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A View From the Ground

A View From the Ground. Better Care at Lower Cost for High Risk Patients. LifeLong Medical Care. Gray Panther founded FQHC in Berkeley/Oakland/Richmond, California 12 licensed sites, 40,000 patients

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A View From the Ground

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  1. A View From the Ground Better Care at Lower Cost for High Risk Patients

  2. LifeLong Medical Care • Gray Panther founded FQHC in Berkeley/Oakland/Richmond, California • 12 licensed sites, 40,000 patients • Emphasis on developing models of care to serve elderly, disabled, homeless and complex patients • Supportive Housing Provider • Integrated primary care/behavioral health

  3. Life Expectancy

  4. Health Issues Faced by Homeless Patients • Homelessness • Serious mental illness • Drug and/or alcohol addiction • Trauma – adverse childhood events and as homeless adults • Advanced chronic disease • Poor nutritional status • Lack of income – while Affordable Care Act will insure MediCal coverage for most homeless lack of income will still be a significant issue

  5. ServiceModels That Work • Data to identify which patients require intensive services and to track outcomes • Integrated team approach • Intensity of services determined by need • High frequency of interaction • Strong linkages to community-based services, especially access to housing • Low Caseloads • Highly individualized/relationship based • Close communication with partners (primary care, behavioral health, benefits advocates, ED, discharge planners)

  6. So What Does a Health Home for the Homeless Look Like? • Care model and payment systems that support intensive services • Flexible service models • who provides care (non-licensed staff can be highly effective) • where the care is provided (office, home, streets) • what “care” is (medical and social case management, flexible funds for transportation, basic needs) • Marriage of medical and social services models to provide responsive care coordination • Fast access to supportive housing and other housing resources • Linkages to benefits

  7. Change is PossibleCA Frequent User 2 Year Results for Medicaid Population *Indicates statistically significant

  8. Policy Issues • Payments for medical providers to support very intensive medical and psychosocial services and that potentially reward for reducing overall cost to the system • Managed care plans must develop appropriate care and reimbursement models, link community based services • Case management as a recognized “medical” service • Eliminate barriers to qualify for SSI/Medicaid • Housing subsidies as cost effective health benefit • Discharge policies and funding for medical respite to insure that patients don’t get discharged to homelessness • Community Health Centers as key providers for this high risk, high cost population

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