1. Working together to provide support and choice
Substance Use,
Recovery,
and Housing:
Working together to provide support and choice
Becky Vaughn
Principal Consultant

3. Thank you for what you do!

4. 30% 2/3
Approximately 30 percent of the chronically homeless population has a serious mental illness and around two-thirds have a primary substance use disorder or other chronic health condition that create major difficulties in accessing and maintaining stable, affordable, and appropriate housing.

6. Housing First!!!
No, Recovery Support!!

7. Challenges and opportunities

10. Common Language Housing Choice treatment recovery Person-centered care
Recovery Housing
Supportive housing
Harm reduction

11. Data Systems
Fee for Service
$ $ $
Regulations
Competitive
Inadequate

12. Recognizing Housing as a platform for recovery is not simply about putting a roof over someone’s head to meet basic needs
A foundation for moving beyond stability, regaining hope and achieving long-term wellness and recovery goals

13. Research and evidence
A critical obstacle to discerning the efficacy of various housing and service interventions is the lack of consistency in how “success” is measured and operationalized across studies

15. Recovery Housing Policy Brief

16. Clear guidance
Defined: housing in an abstinence-focused and peer-supported community for people recovering from substance use issues Recognizes the importance of individual choice to support various paths towards recovery
Expected and effective operation of HUD-funded Recovery Housing programs

17. Communities should ensure that all projects serving people with SUDs support a life in recovery to include these dimensions:
Home
Taken from SAMHSA’s working definition of Recovery

18. Operations for People with SUDs
Low barrier, evidence –based
Emphasize housing stability and recovery goals
Rights of privacy, dignity, respect, freedom from coercion and restraint
Optimize autonomy and independence
Highest levels of national, State, and/or local accreditation/licensure
Move to permanent housing as they exit

19. Operations of RH for homelessness
Transitional, but time-limited/resident- determined, not program-determined
Generally single-site
Personal privacy and 24/7 access
Recovery goals include housing stability, employment
Relapse is not automatic cause for eviction
Upon leaving offer assistance in accessing other housing
Different from Residential treatment programs

20. may serve people with other disabling conditions
How do they differ?
Transitional Housing
Permanent Supportive Housing
outcomes emphasize exits to permanent housing
outcomes emphasize housing retention and income progression
high level of services and peer/staff supports
services and peer support because SUD impedes independent living; participation not a condition of tenancy
generally time-limited
not time limited
lease or occupancy agreement
participants have a lease and must operate in compliance with local landlord-tenant laws
may serve people with other disabling conditions
in cases of significant lapses or set-backs, the program may hold the unit of the program participant for up to 90 days
The
key is that the program participant has sought out this type of program as their
preferred choice for supporting their personal commitment to their sobriety and
holistic recovery.

21. How can they work together?
HUD strongly encourages Continuum of Care’s to adopt a system-wide Housing First orientation that removes barriers whenever possible and that addresses the housing needs of people at all stages of recovery.
Recovery Housing is not in conflict with that as long as entry is voluntary
This is a guide for any RH not currently operating under these standards

22. How can they work together?
When operated in a manner consistent with this guidance, Recovery Housing might not be in conflict with this approach so long as entry into the program is based on the choice of the program participant.

23. Outcomes Housing Stability Income Sobriety
Communities can develop local measures that are appropriate to the model.
Housing Stability
Income
Sobriety
caution comparing other TH/PSH to Recovery Housing programs. take longer to achieve permanent housing, employment, and stability outcomes, but outcomes clear expectations
Housing Stability–In TH Recovery Housing, exits to stable permanent housing
PSH Recovery Housing, maintenance of that housing
Income–Obtaining and maintaining employment and/or increasing income
Sobriety–An increase in number of days sober in comparable periods before and
after treatment or across two equal treatment periods is a positive outcome.
Alternatively, a decrease in the number of days of relapse in comparable periods
could be measured.

26. Currently…
Public behavioral health authorities and community behavioral health organizations are increasingly recognizing the critical role of permanent affordable housing in supporting individuals' recovery from M and/or SU disorders.

27. Currently…
Many have endeavored to make available a range of housing and service options consistent with the needs, preferences and what is considered effective for each respective population at various stages of treatment and recovery.

28. Currently…
Yet access to an array of community-based services matched with permanent affordable housing for people with M and/or SU disorders remains a major challenge.

29. Olmstead vs L.C. 1999
2011 DOJ guidance defining integrated settings SAMHSA Permanent Supportive Housing (PSH) EBP Kit ADA/Olmstead violation suits 2013 HUD guidance with methods for scattered-sites

30. Culminating in need to better leverage Medicaid funding
Olmstead vs L.C. 1999
Section 811 Project Rental Assistance (PRA) requires partnering with Medicaid
HUD’s move to CoC funding for housing- specific costs and prioritization of chronic homeless
Culminating in need to better leverage Medicaid funding

31. CMS has supported provisions in the ACA to reduce care in institutional settings and expand home and community-based services (HCBS) through rebalancing initiatives like the Balancing Incentives Program (BIP), expansion of its Money Follows the Person (MFP) demonstration program, and new and improved options for the delivery of Medicaid HCBS.

32. What does it mean for us?
Many states are now financing integrated housing like PSH with their state/local housing resources—the same resources many of us have relied on for owner operated housing and service programs.
More need to adapt to changing environment
Traditionally, many providers purchased or developed group homes, residential treatment facilities or “single purpose” (e.g., serving one disability or other eligible target population) PSH buildings to meet housing demand for those they served because mainstream affordable housing did not exist or was not accessible

33. What does it mean for us?
Providers will have to adapt to a system that partners with and relies more on the affordable housing community to fund and develop housing, while services are delivered independent of or separate from housing in a flexible, individualized manner.
providers who also own and/or operate housing will need to consider how this policy
context impacts their current housing and service delivery model

35. Housing-related services have historically been financially supported with program-based funding through contracts
Providers will need to adapt to reimbursement for services based on individual needs in a Medicaid environment

36. While there is no specific Medicaid-financed “supportive housing service” covered under any of the Medicaid authorities, key service activities and interventions necessary for individuals to get and keep housing may be covered by Medicaid.

37. June 2015, CMS released Bulletin 22 that describes the housing related activities and services Medicaid can assist in covering that have proven to be cost- effective and to facilitate community integration

38. Those services that provide direct support to assist individuals prepare for and transition to housing, as well as successfully maintain housing after move-in.

39. These activities can be embedded in part or whole into three broad categories of services which may be included in an individual's person-centered care plan and are already covered by Medicaid.
For many persons with complex behavioral health conditions, embedding housing-related services into these other essential services ensures access to the broader spectrum of services necessary to an individual’s success in PSH

40. Housing as integral, but non-essential
Best practice community-based services that are typically long- term in nature and designed to assist people with serious and long-term disabilities live successfully in the community
This approach views housing as an integral rather than non-essential part of
treatment and recovery, enhancing a person's overall well-being and community tenure. An
example would be a case manager or housing specialist on an ACT team assisting an individual to making a housing choice or negotiate with a landlord.

41. Housing as integral, but non-essential
Housing-related interventions may be embedded into existing and routinely covered services
Intensive outpatient programs (IOP)
Assertive Community Treatment (ACT) community support
Psychiatric rehabilitation
Direct services case management
This approach views housing as an integral rather than non-essential part of
treatment and recovery, enhancing a person's overall well-being and community tenure. An
example would be a case manager or housing specialist on an ACT team assisting an individual to making a housing choice or negotiate with a landlord.

42. Pre-existing or Emerging Condition
Existing targeted support/treatment that enable people to move into/live in own home.
personal care
home health
specialized care for chronic conditions
supported employment
Critical Time Intervention(CTI)
respite/crisis prevention
stabilization
These services are reimbursed by Medicaid as related to a person's pre-existing or
emerging chronic health condition, a cognitive impairment or some other type of disability or
condition that requires very specific attention for a person to live in their own home. If not for this
specific type of in-home intervention, a person needing daily nursing assistance, for example,
would have to live in a relative's home or a nursing home rather than their own home

43. Support for Integrated Settings
Existing ongoing supports received from
Community/housing support staff
Peers
Recovery support groups (AA/NA)
Wellness
Community-based organizations
These
ongoing supports are essential to ensuring that individuals living in integrated community settings
like PSH have support within their community as well as options for how they spend leisure time.
While many of these supports are available, not all are covered by Medicaid. Some of these
supports are available at little or no cost to persons living in the community, while others will need
to be paid for by other non-Medicaid resources.
community-based organizations such as neighborhood, wellness or drop-in centers, etc.

44. Case Study: New Jersey Division of Mental Health and Addiction Services (DMHAS)
DMHAS ceased further development of congregate group home settings and began developing permanent supportive housing (PSH) options through the development of a state subsidy program.
To comply with the Olmstead Settlement Agreement, DMHAS ceased further development of congregate group home settings and began developing permanent supportive housing (PSH) options through the development of a state subsidy program.

45. Recommendations
Systems Change Improve Practice Cultivate and Disseminate Knowledge
promote integration of housing, treatment and recovery support systems at the federal, state and local levels
Build the evidence base housing models/best practices for serving individuals/families with SUDs and work with partners to disseminate
Build the capacity of supportive housing and recovery housing providers to integrate best practices at the nexus of housing and services for individuals with SUDs

46. Systems must not simply promote an ethic of person-centeredness, it must be the central organizing principle woven into the fabric of new systems to ensure support of people as their own agents of change pursuing self-defined goals building on their own personal assets and capital

47. Questions?
Becky Vaughn

48. Knowledge is knowing that a tomato is a fruit, Wisdom is not putting it in a fruit salad.
Miles Kington

49. STAY STRONG!