Supportive Housing for
People with Mental Illness: Regaining a Life in the
Community
National Governor’s
Association: Center for Best Practices
Overview
Having a home
is a universal human need and one that is necessary for
adequate psychological health. Without a place to call
home, people with mental illnesses have trouble
recovering their health, becoming self-sufficient, and
reclaiming valued roles in their families and
communities. Unfortunately, many people with serious
mental illnesses are extremely poor. As noted by The New
Freedom Commission on Mental Health, poverty combined
with a lack of affordable housing and support services
in our Nation’s communities, causes people with mental
illnesses to “cycle among jails, institutions, shelters,
and the streets; to remain unnecessarily in
institutions; or to live in seriously substandard
housing.”
This Issue
Brief examines the need for supportive housing and
describes the possible supports that might be available
to someone living in supportive housing. Next, the issue
brief outlines the characteristics of supportive housing
as an evidence-based practice, followed by a review of
options States can engage in to create a range of
affordable housing with support services for people with
mental illnesses. Finally, it concludes with a list of
resources for more information.
The
Need for Supportive Housing
Currently, in
the United States, people with serious mental illnesses
are the poorest of the poor. In fact, people with mental
disorders constitute the largest disability group
receiving Supplemental Security Income (SSI), the
federal income support program for very low income
people who are aged or disabled. In 2006, on average,
across the United States, people receiving SSI benefits
had incomes equal to only 18.2 percent of the median
one‐person household income. These individuals would
have to pay 113.1 percent of their entire monthly income
to rent a modest one-bedroom unit, an increase from
109.6 percent in 2004.
Even if a
person with a mental illness could afford to rent an
apartment, an apartment may not be available.
Nationwide, there are 6.2 million rental units available
for the 9 million renter households who are considered
extremely low-income (i.e., those that make less than 30
percent of area median income), and the gap continues to
widen. Available housing options is one of the reasons
that people with serious mental illnesses are
overrepresented among the homeless population.
But
housing alone is not enough. Many individuals with
serious mental illnesses, particularly those who have
become homeless, need supportive services to help them
remain in housing. Supportive services will vary,
depending on individual needs. At minimum, case
management must be included to provide or link
individuals with the full range of services needed to
promote stability including, but not limited to: primary
health care, mental health services, substance abuse
treatment, money management, benefits assistance, job
training, transportation, day care, etc.
Supportive
Housing: An Evidence-Based Practice
Over the past
35 years, the notion of what constitutes appropriate
housing for people with mental illnesses has changed
dramatically. Until the early 1970s, people with mental
illnesses who could not live independently without
support generally were housed in state hospitals and
institutions. In the late 1970s and early 1980s,
institutional housing was replaced with a “residential
continuum” model that was designed to move people with
serious mental illnesses through a series of
progressively more independent residential treatment
settings until they achieved independent living.
Frequently, individuals had to be deemed “ready” to move
to the next step, and many remained in unnecessarily
restrictive settings due to lack of services to help
them manage on their own. Unfortunately, this model
generally was unsuccessful in helping people achieve
long-term success in the community.
In the 1980s,
independent, subsidized rental housing with access to
supportive services emerged as an alternative to the
“residential continuum” model. In contrast to earlier
approaches, supportive housing is a successful,
cost-effective model that combines affordable housing
with services to help people live more stable,
productive lives. People living in supportive housing
may have a long history of homelessness and typically
face persistent obstacles to maintaining housing, such
as a serious mental illness, a substance use disorder,
or a chronic medical problem. Many tenants may face
multiple serious conditions. Services are necessary to
help tenants maintain stability, and being housed is an
essential first step in providing these services and
addressing untreated conditions. Supportive housing has
the following important characteristics:
·
The housing
is permanent and tenants sign leases and pay rent, just
like their neighbors.
·
Each tenant
may stay as long as he or she pays rent and complies
with the terms of the lease or rental agreement.
·
The housing
is affordable, meaning each tenant pays no more than 30
to 50 percent of household income.
·
Access to
supportive housing is not contingent on receipt of
services.
Supportive
housing options can range from individual apartments
scattered throughout the community (scattered-site) or
in a single building or complex of buildings
(single-site) where individuals living together receive
services. Single-site buildings that also house people
with low incomes who don’t require support services are
called mixed-use housing. Because supportive housing
integrates housing and services for people with
extremely low-incomes who have disabilities, it requires
more complex funding than other types of affordable
housing. Most supportive housing projects require some
combination of the following:
·
Capital
funding—This
is the “bricks and mortar” funding, used by providers to
purchase, rehabilitate, or newly construct permanent
supportive housing.
·
Subsidies—A
subsidy pays the difference between the rent a tenant
can afford (typically 30 percent of income) and the
actual monthly cost of the housing.
·
Supportive
services—To
help tenants maintain stability, support services can be
offered onsite, offsite, or may be provided by a mobile
service team. In all cases, receipt of services is
voluntary.
The Benefits of Supportive Housing
Supportive
housing is strongly supported by federal policy and is
being adopted in states and communities around the
country for the simple reasons that it works
and it is cost-effective.
·
Supportive
housing is a proven approach to addressing homelessness,
particularly for people with serious mental illnesses.
Many individuals with serious mental illnesses are
precariously housed, and others who become homeless
remain so for long periods of time. Studies show that
once in housing with supports, the majority of
individuals and families—regardless of their
disabilities and other needs—stay housed, are less
likely to become homeless, and are less likely to be
hospitalized or spend time in jail or prison.
·
Supportive
housing promotes independence for people who might
otherwise remain in segregated or custodial settings.
Both the Americans with Disabilities Act (ADA) and the
U.S. Supreme Court’s 1999 decision in Olmstead v.
L.C. require that individuals with disabilities be
permitted to live and work in the least restrictive
setting appropriate to their needs. Most people with
mental illnesses, when provided with the type and level
of supports they choose, are able to live independently
in supportive housing.
·
Supportive
housing improves an individual’s health.
According to data from various studies compiled by the
Corporation for Supportive Housing (CSH), supportive
housing tenants, when compared to people without access
to this evidence-based practice, use more preventive
health services and make 50 percent fewer emergency room
visits, require 80 percent fewer emergency
detoxification services, are more likely to remain
sober, and experience a decrease in symptoms of
schizophrenia and depression.
·
Supportive
housing helps individuals retain employment.
Preliminary data indicates that, halfway through a
five-year federal initiative to end chronic homelessness
through employment and housing, half of participants
have entered competitive employment.
·
Most
importantly for state-level policymakers and state
budgets, supportive housing is cost-effective.
The frequently cited Culhane, Metraux, and Hadley study
(2002) tracked homeless people with mental illnesses who
moved to permanent supportive housing in New York City.
The study showed marked reductions in shelter use,
hospitalizations, length of stay per hospitalization,
and time incarcerated, generating an annual savings of
$16,282 per person. When these savings were factored in,
the net cost per unit to housing providers was $995 a
year. Similar results are being reported in cities
around the country, such as Denver, where the $13,400
annual cost of supportive housing is more than offset by
a $15,773 per person per year savings in public
services.
- The table
below compares the costs per person per day of
serving people who would otherwise be homeless in
supportive housing, compared to more restrictive and
potentially more expensive settings, in nine cities
around the country (The Lewin Group, 2004).
Costs
of Serving Homeless Individuals in Nine Cities
(2004)
|
City
|
Supportive Housing |
Jail |
Prison |
Shelter |
MH
Hospital |
Hospital |
|
Atlanta |
$32.88 |
$53.07 |
$47.49 |
$11
|
$335
|
$1,637 |
|
Boston |
$33.45 |
$91.78 |
$117.08 |
$40.28 |
$541
|
$1,770 |
|
Chicago |
$20.55 |
$60
|
$61.99 |
$22
|
$437
|
$1,201 |
|
Columbus |
$30.48 |
$70.00 |
$59.34 |
$25.48 |
$451
|
$1,590 |
|
Los
Angeles |
$30.10 |
$63.69 |
$84.74 |
$37.50 |
$607
|
$1,474 |
|
New
York |
$41.85 |
$164.57 |
$74
|
$54.42 |
$467
|
$1,185 |
|
Phoenix |
$20.54 |
$45.84 |
$86.60 |
$22.46 |
$280
|
$1,671 |
|
San
Francisco |
$42.10 |
$94
|
$84.74 |
$27.54 |
$1,278 |
$2,031 |
|
Seattle |
$26
|
$87.67 |
$95.51 |
$17
|
$555
|
$2,184 |
·
Conduct a
Needs-Assessment.
To assess the extent of need for supportive housing in
your state, data such as the number of people receiving
SSI and the number of people with mental illnesses who
are homeless or living in institutions, including jails
and psychiatric hospitals must be compiled. CSH has
developed a guide for using a community’s annual
estimate of the number of homeless people to plan for
permanent supportive housing. (See Resources
below for more information.)
·
Develop a
Strategic Plan for Supportive Housing.
State data should be utilized to develop a strategic
plan for supportive housing with both short and long
term goals and measurable outcomes. For example, in
2000, the Tennessee Department of Mental Health and
Developmental Disabilities established a 5-year goal of
creating 2005 new housing units and supports by the year
2005—a goal reached in 2002. Many communities are
building such housing outcome goals into their Ten-Year
Plans to End Homelessness. For an example of a strategic
plan for supportive housing focused on people with
mental illnesses, the Florida Department of Children and
Families plan is cited in Resources below.
·
Gather
Information on Financing Options.
Some of the most common sources of capital funding used
to finance permanent supportive housing include the
following federal programs: Community Development Block
Grant (CDBG), HOME Program, Low Income Housing Tax
Credits, Section 811 Supportive Housing for Persons with
Disabilities, Housing Opportunities for Persons with
AIDS, and the McKinney-Vento Supportive Housing Program.
The CSH Supportive Housing Financing Sources Guide,
listed under Resources below, describes these and
similar programs.
·
Create a
Housing Trust Fund.
Housing trust funds are distinct funds established by
cities, counties, and states that dedicate a source of
public revenue to support the production and
preservation of affordable housing. There are nearly 600
city, county, and state housing trust funds in 43
states. New Jersey established a $200 million special
needs trust fund that creates a capital pool for
supportive housing which prioritizes housing for people
with mental illnesses. For more information on housing
trust funds, see Resources below.
·
Reinvest
Savings.
Savings realized in the mental health system or other
systems that serve people with mental illnesses can be
reinvested in supportive housing. The Oregon Office of
Mental Health and Addiction Services created a Community
Mental Health Housing Fund out of revenues from the sale
of a former state hospital property. To help reduce
recidivism, both Texas and Kansas have recently passed
legislation to reinvest millions of dollars from the
corrections system into community‐based mental health
programs, including re‐entry of prisoners into
supportive housing.
Make Housing Affordable
To ensure
that supportive housing remains affordable to people
with the lowest incomes, some type of rental or
operating subsidy is required.
·
Create a
Bridge Subsidy Program.
Rental subsidies make up the difference between what a
tenant pays and the actual monthly cost of operating the
housing. The Section 8 Housing Choice Voucher Program is
the most common source of rental subsidies, but in many
cities, waiting lists are long or closed. A bridge
subsidy is funded with federal, state, or local
resources and is designed to provide rental assistance
until Section 8 or another subsidy is available, or
until the individual’s income increases to a level where
they can attain affordable housing without assistance.
Units rented using a bridge subsidy must meet the
Housing Quality Standards set by the U.S. Department of
Housing and Urban Development (HUD) so the individual
can remain in his or her home when a Section 8 voucher
becomes available. Hawaii’s Adult Mental Health Division
created and funds a Supported Housing/Bridge Subsidy
program which provides a temporary rental subsidy and
housing supports for its clients, along with assistance
to landlords.
Invest in
Services
Recently,
when residential services for people with mental
illnesses were more common, funds for housing and
services would have been bundled at the state level,
often within the state mental health agency budget.
Also, some programs, such as HUD’s Supportive Housing
Program, have provided funds for supportive services in
addition to housing subsidies, but HUD has made clear
its intention to focus more of its resources on housing
rather than services. Today, service dollars often are
separate from housing dollars, which mirrors the
separation of housing and services in supportive
housing.
·
Use the
Medicaid Rehabilitative Services (Rehab) Option.
Although Medicaid does not cover housing costs, many
states use the Medicaid Rehab Option to help fund
housing supports such as Assertive Community Treatment
(ACT) and peer support. ACT is an evidence-based
practice where services are delivered in the person’s
home and are available 24 hours a day, 7 days a week.
Services are available for people with serious mental
illnesses and feature a multidisciplinary treatment team
that often includes consumers as staff, low client/staff
ratios, flexible services, and long-term follow-up.
Recently, the Centers for Medicare & Medicaid Services
published proposed rules that some advocates fear might
make it more difficult to use the Rehab Option to
provide the type of services that individuals with
serious mental illnesses need to maintain community
living. See Resources below for more information.
·
Utilize
Available State and Local Funds.
In some states, mental health authorities have
designated federal Mental Health Block Grant funds or
local mental health funds to fund services for
supportive housing tenants. In Massachusetts, the
Department of Mental Health (DMH) operates a Special
Homeless Initiative, that provide services to support
individuals in housing. DMH has used its service money
to leverage more than $138 million in housing resources
in the Metro Boston area alone from federal and other
housing programs. The program is funded through a state
appropriation of more than $20 million per year.
Conclusion
States and
communities around the country have begun to embrace
supportive housing as a cost‐effective, evidence‐based
solution to meet the housing needs of people with
serious mental illnesses. The Substance Abuse and Mental
Health Services Administration, a federal agency, is
preparing to field test an evidence-based practices
toolkit on the principles and practices of supportive
housing that will include a fidelity scale. States can
support adoption of supportive housing by convening
stakeholder coalitions that develop strategic housing
plans; taking full advantage of federal, state, and
local funding resources; and planning and funding the
types of services that will help promote the ability of
people with serious mental illnesses to live, work,
learn, and participate full in their communities.
Resources
The
following resources include the facts and statistics
cited above, as well as strategies for developing and
financing supportive housing programs.
Background
and Statistics
New Freedom
Commission on Mental Health (2003). Achieving the
Promise: Transforming Mental Health Care in America,
Final Report. DHHS Pub. No. SMA‐03‐3832.
Rockville, MD. www.mentalhealthcommission.gov
Chronic
Homelessness Employment Technical Assistance (CHETA)
Center. www.csh.org/cheta
Lipton, F.,
Siegel, C., Hannigan, A., et al. (2000). Tenure in
supportive housing for homeless persons with severe
mental illness. Psychiatric Services, 51(4),
479‐486.
New Freedom
Commission on Mental Health (2004). Subcommittee on
Housing and Homelessness: Background Paper. DHHS
Pub. No. SMA-04-3884. Rockville, MD.
www.mentalhealthcommission.gov/papers/Homeless_ADA_Compliant.pdf
Opening
Doors: Permanent Supportive Housing – A Proven Solution
to Homelessness
(2003), a
publication of the Technical Assistance Collaborative,
Inc., and the Consortium of Citizens with Disabilities
Housing Task Force. www.tacinc.org
Priced Out in
2006,
a report of the Technical Assistance Collaborative,
Inc., and the Consortium of Citizens with Disabilities
Housing Task Force. www.tacinc.org
Costs/Cos-Effectiveness Studies
Culhane, D.P.,
Metraux, S., & Hadley, T. (2002). Public service
reductions associated with placement of homeless persons
with severe mental illness in supportive housing.
Housing Policy Debate, 13(1), 107-163.
www.fanniemaefoundation.org/programs/hpd/pdf/hpd_1301_culhane.pdf
The Lewin
Group (2004). Costs of Serving Homeless Individuals
in Nine Cities Chart Book. Prepared for the
Corporation for Supportive Housing. www.rwjf.org/files/newsroom/cshLewinPdf.pdf
Supportive
Housing Is Cost-Effective
(2007),
prepared by the National Alliance to End Homelessness.
www.naeh.org
Corporation
for Supportive Housing Resources
Corporation
for Supportive Housing Web site. www.csh.org.
Click on the “Supportive Housing” tab for background and
statistics. Also, see publications listed under
“Resources.”
Estimating
the Need: Projecting from Point in Time to Annual
Estimates of the Number of Homeless People in a
Community and Using This Information to Plan for
Permanent Supportive Housing
(2005).
http://documents.csh.org/documents/pubs/csh_estimatingneed.pdf
Supportive
Housing Financing Sources Guide
(2004).
http://documents.csh.org/documents/ke/SHFinanceSourceGuide.pdf
Toolkit for
Developing and Operating Supportive Housing.
www.csh.org/toolkit2
Housing
Trust Funds
Housing Trust
Fund Progress Report 2007.
www.communitychange.org
National
Housing Trust Fund Web site. www.nhtf.org
Proposed
Medicaid Changes
Federal
Register,
Vol. 72, No. 155. Monday, August 13, 2007. Proposed
Rules, page 45201. www.gpoaccess.gov
For analysis
of the proposed changes, see the Bazelon Center
Information Alert at www.bazelon.org/takeaction/2007/RehabRule08-16-07.htm
or the National Alliance on Mental Illness (NAMI)
Web site at www.nami.org. Click on “CMS Releases
Proposed Rules for Rehabilitation” under the
Policy/Advocacy/Action banner.
State
Strategies
Florida’s
Strategic Plan for Supportive Housing for Persons with
Mental Illnesses
(2003),
prepared by the Florida Department of Children and
Families in partnership with Statewide Supportive
Housing Coalitions. www.flshc.net/documents/StrategicPlan2003.pdf
Housing
Resources Leveraged by the Special Homeless Initiative
of the Massachusetts Department of Mental Health,
1992-2006
(2007), an
evaluation conducted by the Urban Institute.
www.urban.org/UploadedPDF/411499_housing_resources_leveraged.pdf
A New Vision:
What is in Community Plans to End Homelessness?
(2006), a
report by the National Alliance to End Homelessness on
community strategies for ending homelessness.
www.naeh.org/content/article/detail/1397
Housing Within Reach: Permanent
Housing Solutions for Tennesseans Diagnosed with a
Mental Illness, a Web site developed by the
Tennessee Department of Mental Health and Developmental
Disabilities.
www.housingwithinreach.org
This
briefing document was prepared for the National
Governors Association, Center For Best Practices (NGA)
Webcast Transforming State Mental Health Systems:
Supportive Housing for People with Mental Illness:
Supportive
Housing for People with Mental Illness:
Regaining a Life in the Community,
September 25, 2007.
The Webcast was funded by the
Substance Abuse and Mental Health Services
Administration, Center for Mental Health Services
through a contract (No. 270-03-1000, Task Order No.
270-03-1009) to JBS International, Inc., and was
developed in collaboration with the National Association
of State Mental Health Program Directors (NASMHPD) and
Advocates for Human Potential, Inc.
