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���������� Note: As states like ���������� look to ramp up their managed integrated care programs to particularly improve care and reduce cost to people with complex, ongoing conditions, here’s an account of a model that funds one of the key ‘social determinants of good health’: housing.
Both the Behavioral Health and Affordable Housing Work Groups of ����������’s Medicaid Redesign Team have called for reinvestment of savings from reduced use of hospitals and ERs to boost housing and other key supports (like peer support and employment).

Partnerships, Support Fuel Success of Creative Louisiana Housing Program

Mental Health Weekly March 4, 2012

A Louisiana permanent supportive housing initiative, with the support of key state agency partnerships, is offering more than 3,000 people with mental disabilities and other chronic health conditions across the Gulf Coast access to affordable, rental housing in integrated settings with the most appropriate services and supports.

The state is moving toward a managed care behavioral health system and hopes to include the initiative as part of that program, a move that would make the state’s Permanent Supportive Housing (PSH) the first to go statewide under a managed care umbrella, said officials.

The PSH program is considered the first large scale cross-disability PSH initiative in the country to include sustainable funding for both housing and support services, according to program officials. The PSH was initially created as part of the state’s Road Home hurricane recovery plan following hurricanes Katrina and Rita in 2005.

In 2008, Congress appropriated funding for 3,000 vouchers and subsidies specifically for Louisiana’s PSH program. The PSH model combines deeply affordable rental housing with voluntary, flexible, and individualized community‐based services to assist people with the most severe and complex disabilities to live successfully in the community.

As part of the program, the Department of Health and Hospitals (DHH) designated six entities to serve as Local Lead Agencies (LLAs) responsible for managing PSH infrastructure activities across all disability groups. LLAs are also responsible for mental health, substance use and developmental disability services.

Serving cross-disability groups

The PSH program serves individuals with mental illness, developmental disabilities, substance abuse, HIV/AIDS and other chronic and debilitating

illnesses physical disabilities, youth aging out of the foster system and the elderly.

“This is a service program first; then a housing program,” Marti Knisley, director of the community support initiative at the Technical Assistance Collaborative (TAC), Inc., in Boston, Mass., told MHW. Many states with permanent supportive housing initiatives design their program for specific disability groups, said Knisley. “This drives housing folks wild,” she said. “It’s best to have one program. It costs more money to have different management groups.”

TAC, a national nonprofit organization that offers solutions to housing and community support needs to low-income populations with long-term disabilities, is providing policy and program support for PSH.

To steer away from problems associated with complying with Olmstead, it’s important that states avoid creating an “institution-like” complex, said Knisley. “Don’t concentrate large numbers of people with disabilities in [one housing unit],” she said. Consumers in the program should live in the most integrated setting as possible, Knisley said.

State officials created 3,000 affordable housing units. About 2,500 individuals with cross-disabilities and their families have already been accommodated, said Knisley. Officials hope to fill the rest of the slots by early 2013, she said. “For the people who have moved in to the housing units, less than 5 percent have been evicted from the program since 2008,” Knisley said.

Agency partnerships

State agency partnerships helped provide the overall framework for the program’s design. The Louisiana Department of Health and Hospitals (DHH) and Children and Family Services, the Louisiana Office of Community Development and the Louisiana Housing Finance agency were critical for the creation of the program, according to the TAC policy brief. Homeless and disability advocates were instrumental in urging the federal and state government to take the required policy and funding actions necessary for the program’s success.

Funding for the program comes from multiple sources: The Office of Community Development, which distributes community development block grants (CDBG), state general funds, and the Department of Health and Hospitals (DHH).

“Producing positive individual and systemic outcomes in mental health often requires multiple stakeholders to come together,” Kevin Martone, director for behavioral health at TAC, told MHW. “PSH is a unique blend of housing and services, requiring expertise from the “The commitment of federal, state and local housing and service agencies to bring resources together is critical. Other states have struggled with this, and Louisiana is a

good example of forging these partnerships,” said Martone, former New Jersey mental health commissioner and former president of the National

Association for State Mental Health Program Director (NASMHPD).

Housing support teams

The PSH program includes eight providers who have multiple teams of case managers and peers to offer assistance to the populations served

in the program, said Knisley. Assertive Community Treatment (ACT) teams also assist individuals in the program with medication needs, helping them return to work, and with other services, she said. “We strongly encourage teams to hire peers, [especially because] of their track record of helping people obtain housing, jobs and remain stable in the community,” said Knisley.

Gay Leblanc, director of programs for the Jefferson Parish Human Services Authority (JPHSA), the local lead agency in the Parish district, oversees the PSH program in that district. “Our teams are able to work with a wide variety of disability groups,” Leblanc told MHW. “The housing support teams provide housing supports so the individuals also receive mainstream mental health services, for example, mental health clinic services, as well as mainstream substance abuse services, developmental disability services, etc.,” she said.

“The housing support teams do hands-on support work with the individuals we support,” said Leblanc. JPHSA monitors and provides technical

assistance to the team, she said. “The teams provide pre-tenancy, move-in, housing stabilization services, as well as crisis prevention and intervention,” she said. “Housing support teams have been very proactive in addressing any problems individuals in the program may be having.” To date, all 330 available housing slots under the program in Parish are filled, said Leblanc.

Managed care efforts

State officials are moving toward a managed behavioral health care system for Medicaid recipients in the state and have tapped Magellan Health Services, Inc., to provide the services. State officials are working on trying to get PSH to be a part of that program, said Christine Rhorer, program director for DHH/Office of Aging and Adult Services (OAAS).

“We’re in the early stages of a relationship with the new managed care organization for behavioral health,” Rhorer told MHW. “We’re looking at a mechanism to fund services with Medicaid.” While there’s been talk about Magellan beginning services as early as July, there has been no official agreement drawn up yet, said Rhorer.

Meanwhile many states are using various Medicaid programs, such as rehab option, waivers, and 1915(i) plan amendments to pay for some services in supportive housing, added Martone. “Many states though are still using state funds or have not taken their PSH programs to scale; for example, they’re small, scattered and in only parts of states,” he said.

“Louisiana’s managed care approach to PSH through Magellan and LLAs will ensure that Medicaid is used to fund eligible services thus leveraging federal financial participation and maximizing state and local funds to serve as many people as possible,” Martone said.

This model builds on managed care strategies by having the managed care provider also assume a role in coordinating the provision of PSH across disability groups and payer sources, he said. In other states, managed care may cover some services in PSH, but Louisiana established PSH as a priority and set clear expectations for the managed care provider in managing PSH in the system.

Martone added, “It will also ensure that those who can benefit from PSH have access to both permanent, affordable housing and a flexible continuum of services.” Other states can learn from Louisiana’s approach to PSH, Martone said. “It is a good example of implementing a Housing First PSH model on a large scale rather than random, small, program by program implementation we often see,” he said.

This approach is attractive to states seeking to implement Olmstead plans on a system-wide level, Martone said. “It is also important because it involves a cross-disability approach, serving not only people with mental illness, but also with substance use disorders and other disabilities,” he said.

For a copy of the policy brief, “Taking Integrated Permanent Supportive Housing (PSH) to Scale: The Louisiana PSH Program,” please visit

www.tacinc.org.