For adults with psychiatric disabilities of all ages, stable housing is a critical need—perhaps, in fact, their most critical need. Sadly, appropriate housing is not adequately available at any age. For older adults with long-term psychiatric disabilities, finding decent, affordable, and stable housing is an even greater challenge than it is for younger adults. Why?
- Because they are less likely to be able to live at home with their parents, who are increasingly likely over time to become disabled themselves and, ultimately, to die
- Because there are very few housing programs designed for older adults with psychiatric disabilities
- Because older adults with psychiatric disabilities are increasingly likely to have co-occurring physical disorders and/or dementia.
Recognizing these complications, in 2008 the Geriatric Mental Health Alliance of New York published a report entitled Housing In The Mental Health System For Aging People With Serious Psychiatric Disabilities.(1) The report was based on work done by a consensus workgroup chaired by Antonia Lasicki of The Association for Community Living with representatives from The NYS Offices of Mental Health and of Aging, The Supportive Housing Network, the Alzheimer’s community, and mental health housing providers. The workgroup suggested three overall goals:
- Help older adults with psychiatric disabilities to live where they choose—generally in the community—and to avoid institutionalization in adult homes, nursing homes, psychiatric hospitals, and correctional facilities.
- Increase life expectancy of older adults with psychiatric disabilities, who generally die considerably younger than the general population
- Promote recovery and improved quality of life.
In order to achieve these goals, the Consensus Workgroup’s primary recommendations were:
- Develop additional community housing for older adults with serious mental disorders
- Develop additional home-based mental health services
- Help families currently caring for family members with psychiatric disabilities with future care planning
- Modify housing programs in the mental health system to:
- provide additional permanent housing,
- improve accessibility and safety,
- enhance wellness programs and health care on-site,
- increase supports for those with limited activities of daily living skills (ADLs), and
- deal with issues regarding death and dying.
Because it did not have adequate information about the numbers of older adults with psychiatric disorders living in adult homes, nursing homes, and supportive housing, the Consensus Workgroup recommended data gathering regarding where older adults with psychiatric disabilities live and the nature and quality of care they receive.
Recommendations regarding housing outside the mental health system could be developed on the basis of these data.
What has happened since these recommendations were made in 2008? There is a bit of good news:
- Some additional community-based housing will be made available to help people with psychiatric disabilities leave adult homes.
- In addition, as OMH’s housing system has grown over the past decade by approximately 5000 beds, both the number and proportion of adults 65 and older has grown from about 1350 (5.6%) to 2100 (7.1%).(2)
- In addition, all OMH housing programs have been encouraged to develop wellness programs and pay more attention to the health of their residents.
- And, NYS’s Medicaid reform efforts include recognition of the importance of stable housing for people with disabilities.
- It is not clear how many older adults, especially older adults with physical as well as psychiatric disabilities, will benefit from additional supported housing for people now in adult homes.
- Despite the increasing numbers of older adults in mental health housing, older adults are under-represented—less than half of their proportion of the population. This may reflect the fact that people with serious mental illness sometimes experience recovery over the course of their lifetime. Or it may reflect the facts that they are likely to die younger than the general population or that they tend to shift from the mental health system into the long-term care system as they develop physical disabilities. Still, it is striking that older adults are nearly 15% of the population of NYS but just over 7% of the population in residential care in the mental health system.
- Despite the increasing number of older adults in mental health housing, there has been no increase in the number of beds specifically designed to serve older adults (less than 10% of the beds occupied by older adults.)
- According to the Association for Community Living (ACL), no additional resources have been provided to support on-site wellness programs and increased attention to physical health.
- ACL also reports that even the residential programs specifically designed for older adults generally struggle to respond adequately to the chronic physical disorders that are increasingly common as people age, because resources are not built in to do this.
- ACL has long argued that a higher level of care needs to be put in place to meet the needs of older adults with co-occurring psychiatric and physical disabilities within the mental health system.
- It is also worth noting that the growth of 5000 beds over the past decade is well below the 35,000 additional units of housing that The Campaign for Mental Health Housing identified as needed in 2004.(3)
- Despite recent recognition in New York State of the importance of providing stable housing for the people who are likely to be the most costly Medicaid cases—usually people with co-occurring, severe, physical and behavioral disorders, it is not at all clear that housing being developed as part of Medicaid reform will be of much help to older adults with psychiatric disorders. The Requests for Applications (RFAs) to establish housing for “senior supportive housing” (4) and for “nursing home to independent living supportive housing” (5) released in March do not mention people with psychiatric disabilities. Since a considerable number of seniors in and out of nursing homes have both physical and mental disabilities, some older adults with psychiatric disabilities might qualify. Whether there would be appropriate design is another question.
- In addition, the funding for new housing units coming out of the recent RFAs is remarkably small. $250,000 per year for two years with no refunding for eight supportive housing projects and $2 million per year for two years with no refunding for two nursing home transition housing projects. This is not very encouraging given the rapid growth of the elder population over the next quarter century.
- Despite the fact that thousands of older adults with psychiatric disabilities live in adult homes, nursing homes, supportive housing, and prisons, so far as I know no one has gathered meaningful data about their numbers, where they are, how they are treated, and what changes are necessary so that they get humane and clinically appropriate care as well as a real opportunity to live where they would prefer in the community.
So, it appears that there has been a bit of progress since 2008 when the Geriatric Mental Health Alliance pointed out vast need to enhance housing for older adults with psychiatric disabilities. But it also appears that that progress has been exceedingly limited.
For both humane and economic reasons, we need to find out whether Medicaid reform and other efforts to “transform” the physical and behavioral health service systems are responsive to the housing needs of older adults with psychiatric disabilities. And we need to know before the elder boom is so far advanced that there will be no possibility of catching up with it.
This is exactly the sort of issue that The NYS Geriatric Mental Health and Chemical Dependence Planning Council should take up. Hopefully, they will make it their business to identify the extent and nature of the need and then develop a plan so that older adults with psychiatric disabilities will have adequate community housing before it’s too late.
Michael Friedman retired as Director of the Center for Mental Health Policy, Advocacy, and Education in 2010. He continues to write frequently on mental health policy issues. His writings are collected at www.michaelbfriedman.com. He can be reached at email@example.com.
(1) Friedman, MB and Williams, KA. Housing in The Mental Health System for Aging People With Serious Psychiatric Disabilities. Published by The Geriatric Mental Health Alliance of NY/ The Mental Health Association of NYC. 2008. http://www.networkofcare.org/library/Housing%20in%20the%20Mental%20Health%20System%20for%20Aging%20People%20with%20Serious%20Psychiatric%20Disabilities.pdf
(2) NYS OMH Patient Characteristics Survey. http://bi.omh.ny.gov/pcs/index
(3) Coe. S. Testimony Regarding Housing Needs in NYS. NYS Mental Health Budget Hearing in 2007. http://www.budget.ny.gov/pubs/press/2007/hearings/budgetIssueHearings/housing/NewYorkStateCampaignforMentalHealthHousing.pdf
(4) NYS Department of Health. RFA for Senior Supportive Housing. http://www.health.ny.gov/funding/rfa/1212230202/index.htm
(5) NYS Department of Health. RFA for Nursing Home to Independent Living Supportive Housing. http://www.health.ny.gov/funding/rfa/1310280314/index.htm