Homeless Outreach and Stabilization Team (HOST)
The Homeless Outreach and Stabilization Team (HOST) is a multi-disciplinary team model that integrates health and behavioral health services which are partially reimbursed by Medicaid. Bonita House and Lifelong Medical Care deliver services to people with serious mental illness, and often co-occurring substance use problems, who are experiencing chronic homelessness. Supportive services are connected to permanent supportive housing opportunities that include both single-site and scattered-site options using a Housing First approach.
Problem or Challenge:
Many people who are experiencing chronic homelessness have untreated mental illness or substance use problems as well as serious chronic health conditions that may contribute to mortality or avoidable hospitalizations and emergency room visits. If people experiencing homelessness are enrolled in Medicaid, these benefits often pay for emergency room visits, hospitalizations, or visits to clinics. Care for medical and behavioral health conditions, however, is too often fragmented and not connected to housing opportunities or tailored to meet the complex needs of people who have been homeless for a long time. Meanwhile providers of permanent supportive housing are often challenged by insufficient funding to pay for supportive services to help people experiencing chronic homelessness achieve stability.
Bonita House, a mental health services provider, operates a program known as HOST. Lifelong Medical Care, a Federally Qualified Health Center (FQHC), partners with Bonita House to employ a primary care provider (a physician’s assistant) who works as a member of the HOST team. Lifelong also provides on-site services in several permanent supportive housing projects and operates a clinic that provides more comprehensive health and behavioral health services and housing stabilization support services for tenants of supportive housing and other HUD-assisted housing.
HOST provides supportive services that do whatever it takes to engage and support recovery for adults with serious mental illness and co-occurring substance use problems who experience homelessness, using a Full Service Partnership model. The model incorporates many elements of the Assertive Community Treatment model. The team includes case managers, a peer counselor, a psychiatric nurse practitioner, a physician’s assistant, an employment specialist, housing staff, a supervising social worker, plus administrative support.
The staff to client ratio is 1:10. The team meets for 90 minutes every day, and team members spend 80 percent of their time in the field, making home visits or seeing clients in other community settings. A team member is on call 24 hours a day, seven days a week for crisis intervention, coaching in relapse prevention, and responding to landlords.
Clinical staff often works in partnership with other community outreach workers who have known and built a trusting relationship over time with the person who is experiencing homelessness who may be living on the streets or in an encampment. They use screening tools and complete assessments in the field to make a preliminary determination about eligibility for mental health services and then they call the county access team to review and get approval to enroll the person. This process streamlines access to county-funded mental health services. Because resources are scarce, there is a lot of pressure to ensure that only those with serious mental illness are served in programs funded in part through resources allocated by the county Mental Health Department, but Medicaid eligibility is not a condition or criterion used to determine eligibility for services or housing.
In California (and in many other states) Medicaid-covered mental health service contacts must be documented with progress notes that include date and duration (number of minutes), location, and a clear explanation of how the service meets the client’s mental health needs. For team consultations, only the minutes spent discussing a particular client are billable, and notes must describe the unique contribution of each staff member involved in the discussion.
The partnership between Bonita House and Lifelong Medical Care integrates the services of an experienced provider of mental health services and an experienced FQHC primary care provider. Team members from both organizations consult with one another during team meetings and as needed in order to coordinate care to the same group of people who are living in or linked to single-site or scattered-site supportive housing. The FQHC and the mental health service provider are funded and receive Medicaid reimbursement separately.
The mental health provider can receive reimbursement for a flexible range of services provided by unlicensed staff (with appropriate training and supervision), but only for persons with serious mental illness and for services and goals that can be related to symptoms of mental illness.
The FQHC provides and can receive Medicaid reimbursement for services delivered by licensed clinicians, including doctors, psychiatrists, nurse practitioners, physician assistants, and licensed clinical social workers; The FQHC can get reimbursed for services that address a broader range of health or behavioral health conditions whether or not a person has serious mental illness.
The partnership model bridges the gaps in reimbursement rules. Staff members coordinate to link care for needs related to medical, mental health, or other support services needs, and warm handoffs from one team member to another often allow clients to access different types of services on the same day in the same location. Each provider does what they do best and what they can get reimbursed.
HOST can offer housing assistance through several sources, including Shelter Plus Care vouchers, access to permanent supportive housing units that are set-aside in affordable housing developments, and other single-site and scattered-site permanent supportive housing options that are available through partnerships with the Oakland Housing Authority and non-profit housing providers as well as some flexible funding that can be used for interim housing or moving costs. The team includes a housing specialist who can help to streamline access to housing for program participants and services provided by HOST include a strong emphasis on housing stabilization support as well as helping to address symptoms of mental illness and supporting recovery from substance use disorders.
Build and sustain strong partnerships
Bonita House and Lifelong Medical Care initially received grant funding from sources that included foundations and HUD’s Supportive Housing Program to create partnerships to establish multi-disciplinary Integrated Services Teams to deliver on-site services in permanent supportive housing. Executive directors and program managers from both organizations have developed a shared mission and goals and a coordinated approach to hiring, training, and supervising staff for their collaborative work while also respecting and understanding each organization’s unique culture and role in the community. Leaders and staff from both organizations maintain ongoing communication and collaborate to plan new programs and solve problems.
Use flexible funding to implement integrated client-centered services and seek Medicaid reimbursement for covered services whenever possible
Many people experiencing homelessness have not been able to establish or maintain their eligibility and enrollment in Medicaid while cycling between life on the streets and time in jails or other settings and it can take time to document a person’s disability and establish (or re-establish) eligibility for SSI and Medicaid. Medicaid covers some but not all of the services needed to engage people experiencing chronic homelessness and do whatever it takes to help them move into permanent housing and pursue their hopes and goals while addressing challenges to stability. California’s voters approved funding for the Mental Health Services Act (MHSA), which pays for Full Service Partnership services for people with untreated mental illnesses, including people experiencing homelessness. HOST uses this flexible funding to engage and begin serving people who do not have Medicaid benefits and to fill gaps by paying for services that are not covered by Medicaid.
Provide training to guide staff in providing appropriate documentation for Medicaid-reimbursed services
Alameda County provides training to support efforts to obtain Medicaid reimbursement for covered services delivered by HOST and other service providers that use funding provided through MHSA to serve people experiencing homelessness who have serious mental illnesses and often co-occurring substance use problems. The training focuses on ensuring that service providers understand the definitions of Medicaid-reimbursable community mental health services and the medical necessity (or service necessity) criteria associated with each service, and that they know how to provide appropriate documentation in client assessments, service plans, and progress notes.
Engage clients by offering flexible services that respond to individual needs and priorities
Some people with serious mental illness who experience chronic homelessness may be reluctant to accept mental health services or treatment for co-occurring substance use problems but who are willing to accept care for other health conditions. The team can offer primary care services as the doorway into engagement in services that are connected to housing opportunities.
Even with staff doing home visits and accompanying clients to appointments or stores, or offering help to access neighborhood resources and build community-living skills, some clients are lonely and want a safe place to socialize. The HOST office provides space for group meetings as well as computers for web-based skills training through a partnership with Manpower that also offers help finding jobs or internships.
Medicaid reimbursement covers about 30 percent of the costs of services provided by HOST and about 40 percent of the costs of primary care services provided by Lifelong Medical Care.
In 2010, Bonita House reported outcomes for people served by the HOST program since 2006. When comparing the year prior to enrollment with the most recent year of enrollment, program participant outcomes included:
96 percent decrease in psychiatric hospital admissions
45 percent decrease in psychiatric hospital days
83 percent decrease in new incarcerations
94 percent decrease in days of homelessness
Contact Info for Follow-up:
Evidence Based Practice: Permanent Supportive Housing
Evidence Based Practice: Housing First
Evidence Based Practice: Integrated Treatment for Co-Occurring Disorders
Promising Practice: Streamlining Access to Housing
Promising Practice: Housing Stabilization Supports
Model Program: Community Support Program to End Chronic Homelessness