With the current changes in Medicaid reform about to take place, it has become more important than ever to produce measurable results in resource administration. The management of limited high cost Medicaid and or Medicaid support services is imperative as well. With the proposal from the New York State Medicaid Reform Team, the Department of Health will be producing lists of high priority individuals using Medicaid expense patterns. Resource match to need is a method of assuring the right person receives the right service at the right time for the right length of time to achieve the right outcomes. The general goal of the Regional Behavioral Health Organization reflects a decrease in high cost Medicaid services/settings. The benchmarks are projected to be associated with a decrease in unnecessary psychiatric hospitalizations/re-hospitalizations, decrease in ER use, decrease in arrests, increase in community based clinical linkages and a increase in consumer’s overall health and well-being.
An important resource that can produce critical outcomes within a community is safe and affordable housing of one’s choice. A highly effective method to produce such outcomes with a high-end consumer base is harm reduction using the supported housing model. The concept of harm reduction has been a significant contributor in the stabilization of cereal inebriates and rapid recidivist in chemical dependency programs for decades. There are a multitude of clinical studies supporting the results of decrease harm and cost in this population using this approach. Generally speaking, success is measured in any type of improvement weather that is a decrease in substance consumption or just maintaining residential stability in the community. Not being homeless is viewed as a significant event towards recovery goals even if chemical usage and treatment resistance continues. The opportunity for change is viewed as an ongoing process and may occur at any given point in time. Support is unconditional that allows for the individual to emulate positive relationship building that can have a long-standing impact on the individual’s view of the world and their place in it.
Many deep end penetrators into the Medicaid resource pool can be stabilized by using relatively inexpensive supportive housing dollars (Interactive Tool; 1 March 2010. National Alliance to End Homelessness). With the use of the harm reduction model, these housing programs operate under the basic premise that it is important to meet an individual where they are in recovery instead of producing additional obstacles that could elongate the process of obtaining stable housing. Traditional methods in chemical dependency treatment as well as housing management insist the individual with chemical dependency issues provide some period of abstinence (6 months is common) before housing resources will be provided. “There is no empirical support for this practice of requiring individuals to participate in psychiatric treatment or attain sobriety before being housed” (April 2004, No.4, American Journal of Public Health 651-656). Many high-end consumers have become disenfranchised by these models which produce limited outcomes while the individual still is engaged in high risk, high cost behaviors. These individuals remain on the streets, in homeless shelters or in places not meant for human habitation such as burned out buildings or under bridges. Combine all these factors with a Severe Mental Illness and the measurable outcome for decreasing high cost services does not seem likely. Attempting to obtain much less maintain sobriety while on the streets is nearly an impossible expectation. The lack of a positive support system combined with the general day to day homeless lifestyle does not support the abstinent model. Many individuals in these situations have untreated medical conditions that are exacerbated by the unstable environments they have been forced to survive in. However, the use of supported housing dollars has shown to produce a significant decrease in the cost of delivering such services (Culhane, Dennis, 2002. The NY/NY initiative Housing Policy Debate 13.1(2002):107-163).
Coordination of care is another significant factor in reducing the utilization patterns of such individuals. The use of the Continuous Case Management Model has shown to be a successful practice in working with individuals in housing with various needs (Drake,et al 1993; Journal of Nervous Mental Disease; 181:606-611). This model is based on the premise that a single case manager will be responsible for the coordination of service and communicating change in the individual’s profile. These services include housing issues, medical, clinical, chemical dependency and any other significant service need that is assessed. The primary goal is to engage, make linkages, assure linkages are in place and maintained and then introduce natural support systems in the community that will eventually illuminate the need for continued usage of reimbursed services. Generally, these services are front loaded in nature, meaning the frequency of contact is highest in the engagement phase and decreases as the individual goals are met. Case management in supported housing remains with the individual until alternative permanent housing has been secured in the community. This allows for case management to remain in place much longer than other traditional Medicaid reimbursed Intensive Case Management services. Relationships can be developed further and trust can be fostered. Individuals who may have refused services in the past may now be willing to explore methods that may create long term achievements in reducing harmful behavioral activities. This model allows for an ongoing relationship that can be increased or decreased depending upon changing needs.
In conclusion, the cost savings in supported housing has been well demonstrated across the high cost resource pool. With the anticipated changes in Medicaid reform, these savings become more important in the management of such resources. Harm reduction in housing allows for the availability of housing to become more accessible and therefore more likely to produce critical outcomes and cost savings against Medicaid billable services. Ongoing case management in housing allows for the opportunity to provide important support that can create long term stability in the community. Meeting individuals where they are in recovery produce a nonjudgmental framework and can support movement in treatment goals. Harm reduction uses abstinence as a long-term goal that the individual needs to embrace first before attempting to obtain. One of the most significant outcomes is the improvement in quality of life indicators. Harm reduction in housing can produce both, cost savings while providing safe and affordable housing in the SMI/CD population.
