In many communities, individuals who are chronically homeless—many of whom are Medicaid beneficiaries—are being served by coordination between community providers of healthcare, housing, and housing assistance. However, the “revolving-door” effect of recidivism tends to drive up Medicaid costs.
One common story among Medicaid-funded providers is that of the “super-utilizer”: a patient whose chronic conditions lead them to frequently seek treatment, often because of unaddressed root causes, and therefore disproportionately use already-scarce resources. Many of these Medicaid beneficiaries with multiple chronic conditions can unnecessarily drive up costs when they become super-utilizers of services, due to the compounding effect of repeated service.
So how are communities tackling this issue? One answer lies in the utilization of Medicaid expansion and home- and community-based services (HCBS), as well as supportive housing.
In this article, we’ll explore the intersection between HCBS, 1115 waiver programs, and supportive housing for health-related social needs (HRSN)—and how communities can use case management and reimbursement workflows to address these root causes of super-utilization.
Supportive Housing and Healthcare Costs
Permanent supportive housing (PSH) remains one of the more powerful methods of improving some social determinants of health (SDoH). To illustrate, one large meta-analysis performed by researchers found the following (emphasis added):
PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant c[o]morbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitali[z]ed.
Reduced ER visits and hospitalizations would, obviously, reduce healthcare costs for all involved. However, in the same paragraph, the researchers noted that PSH was not sufficient for other SDoH improvements (emphasis added):
Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found.
The researchers further concluded that, while some costs to healthcare increased because of expanded services, those costs to the community and Medicaid were often off-set by the decrease in emergency services.
Does that mean we should give up on supportive housing or Housing First as a model? Not exactly. In fact, let’s look at homeless veterans to see one part of the picture. In another large review of research, this time on VA programs, authors concluded the following:
Full-time employment at baseline, part-time employment at baseline, and [substance use disorder] (SUD) visits over 1 year were associated with increased [odds ratio] of good employment outcomes. Individuals with employment at baseline likely continued to engage in employment 1 year after housing. The beneficial effects of SUD visits on employment may reflect the value of the VA’s programs to provide stability for individuals coping with these disorders. In contrast, mental health visits over the year were associated with poor employment outcomes, suggesting that those with mental illness struggle to find and/or maintain employment.
Source: Frontiers in Psychiatry.
In other words, housing is a start for vulnerable populations—but providing the ability for self-determination is also crucial. The researchers also observed that employment was a strong predictor for stability in housing and community integration.
That’s why home- and community-based services (HCBS) come into play.
Home- and Community-Based Services and Healthcare Costs
HCBS is the opportunity for “Medicaid beneficiaries to receive services in their own home or community rather than institutions or other isolated settings. These programs serve a variety of [populations], such as people with intellectual or developmental disabilities, physical disabilities, and/or mental illnesses.” However, because US states are expected to partially fund HCBS reimbursement programs, HCBS varies wildly by state; states are given wide latitude on targeted populations, services covered, and so on.
For elder care and disability populations, HCBS covers things like personal assistance services (PAS), such as employment coaching, transportation, and more, depending on the state. HCBS also includes assisted daily living (ADL), such as housework, managing money, preparing meal, and the like.
In a study looking at the risk of hospitalization for older populations, there was a lower risk of hospitalization when patients received PAS: “… [P]eople using high and medium levels of PAS face a lower risk of hospitalization than the community dwelling elderly people with no HCBS as well as people using less than four hours of PAS per day.” However, in the chart below, we notice that older people receiving PAS, adult day services, and medically-tailored meals were still at higher risk for hospitalization the more hours they received per day. This correlation is likely due to their already-declining health, which necessitated the increased services in the first place.
So it stands to reason that, when looking at the increase of PAS hours per day, if a client already needs a lot of help, they’re likely to need hospitalization anyway. But when outcomes can be improved proactively, an ounce of prevention can be worth a pound of cure.
Medicaid Expansion Is Happening: Here’s How to Take Advantage
In 41 US states, Medicaid reimbursement programs have expanded to improve SDoH outcomes—rental assistance, supportive housing, HCBS, and so forth—often through 1115 waivers. This new funding opportunity has unlocked an entirely new stream for communities that need to rely less on individual donors or grants, which can be fickle or unpredictable, in exchange for more stability.
However, taking advantage of Medicaid reimbursement is a challenging process for community-based organizations (CBOs). One example of such a program is CalAIM, for the State of California, which focuses on many vulnerable populations, including behavioral health services, homelessness, inmate re-entry, and more. Another example is the State of Minnesota’s substance abuse initiative using 1115 waivers.
Such programs cannot be fully realized without effective case management technology and an adequate billing workflow for reimbursements that comply with Medicaid standards. That’s why we at Eccovia have partnered with Health Roads, a technical assistance provider that has broken new ground in helping CBOs obtain Medicaid reimbursement for SDoH programs.
In this article, we detail the way data collection, client communication, and billing all work together with ClientTrack and Health Roads’ services.
As the federal and state governments expand the use of healthcare for improving SDoH outcomes, Eccovia and Health Roads stand ready to help communities realize their full funding potential—so they can play their part in mitigating homelessness, domestic violence, and other adverse events.
Schedule a demo with Eccovia today if you’re ready to discover what’s possible for your community.
