4. Recommendations: FUTURE VISION Seven More Burden Steps Toward Greater Person- Member churn. Within and between MCPs, churn Centered Care Enrollees and is well documented among those experiencing Public- and private- their families The following seven policy recommendations sector collaboration for 94 homelessness, as people lose their benefits or DHCS and other California policymakers are based change plans while seeking care from different pro- on data, analysis, expert consultations, and literature viders. Churn causes members to lose Providers and gain Providers cited in this report. They are intended to support Medi-Cal benefits frequently, leading to higher and promote a stronger focus on person-centered administrative costs and less predictable federal Public- and private- care that is operationally and financially Enrolleesviable and , and 95 funding for states. When MCPs lack the collaboration sector partner- their families to support the program improvement work DHCS ships or structures necessary to bridge gaps in already has underway. Less Burden Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 25 1. Seek Federal Approval for a Housing ECM and optional Community Supports. These Support Services Medi-Cal Benefit by the goals include a whole-person approach to services, end of 2024 greater standardization, and high-quality outcomes. To meet the goals articulated in the CalAIM pro- See Appendix F for more information on achieving posal to "provide a whole-person, interdisciplinary CalAIM goals through a housing support services approach to care" and avoid challenges of ineq- benefit. uitable access to services, DHCS could move away from offering housing support services As with other recently approved waivers in through an ECM benefit and separate optional Massachusetts and Arizona, covered services should Community Supports and instead seek federal be needs-based. In creating a benefit, DHCS could approval and funds for a uniform housing sup- promote policies offering certainty that providers port services benefit by the end of 2024. will be able to continue to offer services to people for as long as they need and want them, so long All Medi-Cal members experiencing homelessness as federal financial participation continues and the (or who previously experienced homelessness and state can fund its share of costs. now live in housing), regardless of what county they live in or which MCP provides their coverage, should Because a benefit could achieve a more person- be eligible for a benefit covering a comprehensive centered approach to care for people experiencing range of services (housing navigation/transition, homelessness and addresses several challenges to tenancy-sustaining, and supported employment the ECM and Community Supports structure, the services, all of which are described in Table C1 in following recommendations relate to creation of Appendix C) rather than a siloed services approach this benefit. requiring authorizations for each set of services. A benefit would also reduce the risk of adverse selec- 2. Set Rates That Adequately Support tion as well as the burden of multiple authorizations. Housing-Related Services DHCS could explore with CMS which Medicaid California could offer a comprehensive rate authority will work best to achieve the objectives structure to providers that includes the full of a sustainable benefit, including which author- costs of services. The rate would take into con- ity would allow the state to require services to be sideration staff time to travel community-wide to offered statewide. A well-structured benefit would deliver services and coordinate with housing and allow the state to fund, at scale, needed services other health and social service providers to ensure and to receive substantial federal share of the costs. seamless access to services and should cover And, as DHCS previously set "by 2024" as a target everyone in a team needed to offer a comprehen- for seeking federal approval of a benefit, it seems sive person-centered approach, including licensed that "by the end of 2024" is a reasonable revision.96 supervisory staff and peers with lived experience. Also, plans and providers who know a benefit is Rates would initially reflect a provider-to-member coming will be far more eager to prepare for it. ratio of 1:15.97 Most important, rates would match the costs of services offered in evidence-based ser- Importantly, a comprehensive housing support vices programs, such as programs DHCS reported services benefit would accomplish CalAIM goals as improving health outcomes and decreasing more efficiently than the current pairing of CalAIM Medicaid costs. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 26 A benefit could pay a supplemental per-person homelessness. That pilot evaluation showed that per-month or per diem rate for housing support failure to adequately fund outreach was a barrier services provided to people experiencing home- to finding and engaging Medicaid enrollees who lessness and people formerly homeless living were unhoused.99 In California, the Health Homes in supportive housing. A benefit could also offer Program evaluation indicated that MCPs and pro- providers payment incentives for moving a specific viders similarly struggled to identify, reach, and percentage of people into housing.98 enroll people who were homeless, a barrier to suc- cessful implementation of that program. Providers' capacity to deliver services cannot reach scale without simplifying a billing structure for a ben- To effectively reach and connect with people efit, as several other states have done. Billing based experiencing homelessness, Medi-Cal could fund on encounters requires administrative complexity evidence-based homeless outreach and engage- and creates burdens beyond the capability of many ment strategies through a reliable, sustainable homeless service providers. A per diem or per-mem- source of funding. California should consider ber per-month rate saves providers from spending including homeless outreach and engagement inordinate resources on administrative costs. services as part of a bundled rate, but California may need to pursue a different Medicaid authority In the near term, for more effective CalAIM to fund these services if the state decides to pur- implementation, DHCS could update rate guid- sue a Section 1915(i) State Plan Amendment for ance for housing-based Community Supports to a housing support services benefit. CMS recently take into consideration that members accessing approved Arizona's request for coverage of a range Community Supports often have complex needs of services for people experiencing homelessness, and multiple health conditions, and they require including outreach services, in its Section 1115 intensive team-based services with lower provider- Medicaid demonstration waiver, though the waiv- to-member ratios, such as 1:15. An adequate rate er's Special Terms and Conditions did not define will also help attract more provider interest in outreach in its approval.100 Community Supports. DHCS has relied on studies that acknowledge that housing support services are In the near term, to better support homeless cost-effective and supports an intensive, multidisci- outreach and engagement through the CalAIM plinary structure that requires higher rates. structure, DHCS could consider revising the ECM benefit in the following ways: 3. Fund Homeless Outreach and Engagement Services $ Require MCPs and their contracted providers to Homeless "outreach" is typically far more extensive contract or subcontract with homeless service than outreach as MCPs traditionally understand it. agencies to provide intensive, longer-term out- Rather than a process for enrollment into a single reach and engagement services, even if these program, homeless outreach involves locating, providers are not ECM providers. identifying, and building relationships with people $ Adjust ECM rate guidance to reflect higher experiencing homelessness. It often requires months provider-to-member ratios for members expe- or even years of persistent, assertive engagement. riencing homelessness who receive homeless outreach services (or offer incentives to MCPs New York, through a care management pilot, iden- specifically to contract for the provision of these tified outreach and engagement strategies as a services). critical component to serving people experiencing Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 27 4. Build Capacity of Community-Based $ The California Interagency Council on Organizations for Implementation of CalAIM Homelessness (Cal ICH) could assist DHCS staff A DHCS commitment to seek federal approval for in identifying criteria for providers to receive a housing supports benefit would offer providers seed funding grants under CITED and HHIP to incentives to build their capacity, potentially initially help build a robust network of competent pro- in partnership with MCPs under CalAIM, and then viders. Cal ICH staff could reach out to providers through a benefit. DHCS could continue to help well respected but not well resourced to recruit build a network of providers with experience them in growing a network of providers. using evidence-based models to help people who are unhoused move into permanent hous- 5. Establish a Plan for Integrating Inter- ing and remain stably housed and able to pursue Agency Health and Housing Policies meaningful care. To achieve this objective, state Providers that offer both health and housing ser- departments could do the following: vices find it challenging to braid funding. For example, housing providers/developers interested $ DHCS could target a portion of PATH CITED in building a new supportive housing develop- funds to strengthen implementation of hous- ment must secure capital, operating, and services ing-related Community Supports with the goal funding to get the project off the ground. To of building a sufficient network to implement obtain capital funding through programs like the a benefit. CITED funding for homeless service Multifamily Housing Program and the Low-Income providers can help these providers obtain infor- Housing Tax Credit, developers must first secure mation technology systems, hire staff to take on ongoing and sustainable funding to cover the costs Medicaid billing and reporting, and receive train- of operating the development (i.e., rental subsidies ing and technical assistance to become agencies to cover the costs of operating and maintaining that can sustain themselves through a health care the building) and the costs of providing support- financing model of a benefit. ive services (e.g., tenancy support services). This financing model cannot rely on time-limited fund- $ DHCS, through HHIP or IPP, could offer incen- ing for services. Since MCPs often limit the period tive payments to foster partnerships between of coverage for housing support services under current billing entities - such as community Community Supports, developers and financing health centers, Program of All-Inclusive Care for institutions cannot rely on this source of services the Elderly (PACE) providers, and county agen- funding in creating supportive housing. As housing cies - and homeless service providers who providers try to stitch together resources to offer will likely be unable to bill Medi-Cal but have housing and services for as long as people need expertise in providing housing support ser- to exit homelessness and remain stably housed, vices. Current billing entities could help build a more can be done to align funding models so pro- provider network through subcontracts paying viders can effectively leverage capital, operating, adequate rates for services. and services resources. $ DHCS could reduce administrative barriers to the extent that federal law allows, including removing the once-in-a-lifetime limits on services provision and authorization for each set of services, rather than for individual services. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 28 Figure 4. Coordination of Health and Housing: Lessening the Burden for Enrollees and Their Families CURRENT REALITY FUTURE VISION More Burden Enrollees and Public- and private- their families sector collaboration Providers Providers Public- and private- Enrollees and sector collaboration their families Less Burden Source: Stuart M. Butler and Marcella Maguire, "Building Connective Tissue for Effective Housing-Health Initiatives," Brookings Institution, May 3, 2022. As noted above, members or providers typically Although DHCS, in HHIP, requires MCPs to form bear the burden of accessing housing subsidies, partnerships with homeless Continuums of Care to finding landlords willing to take those subsidies, receive incentive payments, CalAIM materials offer and then enrolling in whatever service program for little guidance on how a member will be able to which the member is eligible. A seamless approach access both housing and services more seamlessly would be challenging under any Medicaid authority. as a result. Materials should offer specific guidance. Still, the state can take steps to align state-funded To clarify the way forward, DHCS could work with housing with services offered under a benefit or Cal ICH, now cochaired by the secretaries of Health CalAIM. and Human Services and Business, Consumer Services, and Housing (BCSH), to do the following: The state could further work with health, housing, and homeless sectors - at the provider, admin- $ Collaborate on a suggested list of MCP uses of istrator, and government levels - to identify a HHIP dollars to pay for services that could poten- shared vision of alignment, with the purpose of tially make more housing units available for MCP using each system's ability to assimilate provider members. For example, incentive dollars could networks and leverage each other's expertise and fund capitalized service reserves that would allow resources to address the challenges of homeless- a housing developer to draw from the reserve for ness. As a federal example, the US departments 15–20 years to support the MCP members who of Housing and Urban Development and Veterans live in the developer's housing project. Affairs partnered to offer veterans permanent hous- $ Partner to offer technical assistance to MCPs and ing vouchers along with VA-funded services. This local homeless response systems on best prac- program has successfully reduced homelessness tices in use of onetime HHIP or PATH dollars to among veterans by 55% since 2010.101 braid services and housing funding. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 29 $ Encourage MCPs to use HHIP payments to $ An ideal delivery system that ensures equitable establish a process (including a dedicated point access to a benefit, ease of access to services, person) for creating a referral pathway through an adequate and supported workforce, and Coordinated Entry Systems that already refer alignment with housing at the systems levels people to housing. $ Services and cost models matched to the $ In establishing a benefit, work with housing needs of people experiencing homelessness agencies to align eligibility for capital fund- $ Eligibility criteria to include people who are ing to build supportive housing units (through formerly homeless and living in supportive California's Homekey, Multifamily Housing, housing National Housing Trust Fund, and other state- administered programs) with eligibility for a $ Services requirements that align effectively housing support services Medi-Cal benefit. with housing If, for example, eligibility for a percentage of $ Referral systems for cross-sector collaboration Homekey units were based on eligibility for a between health and housing sectors housing support services benefit, developers and housing financers could rely on services 6. Develop Benchmarks to Create a More funding (based on need) in Homekey-funded Equitable Program supportive housing. To secure public subsidies DHCS should set service goals toward achiev- to build supportive housing, developers must ing greater health equity and reducing health typically secure funding commitments to pay for disparities. DHCS could include specific equity the "supportive services" that accompany the benchmarks in HHIP benchmarks and should housing unit for 5–20 years. The option to pair guide next steps for reform. housing-related service dollars with supportive housing (and spurring more supportive housing Equity benchmarks might include resetting eligibil- development) is only feasible through a sus- ity for programs based on need rather than cost. tained and reliable services funding source, like Evidence suggests that people experiencing home- a benefit. Without this reliable funding source lessness who have had few or no connections to the for services, housing providers cannot be certain health system often have substantial needs. These their tenants will be able to access the support- Californians may fail to get served under CalAIM. ive services they need and for as long as they need, through Community Supports. Under Community Supports and ECM, MCPs (or $ Create a state-level supportive services work- any alternate future benefit administrators) should group consisting of subject matter experts serving track outcomes and be required to course correct if people experiencing homelessness, people with the racial makeup of members accessing services or lived experience, and staff of DHCS, BCSH, benefits is not consistent with the racial makeup of the Department of Housing and Community people experiencing homelessness in the county in Development, and Cal ICH. The workgroup which they are operating. Importantly, to establish would develop a blueprint for the following: equity benchmarks and outcome measures, and to complete course correction, DHCS and MCPs should include people with lived experience in pol- icy development and benefit design. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 30 7. Create a Process for Referrals That When Coordinated Entry staff begin to assess Begins with the Homeless Response System housing needs, they may also identify eligibility for The Coordinated Entry System (CES) assesses the housing support services (or Community Supports housing and services needs of people experienc- under CalAIM). Identifying eligible members expe- ing homelessness and prioritizes those with the riencing homelessness should include the following highest needs for supportive housing. CES proto- elements: cols are intended to coordinate resources to offer a more seamless experience. Though these protocols $ CES, Continuum of Care, or county outreach are complex, state leadership is needed to sup- staff receive training on eligibility and autho- port information exchange. DHCS could promote rization criteria, so they can identify people identifying and referring people potentially eli- who are potentially eligible, and receive pay- gible for Community Supports, or a new benefit, ment for creating a referral process, including through the Coordinated Entry process. A ben- entering assessed people into their Homeless efit would make referrals through a coordinated Management Information System (HMIS). entry process more feasible, if all experiencing $ CES, Continuum of Care, or county outreach staff homelessness are eligible for the covered benefit. obtain consent from people to share data with an MCP. If the person consents, designated CES In drafting HHIP benchmarks, DHCS included staff receive data from the person's MCP. a benchmark of partnership with the homeless response system. DHCS should offer MCPs fur- $ Within 24–48 hours, designated MCP staff ther guidance on using HHIP incentive payments could confirm eligibility, authorize for services, to fund homeless Continuum of Care staff to help and assign a homeless service provider or establish this referral process. Pilots for CES referral work with Coordinated Entry staff to identify to Community Supports could work toward achiev- potential providers. Alternatively, MCPs can ing the following design: offer presumptive eligibility for Community Supports to people CES staff identify as eli- $ MCPs within a single jurisdiction all align gible and high priority for supportive housing. Community Supports referral and authoriza- tion procedures through work to achieve HHIP Further, Cal ICH can play a leading role in encour- benchmarks aging local data matching between HMIS and MCP data to identify MCP members experiencing $ MCPs support staff at homeless Continuums of homelessness. Cal ICH and DHCS can also accel- Care to work with MCPs countywide to establish erate efforts to use the Homeless Data Integration the following: System to match identified records with the $ Systems for entering data and completing state's Medi-Cal data, to identify Medicaid mem- assessments, which would allow for hospital bers who are unhoused. staff or other health providers to complete a Coordinated Entry assessment and enter information into a Coordinated Entry data- base after obtaining Homeless Management Information System (HMIS) licenses $ Continuums of Care and MCPs communicate regularly through designated staff at each entity Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 31 Conclusion Organizations and communities across the state on return on investment to reach scale, especially engage in countless efforts to help Californians considering the health risks people experiencing experiencing homelessness every day, but behind homelessness face. Continuing a systems-centered each success is often a long slog through layers of approach, in fact, continues to allow people to die administrative barriers and complex, siloed pro- from homelessness. grams. The process is unnecessarily complicated for those who are unhoused as well as for the pro- "Once I got into housing and got the right viders working hard to help them. It is also far too expensive. services, I was able to stabilize, get regular appointments with doctors, and take care of In recent years, California has made progress in my teeth. Now I seek care as soon as I start acknowledging the need for housing support ser- vices through CalAIM, the HCBS Spending Plan, to feel sick." and PATH, as well as the need for specific, special- - A person with lived experience of homelessness ized processes for reducing barriers to care. These efforts represent significant state investment and At this moment, California policymakers and officials commitment toward Medi-Cal redesign. have an opportunity to redesign Medi-Cal housing supports toward approaches effective in helping However, in the face of severe and growing need people find and access housing, stabilize their health statewide, California must do more. Though the conditions, and thrive. Designing a housing sup- homeless population represents a relatively small port services benefit to fund what works - one percentage of Medi-Cal members, a program that places people at the center of their health care must be designed around the unique needs of and removes barriers to needed services - should Californians experiencing homelessness to achieve be California's immediate next step. These policy the results the state is seeking. California cannot advances would provide a foundation for success accomplish equitable outcomes when erecting a stories at scale. People like Bob (see foreword), system too complex for providers and people expe- along with the many thousands of Californians with- riencing homelessness to navigate, and too focused out high-cost needs, are waiting for bolder reforms. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 32 Appendix A. Acknowledgments The author wishes to acknowledge and thank the following people for assistance in drafting this report: Lisa Bethel, Gloria Johnson, Sage Johnson, Emily Martinuik, and Vikki Vickers, the Corporation for Supportive Housing (CSH) Speak Up! Advocates who informed this report through their lived experience with accessing health care while homeless. The author also wishes to thank the following people for additional technical expertise:* Marcella Maguire, PhD; Debbie Thiele; and Cheryl Winter, MPH, MSW; all with CSH Jamie Almanza, MBA, Bay Area Community Services Celina Alvarez, Housing Works Allie Budenz, MPA, and Laura Sheckler, MS-HAIL, California Primary Care Association Cynthia Carmona, MPA, and Alison Klurfeld, MPH, MPP, L.A. Care Health Plan Tramecia Garner, LPCC, Swords to Plowshares Brenda Goldstein, MPH, LifeLong Medical Care Lauren Hall, Delivering Innovation in Supportive Housing Kris Kuntz and Beau Hennemann, Anthem Health Plan Julie Lo, California Interagency Council on Homelessness Sarah Mahin, MPA, Housing for Health, Los Angeles County Linda Nguy, MPP/MBA, Western Center on Law & Poverty Elise Pomerance, MD, MPH, Inland Empire Health Plan Jonathan Porteus, PhD, and Ben Avey, WellSpace Health Ned Resnikoff, MPP, UCSF Benioff Homelessness and Housing Initiative Erika Rogers, Community Clinic Association of Los Angeles County Martha Santana-Chin, MBA, Health Net Cheri Todoroff, MPH, Los Angeles County Homeless Initiative Carol Wilkins, MPP, consultant *Affiliation indicated was at time of expertise provided. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 33 Appendix B. Housing for People Experiencing Homelessness "Housing" under a Housing First approach is perma- of a larger category called "interim interventions" nent, meaning that tenants can remain without time or "interim housing"; these include tiny homes, limits so long as they follow the terms of the lease. navigation centers, and bridge housing. All are Tenants are subject to the rights and responsibilities temporary places to stay, ideally where people of California's landlord-tenant law under that lease.102 can receive services to help them access the Coordinated Entry System, complete housing and People experiencing homelessness need a housing benefits applications, connect to health care and subsidy to fund the difference between what the service providers, and receive referrals to permanent tenant can afford to pay, considered 30% of the ten- housing. Congregate settings referred to as shel- ant's income, and what the apartment costs. When ters are rarely funded in California post-COVID-19. accessing housing that is affordable because a sub- But the state funds non-congregate interim inter- sidy allows the tenant to afford the rent, the housing ventions. In fact, since 2018, the state has trended is "affordable housing." If the tenant is also receiv- toward more and more funding for these temporary ing intensive services integrated in the housing to interventions in response to the alarming number help them remain stably housed, the tenant is living of unsheltered Californians. People living in interim in "supportive housing." The federal government, interventions are still considered homeless.103 the state of California, and local governments offer subsidies for the following: Licensed settings, like some "board and care" - Adult Residential Care Facilities (ARFs) and $ "Capital" to build affordable apartments. Residential Care Facilities for the Elderly (RCFEs)104 - are residential facilities providing care and super- $ "Operating costs" to operate buildings created vision. They are not subject to landlord-tenant law through capital funds. and therefore are also not "housing."105 As with $ "Rental assistance" or "rental housing subsidies" other licensed residential settings, people stay in for tenants who rent apartments from individual ARFs and RCFEs so long as they require some form private-market landlords or from a nonprofit that of care and supervision, but then ideally move on to "master leases" multiple apartments from a pri- independent permanent housing. Other licensed vate-market landlord. residential settings provide treatment or personal care services with skilled medical care. They are not $ "Public housing" the federal government owns meant to provide a place to live, but instead to offer and operates. A new movement to reinvigorate treatment to people who cannot live independently. publicly owned housing calls it "social housing." Federal and state laws require people to live in the Public funding exists for each type of subsidy, but most integrated setting possible, where people with not at anywhere near sufficient scale. disabilities are living with people without disabilities, and in the most independent setting possible.106 Creating supportive housing requires services to be As a result, any homeless response from a public available to residents who want and need them, in entity receiving federal or state funding must do addition to housing subsidies. everything possible to refer people to independent housing of their choice, rather than referring people Not all publicly funded places to stay are consid- to licensed settings, so long as the individual can ered housing. Temporary places - often referred live independently with the right services. to as "emergency shelters" in the past - are part Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 34 Figure B1. Types of Interventions People Who Are Unhoused Need to Exit Homelessness Fewer People Need LICENSED RESIDENTIAL SETTINGS (NOT HOUSING) About 3–5% of Californians INTERIM HOUSING experiencing homelessness may require care in a licensed facility Californians experiencing until they can live independently. homelessness may want interim housing as a temporary place to stay and receive services SUPPORTIVE HOUSING (like housing navigation) while About 30%–35% of Californians awaiting permanent housing. experiencing homelessness need People staying in interim housing affordable housing and intensive tenancy ideally exit into either affordable support services (and potentially, help with or supportive housing. activities of daily living). AFFORDABLE HOUSING Most Californians experiencing homelessness need an affordable place to live, made affordable through capital More investment and operating funding or rental housing subsidies. People Need Sources: "Solutions," National Alliance to End Homelessness; and All In: The Federal Strategic Plan to Prevent and End Homelessness, US Interagency Council on Homelessness, December 2022. The amount of a housing subsidy depends on the housing subsidy to cover a portion of the tenant's income of the tenant. Many affordable apartments rent. People with extremely low incomes and below, built with state dollars in California do not house however, have incomes too low for the tenant to pay people experiencing homelessness. Our state dol- sufficient rent for a manager to operate an affordable lars pay for housing for households with moderate, or supportive housing project. To provide this level of low, very low, and extremely low incomes, measures affordability, the housing developer must also secure based on the tenant's income as a percentage of funding to operate the building, often through fed- an area's median income (Table B1).107 People with eral vouchers aligned with the project and sometimes extremely low incomes, for example, have incomes through a onetime disbursement meant to last 15–20 up to 30% of an area's median income, and are years, paid for by California's state housing agency typically working part-time or full-time but making ("capitalized operating subsidy reserves"). Table B2 minimum wage. People with Supportive low incomes are earn- Housing provides an overview of funding programs for people ing up to 60% of an area's median income. experiencing homelessness in California. Under California's programs funding capital to People experiencing homelessness typically have build housing, tenants typically pay 30% of their incomes well below the extremely low-income cat- incomes on rent. People with low incomes or very egory, with the average income at about 14% of low incomes cannot afford market rent in California an area's median income. California's legislature on their incomes, but can rent in an affordable hous- recently created a new category of income, called ing project and pay rent sufficient for the manager to "acutely low income," defined as 15% or less of an CAPITAL OPERATING operate and maintain the affordable FUNDS housing prop- FUNDS area's median income.108 Most people experiencing erty without an "operating subsidy," an additional homelessness fall into this category. SERVICES FUNDS Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 35 Table B1. Housing Affordability Under California's Capital Programs HOUSEHOLD PERCENTAGE IN INCOME INCOME CATEGORY SPENDING OVER CATEGORY THRESHOLD DESCRIPTION HALF THEIR INCOME ON RENT Moderate 80%–120% of the area's Households making incomes consistent 6% median income (AMI) with what others are making in that area Low 60% of AMI Households with more than one income or 24% making low wages but not minimum wage Very Low 50% of AMI Households with more than one income 53% or making low wages but above minimum wage Extremely Low 30% of AMI Households making minimum wage, 78% working part-time or full-time Acutely Low 15% of AMI Households making minimum wage, working part-time, or living on fixed incomes, like Supplemental Security Income, or no incomes Source: Danielle M. Mazzella and Lindsay Rosenfeld, California Affordable Housing Needs Report 2021, California Housing Partnership, March 2021. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 36 Table B2. Funding Programs for People Experiencing Homelessness in California FUNDING SOURCE ADMINISTERING AGENCY HOUSING FUNDED Federal and State Homeless Continuums of Care CoCs contract with agencies to fund housing subsidies, interim Homeless Assistance (CoCs) interventions, onetime prevention assistance, and funding for people to move back in with family ("diversion"); this may include funding for capital to build supportive housing. Mental Health County health agencies Housing subsidies for people with serious mental illness who Services Act / would benefit from intensive services (e.g., people eligible for Proposition 63 "full-service partnerships"). Federal Housing Local public housing agencies Subsidies to private-market landlords and affordable housing Choice Vouchers developers, often through "preferences" for people experienc- ("Section 8") ing homelessness, allowing vouchers that turn over (when a current household no longer needs a voucher, it "turns over") to go to someone experiencing homelessness. Housing authori- ties may also set aside 20%–30% of their allocation of Housing Choice Vouchers to pay for project-based vouchers that attach to capital funds to create housing available to people with extremely low incomes or below (otherwise, Housing Choice Vouchers are tenant-based). "Flexible Housing Usually a county health or Housing subsidies and services, or services combined with Subsidies" Through housing agency Housing Choice Vouchers that local housing authorities priori- Mainstream Health or tize for eligible populations. Justice Resources California's Capital State agency, usually the Loans to developers (e.g., Multifamily Housing Program, Programs California Department of Homekey) or funding through tax credits that developers sell to Housing and Community investors to create affordable and supportive housing (state and Development or the State federal Low-Income Housing Tax Credits). Treasurer's Office State or Local Funds Cities or counties Capital to build housing and sometimes fund operating reserves (i.e., a onetime payment to operate the building for 15–20 years). Source: California State Homelessness Funding Programs (PDF), California Homeless Coordinating and Financing Council, September 2018. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 37 Appendix C. Trauma-Informed Housing Support Services for People Experiencing Homelessness Homelessness is traumatic for all who experience $ Provider-to-client ratios beginning at 1:10 to it. And many people experiencing homelessness 1:15.111 have past histories of additional trauma. Trauma $ Access to service providers 24 hours a day, can change a person's view of the world, impact- seven days a week through a "warm line" for ing one's ability to trust others and to feel hope. nonemergency support.112 On top of trauma, and often because of it, people experiencing homelessness have higher incidences However, due to the traditionally low rates paid for of mental health and substance use disorders.109 service providers in California, provider-to-client ratios are typically 1:20 or 1:25, and no 24/7 line is Trauma-informed care (TIC) is an evidence-based offered. approach to homelessness that requires service providers to have a deep, organization-wide under- 2. Trustworthiness and transparency. Unlike tel- standing of trauma and awareness of impacts ephonic case management, homeless service leading up to and resulting from homelessness. providers offer frequent in-person contact when Staff providing TIC build a sense of trust and safety getting to know clients. A Housing First service and are knowledgeable about potential triggers approach promotes trust when the following that could retraumatize people. Moreover, TIC conditions are met: providers are culturally aware of the marginaliza- tion people may have experienced. When offered $ Throughout their relationship, a provider's through a trauma-informed approach, housing sup- level of contact is frequent enough that the cli- port services are transformational, allowing people ent can identify their primary service provider. with complex, often comorbid or trimorbid condi- The first six months includes very frequent tions, to recover and thrive.110 contact with the client and eventually tapers to two to three contacts per month.113 Housing First service approaches incorporate the $ Case managers work closely with clients to following six TIC principles: ensure they can retain housing and avoid evic- tion once housed. Case managers also offer 1. Safety. After initial interactions over a period clients help orienting to their neighborhood, of months, service providers promote a sense understanding how to build relationships of safety by forming trusting, long-term rela- with their landlords, creating a budget, going tionships with people who likely have had past shopping, accessing mainstream services, and negative, sometimes traumatic, experiences with developing social roles and networks.114 health care or social service providers, who may have turned over frequently. When providers pay $ Service teams provide the full range of ser- attention to safety, people report feeling safe vices to maintain client trust and continuity, and satisfied with their housing location. Housing from initial outreach and relationship-building First service models promote safety when the engagement, to housing navigation, to ten- provider offers all the following: ancy supports in housing, to rehousing those Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 38 who face eviction or want to relocate. When a service team cannot stay with the client to Role of Peer Providers offer this full range of services, service provid- Peers with lived experience of homelessness ers can offer critical-time intervention, which play critical roles in providing outreach to people experiencing homelessness, helping people in offers intensive services for nine months after adjusting to living in housing, and connecting the client moves into housing, and then con- them to resources in the community. People often ducts a "warm handoff" to services the client trust peers more or feel a connection to peers can access from mainstream resources in the more quickly. However, low rates for services have community. A warm handoff means service resulted in frequently underpaying peers as front- providers have relationships/linkages with line staff.* multiple community service providers, match * Manuela Tobias, "Will Worker Shortage Disrupt California needs of clients with providers, directly intro- Homeless Strategy?," CalMatters, January 27, 2022. duce clients to new providers, and conduct ongoing follow-up with new providers and cli- ents afterward.115 3. Multidisciplinary teams that include peer support. Housing First services promote mul- $ Service providers also work to connect clients tidisciplinary services when they adopt these to permanent housing - housing without practices: actual or expected time limits - ideally within one week to four months after program $ Because people experiencing homelessness intake.116 Services are far more effective when may have multiple service needs, multidis- offered in housing than when offered while ciplinary teams offer partnerships through the person is still homeless,117 and people are memoranda of understanding that connect more likely to seek and receive services when clients to resources and other services in the housed.118 community, like primary care and specialty care, and include clinical staffing (such as $ Service providers and leaders at the organiza- a psychiatrist, nurse, and/or mental health tion reflect the life experiences and identities professional),120 other health care providers, of populations served. Having service provid- benefits advocates, and workforce develop- ers who have lived in the same communities ment / employment services providers.121 where their clients are living can make a sig- nificant difference in empathy, trust building, $ Multidisciplinary teams have daily case con- and client satisfaction.119 ferences about all clients on their shared caseload.122 $ Service providers work to relocate clients to other housing when they are evicted or the $ Peers with lived experience of homelessness housing is not the right fit. Connecting clients are effective members of a multidisciplinary to housing takes longer than ideal in California team in building trust with clients and helping due to limited affordable and available hous- them adjust to living in housing.123 ing - often 9 to 12 months. Relocation of a $ Tenants in an affordable or supportive hous- client does not mean that the services pro- ing project also have meaningful leadership vided or the client was "unsuccessful." opportunities, such as tenant associations or positions on boards.124 Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 39 4. Collaboration and mutuality.125 Housing First ser- vices promote collaboration when providers tailor People are far more likely to remain stably services based on tenant-stated wants and needs: housed and report feelings of satisfaction $ Services are voluntary for tenants but not for when they have choices. staff. Housing is functionally separate from ser- vices, meaning a tenant should still be able to access and maintain housing even if the ten- ant does not want to participate in services.126 5. Empowerment, voice, and choice. Housing $ Service providers meet clients where they First services empower people when providers are or in a location most convenient to the emphasize choice: client - the streets, a shelter, a hotel, a car, $ When moving into housing, people choose an institutional setting, or a supportive hous- between multiple apartments and view the ing project - rather than require the client to apartment and building before moving in. come to a clinic.127 Likewise, a provider does not force people to $ Importantly, providers assertively engage live with others, particularly others they don't clients to want to participate in services the choose to live with, and does not require client chooses. Providers regularly attempt to people to share a bathroom with strangers.134 connect in meaningful ways with tenants, and People prefer living alone or with roommates then document those attempts. Services staff or housemates of their choice. In fact, people use a variety of proven interventions, like moti- are far more likely to remain stably housed and vational interviewing and stages of change, to report feelings of satisfaction when they have engage and support people.128,129 choices.135 Due to low availability of housing and the pressure to move as many people into $ Service teams have regular team meetings to housing as quickly as possible, people often discuss emerging issues and strategies, and do not receive these choices in our current to identify resources to further assist clients.130 homeless response systems. Clients receiving voluntary services paired with assertive engagement are more likely to $ Providers also work with clients to direct their participate in services than clients with pro- own care. Services staff actively involve cli- viders who expect them to seek services.131 ents in the design and implementation of a Program outcomes show that tenants in a services plan, and work with them to set real- voluntary-services model stay stably housed istic, measurable goals the client wants to for longer periods, are more likely to receive meet, then update plans regularly with the cli- mental health, substance use, and primary ent to meet their changing needs.136 Clients care treatment,132 and are more satisfied with participate in regularly scheduled treatment- their services than people accessing programs planning meetings.137 that require services participation or evidence of compliance with a program.133 Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 40 $ Providers do not terminate services unless the $ Providers have formal and informal processes client demonstrates violence or threats of vio- for receiving input from clients on both hous- lence. Instead, providers work with clients to ing and services they are receiving, including address behaviors related to their conditions, evaluations that seek their input.142 have formal policies and protocols to prevent $ Housing providers offer housing options in eviction, and may have staff dedicated to "scattered-site" housing in the private market eviction prevention. or in projects where apartments for people $ Providers use harm reduction, an evidence- with disabilities are integrated with apartments based approach to working with a client to not designated for people with disabilities, avoid risky behaviors, including behaviors that and offer housing in the least restrictive set- could lead to eviction, and can involve counsel- ting possible.143 ing clients on safer substance use.138 Programs offer ongoing staff training in harm reduction People experiencing homelessness with multiple and crisis intervention, and regularly educate health conditions or disabilities may need and clients on harm reduction principles.139 want all of the services or a variety of the services listed in Table C1 on page 43. Housing support 6. Understanding of cultural, historical, and gen- services are related to each other: Housing navi- der issues. People experiencing homelessness gation correlates to move-in assistance / housing have been persistently underserved by main- deposits, which, for people with barriers to hous- stream service systems. Housing First services ing stability, leads to the need for tenancy support promote cultural awareness when the following services. Offering one service without the others conditions are met: hampers a person's ability to access housing or remain stably housed. An important feature of $ Providers ensure low caseloads and diverse all services is a single point of contact, often a staff - staff who reflect the identities and case manager, whom the person experiencing experiences of people served. Both factors homelessness knows and trusts in receiving a are critical for responding to clients' changing comprehensive range of services. needs in flexible, trauma-informed, culturally appropriate ways.140 $ Staff work to support clients in developing and strengthening connections to their commu- nity, a community the client ideally chooses, to overcome the stigma and social isolation of homelessness.141 Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 41 Table C1. Types of Services People Experiencing Homelessness May Need METHOD OF PROVISION (HOW / OTHER SOURCES TYPE OF SERVICE DESCRIPTION BY WHOM) DURATION MEDI-CAL COVERAGE OF FUNDING Homeless $ Finding people (on the streets, in shelters or In person: parapro- Depends on client Potentially funded Local, federal grant, Outreach interim housing, in cars, etc.) and beginning to fessionals who are needs, potentially under Enhanced Care and state Homeless form a relationship outreach workers, months Management (ECM) Housing, Assistance, often peers with benefit. Community and Prevention lived experience of Health Worker benefit (HHAP) grant homelessness could help support program staffing Engagement $ Repeated visits over time - often months - to In person, wherever Potentially months or Could be provided Local, federal grant, engage the person and form a trusting relation- the person lives or in years, ideally within under ECM with and HHAP ship a location convenient four months while the experienced to the person person is homeless, homeless service ongoing after housed provider Housing $ Help navigating the homeless response system Primarily in person, Month 1 to poten- Under Community Local and HHAP Navigation* and applying for housing subsidies/vouchers some telephonically: tially month 12 or Supports (CS) of $ Assessment of housing preferences/barriers paraprofessionals beyond housing navigation related to tenancy skilled in navigat- and tenancy transition ing the homeless services $ Development of an individualized housing response system support plan with the client, including a crisis plan $ Landlord recruitment $ Help with collecting documentation $ Help with a housing search and completing housing applications $ Ensuring housing unit is safe and ready for move-in $ Help with move-in $ Orientation to the neighborhood * Other states fund through a Medicaid benefit. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 42 Table C1. Types of Services People Experiencing Homelessness May Need (continued) METHOD OF PROVISION (HOW / OTHER SOURCES TYPE OF SERVICE DESCRIPTION BY WHOM) DURATION MEDI-CAL COVERAGE OF FUNDING Housing $ Establishing a services plan with tenant Primarily in person, Upon move-in, Under CS of tenancy- Mental Health Stabilization or $ Early identification and intervention in behaviors occasionally ideally with the same sustaining services Services Act (MHSA) Tenancy Support that may jeopardize housing telephonically after person who engaged and Short-Doyle/ Services* a relationship has with the tenant to Medi-Cal (SDMC) $ Education on tenant and landlord rights and been established: ensure continuous funding for people responsibilities case managers engagement with serious mental $ Harm reduction with a range of illness experiences (often $ Eviction prevention planning and coordination under supervision of $ Connecting the tenant with community resources licensed clinicians) $ Coaching on developing and maintaining relationships with landlords $ Assistance with credit repair activities and skill building $ Assistance with housing recertification process $ Continued training on tenancy and household management $ Benefits advocacy Employment $ Help with finding employment that meets In person: employ- When tenant No Some workforce Services* tenant's preferences and strengths ment specialists expresses desire to development grants $ Support during challenging periods of employ- work and some federal ment grants $ Liaison between employer and tenant to address challenges and help align the tenant with employment opportunities Tenant $ Identifying whether tenants are thriving, through In person or Upon move-in and Under CS of tenancy- MHSA and SDMC Satisfaction surveys or assessments on health status telephonically periodically thereafter sustaining services funding for people Surveys with serious mental illness Health Advocacy* $ Health and wellness education In person or Before move-in and Potentially under CS MHSA and SDMC $ Peer support telephonically afterward of tenancy-sustaining funding for people services. Community with serious mental $ Nonemergency transportation Health Worker benefit illness $ Case conferencing to support staffing $ Advocacy with health professionals Housing $ Same services as housing navigation (see above) In person and If tenant needs to No, if used already in Some local, state, and Navigation (for should tenant need rehousing telephonically relocate tenant's lifetime federal funding Rehousing) * Other states fund through a Medicaid benefit. Sources: Housing First Model Fidelity Index for Providers, Midwest Harm Reduction Institute; and Community Supports Policy Guidance, Dept. of Health Care Services. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 43 Appendix D. What the Federal Government and Other States Are Doing to Fund Housing-Based Services Other states are increasingly looking to Medicaid States have a variety of policy levers to fund to fund housing support services for people housing support services. Similar to California's experiencing homelessness.144 Since a 2015 Whole Person Care Pilot, other states, like Hawaii Information Bulletin on Housing-Related Activities (Community Integration Services), Massachusetts and Services, the federal Centers for Medicare & (Flexible Services), and Washington (Foundational Medicaid Services (CMS) has made clear, in both Community Supports), have used Medicaid's Republican and Democratic administrations, that Section 1115 research and demonstration waiver Home and Community-Based Services (HCBS) and to implement housing support services demonstra- other Medicaid authorities can be used to support tions. Some states have submitted Section 1115 Medicaid recipients to obtain and maintain hous- waiver requests to CMS to fund specific services ing stability.145 A more recent CMS state health for people experiencing homelessness, such as official letter, in fact, encourages states to use Arizona's request to fund outreach and engagement existing Medicaid authorities to fund high-quality services, which CMS approved,149 and Vermont's services sufficient in amount, duration, and scope request for a permanent supportive housing pilot to achieve goals of greater integration of social to fund tenancy support services for tenants in sup- services into the health care system. The letter portive housing.150 Vermont remains in discussion describes ways in which states can fund services to with CMS around these requests. These Section help enrollees secure housing, tenancy supports, 1115 Medicaid waivers, however, are commonly in nonmedical transportation, and individualized sup- place for only five years, making ongoing services ported employment services. The letter identifies commitments challenging. potential Medicaid authorities to fund these ser- vices, including Medicaid demonstration waivers Other states embraced a comprehensive strategy under Sections 1905(a)(13) or 1915(b)(3), or State to add a long-term benefit to a state's Medicaid Plan Amendments under Sections 1915(c) or 1915(i) plan, most commonly via a Section 1915(i) State of the Social Security Act.146 Plan Amendment (SPA). Using this Medicaid author- ity signals the state's long-term commitment to The earliest state using Medicaid to fund housing fund housing support services, as a Section 1915(i) support services was Massachusetts, which cre- SPA does not require renewal. It also does not ated its Community Support Program for People require the state to prove federal budget neutral- Experiencing Chronic Homelessness (CSPECH).147 ity. The Section 1915(i) SPA allows states significant CSPECH expanded from a pilot serving 50 people flexibility to design the benefit's "needs-based cri- to serving over 800. Louisiana similarly created teria" to ensure that the population eligible for the a statewide permanent supportive housing pro- benefit aligns with populations who need housing gram for people with serious mental illness, using assistance. Minnesota used this authority to create the state's "Rehab Option."148 Since the 2015 CMS its Housing Stabilization Services benefit,151 and Information Bulletin, more and more states have North Dakota used it to create its Housing Support either implemented programs designed to scale up Services benefit.152 supportive housing services or are in the process of developing programs to fund housing support services at scale. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 44 A third strategy is a value-based payment (VBP). VBPs are challenging to implement because provid- VBPs allow states and managed care plans to con- ers must be sophisticated in their cost and revenue tract directly with providers, as North Carolina has models, and one provider may pay for housing done in designing a program intended to pay for support services while another does not. Further, specific health outcomes, rather than the volume or providers must accurately predict the total cost of type of health care.153 In this payment model, provid- care, which most providers find difficult to do. ers receive a per-member per-month rate to assist a person in maintaining health. This rate may cover Table D1 on page 46 shows a sampling of state inpatient care, outpatient visits, and pharmacy costs, approaches to fund housing support services. as well as any Home and Community-Based Services. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 45 Table D1. Different State Approaches to Funding Housing Support Services MEDICAID STATE AUTHORITY FUNDED SERVICES ADMINISTRATION/PAYMENT METHOD SOURCE Arizona Section 1115 Housing and health opportunities Recently approved, still in planning Centers for Medicare & Medicaid Medicaid waiver coverage, to include rent / temporary process. Administered by managed Services Waiver List (PDF), housing for up to six months for people care plans. 11-W-00275/9, Arizona Medicaid Section transitioning out of institutional or 1115 Demonstration, Arizona Health congregate settings, homelessness or Care Cost Containment System (pages risk of homelessness, or foster care. 10, 26–27) (approved October 14, 2022). Pre-tenancy and tenancy supports, move-in costs, housing deposits, case management, and education for people experiencing homelessness. California Section 1115 Whole Person Care Pilot (ended Dec. Twenty-five (out of 58) California "Whole Person Care Pilots," California Medicaid waiver 31, 2021). counties administered and provided Department of Health Care Services local funding to match federal funds of (DHCS), last modified May 23, 2022. $1.5 billion. Each county established eligibility criteria for "high-need, high- cost populations." Counties established their own rates. California Health Homes State Health Homes Program (funding ended MCPs in 14 counties administered "Health Homes Program," DHCS, last Plan Amendment for program on Dec. 31, 2021, in some Health Homes Program services, includ- modified March 29, 2022. counties as CalAIM began rolling out). ing housing navigation and tenancy support services. Plans set their own rates to providers and negotiated different rates with DHCS. Hawaii Section 1115 Community Integration and Transition MCPs administer a per-person Danielle Daly (director, Div. of Medicaid waiver Services, funding pre-tenancy and per-month supplemental rate. Demonstration Monitoring and tenancy support services. Evaluation) and Angela D. Garner (director, Div. of System Reform Demonstrations) to Judy Mohr Peterson (administrator, Med-QUEST Division, Hawaii Dept. of Human Services), QUEST Integration Medicaid Section 1115 Demonstration (PDF), October 14, 2020. Maryland Section 1115 Assistance in Community Integration, Counties administer based on a cost- "Maryland Waiver Factsheet," Medicaid. Medicaid waiver funding tenancy support services and based payment rate. gov, accessed January 3, 2023. housing-based case management. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 46 Table D1. Different State Approaches to Funding Housing Support Services (continued) MEDICAID STATE AUTHORITY FUNDED SERVICES ADMINISTRATION/PAYMENT METHOD SOURCE Massachusetts Section 1115 Community supports program for Recently approved, still in planning Massachusetts State Profile (PDF), US Medicaid waiver people experiencing chronic homeless- process. Previous program funded Dept. of Health and Human Services. ness previously approved. In September services at $17 per person per day for 2022, the Centers for Medicare & housing-focused case management for Medicaid Services (CMS) approved up to 60 days. an extension to provide housing supports - including outreach, educa- tion, and transportation to access housing supports - for people experi- encing homelessness or involved with the judicial system. Minnesota Section 1915(i) Housing Stabilization Services to fund MCPs administer, based on payment "Housing Stabilization Services," State Plan tenancy-sustaining services. rate in 15-minute increments of $17.17. Minnesota Dept. of Human Services, Amendment updated January 5, 2023. Oregon Section 1115 Requires MCPs to fund housing-related Recently approved, still in planning Chiquita Brooks-LaSure (administrator, Medicaid waiver services for people experiencing process. CMS) to Dana Hittle (interim Medicaid homelessness or at risk, and for people director, Oregon Health Authority), leaving institutional or congregate care Oregon Health Plan (OHP) (PDF), settings, including short-term housing September 28, 2022. for up to six months. Rhode Island Section 1115 Home Stabilization Services benefit, MCPs administer with a per-member "Rhode Island Comprehensive Medicaid waiver funding tenancy-sustaining services. per-month payment rate. Demonstration," Medicaid.gov, accessed January 3, 2023. Washington Section 1115 Foundational Community Supports to Third-party administrator pays per diem Angela D. Garner (director, Div. of Medicaid waiver pay for supportive housing and employ- rate of $112 (limited to 30 days every six System Reform Demonstrations) to ment services. months), amounting to $560 per person MaryAnne Lindeblad (Medicaid direc- per month. tor, Washington State Health Care Authority), Foundational Community Supports Program (PDF), November 21, 2017. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 47 Appendix E. Additional Challenges with CalAIM Implementation MCP Member Identification MCP Outreach To address the challenges managed care plans Even if MCPs know which members are experiencing (MCPs) have in identifying members experiencing homelessness, their customary method of communi- homelessness, CalAIM proposes that MCPs receive cating with members, a mailed letter, will by and large Whole Person Care enrollee data to help them iden- not reach members experiencing homelessness. For tify some people experiencing homelessness. Also, example, if an MCP identifies someone experienc- some plans have secured (or are securing) licenses ing homelessness via a last-known address, a letter to Homeless Management Information Systems sent to that address is unlikely to reach them. Many (HMIS), the data system Continuums of Care (CoCs) who use a DPSS office address rarely pick up their use to track services provided to people experi- mail, as wait times are exceedingly long. encing homelessness in the region. The California Department of Health Care Services is encouraging Other common types of MCP outreach to members MCP partnerships that would allow CoCs to share experiencing homelessness are likely to fare just as identified HMIS data with MCPs.154 Yet several fac- poorly. Robocall reminders for screening tests may tors hamper these efforts: not be heeded when people are focused on day- to-day survival. Even in-person outreach may be $ Not every county implemented Whole Person challenging for contracted providers when they do Care. not know how to find people. $ Mismatches in data platforms between MCP Provider Assignments data and HMIS data can complicate attempts to MCPS are likely to assign a treatment provider as the use HMIS data effectively. member's Enhanced Care Management (ECM) pro- $ HMIS tracks data only on people seeking ser- vider, and are often unaware that the member has a vices, rather than on every person experiencing trusting relationship with a homeless service provider homelessness. that is not a provider under ECM.155 Many ECM pro- viders, more likely to be traditional MCP providers, $ Most plans do not have licenses or partnerships have not had training or experience in engaging peo- with CoCs to begin the process of attempting a ple experiencing homelessness. The UCLA interim data match. evaluations of the Health Homes Program (HHP) showed that over 84% of Community-Based Care Some plans try to identify members experienc- Management Entities (CB-CMEs) - HHP providers ing homelessness by tracking those (1) without who were primarily health centers, specialty provid- addresses, (2) with addresses of Department of ers, and primary care providers - used medically Public Social Services (DPSS) offices, or (3) with oriented in-house staff to provide housing support ser- addresses of homeless service providers. Yet the vices. Among MCPs offering HHP, only two partnered number of people experiencing homelessness at with Whole Person Care providers to offer housing any one time is fluid, creating complexities in iden- navigation services to people experiencing home- tifying those currently experiencing homelessness. lessness, and two partnered directly with homeless These methods do not provide an accurate reflec- service providers by the time of the first interim eval- tion of members experiencing homelessness and uation. The results of the initial evaluations showed fail to capture most of them. most providers struggled to know who among their members were homeless and to offer services to eli- gible members experiencing homelessness.156 Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 48 Staffing no longer enrolled, or when people change MCPs Staff capacity is a challenge statewide, for both and the provider does not contract with the new health care and housing providers. In Los Angeles MCP in its region. MCP notification to providers County, Community Clinic Association of Los that a former member has changed plans is cur- Angeles County (CCALAC) members cited staff rently slow. So a homeless service provider who capacity as the most common barrier to contracting has a contract with plan A may have spent months with MCPs under CalAIM, even among the provid- providing outreach and engaging someone who ers who already have contracts with MCPs. Only 26 has changed to plan B, and may fail to get reim- of the 64 members of CCALAC were planning to bursed for forming a trusting relationship with contract with MCPs to provide ECM services in the that person. Also, a person deemed eligible for first year, the same providers who were CB-CMEs Community Supports under one plan may not be under the Health Homes Program. Only eight eligible under a different plan. CCALAC members plan to provide Community Supports. While a number of incentive payments to Funding MCPs are tied to building staff capacity, such pay- Most community-based nonprofits are grants based, ments may fail to offer community-based providers with budgets and administrative structures built enough funding to boost capacity to provide ECM around the grants process. Much of the housing or Community Supports. world also operates from that prospective payment model. The health care world, in contrast, operates One of the biggest drivers of low staffing among on a retrospective payment model. Reporting in the homeless service providers and other social service homeless response system relies on general reports providers is low pay. The rates offered by MCPs of services provided and outcomes achieved in for Community Supports are too low to maintain housing placement and retention. Health care adequate staffing levels or pay staff livable wages, (Medi-Cal) requires billing and reporting in 15-min- and may result in high staff turnover, particularly ute increments, and many providers do not contract given the intensity of services people experiencing under Medi-Cal for this very reason. The start-up homelessness require. If ECM capitated payments, and transition costs (staff, technology) that organi- incentives, or In Lieu of Services payments trickle zations must incur to be able to bill Medi-Cal will down through delegation or subcontracts (MCPs prevent many community-based organizations to independent physician associations to health working to respond to homelessness from partici- centers to subcontractors, or MCPs to counties to pating in CalAIM. subcontractors providing services to people experi- encing homelessness), rates will yield ratios of case Site/project-based supportive housing financing managers to clients of 1:35 to 1:50, rather than commonly requires a three-legged stool: (1) capi- ideal ratios of 1:10 to 1:15. tal funds to build the housing, (2) operating funds to keep the property affordable to people with Medi-Cal Churn extremely low incomes, and (3) services funds to For providers as well as for MCPs, churn presents ensure assertive housing supports are available. challenges. People experiencing homelessness Scattered-site or master-leased supportive housing often lose Medi-Cal when they fail to get recer- uses rental housing subsidies to help a tenant lease tification notices or are unable to act on these an apartment from a private landlord. In this model, notices. Churn creates holes in financial benefits service providers offer services, ideally, where the to homeless service providers when people are tenant lives. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 49 To align services resources from Community Figure E1. The Three-Legged Stool of Financing to Create Supportive Housing Supports with capital and operating funding for housing projects, services must be offered with cer- tainty for as long as tenants want and need them. They must align, on a project basis, with the hous- Supportive Housing ing. To receive housing funding to build a housing project, developers must commit to funding ser- vices for the housing units they are creating for at least 15 years. Similarly, to house people with rental housing subsidies in private-market housing, par- ticularly if the rental subsidies are prioritized for people experiencing homelessness, housing pro- viders must put in place services funding that will persist for as long as the tenant wants and needs CAPITAL OPERATING FUNDS FUNDS the services. Because MCPs could end Community Supports, and MCPs may limit time periods during SERVICES FUNDS which tenants could receive services, housing pro- viders will face uncertainty about the stability of the Source: Dimensions of Quality Supportive Housing Guidebook (PDF), services and how these services will align with hous- Corporation for Supportive Housing. ing. To create housing opportunities, all three legs of the stool must be in place (Figure E1). Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 50 Appendix F. Achieving the CalAIM Goals Table F1. Using the Current CalAIM Structure versus a Housing Support Services Benefit to Achieve California's Goals STATED CALAIM GOALS MID-2023 USE OF COMMUNITY SUPPORTS AND ENHANCED TOWARD PERSON-CENTERED CARE MANAGEMENT (ECM) TO FUND HOUSING-BASED WITH A HOUSING SUPPORT SERVICES BENEFIT, STRUCTURED AS CARE SERVICES RECOMMENDED Ability to Identify and $ Services offered through separate lanes: ECM funds $ If the California Department of Health Care Services (DHCS) creates Manage Comprehensive outreach, engagement, and care coordination, while a demonstration through a Section 1115 Medicaid waiver, a single Needs Through a Whole- separate Community Supports fund housing-based homeless service provider could offer a full range of services, from Person Approach services. outreach to tenancy supports, based on client needs. $ Managed care plans (MCPs) decide which Community $ If DHCS creates a benefit through a Section 1915(i) State Plan Supports to offer; some MCPs decided not to offer the Amendment, this authority may result in multiple providers offering full range of housing-related Community Supports. different services. $ Enrollees receive services for as long as they need them. Improve Quality Outcomes $ ECM care coordination may not improve outcomes $ Improve access to a range of services with adequate rates. without housing. $ Potential to scale services to all who need them. $ Siloes between Community Supports and between ECM and Community Supports interrupt continuity of care. Consistent and Standardized $ No standardization, as each MCP designs its $ Standardized, consistent approach to funding housing support services Approach Community Supports differently. statewide. $ Potential for adverse selection is high, as people may choose plans offering more comprehensive services. Seamless Access for $ Extremely complex process for accessing services, with $ Simpler funding, seamless to member if designed to reduce barriers. Members by Reducing member navigating different programs. Complexity $ Funding for services based on MCP return on invest- ment. $ Restrictions on members, such as lifetime limits, multiple assessments, and denied services if member is deemed unresponsive. Flexibility for Providers $ Providers must contract with different MCPs with $ Regular, ongoing payment for a range of services, for as long as the potentially different rates, different programs, and member needs them, ideally statewide. different rules. Equity in Access $ In some cases, excludes members who have not $ As an entitlement, potential for greater scale and more equitable access accessed high-cost care, leading to disproportionate to services. exclusion of people of color. Scalability $ In some cases, limited to high-cost members. $ As an entitlement, potential for scalability. Coordination with Housing $ Not well coordinated or aligned with housing. $ Certainty of services funding could be coordinated with housing resources more easily, and housing providers can set aside units avail- able to people eligible for the benefit (under a Section 1915[i] State Plan Amendment, tenants would have the ability to choose their providers, and services end if an assessment indicates a tenant no longer needs the services). Source: "Guiding Principles," in California Advancing & Innovating Medi-Cal (CalAIM) Proposal (PDF), California Dept. of Health Care Services, January 2021. Building on CalAIM's Housing Supports: Strengthening Medi-Cal for People Experiencing Homelessness www.chcf.org 51 Endnotes 1. "CalAIM," California Dept. of Health Care Services (DHCS). accessed homeless services (unduplicated) throughout 2021. The number leaves out people experiencing 2. James J. O'Connell, Premature Mortality in Homeless homelessness who did not access services. While not Populations: A Review of the Literature (PDF), Natl. everyone experiencing homelessness accesses the Health Care for the Homeless Council, December 2005. homelessness system, those who do are more likely to 3. "Data: Racial Disparities and Disproportionality connect to other social services, including Medi-Cal. Index," Corporation for Supportive Housing (CSH), 14. Dawn Foster, "Crisis Report Reveals Shocking Dangers accessed December 20, 2022. The Racial Disparities and of Being Homeless," The Guardian, December 22, 2016; Disproportionality Index examines 16 unique systems Julia-Grace Sanders, "Homelessness and Sexual Assault: and measures whether a racial and/or ethnic group's Experts Say the Connection Is Clear, but Help Is Elusive," representation in a particular public system is proportionate Seattle Weekly, June 9, 2016; Lisa A. Goodman et al., to, or is disproportionate to, its representation in the overall No Safe Place: Sexual Assault in the Lives of Homeless population. It allows for the examination of systematic Women, VAWnet (a project of the Natl. Resource Center between groups and geographies (disparities). on Domestic Violence), September 2006; and Jana L. 4. "CalAIM Providing Access and Transforming Health Jasinski et al., The Experience of Violence in the Lives of Initiative," DHCS, last modified April 4, 2023. Homeless Women: A Research Report, Office of Justice Programs, September 2005. 5. "Home and Community-Based Services Spending Plan," DHCS, last modified February 21, 2023. 15. Harper Sutherland, Mir M. Ali, and Emily Rosenoff, Individuals Experiencing Homelessness Are Likely to 6. CalAIM Enhanced Care Management Policy Guide (PDF), Have Medical Conditions Associated with Severe Illness DHCS, updated May 2022. from COVID-19 Issue Brief, US Dept. of Health and 7. Medi-Cal In Lieu of Services (ILOS) Policy Guide (PDF), Human Services (HHS), June 24, 2020. DHCS, September 2021. 16. Karen W. Linkins, Jennifer J. Brya, and Daniel W. Chandler, 8. Program Descriptions - Alameda County: Project Frequent Users of Health Services Initiative: Final RESPECT (PDF), Partnership for Strong Communities. Evaluation Report (PDF), CHCF, August 2008. 9. Katherine A. Koh et al., "Health Care Spending and Use 17. Linkins, Brya, and Chandler, Frequent Users. Among People Experiencing Unstable Housing in the 18. "Data: Racial Disparities and Disproportionality Era of Accountable Care Organizations," Health Affairs Index," Corporation for Supportive Housing (CSH), 39, no. 2 (Feb. 2020): 214–23; and Homelessness & accessed December 20, 2022. The Racial Disparities Health: What's the Connection? (PDF), Natl. Health Care and Disproportionality Index examines 16 unique for the Homeless Council, February 2019. systems and measures whether a racial and/or ethnic 10. Mortality Among People Experiencing Homelessness group's representation in a particular public system in Los Angeles County: One Year Before and After the is proportionate to, or is disproportionate to, its Start of the COVID-19 Pandemic (PDF), Los Angeles representation in the overall population. It allows for the County Dept. of Public Health, April 2022. Los Angeles examination of systematic differences between groups and County alone has reported an increasing rate of mortality geographies (disparities). among people experiencing homelessness, more 19. "CoC Analysis Tool: Race and Ethnicity," HUD, March than tripling from 2014 to 2021. About 1,988 people 2022. Nationally, Black people's disproportionate rate of experiencing homelessness died in 2021. homelessness (seven times that of the general population) 11. O'Connell, Premature Mortality; and Travis P. Baggett et al., far outpaces their disproportionate rate of experiencing "Mortality Among Homeless Adults in Boston: Shifts in poverty (three times that of the general population). Causes of Death over a 15-Year Period," JAMA Internal Homelessness similarly has a far greater disproportionate Medicine 173, no. 3 (Feb. 11, 2013): 189–95. impact on Indigenous populations than does poverty. 12. Rebecca T. Brown et al., "Pathways to Homelessness 20. Health Disparities by Race and Ethnicity in California Among Older Homeless Adults: Results from the HOPE Almanac, 2021: Pattern of Inequity, CHCF, October 2021. HOME Study," PLoS ONE 11, no. 5 (May 10, 2016): 21. See, for example, Koh et al., "Health Care Spending and e0155065. Use"; Joel C. Cantor et al., "Medicaid Utilization and 13. "Homeless Data Integration System," Business, Spending Among Homeless Adults in New Jersey: Consumer Services and Housing Agency, September 30, Implications for Medicaid-Funded Tenancy Support 2022. 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Dohler et al., Supportive Housing Helps; Basu et al., 96% of tenants remained stably housed after 12 months, "Comparative Cost Analysis"; and Perlman and Parvensky, and tenants decreased inpatient days by 75% in the year Denver Housing First. following Housing First intervention); Daniel Gubits et al., Family Options Study: 3-Year Impacts of Housing and 32. Sadowski et al., "Effect of a Program." Services Interventions for Homeless Families, HUD, 33. DeSilva, Manworren, and Targonski, "Impact of a Program." October 2016 (finding long-term housing subsidy with services resulted in longest terms of housing stability and 34. Padgett et al., "Substance Use Outcomes." lower costs than transitional housing and usual care); and 35. Deborah K. Padgett, Benjamin F. Henwood, and Sam Molly M. Brown et al., "Housing First as an Effective J. Tsemberis, Housing First: Ending Homelessness, Model for Community Stabilization Among Vulnerable Transforming Systems, and Changing Lives (New York: Individuals with Chronic and Nonchronic Homelessness Oxford Univ. Press, 2016). Histories," Journal of Community Psychology 44, no. 3 (Apr. 2016): 384–90 (finding 90% of tenants in Housing First 36. "Deploy Housing First Systemwide," US Interagency programs were still housed after 12 months and had better Council on Homelessness, last updated August 15, 2018. health outcomes compared to the 35% of people receiving Some veterans programs require tenants of housing to usual care who remained housed). participate in services, counter to the Housing First core components. Federal homeless programs otherwise 26. 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