Creating and evaluating innovations in homeless services: The challenges of integrating social services and medical services for high- need homeless populations

A major contributor to public spending on Medicaid is a small subset of individuals who are caught in a revolving door of emergency room visits, hospitalizations, detox stays, and involvement in other costly health services. Often referred to as ‘super-utilizers' or the ‘5:50 population' (the 5% of beneficiaries who account for 50% of costs), these individuals have complex and co-occurring physical and behavioral health needs and limited support. Efforts to reduce these costs have relied on either traditional case management (with or without housing) or medical care management (with little attention to housing or other service needs), and have proven to be of limited efficacy. Although many public health and homeless service providers believe that the costs created by high-risk, high-need individuals could be reduced through the use of housing programs that integrate medical care management models and social service case management models, achieving this integration is less well understood. This paper analyzes the challenges that the Corporation for Supportive Housing faced when trying to implement a program that achieved this type of integration. Specifically, we examine how a lack of coordination between social service providers and institutions, e.g. state Medicaid offices, can limit the ability of evaluators and program staff to both measure the effects of a program and to identify and serve the target population. By identifying the different challenges that medical versus social service agencies faced when responding to this type of innovation, programs wishing to design similar innovations will be better equipped to avoid these pitfalls.