Permanent Supportive Housing and Mental Health System Transformation: Key Elements in the Efforts to End and Prevent Homelessness Ending Homelessness: Plan, Act, Succeed The National Alliance to End Homelessness Annual Meeting July 17, 2006 Marti Knisley and Steve Day The Technical Assistance Collaborative Ending Homelessness: Plan, Act, Succeed The National Alliance to End Homelessness Annual Meeting July 17, 2006 Marti Knisley and Steve Day The Technical Assistance Collaborative

2 Today’s Discussion  What is MH Transformation?  Why MH Transformation?  Why are we talking about it today?  Why is permanent supportive housing (PSH) essential to MH transformation?  What are the benefits of PSH + MH transformation?  What happens to people in systems that do not have PSH + a transformed MH system  What is MH Transformation?  Why MH Transformation?  Why are we talking about it today?  Why is permanent supportive housing (PSH) essential to MH transformation?  What are the benefits of PSH + MH transformation?  What happens to people in systems that do not have PSH + a transformed MH system

3 What is MH Transformation?  Changing the way that states, local jurisdictions and even the federal government do business, and  Changing how business is done in a way that more people get help and help that works  Stems from President’s New Freedom Commission on Mental Health: “To improve access to quality care and services, the Commission recommends fundamentally transforming how mental health care is delivered in America”  Changing the way that states, local jurisdictions and even the federal government do business, and  Changing how business is done in a way that more people get help and help that works  Stems from President’s New Freedom Commission on Mental Health: “To improve access to quality care and services, the Commission recommends fundamentally transforming how mental health care is delivered in America”

4 What is MH Transformation? The New Freedom Commission and SAMHSA have organized their agendas around five principles:  Focusing on desired outcomes  Focusing on community level models of care that effectively coordinate MH treatment and delivery of other services  Focusing on policies that maximize the utility of existing mainstream resources  Using mental health research findings to influence the delivery of services  Ensuring that the President’s Commission recommendations are used to promote innovation, flexibility and accountability The New Freedom Commission and SAMHSA have organized their agendas around five principles:  Focusing on desired outcomes  Focusing on community level models of care that effectively coordinate MH treatment and delivery of other services  Focusing on policies that maximize the utility of existing mainstream resources  Using mental health research findings to influence the delivery of services  Ensuring that the President’s Commission recommendations are used to promote innovation, flexibility and accountability

5 What is MH Transformation?  The Institute of Medicine has identified the problem as stemming from the complexity of health care and recommends focusing energy on “levers” that can have large scale effect with relatively small efforts in four areas:  Finance  Workforce  Best practice  Information technology  The Institute of Medicine has identified the problem as stemming from the complexity of health care and recommends focusing energy on “levers” that can have large scale effect with relatively small efforts in four areas:  Finance  Workforce  Best practice  Information technology

6 Why MH Transformation?  Perception that the system is fragmented, has big gaps and too many people fall through the cracks of the system  Financing does not reinforce provision of services proven to be effective. Thus, many people don’t have access to effective services  All the above problems have resulted in a lack of confidence in the specialty mental health sector which in turn means this sector is no longer the single payor or policy maker  This in turn requires collaboration beyond the boundaries of traditional mental health systems  Perception that the system is fragmented, has big gaps and too many people fall through the cracks of the system  Financing does not reinforce provision of services proven to be effective. Thus, many people don’t have access to effective services  All the above problems have resulted in a lack of confidence in the specialty mental health sector which in turn means this sector is no longer the single payor or policy maker  This in turn requires collaboration beyond the boundaries of traditional mental health systems

7 Why MH Transformation MH 4/06

8 Why MH Transformation MH 3/06

9 Why are we talking about it today?  50-60% of single adults who are chronically homeless have mental health problems  Consensus that traditional mental health systems don’t have services that are either desired by or work for people who are homeless  Demonstrations and specialty serves for people who are homeless work well but don’t translate into changes in the mainstream service delivery system or long term funding  50-60% of single adults who are chronically homeless have mental health problems  Consensus that traditional mental health systems don’t have services that are either desired by or work for people who are homeless  Demonstrations and specialty serves for people who are homeless work well but don’t translate into changes in the mainstream service delivery system or long term funding

10 Why are we talking about it today?  State and local MH systems are now or soon will be engaged in transformational activities  They will make choices about what activities they are engaged in—and they have many choices  Shifting mainstream resources to reimburse services that are effective for people who are homeless requires a significant shift in resource allocation  MH systems need to have the tools and understand the need to make services and supports for people who are homeless a priority  State and local MH systems are now or soon will be engaged in transformational activities  They will make choices about what activities they are engaged in—and they have many choices  Shifting mainstream resources to reimburse services that are effective for people who are homeless requires a significant shift in resource allocation  MH systems need to have the tools and understand the need to make services and supports for people who are homeless a priority

11 Why is housing essential to MH transformation?  Many people who could benefit from mental health services could also benefit from stable affordable housing  Having your own place to live promotes recovery  The service strategy that helps people get and keep housing—community support—is both clinically and cost effective; if “housing first” is used, the system becomes adept at engagement and relapse prevention  Reduces the need for and likelihood of a costly, duplicative system (homeless services system)  Many people who could benefit from mental health services could also benefit from stable affordable housing  Having your own place to live promotes recovery  The service strategy that helps people get and keep housing—community support—is both clinically and cost effective; if “housing first” is used, the system becomes adept at engagement and relapse prevention  Reduces the need for and likelihood of a costly, duplicative system (homeless services system)

12 What are the benefits of PSH + MH transformation?  Maximizes three sets of resources: housing capital, housing subsidies/ operating funds and services funds--- stretching existing resources and bringing new resources to the table  Provides useful, practical tasks for staff who have responsibilities to help people become stable, contributing community members engaged in their own recovery and on their own terms  Provides a platform for MH system to demonstrate value to stakeholders, public officials and policymakers and most of all to consumers and family members  Maximizes three sets of resources: housing capital, housing subsidies/ operating funds and services funds--- stretching existing resources and bringing new resources to the table  Provides useful, practical tasks for staff who have responsibilities to help people become stable, contributing community members engaged in their own recovery and on their own terms  Provides a platform for MH system to demonstrate value to stakeholders, public officials and policymakers and most of all to consumers and family members

13 What are the benefits of PSH + MH transformation?  More people have access to PSH; PSH provides choice, rights of tenancy and removes conditions for treatment  Community Support Services are tailored to:  Increase emphasis and resources directed toward people getting help to get and keep jobs  Assure integrated MH and SA services are the expectation  Streamline and increase access to benefit programs/ with incentives for going to work  Value social and peer supports  Housing support is a high priority of the Community Support System  More people have access to PSH; PSH provides choice, rights of tenancy and removes conditions for treatment  Community Support Services are tailored to:  Increase emphasis and resources directed toward people getting help to get and keep jobs  Assure integrated MH and SA services are the expectation  Streamline and increase access to benefit programs/ with incentives for going to work  Value social and peer supports  Housing support is a high priority of the Community Support System

14 What is community support in a transformed MH system?  Combined mental health and substance abuse and rehabilitation services and complimentary supports  Organized to resolve the interrelated clinical, social, financial, and residential challenges encountered by priority public mental health system constituents  With services are delivered in natural community settings such as homes, neighborhood venues, schools, homeless shelters, drop-in centers, and on the streets – often delivered by peers  Overcomes barriers to engagement and service access, develops coping skills, and promotes recovery in ways that traditional mental health service can not  Combined mental health and substance abuse and rehabilitation services and complimentary supports  Organized to resolve the interrelated clinical, social, financial, and residential challenges encountered by priority public mental health system constituents  With services are delivered in natural community settings such as homes, neighborhood venues, schools, homeless shelters, drop-in centers, and on the streets – often delivered by peers  Overcomes barriers to engagement and service access, develops coping skills, and promotes recovery in ways that traditional mental health service can not

15 What is housing support in a transformed MH system?  The system explicitly commits resources to one of two service models: stand alone Housing Support Teams or integrated housing support functions to Community Support/ ACT Teams  Housing support functions include:  outreach/ engagement,  helping a person select housing, move in, access benefits, sign a lease and meet all the required functions of tenancy and  other supports so a person can “keep” their housing  How to pay for it: Medicaid, state institution downsizing or health care reinvestment, new state plan requirements, re- direct current allocations  The system explicitly commits resources to one of two service models: stand alone Housing Support Teams or integrated housing support functions to Community Support/ ACT Teams  Housing support functions include:  outreach/ engagement,  helping a person select housing, move in, access benefits, sign a lease and meet all the required functions of tenancy and  other supports so a person can “keep” their housing  How to pay for it: Medicaid, state institution downsizing or health care reinvestment, new state plan requirements, re- direct current allocations

16 What is housing support in a transformed mental health system  Access to continuous and sufficient bridge and long term rental assistance and to contingency funds for deposits and furnishings  How to pay for it: HOME, state and local trust funds, Medicaid or state institution downsizing reinvestment, SSI Supplement, small grants  Interagency agreements to meet service and housing policy imperatives for affordable housing and MH reform – LIHTCs, Trust Funds and other state and local capital or rental and capital funds, private philanthropy  A better trained and compensated workforce with more opportunities for peers  Access to continuous and sufficient bridge and long term rental assistance and to contingency funds for deposits and furnishings  How to pay for it: HOME, state and local trust funds, Medicaid or state institution downsizing reinvestment, SSI Supplement, small grants  Interagency agreements to meet service and housing policy imperatives for affordable housing and MH reform – LIHTCs, Trust Funds and other state and local capital or rental and capital funds, private philanthropy  A better trained and compensated workforce with more opportunities for peers

17 What happens to people in systems that do not have PSH + a transformed MH system?  Institutional care/ incarceration/residential treatment siphons funds away from effective services,  While at the same time costs for maintaining institutions will continue to rise with little to show in return  MH system blamed for homelessness which in turn reduces credibility---ability to attract new resources  People with mental illness even more likely to disengage from the service system  Institutional care/ incarceration/residential treatment siphons funds away from effective services,  While at the same time costs for maintaining institutions will continue to rise with little to show in return  MH system blamed for homelessness which in turn reduces credibility---ability to attract new resources  People with mental illness even more likely to disengage from the service system

18 For discussion: State Transformation Strategies  Pennsylvania  North Carolina  New Mexico  Connecticut  Your state……  Pennsylvania  North Carolina  New Mexico  Connecticut  Your state……  Is PSH a priority?  If not, why not; what can be done to make it a priority  If it is, what is working?  What needs to be done?  What are the challenges to success?  Is PSH linked specifically to MH system transformation?