GenIC #60 (New): SUPPORT Act Survey of Housing-Related Supports and Services Under Medicaid to Individuals with Substance Use Disorders

STATE TECHNICAL ASSISTANCE NEEDS ASSESSMENT -- Regarding housing-related supports and services and care coordination services under Medicaid to individuals with substance use disorders

Glossary of Terms

April 2020

Care coordination: Bringing together various providers and information systems to coordinate health services, patient needs, and information to help better achieve the goals of treatment and care.ⁱ

Chronic Homelessness: The Department of Housing and Urban Development defines a “chronically homeless’’ individual at 24 CFR Parts 91 and 578 to mean a homeless individual with a disability who lives either in a place not meant for human habitation, a safe haven, or in an emergency shelter, or in an institutional care facility if the individual has been living in the facility for fewer than 90 days and had been living in a place not meant for human habitation, a safe haven, or in an emergency shelter immediately before entering the institutional care facility. In order to meet the ‘‘chronically homeless’’ definition, the individual also must have been living as described above continuously for at least 12 months, or on at least four separate occasions in the last 3 years, where the combined occasions total a length of time of at least 12 months. Each period separating the occasions must include at least 7 nights of living in a situation other than a place not meant for human habitation, in an emergency shelter, or in a safe haven.ⁱⁱ

Co-occurring mental health and substance use disorders: When an individual has one or more mental disorders as well as one or more substance use disorders, the term “co-occurring” applies. Although people may have a number of health conditions that co-occur, including physical problems, the term “co-occurring disorders,” in this needs assessment, refers to substance use and mental disorders.ⁱⁱⁱ

Federally Qualified Health Centers (FQHCs): A mandatory Medicaid benefit category which includes primary and preventive services provided in a facility that has been determined by the Health Resources and Services Administration to meet the requirements of section 330 of the Public Health Services Act.

Homeless: Regulations promulgated by the Department of Housing and Urban Development at 24 CFR § 91.5 under the Homeless Emergency Assistance and Rapid Transition to Housing Act of 2009 (HEARTH Act) define homeless as follows:

“(1) An individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning: (i) An individual or family with a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus or train station, airport, or camping ground; (ii) An individual or family living in a supervised publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, or local government programs for low-income individuals); or (iii) An individual who is exiting an institution where he or she resided for 90 days or less and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution;

(2) An individual or family who will imminently lose their primary nighttime residence, provided that: (i) The primary nighttime residence will be lost within 14 days of the date of application for homeless assistance; (ii) No subsequent residence has been identified; and (iii) The individual or family lacks the resources or support networks, e.g., family, friends, faith-based or other social networks, needed to obtain other permanent housing;

(3) Unaccompanied youth under 25 years of age, or families with children and youth, who do not otherwise qualify as homeless under this definition, but who: (i) Are defined as homeless under section 387 of the Runaway and Homeless Youth Act (42 U.S.C. 5732a), section 637 of the Head Start Act (42 U.S.C. 9832), section 41403 of the Violence Against Women Act of 1994 (42 U.S.C. 14043e–2), section 330(h) of the Public Health Service Act (42 U.S.C. 254b(h)), section 3 of the Food and Nutrition Act of 2008 (7 U.S.C. 2012), section 17(b) of the Child Nutrition Act of 1966 (42 U.S.C. 1786(b)), or section 725 of the McKinney-Vento Homeless Assistance Act (42 U.S.C. 11434a); (ii) Have not had a lease, ownership interest, or occupancy agreement in permanent housing at any time during the 60 days immediately preceding the date of application for homeless assistance; (iii) Have experienced persistent instability as measured by two moves or more during the 60-day period immediately preceding the date of applying for homeless assistance; and (iv) Can be expected to continue in such status for an extended period of time because of chronic disabilities, chronic physical health or mental health conditions, substance addiction, histories of domestic violence or childhood abuse including neglect), the presence of a child or youth with a disability, or two or more barriers to employment, which include the lack of a high school degree or General Education Development (GED), illiteracy, low English proficiency, a history of incarceration or detention for criminal activity, and a history of unstable employment; or

(4) Any individual or family who: (i) Is fleeing, or is attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening conditions that relate to violence against the individual or a family member, including a child, that has either taken place within the individual’s or family’s primary nighttime residence or has made the individual or family afraid to return to their primary nighttime residence; (ii) Has no other residence; and (iii) Lacks the resources or support networks, e.g., family, friends, faith-based or other social networks, to obtain other permanent housing.”^iv

Homeless individual: For purposes of regulating health centers, the Public Health Service Act at § 330(h), 42 USC § 254b(h)(5)(A), defines a homeless individual as “an individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations and an individual who is a resident in transitional housing.”^v

Homeless Management Information System (HMIS): “A [HMIS] is a Department of Housing and Urban Development-funded local information technology system used to collect client-level data and data on the provision of housing and services to homeless individuals and families and persons at risk of homelessness. Each Department of Housing and Urban Development-funded Continuum of Care is responsible for selecting an HMIS software solution that complies with the Department of Housing and Urban Development’s data collection, management, and reporting standards.”^vi

Housing First: As recognized by the Department of Housing and Urban Development and the Substance Abuse and Mental Health Services Administration, Housing First is an evidence-based practice approach used “to quickly and successfully connect individuals and families experiencing homelessness to permanent housing without preconditions and barriers to entry, such as sobriety, treatment, or service participation requirements. Supportive services are offered to maximize housing stability and prevent returns to homelessness as opposed to addressing predetermined treatment goals prior to permanent housing entry.”^vii

Housing navigator: Housing navigators have a strong working knowledge of available resources to link individuals to needed programs, and making warm handoffs whenever possible. Navigators have a comprehensive knowledge of state, county, city, and community resources including not only housing options, locations, and availability, but also services including health, mental health, benefits, employment, and transportation, etc. The Navigator uses this knowledge to facilitate ‘active’ linkages before, during, and/or after permanent housing has been established as well as work to enhance individual’s skills in utilizing these various resources, which are critical to the maintenance of permanent housing.^viii

Housing-related supports and services: Federal financial participation is not available to state Medicaid programs for room and board (except in certain medical institutions). However, federal financial participation is available under certain federal authorities for housing-related supports and services that promote health and community integration to include (1) Individual Housing Transition Services - services that support an individual’s ability to prepare for and transition to housing; (2) Individual Housing & Tenancy Sustaining Services - services that support the individual in being a successful tenant in his/her housing arrangement and thus able to sustain tenancy; and (3) State-level Housing Related Collaborative Activities - services that support collaborative efforts across public agencies and the private sector that assist a state in identifying and securing housing options for individuals with disabilities, older adults needing long term services and supports (LTSS), and those experiencing chronic homelessness.”^ix

HUD Continuum of Care Grant: The Department of Housing and Urban Development Continuum of Care grant program is designed to: “promote community-wide commitment to the goal of ending homelessness; provide funding for efforts by nonprofit providers, and state and local governments to quickly rehouse homeless individuals and families while minimizing the trauma and dislocation caused to homeless individuals, families, and communities by homelessness; promote access to and effect utilization of mainstream programs by homeless individuals and families; and optimize self-sufficiency among individuals and families experiencing homelessness.”^x

HUD Continuums of Care: To carry out the primary purpose of the Continuum of Care grant program, the Department of Housing and Urban Development requires representatives of relevant organizations, such as nonprofit homeless providers, victim services providers, and local governments, to form a Continuum of Care to take on coordination of homeless services and homelessness prevention activities across a specified geographic area.^xi

Long-term Services and Supports (LTSS): Long-term services and supports (LTSS) encompass a variety of health, health-related, and social services that assist individuals with functional limitations due to physical, cognitive, or mental conditions or disabilities. LTSS includes assistance with activities of daily living (ADLs, such as eating, bathing, and dressing) and instrumental activities of daily living (IADLs, such as housekeeping and managing money) over an extended period of time.^xii

Managed Care Organizations (MCOs): A managed care organization (MCO) is a type of managed care plan that has a risk contract to provide comprehensive Medicaid state plan services and meets certain requirements under section 1903(m) of the Act and 42 C.F.R. Part 438.2. MCOs are paid a set actuarially sound per member per month capitation rate for furnishing these services.^xiii

Medicaid Innovation Accelerator Program (IAP): This Centers for Medicare & Medicaid Services program works to improve the health and health care of Medicaid beneficiaries and to reduce costs by supporting states’ ongoing payment and delivery system reforms through targeted technical support. The Medicaid IAP represents the Centers for Medicare & Medicaid Services’ unique commitment to support state Medicaid agency efforts toward system-wide payment reform and delivery system innovation.^xiv

Opioid use disorder (OUD): Defined in the Diagnostic and Statistical Manual of Mental Disorders-5 as a “problematic pattern of opioid use leading to clinically significant impairment or distress.”^xv

Outreach and engagement: Medicaid administrative costs for outreach and engagement activities relate directly to a Medicaid State plan or waiver service. Costs could include activities such as explaining Medicaid requirements; conducting Medicaid outreach; facilitating application to Medicaid; or providing referral assistance.^xvi

Permanent supportive housing: The Department of Housing and Urban Development defines permanent supportive housing as “permanent housing with indefinite leasing or rental assistance paired with supportive services to assist homeless persons with a disability or families with an adult or child member with a disability achieve housing stability.”^xvii

Public Health Agencies: Public health agencies at state and local levels that comprise a public health system. Public health systems are commonly defined as “all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.” This concept ensures that all entities’ contributions to the health and well-being of the community or state are recognized in assessing the provision of public health services.^xviii

Public Housing Authorities: Any state, county, municipality, or other governmental entity or public body, or agency or instrumentality of these entities that is authorized to engage or assist in the development or operation of low-income housing under the U.S. Housing Act of 1937.^xix

Rapid Rehousing : Rapid rehousing is a Department of Housing and Urban Development-funded “intervention, informed by a Housing First approach that is a critical part of a community’s effective homeless crisis response system. [Rapid rehousing] rapidly connects families and individuals experiencing homelessness to permanent housing through a tailored package of assistance that may include the use of time-limited financial assistance and targeted supportive services.”^xx

Recovery housing: As funded by SAMHSA, recovery residences are safe, healthy, family-like substance-free living environments that support individuals in recovery from addiction. While recovery residences vary widely in structure, all are centered on peer support and a connection to services that promote long-term recovery. Recovery housing benefits individuals in recovery by reinforcing a substance-free lifestyle and providing direct connections to other peers in recovery, mutual support groups and recovery support services. Substance-free does not prohibit prescribed medications taken as directed by a licensed prescriber, such as pharmacotherapies specifically approved by the Food and Drug Administration (FDA) for treatment of opioid use disorder as well as other medications with FDA-approved indications for the treatment of co-occurring disorders.^xxi

Single State Agency for Substance Abuse Services: State’s authority who oversees the Substance Abuse and Mental Health Services Administration Substance Abuse Prevention and Treatment Block Grant (SABG) and funding for substance abuse programs in their state as indicated by US Code - 42 USC §300x–32.^xxii

Substance Abuse and Mental Health Services Administration (SAMHSA) grants: SAMHSA funds a variety of grants that address issues related to mental health and substance use, including a significant housing and homelessness portfolio. Grant programs that are likely to support work related to housing, homelessness, and people with substance use disorders include:

• Treatment for Individuals Experiencing Homelessness (https://www.samhsa.gov/homelessness-programs-resources/grant-programs-services/tieh-program),

• Grants for the Benefit of Homeless Individuals (https://www.samhsa.gov/homelessness-programs-resources/grant-programs-services/gbhi-program),

• Projects for Assistance in Transition from Homelessness (https://www.samhsa.gov/homelessness-programs-resources/grant-programs-services/path),

• Cooperative Agreements to Benefit Homeless Individuals (https://www.samhsa.gov/homelessness-programs-resources/grant-programs-services/cabhi-program), and

• The Substance Abuse Prevention and Treatment Block Grant (https://www.samhsa.gov/grants/block-grants/sabg).

Please visit https://www.samhsa.gov/homelessness-programs-resources for more information about SAMHSA activities related to housing and homelessness and www.samhsa.gov/grants for more information about these and other SAMSHA grant programs.

Substance use disorder (SUD): Substance use disorders “occur when the recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.”^xxiii

State Mental Health Agency: State’s authority who oversees the Substance Abuse and Mental Health Administration Mental Health Block Grant and funding for mental health programs for adults with serious mental illness and children with serious emotional disturbances in their state.^xxiv

State Housing Finance Agency: State-chartered authorities established to help meet the affordable housing needs of the residents of their state.^xxv

Transformed Medicaid Statistical Information System (T-MSIS): Encompasses the set of data produced in the daily operation of the Medicaid and CHIP programs. These are the data about enrollees, services, and costs, including but not limited to: fee-for-service (FFS) claims, encounters performed under managed care arrangements, beneficiary eligibility and demographic information, and provider enrollment data. ^xxvi

Transitional supportive housing: Department of Housing and Urban Development-funded transitional housing provides people experiencing homelessness a place to stay combined with supportive services for up to 24 months.^xxvii

U.S. Department of Housing and Urban Development (HUD): Established in 1965, the Department of Housing and Urban Development’s mission is to increase homeownership, support community development, and increase access to affordable housing free from discrimination. To fulfill this mission, the Department of Housing and Urban Development will embrace high standards of ethics, management and accountability and forge new partnerships — particularly with faith-based and community organizations — that leverage resources and improve the Department of Housing and Urban Development’s ability to be effective on the community level.^xxviii

i Substance Abuse and Mental Health Services Administration-Health Resources & Services Administration. “Care Coordination”. Date unavailable. Available at https://www.integration.samhsa.gov/workforce/care-coordination.

ii Chronically Homeless Final Rule, HUD, 24 CFR Parts 91 and 578 (2019).

iii Substance Abuse and Mental Health Services Administration. “Trauma-Informed Care in Behavioral Health Services.” HHS Publication No. (SMA) 14-4816. 2014. Available at https://store.samhsa.gov/product/TIP-57-Trauma-Informed-Care-in-Behavioral-Health-Services/SMA14-4816.

iv 24 CFR § 91.5 (2019).

v Public Health Service Act § 330(h), 42 USC § 254b(h)(5)(A).

vi U.S. Department of Housing and Urban Development. “Homeless Management Information System.” 2019. Available at https://www.hudexchange.info/programs/hmis/.

vii U.S. Department of Housing and Urban Development. “Housing First in Permanent Supportive Housing.” Date unavailable. Available at https://files.hudexchange.info/resources/documents/Housing-First-Permanent-Supportive-Housing-Brief.pdf.

viii VA National Center on Homelessness Among Veterans. “VA Navigator Toolkit.” 2016. Available at https://www.va.gov/HOMELESS/nchav/docs/Housing_Navigator_Toolkit_PDF.pdf.

ix Centers for Medicare & Medicaid Services. “Coverage of Housing-Related Activities and Services for Individuals with Disabilities.” CMCS Informational Bulletin. June 26, 2015. Available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib-06-26-2015.pdf.

x U.S. Department of Housing and Urban Development. “Continuum of Care (CoC) Program.” 2019. Available at https://www.hudexchange.info/programs/coc/.

xi U.S Department of Housing and Urban Development. “Introductory Guide to the Continuum of Care Program.” 2012. Available at https://files.hudexchange.info/resources/documents/CoCProgramIntroductoryGuide.pdf

xii Thach, N.T., & Wiener, J.M. (2018). An Overview of Long-Term Services and Supports and Medicaid. Final Report.

xiii US Code- 42 CFR 438.2. Date unavailable. Available at https://www.govregs.com/regulations/expand/title42_chapterIV_part438_subpartA_section438.2.

xiv Centers for Medicare & Medicaid Services. “Medicaid Innovation Accelerator Program:” 2019. Available at https://innovation.cms.gov/initiatives/MIAP/.

xv Centers for Disease Control and Prevention. Date unavailable. “Module 5: Assessing and Addressing Opioid Use Disorder (OUD).” Available at https://www.cdc.gov/drugoverdose/training/oud/accessible/index.html.

xviAllowable Administrative Expenditures. https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SMD122094.PDF

xvii U.S. Department of Housing and Urban Development. “Continuum of Care (CoC) Program Eligibility Requirements.” 2019. Available at https://www.hudexchange.info/programs/coc/coc-program-eligibility-requirements/.

xviii Center for Disease Control and Prevention. “The Public Health System & the 10 Essential Public Health Services”. Date unavailable. Available at https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html.

xix U.S. Department of Housing and Urban Development. “HUDUser Glossary.” Date unavailable. Available at https://archives.huduser.gov/portal/glossary/glossary_p.html.

xx U.S. Department of Housing and Urban Development. “Rapid Re-Housing Brief.” July 2014. Available at https://www.hudexchange.info/resource/3891/rapid-re-housing-brief/.

xxi Substance Abuse and Mental Health Services Administration. “Recovery Housing: Best Practices and Suggested Guidelines.” Date unavailable. Available at https://www.samhsa.gov/sites/default/files/housing-best-practices-100819.pdf.

xxii US Code - 42 USC §300x–32. Date unavailable. Available at https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300x-32&num=0&edition=prelim.

xxiii Substance Abuse and Mental Health Services Administration. “Mental Health and Substance Use Disorders.” April 13, 2019. Available at https://www.samhsa.gov/find-help/disorders.

xxiv Substance Abuse and Mental Health Services Administration. “Funding and Characteristics of Single State Agencies for Substance Abuse Services and State Mental Health Agencies, 2015.” 2017. Available at https://store.samhsa.gov/system/files/sma17-5029.pdf.

xxv Transformed Medicaid Statistical Information System (T-MSIS) Data Memo.” Available at https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/SMD-13-004.pdf

xxvi Centers for Medicare & Medicaid Services. “Transformed Medicaid Statistical Information System (T-MSIS).” Date unavailable. Available at https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/index.html.

xxvii U.S. Department of Health & Human Services. “The 2018 Annual Homeless Assessment Report (AHAR) to Congress. Part 1: Point-in-Time Estimates of Homelessness.” December 2018. Available at https://files.hudexchange.info/resources/documents/2018-AHAR-Part-1.pdf.

xxviii U.S. Department of Housing and Urban Development. “HUDUser Glossary.” Date unavailable. Available at https://archives.huduser.gov/portal/glossary/glossary_u.html.