The New York City Department of Health and Mental Hygiene (DOHMH), together with community partners and providers, is working to increase access to employment and affordable housing for all people with mental illnesses. Local governments, including health departments, are ideally positioned to promote a broad view of what makes a community healthy. Safe, affordable housing and equal access to job opportunities are two of the most important factors in promoting health and wellness. At DOHMH, we seek to foster access to housing and employment as key elements to promoting recovery from a mental illness. Our triple aim is to improve access to care, increase the economic self-sufficiency of all those we serve and to help people live integrated lives in their communities. To achieve these goals we are: (A) Advocating for changes to laws that create barriers to employment and housing; (B) Creating access to affordable housing; (C) Improving employment services for individuals with serious mental illness including access to City-wide vocational supports; and (D) Strengthening the peer workforce of individuals with lived mental health experience.
1) Advocating for change: People living with mental illness want to work. In a survey conducted by DOHMH, more than 70% of people living with mental illness reported that they want to work. Unfortunately, numerous studies over the years have shown a consistent pattern: people with disabilities have high unemployment rates and people with serious mental illnesses have the highest unemployment rate of any group with disabilities, despite the fact that most of these people have both the desire and the capacity to work (SAMHSA/NASMPHD, 2007). For people living with serious mental illnesses, unemployment rates can be as high as 90 percent (National Governors Assoc., Center for Best Practices, 2002).
The road to work should be smooth for individuals with disabilities. However, the existing Social Security system creates inadvertent barriers for beneficiaries who aim to become self-sufficient and financially stable. National research consistently shows that many people with serious mental illness who receive Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) benefits hesitate to participate in paid employment out of fear they will lose critical cash benefits as well as Medicaid/Medicare health insurance. Although there are ways for people to maintain these benefits, they are not widely known nor understood. Under the existing regulations, Medicaid can be maintained by persons who formerly received SSI once they begin working, provided their annual income is under $46,000/year. DOHMH is working to raise awareness of these benefits by providing training. To date, DOHMH has trained 342 staff representing 230 providers of Assertive Community Treatment, Rehabilitation and Supportive Housing services on Social Security work incentives in order to promote employment. DOHMH is also tracking the employment rates for these programs in order to assess the impact over time with the expectation that employment rates of individuals served by these programs will increase.
Preserving Medicaid eligibility through job gains and losses is another important part of promoting employment. For example, SSI recipients who lose their job can lose Medicaid insurance because they are receiving unemployment or workers’ compensation benefits. Additionally, individuals and families frequently face challenges in navigating complex benefits issues. We need to make the benefits rules and systems easier to understand and more transparent. To address the problem of unemployment among people receiving SSI, public education is needed about the ways that they can work, maintain the benefits they need and achieve goals of financial independence. At the same time, we need to advocate for parallel efforts to simplify and improve the benefits system, which remains complex and provides support at levels set decades ago.
The National Association of Benefits and Work Incentives Specialists (NABWIS), National Council of Independent Living Centers, Cornell University Employment and Disability Institute, Virginia Commonwealth University Rehabilitation Research and Training Center, as well as other advocacy groups nationwide have proposed changes to SSI related work incentives regulations that will further help individuals manage their illnesses, go back to work and maintain their benefits. Their proposal allows SSI beneficiaries to keep a higher monthly cash benefit amount when returning to work.
2) Affordable Housing: For many formerly homeless people, stable housing has served as a springboard from which to take steps toward competitive employment and increased self-sufficiency. Since the 1980s, New York City has been at the forefront of developing supportive housing for people who have been homeless and have a mental illness. DOHMH oversees thousands of units of supportive housing, working with each provider to help tenants achieve their goals.
Staff in supportive housing face many demands and understand that helping people pursue employment is a process that can be complicated and time consuming. To support housing providers to help tenants gain employment, DOHMH works with its 200 supportive housing programs to educate staff about the impact of employment on tenants’ benefits. We have trained staff in 50% of the programs, and will continue until all programs have the capacity to help residents with employment and benefits. To provide ongoing support and information, we also created and disseminated a toolkit for housing providers.
3) Supported employment can help people to navigate employment challenges and gain competitive work. There are a host of challenges related to securing employment. For example, if an individual with mental illness leaves the workforce for periods of time due to illness, they may have to choose between appearing to be an unreliable employee who leaves without warning for periods of time or disclosing their illness and facing the potential stigma.
DOHMH oversees a portfolio of Assisted Competitive Employment (ACE) programs that provide supported employment services to obtain and retain jobs at or above the minimum wage. The goal of these programs is long-term competitive employment; DOHMH is currently transforming the reimbursement of these services to “pay-for-performance” where providers will be paid according to how many people they place in jobs and how long they retain them. This major change will occur this July.
4) Finally, we are deeply invested in integrating peers into the workplace and expanding the peer workforce in New York City. Hiring individuals with lived psychiatric experience is critical to changing the paradigm and making all services – housing, employment and everything else we do, a more responsive and successful system. Through Parachute NYC, a crisis intervention program and NYC Start which facilitates young adults experiencing their first psychotic break to re-integrate back into the community after hospitalization, we have created more than 65 peer positions. Our annual spending on peer services is $20 million and growing. With a trained peer workforce and fair payment structure for their work responsibilities, peer-delivered services will be successfully integrated into all facets of service delivery.
The Way Forward
DOHMH will continue to support affordable housing, competitive employment, and a peer workforce as key elements in promoting recovery and community integration for people with mental illness. DOHMH supports these key elements through oversight and delivery of effective services, advocacy to inform policy change, and training and education for individuals and community-based organizations. Medicaid reform and the imminent reimbursement of mental health rehabilitation services such as supported employment and residential supports are bringing yet new opportunities to incorporate these critical supports for substantial health outcomes and recovery into the health system.