SAMHSA and Bazelon Center for Mental Health Law Conference Changing Systems: Changing Lives

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

2. Financing Community Supports in Partnership with Permanent Supportive Housing: Medicaid Combined with Other Funding Sources SAMHSA and Bazelon Center for Mental Health Law Conference Changing Systems: Changing Lives September 29 and 30, 2008

3. Permanent SupportiveHousing • 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: • Blending funding sources into a single approach • Utilizing state and local funds to fill in gaps created when using Medicaid as a major fund source • 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. 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 Key Community Supports

9. 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 Key Community Supports

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

13. Relation Between Medicaid Funding and Evidence Based Practices

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