This issue of networks reflects the growing importance of expanding the range of housing options for persons with psychiatric disabilities in today's changing health care environment. Faced with funding cuts and restrictions on the use of available resources, State Mental Health Agencies (SMHAs), State Housing Authorities, consumers, families and housing advocates at the state and local levels are teaming up to develop innovative responses to the dramatically increased need for affordable housing.
NTAC is responding to this need in a number of ways. Our staff provides ongoing support to the work of the National Association of State Mental Health Program Directors President's Task Force on Housing, which was recently charged with advising the Board of Directors and membership on short- and long-term strategies necessary to respond to shrinking federal resources, to guide state efforts in developing permanent and affordable housing and to forge partnerships with key stakeholders to facilitate the development of housing for persons with psychiatric disabilities.
NTAC provides funding for several on-site technical assistance projects designed to help state mental health systems develop and finance housing for persons with psychiatric disabilities.
In addition, NTAC has just published Housing for Persons with Psychiatric Disabilities: Best Practices for a Changing Environment, a technical assistance Tool Kit that synthesizes models and best practices in the context of the rapidly changing housing environment at the federal and state levels. The Tool Kit addresses the information and technical assistance needs of SMHAs, state housing finance agencies, and public and private housing developers, as well as a broad audience of clinicians, consumers, family members, advocates and technical assistance providers.
One copy of the Tool Kit will be provided free to each SMHA. Additional copies are available directly from NTAC. [See order information under Suggested Reading] For additional information on NTAC's services and activities, we encourage you to visit our Web site at: http://www.nasmhpd.org/ntac
We are very pleased to be a part of this important work and, as
always, look forward to hearing from you about how we can best
meet your needs for information and technical assistance. -Bruce D. Emery
The work of the National Technical Assistance Center for State Mental Health Planning (NTAC) is guided by a 13-member national Steering Committee. Its members include State Mental Health Commissioners and representatives of the Center for Mental Health Services, consumers and family member organizations, academia, and state mental health planning and advisory councils.
The Steering Committee provides crucial support to NTAC by: (1) articulating values and principles that guide activities, (2) establishing criteria for the overall operation of NTAC, (3) reviewing and approving operation plans, and (4) providing ongoing linkages between NTAC and the national mental health community.
Below is a brief biographical sketch of each member of NTAC's Steering Committee.
Richard Bast is NTAC's Government Project Officer with the federal Center for Mental Health Services, where he also monitors state implementation of the Community Development Mental Health Services Block Grant funds and serves as the primary contact for inquiries from state agencies and others on block grant requirements, the block grant funding cycle and related topics.
Paolo del Vecchio is the consumer affairs specialist at the federal Center for Mental Health Services. A consumer and survivor, Mr. del Vecchio has been involved in activities in a wide range of areas during the past decade including homelessness, managed care, HIV/AIDS and in organizations such as the Consumer/Provider Research & Policy Work Group. He was co-chair of the World Federation of Psychiatric Users.
Joseph N. de Raismes, III, J.D., is city attorney of Boulder, Colorado. He is a member and past president of the Colorado Mental Health Planning Advisory Council and a founder and president of the National Association of State Mental Health Planning and Advisory Councils. Previously, Mr. de Raismes was first assistant attorney general for Colorado (Human Resources Section), representing state human service agencies including the mental health agency. In 1995 Mr. de Raismes received the Fletcher Gaylord Advocacy Award from the Colorado Mental Health Association.
Bruce D. Emery, M.S.W., is director of the National Technical Assistance Center for State Mental Health Planning, a three-year Cooperative Agreement between the National Association of State Mental Health Program Directors (NASMHPD) and the Center for Mental Health Services. In this role, he coordinates efforts to provide technical assistance and information to State Mental Health Agencies (SMHAs) on a wide range of issues including managed care, housing and other topics. In addition Mr. Emery serves as director of technical assistance for NASMHPD and the NASMHPD Research Institute, Inc. He maintains a clinical practice with children and families and serves as a family mediator with the District of Columbia Dispute Resolution Program.
Don A. Gilbert, M.B.A., is Commissioner of the Texas Department of Mental Health and Mental Retardation, which operates 25 institutions, 37 community mental health/mental retardation centers and a statewide network of outreach programs. In addition to his extensive experience as a senior state mental health official, Mr. Gilbert has served as the chief executive officer of the Dallas County Mental Health and Mental Retardation Center and as superintendent of Terrell State Hospital. Mr. Gilbert received the Alliance for the Mentally Ill's Professional of the Year Award in 1990. Mr. Gilbert is a member of the NASMHPD Board of Directors.
David A. Granger, M.S.S.A., is a planner, program development specialist, manager of consumer affairs, and manager of quality outcome monitoring for the Cuyahoga County Community Mental Health Board in Cleveland, Ohio.
He is past president of the National Mental Health Consumers Association, a member of the Executive Committee of the Ohio Multi-Ethnic Mental Health Consortium, and a founding co-convener of the American Association of People of Color Mental Health Consumers. Mr. Granger has made presentations at numerous state and national conferences and training activities.
Ronald Manderscheid, Ph.D., is chief of the Survey and Analysis Branch, Division of State and Community Systems Development, Center for Mental Health Services. In 1993 Dr. Manderscheid was a member of the Mental Health and Substance Abuse Work Group of the President's Task Force on Health Care Reform and later served as policy advisor on National Health Care Reform in the Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services. Previously, he served as chief of the Statistical Research Branch of the National Institute of Mental Health. Dr. Manderscheid is noted for his publications on service delivery to persons with psychiatric disabilities and the organization of mental health service systems.
Pamela K. Marshall, J.D., a private consultant on mental health issues, was formerly director of the Division of Mental Health Services in Arkansas. During her tenure as director, Ms. Marshall established five regional mental health planning councils to guide the mental health system and strengthen consumer and family involvement in the mental health planning process. One of Ms. Marshall's primary concerns is ensuring that persons with psychiatric disabilities have access to livable, affordable housing as a key component in improving the quality of life for consumers and their families and helping consumers to become self-supporting and productive members of the community.
Sinikka McCabe is director of the Wisconsin Bureau of Community Mental Health, which oversees all public mental health services in the state. Her responsibilities include developing policy; establishing program goals and standards; directing planning; program evaluation and data collection; and providing technical assistance and consultation through collaboration with counties, service providers, consumers and their families. Ms. McCabe has made numerous presentations on housing and supportive services.
A. Kathryn Power is director of the Rhode Island Department of Mental Health, Mental Retardation and Hospitals. In addition to receiving several distinguished service awards for her work in mental health, Ms. Power has served on the boards of the Rhode Island Governor's Council on Mental Health and the Child and Adolescent Service System Project. Previously she directed the Rhode Island Office of Substance Abuse and the Governor's Drug Program. Ms. Power is a current member and president-elect of the NASMHPD Board of Directors.
Teresa J. Sanders is a statewide family advocate for the Phoenix, Arizona-based MIKID (Mentally Ill Kids in Distress) program, promoting the development of behavioral health services for children, youth and families throughout the state. Ms. Sanders is a member of the Arizona Children's Behavioral Health Council and the state Intergovernmental Agreement Executive Committee. She also serves as a technical assistance resource provider in managed care to the Georgetown University Child Development Center in Washington, D.C., and a consultant to the Washington Business Group on Health (National Resource Directory) and the Network for Child and Family Health Services.
David L. Shern, Ph.D., is a professor and dean of the Florida Mental Health Institute at the University of South Florida in Tampa. Dr. Shern was previously director of the National Center for the Study of Issues in Public Mental Health, a research center that is part of the New York State Office of Mental Health, as well as director of the office's Evaluation and Research Bureau. Dr. Shern has been the principal or co-principal investigator for 13 research projects funded by the National Institute of Mental Health and the Robert Wood Johnson Foundation. He has served as chair of the Mental Health Section of the American Public Health Association (APHA) and was recently elected to the governing board of APHA, which honored him with its Mental Health Section Award.
Garrett Smith, M.P.A., is state director of the Office of Consumer Advocacy in the
State Mental Health and Developmental Disabilities Division in
Salem, Oregon. In addition, he is a board member of the National
Mental Health Consumers Association, a member of the Governor's
Mental Health Advisory Committee in Oregon, a consultant to the
National Institute of Mental Health and Center for Mental Health
Services grant review teams, and a member of the advisory board
of the Center for Community Change Through Housing and Supports.
Mr. Smith has made presentations at numerous state and national
conferences on topics including supportive housing, consumer issues
and persons with psychiatric disabilities who are homeless.
The ongoing reduction in the availability of traditional housing options for persons with psychiatric disabilities has moved the housing issue to the forefront for Commissioners of State Mental Health Agencies (SMHAs). This reduction is the result of a number of factors, including a shrinking federal financial commitment to affordable housing, the devolution of control of housing funds from the federal level to the state and local levels, housing laws favoring the elderly over the disabled and the introduction of new managed health care policies.
Developing strategies for addressing the housing issue in a proactive manner was the topic of "Housing for Persons with Psychiatric Disabilities: Responding to the Impact of HUD Policy Changes and Managed Care," a panel discussion sponsored by the National Technical Assistance Center for State Mental Health Planning (NTAC) at the 1996 National Association of State Mental Health Program Directors (NASMHPD) Summer Commissioners Meeting in Chicago.
While acknowledging that there are hurdles to overcome, panelists urged State Mental Health Commissioners to adopt a proactive role in forging partnerships with state and local housing authorities and positioning their agencies to take advantage of opportunities provided by the changing health care and housing environments. Panelists emphasized that State Mental Health Commissioners must take the lead on this issue.
Consumers Prefer Independent Living
Panel moderator Sinikka McCabe, Director of the Bureau of Community Mental Health in Madison, Wisconsin, said that the trend during the past two decades away from inpatient facilities and group homes toward more independent living for those with psychiatric disabilities has begun to provide definitive data demonstrating that living in the community offers the greatest potential for recovery, including a return to productive work. An analysis by the Center for Community Change in Vermont of more than 50 consumer housing studies conducted in the United States and Canada revealed that the vast majority of individuals with psychiatric disabilities express a clear preference for living in non-institutional settings with access to flexible, comprehensive support services on an as-needed basis. "These individuals want to live with friends, families or other loved ones rather than in group homes or inpatient settings," said Ms. McCabe.
The problem is that many individuals with psychiatric disabilities cannot afford to buy or rent housing at current market rates, even with financial help from existing government housing assistance programs. According to Ms. McCabe, persons with psychiatric disabilities are among the least affluent Americans, with Social Security Insurance (SSI) incomes averaging about 24 percent of median income for single heads of households. Assisted housing programs funded by the U.S. Department of Housing and Urban Development (HUD) are typically designated for individuals with incomes at 50 percent of the median, federal housing tax credits for those with incomes at 60 percent of the median, Community Development Block Grants for those with incomes at 80 percent of the median, and programs for first-time home buyers for those with incomes at 115 percent of median.
Except for several jurisdictions in Oklahoma, Ms. McCabe stated, there is virtually nowhere in the United States where persons with psychiatric disabilities who depend on SSI for their entire income can afford to rent or purchase housing. She said that unless they receive additional housing assistance, many of these individuals end up in homeless shelters, on the streets or in jails. The breakdown of family support systems and the rapid disappearance of inexpensive single-room occupancy dwellings serve to exacerbate this problem.
Nonetheless, federal housing assistance for persons with psychiatric disabilities has diminished in recent years. Funding for HUD's Section 811 Program, which provides housing assistance for persons with psychiatric disabilities, was reduced from $387 million in FY95 to $258 million in FY96, a 33 percent decrease. Under the recently enacted HUD appropriations legislation, Section 811 funding will decrease to $194 million in FY97.
Managed Care Presents Opportunities
Ann O'Hara of the Technical Assistance Collaborative in Boston maintained that the trend toward managed care provides an opportunity for public mental health systems to shift from traditional finance models that link payments to specific services to models that link payments to individual clients based on their particular needs. New financing mechanisms have the potential to bring together different funding streams to create a single service package that fits the requirements of the consumer. According to Ms. O'Hara, the ultimate goal of managed care in this area is to maximize the impact of investments in mental health services by producing positive, effective outcomes.
Providing supportive housing opportunities is a key element in achieving positive outcomes for persons with psychiatric disabilities. "We have empirical knowledge that supportive housing works," stated Ms. O'Hara in citing research funded by the federal Center for Mental Health Services' Community Support Program, the Stewart B. McKinney Homeless Assistance Act Demonstration Program, the Robert Wood Johnson Foundation Program on Chronic Mental Illness and, more recently, a 3-year study conducted by the Texas Department of Mental Health and Mental Retardation. "Supportive housing is cost-effective, it produces positive consumer outcomes, it reduces hospital stays and emergency room visits, and it increases consumer satisfaction," Ms. O'Hara said.
Cost Shifting and Collaboration
To ensure adequate housing for those with psychiatric disabilities without depleting mental health services funds, it is necessary to forge partnerships with housing delivery systems at the federal, state and local levels. In states such as Connecticut, Massachusetts, Michigan and Ohio, some housing costs have been successfully shifted from the mental health system to the affordable housing system. [See Michigan article.] However, cost shifting cannot be achieved overnight. State Mental Health Commissioners must convince state policy makers and housing commissioners as well as nonprofit developers that providing housing is a cost-effective strategy. According to Ms. O'Hara, Commissioners can point out, for example, that each public housing unit or Section 8 Certificate that is used by a person with a psychiatric disability saves the mental health system an average of $4,000 a year. In cities such as Boston and New York, where above-average housing costs are typical, cost-shifting can save as much as $7,200 per person a year. "That's money you won't have to come up with," she said.
Despite retrenchment in housing programs, the federal government still provides substantial funding for housing assistance. Ms. O'Hara noted that about four million federally subsidized housing units and Section 8 Certificates exist. Of the $19.4 billion HUD appropriation in FY97, more than $6.5 billion will go to federal housing and community development programs (e.g., HOME, Community Development Block Grant and McKinney). About $2.5 billion of this amount will go to state housing agencies.
However, resources available for developing and subsidizing new affordable housing continue to shrink at a time when mental health systems have become increasingly reliant upon access to the housing market. Limits placed on discretionary spending and HUD's growing Section 8 renewal problem sharply limit new initiatives. What federal resources are available are being shifted to the state and local levels, where local priorities will determine use.
State Mental Health Commissioners must build bridges to housing agencies, suggested Stephen Norman of the Corporation for Supportive Housing in New York City. "Housing is not an entitlement in the United States," he said. "Your ability to secure affordable housing for your clients will depend on your ability to broker relationships at the state and local level."
Mr. Norman said that Commissioners must make the case that expanding access to housing for those with psychiatric disabilities is a cost-effective strategy for states. "The bottom line is that it's cheaper to keep people stabilized in permanent housing with wraparound services than it is to leave them without housing," he said. A larger state investment in housing for special-needs populations will result in future savings in emergency shelter programs, the health care and criminal justice systems, and other areas.
"Take that calculus and get involved in the planning process in your states," Mr. Norman said. "Look to HUD's Consolidated Plan, which is the road map for how states and localities decide to use the housing funds they have."
State Mental Health Commissioners should explore other sources of housing assistance, including federal Tax Credit Qualified Allocation Plans (QAPs), which enable states to set specific terms for allocating federal tax credits for low-income housing. "Local developers are competing hard for these credits, which essentially provide tax shelters for a 15-year period," Mr. Norman said. "There's a scoring system, with some states awarding extra points to developers who are willing to set aside a percentage of their units for mental health consumers with low incomes."
Even with alternative funding sources, SMHAs must still be willing to invest their own resources in affordable housing for consumers, Mr. Norman said. For example, some of the money saved when a large state psychiatric institution closes could be used to develop a range of affordable housing options for mental health consumers. SMHAs can also participate in housing acquisition and development programs with State Housing Finance Agencies by subsidizing rents on housing units that are typically too expensive for persons with psychiatric disabilities.
Mr. Norman noted that demonstration programs involving collaborative efforts in Connecticut, Georgia, Michigan and New York City have proven to be cost effective and resulted in long-term savings. In New York City, the creation of 5,000 units of supportive housing under an agreement between the city and the state of New York has led to a corresponding reduction in the size of the city's emergency shelter system. As a result, many persons with psychiatric disabilities now live in efficiency units with wraparound services at one-third the public cost of having them circulate among emergency shelters, the streets and jails.
NTAC Housing Initiatives
NTAC Director Bruce Emery said that NTAC is working with the NASMHPD President's Task Force on Housing to develop a technical assistance initiative "to offer the opportunity to come together in teams-SMHAs, housing finance agencies and state and county representatives-that facilitate partnership building and create new models of housing finance and development."
Mr. Emery pointed out that NASMHPD's Housing Policy Statement, originally drafted in 1987 and adopted at this meeting with several minor revisions, "remains remarkably fresh, despite the passage of nearly 10 years. NASMHPD can be proud of its efforts to provide a coherent policy direction in the changing field of housing for persons with psychiatric disabilities." (See article on Position Statement).
NTAC recently published Housing for Persons with Psychiatric Disabilities:
Best Practice for a Changing Environment, a technical assistance
Tool Kit that synthesizs models and best practices in the context
of the rapidly changing housing finance and development environment
at the federal and state levels. According to Emery, the Tool
Kit addresses the information and technical assistance needs of
State Mental Health Agencies, state housing finance agencies,
and public and private housing developers, as well as a broad
audience of clinicians, consumers, family members, advocates and
technical assistance providers. One copy of the Tool Kit is provided
free to each SMHA. (See also Suggested Reading column).
In the recently enacted fiscal year (FY) 1997 budget for the U.S. Department of Housing and Urban Development (HUD), Congress has begun to fund replacement housing resources for people with disabilities who are likely to be harmed by recent legislative changes that allow for an increase in "elderly-only" housing designations. For FY97, Congress appropriated $50 million for tenant-based rental assistance targeted to people with disabilities who are adversely impacted by elderly-only housing.
As a result of changes enacted by Congress in 1992, and expanded in 1996, public housing authorities (PHAs) and assisted housing providers may exclude nonelderly people with disabilities by designating buildings and developments as "elderly only." Such elderly-only housing designations are expected to have a devastating impact on the availability of decent, safe and affordable housing for people with disabilities. Although the law contains protections for current lease-compliant tenants, people with disabilities on waiting lists for public and assisted housing are particularly vulnerable. This is especially true for people with psychiatric disabilities, who already face stigmatization and discrimination in both public housing and the private rental market. This erosion of housing resources is compounded by recent legislation that repealed federal preferences in tenant selection policies and placed tight eligibility restrictions on persons with a history of substance abuse.
The Consortium for Citizens with Disabilities (CCD) Housing Task Force estimates that by the year 2000, there will be at least 273,000 fewer units occupied by people with disabilities than would have been the case without elderly-only housing designations. Although the $50 million allocation (expected to fund 10,000 1-year certificates and vouchers) will not make up for the anticipated affordable housing shortage during the next few years, this marks the first time Congress has recognized the need to replace resources for the disability community. The $50 million HUD appropriation was supported by Representative Rodney Frelinghuysen (R-N.J.) and Senators Pete V. Domenici (R-N.M.) and John F. Kerry (D-Mass.).
Even with this modest infusion of funds, the public mental health system is likely to have difficulty coping with the loss of affordable housing. As Congress moves to shift responsibility for housing programs to state and local governments, state mental health agencies (SMHAs) and local mental health authorities will need to intervene with state housing finance agencies and community- level PHAs to ensure that people with psychiatric disabilities have a voice in local planning decisions. Although the 104th Congress did not approve proposals to abolish HUD, the department's budget was cut by nearly 20 percent (down to $20 billion). In addition, other changes have nearly ended the federal role in producing new housing and dramatically reduced the Federal role in determining how federal funds are allocated at the local level. Thus the modest increases in funding for housing for people with disabilities is an important accomplishment for disability advocates.
The expanded authority for PHAs to designate housing as "elderly only" was contained in a bill signed by President Clinton in March 1996 extending the authority for certain expiring HUD programs. A separate bill converting numerous federal housing programs into block grants died in a House-Senate conference committee immediately prior to final adjournment. Nevertheless, Congress is expected to continue to push to consolidate federal housing programs and shift responsibility for housing policy to state and local governments. For example, funds for homeless services under the Stewart B. McKinney Homeless Assistance Act are likely to be block granted and may be cut below their current level of $823 million (having been reduced by nearly $300 million during the past two years).
Another important housing resource is the Section 811 program, which funds capital advances and project-based certificates for nonprofit groups that serve the housing needs of people with disabilities. Since 1994 the Section 811 program has been cut by nearly $40 million to $194 million. Congress gave HUD authority to transfer up to 25 percent of the funds appropriated under this program to tenant-based rental assistance, which allows HUD to fund roughly the same number of units (2,915) as in FY95 and FY96.
Although these new housing resources are a positive development, the long-term trend for solutions at the federal level is not encouraging. As with all federal discretionary programs, HUD funding faces severe constraints during the next five to seven years. If, as expected, HUD's budget is further squeezed between now and the year 2000, responding to the housing crisis for people with disabilities will require creative approaches at all levels.
There are other federal resources that SMHAs and local mental health authorities can tap. The Low-Income Housing Tax Credit (LIHTC) and Community Development Block Grant (CDBG) programs both enjoy broad bipartisan support in Congress and their funding is likely to remain stable. Both programs are administered by state housing finance authorities and state and local economic development agencies, rather than by HUD.
SMHAs and their allies in the provider community, as well as families and consumers, can play an important role in deciding how these resources are used at the community level. State and local officials who administer programs such as LIHTC and CDBG must go through a planning process (ConPlan) and a local housing assessment (CHAS) that require a survey of the housing needs of people with disabilities and input from concerned parties. Proactive engagement on the part of the entire mental health community with state housing finance authorities and local economic development officials will help ensure that resources keep pace with increased demand.
Finally, the public mental health system must employ creative solutions at the local level, including partnerships with private-sector organizations. Increasingly, managed care firms that serve clients in the public mental health system are investing resources in community-based housing. Many managed care firms view access to housing as an important strategy to minimize expensive inpatient hospitalization.
This article is excerpted from "Managed Care: The Impact on Housing and Supports," a chapter written by Martin D. Cohen, M.S.W., and Stephen L. Day, M.S.W., of the Technical Assistance Collaborative, Inc., a Boston-based nonprofit organization providing managed care and supportive housing consultation to state and local mental health systems. The chapter appears in its entirety in Housing for Persons with Psychiatric Disabilities: Best Practices for a Changing Environment, a technical assistance Tool Kit published this fall by the National Technical Assistance Center for State Mental Health Planning (NTAC). In addition to providing an indepth discussion of issues addressed in this article, the full chapter discusses the challenges that managed care poses to supportive housing and the question of what services should be included under managed care.
Other Tool Kit chapters address the role of State Mental Health Agencies (SMHAs) in providing supportive housing; housing finance; approaches to the development, management, and ownership of supportive housing; rental assistance strategies; consumer preferences in housing; services and supports; and the law and community-based housing for persons with psychiatric disabilities. To order a copy of the Tool Kit, see Suggested Reading of this issue.
Managed care does not have to be a threat to supportive housing or to those whom it serves. The impact of managed care will depend largely on how effectively supportive housing practitioners, advocates and consumers emphasize the clinical value and cost effectiveness of these services. To do so requires an understanding of how supportive housing fits into the managed care arena and how managed care technologies and principles apply to supportive housing services. This article discusses ways that state and local jurisdictions can prepare for managed care and ensure that supportive housing initiatives are not lost in financing mechanisms that employ managed care technologies.
Many state and local mental health agencies are exploring how the principles and technologies of managed care can be applied to publicly financed mental health services. In many cases the impetus for embracing managed care comes from outside the mental heath agency-from governors, Medicaid directors, county commissioners or managed care organizations, in an effort to obtain cost savings and improvements in access and quality of care. To date at least 40 SMHAs are exploring managed care, either through their state Medicaid agencies or on their own.
An unanswered question about the trend toward managed care is what impact managed care technologies such as utilization management, outcome measurement and selective contracting will have on housing and supportive services for persons with psychiatric disabilities. Although most public mental health agencies operate under tight budgets, few have used the technology of managed care to deliver services, including services to individuals in supportive housing. Managed care in employer-based health plans has been concerned largely with limited inpatient and outpatient mental health benefits and has not entered the arena of housing or the psychosocial and rehabilitative services provided to those in supportive housing environments.
Applying Managed Care to Mental Health Services
The goal of managed care is to ensure that the most appropriate clinical care is provided in a cost-effective manner. Most managed care plans use a standard approach to managing care that is designed not only to contain costs but also to ensure access to appropriate and high-quality services. The table below outlines key managed care principles and the methods used to attain them.
| Principles and Technologies in Managed Care | |
|---|---|
| Principle Treatment is individualized to meet client needs. Level of care and courses of treatment are authorized and monitored. Defined clinical outcomes are measured to guide service planning and eliminate ineffective services. Providers are selected base on their ability to deliver outcomes at a cost-effective price. |
Technology |
Managed Care Models
Public mental health systems employ the following two distinct models of managed care:
| Carve-in: Mental health services are among the health care benefits made available to beneficiaries (e.g., Medicaid enrollees). |
| Carve-out: Mental health services are separated from physical health benefits and managed as separate and distinct benefits. |
In the carve-in model, the mental health benefit may be managed by a primary care physician or health maintenance organization using a defined benefit package. In the carve-out model, an organization that specializes in managed care may manage benefits within a defined budget or based on a capitation rate (fixed dollar amount for each eligible client). In both of these models, the care manager is responsible for ensuring that consumers receive the services they need, when they need them, but not more than they need. Opportunities for Supportive Services Among the opportunities presented by managed care is the potential for public mental health systems to move away from traditional finance models that pay for service capacity and toward models that link payments to the needs of clients. Paying for capacity limits the types of services that are available and reduces client options. Managed care has the potential to provide flexible and individualized funding linked to individual consumers and not necessarily limited to specific service types or program components. This approach can facilitate service planning and access to care for individuals who live in supportive housing by allowing them to tailor the services they receive to meet their changing needs. Managed care also allows for non-facility-based and nontraditional services such as community treatment teams and social support services, which are important elements of the supportive housing model.
Under traditional mental health financing, Medicaid pays for certain services and state or county mental health agencies pay for others. With managed care, funds from different sources can be pooled into a "one-stop-shop" set of benefits that are available to consumers based on eligibility and clinical need. This would eliminate the need for case managers and other service providers to negotiate with various funding sources to create a service package.
How To Thrive in a Managed Care Environment
Managed care can help to focus health care organizations and financing systems on goals that public mental health systems have long advocated, including linking payments to consumers and providing flexibility and accountability. To thrive in a managed care environment, providers of mental health services including services to consumers in supportive housing understand the changing marketplace. Here are several recommendations that can help practitioners meet this goal:
The Michigan Department of Community Health has joined with the Michigan State Housing Development Agency (MSHDA) and the New York City-based Corporation for Supportive Housing (CSH) to initiate demonstration programs in four Michigan sites to develop affordable supportive housing for individuals who are homeless or at risk of becoming homeless, including those with psychiatric disabilities. The program will explore ways that state health (including mental health) and housing agencies can work together, in cooperation with other public and private organizations, to provide housing and supportive services to individuals who have very low incomes and special needs.
Virginia Harmon, director of Michigan's Bureau of Community Placement and Residential Services in the Department of Community Health, said the "state seeks new ways to provide affordable housing for low-income and special-needs populations at a time of increasing fiscal austerity at the federal level."
Local nonprofit sponsors selected by community-level partnerships will develop about 300 units of housing. Funding for the initiative will come from state allocations of federal housing and development program moneys including HOME, Community Development Block Grants (CDBG), low-income tax credits, and donations from private sources such as foundations. CSH will assist nonprofit housing developers to build organizational capacity and will provide bridge financing. To date the program has generated $650,000, with the goal of reaching $1.4 million for capacity building and bridge financing.
Ms. Harmon said a primary goal of the demonstration projects is to promote partnership models among state and local human service (including mental health) and housing systems. Another goal is to promote innovative approaches to supportive housing that reflect consumer preferences for independent, noninstitutional settings. She pointed out that the housing will be used for permanent, nontransitional occupancy and provide self-contained units for all tenants (with private bathrooms and cooking facilities and an emphasis on physical accessibility). Housing will also reflect the characteristics of the surrounding community and meet high-quality design and site standards. Ms. Harmon said the project will involve both new construction and rehabilitation of existing structures. Projects will range from single-family homes to larger apartment units.
Of 15 county-based consortia that submitted concept papers for the project to the state, four have been selected to participate in this three-year demonstration program. Three sites are located in the highly urbanized communities of Flint, Grand Rapids and Washtenaw County (Ann Arbor/Ypsilanti). The fourth site is located in Allegan County in rural western Michigan. Each participating community consortium will receive up to $50,000 and technical assistance to create a strategic plan, select not-for-profit organizations to develop and operate the housing, determine the supportive services model and identify funding resources.
Strategic plans will be reviewed by the Michigan Interagency Steering Committee, which is cochaired by the Department of Community Health, the Michigan Housing Development Agency, and the Corporation for Supportive Housing. Other steering committee members are the Michigan Family Independence Agency (formerly, Department of Social Services), Office of Services to the Aging and the Michigan Department of Management and Budget. Once plans are approved, construction and/or rehabilitation of units will be phased in. The steering committee's role is to facilitate policy changes and remove barriers to the financing and provision of comprehensive supportive services. Ms. Harmon said services will vary depending on the needs of consumers and the resources of participating communities. Services will be easy to access, comprehensive and of high quality.
Ms. Harmon emphasized that a key principle of the program is that a person does not have to receive supportive services to obtain housing and that no person will lose housing simply by choosing not to take advantage of services. Nonetheless, services will be available and accessible for those who seek them.
For more information, contact Virginia Harmon, Director, Bureau of Community Placement and Residential Services, Sixth Floor, Lewis Cass Building, Lansing, Michigan 48913. Telephone: 517-373-2900, Fax: 517-373-8133 or e-mail: harmon@state.mi.us
My Own Place, a 20-minute videotape produced by the Michigan Department
of Mental Health (now part of the Michigan Department of Community
Health), provides an overview of the variety of supportive housing
options that are available to persons with psychiatric and other
disabilities. Featuring actor Christopher Burke of the television
series "Life Goes On," the video is directed toward an audience
that includes individuals with disabilities, their families and
advocates. The video makes it clear that people can have "their
own place" regardless of the type or pervasiveness of their disabilities
and that showcases several different approaches to supportive
housing. To order a copy of My Own Place, contact Virginia Harmon
at the telephone number, fax number or e-mail address noted above.
The cost, including shipping and handling, is $29.95.
Center for Mental Health Services.(1994). Blueprint for a Cooperative Agreement Between Public Housing Agencies and Local Mental Health Authorities. Rockville, MD. (Contact the Knowledge Exchange Network at 800-789-2647.)
Hurlburt, M.S., Hough, R.L., and Wood, P.A. (1996). "Effects of Substance Abuse on Housing Stability of Homeless Mentally Ill Persons in a Supported Housing Program," Psychiatric Services 47(7):731-736.
Lehman, A.F., et al. (1995). "Effects of Homelessness on the Quality of Life of Persons with Severe Mental Illness," Psychiatric Services 9(44): 922-926.
McCabe, S.S., et al. (1991). Holes in the Housing Safety Net...Why SSI is Not Enough: A National Comparison Study of Supplemental Security Income & HUD Fair Market Rents. Burlington, VT: University of Vermont, Center for Community Change Through Housing and Support. (Cost: $10; contact CCC at 802-658-0000.)
National Law Center on Homelessness and Poverty. (1995). No Room for the Inn: A Report on Local Opposition to Housing and Social Service Facilities for Homeless People in 36 United States Cities. Washington, DC. (Cost: $25 plus $3 postage and handling; call 202-638-2535.)
National Law Center on Homelessness and Poverty. (1996). Using the HUD ConPlan Process and Federal Civil Rights Laws on Behalf of Homeless People: A Handbook. Washington, DC. (Cost: $15 plus $2 postage and handling; call 202-638-2535.)
National Resource Center on Homelessness and Mental Illness. (1996). Annotated Bibliography: Housing for Homeless People with Serious Mental Illnesses. Delmar, NY. (Cost: Free; contact NRC at 800-444-7415.)
National Technical Assistance Center for State Mental Health Planning. (1996). Housing for Persons with Psychiatric Disabilities: Best Practices for a Changing Environment. Alexandria, VA. (Cost: $20; contact NTAC at 703-739-9333.)
U.S. Department of Housing and Urban Development, Office of Policy Development and Research. (1996). Evaluation of Supportive Housing Programs for Persons With Disabilities, Volume I: Findings; Volume II: Case Studies and Technical Appendices. Washington, DC. (Cost per volume: $5; contact HUD USER at 800-245-2691.)
U.S. Department of Housing and Urban Development, Office of Policy
Development and Research. (1995). Review of the Stewart B. McKinney
Homeless Programs Administered by HUD: Report to Congress.Washington,
DC. (Cost: $5; contact HUD USER at 800-245-2691.)
The National Association of State Mental Health Program Directors (NASMHPD) membership has called for expanded housing options and more "flexible and individualized" support services for people with psychiatric disabilities. In revising its Position Statement on Housing and Supports for People with Psychiatric Disabilities in July 1996, the Association membership said the statement will continue to provide a framework for State Mental Health Agencies to guide their housing policies and activities. The Association membership approved an earlier version of the position statement in 1987. Below is the text of the new NASMHPD position statement:
Housing Options - It should be possible for all people with psychiatric disabilities to have the option to live in decent, stable, affordable and safe housing that reflects consumer choice and available resources. These are settings that maximize opportunities for participation in the life of the community and promote self-care, wellness and citizenship. Housing options should not require time limits for moving to another housing option. People should not be required to change living situations or lose their place of residence if they are hospitalized. People should choose their housing arrangements from among those living environments available to the general public. State mental health authorities have the obligation to exercise leadership in the housing area, addressing housing and support needs and expanding affordable housing stock. This is a responsibility shared with consumers and one that requires coordination and negotiation of mutual roles of mental health authorities, public assistance and housing authorities, and the private sector.
Provision of Services - Necessary supports including case management, onsite crisis intervention, and rehabilitation services should be available at appropriate levels and for as long as needed by persons with psychiatric disabilities regardless of their choices of living arrangements. Services should be flexible, individualized and promote respect and dignity. Advocacy, community education and resource development should be continuous.
Adoption - Adoption of this position statement empowers a NASMHPD President's Task Force on Housing for Persons with Psychiatric Disabilities to advise the Board of Directors and NASMHPD membership of:
For more information on housing, visit these sites on the World Wide Web:
November 17-23: National Coalition for the Homeless: National Hunger and Homelessness Awareness Week. Michael Stoops at 202-775-1322.
November 20-22: Association of Local Housing Finance Agencies (ALHFA) / National Association for County Community and Economic Development (NACCED): Affordable Housing Finance: Putting the Deal Together and Bringing It All Home, Atlanta, GA (HUD Sponsored). Contact Karen Grappe at 202-857-1197.
December 4-6: National Association of Housing and Redevelopment Officials (NAHRO): Financing Affordable Housing, San Francisco, CA. Contact Jill Quaid at 202-289-3500 x272.
December 4-7: Enterprise Foundation 15th Annual Network Conference: A Time of Change, Miami, FL. Contact Bobbie McAdam at 410-715-2267.
December 9-13: Consortium for Housing and Asset Management (CHAM): Training for Nonprofit Housing Management Specialists, Denver, CO (HUD sponsored). Contact Diane Benedictis at 410-715-3624.
December 12-14: Housing Assistance Council (HAC): National Rural Housing Conference. Contact Irene Schneeweis at 202-842-8600.
December 14-18: National Mental Health Consumers' Self-Help Clearinghouse: Creating Healing Alternatives for Real Health Care Reform, Orlando, FL. Contact John Farmer at 800-553-4539 x258.
January 11-14, 1997: Public Housing Authorities Directors Association (PHADA): Commissioner's Conference, Phoenix, AZ. Contact Judy Brown at 202-546-5445.
February 25, 1997: New York State Department of Housing and Community Renewal (NYSDHCR): Managing an Affordable Housing Portfolio: Operation and Expansion of an Existing Housing Portfolio, Albany, NY (HUD sponsored). Contact Denise Vargas of Landair Project Resources at 212-463-7980.
February 27, 1997-March 3, 1997:National Housing and Rehabilitation Association Annual Conference, Naples, FL. Call 202-328-9171.
Opening Doors: Recommendations for a Federal Housing Policy To Address the Housing Needs of People with Disabilities, co-authored by the Consortium of Citizens with Disabilities Housing Task Force in Washington, D.C., and the Technical Assistance Collaborative, Inc., (TAC) in Boston.
This report describes the profound impact that a recent change in federal housing policy - allowing federally assisted private and public housing to be designated "elderly only" - is having on the supply of affordable housing available to people with disabilities throughout the country. The report also points out that this change in housing policy is occurring at a time when the U.S. Department of Housing and Urban Development is reporting that people with disabilities face "worst case housing needs" in this country.
Copies of the report are available from TAC for $5 at 617/742-5657
or may be downloaded from the World Wide Web at: http://thearc.org/ga/opendoor.html
networks is published quarterly by the National Technical Assistance Center (NTAC) for State Mental Health Planning (NTAC) and is supported under a Cooperative Agreement between the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration CMHS/SAMHSA) and the National Association of State Mental Health Program Directors (NASMHPD).
Fall 1996 Issue -
Bruce D. Emery, M.S.W., director
Gail P. Hutchings, M.P.A., associate director
John D. Kotler, M.S.J., senior writer/editor
Andrea Sheerin, information specialist
Rebecca Crocker, meeting/design specialist
Christine Diaz, administrative assistant
Cited reproductions, comments, and suggestions are encouraged.
You may also be added to the mailing list for networks. Contact Christine Diaz at 703/739-9333, ext. 30, or send e-mail
to: christine.diaz@nasmhpd.org. [Please include your name and return mailing address, email address
and/or telephone number in the body of your message so we may
respond to your inquiry].