Community Support Program For People Experiencing Chronic Homelessness (CSPECH)
The Community Support Program for People Experiencing Chronic Homelessness (CSPECH) provides non-clinical support services to adults who are experiencing chronic homelessness so that they can be permanently housed in the community and prevent avoidable hospitalizations. CSPECH was created as one of the performance incentive projects supported by the Massachusetts Behavioral Health Partnership under contract with MassHealth, the Massachusetts Medicaid Program. MassHealth operates under a Medicaid Section 1115 demonstration waiver, which allows Massachusetts to offer an alternative set of benefits and payment mechanisms for services covered by Medicaid. The program is a promising example of opportunities to use Medicaid managed care to fund services linked to housing for people experiencing chronic homelessness.
Problem or Challenge:
There is significant evidence demonstrating the high cost of avoidable hospitalizations and emergency room visits for people experiencing chronic homelessness and the savings that can be achieved when people move into permanent supportive housing. Still, it can be challenging to use Medicaid reimbursement to pay for the services that support recovery and housing stability. In many states, people who are eligible for Medicaid are required to enroll in Medicaid managed care plans for health care and/or behavioral health services. Providers of services linked to Housing First models of permanent supportive housing often have limited experience contracting with managed care organizations (MCOs) and most MCOs have limited experience serving people experiencing homelessness who may have complex health problems, limited ability to care for themselves, and difficulty obtaining or becoming engaged with health care and treatment services.
CSPECH provides Medicaid reimbursement for community-based support services for individuals experiencing chronic homelessness who are placed in permanent housing using a Housing First approach. CSPECH is a unique innovation of the Massachusetts Housing and Shelter Alliance in partnership with the Massachusetts Behavioral Health Partnership, the state's MCO for behavioral health services for Medicaid recipients in the MassHealth Primary Care Clinician Plan (1). The Massachusetts Behavioral Health Partnership has the flexibility to identify special needs population cohorts and create special contracts to cover their needs. The capitated (per person) Medicaid financing provided to the Massachusetts Behavioral Health Partnership creates strong incentives to identify and more effectively coordinate and manage care.
Under the terms of a Federal Medicaid Section 1115 waiver, the state's Medicaid program covers diversionary services that are coordinated by the Massachusetts Behavioral Health Partnership and are intended to provide community-based alternatives to inpatient services. The covered services include Community Support Programs (CSP) that offer an array of services delivered by community-based, mobile, multi-disciplinary teams of paraprofessionals. CSP services are available to people enrolled in the MassHealth Medicaid program who have mental health or substance use conditions or are at increased medical risk. The services are designed to respond to the needs of people at high risk of hospital admission. CSP services are highly flexible in supporting people who have been unable to independently access and sustain involvement with needed services.
CSP covered services can include:
Assisting consumers in enhancing daily living skills
Providing service coordination and linkage
Assisting with obtaining benefits, housing, and health care
Developing a crisis plan
Providing prevention and intervention
Fostering empowerment and recovery, including linkages to peer support and self-help groups
The CSP services covered by MassHealth have been tailored in CSPECH to meet the needs of people who are experiencing chronic homelessness at the time of enrollment and who frequently have not been effectively engaged in other treatment services. Reimbursement rules for CSPECH allow payment for services based on a daily rate for the time during which a person is enrolled in the program. This payment mechanism makes it easier for service teams to provide assertive outreach and to build and sustain trusting relationships with people who have long histories of homelessness, who may need help with day-to-day activities or who may have problems that impede access to treatment. For individuals enrolled in CSPECH the frequency and intensity of services can vary from day-to-day or week-to-week; this program structure ensures that the service team can respond flexibly to clients’ needs and preferences over an extended period of time.
CSPECH participants meet three entry criteria: 1) coverage under the Massachusetts Behavioral Health Partnership insurance plan; 2) chronic homelessness status; and 3) medical necessity criteria for CSP services (which consider a diagnosis of mental illness or substance abuse disorder recognized in the DSM-IV). Additionally, participants must either be receiving intensive outreach prior to living in a Housing First model of permanent supportive housing or currently living in Housing First permanent supportive housing.
CSPECH began in September 2005, when Massachusetts Behavioral Health Partnership was asked by the Commonwealth's Executive Office of Health and Human Services to develop a behavioral health model that could support individuals who were experiencing chronic homelessness using a Housing First program as one of that year's Pay for Performance Outcome projects. Massachusetts Housing and Shelter Alliance and the Massachusetts public welfare agency were partners with the Massachusetts Behavioral Health Partnership in this effort.
CSPECH includes nine strategic partnerships around the state that were facilitated by the Massachusetts Behavioral Health Partnership and Massachusetts Housing and Shelter Alliance. The partnerships involve behavioral health providers in the Massachusetts Behavioral Health Partnership network and programs with housing vouchers from Federal or state funds to create scattered-site or single-site, low-threshold Housing First tenancies. Housing First is the foundation for CSPECH.
Innovative program models can begin as pilots and use evidence of savings to make the case for sustainability and expansion: CSPECH began as a pilot program with a cap on enrollment. This allowed the partners to launch the program and establish new partnerships, service models, and payment mechanisms. When the pilot program demonstrated results, including savings associated with reductions in hospitalizations, it was sustained and the enrollment cap was lifted.
Services that focus on trust and relationship are essential to help people keep housing and make connections to care after long periods of homelessness. Health care and clinical treatment services to address mental health or substance abuse problems are important, but the key to CSPECH’s impact has been the flexible, person-centered services, often provided by paraprofessionals, that establish trust and build relationships through home visits and help with life skills; doing whatever it takes to restore a person’s hope and resolve problems that threaten stability and recovery.
Currently, approximately 300 individuals covered by MBHP participate in CSPECH. The program estimates that this intervention results in a net Medicaid savings of more than $3 million.
Contact Info for Follow-up:
Joe Finn, President and Executive Director, Massachusetts Shelter and Housing Alliance firstname.lastname@example.org
Click here for a description of Community Support Programs (CSPs)
Evidence Based Practice: Permanent Supportive Housing
Evidence Based Practice: Housing First
Promising Practice: Housing Stabilization Supports
Model Program: Homeless Outreach and Stabilization Team (Alameda County, CA)
1. Most people who are approved for MassHealth must choose either a Primary Care Clinician Plan or a MassHealth MCO managed care plan. There are five MassHealth MCO plans but most people choose the Primary Care Clinician Plan.