Individuals with serious mental illness (SMI), outside the supports of permanent supportive housing (PSH), may present with additional health related social needs (HRSNs) that also need to be coordinated in order to promote success. Medical and mental health, coupled with social health, are a whole health approach to supporting individuals with complex need.

The waiver language under Milestone 2.b recognizes that “Connecting members to housing resources also helps to drive down ED utilization. Several MCOs reported that members with a SMI diagnoses and housing instability often present at the ED as a means of temporarily accessing shelter and food. MCOs will continue to engage CSBs and other stakeholders across the housing continuum to understand and proactively address member housing needs in the most appropriate setting possible.”

Creative housing options to support transitions, and the coordination of services to access HRSNs remains a barrier. There is a need for waiver language around medical transition housing to support transitions from the emergency department and/or inpatient stays. Patients may need a place to be safe and heal prior to entering into PSH environments. Additionally, language supporting community care hubs or backbone organizations that enable successful access to HRSN resources in the community will help sustain patients in the community. Infrastructure to empower mission critical community partners that serve HRSNs through the coordination of supports would supplement the care needed for the SMI population being addressed.