"How Do We Force Six Visits on a Consumer?": Street-Level Dilemmas and Strategies for Person-Centered Care Under Medicaid Fee-for-Service

This qualitative study examines the delivery of person-centered care in Medicaid-funded supportive housing for adults with serious mental illness. While much work has been done to promote the uptake of a person-centered approach in healthcare, less is known about how this approach functions in homeless services and supportive housing where many individuals with mental health issues receive rehabilitative services. Eighty-four semistructured interviews were collected from a purposeful sample of 35 frontline providers. Transcripts were analyzed inductively using Boytazis’s (1998) thematic analysis. Three principal themes characterize the dilemmas that street-level workers in these programs experienced: “putting the consumer first” versus achieving maximum billing, doing the “real work” versus paperwork, and juggling clinical supervision versus administrative oversight. To meet the demands of Medicaid, as well as the expectation for person-centered care delivery, providers enacted several discretionary strategies at the street level: (a) staying late and taking work home, (b) padding the numbers, (c) offering service recipients small choices, (d) redirecting small talk to get to billable goal talk, and (e) keeping consumers home. Findings highlight tensions between the accountability-focused fee-for-service model and the prioritization of consumer choice and individualization of services in person-centered care delivery.