Much discussion has occurred during the last few years on reducing the high health care cost and improving outcomes for people with a serious mental illness. These individuals use a disproportionate amount of care, much of which may be unnecessary or avoidable, and tragically die 25 years earlier on average than people without a mental illness.
Since coming into office in January 2011, Governor Cuomo has implemented ambitious efforts to transform Medicaid spending in NYS. He created Medicaid Redesign Teams to look at how to reduce costs and increase quality and efficiencies. Much of the focus of these Teams has been on the high users – often people with serious mental illness.
Out of these efforts, Behavioral Health Organizations (BHO) and Health Homes have been designed to address better care coordination for people with serious mental illness and people with chronic health conditions, and to reduce the use of inpatient psychiatric and substance use services, readmission, and emergency room visits. By 2014, people with serious mental illness or substance use disorders will be folded into managed care – Special Needs Plans – for their health and behavioral health services. These Special Needs Plans will provide care coordination and become the fiscal intermediary, similar to those in place for people with HIV.
Ongoing Need for Housing
While policy makers will continue to refine how to right size New York State’s Medicaid expenditures, the value of supportive housing needs to be in the forefront. Housing programs have a proven track record of keeping people out of hospitals and emergency rooms, connecting with medical and psychiatric services, and coordinating care for the people who live there. Numerous studies have shown that supportive housing improves the quality of life and reduces medical and institutional costs. (1)(2)
Housing is a key determinant of a stable, productive life, and the foundation for recovery for people with a mental illness or substance use disorder. For all of us, housing is one of the most basic necessities. This incredibly valuable resource needs to expand to address the needs of the thousands of New Yorkers who are targeted by the BHO and Health Home Initiatives. The Governor has recently announced a Medicaid Redesign Team for Affordable Housing. This is a big step in recognizing and showcasing the impact of housing, and the need to develop more units. A NY/NY IV Supportive Housing Agreement to increase the existing supply of supportive housing is sorely needed.
F∙E∙G∙S houses over 1300 people each day, more than half (800) are people with serious mental illness who formerly were homeless or lived in a variety of settings: state psychiatric centers, shelters, prison, adult homes or hospital inpatient units.
The mission and core values that drive the work of staff each day is:
- Keep people housed
- Help the men and women live as independently as possible
The Motto of the F∙E∙G∙S Residential and Housing Services Division is “Whatever It Takes.” People with mental illness often have fragile lives due to ravages of the illness and the trauma from institutionalization, foster care placement or living on the streets. Support is necessary to keep them in housing and out of hospitals or other institutions. F∙E∙G∙S has adopted two practices that are making a difference:
- Critical Time Intervention, providing critical linkages during transitions
- Creating Crisis Beds to keep people housed instead of calling 911 or being lost to care
Critical Time Intervention
Critical Time Intervention (CTI) is an Evidence Based Practice designated by the Substance Abuse and Mental Health Services Administration (SAMHSA) that promotes housing stability by providing direct support during the transition to a new home or other critical periods in a person’s life.(3) Transitional periods are often difficult for people, and CTI offers staff support to ensure that residents adjust and remain in their new home.(4) The connection with staff who know the person, regardless of where they move, has made a difference in keeping people in housing.(5) An example of the effectiveness of CTI is Robert Q.
Robert Q. began his road to recovery when he moved to the F∙E∙G∙S Simon Community Residence (CR) in 1995. Prior to that Robert experienced periods of homelessness. Robert moved into the F∙E∙G∙S Brooklyn Apartment Program in 2002 where he relapsed, was hospitalized multiple times and hit a roadblock in his recovery. With his symptoms reappearing, Robert moved to Simon CR where he would receive 24-hour staff support to help him get back on his feet. Robert was his old self; he socialized, kept appointments, and remained hospital free. He was ready to move back to the Apartment Program. Unfortunately, following his move, he became very depressed and anxious and was having a difficult time adjusting. But this time around staff did something different; they adopted CTI. The staff from Simon CR made multiple visits to Robert as he was struggling and plans were put in place to support Robert’s stay in his apartment. The staff from Simon worked collaboratively with the Apartment staff sharing what had worked with Robert in the past. The continued connection with the Simon staff meant a great deal to Robert. Robert said that he never knew how much the staff cared for him. He has remained hospital free for over a year and now is thinking of moving to Supported Housing. He knows he is not alone and confident he is on the right path.
Flexing Residential Beds as Crisis Beds to Avert 911 Calls and Hospitalizations
F∙E∙G∙S had designated Riveredge Community House (RCH) as its in-house crisis residence. When residents of the apartment programs in NYC have a relapse or experience issues where 24-hour staff support and structure would make the difference between calling 911 or losing their apartments, residents are temporarily moved to this residence while retaining their housing. At the in-house crisis residence, people can receive the mental health or substance use services to get them back on the road to recovery. After a short stay, consumers move back to their apartment or to another location that may be better suited to their recovery. In-house crisis beds are also used when hospitals discharge a resident who is in need of additional support before moving back to their own apartment. During a recent 5-month period, 72% of the admissions to the CR were for crisis stabilization. We believe this model can be built upon to provide crisis services for people showing up to emergency rooms, or leaving inpatient care in other environments as regulatory and funding models are revised. An illustration of how crisis stabilization beds keep people in the community is Paul’s story.
Paul came to the F∙E∙G∙S Program at the Willow Shelter in the Bronx in 2000. He gained the skills to move to a Community Residence, then an SRO, and into Supported Housing in 2008. His success in staying in housing while working towards more independent living was a major life accomplishment. He continued attending groups at the F∙E∙G∙S outpatient program and had become fully integrated into the community at large. Paul was very articulate and able to advocate for himself in many situations. In December 2010, Paul needed additional support in the area of substance abuse to safely stay in his apartment. Not wanting to be hospitalized, he agreed to move to RCH where he would receive 24-hour staff support. At RCH he began once again to attend substance abuse groups, participate in in-house recreational activities, volunteering and helping his peers. While at RCH, he was able to remain sober and continued to attend support groups in the community. Paul moved back to his apartment in August 2011. He continues to do well, and he receives support services from the CTI team at RCH and his supported housing case manager.
Paul has come a long way, utilizing the resources of each housing program toward his recovery goals. His desire to achieve self-sufficiency has contributed to his personal goal of independence. Paul accomplished all of this without the need for hospitalization and with the full range of community support services available to him. He is an example of the recovery process dynamic that include staff partnerships and flexibility in housing to meet his needs.
These are true life stories of where housing enabled someone to stay out of a hospital and remain in the community. Let’s advocate for the Medicaid Redesign Team for Affordable Housing to recommend the expansion of supportive housing as a smart, well proven way to help people live decent lives and reduce unnecessary health care costs.
- Martinez, T. & Burt, M. “Impact of Permanent Supportive Housing on the Use of Acute Care Health Services by Homeless Adults.” Psychiatric Services, July 2006; 57(7):992-999
- Culhane, D., Metraux, S., & Hadley, T. Public Service Reductions Associated With Placement of Homeless Persons with Severe Mental Illness in Supportive Housing. Housing Policy Debate. 2002;13(1):107-163.
- National Registry of Evidence-Based Programs and Practices: Critical Time Intervention SAMHSA, August 2006
- Herman, D., Conover, S. et al “Randomized Trial of Critical Time Intervention to Prevent Homelessness After Hospital Discharge.” Psychiatric Services, September 2011;62(7) 713-719
5. F∙E∙G∙S Health and Human Services System Residential and Housing Services. “Adapting Critical Time Intervention (CTI) For Community Housing,” 2011