"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. A total of 84 semi-structured interviews were collected from a purposeful sample of 35 frontline providers. Transcripts were analyzed inductively using Boytazis' thematic analysis. Three principle themes characterize the dilemmas experienced by street-level workers in these programs: (1) Putting the "consumer first" vs. achieving maximum billing; (2) Doing the "real work" vs. paperwork; and (3) Juggling clinical supervision vs. administrative oversight. In order 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: (1) Staying late and taking work home; (2) Padding the numbers; (3) Offering service recipients small choices; (4) Redirecting small talk to get to billable goal talk; and (5) 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.