1. The Source for Housing Solutions Medicaid & Supportive Housing

2. Improving Lives

3. Our Mission Improve lives of vulnerable people Maximize public resources Build strong, healthy communities Advancing housing solutions that:

4. Maximizing Public Resources Public Systems CSH collaborates with communities to introduce housing solutions that promote integration among public service systems, leading to strengthened partnerships and maximized resources. Maximized Resources

5. What We Do CSH is a touchstone for new ideas and best practices, a collaborative and pragmatic community partner, and an influential advocate for supportive housing. Lines of Business Training & Education Policy Reform Consulting & Assistance Lending Research-backed tools, trainings and knowledge sharing Powerful capital funds, specialty loan products and development expertise Custom community planning and cutting-edge innovations Systems reform, policy collaboration and advocacy

6. INTRODUCTION TO SUPPORTIVE HOUSING Medicaid & Supportive Housing

7. Supportive Housing - A more humane solution to ending homelessness for families and individuals struggling with addiction, mental health and/or other disabilities who lack the social support, resources or ability to sustain and maintain housing without supportive services and subsidized housing. Introduction to Supportive Housing

8. Supportive Housing is the Solution Coordinated Services Housing: Affordable Permanent Independent Support: Flexible Voluntary Tenant-centered Supportive housing combines affordable housing with services that help people who face the most complex challenges to live with stability, autonomy and dignity. Employment Services Case Management Primary Health Services Mental Health Services Substance Abuse Treatment Parenting/ Coaching Life Skills Affordable Housing

9. Combining affordable housing with access to support services like case management, employment training, and mental health treatment, supportive housing is a nationally recognized best practice which gives vulnerable individuals and families the opportunity to live stable, autonomous, and dignified lives.

10. Supportive Housing Populations Residents of Institutions who Prefer to Live in the Community Chronically Homeless People Exiting Jail or Prison with Chronic Health Conditions (esp. mental health) Mental health, substance use and/or physical health disabling conditions coupled with housing need Includes individuals, families and youth

11. Permanent: Not time limited; not transitional Affordable: Tenants pay no more than 30% of their income for rent Independent as possible: Resident holds lease with normal rights and responsibilities Housing

12. Targeted: Based on populations served Flexible: Responsive to residents’ needs Voluntary: Participation is not a condition of residency Independent: Focus is on housing stability Services

13. Types of Supportive Housing - Single site: buildings developed / rehabilitated - Scattered Site: rent-subsidized apartments - Mixed-income buildings - Master-leased buildings or units

14. Financing Supportive Housing Capital Operating Traditional Affordable Housing Supportive Housing The most difficult and  least stable to finance as residents have complex needs Capital Operating Services

15. Services Resource Picture HUD/HEARTH Spends 26% on Services (~$572 m) Decreased steadily since 1998 (55%) Only Homeless Population SAMHSA Short Term 3- 5 year grants $75 million 30 grants – 300 applied Other Federal CSBG, SSBG, TANF, Child Welfare Not dedicated to SH, local discretion State and Local Very Few states have dedicated $$ Increasing examples innovation Tight budgets limit growth Philanthropy Spark innovation, lack sustainability Small communities have few options Benefits of Medicaid $344 billion budget, reimburses services and overlaps population

16. THE CASE FOR MEDICAID Medicaid & Supportive Housing

17. Braiding Funding State Funds Other Housing Funds Current Services Financing Future Services Financing State/ Local Funds Other Funds Medicaid

18. Medicaid Basics  Medicaid (called Medical Assistance in Pennsylvania) is a public health insurance that pays essential medical and medically-related services for people with low-incomes. The state and federal government jointly fund Medicaid.  The State Medicaid Plan serves as a contract between the State of Pennsylvania and the federal Centers for Medicaid and Medicare (CMS).  The Plan authorizes federal financial assistance. - Waivers and Amendments: States and CMS can agree to provide optional benefits and states can apply for waivers or plan amendments.

19. Affordable Care Act (ACA)  Expands health insurance.  Clears the path for innovation for new service-delivery models and financing mechanisms.

20. ACA Implementation Trends  Move away from fee-for service payment mechanisms.  Create better Coordinated Care.  Integrate primary and behavioral health care.

21. The Affordable Care Act: An Opportunity - Expansion states now include homeless single adults - 5% of Medicaid beneficiaries account for 50% of program costs - Additional resources in ACA provided to find new approaches to cost containment

22. Housing as Healthcare Why is a Crosswalk important? - Target supportive housing to appropriate populations and grow capacity for permanent supportive housing  End chronic homelessness  Reduce Institutionalization (jail, prison, nursing facility, mental health, etc.)  Control Medicaid cost for most expensive  Improve health outcomes - Improve services financing  Stretch current resources farther  Make case for increased housing resources - National supportive housing cost studies show as much as a 61% decrease in costs  Identify opportunities in PA to achieve similar results

23. MEDICAID BUSINESS CASE Medicaid & Supportive Housing

24. Medicaid Business Case Four key steps 1.Summarize national evidence of cost savings. 2.Use cost data for people with the highest costs who are not stably housed. 3.Apply a cost reduction percentage that supportive housing can achieve. 4.Demonstrate total and state portion of cost savings.

25. Determines if there is a Return on Investment (ROI) potential for Medicaid financing supportive housing services If a business case does exist to cover services, it may provide financial justification to reevaluate how the state (and Managed Care Organizations) provides coverage for services for individuals living in supportive housing. Business Case

26. Denver study found 50% of tenants improved health status and 43% had improved Mental Health Seattle study found 30% reduction in alcohol use among chronic alcohol users in Supportive Housing Chicago study found 55% survival rate for people living with aids in supportive housing compared with 35% of control group, and lower viral loads among housed group For this population the lack of housing itself dictates health outcomes

27. Chicago, IL: PSH saved almost $25,000* Portland, ME: Medicaid costs were reduced by almost $6,000* * All $ amounts are per person, per year CSH’s Frequent Users of Health Systems Initiative found that prior to housing residents of supportive housing had ER and hospital inpatient costs over $58,000.* Two years after housing, residents incurred only $19,000.* ACCESSING MEDICAID FOR SERVICES ATTACHED TO HOUSING ALSO SAVES COSTS

28. Where to Start  Great examples in Pittsburgh and Philadelphia  Include national data where needed  Evaluate cost savings opportunity  Analyze data b/t homeless and Medical Assistance (Medicaid)  Review opportunities to reinvest savings to grow housing and services availability  Engage providers and build partnerships

29. MEDICAID CROSSWALK Supportive Housing

30. Services Crosswalk  Compare Supportive Housing Services chart with Medicaid - State Plan - Medicaid waivers - Behavioral Health MCO covered services  Interview and survey agencies (urban and rural) - Both Medicaid and non-Medicaid billers

31. Supportive Housing Services Tenancy SupportsHousing Case Management Outreach and engagementService plan development Housing search assistanceCoordination with primary care and health homes Collecting documents to apply for housingCoordination with substance use treatment providers Completing housing applicationsCoordination with mental health providers Subsidy applications and recertificationsCoordination of vision and dental providers Advocacy with landlords to rent unitsCoordination with hospitals/emergency departments Master-lease negotiationsCrisis interventions and Critical Time Intervention Acquiring furnishingsMotivational interviewing Purchasing cleaning supplies, dishes, linens, etc.Trauma Informed Care Moving assistance if first or second housing situation does not work outTransportation to appointments Tenancy rights and responsibilities educationEntitlement assistance Eviction prevention (paying rent on time)Independent living skills coaching Eviction prevention (conflict resolution)Individual counseling and de-escalation Eviction prevention (lease behavior requirements)Linkages to education, job skills training, and employment Eviction prevention (utilities management)Support groups Landlord relationship maintenanceEnd-of-life planning Subsidy provider relationship maintenanceRe-engagement

32. Pennsylvania’s Medicaid Crosswalk  Identification of alignment and gaps  Alignment: what can be billed now  Gaps: what isn’t included

33. Crosswalk- Common Alignment Found There are ways to currently bill for Supporting Housing Services Behavioral Health Managed Care Organization (MCO) contracting – provides most comprehensive coverage Medicaid Home and Community-Based Services Waivers offer some coverage

34. Crosswalk- Common Gaps Found Common Gaps  Pre-tenancy Supports  Tenancy Supports  Transportation  Case Management  Team Oriented Care  Populations not served  Licensing/credentials

35. Common Next Steps -Feasibility Analysis: Determine initial feasibility for Supportive Housing providers to become billing agencies or subcontractors of billing agencies. -Research state licensing and BH MCO provider qualification requirements to establish an array of the most strategic approaches for agencies to pursue. -If access and expansion of Medical Assistance (PA Medicaid) billing is feasible, begin assessing interest in the provider community statewide. -Develop new curriculum and deliver Medical Assistance billing toolkits to educate providers about Medical Assistance requirements. Can include technical assistance and business modeling for select providers. Crosswalk- Common Next Steps Taken

36. Resources  CSH and USICH – Quick Guide to Medicaid for Supportive Housing http://www.csh.org/resources/a-quick-guide-to-improving- medicaid-coverage-for-supportive-housing-services/  CSH State Action: Medicaid and Housing http://www.csh.org/wp-content/uploads/2015/06/Summary-of- State-Action-Medicaid-and-Housing-2015-update.pdf  CSH State Action: Medicaid and Supportive Housing Services http://www.csh.org/wp-content/uploads/2015/06/Summary-of- State-Action-Medicaid-and-Supportive-Housing-Services- 2015-updated.pdf

37. HOW YOU CAN BE INVOLVED Medicaid & Supportive Housing

38. QUESTIONS? Medicaid & Supportive Housing