Evaluation of a Massachusetts Medicaid housing support program among people with opioid use disorder: implementation and healthcare utilization outcomes - PROJECT SUMMARY Adults experiencing homelessness face particularly high risk of harm from opioid use, with some estimates showing overdose mortality rates 12-times higher than in the general population. Opioid use is also associated with costly healthcare utilization among people experiencing homelessness. Addressing housing needs among people experiencing or at risk of homelessness (PERH) with opioid use disorder (OUD) could improve health outcomes. At present, Massachusetts is one of eight states with a Medicaid waiver authorizing services to address housing needs for specific high-need populations. In 2020, through this waiver, Massachusetts Medicaid (MassHealth) implemented a pilot Flexible Services Program (FSP) in which Accountable Care Organization (ACO) members could receive housing supports, including pre-tenancy supports, tenancy-sustaining supports, and home modifications; the program was fully rolled out in 2023. This presents a unique opportunity to fill key gaps in the evidence base. The proposed R36 will be the first known study to investigate the impact of a Medicaid housing support program on healthcare utilization among PERH with OUD. In Aim 1, I will compare hospitalizations and emergency department visits between adult PERH with OUD who are enrolled in MassHealth FSP housing supports with those who are not ACO members and therefore not enrolled. In this way, I will leverage a natural experiment, as only ACO members are eligible for MassHealth FSP. Aim 1 will use a novel data source, a linkage of electronic health records and insurance claims data that includes detailed housing information. Staggered difference-in-difference methods will be used to evaluate outcomes between these two groups; this method will account for variation in individuals’ timing of MassHealth FSP enrollment. In Aim 2, I will conduct semi-structured in- depth interviews to assess key informants’ perspectives on implementation of MassHealth FSP for PERH with OUD. I will interview ACO administrative staff who manage MassHealth FSP to provide perspectives on administrative barriers and facilitators to the program, as well patient-facing clinical staff who can provide insight on patients’ experiences with MassHealth FSP. These rich qualitative data will enhance context-specific understanding of barriers and facilitators of MassHealth FSP for addressing housing needs in PERH with OUD. The setting for both aims is a safety-net health system that serves a high concentration of patients with unmet housing needs; evaluating housing support programs is especially crucial in such settings. As such, the proposed research will address the NIDA priority of improving implementation of evidence-based strategies in real-world settings. This R36 will utilize both quantitative and qualitative methods to evaluate MassHealth FSP, which will provide robust insights to inform program improvement. Findings will be relevant to other states planning and/or implementing housing support programs through Medicaid to improve outcomes for PERH with OUD. I am well-prepared to conduct this research based on my academic training and experience and will have the support of mentors with wide-ranging expertise in the proposed methods and content areas. The proposed R36 will catalyze my goal of becoming an academic health services researcher focused on housing and substance use.
