In January 2022, California’s Department of Health Care Services (DHCS) rolled out the first phase of California Advancing and Innovating Medi-Cal (CalAIM), the state’s Medicaid waiver program and transformation initiative. Through CalAIM, Medi-Cal (Medicaid) managed care plans (MCPs) will forge partnerships with a wide variety of community-based organizations (CBOs), including housing and homeless service providers, to deliver person-centered care through a new statewide Enhanced Care Management (ECM) benefit and optional Community Supports. Several services designated as Community Supports aim to support Medi-Cal members experiencing homelessness, including housing transition services, housing deposits, housing tenancy and sustaining services, short-term post-hospitalization housing, and medical respite care.

The Center for Health Care Strategies (CHCS) spoke with Cheryl Winter, MPH, LICSW, senior program manager at the Corporation for Supportive Housing (CSH), to explore implementation considerations for MCPs and housing and homeless service providers as they establish partnerships to support people experiencing homelessness. This blog post is a product of CHCS’ California Health Care and Homelessness Learning Community, a project supported by the California Health Care Foundation.

Q: What do MCPs need to think about as they forge partnerships to support people experiencing homelessness?

A: MCPs will need to build a strong network of housing and homeless service providers who are experts at offering community-based, person-centered homeless outreach and housing support services. MCPs need to understand that the current homeless service provider system is underfunded and at risk because of staffing shortages and low pay. MCPs looking to build a network of providers will need to cover upfront costs of hiring, data, and finance infrastructure to strengthen the provider network by ensuring appropriate compensation that sustain the services and workforce.

Luckily, some provider networks do exist, as many homeless service providers are already connected to regional homeless service networks known as the Continuum of Care (CoC), a Housing and Urban Development (HUD) coordinating body. So in addition to connecting with individual providers, unhoused Medi-Cal members will benefit most if MCPs prioritize coordinating upstream with existing housing prioritization systems — like the Coordinated Entry System that is managed by a locality’s CoC — in order to optimize coordination of housing resources. Collaborating with CoCs and county entities that manage affordable housing resource allocation will be critical to helping members access housing and stay housed.

Finally, in many places in California, we’re operating with little to no available affordable housing. MCPs that want to help their members exit homelessness will need to invest in creating housing, a model we’ve seen some health care partners already doing around the country.

Q: How can organizations use Providing Access and Transforming Health (PATH) funding to support infrastructure development and better care for people experiencing homelessness?

A: There are so many opportunities to use PATH funding, and it is exciting to see the flexibility in how DHCS said the money can be used, including for additional staff, billing systems, data exchange enhancements, and collaboration across planning and implementation activities. Some specific opportunities are:

• Providing needed training. DHCS’ CalAIM Community Supports Evidence Library acknowledges evidence-based practices as critical elements of success, and PATH funding can be used to incorporate these elements into Community Supports, such as hiring more people with lived experience, building out multidisciplinary teams, and supporting staff in professional development so that they can specialize in person-centered outreach and engagement.
• Growing expertise in care coordination. Homeless service providers often have strong relationships with the clients they serve and can play a key role in helping individuals access health care services. PATH funds can be used to build out ECM clinical expertise and administrative support for homeless service providers who are already closest to and trusted by people experiencing homelessness.
• Resolving data exchange challenges. For people experiencing homelessness, navigating the back and forth between agencies, programs, MCPs, housing providers, and a variety of other complex systems can mean telling and retelling your life story, the traumatic events that led to homelessness, diagnoses, and challenges. Our systems can unintentionally retraumatize these individuals, because our data systems and programs often don’t share information. PATH funding can help to resolve data exchange challenges at the system and provider levels. For example, PATH funding can be used to ensure that existing data systems used by homeless service providers become HIPAA compliant. Right now, providers are entering data into multiple systems related to their many sources of funding. PATH funding can support changes to the existing Homeless Management Information System (HMIS) for an entire CoC, covering the costs to add new fields for Community Supports providers and granting access to the HMIS for appropriate health care partners.

Q: What are you most excited about in the CalAIM initiative?

A: DHCS’ recognition that housing brings stability in health and the state’s movement toward person-centered approaches are both exciting to me. While CalAIM starts to move us in this direction, more work will need to be done to shift the paradigm in the way services are delivered and paid for if we want to actually support the people Medi-Cal is trying to reach with this good intention. Knowing that DHCS sees housing-related Community Supports as health care services that are critical for member health is very promising. The intent of CalAIM’s Community Supports benefit — which acknowledges that housing-related services need to happen in the community rather than health care settings if we want to end homelessness — is very meaningful to everyone who works in this space.

Q: What do you think is a potential hurdle in the current rollout, and what are possible remedies?

A: Currently, Community Supports is an optional service and is being rolled out differently by each MCP, in each county, with different eligibility, authorization, rates, and referral processes that are subject to change. Early adopters of Community Supports are facing real business concerns as they attempt to staff up and provide high quality services that meet the strong evidence base, all while not knowing how many referrals they’ll receive, how long services will be authorized for, and many times, with rates that do not cover their ongoing program costs. Housing and homeless service providers must adapt by moving into the health care sector, which is a big lift because it changes how they receive referrals, how they document services, how they are paid, and adds new legal compliance and monitoring. This is a lot for CBOs to adjust to for an optional service. The flexibility built into Community Supports reflects the learning curve of adding new services for MCPs but can pose real challenges to providers seeking a sustainable funding source to provide much needed services to unhoused members.

Q: What are the ground-level impacts you would like to see from CalAIM in five years related to supporting the needs of people experiencing homelessness?

A: Ideally, we will see alignment of housing services and prioritization of housing for those who need it most, so that no member receives housing navigation services that don’t lead to housing. In addition, I’d love to see a strong homeless services workforce pipeline with a robust training program so that housing and homeless service providers don’t have to do all their own training. I would like to see service funding that will pay livable wages to support hiring adequate staff with lived experience, to maintain low caseload sizes, reduce turnover, and retain qualified staff. I would like to see housing-related services valued as health care services and housing and homeless service providers supported by funders to be able to produce the outcomes that we know are possible.

Q: Do you have any advice for organizations as they prepare to launch their own CalAIM implementation?

A: For MCPs, it is important to listen to what your providers are saying they need to meet fidelity to the evidence base. MCPs should use DHCS’ evidence library when contracting with housing and homeless service providers, and tailor the contracts after asking themselves: Are these providers able to offer services that meet the evidence base in caseload sizes with the rates we are offering? What can we do to support them in startup and sustainability? What can we expect in terms of outcomes? What partnerships do we need to foster to align housing with our services? MCPs can either contract with housing and homeless service providers that are able to meet those elements or provide incentives and start-up costs so that existing providers can work toward incorporating these best practices.  

For housing and homeless service providers, my advice is to know your total cost of care to achieve positive outcomes. If providers cannot currently meet evidence-based practices, they should identify what it will cost to get there in terms of improving service offerings and staffing models to achieve the desired outcomes. Reach out to MCPs and DHCS about the gaps in funding and alignment you are experiencing, and articulate what rates and incentives will enable you to scale up evidence-based practices to serve unhoused members well.