How can a patient with no financial resources and extensive co-morbidities who is experiencing homelessness qualify for skilled nursing or assisted living facility care?

Qualifying for Skilled Nursing or Assisted Living Facilities for Homeless Patients with Extensive Comorbidities

Patients experiencing homelessness with extensive comorbidities face significant barriers to qualifying for skilled nursing facilities (SNF) or assisted living facilities (ALF), primarily due to strict eligibility criteria that often fail to recognize disease severity, but can access these services through Medicaid coverage for SNF if they meet medical necessity criteria, or through targeted housing programs like medical respite care, permanent supportive housing, and rapid rehousing that prioritize medical needs.

Understanding the Qualification Pathways

Skilled Nursing Facilities (SNF)

• Medicaid is the primary payer for patients without financial resources, covering SNF care when medical necessity is documented 1
• Medical necessity criteria typically require skilled nursing or rehabilitation services that cannot be provided in a lower level of care 1
• The patient's extensive comorbidities work in their favor for SNF qualification, as these demonstrate the need for skilled medical care 1

Assisted Living Facilities (ALF)

• ALF qualification is more challenging because most states do not cover ALF through Medicaid, and these facilities typically require private pay 1
• Some states offer Medicaid waiver programs that can cover ALF for eligible individuals, but availability varies significantly by location 1

Critical Barriers to Navigate

Housing Eligibility Restrictions

• HUD does not recognize all forms of homelessness equally: patients who are "doubled-up" (living temporarily with friends/family) may not qualify for the full range of housing services 1
• Chronic homelessness criteria require documented disability (mental, behavioral, or physical) combined with duration and frequency of homelessness for permanent housing subsidies 1
• Imminent risk of homelessness requires verifiable documentation that residence will be lost within 14 days with no subsequent housing identified 1

Prioritization System Failures

• Community Coordinated Entry systems often disadvantage patients with severe medical conditions: current algorithms prioritize the number of problems rather than severity of disease 1
• Patients requiring dialysis or other life-saving interventions may score lower than those with multiple behavioral health issues or social vulnerabilities 1

Actionable Steps for Providers

Immediate Documentation Requirements

• Document all comorbidities thoroughly in the medical record with specific functional limitations and care needs 1
• Use ICD-10 code Z59.0 for homelessness to ensure housing status is captured in clinical documentation 1
• Obtain written verification of housing loss if the patient faces imminent homelessness (within 14 days) to meet HUD criteria 1
• Document any documented disability (physical, mental, or behavioral) as this is required for chronic homelessness designation and permanent housing subsidies 1

Engage Social Work and Case Management

• Coordinate with hospital or clinic social workers immediately to facilitate connection with community resources and navigate the complex eligibility requirements 1
• Request assessment for medical respite care as a bridge option for patients too ill to return to unsheltered conditions after medical facility discharge 1
• Invest in or connect with "bridge organizations" like the Accountable Health Communities (AHC) model that facilitate linkage with community resources 1

Target Specific Housing Programs

Medical Respite Care (First Priority)

• Medical respite provides temporary shelter specifically for people recently discharged from medical facilities who are too ill to return to unsheltered conditions 1
• This is the most appropriate immediate option for patients with extensive comorbidities who need stabilization before transitioning to permanent housing 1
• Advocate for development of more medical respite beds in your community if this resource is limited 1

Permanent Supportive Housing

• Provides indefinite rental assistance combined with supportive services, making it ideal for patients with chronic medical conditions 1
• Requires meeting chronic homelessness criteria: documented disability plus duration/frequency of homelessness 1

Rapid Rehousing Programs

• Offer time-limited financial assistance with fewer eligibility restrictions using a "housing first" approach 1
• May be more accessible than permanent supportive housing but provides less long-term stability 1

Housing Choice Vouchers

• Provide rental assistance for very low-income individuals, elderly, and people with disabilities 1
• Require meeting specific income and disability criteria but can provide long-term housing stability 1

Advocate for System Changes

• Advocate to local Continuum of Care (CoC) agencies to prioritize individuals who require housing stabilization for life-saving medical interventions like dialysis 1
• Push for expansion of eligibility criteria in existing housing services to include people with high medical needs 1
• Work with community coalitions to advocate for more rapid rehousing vouchers and medical respite beds 1

Common Pitfalls to Avoid

Fragmented Care Documentation

• Avoid labeling patients as "nonadherent" when housing instability prevents medication adherence or appointment attendance 1
• Recognize that unstable housing fragments care through inability to store medications, lack of restroom access for diuretics, and transportation barriers 1

Inadequate Screening

• Screen all patients for housing instability at multiple contact points, not just at admission 1
• Use validated screening tools like the brief risk assessment tool developed for veterans to identify housing risk 1
• Discuss housing as part of treatment plans for all patients with chronic conditions 1

Missing Alternative Pathways

• Do not assume ALF is the only option: SNF may be more appropriate and accessible through Medicaid for patients with extensive comorbidities 1
• Consider transitional housing which provides time-limited shelter with intensive support services while establishing permanent housing 1
• Emergency shelters are inadequate for patients with complex medical needs and should only be considered as last resort 1

Special Considerations for Complex Medical Needs

Dialysis and Kidney Disease

• Housing instability precludes use of home dialysis modalities and kidney transplantation due to requirements for stable environment and supply storage 1
• Advocate specifically for housing prioritization for patients requiring dialysis as a life-saving intervention 1

Medication Management

• Simplify medication regimens and avoid medications requiring refrigeration or frequent dosing when housing is unstable 1
• Consider dosing medications at dialysis or other regular medical appointments to improve adherence 1

Care Coordination

• Bundle lab and clinic visits to increase consistency in contact 1
• Consider telemedicine to maintain continuity when transportation is a barrier 1
• Provide trauma-informed care and prioritize mental health and physical safety 1