[NYAPRS Enews] TAC, NYAPRS: Robust Supported Housing Can Serve People with the Most Advanced Needs

[Harvey Rosenthal]

NYAPRS Note: The following comes from Technical Assistance Collaborative* director and former NJ mental health commissioner Kevin Martone, who wrote yesterday that the following excellent response to the New York Times' recent article<https://features.propublica.org/supported-housing/new-york-mentally-ill-housing-group-homes/>.... highlighting negative stories about permanent supportive housing (PSH) in New York and painting a picture of a model that had too often failed persons with serious mental illness.
The excellent piece underscores the value of below makes a number of critically important observations including that even people with the most advanced needs can recover and benefit from supported housing that is voluntary, paired with a menu of responsive and comprehensive service choices that are delivered by well-trained adequately funded housing staffers and supports.
He concludes that "providers that struggle to adequately support people in PSH are often those with inadequate staffing, which makes them unable to respond quickly and appropriately. To underfund services is to undermine the ability of providers to meet the needs of PSH tenants" and that while people with mental illness and other disabilities may need lots of things - but that doesn't mean we should return to institutionalization at a cost that is much greater than the sum required to meet all of those needs."
NYAPRS agrees that supported housing can help support adult home residents with the most complex needs, supports presiding state settlement Judge Garaufis' questions about the adequacy of greater state accountability (https://tinyurl.com/y78uz2z8) if not funding for the currently deployed adult home case manager who works with a 1:12 ration of residents, greater use of Medicaid funded home makers and home health aides, the imminent deployment of the recently funded 60+ peer bridgers and with funding increases for housing programs.
See our letter sent last week to the Times below that concludes, in response to claims that we've gone too far in pressing for community based options for the residents, "some would say that legal rights and advocacy groups have gone too far, but the answers here are not to shrink rights and choice protections but to offer residents more and better choices."

Permanent Supportive Housing: Renewing Our Commitment
By Kevin Martone  Executive Director Technical Assistance Collaborative December 12, 2018

Last week, I had the pleasure of delivering the keynote address at the annual conference of the Supportive Housing Association of New Jersey<http://www.shanj.org/>. This gathering marked the association's 20th anniversary, an opportunity to reflect on two decades of work to make permanent supportive housing - i.e., lease-based housing paired with voluntary, flexible services - a primary intervention for people with a wide range of disabilities and for people experiencing or at risk of homelessness. Many other states, too, have invested time and resources in the successful expansion of this approach for their homeless and disabled populations.

In an interesting fluke of timing, the New York Times had published an article<https://features.propublica.org/supported-housing/new-york-mentally-ill-housing-group-homes/> the day before the conference, highlighting negative stories about permanent supportive housing (PSH) in New York and painting a picture of a model that had too often failed persons with serious mental illness. The tone of the article was keenly felt by this group of PSH practitioners, and several leaders from other states and policy groups have since contacted me to discuss the article's potential impact. How could PSH - an approach that leaders in many states are working to expand in order to support the community integration needs of those who are homeless or disabled - be represented as a failure? What are the article's implications for those seeking to invest in or expand PSH, for providers, and for people determined to live independently?

While the Times article was alarming, strong evidence nevertheless suggests that people with serious mental illness can succeed in PSH, and that use of the model should indeed be expanded. But there are considerations that must be addressed to ensure that PSH meets the needs of the people it is intended to serve.

Supportive Housing Works
People with serious mental illness have historically lived in institutional settings whether they actually needed to or not. Over time, however, understanding has grown that the policy of housing people in state psychiatric hospitals, for example, is both cost-ineffective and inhumane, and that it fails to demonstrate positive outcomes.

Deinstitutionalization efforts from the 1970s to the 1990s meant that many more people with mental illness began living in the community. We all know the story of the resulting growth in homelessness and trans-institutionalization to correctional settings, as public systems failed to develop their community-based services capacity and affordable housing resources to meet the increase in demand. Some people had access to services and residential supports, but many did not, and many still do not today.

When I was a case manager over 20 years ago, "supportive housing" meant doing everything possible to get people with mental illness into housing and helping them stay there. Over time, anecdotal stories of success across the country evolved into an evidence base for what we now know as permanent supportive housing.

There is plenty of evidence<https://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201300261> to demonstrate the effectiveness of PSH for people with mental illness and for people transitioning from homelessness. Many PSH programs have shown increased housing stability<https://shnny.org/research/new-york-new-york-iii-supportive-housing-evaluation/>, decreased emergency department and inpatient use<https://www.ncbi.nlm.nih.gov/pubmed/16816284>, reduced jail days<https://repository.upenn.edu/spp_papers/65/>, and significant cost savings<https://www.enterprisecommunity.org/download?fid=5703&nid=4247> compared to homelessness, inpatient care, and other institutional or supervised settings.

Even the statistics noted by the Times suggest that a large majority of people have succeeded in supportive housing. It is important to regard this in light of evidence showing safety and quality of care concerns<https://mhp.urbanjustice.org/sites/default/files/the_Complaint.pdf> in New York's adult homes, the housing situation from which many people with mental illness move into supportive housing.

Services Must Be Well-Designed and Adequately Funded
Does supportive housing work for everyone? No. Some people need supervised treatment settings, or prefer group residential programs. However, contrary to the assumptions that used to govern our mental health care systems, supportive housing in the community has been shown to work for a variety of people, including those with the most significant needs who are transitioning from state psychiatric hospitals, nursing facilities, jails, or homelessness. Even people with the most complex conditions need a place to call home that is not contingent on being a "compliant" patient or a "good" client; in fact, providing a choice of housing together with voluntary services has been shown to strengthen retention in housing and services<https://aspe.hhs.gov/system/files/pdf/77121/PSHprimer.pdf>.

In order for PSH to be successful, particularly for persons with complex needs, services must be voluntary, flexible, responsive, robust, and comprehensive. Furthermore, they must be delivered by well-trained staff who are able to provide the right types of services, in the right locations (i.e., where people live), and at the right times, adapting what is offered to meet individuals' evolving needs. Providers that struggle to adequately support people in PSH are often those with inadequate staffing, which makes them unable to respond quickly and appropriately.

To underfund services is to undermine the ability of providers to meet the needs of PSH tenants. In my experience, the services covered by Medicaid are not, on their own, enough to meet the needs of many people who could otherwise succeed in PSH. If systems will be expected to serve an increasingly complex population, state and county funding agencies and Medicaid managed care organizations must have adequate resources available to pay for a full range of services; successful permanent supportive housing programs are those that braid or blend Medicaid with other resources<https://nashp.org/wp-content/uploads/2016/02/Jean1.pdf>.

Building On the Evidence
As a former state mental health commissioner, a behavioral health provider, and the family member of someone with a mental illness, it boggles my mind that we would rather pay several hundred thousand dollars per year to house a person in an institutional setting than commit a fraction of that amount to support them in an integrated, community-based setting with demonstrated positive outcomes.

Too often, the response to challenges that arise in PSH is an assumption that a person is "not ready," or "needs supervision," instead of a person-centered mindset that tailors and continually adapts services to each individual's needs and choices.

Yes, people with mental illness and other disabilities may need inpatient treatment, at times. They may need round-the-clock support, at times. They may need assistance with their medications, at times. They may need transportation to medical appointments, at times. People with mental illness and other disabilities may need lots of things - but that doesn't mean we should return to institutionalization at a cost that is much greater than the sum required to meet all of those needs. With sufficient resources to pay for both rental assistance and robust, flexible services, permanent supportive housing can be a primary intervention for individuals with complex needs.

Systems should move forward on bringing well-designed, fully funded permanent supportive housing to scale, so that all who can benefit from living in safe, independent, community-integrated housing have the opportunity to do so.

Kevin Martone, L.S.W. is TAC's Executive Director and a former New Jersey state mental health commissioner.
https://tinyurl.com/y7gng2cf
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How N.Y. Can Best Help Adult Home Residents with Mental Disabilities
December 7, 2018
The Times' investigative piece "Where N.Y. Fails Its Mentally Ill" well demonstrates that current adult home residents with mental disabilities must be offered a full choice of well-coordinated residential and community supports, across the entire continuum of care that emphasizes but is not necessarily limited to supported apartment options.
But without adequate investments and oversight from the state, thousands of vulnerable New Yorkers will be unable to get the housing and services they need - resulting in avoidable suffering, isolation, hospitalization, homelessness and incarceration. NYAPRS calls on Governor Cuomo and State legislators to make a major investment in these life-altering programs in the 2019-20 budget.
Some would claim that the residents are 'too sick' to live in more independent settings in the community but we now know in 2018 how to successfully support even those with the most advanced mental disabilities to succeed with well-coordinated residential, rehabilitative, peer support and treatment services. Some would say that legal rights and advocacy groups have gone too far (see https://tinyurl.com/y9juqq67), but the answers here are not to shrink rights and choice protections but to offer residents more and better choices.
Harvey Rosenthal, NY Association of Psychiatric Rehabilitation Services

*TAC here refers to the Technical Assistance Center not the Treatment Advocacy Center.
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