UM Guidelines

Applies to BlueCare Only.

Clinical Indications for Admission to Medically Fragile Supported Housing

• Admission to Medically Fragile Supported Housing is indicated due to ALL of the following:
  • Age 18 or older
  • Is medically stable (Health status won’t impair or impede gains and benefits in SH – those qualifying for PAR or PASRR for a higher level of care (such as nursing home) are not appropriate
  • Serious mental illness is present, as indicated by ALL of the following:
    • Current primary DSM-V-TR diagnosis (excluding primary diagnosis of severe I/DD, TBI, and dementia)
    • Chronic mental illness has been present for at least 2 years
    • Moderate dysfunction in daily living related to admission diagnosis for at least 3 months, as indicated by impairment in ALL of the following:
      • Interpersonal functioning: has lost all means of caregiver support within the community and cannot independently sustain a safe living environment due to mental illness
      • Ability to adapt to change – Has had numerous, extended inpatient treatment attempts with one occurring within the last 6 months and has demonstrated failed community tenure with maximum effort of natural and community supports
      • Ability to concentrate and complete tasks – exhibits inability to complete tasks and concentrate, BUT has capacity to respond favorably to rehabilitative counseling and training and other psychosocial rehabilitative services in order to meet 1 or more of the following:
        • Maximize his or her ability to independently participate in community, home, school or work activities 
        • Prevent relapse to lower levels of functioning
    • Psychiatric, behavioral, or other comorbid conditions related to admission diagnosis have been associated with significant life disruption in past 2 years, as indicated by 1 or more of following: 
      • 2 or more inpatient hospitalizations AND transitioning from a higher level of care, such as inpatient/subacute care and requires supervision in a structured setting due to mental health symptoms that prevent independent living and personal and community safety. 
      • 2 or more residential admissions AND transitioning from residential services, now in need of structured housing services to maintain tenure in the community
      • Criminal justice involvement (eg, arrest, incarceration) – Transitioning from incarceration where significant mental health issues have been noted and requires structured setting due to mental health symptoms that prevent independent living and personal and community safety
  • A need for Medically Fragile Supported Housing and patient presents with ALL the following criteria:
    • Has a medical condition requiring daily medical assistance in the form of specialized care (e.g., nursing, health technicians, durable medical equipment, etc.) which are manageable physical limitations (except inability to ambulate) and can perform all ADL’s.
    • Is not able to be maintained in Routine Supported Housing or Enhanced Supported Housing services due to the needs arising from a medical condition

Discharge Guidelines to Medically Fragile Supported Housing

• Continued Medically Fragile Supported Housing is generally needed until 1 or more of the following:
  • Medically Fragile Supported Housing is no longer necessary due to adequate patient stabilization or improvement, as indicated by ALL of the following:
    • Patient and supports understand follow-up treatment and crisis plan.
    • Provider and supports are sufficiently available in outpatient setting.
    • Patient or caregiver can safely manage care in outpatient setting without long-term community-based residential behavioral health care support.
    • Risk status acceptable, as indicated by ALL of the following:
      • Danger to self or others manageable/treatable, as indicated by 1 or more of the following:
        • Absence of thoughts of suicide, homicide, or serious harm to self or to another
        • Thoughts of suicide, homicide, or serious harm to self or to another present but manageable/treatable at available lower level of care
  • Lack of decompensation due to mental health conditions warranting close staff supervision
  • Medical needs absent or manageable/treatable at available lower level of care, as indicated by ALL of the following:
    • Medical comorbidity absent or manageable/treatable
    • Medical complications absent or manageable/treatable (eg, complications of eating disorder)
  • Medically Fragile Supported Housing is no longer indicated due to 1 or more of the following:
    • Higher level of care is indicated (eg, patient condition has deteriorated, greater service intensity is necessary to support engagement in care or reinforce skills, or more intensive supervision is necessary to address clinical needs).
    • Patient or guardian refuses treatment

References

Clark C, Guenther CC, Mitchell JN. Case Management Models in Permanent Supported Housing Programs for People With Complex Behavioral Issues Who Are Homeless. J Dual Diagn. 2016 Apr-Jun;12(2):185-92. doi: 10.1080/15504263.2016.1176852. Epub 2016 Apr 12. PMID: 27070841.

Culhane, Dennis & Metraux, Stephen & Hadley, Trevor. (2001). The Impact of Supportive Housing for Homeless People with Severe Mental Illness on the Utilization of the Public Health, Corrections, and Emergency Shelter Systems: The New York-New York Initiative. Housing Policy Debate. 13 (1).

Diamond, R.J. The psychiatrist’s role in Supported Housing. Hospital and Community 1993; Retrieved May 22, 2014 from http://ps.psychiatryonline.org/article.aspx?articleid=76782.

Goering, P., Tolomiczenko, G., Sheldon, T., Boydell, K. , Wasylenki, D. Characteristics of persons who are homeless for the first time. 2002; retrieved May 22, 2014 from http://ps.psychiatryonline.org/data/Journals/PSS/3591/1472.pdf.

Goldfinger, SM, Schutt, RK, Tolomiczenko, GS, Seidman, L, Penk, W, Turner,W, Caplan,B. Housing placement and subsequent days homeless among formerly homeless adults with mental illness. Psychiatric Services 1999;50: 674- 678.

Loubière S, Lemoine C, Boucekine M, Boyer L, Girard V, Tinland A, Auquier P; French Housing First Study Group. Housing First for homeless people with severe mental illness: extended 4-year follow-up and analysis of recovery and housing stability from the randomized Un Chez Soi d'Abord trial. Epidemiol Psychiatr Sci. 2022 Feb 7;31:e14. doi: 10.1017/S2045796022000026. PMID: 35125129; PMCID: PMC8851060.

McCarthy, J., Nelson, G. An evaluation of supportive housing for current and former psychiatric patients. Hospital and Community Psychiatry 1991; 42(12), 1254-56.

MEDICAID AND PERMANENT SUPPORTIVE HOUSING FOR CHRONICALLY HOMELESS INDIVIDUALS: Emerging Practices From the Field, Martha Burt Carol Wilkins Gretchen Locke Abt Associates August 20, 2014 Prepared for Office of Disability, Aging and Long-Term Care Policy Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Contract # HHSP23320095624WC

Morrell-Bellai, T. Becoming and remaining homeless: a qualitative investigation. Mental Health Nursing 2000; 21(6), 581-604.

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Policy and Global Affairs; Science and Technology for Sustainability Program; Committee on an Evaluation of Permanent Supportive Housing Programs for Homeless Individuals. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington (DC): National Academies Press (US); 2018 Jul 11. 3, Evidence of Effect of Permanent Supportive Housing on Health. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519591/

Owen C, Rutherford, V,Jones, M, Wright, C,Tennant C, Smallman, A. Housing accommodation preferences of people with psychiatric disabilities. Psychiatric Services 1996; 4(6), 628.

Stergiopoulos V, Mejia-Lancheros C, Nisenbaum R, Wang R, Lachaud J, O'Campo P, Hwang SW. Long-term effects of rent supplements and mental health support services on housing and health outcomes of homeless adults with mental illness: extension study of the At Home/Chez Soi randomised controlled trial. Lancet Psychiatry. 2019 Nov;6(11):915-925. doi: 10.1016/S2215-0366(19)30371-2. Epub 2019 Oct 7. PMID: 31601530.

Substance Abuse and Mental Health Services Administration. Permanent supportive housing: evaluating your program. HHS Pub. No. SMA-10-4509, Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services 2010. http://store.samhsa.gov/shin/content/SMA10-4510/SMA10-4510-05-EvaluatingYourProgram-PSH.pdf.

Substance Abuse and Mental Health Services Administration. Permanent Supportive Housing: Building Your Program. HHS Pub. No. SMA-10-4509, Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2010.

Tinland A, Loubière S, Boucekine M, Boyer L, Fond G, Girard V, Auquier P. Effectiveness of a housing support team intervention with a recovery-oriented approach on hospital and emergency department use by homeless people with severe mental illness: a randomised controlled trial. Epidemiol Psychiatr Sci. 2020 Sep 30;29:e169. doi: 10.1017/S2045796020000785. PMID: 32996442; PMCID: PMC7576524.

Tsemberis, S., Eisenberg R. Pathways to housing: Supported Housing for street-dwelling homeless individuals with psychiatric disabilities; 2000. Retrieved May 22, 2014 from http://ps.psychiatryonline.org/data/Journals/PSS/3540/487.pdf.

Footnote

HCPCS code used in addition to U2 modifier for medically fragile level of care.