Strategies to Strengthen Health and Housing Partnerships Through Medicaid to Improve healthcare for Individuals Experiencing Homelessness

Dorr H, Townley C
Publication Year: 2017
Patient Need Addressed: Behavioral health, Chronic Conditions, Homelessness/housing
Population Focus: Medicaid beneficiaries
Intervention Type: Service redesign
Type of Literature: Grey

Individuals experiencing homelessness are disproportionately impacted by chronic medical and behavioral health conditions, and many of these individuals lack health insurance or a usual source of care. State Medicaid agencies and safety net providers are important partners in meeting the medical, behavioral health, and social service needs of individuals and families experiencing homelessness. In this new issue brief, along with the companion summary, NASHP explores how states have leveraged a range of federal authorities and care models to increase access to housing-related services, including Section 1115 Demonstrations, home and community-based services waivers and state plan options, contracted managed care organizations, accountable care models, and the health home state plan option. For additional information and detail, please see the full issue. This work was funded through a cooperative agreement with the Health Resources and Services Administration.

Insights Results

Overview of article/model

  • This brief explores how state Medicaid agencies have utilized a variety of federal authorities and delivery systems to increase access to supportive housing services and highlights important implementation considerations. Overall, the growth of managed care and accountable care models provide unique opportunities for Medicaid leadership to incentivize—or require—a focus on improving care for individuals experiencing homelessness
  • Many states have used Section 1115 authority to implement and expand access to supportive housing services. State examples implementing Section 1115 demonstrations include: 1) Increased access to housing and supportive services is an explicit goal of California’s Medi-Cal 2020 Demonstration; 2) Washington prioritized supportive housing services in its 1115 demonstration. Community Transition and Community Support services are included through the Foundational Community Supports program, which also includes a supportive employment benefit; and 3) New York included transitional supportive housing services as an optional system transformation project for participating provider groups
  • MCOs can be critical partners for states and providers working to better connect Medicaid beneficiaries experiencing homelessness with housing and housing-related support services. For example, In Minnesota, Hennepin Health, a county-administered Medicaid MCO that leads a local safety-net accountable care organization partnership, has created a Social Services Navigation Team that identifies individuals experiencing unstable housing and assists to secure permanent housing
  • While the majority of individuals experiencing homelessness live in urban areas, estimates of rural homelessness range from 7-28%. Data from a grant-funded initiative in Maine that provided permanent supportive housing to individuals and families experiencing homelessness in both rural and urban areas found second-year reductions in healthcare spending for rural participants. State Medicaid leadership should review the extent to which telehealth or mobile healthcare programs are utilized in rural areas and determine the feasibility of further implementing these models to expand access to care


    • Overall, the results indicate that the collaborative housing services improved individuals’ health so hospital services were not required, reduced unnecessary hospital utilization, and increased access to outpatient services

    Key takeaways/implications

    • The Medicaid Health Home State Plan Option may be a useful authority to better connect individuals experiencing homelessness with housing-related services and supports. Health homes are designed to ensure individuals receive whole-person, integrated care, including comprehensive care management, care coordination, and referral to relevant community and social support services as necessary and appropriate
    • Key considerations for implementation: 1) State waivers or demonstrations may allow greater flexibility to waive federal requirements (e.g., state-wideness), but these are typically time-limited and include budget- or cost-neutrality requirements; 2) Some Medicaid MCOs may not have the experience or expertise to meet the needs of individuals experiencing homelessness; 3) State Medicaid programs must ensure there is no duplication of services between health homes and other authorities, including targeted case management programs, HCBS waiver services, or care management services provided by managed care plans; 4) It’s important to cover tenancy support services as a standalone benefit rather than including them in a broader case management benefit, given most case managers do not have the capacity to address tenancy crises; 5) Medicaid agencies have limited opportunities to improve housing stock. In addition to restrictions on paying monthly rental or mortgage costs, federally-matched Medicaid funds cannot be used to fund the capital or brick-and-mortar costs associated with new construction or housing rehabilitation; and 6) Strong relationships between state health and housing agencies, service providers, and other key stakeholders is integral to improving care for individuals experiencing homelessness