RD12 - Opportunities to Expand Permanent Supportive Housing for Virginians with Serious Mental Illness – January 2018

Executive Summary:

Permanent Supportive Housing (PSH) is an evidence-based practice that meets the housing preferences of many individuals with serious mental illness (SMI) and demonstrates positive outcomes such as reduced hospitalizations and homelessness, increased housing stability, and improved behavioral and physical health. These outcomes avoid costs associated with use of expensive systems such as psychiatric in-patient facilities, emergency departments and corrections facilities and helps the state comply with the Americans with Disabilities Act and Olmstead.

Recognizing the benefits of PSH, the General Assembly has requested the Department of Housing and Community Development (DHCD) work with state agencies and other stakeholders to develop and implement strategies to expand PSH for individuals with SMI. In order to fulfill the Assembly’s request, DHCD (1) established the Strategy Group, a cross disciplinary group including critical state agencies, stakeholders and other partners, (2) hired subject matter expert technical assistance to assist in developing strategies to expand PSH (Phase I) and an action plan to implement the strategies (Phase II), and (3) conducted Strategy Group meetings, individual agency interviews and collected data to inform decision making.

Based on this data collection and feedback from the Strategy Group, DHCD and its partners Department of Behavioral Health and Developmental Services (DBHDS), Department Medical Assistance Services (DMAS) and Virginia Housing Development Authority (VHDA) identified the following opportunities to expand PSH for individuals with SMI. Appendix C includes a Glossary of Terms.

Opportunities to Expand PSH through DMAS

Existing Medicaid Services

• Review existing Virginia State Plan and Medicaid Home and Community Based Waivers to:

o Identify what housing transition and tenancy support services, as described per Center for Medicare and Medicaid Services (CMS) guidance, are currently allowable under Virginia Medicaid and identify any gaps or opportunities for Virginia to cover new housing related services under Medicaid.

o Identify and address operational barriers to existing housing transition and tenancy support services for those individuals with SMI who are eligible for Medicaid (MA).

New Medicaid Services

• If new services are needed to cover the full array of transition and tenancy support services for Medicaid and Governor’s Assistance Program (GAP) enrollees with SMI, Virginia would need to obtain authority and funding from the Virginia General Assembly to include transition and tenancy support services as Medicaid-covered services, and:

o Amend the State Plan to include a full array of transition and tenancy support services for those individuals with SMI who are eligible for Medicaid (MA); and/or o Amend the Managed Care Waivers with CMS and the Medicaid Managed Care contracts to include the new services; and

o Amend the GAP Program Waiver with CMS to allow individuals who have SMI but don’t otherwise qualify for Medicaid to access these services.

Managed Care Organizations (MCOs)

• MCOs can be engaged in risk sharing approaches to support PSH such as:

o Implement performance/outcomes measures clearly related to housing stability.

o Add PSH as a performance measure for Medicaid managed care contracts.

o Develop alternative payment arrangements that support a package of transition/tenancy sustaining services and supports.

• DMAS to add housing status to assessments and require for MCO reporting, to better identify housing instability and evaluate the impact of services.

Opportunities to Expand PSH through DBHDS

DBHDS will seek to:

• Continue to emphasize the role of PSH (housing and community-based supportive services) in the STEP-VA model for strategic transformation of the publicly-funded behavioral health system by:

o Including PSH in the STEP-VA rollout, including planning, funding, and system alignment activities.

o Ensuring that PSH implementation adheres to STEP-VA’s goals to increase access, strengthen quality, build consistency, and bolster accountability across the Commonwealth.

• Examine current Discharge Assistance Program (DAP) utilization and explore strategies to align this funding with other housing initiatives for individuals with SMI, such as bridge funding to housing.

• Expand current, and explore additional, options to fund housing transition and tenancy support services for uninsured individuals, for example using state general funds and Mental Health Block Grant funds.

• Promote the impact of PSH on reducing criminal justice involvement for individuals with SMI.

• Fund additional DBHDS staffing to conduct evaluation, monitoring, and provide operational support to assure fidelity to PSH.

Opportunities to Expand PSH through Capital and Rental Assistance


DHCD and their partners recognize the need for capital funds to incentivize the development of PSH for individuals with SMI. Opportunities to expand capital include:

• Increasing funding for State Housing Trust Fund.

• Continuing to serve special populations, including individuals with SMI, within existing DHCD and VHDA housing efforts.

• Providing education and training to strengthen housing developers’ ability to successfully apply for funding to develop PSH for individuals with SMI.

• Exploring opportunities to use housing resources to create additional PSH for individuals with SMI.

• Through participation in the Innovation Accelerator Program (IAP), identifying need for new resources to create additional PSH for individuals with SMI, e.g. health care investments.

Rental Assistance

DHCD and their partners recognize the need for operating or rental assistance to make housing affordable to extremely low-income individuals with SMI. Opportunities to accomplish this include:

• Continuing to expand DBHDS PSH Program.

• Exploring project-based PSH including:

o Opportunities to project-base a limited number of DBHDS PSH vouchers.

o Opportunities for local Housing Authority Project-Based Vouchers targeted for SMI.

Opportunities to Expand PSH through Systems Supports

State Level Systems

• Expand the existing interagency, collaborative infrastructure to include the Strategy Group to address the housing needs of the SMI population:

o Through a network mapping process, analyze where there are overlapping efforts working on housing for special needs populations.

o Through state and federal initiatives aligning housing and services for individuals with disabilities, e.g., IAP and continued work with the Strategy Group, assess the capacity of state partners to implement recommended strategies; enhance systems capacity as needed.

o Through IAP and continued work with the Strategy Group, work to align PSH funding, policies and systems across partner agencies e.g. screening, assessment and referral processes; data matching systems, etc.

o Through IAP and continued work with the Strategy Group, explore how to “braid funding" to maximize use of state resources.

• Explore incorporation of PSH – SMI needs in planning processes, e.g. Consolidated Planning, Public Housing Authority Plans, and the Olmstead Plan.

Local/Regional Level Systems

• Continue to expand local PSH Program Housing Specialists to ensure all consumers in DBHDS PSH-funded programs have this service.

• Ensure CSBs and providers in all regions of the state have the opportunity to participate in a PSH Learning Collaborative.

Opportunities to Expand PSH through Public/Private Partnerships

• Engage health care systems to improve health by investing in housing:

o Educate health care systems on benefits of investment in housing.

o Identify opportunities to provide incentives for health care system investments in housing.

• Engage the philanthropic community.

DHCD plans to continue to work with the Strategy Group to develop and implement an Action Plan based on this Report and these identified opportunities. Working collaboratively at the state and local levels, the Commonwealth was able to decrease overall homelessness by 33 percent from 2010 to 2017, and in 2015, Virginia became the first state to effectively end veterans’ homelessness. Similarly, since 2015, the Commonwealth has housed approximately 700 individuals with developmental disabilities through the Housing & Supportive Services Initiative. The Commonwealth will build on these successes to inform the expansion of PSH for individuals with SMI and decrease homelessness and institutionalization for this population.