Finding Shelter And Support Along The Road To Better Health

Under California's Whole Person Care program, Sacramento is using Medicaid funds to help its homeless population find housing.

D riving along the north edge of downtown Sacramento, California, in a maroon minivan, community health worker Jamie Kaihe-Valles flipped on the turn signal and took a right onto a wide road that led to the homeless shelter where one of her clients was staying. Along the road, people had pitched tents and made camps by tying tarps and tattered blankets to a chain-link fence. There aren't nearly enough shelter beds for the city's growing homeless population, so the area surrounding this shelter has become a popular spot to hang out.
"There are a lot of campers out here," Kaihe-Valles said, as she slowed the van to a stop for a man walking in the street who didn't seem to notice her. "Hello," she quietly said to herself, and then honked the horn-which got the man's attention. "Sorry, don't want to hit you, buddy," she said, driving ahead.
Kaihe-Valles spotted her client, Noel Tyler-a fifty-three-year-old man who had had his right leg amputated last year-waiting for her in a wheelchair outside the shelter near a pile of various bike parts, as she pulled into a parking spot. Tyler, a solemn man with distant eyes and a graying horseshoe mustache, had landed at the shelter not long after he lost his leg. He had an appointment with a housing counselor that afternoon, and he was excited about the possibility of getting his own space with some actual privacy, rather than having to share with seventy-nine other men. Every day the shelter closed from 6 a.m. to 8 p.m., so Tyler, and everyone else staying there, had to leave for fourteen hours. Tyler often went to Loaves and Fishes, a nearby homeless services provider that offered food, coffee, showers, and a safe place to hole up for the morning. Then he'd head over to the public library and then back to the shelter, to wait outside until they opened the doors for dinner.
Kaihe-Valles had been working with Tyler for about a year as part of a cityled program called Pathways to Health and Home (commonly referred to as Pathways), an all-hands-on-deck effort to house the area's most vulnerable and highest-need people experiencing homelessness. She took Tyler to numerous medical appointments, including for prosthetic fittings, physical therapy, pain management, and primary care.
Before arriving at the shelter, Tyler had rarely lived indoors-he had slept outdoors on the streets, mostly in public, on and off since 2009. He was living outdoors when an open sore on his right leg became infected with maggots. If he hadn't gone to the hospital when he did, the infection would have spread. Instead, his leg was promptly amputated. Now Tyler was one of 745 active clients enrolled in Pathways, a Medicaidfunded four-year pilot program that provides coordinated delivery of an array of physical and behavioral health services, as well as homeless outreach, social services, case management, and housing support, for some of the county's most medically and behaviorally complex people experiencing or at risk of homelessness. In response to the increasing homeless population in Sacramento, the city announced an ambitious goal to house 2,000 people by 2020, and Pathways was the driving force behind that commitment.
Not only did Tyler and the other clients have a health care worker (Kaihe-Valles, in Tyler's case), but they also got an outreach worker to help with social services and overall coordination among referrals and a housing navigator to help with apartment searches; rental applications; transportation; mediation with landlords; and financial support for a deposit, furniture, or the first month's rent.
Tyler pulled himself into the front passenger seat, Kaihe-Valles packed his wheelchair away in the back, and they drove off to a downtown health clinic to meet a housing counselor. On the way, the two talked about Tyler's recent prosthetic appointment. Tyler told Kaihe-Valles that the doctor wanted him to wear the prosthetic leg more often so he could get used it and learn to walk again. "Well, have you been?" she asked. "No," he replied, telling her it hurt and felt weird.
Even with a lot of support, finding permanent housing for Tyler was going to be difficult. He most likely would qualify for a housing voucher, but because he did not have any income, the subsidy would max out at $700, give or take, depending on the ZIP code. And like in most California cities, rents were skyrocketing in Sacramento, which was listed on Zillow as one of the top-ten hottest housing markets in the nation in 2017, 1 with both prices and volume of sales increasing. 2 Even in an affordable part of town, a one-bedroom apart-ment rented for at least $1,000. And Tyler needed a ground-floor apartment or a unit in a building with an elevator, which made the search even more challenging.
The end goals for Pathways clients are self-sufficiency and housing, but the latter is proving to be one of the program's greatest challenges. Because Pathways is funded by Medicaid, which doesn't allow funding to be used for housing, it can't guarantee clients a place to live. Instead, what it can do is pull together existing resources in a coordinated effort among local partners-health clinics, hospitals, managed care plans, and community-based organizationsto support each client with a "whatever it takes" mentality, while helping them navigate a bureaucratic maze to get from a life outdoors to one indoors, leaping obstacle after obstacle until each client is housed. At least, that is the hope.

Whole Person Care Pilots
Pathways is Sacramento's adaptation of Whole Person Care, a statewide pilot program offered through Medi-Cal, California's version of Medicaid. Whole Person Care is an opportunity for communities to pull down matching federal dollars to improve health outcomes among vulnerable populations with services that aren't typically funded by Medicaid. 3 Whole Person Care operates under the Medi-Cal 2020 Waiver, a Section 1115(a) waiver, which was approved in December 2015 by the Centers for Medicare and Medicaid Services for a five-year trial period to investigate new strategies for using Medicaid to drive system change to improve health outcomes across the state. Within the Whole Person Care framework, eligible populations must be high-risk patients who are also high utilizers of system services and continue to have worsening health outcomes.
Whole Person Care's approach recognizes that the health status of these high-risk, high-utilizing populations is worsened by the social determinants of health related to poverty, such as lack of safe and stable housing, food insecurity, income insecurity, unemployment, and incarceration. To address the root causes of this problem, the program provides local entities with up to $3 billion in matching one-for-one funds-half of which comes from federal Medicaid and the other half of which comes from local funds-to support collaboration among health, behavioral health, and social service providers, as well as community-based organizations and managed care plans. The goal is to deliver coordinated care that is tailored to the target population-hence the name Whole Person Care, an approach also referred to as patient-centered care.
Nearly all of the lead agencies for the twenty-five Whole Person Care pilots across the state are either counties or health care systems; Sacramento is the only city to implement a pilot. It is rare for a city to go after a Medicaid program such as Whole Person Care because cities don't typically deal with the delivery of health care, deferring instead to the county of which the city is a part.
At the time the state was accepting applications for Whole Person Care pilots, Sacramento was in the midst of a homeless and housing crisis. From 2015 to 2017 the homeless population in Sacramento County increased by 30 percent, 4 and the number of people experiencing chronic homelessness more than doubled. At the same time, affordable housing vacancies were shrinking, as rents and home prices continued to rise.
Many people within the housing, health, and homeless services sectors saw Whole Person Care as an opportunity to address an issue that had become an increasingly vexing problem in the community. However, Sacramento County decided not to apply for Whole Person Care, arguing that the funding would "not address the most critical needs of those who are homeless," according to a document released by the county. 5 Because the funding couldn't be spent on housing and instead went to hiring health navigators and case managers, the county claimed it would actually lead to longer waiting lists for services instead of actually providing services.
At the end of 2016 Sacramento elected a new mayor, Darrell Steinberg, a longtime advocate for mental health reform and a seasoned politician. He had served in the state legislature for more than a decade and was the author of the California Mental Health Services Act, which passed as Proposition 63 in 2004. Steinberg said that he had been elected mayor in large part on a platform of "making an unprecedented effort to try to make the homeless problem better in Sacramento." He recognized the value of Whole Person Care as one of the ways to make good on his campaign promise of housing the homeless, and he had no intention of leaving tens of millions of dollars on the table if he could help it.
After the county refused to apply again during the second and final round of application requests, Steinberg set out to see whether a city could apply as the lead agency. "I had good connections over at the Capitol," Steinberg said. "Someone from my old staff-actually, from the health care world-called me and said, 'There's nothing in the law that says a city could not apply for Whole Person Care.'" With a week left until the deadline for applications, Steinberg jumped on the phone with Howard Chan, the city manager, and Emily Halcon, the city's homeless services coordinator, and after a fifteen-minute meeting, they all agreed, "We got to go for this," Steinberg recalled. Halcon and her team squeaked in a preliminary, bare-bones application just in time. "But then the real work began," Steinberg said. Before the city could get approved, it would need to secure a commitment of $32 million from local health partners.

The Real Work Begins
With Whole Person Care, Sacramento would put to use up to $64 million in funds over four years, meaning the city and its partners would need to front $32 million over the course of the program in biannual installments. Medicaid would then reimburse, or match, that amount, contingent on the city's delivering upon the terms agreed to:providing services to the identified number of Medi-Cal clients, reporting metrics, and achieving outcomes.
The city initially put in $2.3 million and secured another $5.7 million as an investment from three hospital systems-Sutter Health, Kaiser Permanente, and UC Davis Medical Center. 6 In addition, the city needed to put together a comprehensive application explaining what the program would do and how it would implement the pilot. But the city didn't have a health care staff, so it contracted with Transform Heath, a women-and minority-owned consulting firm that specialized in health system transformation, to help with the application-which was due in a few months.
The city narrowed its target population to people experiencing or at risk of homelessness who were also the highest utilizers of services: They cost the most and needed the most. At a minimum, the pilot-according to the city's plan-would serve 3,250 people by December 2020. To participate in Whole Person Care, which the city branded as Pathways to Health and Home, a person needed to be eligible for Medi-Cal and meet the following criteria for the past twelve months: one or more inpatient hospital stays, four or more emergency department visits, or four or more crisis interventions. The program does not allow for open referrals. Rather, a person must be referred by a partner community health clinic, hospital, managed care plan, or community-based organization or through the police department's Impact Team, which provides outreach for the city's chronically homeless population.
The state approved the application in June 2017, and-after winning a competitive bid to manage the program-Transform Health began supporting the city to get Pathways up and running to serve clients by November of that year.
The city planned an evaluation of Pathways beginning in July 2019 and running through the life of the program, ending on March 31, 2021. The evaluation will look at outcomes including health and behavioral health stability and self-management, emergency department and inpatient hospital use, and housing type. One possible problem is that hospital partners might not provide the data needed to conduct the analysis.
Among the early challenges was the fact that the Sacramento area had a vast number of fragmented service providers that came in contact with the highutilizing homeless population. Most of them operated in silos, so getting them all on the same page under Pathways was a difficult but essential task.
The team launched a collective impact model to break through the silos and aligned them all under the common mission to house 2,000 unsheltered people in a coordinated and seamless fashion.
"The collective impact model was deliberately created with this intention of bringing together formerly isolated or siloed organizations that may be doing very great work in their own insulated pockets of excellence, but they were not meeting the greater need of the community," said Jodi Nerell, director of behavioral health integration at Sacramento Covered, the lead outreach and eligibility organization for Pathways.

Implementation
The city and consulting team knew that rolling out Pathways would be a challenging task, even with a solid framework and plan in place. That's because as a city, and not a county, Sacramento simply lacked a lot of processes. For one thing, most counties have a Medi-Cal eligibility and enrollment office, but the city did not. This was a big must-have, as every client in Pathways had to be enrolled in Medi-Cal and maintain that status, as well as being specifically enrolled in Pathways. The launch team worked with Sacramento Covered, which had experience enrolling people in Medi-Cal, to build an eligibility and enrollment function for the program. To do this, they explored best practices in other states and Whole Person Care pilots and then tailored the ones they liked to meet the needs of Sacramento's homeless population. For example, the enrollee assessment form was adapted from Oregon's Department of Human Services, and the client consent form was based on one used by the Los Angeles County Whole Person Care pilot.
Counties can also generate enrollment lists using Medi-Cal data, but because Pathways was city led, it didn't have access to this type of data. So instead the team created a referral process for providers (hospitals, managed care plans, health clinics, and the police Impact Team) to submit referrals for potentially eligible clients. Outreach workers, armed with iPads, then connected with the referrals-whether in camps by the river, shelters, clinics, emergency departments, coffee shops, or hospital rooms or during patrol with the Impact Team-and enrolled eligible clients on the spot. In June 2019 the most recent data showed that 37 percent of the enrollment referrals came from the Impact Team, while 38 percent came from hospitals and managed care plans and 25 percent came from federally qualified health centers. 7 One of the core elements of Whole Person Care is sharing data. For Pathways, creating and implementing a shared data agreement among partners was essential for coordinating care among clients and for understanding and reporting outcomes generated by the program. But some health care providers, especially the large hospital systems, were uneasy with sharing patients' personal health data with smaller community-based homeless service providers.
"The data sharing piece was problematic," said Lisa Chan-Sawin, CEO of Transform Health. "Providers were really anxious and hesitant to share data because of how expensive it could be if a breach were to happen." The health care providers were worried about security breaches among the smaller community-based organizations. If there was a lawsuit, providers feared that it would likely target those bigger organizations with deeper pockets. To address these issues, Chan-Sawin said, they needed to build trust among partners. So there was a lot of education, especially for the housing partners, about why the security protocols were so important and what the expectations would be when working with health care providers. The data sharing agreement spelled out how data could be used. And even if a data breach did occur, the partners agreed not sue each other as long as they had been using the data according to the agreement.
Working with Sacramento Covered and an information technology vender, the team built a secure online platform using Salesforce health care software to manage and house client case information, which allowed front-line workers to provide care coordination in real time. It also offered an extra layer of security for nervous partners, because all of the personal data lived in a single secure portal and not on providers' local systems.
Even with a collective impact model to guide collaboration, hiccups still emerged in the beginning, particularly around language-such as the term case management. "We were using the same terms and meaning completely different things, and people were getting really frustrated," Chan-Sawin said.
Some referral partners said that they were doing case management, which they thought of as giving a client a name and address of an organization that could help. That was different from the vision of a case manager who says, "Here is somebody who can help you with your specific issue. I'll take you to your appointment or arrange transportation for you. I'll sit in on the appointment with you, if you would like an advocate on your behalf." But through the regular learning community meetings, staff were able to identify this issue and remedy it with education on how Pathways defined such terms.
After a soft opening with selected partners in November 2017, Pathways has been working out the kinks and growing with partner organizations ever since.
Serendipitously, in December 2017 the city partnered with Volunteers of America to open a temporary winter shelter with a "come as you are" mentality for people experiencing homelessness, which allowed clients to bring their belongings and pets. The open policy of the shelter attracted people who rarely used such services. The shelter turned into a de facto staging ground for Pathways enrollees-a one-stop shop of health, social, and housing services.
"It tremendously helped us with some of the housing outcomes we were able to have, since we had them as a captive audience in that shelter," said Nerell of Sacramento Covered.
At the shelter's peak, more than 200 people were staying there. It was slated to close in March 2018, but it stayed in operation for seventeen months, thanks to hospital donations and other funding. It closed for good in April 2019. After it was gone, Pathways clients who hadn't been housed went back to living outdoors or sought refuge at other shelters, which made it difficult for Pathways to stay connected with clients. Nerell likened the challenges of not having that central shelter to those of a mechanic working on a car while it's moving. "It can be done, but it's not going to be perfect, and there's going to be mistakes, and it's not efficient, and, like, who wants to have that happen?" she said. No similar type of shelter has replaced it, though the city is pursuing new permanent and temporary shelter developments.
In June 2018 the full program launched. As of June 2019 Pathways had 1,344 clients enrolled-of whom it housed 356, according to Sacramento Covered. That is a far cry from the mayor's lofty goal of housing 2,000 people by 2020. The primary obstacle to housing more Pathways clients is the limited supply of affordable housing units, coupled with the inability to use Medicaid funding directly for housing.
So even with a team of dedicated workers-who help with everything from verifying income histories for rental applications and aiding clients in obtaining identification and Social Security cards and doctor's letters for support animals to offering financial assistance through housing vouchers and onetime monies for move-in fees and furniture-the program runs up against the larger, systemic barrier: There's just not enough housing.
To work around this, Pathways is experimenting with housing clients together, each with their own lease, in two-bedroom apartments.
Other funding from the state and county has been made available to help with housing and shelters for people experiencing homelessness. In April of this year Gov. Gavin Newsom provided the Whole Person Care pilots with $100 million for housing, of which Sacramento was allocated a bit above $3 million. 8 Steinberg has also made inroads with the county, which has come around to supporting Pathways. After some public prodding by the mayor, the county agreed to release $44 million from the Even with a team of dedicated workers, the program runs up against the larger, systemic barrier: There's just not enough housing.
Mental Health Services Act for programs to complement Pathways, and in partnership with the county, 450 housing choice vouchers were reallocated specifically to serve people experiencing homelessness. 9 The county has also signed data sharing agreements with Pathways and has agreed to bidirectional referrals, and the county's clinic for the homeless is joining the program in the summer of 2019.
The process of fully implementing Whole Person Care and the continued effort to secure more money for housing and temporary shelters have been "exhilarating, invigorating, and very frustrating," Steinberg said. "Hundreds of people's lives have been saved, including some of the most vulnerable people in our community. And yet we want to go from the hundreds to the thousands. Because that's how serious the problem is out there. And that will take time."

Graduating From Pathways
On a weekday afternoon in May, Pathways client Tim Doyle, age sixty, was ready to graduate from the program after nearly four months. To graduate from Pathways, clients need to demonstrate that they can live self-sufficiently.
"We want to put them in housing; we want them to be able to self-manage their illnesses and their behavioral health, mental health, and substance use issues," said Holly Webb, program manager at WellSpace Health, a large health care provider and Pathways part-ner. Eventually, clients will be able to make their own calls to the health plan, set up transportation to and from appointments, and pick up prescriptions on their own,Webb said. On the housing side, skills include paying rent on time, following the terms of the lease, requesting repairs, and knowing the phone number to the housing hotline.
Doyle was living in a transitional housing complex that provided job training and various other support services, such as credit counseling. In Doyle's studio apartment, his outreach community health worker, Wesley Colter, ran through the self-sufficiency basics, such as where Doyle could get his medical care and pick up his prescriptions and whom to call if he needed assistance. Before he enrolled in the program, Doyle had been homeless, had attempted suicide by swallowing a bottle of sleeping pills, and had little hope that he would ever get back on his feet again. Now he was almost ready to live independently, and once he secured permanent housing, Pathways would graduate him.
With any luck, he will find a job in his previous field (he worked in political research and nonprofit policy), and when his transition time is up, he'll have his housing voucher approved. If he can find a landlord to accept the voucher, he'll never have to pay more than one-third of his income for housing, Colter said.
Doyle was particularly grateful for Colter, whom he met moments after getting a referral to Pathways from a partnering health clinic. "Wes literally called me as I walked out of the doctor's office," Doyle said, adding that he gets emotional thinking back on what Colter has done for him. "It's beyond case management.Wes stayed in touch with me. He treated me like an adult. He wasn't condescending. It was more helping me figure it out." Doyle remembered how impressive and technologically savvy Colter seemed during one of their early meetings at a Starbucks. Doyle was already enrolled in Medi-Cal at the time, but through a different county. So Colter pulled out his iPad and two phones at the Starbucks and spent the next forty-five minutes on the phone transferring Doyle's Medi-Cal to Sacramento County. "I no longer need that level of care," Doyle said. But he added, "If I needed assistance, I would not hesitate to get a hold of him." ▪ This article is part of a series on transforming health systems published with support from The Robert Wood Johnson Foundation. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/ licenses/by/4.0/. Brian Rinker (brianrinker@gmail.com) is an independent journalist in San Francisco, California.