Financing Community Supports in Partnership with Permanent Supportive Housing: Medicaid Combined with Other Funding Sources

2 SAMHSA and Bazelon Center for Mental Health Law Conference Changing Systems: Changing Lives September 29 and 30, 2008

3 Permanent Supportive Housing Permanent Supportive Housing (PSH) is possible when essential individualized supports are available and accessible Individualized supports can be funded in a variety of ways The good news is that we know more today than ever about how financing can be structured to support a person’s successful tenancy and personal recovery goals living in PSH

4 How can supports be financed? A mix of local and federal funds can be used to finance supports No one source of funding covers all necessary service and support costs Funding for services is sometimes attached to housing and sometimes separate— Medicaid is attached to a person and their eligibility for services

5 How can supports be financed? Funding alone is not sufficient to build the program. Three strategies are key: 1. Blending funding sources into a single approach 2. Utilizing state and local funds to fill in gaps created when using Medicaid as a major fund source 3. Creating incentives and minimizing disincentives in policy and the allocation process

6 Identifying supports and sources of funds---financing plan To maximize financing using multiple sources, it is important to develop a financing plan: Identify support by type of support and by function Match each support with fund source and identify limits (including such items as provider qualifications and documentation requirements) Identify benefits such as potential for credentialing peer counselors

7 How supports are reinforced Identify the treatment or service planning requirements for each fund source and ways that planning can become the responsibility of a single entity called a “clinical home” Establish mechanism for consumers to set their recovery goals matched with one or more of the available supports Articulate goals in a consumer's Individual Recovery Plan (IRP) with specific needs based objectives Credential staff and peers with pre service competency requirements and post services coaching and supervision standards

8 Key Community Supports Life skills training In-home supports Employment and employment related follow-along services (supported employment) Peer counseling and peer supports Accessing natural community services and supports Assistance and resources to obtain and keep housing

9 Key Community Supports Family/caregiver support Crisis response Assertive Community Treatment Clinical/Community Support Case Management Substance Abuse Treatment Primary and Specialty Health Care Medication-self management/symptom self-management

10 Why Medicaid… Medicaid is not the only answer, but it has to be a big part of any financing strategy Medicaid brings needed federal funding to the state Medicaid requires individualized support, critical to permanent supportive housing Medicaid advances access, quality and choice Medicaid can be more responsive and has more flexibility than often used

11 Current Medicaid Policy Issues Medicaid is difficult but not impossible to work with States can get more things approved by CMS than they usually do But new guidance from CMS on the Rehab Option and case management may make it more complex Administrative reluctance and bureaucracy: plan amendments, waivers, audits, etc. Eligibility: limits for single adults; limits re: substance abuse On the plus side: CMS system change grants; new waiver and state plan possibilities

12 Medicaid and Permanent Supportive Housing Medicaid Clinical treatment – MH and SA Primary health and chronic health care Rehabilitation Option Tenancy supports and community integration

13 Relation Between Medicaid Funding and Evidence Based Practices EBPTradMROTCMPC 1915 (c) 1915 b) 1115 ACTX XXX Sup. Emp X (not job) XXX Dual DxXXXX XXX Illness Mgt.XXX XXX Family supp.X XXX Peer SupportX XXX Sup. housing X (Not rent) XXX

14 Medicaid Solutions Standard benefit plan across funding streams and eligibility categories (New Mexico, Arizona, Washington State, Massachusetts, Michigan) Incentives for linkage with supportive housing (Maine, Michigan, Arizona, Pennsylvania, Massachusetts) Waivers for eligibility enhancements (Maine, Massachusetts, Oregon, Minnesota, RI)

15 Medicaid is Only Part of the Answer Other state/local general fund dollars (Match and gap-filling) Creative programs such as D.C.’s SIL Program fill gaps Federal housing subsidy funds (HUD McKinney/Vento; HUD Section 8; HOME, Public Housing, Section 811, etc.) Federal employment funds (Ticket to Work; DOL Workforce Investment Act; DOL VR funds) Other federal funds (HRSA, Child Welfare, SAMHSA grants, etc.) Federal Veterans Services Grant/Per Diem program Veteran’s Integrated Service Network

16 Conclusion PSH can be financed by a combination of funding sources---financing plan can identify how to do this Medicaid is key to bringing PSH to scale--- otherwise PSH is generally funded at a “project level” Supports that can’t be funded by Medicaid can be blended into a PSH to reinforce good service planning and deployment of resources Self determination, independence and recovery are the results