Hawaii-2019-SB431-Introduced

SECTION 1. The legislature finds that homelessness is one of the most pressing problems in Hawaii and requires a robust, comprehensive solution to increase the pace at which the State is gaining ground on addressing the issue. For the first time in years, the homelessness rate in Hawaii decreased in 2017. Hawaii is turning the tide on the homelessness crisis by investing in proven programs like housing first and rapid rehousing. The network of people and resources engaged in addressing homelessness has begun to make more efficient use of available resources by implementing a data-driven, collaborative process that matches individuals and families experiencing homelessness with the services they need. However, Hawaii continues to have the highest per capita rate of homelessness of any state in the United States, with an estimated 7,220 individuals living on the streets and in shelters. Therefore, the legislature finds that it is imperative for the State to increase the investment in and commitment to the solution.

The legislature has identified California's section 1115 demonstration project, known as the Whole Person Care pilot program, which is a collaborative and comprehensive effort authorized under California's Medi-Cal 2020 waiver. The Whole Person Care pilot program is composed of five-year pilot programs to test locally-based initiatives to coordinate physical health, behavioral health, and social services for vulnerable beneficiaries of the California Medical Assistance Program (Medi-Cal), California's state medicaid program, who are high users of multiple health care systems and continue to have poor outcomes. Medi-Cal beneficiaries include, among other groups, individuals who are experiencing homelessness or at risk of homelessness. Pilot groups under the Whole Person Care pilot program are composed of public and private entities that determine the needs for their target populations and provide services that cover activities, which would not otherwise be reimbursed by medicaid, to improve care for their target populations. Through collaborative leadership and systematic coordination, Whole Person Care pilot groups share data between systems, coordinate care in real time, and evaluate individual and population health progress.

The Whole Person Care pilot program is authorized under a section 1115 waiver, which is approved by the Secretary of Health and Human Services as a project that is likely to promote the objectives of the medicaid program by using methods that differ from the standard federal medicaid requirements. The purpose of these demonstrations, which give states additional flexibility to design and improve their programs, is to demonstrate and evaluate state-specific policy approaches to better serve medicaid populations. Many states, such as California for the Whole Person Care pilot program, have used 1115 medicaid waivers to expand medicaid to new groups or to experiment with new or updated delivery systems.

The legislature further finds that, like California's Medi-Cal 2020 program, Hawaii's QUEST Integration project is a statewide section 1115 demonstration project that provides medicaid coverage for medical, dental, and behavioral health services through competitive managed care delivery systems. Through the QUEST Integration demonstration project, the State provides coverage to children and adults who are eligible under the medicaid state plan as well as additional children and adults, including former adoption assistance children, certain parents, and certain individuals who receive home and community-based services. All beneficiaries are eligible for state plan benefits or, in the case of the Affordable Care Act childless adult group, approved benefits under the alternative benefit plan, as well as additional services based on medical necessity and clinical criteria provided through an integrated managed care delivery system.

The legislature notes that the department of human services has a pending request for an extension and expansion of the QUEST Integration section 1115 demonstration project to enable the department to provide and coordinate supportive housing-related activities and services, as appropriate, with the goal of promoting community integration, optimal coordination of resources, and self-sufficiency for beneficiaries experiencing chronic homelessness who also have a disability, mental health condition, substance abuse disorder, or complex health needs. Services include outreach and engagement services, supported employment services, and other services identified as necessary to meet supportive housing goals for the beneficiary.

The legislature further notes that the Hawaii Pathways Project is the impetus for the request to expand the QUEST Integration section 1115 demonstration project in order to assist the department in providing further services and coverage of eligible state medicaid beneficiaries who are experiencing homelessness. The Hawaii Pathways Project was the first to adopt the evidence-based Pathways Housing First model in Hawaii. This initiative, which provided services from August 2014 to March 2018, focused on providing permanent supportive housing to chronically homeless individuals struggling with substance use or substance use with mental illness. The model seeks to lower the barriers to housing by providing housing first, then implementing wraparound treatment and life skill services necessary to help individuals stabilize, improve quality of life, and maintain housing beyond the support of the project. As a result of this collaborative program, ninety-nine individuals moved into permanent housing and maintained a ninety per cent housing retention rate. The results of the program showed significant improvement in the quality of life and physical health that clients experienced from the time of enrollment to the close of the program. Furthermore, the total estimated health care cost was reduced because of the decrease in utilization of health care services.

With the proven success of the Hawaii Pathways Project, the legislature finds that a similar project, such as California's Whole Person Care pilot program, will be beneficial in enabling the State in expanding and providing more comprehensive care and services to a greater number of homeless individuals or individuals who are at risk of being homeless. A comprehensive program will facilitate a collaborative public and private initiative that institutes reforms and focuses on evidence-based interventions to drive better health outcomes and quality of life improvements while decreasing costs in medical care and intervention. Expanding the State's QUEST Integration demonstration project to include services provided by this type of comprehensive program to assist the homeless will allow the State flexibility in instituting greater reform and impact across various systems of care and service that are beyond the federal standard.

The purpose of this Act is to:

(1) Require the department of human services to establish and implement a whole person care pilot program to test locally-based initiatives to coordinate physical health, behavioral health, and social services for beneficiaries of the State's QUEST Integration program;

(2) Require the department of human services to submit an application for an amendment to the QUEST Integration section 1115 demonstration project to expand its QUEST Integration project to provide for the whole person care pilot program; and

(3) Appropriate funds to the department of human services for the establishment and implementation of the whole person care pilot program.

SECTION 2. (a) The department of human services shall establish a whole person care pilot program to test locally-based initiatives to coordinate physical health, behavioral health, and social services for beneficiaries of the State's QUEST Integration program. Each local pilot program established in accordance with procedures adopted by the department of human services shall integrate services among local entities that serve the target population through collaboration procedures, governance, and information sharing data systems and processes. The department of human services shall adopt procedures and requirements for local pilot programs and eligibility criteria for pilot program enrollees.

(b) Each local pilot program shall be composed of the following:

(1) A lead entity, which shall be:

(A) A county;

(B) A Hawaii health systems facility within a regional health care system;

(D) A consortium of any entities identified under subparagraphs (A) through (C); and

(2) A group of participating entities, to be determined by the lead entity through a collaborative process at the local level, which shall include but not be limited to:

(A) One health plan provider participating in the State's QUEST Integration program;

(B) The Hawaii interagency council on homelessness;

(D) The corrections division of the department of public safety; and

(E) At least two community partners that have significant experience serving the target population, such as physician groups, clinics, hospitals, and community-based organizations; provided that the community partner shall not serve as a lead entity;

provided that if the target population consists of individuals who are experiencing or at risk of homelessness and have a demonstrated medical need for housing or supportive services, participating entities shall include local housing authorities, local continuum of care programs, and community-based organizations serving homeless individuals.

(c) Each local pilot program shall work with participating entities to determine and identify a target population composed of high-risk, high-utilizing beneficiaries of the State's QUEST Integration program in the geographic area that the local pilot program serves and assess the target population's unmet need to provide integrated services to high users of multiple systems. The target population shall be identified though a collaborative data approach to identify common patients who frequently access urgent and emergent services across multiple systems. Target populations may include but not be limited to individuals:

(1) With repeated incidents of avoidable emergency use, hospital admissions, or nursing facility placement;

(2) With two or more chronic conditions;

(3) With mental health or substance use disorders;

(4) Who are experiencing homelessness; and

(5) Who are at risk of homelessness, including individuals who may experience homelessness upon release from medical or mental health facilities or incarceration.

Beneficiaries of the State's QUEST Integration program who are included in an identified target population shall be enrolled in the pilot program. Individuals within a target population who are not beneficiaries of the State's QUEST Integration program may enroll in the pilot program only at the discretion of the local pilot program, but funding in support of any services provided to these individuals shall not be eligible for federal financial participation.

(d) Each local pilot program shall develop a plan to support activities that will:

(1) Build infrastructure to integrate services among local entities that serve the target population;

(2) Provide services that are not otherwise covered or directly reimbursed by the State's QUEST program to improve care for the target population, such as housing components; and

(3) Assist in the implementation of strategies to improve integration, reduce unnecessary utilization of health care services, and improve health outcomes.

(e) Services that a local pilot program may provide include but are not limited to:

(1) Individual housing transition services to assist pilot program enrollees with obtaining housing, including:

(A) Conducting a tenant screening and housing assessment that identifies the pilot program enrollee's preferences and barriers related to successful tenancy;

(B) Developing an individualized housing support plan based upon the housing assessment that addresses identified barriers, including short- and long-term measurable goals for each issue, establishes the pilot program enrollee's approach to meeting the goals, and identifies when other providers or services, reimbursed and not reimbursed by medicaid, may be required to meet each goal;

(C) Assisting with the housing application and search process, including identifying and securing available resources to assist with subsidizing rent;

(D) Identifying and securing resources to cover expenses, such as the security deposit, moving costs, furnishings, adaptive aids, environmental modifications, moving costs, and other one-time expenses;

(E) Ensuring that the living environment is safe and ready for occupancy;

(F) Assisting in arranging for and supporting the details of the transition;

(G) Developing a housing support crisis plan that includes prevention and early intervention services when housing is jeopardized; and

(H) Other housing transition services as determined by the local pilot program that best serve the needs of the target population;

(2) Individual housing and tenancy sustaining services to support individuals in maintaining tenancy once housing is secured, including:

(A) Providing early identification and intervention for behaviors that may jeopardize housing, such as late rental payment and other lease violations;

(B) Educating and training on the role, rights, and responsibilities of the tenant and landlord;

(C) Coaching on developing and maintaining key relationships with landlords or property managers with a goal of fostering successful tenancy;

(D) Assisting in resolving disputes with landlords or neighbors to reduce risk of eviction or other adverse action;

(E) Advocating and linking individuals to community resources to prevent eviction when housing is or may potentially become jeopardized;

(F) Assisting with the housing recertification process;

(G) Coordinating with the tenant to review, update, and modify the tenant's housing support and crisis plan on a regular basis to reflect current needs and address existing or recurring housing retention barriers;

(H) Continuing training in being a responsible tenant and lease compliance, including ongoing support with activities related to household management; and

(I) Other housing and tenancy sustaining services as determined by the local pilot program that best serve the needs of the target population;

(3) Transportation services; provided that such services are:

(A) Necessary to achieve or maintain medical or behavioral health stability;

(B) Directly linked to the overarching strategies and goals identified by the local pilot program for the target population; and

(4) Recuperative care or medical respite services that provide short-term residential care after an acute or post-acute medical discharge of individuals who are homeless or those with unstable living situations and are too ill or frail to recover from a physical illness or injury in their usual living environment, but are not ill enough to be in a hospital; provided that such services are:

(A) Necessary to achieve or maintain medical stability, which may require behavioral health interventions;

(B) Directly linked to the overarching strategies and goals identified by the local pilot program for the target population;

(D) Not funded by moneys dedicated to building modification or building rehabilitation; and

(E) Not covered by medicaid;

(5) Sobering centers that provide a safe, supportive environment for individuals found to be publicly intoxicated, primarily for those who are homeless or those with unstable living situations; provided that such services are:

(A) Necessary to achieve or maintain medical stability, which may require behavioral health interventions;

(B) Directly linked to the overarching strategies and goals identified by the local pilot program for the target population;

(D) Not funded by moneys dedicated to building modification or building rehabilitation; and

(E) Not covered by medicaid;

(6) Field-based care, which includes but is not limited to the delivery of services by case managers, therapists, or nurses on the streets or at shelters; provided that such services are:

(A) Necessary to achieve or maintain medical or behavioral health stability;

(B) Directly linked to the overarching strategies and goals identified by the local pilot program for the target population; and

(7) Benefits advocacy and legal assistance to allow pilot program enrollees to enroll in benefits and remove barriers to benefit enrollment, health care, and housing.

(f) The department of human services shall develop and implement policies and procedures for the funding of the pilot program and each local pilot program, including eligibility criteria for the funding of services provided to each target population as well as criteria for the use of federal funds, if applicable.

(g) The department of human services shall develop and implement policies and procedures to require local pilot programs to collect data related to the target population and services provided, share data across systems, coordinate care in real time, and evaluate individual and target population health progress.

(h) The department of human services shall submit progress reports, including any proposed legislation, to the legislature no later than twenty days prior to the convening of the regular sessions of 2020 to 2023 and a final report, including any proposed legislation, no later than twenty days prior to the convening of the regular session of 2024.

(i) The whole person care pilot program shall cease to exist on June 30, 2024.

SECTION 3. The department of human services shall submit an application to the United States Secretary of Health and Human Services for an amendment to the QUEST Integration section 1115 demonstration project to expand its QUEST Integration project to provide for the whole person care pilot program.

SECTION 4. There is appropriated out of the general revenues of the State of Hawaii the sum of $200,000,000 or so much thereof as may be necessary for fiscal year 2019-2020 and the same sum or so much thereof as may be necessary for fiscal year 2020-2021 for the establishment and implementation of the whole person care pilot program.

The sums appropriated shall be expended by the department of human services for the purposes of this Act.

SECTION 5. This Act shall take effect on July 1, 2019.

INTRODUCED BY:	_____________________________

THE SENATE	S.B. NO.	431
THIRTIETH LEGISLATURE, 2019
STATE OF HAWAII