Policy and Practice: A Discouraging Disconnect

As soon as I learned the summer edition of Behavioral Health News would address our efforts to meet the needs of vulnerable populations, I experienced a rather sudden and dispiriting thought. In so many ways we have failed to satisfactorily address the needs of our most vulnerable citizens despite ostensibly progressive public policies, dedicated advocacy efforts and a genuine commitment to infuse our service systems with recovery-oriented principles and evidenced-based practices. We are considerably better off than we were a couple of decades ago to be sure. Regressive institutional modes of care have been largely replaced with community-based alternatives that offer individuals with serious behavioral health conditions opportunities to reside and receive services in settings of their choosing. When viewed from afar our efforts appear to have delivered on many of their promises. But this perspective obscures many failures at a granular level that are bound to worsen in the absence of concerted corrective measures.

A prominent example of this trend concerns a court action advocates brought in support of adult home residents several years ago. This action followed a New York Times investigation that exposed squalid living conditions and widespread neglect within privately operated adult care facilities, many of which served as little more than warehouses for individuals with serious mental illness and other disabling conditions (Levy, 2002). The existence of such facilities and their abysmal failure to provide even a modicum of dignity for their residents was a poorly kept secret within our service system. They were ushered in during the deinstitutionalization movement of decades past and offered “community-based” alternatives for former patients of state-operated psychiatric centers and other institutional care settings. In short, they enabled the state to fulfill its aims, so it is unsurprising they operated unencumbered by rigorous regulatory oversight for many years.

The Times exposé elicited predictable proclamations of outrage from policymakers and the enactment of certain practices designed to protect adult home residents. These included the introduction of independent care management services into select facilities and a prohibition on referrals of adults with serious behavioral health conditions to others. Advocates also secured a court settlement on behalf of a class of aggrieved adult home residents that required the state to allocate funding for the provision of integrated residential accommodations for individuals who fulfilled certain criteria. This settlement was largely consistent with the requirements of the Americans with Disabilities Act (ADA) and findings of the U.S. Supreme Court in Olmstead v. L.C., landmark achievements in the recovery movement that enshrined the rights of individuals with disabilities to reside in the least restrictive settings practicable. Progress was clearly at hand.

Fast forward to 2017. Of the estimated 5,000 members of the aforementioned settlement class approximately 475 have received alternative housing in integrated settings (New York Association of Psychiatric Rehabilitation Services, 2017). In other words, this settlement has achieved a 9% success rate. Sadly, this is no more surprising to many than were the findings of the Times investigation. Supportive housing providers, care managers, behavioral health service professionals and other allied stakeholders can easily enumerate the obstacles to implementation of this settlement. Many individuals who reside in adult homes experience chronic and comorbid primary (medical) and behavioral health conditions for which intensive support services are needed to forestall inpatient hospitalization or transfer to similarly restrictive facilities. Services of such scope and intensity cannot be easily provided within fully integrated settings due to a scarcity of available resources. Current state guidelines for operators of scattered site supportive housing programs (i.e., independent housing with rental subsidies and basic support services) require nothing more than monthly meetings with program residents and quarterly visits to their apartments. Individuals emerging from institutional care settings are often accustomed to continuous support, and although the quality of this support varies considerably among facilities its abrupt removal can jeopardize the stability of the most resilient recipients.

Moreover, state funding for nonprofit supportive housing operators fails to compensate them for the full cost to provide housing and rehabilitative services for their residents. A recent analysis by the Association for Community Living (ACL), a membership organization that represents a broad coalition of supportive housing and behavioral health service providers throughout New York State, determined housing providers experience significant budgetary shortfalls that impede the fulfillment of their missions. State allocations do not properly account for rapidly rising rental and personnel costs nor do they reflect other expenses housing providers regularly incur. Consequently, operators of Office of Mental Health (OMH)-funded scattered site supportive housing programs experience a collective statewide budgetary shortfall of $65 million per year (Association for Community Living, 2017). Tragically, this comes at a time when these providers serve individuals with extensive histories of institutionalization in adult homes, state-operated psychiatric facilities and other restrictive settings, many of whom require considerably more assistance than housing operators were equipped to provide even before an era of budget austerity.

Some observers might object to this characterization on the grounds other community support services are available to formerly institutionalized individuals that may supplement and enhance the impact of supportive housing providers. New York surely boasts a relative wealth of community-based services for individuals with disabilities and they deserve considerable credit for facilitating their beneficiaries’ recovery. Upon closer inspection, however, we find many of these services are plagued with similarly onerous resource constraints that limit their impact on the most vulnerable beneficiaries. For example, Health Homes were established in New York State in 2012 in order to promote service integration and care coordination among individuals with complex medical conditions. This innovation has surely achieved some success insofar as it has delivered care management services to select recipients who were previously ineligible for it. For adults with serious behavioral health concerns, however, the elimination of Targeted Case Management (TCM), a modality that offered a robust level of service coordination by care managers who maintained relatively modest caseloads, and its replacement with a Health Home model of care management has not been an altogether welcome development. Recipients of TCM services who had been accustomed to weekly or biweekly meetings with their care managers are now limited to monthly visits or periodic telephone calls under the Health Home model. For many residents of adult homes and other institutional care settings who require considerable support during their transition to independence such a “light touch” to engagement is grossly insufficient.

As sympathetic policymakers strive to advance the cause of recovery and to promote our recipients’ integration into less restrictive settings, they would do well to acknowledge longstanding discrepancies between their legislative intent and its actual implementation. The examples described above are merely two of many in which progressive public policies fail to secure the resources necessary to fulfill their promise. Our most vulnerable citizens deserve more than policy statements borne of noble intent and purpose. Their success demands adequate reinvestment of resources saved through a continuing decline in state-administered services and related initiatives.

The author may be reached at (914) 428-5600 ext. 9228 or by email at: abrody@searchforchange.org.

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