What an accomplishment! In the past 25 years (I may be off by a year or two) the New York State Office of Mental Health (OMH) has supported the development of 30,000 residential units for persons who have serious mental illness. Development began with the establishment of congregate supervised programs, single-purpose buildings with 24-hour staffing, medication monitoring and, most importantly an opportunity for intensive rehabilitation services so that residents could prepare for more independent housing. Apartment Treatment was developed as the next level in the continuum. These residents live in scatter-site apartments in conventional rental buildings in the community with visiting case management support services. Next, OMH developed a permanent housing alternative, supported housing, in which residents continue to receive rent subsidy and case management services. More recently, OMH developed the CR-SRO and Supported SRO models to fill out the continuum.
The robust housing network developed with OMH support stands as a singular achievement of the partnership between government and community-based agencies (with the participation of a number of committed advocacy organizations). The quality housing provided in these 30,000 residential units has given their occupants an indispensable foundation in their path to recovery. Government, providers, recipients and advocates agree that housing is an essential keystone service in New York’s recovery-oriented mental health system.
Today, as the mental health system in NYS is undergoing major reform through the work of the Governor-appointed Medicaid Redesign Team (MRT) and other related efforts, it is a time to reflect not only on the accomplishments of mental health housing to date, but how it can remain a vital force for recovery in the emerging integrated health and behavioral health system. In this context a number of issues emerge:
Sustaining the Current System: A first priority is the maintenance of the current residential system. While it is robust, there are also some concerning signs of fraying. Government funding must keep pace with rising expenses or else current housing will be in jeopardy. In supported housing, for example, rents rise steadily. Whereas licensed housing has always had the benefit of a property cost pass-through to cover increased rents and operating costs, unlicensed supported housing has not. When funding remains frozen in supported housing programs, more and more of the dollars go to the landlords, less and less to services. This issue has become so critical in some areas of the state that some agencies are hesitant to take advantage of new housing opportunities because of concern about sustainable funding.
Special Populations: OMH has recognized the importance of meeting the housing needs of some special populations; many years ago it supported the development of specialized MICA housing (although much more of this type is needed in the system) and, more recently, it is supporting the development of young adult housing. There are at least four other special populations that require some specialized housing: housing for older persons who have serious mental illness and medical conditions that can be managed in the community; housing for persons with mental illness who have been in the criminal justice system; veterans housing; and housing for families that include a member who has a mental illness.
Housing for older persons is a pressing need and will become a more pressing need as the population ages. While there have been some model programs developed that have demonstrated that older persons with serious mental illness and serious medical conditions can live successfully in the community with some enhanced on-site medical services, OMH has not yet formulated an initiative in this area. This kind of housing, offered in a congregate community setting, not only maintains the quality of life of its residents, it also avoids much more expensive nursing home placements.
The trans-institutionalization of so many persons with serious mental illness to the criminal justice system is a well-documented phenomenon. With many thousands of persons with serious mental illness in State and local correctional facilities, the needs of this population are also a pressing matter. Again there have been models developed to address the special needs of this group. A small number of community-based agencies have developed in-reach teams in cooperation with selected correctional facilities to identify and work with offenders who have mental illness while still incarcerated. Upon release, these individuals transition to community-based agency housing that has appropriate support services. This approach has had significant success in promoting positive integration back to the community and drastically reducing recidivism. While OMH has begun to address this need, a recovery-oriented housing model has not yet been fully developed.
The housing needs of veterans have been well-documented in recent months. This population also deserves some special attention. Quality housing, with access to vocational and behavioral health services, are essential for successful reintegration. Similarly, housing for families in which there is a member with mental illness has been woefully neglected. As more and more mental health recipients achieve recovery, family housing will also become a more urgent need.
Housing in the Emerging Integrated Managed Care Environment: Several policy issues emerge in the context of an integrated, managed care behavioral health system. First, it is essential that our housing resources be allowed to be used more flexibly. So many of the beds in the system, particularly those developed since the mid-90s, are designated for specific populations – i.e., the homeless through NY/NY I, II and III; persons who have had long stays in state psychiatric centers. Housing providers, family members and advocates have always recognized that there are other populations that need mental health housing who have little access (those with serious mental illness who have never been homeless or don’t meet the criteria of a specific NY/NY-designated program, for example). In addition, the current system is highly regulated with each kind of housing having its own set of detailed regulations and funding restrictions.
If housing providers are going to be able to respond to the needs of an integrated health and behavioral health system, they must have the flexibility to create the kind of admission diversion crisis beds and inpatient step-down beds that are needed to both improve recipient outcomes and to reduce costs. OMH has stimulated thinking of this kind in recent years. What are needed now are the concrete actions to begin to make this vision a reality.
One of the elements of a successful integrated system is the positive role that peers can play in the housing. Peers have a role to play in all levels of housing, especially in inpatient admission diversion crisis housing and in step-down housing after hospitalizations.
The place of housing in the State’s health home initiative is also important. In many instances, a resident’s primary service connection is to the housing staff with whom he/she works. It is often the housing case manager who has the closest, most effective therapeutic relationship with their clients. It is crucial, therefore, that in constructing health homes the State take this reality into account. Severing crucial existing therapeutic alliances by assigning residents to new unknown care coordinators might well undo years of resident stability and progress. On the other hand, building on current residential case management relationships to achieve comprehensive care coordination is an important potential strategy to achieve the goals of health homes.
This raises the general question of how housing will fit into an integrated health and behavioral managed care system. It is clear that mental health housing will be an important element of the service system. Over the next two years, as plans for the emerging system are developed, it will be essential for the mental health housing community “be at the table” to play a major role in the design decisions.
The production of new housing: One of the most ominous signs to have emerged in the past year is OMH’s release of an RFP for new housing that will fund services only. The implication here is that OMH has suspended its capital funding of new beds. For the past 25+ years OMH has provided either direct capital funding for the development of new beds or, in recent years when tax credit financing has been the major source of capital development, it has provided debt service funding that is an essential element of such projects. The OMH pause in supporting capital or debt service funding is of great concern. While the 30,000 beds it has developed so far are an outstanding achievement, there is still substantial unmet need for additional beds.
Hopefully, the recently established MRT Affordable Housing Workgroup will address this critical development issue. Included in its charge are: “to develop a statewide plan for increasing access to affordable housing, so that New York State Medicaid beneficiaries are not forced into institutional settings because they cannot access affordable housing… [including] identifying options for financing construction.”
The entire mental health community can take justifiable pride in what has been accomplished in housing over the past three decades. As the process of major reform and restructuring unfolds, housing will remain an essential service. How it will be integrated into the new system, how its future viability will be assured and how the production of new housing will be financed are all major concerns. An active housing community—of providers, recipients, families and advocates—is needed to work in partnership with government to address these concerns.
