Will Nebbitt suffers from seizures and painful blood clots in his legs that prevent him from walking very far. A former addict, he spent more than 25 of his 59 years in prison and almost the rest of his adult life homeless. Men like Nebbitt usually die young and on the street, yet he’s had a home for two years after help from a Los Angeles County program based on a radical new approach to health care.
As part of the so-called “Whole Person” approach, a division of the Los Angeles County Department of Health Services encourages the creation of housing units for the chronically homeless and offers case managers to help navigate the maze of doctors appointments, therapy and other medical care they need. Other California counties have followed suit because medical care doesn’t do much for people who don’t have shelter and food.
Now the federal government has approved a plan that will allow Medi-Cal to pilot a Whole Person Care program, with $1.5 billion in federal funding available over five years.
“The point of the pilot is how do we coordinate care across systems that currently don’t talk with each other,” said Sarah Brooks, Deputy Director of Health Care Delivery Systems at the California Department of Health Care Services.
As part of the approach, for the first time Medi-Cal dollars can be spent on finding housing for the most medically vulnerable and costly residents, and on services to keep them housed, such as landlord and tenant supportive services (the federal funding can’t be used for rent or construction of housing).
“Not only will it create an explosion of local activity, it will also have the eyes of people across the nation,” said Anthony Wright, executive director of the consumer advocacy group Health Access. No other state has ever been approved for using Medicaid dollars to support housing.
California counties, cities, hospitals, health plans, justice departments, housing authorities and others are forming teams and preparing to bid this spring for some of the newly available federal funds.
Like Los Angeles, San Diego and Santa Clara counties have already embarked on county housing programs linked to health care. Los Angeles County is one of the furthest along; its Housing for Health division started in 2012. Tax incentives, subsidies and case management for tenants encourage developers to set aside low-income units, said Leepi Shimkhada, Program Manager for the county’s Housing for Health Division.
One of the newest buildings is the Star Apartments owned by Skid Row Housing Trust. It contains a county clinic and 102 units of permanent housing for homeless people with complex medical and behavioral health conditions. The county saves $32,000 per client per year by helping to house these people, Shimkhada said.
In the last three years Housing for Health has housed 1,300 people and is on track to house more than 2,500 by the end of the year, said Mark Ghaly, deputy director of community health for the L.A. County Department of Health Services. Housing for Health funds the supportive services for clients and has a Flexible Housing Subsidy Pool which can subsidize rents through public and private sources.
Ghaly said L.A. will definitely apply for Whole Person Care pilot funding, and that money could pay for supportive services leaving more local dollars to subsidize rents.
Rene Santiago, director of the Santa Clara Valley Health and Hospital System, said his community is now gathering a team of three hospitals, the health department, a health plan, community clinics and organizations and private foundations to apply for funding.
In San Diego County, Project 25 is already saving money with a pilot which has housed 49 of the county’s highest-cost, chronically-homeless residents. It was initiated in 2011 by the homeless service provider Father Joe’s Villages. An independent study of 28 of Project 25’s clients reported a savings of $1.6 million the first year and $2.1 million the second year in public service costs, said project manager Marc Stevenson.
Stevenson thinks this project will probably apply for the Whole Person Care pilot.
“We’re all excited that this will expand our ability to provide services,” he said.
But flexible spending of the funds will be key. When United Way of San Diego County initially put up funding for Project 25, the only mandate was ‘get it done,’ he said.
“We had to be a crisis team,” Stevenson said. These clients often need intensive and unconventional care. If the client is an addict, he may need daily financial and medication management, or someone to take him shopping or help with detoxing at home, he said.
This unconventional care is paying off and health plans are buying in. Four health plans are contracting with Project 25 for an additional 20 clients. They pay a flat fee and work closely with Project 25 in establishing care. There’s a lot of flexibility in how the money can be used to serve clients, Stevenson said. And that approach saved a health plan $156,000 on one client in a year, Stevenson said.
That flexibility in spending will also be key for the Whole Person Care pilots, said Erica Murray CEO of the California Association of Public Hospitals and Health Systems.
“Part of the impetus for the pilot is to be able to do whatever is necessary to meet the patient’s needs, and we know often the most impactful interventions are not medical in nature…like finding stable housing,” she said.