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Financing Services In Supportive Housing Using Mainstream ... Presentation Transcript

  • 1. Financing Services In Supportive Housing Using Mainstream Resources Carol Wilkins Corporation for Supportive Housing David M. Wertheimer Kelly Point Partners
  • 2. 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
  • 3. 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
  • 4. Eligibility Considerations
    • Tenants / Consumers : individuals and family members
    • Providers : organizations and staff
    • Activities / Services
    • Decision-making and oversight
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. 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
  • 13. Strategies to Access Specific Mainstream Funding Sources
  • 14. Public Mental Health Services
    • Public sector mental health services are funded in a variety of fashions:
    • Fee-for-Service
    • Case Rates
    • Capitation
    • Public sector services are increasingly being managed using a managed care paradigm
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. 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)
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. 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
  • 25. 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
  • 26. Options for using Medicaid to fund services in supportive housing
    • Rehabilitation Option
    • Targeted Case Management
    • Home and Community Based “Waiver” Services
  • 27. 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)
  • 28. 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
  • 29. 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
  • 30. 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
  • 31. 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
  • 32. 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
  • 33. 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
  • 34. 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
  • 35. 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
  • 36. 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
  • 37. 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