HOUSING CONTINUUM FOR ADULTS WITH MENTAL HEALTH …

HOUSING CONTINUUM FOR ADULTS WITH MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS IN FL

By Imelda Medina, MD, MPH

NAMI FL Board Member, Familias Unidas International, Inc. President and ACT! Now for Mental Health FL Advocacy Coalition Member

Miami, FL 1/28/2015

INTRODUCTION

Housing is a cornerstone for recovery. An array of behavioral health housing options working in a continuum, is critical to providing people living with mental health conditions and substance abuse disorders, the continuity of care and stability they need to achieve recovery outcomes, therefore reducing the utilization of shelters, hospitalizations and involvement with the criminal justice system.

At this time, Florida does not have a defined housing continuum structure within their behavioral health systems of care.

Goals for Adult Housing

Goals related to the adult housing system include creating local systems of care that: 1. Are responsive to individual recipient wishes and needs; and 2. Reduce institutionalization and homelessness. In this context, we recognize that:

a. Housing is a basic need and necessary for recovery b. A system of care that is accountable includes staffed specialty housing and residential

treatment programs. c. The primary goal of housing reform will focus on the individual and emphasize expanding

access to supported housing. Person-centered principles of recovery will guide this work. d. On the community system level, the local mental health housing resources will be viewed as

an asset to expand access to supported housing and to facilitate broader reforms (i.e. system accountability and a recovery focus). e. Recipient satisfaction and recovery outcomes are essential.

FLORIDA

Our current system includes the following behavioral health housing services: Florida Residential treatment facilities include: Residential Level 1 These are licensed services that provide structured, live-in, non-hospital settings with 24-hour

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supervision daily. There is a nurse on duty in these facilities at all times. For adult mental health, these services include two different kinds of programs: group homes and short-term residential treatment services. Group homes are for residents who may require longer lengths of stay. These facilities offer nursing supervision provided by, at a minimum, licensed practical nurses, 24 hours a day, seven days per week.

Residential Level 2 These are licensed, structured rehabilitation-oriented group facilities that have 24-hour a day, seven days per week supervision. Level 2 facilities are for persons who have significant deficits in independent living skills and need extensive support and supervision.

Short-term Residential Treatment (SRT) These individualized, acute, and immediately sub-acute care services provide intensive mental health residential and rehabilitative services 24 hours a day, seven days per week. These services must meet the needs of individuals who are experiencing an acute or immediately subacute crisis and who, in the absence of a suitable alternative, would require hospitalization. SRT services provide intensive residential treatment for individuals in need of acute care for up to 120 days.

Rehabilitation Options Include:

Supportive Housing Supported housing/living services are designed to help people with substance abuse or psychiatric disabilities find and keep living arrangements of their choice. They also provide services and supports to ensure continued successful living in the community. The goal of Supportive Housing is to ensure that everyone has the opportunity to live as independently as possible.

Residential Level 3 These are licensed facilities, structured to provide 24-hour a day, seven days per week supervised residential alternatives to persons who have developed a moderate functional capacity for independent living. For adults with serious mental illnesses, these are supervised apartments.

Support Options Include:

Residential Level 4 The facility may have less than 24 hours per day, seven days per week on-premise supervision. This is the least intensive level of residential care and is primarily a support service. For adults with serious mental illnesses, this includes satellite apartments, satellite group homes, and therapeutic foster homes.

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Room and Board with Supervision Levels 1-3 This pays room and board costs for people living in Medicaid-funded residential programs. Medicaid pays for the clinical services, and the SAMH program pays for the rest.

However, at this time, Florida does not have a defined Housing Continuum within our behavioral health systems of care. What this means is that there is not a public mental health structure that integrates housing and other living resources into our mental health services which follows a Housing Continuum to provide medical treatment and support so persons can successfully progress from dependent to independent living.

Florida Assertive Community Treatment (FACT) Teams are perhaps the only service available that offers a housing, medication, and flexible funding subsidy to enrolled individuals in the community. However, each team is mandated to serve no more than 100 individuals, and there are only 31 teams to serve all our state. This is in marked contrast to other states, while Florida has 31 ACT Teams, Michigan has 100 and New York State has 80 ACT Teams. Adding to the compounded public mental health community support & services scarcity, and lack of organization.

How well are these options working? Let's look at Miami Dade County.

MIAMI DADE COUNTY

Here you may find the latest version of Miami Dade County's Housing Directory The Table of Content shows various types of Residential programs. "Transitional Housing" are scattered and provided by agencies such as Agape, Fellowship House, etc. Those are funded through South Florida Behavioral Health Network (SFBHN). The Directory also lists the HUD Permanent Housing Programs, most of which require homelessness, have a mental health or substance abuse disorder and be medically stable (within these circumstances). There are funds from the state that go to these programs. Here is a page from SFBHN's FY12-13 audited statement that shows the "cost centers" that receive funding from SFBHN It would be good to find out exactly how many units and how many people with mental health and substance abuse disorders these programs serve so we could figure out how many more are needed, based on waiting lists.

At this time, the manual is constantly being opened with the hope that within its 86 pages we will find response to the need of so many persons in our community. However, with despair, we discover that due to the programs' requirements, lack of availability and long waiting times, it is not possible to help most of the times.

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In Miami Dade County persons are struggling to find a place where to live or just spend the night. The few existent residential programs which include behavioral health treatment and/or services are working in isolation from each other, there is not a continuity of care which can help persons in their recovery by providing them with assistance to progress from dependent to independent living. Instead, persons are being discharged from a shelter into independent living or from a hospital into independent living, to locations with inadequate services or even into homelessness. There is no order or structure to help persons progress in their recovery journey, and locations which are supposed to have support services, lack quality and the appropriate environment conducive to health and healing. So, often, persons are discharged and lost in the system until they have another crisis.

WHAT IS A HOUSING CONTINUUM? General Information

Housing for persons with mental health and substance abuse disorders can be viewed along a continuum of options from full self-sufficiency to full dependent care at high cost to the state. In a perfect world, the goal is home ownership, however, persons with these conditions are less likely to be able to secure a home on the private market or maintain a mortgage. Renting a home is probably the most common option. However, market rate rentals may be out of reach simply because of poverty. Affordable housing (whether subsidized or unsubsidized), although scarce, may be a viable option for those that are not highly disabled. But barriers exist

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to obtaining affordable housing. These programs usually have very strict eligibility criteria and long waiting lists.

The next housing option, supportive housing are permanent housing options coupled with support services on-site. These types of housing are most often partially or wholly supported by HUD (U.S. Department of Housing and Urban Development) and specifically designed to support homelessness and/or disadvantaged populations. Regardless of program length or permanency, supportive or service-enhanced housing programs usually offer a range of services aside from housing, including family counseling, case management, medical services, mental health treatment, substance abuse counseling, socialization skills groups, anger management, vocational training, and assistance with obtaining vital documents such as Social Security cards and birth certificates. Services may also include income support, education, transportation, clothing, advocacy, and child care (Burt et al., 2004).

Service configurations vary from community to community, as well as within community. This variation is not always deliberate, as the variety of stakeholders involved must sort through availability of services and capacity of stakeholders that include funders, housing developers, property managers, and on-site and off-site program staff. Housing configurations will vary across programs.

Federal, state and local funding streams have also been developed to fund supportive housing. These "special needs" programs often define eligibility for housing funding based upon the disability or health profile of individuals, rather than on the individual's homelessness status. For most programs though, including most of the few housing options available in Miami Dade County, homelessness is a primary requirement for program eligibility. We are coming to recognize the need for permanent housing units accessible to people that lack the necessary credentials that are typically necessary to secure permanent housing, such as rental histories, identification and employment histories.

Unlike transitional programs, permanent housing programs typically require residents to sign a tenancy agreement and although programs may have social service assistance on-site, participation is not a requirement for eligibility. Supportive housing programs are often financed by a creative blending of funds on part of the provider. Financing can come from residential rents, traditional bank loans, federal, state and local government loans or grants and outside contributions by foundations and community organizations.

Moving along the continuum, the next option is emergency shelters. Although emergency shelters may cost less per consumer than transitional housing, emergency shelters are not desirable because they do not support a person's transition to more stable housing. For the most part, emergency housing simply acts as an option when no other housing is available. In Miami Dade County multiple calls per week during a period of time which may last several months is required to secure shelter placement regardless of medical or homeless status.

Transitional housing falls after emergency housing but before full dependent care through any type of institution (prison or a psychiatric hospital). Transitional housing is an umbrella term to capture any housing that is not permanent, but is designed to provide at least some type of service that assists persons with establishing community reintegration or residential stability.

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