The Basics of Permanent Supportive Housing

1. The Basics of Permanent Supportive Housing February 8, 2008 State of Texas Mental Health Transformation Workgroup Presented by: Kelly W. Kent

2. CSH’s Mission CSH helps communities create permanent housing with services to prevent and end homelessness.

3. CSH Products and Services • Project-Specific Financing and Expertise to help create supportive housing • Capacity Buildingto strengthen and expand the supportive housing industry • Public Policy Reformto build an efficient system for producing and financing supportive housing

4. WhereWe Work • National headquarters in New York. • Local offices in Connecticut, Rhode Island, New York, New Jersey, Ohio, Michigan, Illinois, Minnesota, California, Indiana and Washington DC. • Soon in Texas! • Targeted initiatives in Kentucky, Maine, Oregon, and Washington. • CSH’s national teams assist supportive housing practitioners across the U.S.

5. Why Supportive Housing? • As many as 250,000 American households have nowhere to call home for years on end. • For decades, communities have “managed” homelessness without addressing the underlying causes. • Government is spending hundreds of millions of dollars per year, yet homeless rates are growing. • Emergency and institutional systems are significant sources of care and support, yet they discharge people into homelessness.

6. Why Supportive Housing? • Research indicates that approximately 10% of people who experience homelessness are chronically homeless • This 10% consumes more than 50% of all homeless services – leaving the homeless services systems struggling to effectively serve those who could exit homelessness relatively quickly. -- Dennis P. Culhane University of Pennsylvania

7. Supportive Housing Reduces Use of and Costs for: • Hospital inpatient care for medical and psychiatric conditions • Hospital emergency room visits – especially for the most frequent users of ER • Psychiatric emergency and institutional care • Residential mental health & substance abuse treatment – especially detox • Jails and prisons • Emergency shelters

8. Why Should We Care? “Million Dollar Murray” Phenomenon • Richard B. is an actual case study from Chicago, Illinois • 42 years old and has a combined 21 years of homelessness • 3,758 days in a mental health/hospital setting during that time • 399 days in jail (This includes only 6 years of available data) • The Cost of Richard B.’s Homelessness • 3758 State Hospital Days $400 a day $1,503,200 • 399 Jail Days $70 a day $ 27,930 • TOTAL $1,531,130 Average Annual Cost for Richard $ 72,910

9. Why Should We Care? Example of Crisis System Costs – Columbus, OH

10. What Defines Permanent Supportive Housing?

11. A Part of a Continuum Supportive housing works best as part of a well-funded system of care that • Prevents homelessness • Offers shelter and emergency services to everyone in need • Provides affordable housing to all. Supportive Housing is one vital piece of the solution to homelessness.

12. Whatis Supportive Housing? Supportive Housing is PERMANENT AFFORDABLE HOUSING combined with a range of SUPPORTIVE SERVICES that help PEOPLE WITH SPECIAL NEEDS to live STABLE AND INDEPENDENT LIVES

13. Housing + Services • HOUSING • PERMANENT: Not time limited, not transitional; • AFFORDABLE: For people coming out of homelessness; and • INDEPENDENT: Tenant holds lease with normal rights and responsibilities. • SERVICES • FLEXIBLE: Designed to be responsive to tenants’ needs; • VOLUNTARY: Participation is not a condition of tenancy; and • INDEPENDENT: Focus of services is on maintaining housing stability.

14. SupportiveHousing is NOT: • Treatment • Transitional • Licensed community care • ‘Service enriched’ housing (but is a subset of service enriched housing)

15. What Populations are Served by Supportive Housing?

16. Whois Supportive Housing For? People who: Are homeless or at-risk of homelessness and: • Face persistent obstacles to maintaining housing, such as mental health issues, substance use issues, other chronic medical issues, and other challenges. • Cycle through institutional and emergency systems and are at risk of long-term homelessness • Are being discharged from institutions and systems of care with no where to go • Without housing, cannot access and make effective use of treatment and supportive services

17. Veterans Veterans Lens: • Military discharge status - ‘good paper’ • Stand-downs • Veteran-specific resources are available, but limited Homeless Services and Housing Lens: • Veterans may already be accessing homeless/housing services • Outreach- identifying veterans at non-veteran focus service points; increasing provider cultural competency relative to armed services • Focus has been on transitional housing, not permanent, for veterans mostly due to funding source restrictions

18. Criminal Justice - Involved • Every year, more than 650,000 people are released from prison, and more than 7 million different people are released from jail. • An estimated 42% of inmates in state prisons and 49% in local jails were found to have both a mental health and substance use issues. • More than 10 percent of those coming in and out of jail and prison are homeless in the months prior to incarceration. • In Washington, DC and elsewhere, estimates of people exiting to homelessness is 30%

19. Unaccompanied Youth All young people need a home, support and a springboard into independent living, learning and work. Some don’t get it. • Estimated 500,000-1.3 million homeless youth (nationally). • 25-40% of youth in foster care become adult homeless (national study).

20. Quality Assurance

21. Principles of Best Practice • Housing costs must be affordable to the tenant (i.e. < 30% of income towards rent) • Choice and control over one’s environment is essential • Housing must be permanent as defined by tenant/landlord law – and housing is “unbundled” from services • Housing and services roles are distinct • Housing must be flexible and individualized: not defined by a “program” • Integration, personal control, and autonomy • Services are Recovery-Oriented and Adapted to the Needs of Individuals

22. The Seven Dimensions of Quality • Administration, Management and Coordination • Physical Environment • Access to Housing and Services • Tenant Rights, Input and Leadership • Supportive Services Design and Delivery • Property Management and Asset Management Activities • Data, Documentation and Evaluation

23. Financing of Supportive Housing

24. Supportive Service Financing • Federal • HUD • Department of Health and Human Services • Department of Education • Department of Labor • Veterans Administration • State • Variety of Unique Approaches • Local • Local Government • Federal Pass-through funding • Philanthropy

25. HUD • SHP • Individuals or Families who are homeless and have a disability • Services in Permanent Supportive Housing • HOPWA • Low Income Persons with HIV or AIDS and their Families • Support services in permanent supportive housing • Formula Grants (States and Cities) • Competitive Grants (States, Cities, Local Government and Nonprofits)

26. Department of Health and Human Services • Substance Abuse and Mental Health Services Administration (SAMHSA) Mainstream/Block Grants • SAMHSA Discretionary Grants • Medicaid • Projects for Assistance in Transition from Homelessness (PATH) • Formula grant program that provides funding to states and territories • Some states have chosen to allocate a portion of PATH funding to pay for services in supportive housing for people who are homeless and mentally ill. • TANF • Homeless families or youth • Health Center Grants for Homeless Populations • Health Care for the Homeless • Only first 12 months in PSH

27. More on Medicaid • Medicaid and health systems incur substantial costs providing care to homeless people – often without achieving good outcomes • Costs of serving homeless people with serious mental illness over $40,000 / year – mostly in health care systems • Health care costs for public inebriates exceed $8,000/year • Homeless people with co-occurring mental health and substance use disorders are most frequent users of emergency room care • Supportive housing significantly reduces the need for costly emergency care and hospitalizations • More than 50% reduction in utilization of hospitals for medical and psychiatric care • Health outcomes improve with better engagement in more appropriate outpatient care

28. Department of Education • Education for Homeless Children and Youth • Formula grant to states • Eligible activities are educational activities to facilitate enrollment, attendance and success in school for homeless children and youth.

29. Department of Labor • Veterans’ Employment Program or Veterans Workforce Investment Programs (VWIA) • Program can provide, but is not limited to, training, retraining, job placement assistance and support services, may also be used to support other services that enhance the employability of participants. • Homeless Veterans’ Reintegration Program (HVRP) • Reintegrating Veterans into meaningful employment • Employment focused case management

30. Veterans Administration • HUD-VASH • Partnership between HUD and the VA • Veterans who are homeless and mentally ill and/or those with substance abuse disorders • Combines special set aside of HUD housing choice vouchers with community-oriented outreach, clinical care and case management • VA Supported Housing Program • VA services for homeless Veterans focused on getting them housed and retaining housing

31. Creative State Approaches • Minnesota • Supportive Housing Service Grant program in the Department of Human Services • Flexible funding to help counties and PSH providers to leverage other funding and maximize the use of mainstream resources to meet the needs of people experiencing long term homelessness. • Regulatory changes that allow Medicaid to be used for services

32. Creative State Approaches • Illinois • Department of Corrections • Funding Permanent Supportive Housing for Ex-offenders • Challenge: funding ends when parole ends • State Departments of Veterans Affairs • Using Domiciliary Care per diem to fund permanent supportive housing • State Funding for Services in Supportive Housing • Line item in Illinois Department of Supportive Services budget that funds permanent supportive housing

33. Financing the Supports in Supportive Housing Work in progress … • No consistent approach across states • HUD SHP funding is still a major source in most places – but availability is increasingly limited • Funding from mental health systems and Medicaid increasingly important • Growing number of FQHC providers are getting involved in supportive housing • Fragmentation of Medicaid coverage for health, mental health, and substance use treatment services is a big challenge

34. Key Strategies for Creating Supportive Housing • Be willing to commit early to support leveraging. • Acknowledge provisional commitments of other funding, and accept inherent risk. • Align requirements and processes with other systems. • Seek to proactively partner resources with other financing – capital and services. • Encourage partnerships that leverage resources, skills and capacity. • Underwrite the lead organization, the team, and the housing project. • Ensure regulations do not conflict with best practices in supportive housing.

35. Questions & Answers

36. Contact Information Kelly W. Kent Senior Program Manager Corporation for Supportive Housing Tel: 312.332.6690 ext. 17 kelly.kent@csh.org