Financing Services In Supportive Housing Using Mainstream ...
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Transcript of Financing Services In Supportive Housing Using Mainstream ...
Financing Services In Supportive Housing Using Mainstream Resources
Carol Wilkins
Corporation for Supportive Housing
David M. Wertheimer
Kelly Point Partners
Mainstream Services & Funding
More money available from mainstream than in targeted programs
More reliable for sustaining programs after time-limited grants
Make HUD funding available for housing Link tenants and services to Systems of Care
Financing Strategies
Billing for reimbursement under entitlement programs (e.g. Medicaid)
Direct federal grants from programs not targeted to homeless people or people with HIV/AIDS
State or local government decisions to allocate block grant funds for services
Re-investing savings from reduced costs in other systems
Eligibility Considerations
Tenants / Consumers : individuals and family members
Providers : organizations and staffActivities / ServicesDecision-making and oversight
Understand the requirements of potential funding sources
Eligibility determination / verification
Staff credentials and skills required
Service planning Record-keeping Performance
Financial and administrative systems for billing / cost reporting
Frequency of application / grant-writing costs
Cash flow
Service Integration and Systems Integration
Defining service integration: The creation of linkages across multiple
systems at the service delivery level
Defining Systems Integration: The creation of formal linkages across
multiple systems at the structural level
Service Integration: What it Is
Creation of cross-agency/cross-system relationships at the provider level that affords opportunities to construct integrated packages of care for specific clients
Informal opportunities for information sharing, case consultation and cross-training in multiple disciplines
Service Integration: Advantages
Easier to create than systems integration Does not require systematic or strategic
buy-in at senior levels of system Creates useful relationships among
providers across systems Can be highly functional in meeting
individual client needs
Service Integration: Problems
Benefits remain client-specific and do not address systemic gaps and barriers
Is personality-driven Difficult to sustain integration in an
environment with moderate to high staff turnover
Systems Integration: What it Is
Key Components of Systems Integration: Sharing of Information Sharing of Planning Sharing of Clients Sharing of Resources Sharing of Responsibility
Systems Integration: Advantages
Creates structural linkages at the systems level Can be highly functional in meeting individual
client needs Can be highly functional in meeting system
needs (e.g. promoting collaboration) Easier to sustain in an environment with
moderate to high staff turnover
Systems Integration: Problems
Requires stakeholder buy-in at administrative and policy levels
Requires extensive process to mobilize ongoing participation at systems level
Requires formalized working agreements or other linkages to sustain integration over time
Strategies to Access Specific Mainstream Funding Sources
Public Mental Health Services
Public sector mental health services are funded in a variety of fashions:
Fee-for-Service Case Rates CapitationPublic sector services are increasingly being
managed using a managed care paradigm
Mental Health Services: Eligibility
Eligibility is defined in several different ways: Financial eligibility (Medicaid-only systems vs.
other models) “Medical Necessity” (Levels of severity and
levels of need) Diagnostic criteria (e.g. “Axis I” vs. “Axis II”
mental health disorders
Strategies for Accessing Mental Health Services: Service Level
Service Integration Strategies: Forging relationships with mental health
providers Learning the eligibility criteria Knowing what to say and how to say it Quid Pro Quo issues
Strategies for Accessing Mental Health Services: Systems Level
Systems Integration Strategies: Formal working agreements Cross-training in system access and
system issues Prioritization of referrals Contractual obligations Incentive payments
Public Substance Abuse Services
Publicly funded substance abuse and chemical dependency services are usually poorly funded
Access to services is severely limited due to capacity issues
Funding is highly categorical in nature and targets specific populations
Abstinence-only model may dominate
Accessing Substance Abuse Services
Understand the categorical nature of what is funded in your region
Market to the priority population characteristics rather than to your client’s HIV/AIDS status (e.g. IVDU)
Identify range of options that may be more accessible (e.g. specialized self-help groups)
Medicaid
Federal Financial Participation (FFP) matches “state” (non-federal fund) contributions (approx 50/50)
Federal rules and waivers administered by Health Care Financing Agency (HCFA)
State Medicaid Plan : contract between state and federal government
Basic health services + State Options
State Medicaid Plan Defines:
Optional benefits “Medical necessity” Who is eligible to provide services to be
reimbursed under Medicaid Where services must be provided Billing structure requirements
Medicaid Eligibility - Consumers
Generally tied to eligibility for SSI or TANF Low income parents and children are often
eligible even if not receiving welfare benefits – but often they do not apply
New option for states to extend eligibility for people who qualify for SSI (based on disability level) but have earnings from work
Medicaid eligibility issues
Very low income adults without children are usually not covered unless eligible for SSI based on disability level
Adults with disabilities attributable to substance abuse often excluded from Medicaid, in spite of significant health problems
Medicaid eligibility - providers
Federally Qualified Health Centers (FQHC): Health Care for the Homeless programs and Community Health Centers receive cost-based reimbursement under special rules
For other provider organizations and practitioners, eligibility to participate determined by state plan
Managed Care & Freedom of Choice waivers may have exceptions for people with HIV/AIDS or other special needs
Partnering with an FQHC for services in supportive housing
Community Clinic sends a primary care provider (MD or nurse practitioner) to deliver on-site care and health education to tenants, with follow-up at nearby clinic for more complex needs
Mental health services provided by psychiatrist and Licensed Clinical Social Workers employed by (or under contract with) FQHC
Integrated primary care, mental health, health education services are reimbursed through FQHC
Options for using Medicaid to fund services in supportive housing
Rehabilitation Option Targeted Case Management Home and Community Based “Waiver”
Services
Rehab Option
At the option of the state … other diagnostic, screening, preventive and rehabilitative services … for maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level (Federal)
Assistance in improving, maintaining, or restoring … functional skills, daily living skills, social and leisure skills, grooming and personal hygienic skills, meal preparation skills, and support resources, and/or medication education (California)
Rehab Option (cont.)
Most often used for mental health services State plan may define medical necessity differently
for services covered under rehab option State plan may have different requirements for
providers seeking reimbursement under rehab option (e.g. operating under contract with county mental health department)
Requires plan of care reviewed and approved by licensed practitioner
Rehab Option Services May Include (depending on state plan)
Assessment / plan development
Individual or group rehabilitation or therapy
Case management Case management
brokerage
Medication support Collateral Services Crisis intervention Services delivered in a
broad range of settings
Targeted Case Management
Services to assist eligible individuals in gaining access to needed medical, social, educational, and other services
Federal law allows states to limit eligibility for case management services to particular groups of people (e.g. people with HIV/AIDS or other targeted groups)
Requires a separate state plan amendment
Case Management Services Targeted to “High Risk Persons” in California
persons identified as having a need for public health case management services including … persons with HIV/AIDS … and persons with multiple diagnoses
Those who have failed to take advantage of necessary health care services or do not comply with their medical regimen or who need coordination of multiple medical, social and other services due to the existence of an unstable medical condition … substance abuse, or because they are victims of abuse, neglect or violence
Persons with no community support system to assist in follow-up care at home … and persons who require services from multiple health / social service providers in order to maximize health outcomes
Targeted Case Management Services in California
Needs assessment Setting objectives related to needs Individual service planning Service scheduling
Case management services ensure that the changing needs of the person are addressed on an ongoing basis and appropriate choices are provided among the widest array of options for meeting those needs
Home and Community Based Services (HCBS)
Provide broader range of services not otherwise covered under Medicaid plan
Operate under 1915(c) waivers submitted by states and approved by HCFA
Eligibility limited to people who would otherwise be eligible for institutional placement (e.g. nursing home)
Providing housing and services to tenants who meet HCBS eligibility in unlicensed supportive housing may conflict with state licensing laws
Challenges to consider
Many tenants may not be eligible for Medicaid if not receiving SSI
Requires service planning and documentation based on diagnoses and “medical necessity” rather than goals and aspirations of tenant and community
Record-keeping systems must support encounter level data
Skills and credentials required for billing are not the same as those needed for effective engagement and community-building
Federal Block Grants
Temporary Assistance to Needy Families (TANF)
Community Mental Health Services Block Grant
Substance Abuse Prevention and Treatment Block Grant
Social Services Block Grant
TANF
States have significant flexibility to design “welfare to work” programs and services that assist “needy families
Many states have significant surpluses Funding set aside for mental health and substance
abuse services may be under-utilized Some types of assistance subject to time limits Increasing interest in strategies to serve people with
multiple barriers to employment
Community Mental Health Services Block Grant
45% Increase in past two years ($289 million in FY 1999 - $420 million in FY 2001
Go to www.samhsa.gov/funding/funding.html to find your state’s formula grant allocations (for Community Mental Health Services and other SAMHSA grant programs)
Federal law requires Mental Health Planning Council to approve spending plan
States can decide to allocate funds for services in supportive housing