State Mental Health Systems and Housing: A National Perspective

1
State Mental Health Systems and Housing A
National Perspective
October 15, 2007 Michigans Campaign to End
Homelessness Annual Summit Lansing, Michigan

• Presented by
• David W. Miller
• Senior Policy Associate
• National Association of
• State Mental Health Program Directors

2
The National Association of State Mental Health
Program Directors

• represents the 27.3 billion public mental
  health service delivery system serving 6.1
  million people annually in all 50 states, 4
  territories, and the District of Columbia.
• operates under a cooperative agreement with
  the National Governors Association and is the
  only national association to represent state
  mental health commissioners/directors and their
  agencies.

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Quick Snapshot of National Mental Health System

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Unmet Need

• One in every five adults, or nearly 60 million
  Americans, experiences some type of mental
  disorder every year. Of this number, 5 to 7
  percent have a serious mental illness such as
  schizophrenia, major depression, and bipolar
  disorder that substantially interferes with
  major life activities.

• Among children, estimates of serious emotional
  disturbances range from 5 to 9 percent.

• Despite the availability of effective
  treatments, fewer than half of all people who
  require mental health services get the help they
  or their family need.

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Suicide

• 30,000 Americans die by suicide each year - 90
  have a mental illness

• Deaths from suicide outnumber deaths from
  homicide (18,000), AIDS, and most forms of cancer

• Suicide is the 3rd leading cause of death for
  adolescents

6
Corrections/Criminal Justice

• 10 of police service calls involve mental
  illness

• 16 of all inmates - approximately 350,000 -
  have a serious mental illness and of that
  population, over 70 also have a substance abuse
  problem

• Mentally Ill inmates spend 3 to 4 times as long
  in jail as other inmates - many because there is
  no other place for them

• Approximately HALF of the inmates in prison with
  a mental illness were incarcerated for committing
  a non-violent offense

7
Cost of Mental Illness

• Total of direct (treatment-related) and
  indirect (productivity loss) costs exceeds 150
  BILLION annually

• More than 3 million Americans receive disability
  benefits due to mental illness

• Nearly 28 of disabled workers in the SSDI and
  over 35 of people with disabilities on SSI have
  a mental illness

• Of the top 10 causes of disability, 5 are
  related to mental illness

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Causes of Disability
United States, Canada, and Western Europe, 2000
(SOURCE World Health Organization, 2001)
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Why are MH systems focusing more on Housing?

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www.surgeongeneral.gov/library/mentalhealth/home.h
tml
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The Presidents New Freedom Commission on Mental
Health

• Achieving the Promise
• Transforming Mental Health Care in America

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Transformation?

13

14
Websters Dictionary
transformation Function noun1 an act,
process, or instance of transforming or being
transformed
transform Function verb1 a to change in
composition or structure b to change the
outward form or appearance of c to change in
character or condition

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Coordinated Mental Health Services in Theory
SAMHSA-CMHS
Federal level
DMH
State level
Local level
County
Case Mgt.
M.H. Care
Housing
Coordinated Care
Job Support
Consumer
M.D.
Meds
Income Support
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Coordination of Mental Health Services in
Reality
Medicare
Medicaid
CMHS
HRSA
HUD
Education
SSA
DMH
V.R.
State Medicaid Agency
County
PHA
Case Mgt.
M.H. Care
Housing
Job Support
Consumer
M.D.
Meds
?
Income Support
Clinic
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The Campaign for Mental Health Reform
www.mhreform.org
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Achieving the Promise Transforming Mental
Health Care In America www.samhsa.gov/Federalacti
onagenda/NFC_TOC.aspx
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RECOVERY !
Supportive Housing is the Doorway and Foundation
to Recovery

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Mental Illness and Homelessness

• States and local governments are already paying
  high costs for poor outcomes in multiple systems
• High rates of disability and death
• Frequent and avoidable use of hospitals
• Revolving door between streets and jails
  prisons
• Higher risks and costs associated with HIV/AIDS
• Children in out-of-home placement

• Annual costs of public services for homeless
  mentally ill is more than 40,000

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High Costs and Poor Outcomes for the Chronically
Homeless

• The Boston Health Care for the Homeless program
  tracked 119 chronically homeless patients for
  five years
• 33 individuals (27) dies and seven moved into
  institutions
• The reduced group still accounted for 18,834
  emergency room visits an average of 32 visits
  per original member per year, for 5 years

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Frequent Flyers

• The University of California, San Diego Medical
  Center followed fifteen chronically homeless
  individuals for eighteen months
• These fifteen people had 417 visits to the
  emergency department one man had 87 visits
• The combined hospital and criminal justice costs
  for these 15 people were 3 million

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Just the Facts Maam

• 50 reduction in emergency room visits and
  inpatient hospitalizations
• 50 reduction in emergency detox services
• 50 reduction in incarceration
• 50 increase in earned income
• 40 rise in rate of employment when employment
  services are provided
• 80 stay housed for at least one year

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Costs of Serving Homeless Individuals in Nine
Cities (2004)

Cost Per Day, Per Person
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Supportive Housing for People with Mental Illness
Reduces Use of and Costs for

• Hospital inpatient care for medical and
  psychiatric conditions
• Hospital emergency room visits
• Psychiatric emergency and institutional care
• Residential mental health and substance abuse
  treatment
• Jail and prisons
• Emergency Shelters

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Supportive Housing for People with Mental Illness
May Increase Use of and Costs for

• Outpatient primary and specialty medical care
• Some mental health services (e.g. case
  management, pharmacy)
• Methadone (more consistent participation)
• Services to address substance abuse problems
• Vocational and employment services
• Probation

27
Getting mentally ill people off the streets and
into supportive housing costs taxpayers only
slightly more than leaving them to fend for
themselves The Wall Street Journal May 2, 2001

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Wheres the (Services) Beef?

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SMHA-Controlled Revenues by Source as a Percent
of Total Funds, FY81 to FY05
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SMHA-Controlled Revenues for Mental Health
Services, By Source F81 to FY05
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Medicaid the basics

• Federal State Partnership
• Federal Financial Participation (FFP) matches
  state (non-federal fund) contributions federal
  contribution averages 57 of Medicaid costs
• Federal rules and waivers administered by Center
  for Medicare and Medicaid Services (CMS)
• State Medicaid Plan contract between state and
  federal government
• Basic health services State Options optional
  benefits two-thirds of all Medicaid spending

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State Medicaid Plan Defines

• Optional benefits
• Who is eligible to provide services to be
  reimbursed under Medicaid
• Rate Structure (e.g. fee for service, case rates,
  capitation, etc.)
• Every states Medicaid program is different
  opportunities to learn from and replicate
  promising approaches

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Medicaid Eligibility People and Providers

• Children, pregnant women, elderly, and people
  with disabilities who are eligible for SSI are
  most likely to be eligible for Medicaid
• Very low income adults without children are
  usually not covered unless eligible for SSI based
  on disability level there are exceptions in
  some states with Medicaid waivers that include
  initiatives to expand coverage
• Federally Qualified Health Centers (FQHCs)
  Healthcare for the Homeless programs and
  Community Health Centers receive reimbursement
  under special federal rules
• For other provider organizations, state plan
  determines eligibility to participate and
  settings where services can be delivered

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Opportunities to Use Medicaid

• None of these were designed to reimburse
  supportive housing
• Rehabilitation Option (ACT, intensive case man,
  community support, crisis services)
• Targeted Case Management
• Home and Community Based Waiver Services
• FQHCs (getting more involved in SH)
• Peer Specialist Services

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SMHAs stepping forward

• 69 of SMHAs have a housing plan to address the
  housing needs of persons with SMI
• 78 State SMHAs use SMHA dollars to fund some
  portion of their housing support services
• 46 of State SMHAs use Medicaid dollars to fund
  some portion of their housing support services

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Keys to Success

• Know each other and a little about each others
  fields and system
• Willingness for win-win collaboration
• Understanding of each others parameters and
  trepidations
• Joint engagement in the state and local, public
  and private sectors

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Examples of Successful State Activities
38
Minnesota

• State Working Group Business Plan
• Working group compromised of Commissioners of
  Human Services, Economic Development, Housing
  Finance and Corrections
• Developed a business plan with shared
  responsibilities across all four agencies
• Goal of 4,000 supportive housing units
• Plan guides Governors policy and funding
  proposals
• Plan implementation led by a Director of Ending
  Long-Term Homelessness who reports to the
  Commissioners of Human Services, Corrections, and
  Housing Finance

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Tennessee

• Creating Homes Initiative (2002)
• 2.5 million from DMH, 2 million from HFA
• Has leveraged over 167 million
• Built 6,000 units of supportive housing for
  people with mental illness
• 7 local regions
• Local Housing Coordinators
• Local Consumer Coordinators

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New Jersey

• Governors Task Force Statute
• Governors Task Force on Mental Health
• Established goal of 10,000 permanent affordable
  housing opportunities by 2010
• Recommendations led to Governors policy
  proposals
• Legislation establishing a 200 million NJ
  Special Needs Housing Trust Fund
• Establishes a capital funding pool for SH
  specialized and other independent living
  arrangements
• Compliments current Section 8 programs
• Aligned with Governors Task Force on MH
  recommendations
• Prioritizes housing for persons with mental
  illness

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California

• Voter initiative Proposition 63
• New funding 800 million per year
• California Housing Finance Agency, Dept. of
  Housing and Community Development, and Department
  of Mental Health crafted JOINT NOFA
• Requires local housing projects to partner with
  county MHSA implementation plans for services,
  operating subsidies and other local dollars
• MHSA investments leverage other state funding for
  capital costs

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Montana

• 3 Service Area Authorities
• Citizen Board appointed by the Legislature
• Codified into Law Authority to have oversight of
  service delivery system and DMH collaboration
• New Funding 20 Million per year (about the same
  per capita increase as California)
• Large is being devoted to housing

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YOU!!!

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• David W. Miller
• Senior Policy Associate
• 66 Canal Center Plaza, Suite 302
• Alexandria, VA 22314
• 703-682-5194
• david.miller_at_nasmhpd.org
• www.nasmhpd.org