Guide to Supported Living in Florida

Prepared by: Advocates for Human Potential, Inc. National Mental Health Consumers’ Self-Help Clearinghouse Louis de la Parte Florida Mental Health Institute, University of South Florida With funding from and in partnership with the: Florida Department of Children and Families Mental Health Program Office June 2003 Jerry Regier, Secretary Table of Contents Acknowledgements....................................................................................................... 5 Chapter 1 - Philosophy and Values of Supportive Housing ...................................... 6 An Introduction to the Principles of Supportive housing .................................................... 6 Putting Principles into Practice .............................................................................................. 6 Chapter 2 - Who Can Live in Supportive housing? .................................................. 15 Promoting choice and responsibility.................................................................................... 15 Determining eligibility for housing and services ................................................................ 16 Defining support needs ......................................................................................................... 19 Services to Support Informed Choice in Housing ............................................................. 19 Promoting Employment Opportunities ................................................................................ 19 Natural Supports .................................................................................................................... 21 Notes to Chapter 2 ................................................................................................................. 22 Chapter 3 - Basic Components of Supportive Housing........................................... 23 Rental assistance ................................................................................................................... 23 Start-up funds ......................................................................................................................... 26 Contingency funds ................................................................................................................. 27 Core housing support services ............................................................................................ 27 Linkages to other community support services ................................................................. 29 Notes to Chapter 3 ................................................................................................................. 29 Chapater 4 - Developing Individualized, Flexible Support Services ....................... 30 Identifying values and preferences...................................................................................... 32 Goal planning.......................................................................................................................... 32 Identifying skills and support needs .................................................................................... 36 Self-help and peer support ................................................................................................... 38 Systems advocacy ................................................................................................................. 39 Notes to Chapter 4 ................................................................................................................. 41 Chapter 5 - Supportive Housing Management and Operations: ............................. 42 A new management philosophy........................................................................................... 42 Staff competencies ................................................................................................................ 43 Knowledge............................................................................................................................... 43 Skills ......................................................................................................................................... 46 Attitudes ................................................................................................................................... 47 Service management............................................................................................................. 48 Balance and flexibility ............................................................................................................ 48 Staffing ratios: Understanding profiles and needs ............................................................ 50 Building Organizational Capacity......................................................................................... 51 Operating Policies, Procedures, and Tools........................................................................ 51 Quality assurance................................................................................................................... 52 Individuals as staff and peer models................................................................................... 54 Notes Chapter 5 ..................................................................................................................... 55 State of Florida Guidelines for Supportive Housing Page 2 of 67 Chapter 6 - Increasing the Supply of Affordable Housing....................................... 56 Providing rental assistance................................................................................................... 56 Improving access to housing................................................................................................ 57 Working with landlords .......................................................................................................... 58 Accessing subsidized housing ............................................................................................. 58 Developing affordable housing ............................................................................................ 59 Advocating for more funds.................................................................................................... 59 Federal funding sources........................................................................................................ 60 State funding sources............................................................................................................ 65 Private funding sources......................................................................................................... 66 Notes to Chapter 6 ................................................................................................................. 66 State of Florida Guidelines for Supportive Housing Page 3 of 67 Introduction In 1999-2000, Florida’s Department of Children and Families (DCF), Mental Health Program Office in Tallahassee began several supportive housing initiatives. With administrative funds provided by the federal Projects for Assistance from Homelessness (PATH), DCF began a series of statewide training and technical assistance services on supportive housing through a contract with the University of South Florida, Florida Mental Health Institute and their national subcontractor, Advocates for Human Potential. The timing of this initiative coincided with the closure of G.Pierce Wood Memorial Hospital. Also, the DCF District Mental Health Program Offices were expanding supportive housing services and contracts with their community mental health, substance abuse and housing providers, including the expansion of Florida Assertive Community Treatment Teams (FACT), throughout the state. In 2002, the Florida Legislature passed Senate Bill 2254 (Laws of Florida 2002248) that directed the Secretary of DCF to establish a statewide stakeholder workgroup to review issues associated with publicly funded supportive housing living arrangements. The workgroup was charged with addressing the following issues: • • Definition of supportive housing services Individual’s health and safety (resident’s rights, concerns and standards) • Use of subsidies funded by the Department of Children and Families As a result of the SB 2254 Supportive Housing Workgroup, DCF will write administrative rules for supportive housing. These “Guidelines for Supportive Housing for Persons with Mental Illnesses” were reviewed by the workgroup and intended to be a “GUIDE”. In FY 2002-2003, the DCF Mental Health Program Office initiated a “Strategic Plan for Persons with Mental Illnesses” that included many of the same stakeholders who reviewed this document. The purpose of these guidelines is: • • Establish a common set of principles and philosophy for supportive housing Establish consistent statewide values of supportive housing for model development by DCF District or Regional Mental Health Program Offices Promote practice guidelines for providers Disseminate national supportive housing best practices Provide a technical assistance tool for individuals, families and providers • • • State of Florida Guidelines for Supportive Housing Page 4 of 67 Acknowledgements Department of Children & Families Mental Health Staff: Celeste Putnam, DCF Mental Health Director & Acting Assistant Secretary for Programs Cynthia Holland, DCF Chief of Adult Community Mental Health Susan Dickerson, DCF Management Analyst National Alliance for the Mentally Ill of Florida (NAMI, Florida) Carrfour Corporation Day Springs Village DCF Office on Homelessness DCF Substance Abuse Program Office DCF District 1, 8 & 11 Mental Health Program Offices Florida Assisted Living Association Florida Agency for Health Care Administration Florida Association of Homes for the Aging Florida Health Care Association Florida Housing Finance Corporation Florida Coalition for the Homeless Florida Housing Coalition Florida Supportive Housing Coalition, Inc. Florida Aids Action Council Florida Hospital Association Florida Long-Term Care Ombudsman Florida Psychiatric Society Florida Sheriffs Association Florida Partners in Crisis Florida Statewide Advocacy Council Florida Association of Counties Florida Department of Elder Affairs Florida Council for Behavioral Health Care Florida Alcohol & Drug Abuse Association (FADAA) Volunteers of America Contactors, co-authors, consultants, facilitators: Alan Marzilli, Training and Education Consultant, National Mental Health Consumers’ Self-Help Clearinghouse Carol Bianco, Mental Health Director Advocates for Human Potential, Delmar, NY Mark A. Engelhardt, MS, ACSW, Faculty-University of South Florida, Louis de la Parte Florida Mental Health Institute, Department of Mental Health Law & Policy Stakeholder participants and reviewers: Self-Advocates Family members Advocacy Center for Persons with Disabilities State of Florida Guidelines for Supportive Housing Page 5 of 67 Chapter 1 - Philosophy and Values of Supportive Housing An Introduction to the Principles of Supportive housing What is supportive housing? It is more than a philosophy or a set of procedures. It is a comprehensive system of voluntary, flexible, individualized supports that allow people with disabilities to live in housing of their own choice rather than in residential treatment settings. services are determined by individual needs and preferences. Housing cannot be contingent upon accepting services or compliance with a treatment plan. Individuals have the full rights and responsibilities of tenants. Service provision and housing management are functionally separated. Support services are flexible enough to meet individual’s needs as they change over time. Supports help individuals become fully integrated into the community; Services and supports promote recovery. Services utilize rehabilitation principles and practices. Housing is decent, safe, and affordable. • • • • • • • • A major goal of supportive housing is to integrate people fully into the community, meaning that in addition to living in non-segregated housing, they also participate in everyday activities in the community. This guide focuses on the development of support services for adults with serious mental illnesses. Some of the basic principles of supportive housing are: • • • Services are evaluated according to measurable outcomes. Services support individual choice and empowerment. Each person is different and therefore housing and support Putting Principles into Practice A. Services are evaluated according to personal and system outcomes. Developing system outcomes for supportive housing is important for several reasons. First, it is essential to know how well supportive housing services are serving people, so that changes or improvements to the services can be made. Additionally, funding for supportive housing is often based on evidence that it works. Continued state funding may well be determined by the success of the services provided in Florida. State of Florida Guidelines for Supportive Housing Page 6 of 67 Outcomes for supportive housing can look much different from those of traditional mental health programs. Because—as will be discussed below— supportive housing is based on rehabilitation principles rather than on clinical models, supportive housing must measure outcomes that relate to aspects of mental illness other than symptoms. System outcome measurement must include individual outcomes that look at a person as a whole, such as work skills, utilization of crisis services or hospitalization, risk behaviors such as substance use, and physical and dental health. Examples of individual outcomes are listed in Table 1. • • • • • • • • Table 1 Suggested Measurable Outcomes Examples of Individual Community Living Skills Quality of Life Inventory Outcomes Scale Symptom Relief • Personal Care • Self-Esteem Personal Safety Assured • Socialization and • Goals and Values Relationships Services Accessed • Money • Activities and Leisure Role Functioning • Work Skills Self-Development • Play • Vocational Skills Equal Opportunity • Learning Personal Survival • Creativity Assured • Helping Empowerment • Love • Friends • Children • Relatives • Home • Neighborhood • Community Source: Bullock et al. (2000)1 Source: Bullock et al. (2000)1 Source: Anthony (1993)1 Throughout the remainder of this section, suggestions are offered for measuring outcomes related to the philosophy and values of supportive housing. Many of these suggestions come from Personal Outcome Measures in Consumer-Directed Behavioral Health Care, produced by the Council on Quality and Leadership in Supports for People with Disabilities (the Council) in Towson, Md. State of Florida Guidelines for Supportive Housing Page 7 of 67 B. Services support individual choice and empowerment. Empowerment comes from the individual, rather than from a program. However, for people to become empowered, they must feel confident that their rights are being respected. Therefore, it is the role of supportive housing to educate individuals about their rights and ensure that they have a mechanism for exercising their rights. Above all, empowerment of individuals requires that services be provided voluntarily. In times of crisis, a person can have his or her preferences in mental health care respected if he or she has prepared an advance directive that spells out these preferences. It is, therefore, important that all individuals have the opportunity to prepare advance directives, a crisis or contingency management plan. One method for measuring outcomes is to use the Empowerment Scale, which measures five factors: 1. 2. 3. 4. 5. Self Esteem Power Activism Optimism Righteous Anger1 Another primary method of empowerment is setting--and working toward--personal goals. The Council recommends measuring outcomes regarding goal setting by asking the following questions: • • • Have the person’s priorities regarding goals been solicited? Does the person choose personal goals? Are these the goals the person is working toward?3 For staff, empowerment requires that staff respect an individual’s choices, even when those choices may conflict with the staff’s judgment. The position of the American Association of Community Psychiatrists (AACP) is: “Consumers are presumed to be competent to make housing choices, even if those choices are in conflict with the recommendations of their caregivers, and are entitled to access to supports in the settings of their choosing. In addition, choices regarding participation in treatment, [legal] substance use, and living companions should be respected as much as possible.”4 Chapter 5 of these Guidelines discusses some methods for providing support to people whose decisions do not reflect others’ views of what is best. C. Each person is different and, therefore, housing and support services are determined by individual needs and preferences. People served by supportive housing models must be able to choose their own housing, as would any other In addition, the Council recommends measuring outcomes regarding rights protection by asking the following questions: • • What rights does the person exercise? Are there any rights not exercised?2 State of Florida Guidelines for Supportive Housing Page 8 of 67 person. This means choice in terms of type of housing, location and type of neighborhood, and roommates or family members who share the housing. The supportive housing staff helps the individual to determine their housing preferences and then help him or her to find housing within available financial resources. Staff can provide support to individuals to help them choose housing, but the ultimate choice lies with the individual. Staff also provides support in finding housing that meets the individual’s goals, making arrangements to obtain the housing and helping to retain the housing. The Council recommends measuring outcomes regarding housing choice by asking the following questions: • • • Does the person have options about where and with whom to live? Does the person decide where to live? Does the person select with whom he or she lives?5 stay in their home, even as their service needs change considerably. In the vast majority of cases, the landlord is a private or public entity with no responsibility for mental health services. However, some community mental health centers and other human service agencies have responded to the needs of individuals by purchasing or building affordable housing to help increase the available supply. Although, if the community mental health center owns or leases the housing, services must remain voluntary, and there should be a clear distinction between staff providing support services, and those responsible for property management. The goal is to create an independent relationship between landlord and tenant, in which the individual holds the lease in his or her name. Additionally, the individual should have a standard lease, with no extra provisions based on his or her disability. This tenancy arrangement allows the person to have his or her own “real” home: D. Housing can not be contingent upon accepting services or compliance with a treatment plan; individuals have the full rights and responsibilities of tenants; service provision and housing management are functionally separated. A major difference between supportive housing and residential treatment programs is that in supportive housing, services are separate from housing. In short “housing is housing”. Under the residential treatment model, as individuals’ needs for services change, they move to different settings. In supportive housing an individual might “In their own real homes, people have a private and secure physical place for activities that match up with the lifestyles they have chosen and that reflect their personal rituals and tastes. Individuals who have a real home control what happens there, including daily routines and who enters to visit or stay. Finally, people in a real home have State of Florida Guidelines for Supportive Housing Page 9 of 67 an investment in ownership or legally assured tenancy.”6 Supportive housing staff should work with landlords to ensure success. According to a report by the Center for Healthcare Strategies (CHCS), “In the ideal model of supportive housing, the owner of the housing becomes a ‘benevolent’ landlord whose first approach to tenancy problems is to seek additional support for the tenant.”8 This ideal can be achieved through responsibly providing services to individuals and being available to landlords at all times. In order to succeed, supportive housing staff should be based offsite but available onsite. According to the CHCS report: “Inherent in the implementation of best practice service models is the conversion of place-based congregate service models to mobile, in-vivo service models. For example, Assertive Community Treatment models for people with serious mental illness take A parallel responsibility of service systems is to assure that their services are accessible and responsive. Implementation of off-site, as opposed to place-based services is critical to fulfilling that responsibility. To be accessible and responsive, services for people with disabilities living in [supportive housing] settings must be available 24 hours a day, seven days per week. They must be available exactly when a person with disabilities or their neighbor, landlord, or family member calls for help. Services must also be appropriate to what people need and choose, must be welcoming and customer friendly, must be culturally competent, and must assure physical accessibility.”9 E. Support services are flexible enough to meet individual’s needs as they change over time. A major principle of supportive housing is that participation in any services must be voluntary for the individual, although the mission of supportive housing is to serve individuals who are unable to live independently without supports. This principle might seem to be a paradox; however, the goal of supportive housing is to allow people to live in real homes. If a housing program requires compliance with a treatment plan, then it is a residential treatment program rather than a supportive housing. In order to encourage people to rely upon the services and supports that they need, it is important that the services and supports be available to people whether or not they have chosen to participate in them. This also promotes the empowerment of individuals, as people are most likely to accept services that are effective and meaningful. the psychiatrist, the nurse, and the case manager out of the clinic and away from the office encounter, and instead deliver services to consumers in their homes, in their places of work, or in other natural settings …” State of Florida Guidelines for Supportive Housing Page 10 of 67 Unlike residential treatment programs, which provide a set of services and supports that are defined by the program, supportive housing must provide services that meet an individual’s needs. As a person’s needs intensify, more support can be provided without necessitating that the person move. Supportive housing does not impose “graduation” requirements like residential treatment programs do. Nor are there time limits: Services are provided to the person as long as he or she needs them. Conversely, separating services from housing allows supportive housing to provide less intensive services when appropriate to the person’s needs. The separation allows the supportive housing provider to provide services in the least restrictive manner possible. The Council recommends measuring outcomes regarding choice by asking the following questions: • • • • Does the person select the services and/or supports that he or she receives? Do the services and/or supports focus on the person’s goals? Does the person have choices about service providers?10 The answers to these questions will reflect the measure of success for individuals receiving supportive housing services and supports. Supportive housing helps people with psychiatric disabilities live in housing that is available to other people in the community, not in housing that is reserved for people with disabilities. This principle is especially important in the wake of the U.S. Supreme Court’s Olmstead decision, which held that the Americans with Disabilities Act (ADA) requires states to provide treatment to people with disabilities in the least restrictive setting possible—meaning a setting that allows the person the greatest opportunity to interact with people who do not have disabilities. The ruling was based on the principle that “confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.”11 In order for community integration to be successful, supportive housing must facilitate “scattered site” housing. In Texas, for example, the standard is that a maximum of 40% of the units in a multi-unit dwelling may house people with disabilities. Of course, the ultimate goal of helping people with disabilities to acquire housing from the general housing stock is to maximize their opportunities to engage in everyday activities like those described in the Olmstead decision. The Council recommends measuring outcomes regarding community integration by asking the following questions: • What does the person do when he or she participates in the life of the community? F. Services and supports help individuals become fully integrated into the community. State of Florida Guidelines for Supportive Housing Page 11 of 67 • • How often does the person participate in the life of the community? Is this type and frequency of participation satisfactory to the person?12 dreams. Recovery is often a complex, time-consuming process.”13 It is not up to supportive housing to define recovery, but all providers must have a philosophy of hope for recovery in order to facilitate each person’s recovery process. As Anthony notes, “Recovery is what people with disabilities do. Treatment, case management, and rehabilitation are what helpers do to facilitate recovery.”14 The promotion of recovery is extremely important to satisfaction with services: “[R]ecovery is an internal, ongoing process requiring adaptation and coping skills, promoted by social supports, empowerment, and some form of spirituality or philosophy that gives hope and meaning to life. How professionals promoted or deterred recovery were identified as important measures of quality in psychiatric care.”15 In addition to recovery, which is a personal process, supportive housing must also strive to support role recovery, which means regaining the social roles, such as community The answers to these questions reflect the degree to which the individual chooses to be integrated into the life of their community and identifies areas that need additional attention. G. Services and supports promote recovery. Recovery, like empowerment, is a personal process that is unique to each individual. Recovery, as described by William Anthony, “does not mean that the suffering has disappeared, all the symptoms removed, and/or the functioning completely restored;” rather: “Recovery is described as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness. Recovery from mental illness involves much more than recovery from the illness itself. People with mental illness may have to recover from the stigma they have incorporated into their very being; from the iatrogenic effects of treatment settings; from lack of recent opportunities for self-determination; from the negative side effects of unemployment; and from crushed member, employee, friend, or family member, that a person might have lost due to illness or other factors such as stigma, unemployment, poverty, and State of Florida Guidelines for Supportive Housing Page 12 of 67 lack of opportunity for selfdetermination. Many of the services provided by supportive housing are not related directly to housing, but are designed to facilitate role recovery; these services will be discussed in greater detail in Chapter 4. The Council recommends measuring outcomes regarding role recovery by asking the following questions: • • • What social roles does the person fill? Does the person fill a variety of social roles? Are the number and types of social roles satisfactory to the person?16 “Psychiatric rehabilitation services are designed to assist a person with a serious psychiatric disability to manage the disability effectively and to compensate for its functional deficits. Research in the field has demonstrated persons who receive psychiatric rehabilitation services are significantly less likely to be hospitalized and more likely to be able to return to work, school, or a productive role in the community. The range of services may include rehabilitation, case management, residential treatment and support, crisis services, social services, housing, vocational rehabilitation, substance abuse treatment, peer support, and family support.”17 These services are based on a value system in which hope for individual’s recovery is paramount. As defined by the Boston University Center for Psychiatric Rehabilitation, the values of the Psychiatric Rehabilitation approach are: • • • • • • belief in a person's right to choose belief in every person's potential for growth, regardless of disability belief in the importance of focusing on functioning belief in the importance of focusing on real world environments (e.g. real work, real school, real housing) belief in the importance of focusing on the whole person, rather than the illness or the disability belief in the importance of focusing on outcomes rather than theory18 Success for each individual should be measured by the degree to which their community involvement needs are met. H. Services utilize rehabilitation principles and practices. Supportive housing takes a much broader view of desired outcomes than many traditional housing programs. Stability in housing is a primary goal. Improvement of symptoms may be an outcome, but is not necessary. In fact, people can and do succeed in housing without any improvement in symptoms. Instead, the supportive housing approach emphasizes the development of the skills and resources necessary to achieve success in this environment. The International Association of Psychosocial Rehabilitation Services (IAPSRS) defines rehabilitation as follows: Designing rehabilitation services that reflect these values will be discussed in further detail in Chapter 4. State of Florida Guidelines for Supportive Housing Page 13 of 67 I. Housing should be decent, safe, and affordable. Even if all of the above principles are put into practice, if the housing itself is not decent, safe, and affordable the goals of supportive housing have not been achieved. Chapter 6 explores in detail the various methods utilized to ensure affordability. The generally accepted standard for housing affordability is that housing cost should not exceed 30 – 40% of household income. People paying more than 50% of their income on housing are considered “rent burdened”, by the U.S. Department of Housing and Urban Development (HUD), and at risk of losing their housing. Until housing falls within this standard, then the outcome of stable, permanent housing has not been achieved. Similarly, housing must meet community standards of quality, safety, and access. Too often, people with disabilities live in sub-standard housing in marginal neighborhoods or remote locations. Simply put, housing that one is proud to call home is the goal of supportive housing. This is the platform upon which so much is built. Notes to Chapter 1 Wesley A. Bullock et al., “Leadership Education: Evaluation of a Program to Promote Recovery in Persons with Psychiatric Disabilities,” Psychiatric Rehabilitation Journal 24(1) (Summer 2000), 6. 2 Personal Outcome Measures, 141. 3 Personal Outcome Measures, 51. 4 AACP Position Statement on Housing Options for Individuals with Serious and Persistent Mental Illness (SPMI) (June 18, 2001), 2. 5 Personal Outcome Measures, 55. 6 Supportive housing Project, A Guide to Supportive housing in Florida (September 1997), 4-1. 7 Personal Outcome Measures, 81. 8 Ann O’Hara and Stephen Day, Olmstead and Supportive Housing: A Vision for the Future (Lawrenceville, N.J.: Center for Healthcare Strategies, December 2001), 12. 9 Olmstead and Supportive Housing, 12. 10 Council on Quality and Leadership in Supports for People with Disabilities, Personal Outcome Measures in Consumer-Directed Behavioral Health (2000), 121. 11 Olmstead v. L.C., 527 U.S. 581 (1999). 12 Personal Outcome Measures, 99. 13 William A. Anthony, “Recovery from Mental Illness: The Guiding Vision of the Mental Health Service System in the 1990s,” Psychosocial Rehabilitation Journal 16(4) (1993), xxx. 14 Anthony, “Recovery from Mental Illness,” xxx. 15 Jean Campbell, “How Consumer/Survivors Are Evaluating the Quality of Psychiatric Care, “ Evaluation Review 21(3) (June 1997), 360. 16 Personal Outcome Measures, 107. 17 See http://www.iapsrs.org 18 See http://www.bu.edu/cpr/ 1 State of Florida Guidelines for Supportive Housing Page 14 of 67 Chapter 2 - Who Can Live in Supportive housing? Who Can Live in Supportive housing? The answer to this question is determined by the quality and flexibility of supportive housing. Many believe that any adult with a disability who needs support—no matter how much support—can live in supportive housing. Remember: Supportive housing is designed with services specifically for each individual. The measure of supportive housing is not whether a person succeeds or fails with a package of services that the organization offers. Rather, supportive housing is measured by whether it provides the services that offer each person an opportunity to succeed. • Staff conducts outreach to prospective participants, including providing an opportunity to visit residences. The service provider actively develops access to affordable housing and offers a wide variety of normal housing choices. Available housing is safe, accessible, and convenient to transportation and other supports. The support system offers rental assistance that serves as a bridge to permanent subsidies. The support system offers a wide variety of voluntary community supports. People are treated with dignity and respect. • • • • • Promoting choice and responsibility Many supportive housing providers, as well as many people who live in supportive housing arrangements, believe that anyone can live in supportive housing, and that having a home of one’s own is far superior to living in a congregate setting. However, it is important to remember that supportive housing is based upon choice, and that nobody should ever be “forced” into supportive housing. Supportive housing requires a new approach. People are more likely to choose supportive housing—and, therefore, benefit from its many advantages—if: A guiding principle of supportive housing is that people have the right to make their own decisions. For many people involved in providing services to adults with serious mental illnesses, this philosophy represents a significant change. Individuals’ rights to make critical life decisions must be promoted, even if staff does not agree with those choices. Examples include choices regarding roommates, legal substance use (i.e. alcohol), and participation in treatment. This does not mean that staff should have no role in decision-making; rather, the answer is support, not coercion. The majority of staff interactions should be focused on helping people make good decisions by understanding State of Florida Guidelines for Supportive Housing Page 15 of 67 themselves and the demands of the environments where they hope to succeed. Some factors1 to consider in getting involved in decision-making include: • • The potential harm—will the decision lead to abuse, injury, death, or loss of housing? The person’s history of decisionmaking—has the person continued to make harmful decisions or is the person’s decision-making ability improving? The long-term and short-term effects of intervention in decisionmaking—will intervention lead to decreased self-esteem, increased dependence on staff, or rejection of services? Maintaining independence—are there guardians, advocates, friends, or family members who can represent the person’s interests? Determining eligibility for housing and services Determination of eligibility for supportive housing starts with an assumption of eligibility. A person is eligible for supportive housing if he or she: • • Is receiving mental health services Is over 18 years old (Supportive housing can also be effective with older adolescents, with additional special considerations. However, these guidelines are addressed to adults.) Wants to live in the community Requires support services in order to live in the community • • • • Remember: “Respecting personal choice is never a valid reason to ignore an obviously harmful behavior or situation. Nor is risk an automatic justification for intervention.”2 Successful supportive housing reflects a delicate balance between choice and safety that is respectful of personal preferences. Remember: These are the only requirements for someone to qualify for supportive housing. Often, other people—such as friends, family members, doctors, or case managers—will try to make excuses as to why a person should not qualify for supportive housing. None of these reasons are valid. Some of these reasons3 include: Severity of disability. Experience has shown that people with serious and persistent mental illness who have spent extended periods of time in state hospitals can nonetheless succeed in supportive housing with the right mix of resources and supports available. History of behavior problems or “severe reputations.” Because many behavior problems are linked to dissatisfaction with congregate housing or residential treatment, State of Florida Guidelines for Supportive Housing Page 16 of 67 many people who have had past problems succeed in supportive housing. Failure to “graduate” from a training continuum. Supportive housing is designed for people who need support in their daily lives. The philosophy of supportive housing requires that services be designed to match an individual’s needs at the present time, not in the future. Therefore, individuals are not required to develop certain skills in residential treatment before they become eligible for supportive housing. Failure of a previous supportive housing arrangement. “Individuals do not fail in supportive housing— arrangements fail to meet their personal needs and preferences. If one thing does not work, then try another. Make every effort to create successful supportive housing arrangements through flexible supports that are responsive to a person’s life circumstances. Don’t give up on people and ‘send them back’ just because previous arrangements did not work out.”4 Lack of personal financial resources. Supportive housing must help individuals find the resources they need to obtain their own housing by creating or accessing subsidies for people who need them. Additionally, people who can afford their own housing should be eligible for the support service component of supportive housing, Family opposition. Although family members’ viewpoints should be respected, the ultimate decision as to whether a person desires to live in supportive housing is his or her own decision. Legal guardianship. Even if a person has been appointed a legal guardian to make legal decisions, he or she can still live in the community with the consent of the guardian. Supportive housing staff should work closely with the guardian to address concerns, and include them in the development of the individual plan for housing and services. Life choices that conflict with others’ ideas. A cornerstone of supportive housing is the right to make life choices. Sometimes, people—whether or not they have a disability—make choices that others think are wrong or harmful. However, the opportunity to learn from mistakes is an important part of independence. Decisions regarding spending, substance use, sexual intimacy, etc., should not be used as excuses for denying supportive housing. Instead, training, counseling, and support should be offered. Co-occurring disorders. By providing additional support services, supportive housing can successfully serve people with HIV/AIDS, developmental disabilities and substance abuse disorders. People who have been dually diagnosed as having a mental illness and substance abuse disorder are a growing target population in Florida. There are 32 Florida Assertive Community Treatment Teams (FACT) that address persons with State of Florida Guidelines for Supportive Housing Page 17 of 67 co-occurring disorders along with their housing needs. Several areas of the state are adopting Dr. Kenneth Minkoff’s Comprehensive, Continuous and Integrated System of Care (CCISC) Model (Minkoff, 1998, 2002). The key points to offering persons support services in this model are: • • Co-occurring disorders is an expectation, not an exception. Core successful supports in any setting is the availability of empathic, hopeful, integrated care through multiple episodes in a persons life. Care management requires a continuous relationship that balances structure and flexibility. Both mental illness and substance use disorders should be considered dual primary disorders. Mental illnesses and substance dependence are both examples of chronic, biopsychosocial disorders that can be understood using a disease and recovery model. Each disorder has parallel phases of recovery (acute stabilization, engagement, motivational enhancement, relapse prevention and growth) and stages of change. There is no one correct dual diagnosis program or intervention. Outcomes must be individualized, including harm reduction (e.g. housing retention) and disease management. In 2001, the American Association of Community Psychiatrists (AACP) developed a position paper on “Housing Options for Individuals with Serious and Persistent Mental Illness (SPMI)”. The AACP recognized the need for a range of housing options, but recommended maximizing availability of supported housing with assessment of individual preferences (choice) and their perceived needs for support. Consequently, the needs of persons vary, but individuals with SPMI who are at particular risk of homelessness include the following choices: • Abstinence-expected or “dry” housing for persons who want and choose to live in a sober setting Abstinence-encouraged or “damp” housing for individuals who recognize their need to limit use and are willing to live in a supported setting where uncontrolled substance use by themselves or others is actively discouraged Individual-choice or “wet” housing has had demonstrated effectiveness in preventing homelessness among individuals This model (“Pathways to Housing Program” in Psychiatric Services, April 2000) is focused on housing retention with case management or “wrap-around” (FACT) services offered. Premotivational and motivational interventions that encourage abstinence are incorporated into the overall approach to providing service supports. • • • • • • • • State of Florida Guidelines for Supportive Housing Page 18 of 67 Defining support needs The case management functions of supportive housing, which are discussed in detail in Chapter 4, include providing direct assistance or linking people to available community supports. Because each person is different and has unique support needs, it is important that the individual define his or her needs so that the supportive housing program is able to meet them. Although the core function of supportive housing is to provide services that enable a person to obtain and retain housing, supportive housing also seeks to integrate people into the community to the fullest extent possible. Therefore, it is important also to assist individuals with defining their goals and preferences as to employment and other activities that help them to live a full life in the community. decision. Although the decision is ultimately the person’s, it can be very helpful to educate family members as well. Common methods of educating people about housing options include: • Giving presentations at hospitals, residential treatment programs, or other congregate living settings Having one-on-one discussions with individuals to explain that supportive housing allows people to choose their own homes and get the services that they need Addressing barriers, such as fear that supports won’t be available, anxieties about being alone, or disruption of the well-established routines of institutional life Arranging for people who live in supportive housing to provide peer counseling Arranging for people who live in institutional settings to visit available housing units, including overnight or short-term stays • • • • Services to Support Informed Choice in Housing A person needs information in order to define his or her own housing needs. Often people who have spent extended periods of time in hospitals, residential treatment, or other congregate living settings might be satisfied with their current arrangement simply because they do not know of any alternatives. The goal of conducting outreach to such people is not to change their minds, but to provide enough information so that the person can reach his or her State of Florida Guidelines for Supportive Housing Promoting Employment Opportunities People who have lived in institutional settings as well as other people with disabilities often have negative attitudes toward employment. In large part, these negative attitudes are shaped by a system that traditionally has failed to provide meaningful employment and educational opportunities for people with disabilities; people with serious mental illnesses in particular have had a difficult time accessing needed supports. This is unfortunate, as Page 19 of 67 earned income can be an important part of the strategy to address the costs of community housing. However, many individuals and family members are concerned about potential loss of financial support (e.g. SSI and SSDI) and medical assistance if they start to earn income. Education and assistance with benefits management is an essential support service for individuals seeking to return to work. As with other supports needed in the community, it is important that employment goals be the person’s own goals. The role of supportive housing staff is to provide as much information as possible to allow the person to develop his or her goals in an informed way. Particularly important is information about the Social Security Administration’s employment programs under the Ticket to Work and Work Incentives Improvement Act (TWWIIA). Additionally, it is important to provide information about the types of employment opportunities that are available, educational opportunities to improve employment prospects and what it would be like to return to work. In addition to providing information about education and employment opportunities, it is vital that a process be in place to determine a person’s employment goals and preferences. Examples of questions that can be asked include: • Do you want to work? • • • • • • • • • • • • • • • • • • • What are some of the reasons that you want to work (don’t want to work)? What supports might help you to work (to consider work)? What types of work experience do you have? Did you choose to do that type of work? Do you think that you could do a different type of work? Do you have any other skills that could help you get a job you enjoy? What type of work do you want to do? What type of environment— office, retail, social services—do you want to work in? What type of boss do you want to work for? How close or far from home do you want to work? How do you want to commute to work? How many hours a week do you want to work? What type of schedule do you want to work? What type of training will you need? How much money do you want to make? What other benefits do you want from your job? Do you want your work schedule to increase over time? Do you want to work someplace with a lot of co-workers, or only a few? Does your religion, culture, or beliefs prevent you from doing certain jobs or working certain times? State of Florida Guidelines for Supportive Housing Page 20 of 67 The answers to these questions should guide the process of assisting the individual in securing employment that offers the greatest potential for success. Natural support networks provide acceptance, belonging, and safety, as well as support, companionship, problem solving assistance, and practical help.5 Some examples of questions to ask that can help a person develop a natural support system that meets his or her needs include: • • • • Do you have people with whom you can share your personal thoughts? Are there people whom you feel you can trust? Do you spend time with your family? Do you get along well? Would you like to spend more time with your family? What supports would you need to do this? Do you feel like you have enough friends? Do you feel like you get to spend time with your friends? Where do you go, and what do you do to have fun—movies, restaurants, sporting events, etc.? Do you take advantage of community resources, like libraries, museums, parks, festivals, etc.? Are you involved with any clubs, civic organizations, neighborhood groups, or houses of worship? Are there places that you’d like to go, or things that you’d like to do? What help would you need—for example, a “buddy”—to do more fun activities? Who do you know in your community—neighbors, merchants, co-workers? Natural Supports Supportive housing does not achieve its goal of community integration by simply finding a place for someone to live and a job for the person to do. Often, institutional life takes away many social roles that are necessary for a person to lead a fulfilling life in the community. In addition to traditional case management roles, such as linking people to income supports, psychiatric treatment, rehabilitation services, and physical health care, another role of supportive housing staff is to help people connect with some of the natural supports in the community that promote recovery. A natural support network is a network of mutually caring and supportive relationships. A natural support network may include family members, friends, neighbors, • • • • • • colleagues and co-workers, as well as people who have shared experiences such as psychiatric hospitalization, or who are from the same cultural or spiritual community. • • State of Florida Guidelines for Supportive Housing Page 21 of 67 • What supports might you need to meet more people in the community? Not only does the exercise of asking these questions assist the individual to identify areas of personal strength, it also provides guidance to support staff in assisting the individual to gain or enhance natural supports. Notes to Chapter 2 A Guide to Supportive Living in Florida, 5-3. Adapted from Patterns of Supportive Living, Allen, Shea, and Associated, 1993. 2 A Guide to Supportive Living in Florida, 5-3. 3 Adopted from Supportive housing Project, A Guide to Supportive Living in Florida (September 1997), 3-2 –3-3. 4 A Guide to Supportive Living in Florida, 3-3. 5 Personal Outcome Measures in ConsumerDirected Behavioral Health, 30-31. 1 State of Florida Guidelines for Supportive Housing Page 22 of 67 Chapter 3 - Basic Components of Supportive Housing Supportive housing has a few basic components, including financial assistance and service provision. In order to assist adults with serious mental illness to live in the community, supportive housing must offer: Rental assistance Start-up funds Contingency funds Core housing support services Linkages to other community support services income tenants and allow them to pay no more than 30 percent of their income on housing. Under the project based voucher program, a Public Housing Authority (PHA) enters into an assistance contract with the owner for specified units and for a specified term. The PHA refers families or individuals from its waiting list to the project owner to fill vacancies. Because the assistance is tied to the unit, a family who moves from the unit does not have the right to continued housing assistance. A common example of a projectbased program is a public housing complex maintained by a local Public Housing Authority (PHA) with funding from the federal Department of Housing and Urban Development (HUD). Project-based funding is also used by community organizations to develop affordable housing for people with low incomes and special needs. • Tenant-based rental assistance, in which funding is tied to a low-income person in need of affordable housing. This funding pays the difference between 30 percent of the tenant’s adjusted income and the tenant’s rent directly to the landlord for any apartment in the community. Under the tenantbased housing choice voucher program, the PHA issues an eligible family a voucher and the Rental assistance A key characteristic of supportive housing is that each person lives in his or her own home. Many people in the public mental health system need financial assistance to live in their own homes; this need is primarily based on poverty rather than mental illness. Financial assistance usually takes the form of monthly rental assistance. The two major forms of housing assistance are project-based rental assistance and tenant-based rental assistance. • Project-based rental assistance, in which funding is tied to a particular unit. Housing funds are provided to maintain affordable housing units for low- State of Florida Guidelines for Supportive Housing Page 23 of 67 family selects a unit of their choice. If the family moves out of the unit, the contract with the apartment owner ends and the family can move to another unit with continued assistance. A common example of a tenantbased program is the HUDfunded Section 8 Housing Choice voucher program, which pays the difference between 30 percent of the tenant’s adjusted income and the tenant’s rent, which must fall within established limits. Other common federal sources for rental assistance include programs funded through the HUD Continuum of Care for Persons who are Homeless. In Florida, the Department of Children and Families also provides rental assistance through contracts with community mental health organizations and others to provide supportive housing and Florida Assertive Community Treatment (FACT). Affordable housing resources are also available from federal and state agencies to fund development, rehabilitation, and operation of housing for lowincome people. For supportive housing to be successful, rental assistance should meet the following standards: A. Rental assistance must make housing affordable. According to Federal affordability standards, this means recipient’s pay no more than 30-40 percent of their income in rent and utilities. The primary goal of rental assistance is to allow the individual to afford housing of his or her choice. For housing to be affordable in accordance with standards set by HUD, a person must not spend more than 30 percent of his or her income on housing,1 which includes rent (or mortgage and taxes) plus basic utilities, not including phone or cable television. It is important that rental assistance programs recognize this standard so that individuals are able to afford other basic needs. In recent years some state and federal programs have adopted a 40% affordability standard, but for people with extremely low incomes, this can impose a substantial cost burden. This standard is based on national “best practice standards”; however, limited resources in Florida may make this a difficult standard to achieve. While we should be moving toward 30-40%, resources may require a higher percentage of personal income to be used for housing. While rental assistance approaches and amounts of subsidy may vary with different programs, the goal of all rental assistance programs is to ensure that individuals have sufficient income (after rent) to pay for food, clothing, transportation, and social activities. Otherwise, people will continue to live on the margins, and not truly integrated into their communities. B. Rental assistance should be available as long as necessary. If the rental assistance is timelimited, the program should State of Florida Guidelines for Supportive Housing Page 24 of 67 help recipients to qualify for other sources of funding. In order to allow individuals to obtain stable, permanent housing, it is important that rental assistance not be time-limited. However, since sources of permanent Rental assistance are in such high demand, (such as the Section 8 program) supportive housing can utilize a wide variety of sources to provide rental assistance to individuals. This may include housing subsidies provided by FACT teams, supportive housing rent stipends, and rental assistance provided through continuum of care programs. These funds are limited to appropriate levels and should not be counted on as a permanent, longterm funding source. Whenever possible, programs should provide this specialized rental assistance for as long as the individual needs it, although this does not mean that the program can or should provide rental assistance on a permanent basis. Rather, the supportive housing program should help the individual qualify for permanent rental assistance from other sources, such as the federal Section 8 program.2 A basic qualification for rental assistance provided by the supportive housing program should be that a recipient has applied for, or is willing to apply for, Section 8 or another form of rental assistance when available. Since the application process and length of waiting lists vary across the state, it is important to establish a close working relationship with the local Section 8 Administrator to facilitate these applications. Sources of rental assistance are discussed below in Chapter 6. C. Rental assistance should be available for housing that meets local Fair Market affordability standards. In order to maximize the impact of rental assistance funds, it is important that recipients live in reasonably priced housing. The local standards for fair market rent (FMR) established by HUD should serve as guidelines for eligible housing. The FMR guidelines are adjusted annually by HUD, and are available on the Web at www.hud.gov. Because the goal of supportive housing is for individuals to retain their homes rather than being forced to move when funding changes, it is important that individuals live in housing that will be eligible for Section 8 rental assistance when it becomes available. D. Rental assistance should be paid to landlords or housing agencies, rather than directly to the person. So that recipients’ other benefits, such as Social Security or SSI, are not jeopardized, it is important that the rental assistance payments go to a landlord or an agency managing the housing program rather than directly to the person. The supportive housing provider enters into an agreement with the landlord that spells out their commitment to pay State of Florida Guidelines for Supportive Housing Page 25 of 67 the difference between 30% of a tenant’s monthly income, and the agreed rent for the apartment. The individual pays his or her designated portion of the rent, either directly or through a representative payee. E. Rental assistance should be pro-rated for people who choose to live with others. Because supportive housing emphasizes individual choice in housing, it is important to allow flexibility in choosing living arrangements, especially when it comes to choosing roommates. Therefore, it is important to provide rental assistance to people who choose to share living arrangements with others. In such cases, the rental assistance is determined by the difference between the recipient’s share of the rent and 30 percent of his or her income. Various methods3 exist to determine the recipient’s share of the rent, e.g.: For people who choose to live with others who receive rental assistance under the supportive housing program, the recipient’s share of the rent should be determined by a fair method, such as by the number of individuals or by the size of respective bedrooms, if applicable. For people who choose to live with others who do not receive any type of rental assistance, then the recipient’s share of the rent should be determined similarly. For people who choose to live with others who receive other types of housing assistance, the others’ housing allowances should be subtracted from the total rent to determine the recipient’s share. F. Program staff should verify that the recipient is living in the unit for which the assistance is paid. In order to verify that housing funds are being disbursed properly, supportive housing staff should verify on a regular basis that the recipient of rental assistance is actually living in the unit for which rental assistance is being paid.4 It is important to remember, however, that people should retain their housing through hospitalizations or brief periods of instability. Start-up funds The costs of establishing a home can be significant. For many adults with serious mental illness, a lack of money for these start-up costs can pose a significant barrier to obtaining housing. Therefore, it is important to ensure that adequate funds are available to defray the individual’s start up costs, including: • • • Security deposit, paid directly to the landlord. Utility hook-up fees, paid directly to the utility company. Furniture, which if supplied by the agency, may be transferred to the recipient after a stable period of housing or when paid for by the recipient. The recipient should be involved in choosing the furniture. Household supplies, such as cleaning supplies, staple groceries, etc. • State of Florida Guidelines for Supportive Housing Page 26 of 67 • Housing modifications for people with physical or sensory disabilities. • Contingency funds Because a major goal of supportive housing is to ensure that individuals continuously maintain housing of their choice, it is important to have contingency funding available for unexpected situations. Sometimes, the funds will be used to help a person maintain his or her current housing. Other times, the funds will be used for an unexpected change in housing arrangements. Contingency funds should not be used on a regular basis, but should fill in the gap when core housing support services are not sufficient for the individual to retain housing. The funds should be used only as a last resort, when other methods have been pursued. Examples of ways in which contingency funds can be used include: • Providing cleaning, maintenance, or repairs. Contingency funds may be used for these purposes to help the tenant maintain a safe living environment and avoid eviction. Paying rent during an extended hospitalization so that the individual can return to his or her home after discharge. Moving expenses, for situations in which an individual must • unexpectedly find new living arrangements. Legal expenses that an individual might incur in retaining housing or obtaining a reasonable accommodation. Providing basic needs, such as food, clothing, transportation, etc., during periods of housing instability. Core housing support services Supportive housing is designed to help people with unique housing and service needs, who previously have been unable to succeed independently in the community. Therefore, a supportive housing program must provide a wide range of housing support services in order to help people maintain stable housing. However, it is also important to remember that these services are voluntary. Although this might seem to be a contradiction, it is only through voluntary services that a person can achieve the goal of having his or her own home and become integrated into the community, rather than being in a residential treatment program. It is the responsibility of the program to make sure that services are available, when and where people need them. There should be enough service capacity to ensure that each person who receives housing can also receive services that he or she chooses. In order to encourage individuals to take advantage of these voluntary services, it is important to provide services that are tailored to individual needs. Even though certain • • State of Florida Guidelines for Supportive Housing Page 27 of 67 populations might tend to need certain types of services, it is impossible to define exactly the services that supportive housing must provide to specific individuals. What differentiates supportive housing services from other community mental health services is the overarching emphasis on helping people to choose, get, and keep integrated, community housing. This means that most services are not provided in an office, but instead in people’s homes or other places in the community. Chapter 5 will provide guidance in developing core housing support services, including case management, that are tailored to individual needs. Examples include: • Identifying individuals’ needs, e.g., types of housing, neighborhood preferences, roommate selection, maintenance requirements, and proximity to transportation or other services Helping individuals develop living skills and decision-making abilities Arranging for housekeeping, maintenance, or other in-home services Negotiating reasonable accommodations with landlords Mediating between tenants and landlords to resolve potential problems such as eviction Mediating among tenants and neighbors if problems arise Tenant directed monitoring Budgeting and money management Helping people acquire and maintain benefits, e.g., income • supports, housing assistance, and medical coverage Accessing necessary community services, such as mental health and medical care Additionally, each individual’s service needs will vary over time. An individual generally needs the most support while acquiring housing and during the first few months of living in a new home. Service needs frequently intensify during other times of change, such as a change in employment status (starting a new job or losing a job), a change in relationships (a breakup or change in roommates, etc.). • • • • • • • • Often, service needs vary with recovery and personal development, and a person’s needs might change greatly during his or her participation in a supportive housing program. Therefore, it is important to periodically review whether appropriate services are being provided and whether the staff is meeting the person’s needs. A major principle that differentiates supportive housing from residential treatment programs is that “while staff may come and go, the individual being served is the one with permanent status.” Frequency of contact with staff will vary greatly over time. Sometimes different staff should be assigned to assist the State of Florida Guidelines for Supportive Housing Page 28 of 67 person based upon their particular needs and preferences. Notes to Chapter 3 Olmstead and Supportive Housing, 11. National Technical Assistance Center for State Mental Health Planning, Best Practices in Housing, 45. 3 New York Guidelines, 6. 4 New York Guidelines, 6. 2 1 Linkages to other community support services Providing a person with a place to live is only part of helping that person become integrated into the community. In order to prevent isolation and facilitate recovery, it is important for supportive housing either to provide additional support services—such as employment programs—not directly related to housing or, more frequently, to link individuals to existing community support services. Examples of support services that are essential to community integration include assisting individuals with: • • • • • • • • Developing employment skills and obtaining and retaining jobs Accessing or using transportation resources Participating in cultural, educational, and recreational activities Connecting with natural support systems, such as friends and family members Participating in treatment and managing medications Becoming involved in neighborhood activities Crisis prevention/intervention. Accessing and utilizing health and dental care State of Florida Guidelines for Supportive Housing Page 29 of 67 Chapter 4 - Developing Individualized, Flexible Support Services For many service providers, tailoring support services to each person’s individual needs—a cornerstone of supportive housing—represents a major change from the traditional model of placing people in programs that provide a pre-defined set of support services. According to a study published by the Center for Health Care Strategies: This challenge requires more than tinkering with service definitions or building programmatic addenda onto the edges of current systems. It requires fundamental but positive changes in the manner that services are organized, delivered, integrated, and incentivized through financing methodologies. The fundamental changes necessary in service systems currently assisting people with disabilities include: • • • • • Implementation of evidencebased best practice service models Conversion of facility-based services to mobile services Assurance of accessibility and responsiveness Integration across multiple systems Coordination of care within supportive housing environments mobile, in-vivo service models. For example, Assertive Community Treatment models for people with serious mental illness take the psychiatrist, the nurse, and the case manager out of the clinic and away from the office encounter, and instead deliver services to consumers in their homes, in their places of work, and in other natural settings.”1 A supportive housing provider must monitor outcomes and constantly reexamine the question of whether it is providing individualized, flexible support services. The Council recommends that an organization ask the following “Individualized Support Questions”:2 • • • Does the organization actively solicit the person’s preferences for services and providers? Does the organization provide options to the person about services and providers? Does the organization honor the person’s choices about services and providers? “Inherent in the implementation of best practice service models is the conversion of place-based congregate service models to State of Florida Guidelines for Supportive Housing The answers to these questions measure the degree to which services are individualized and flexible. Page 30 of 67 Principles of psychiatric rehabilitation Supportive housing is based on the psychiatric rehabilitation model,3 which promotes recovery by focusing primarily on restoring function rather than solely focusing on reducing symptoms. In this way, psychiatric rehabilitation programs are able to than just the illness per se …”5 and require “[d]developing clients’ skills and supports related to clients’ goals.”6 Psychiatric rehabilitation helps individuals regain important social roles, such as that of employee, student, friend, church member, and tenant. Providing comprehensive supports as long as needed. Although the psychiatric rehabilitation model is based on recovery, it is not based on a continuum in which improvements are expected according to a timetable. Instead, a more holistic view is taken, and supports are provided for as long as needed and can become more or less intensive as a person’s needs change. In order for psychiatric rehabilitation to promote recovery, “Consumer goals [must] include functioning in living, learning, working, and/or social environments … [and] functioning in non-mental health environments, not controlled by the mental health settings (e.g., YMCA, religious organizations).”7 Delivering services in normal settings. Psychiatric rehabilitation relies on delivering services in the community, wherever the individual needs them, including home, school, work, or other places. This represents a trend away from officebased mental health services; for example, Florida Assertive Community Treatment (FACT) teams are required to provide 75 percent of services off-site. Outcome orientation. It is important for psychiatric rehabilitation “focus on the person, not the illness.” Although psychiatric rehabilitation programs often emphasize work, the goal of psychiatric rehabilitation is to restore any function that integrates a person with serious mental illness into the community. Like the role of employee, the role of tenant promoted by supportive housing is an important step in the rehabilitation process. Some of the basic principles of psychiatric rehabilitation include: Empowerment and inclusion. Programs based on the psychiatric rehabilitation model welcome service recipient input into service design and hire service recipients as staff members. A desired outcome for the promotion of recovery is that “[u]sercontrolled, self-help services are available in all geographic areas.”4 Strengthening functional capacities. Psychiatric rehabilitation practices emphasize “treating the consequences of the illness rather State of Florida Guidelines for Supportive Housing Page 31 of 67 programs to measure outcomes based on a person’s satisfaction and role functioning. “Primary consumer outcomes identified for each service are measurable and observable (e.g., number of crises, percentage of people employed) … Consumer and family measures of satisfaction [are] included in system evaluation.”8 Provider accountability. Although recovery can occur without professional help and the goal of supportive housing is reduced reliance on professional supports, providers must be accountable because specific supports are often critical at specific times. “Policies insure that a core set of processes (i.e., protocols) are described for each identified service.”9 Hope is essential. Psychiatric rehabilitation providers—at all levels of staff—must believe that recovery is possible. “A common denominator of recovery is the presence of people who believe in and stand by the person in need of recovery.”10 • • • • • • • • • Identifying values and preferences Providing individualized, flexible services begins with a determination of each person’s unique needs. It is important that staff have personal contact with service recipients in order to determine housing preferences. Examples of questions that supportive housing staff can ask the person include: • What type of home would you like to live in—an apartment, a townhouse, etc.? • Would you like to live with roommates, a girlfriend/boyfriend, or family members? Are there any specific people you’d like to live with? If you want help finding a roommate, what do you want the person to be like? What neighborhood (or type of neighborhood) would you like to live in? Do you want to be close to anything specific—bus, shopping, treatment facility, house of worship, friends, parks, etc.? What type of supports do you need? Cooking, cleaning, paying rent on time, shopping, remembering medication, or anything else? Are you making any of these choices because someone else pressured you? How much can you afford to pay per month for rent and utilities? Do you want to live someplace where you would be responsible for making minor repairs, or someplace where the landlord does all of the repairs? Do you need any special accommodations for a physical or sensory disability? These questions prompt the individual to address his or her own preferences and provides a mechanism for support staff to ensure that the services and supports address those preferences. Goal planning In order for people to regain social roles through participation in supportive housing, it is important that they set goals that reflect State of Florida Guidelines for Supportive Housing Page 32 of 67 increased social roles. Assisting individuals in a supportive, nonjudgmental manner to plan their goals is essential. For a person— particularly someone who has experienced past housing difficulties—to be happy and successful, it is important that he or she plan his or her own goals. Too often, under outdated service models, case managers planned individuals’ goals for them. Instead, staff should help individuals develop goal-setting and decision-making skills by: Clarifying values, interests, and preferences. Asking follow-up questions about specific preferences and motivations can be helpful in clarifying goals. Exposing service recipients to new environments and options. Examples include researching and discussing various types of housing options, having individuals meet with peers living in supportive housing, or visiting available housing settings. Evaluating options against personal criteria, skills, and supports. It is important to consider goals in light of a person’s skills and what supports are available in the community. The desired outcome is a housing goal that is based upon the person’s personal criteria and that is the result of the person’s own decision-making process. The goal plan should be written in language easily understood by the person and should contain action steps. For goal planning to be successful, supportive housing staff must address the barriers that individuals might face. Examples of individual barriers, and strategies to address them, include: Fear and poor self-esteem. Often, failed attempts to reach housing goals, employment goals, etc., lead to poor self-esteem and fear of repeated failure. Addressing this barrier involves reinforcing that it is OK to fail sometimes, helping the person set attainable goals, and providing reassurances that support will be available in reaching the goals. Learned helplessness and lack of hope. Many people have been exposed to treatment programs that reinforce the role of “mental health consumer” reliant on the system. Supportive housing must reinforce that achieving recovery and reaching goals are possible—peer role models are especially helpful in this regard. Functional limitations. Although a person’s symptoms—without proper supports in place—can sometimes prevent setting and reaching goals, many people are successful in supportive housing despite their symptoms. Supportive housing seeks not to eliminate symptoms, but to identify needed supports such as a job coach or personal assistant that can enable a person to reach his or her goals even when symptoms are present. State of Florida Guidelines for Supportive Housing Page 33 of 67 Cognitive limitations. Cognitive limitations such as developmental disabilities, memory impairments, and attention deficits can interfere with setting and reaching goals. In such cases, extra care must be taken to explain options, and the advantages and disadvantages of each. Pay attention to the best setting, method, and language for communication so that the person can understand what is being presented. open, honest communication. The best way to develop trust is to be accessible, deliver on commitments, and be realistic about what you can promise. Although it is desirable for people to have goals, setting goals for a person can lead to distrust. Mobility. Extra efforts might be necessary in order to help a person with physical limitations or disabilities reach his or her goals. For example, a person might need education about the types and availability of reasonable accommodations, and staff can play an important role in negotiating accommodations. Legal issues. Too many people with serious mental illness have a history of involvement with the criminal justice system that prevents them from reaching certain goals. For example, criminal convictions can make obtaining housing and employment difficult, and terms of probation might set limits on housing options. It is important for staff to work with representatives of the justice system to allow people to attain their goals within legal limitations. It is often necessary to advocate with landlords and authorities based upon individual circumstances. Frequently, standard exclusions of people with criminal histories can be overcome with patience and communication. Lack of personal documentation. Ironically, many people currently receiving public mental health services who have emigrated from other countries might not qualify for employment in the United States or for supports such as income Literacy. When inability to read and write interferes with goal setting, it is important that staff are understanding and work to make sure any written plans reflect a person’s stated goals and that any goal plans are explained carefully. Linkages to literacy programs can also be offered as a support. Communication deficits. A person’s inability to express his or her goals easily does not mean that he or she does not have goals. It is important that staff work with each person in a setting that facilitates communication. This can involve using interpreters or even a trusted friend or family member as an intermediary. Lack of trust. For many, past experiences have led to a lack of trust of the service delivery system. It is important to build trust through State of Florida Guidelines for Supportive Housing Page 34 of 67 supplements and housing because of their immigration status. For people who do have the necessary immigration status to qualify for employment and public supports, it is important to help them obtain the necessary documentation. Childcare. A lack of support for parenting commitments can pose an obstacle to setting and reaching goals. For example, a lack of childcare can pose an obstacle to employment, regardless of whether a person has any disabilities. Obtaining housing that is adequate for children can be an extra challenge for service recipients and staff. Efforts must be made to address how a person can reach his or her goals while meeting parenting goals and needs. individuals receiving mental health services, who often experience “ups and downs” and might be able to work for a few months and then not be able to work. The Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA) is an effort by the federal government to make it easier for people with disabilities to return to work. For more information go to www.gov/work/ticket. Lack of a permanent address and phone number. Applying for an apartment or job is extremely difficult for people who do not have a permanent address or phone number. Many agencies provide mail and voicemail services to help people achieve their goals. Lack of access to appropriate health care. It is essential that persons with mental illness receive information, assistance and persistence in accessing health care benefits. In many situations this may mean applying to social security for disability insurance (SSDI) or supplemental security income to ensure that the person is eligible for Medicare and/or Medicaid. In Florida, several counties have local health care plans that can be accessed by persons with mental illness either as a permanent plan or a bridge while applying for Medicaid or some other health care insurance. Provider based “entitlement units” or benefit brokers may be very helpful in assisting individuals. Fragmented or inadequate supports. Supportive housing seeks to reverse the tradition of systems that place the burden of coordinating Transportation. Even when housing is available, transportation often serves as a barrier to community integration. When assisting with goal planning, it is important to address how a person will reach needed supports, such as employment, social activities, and medical treatment. Earnings disincentives. A major barrier to employment for people with disabilities has been the fear of losing benefits such as SSI, Social Security, Medicaid, and Medicare when returning to work. This barrier is especially significant for State of Florida Guidelines for Supportive Housing Page 35 of 67 services on the individual. It is important that staff be knowledgeable about a broad range of services and provide individuals with information and contacts. Often, the supportive housing staff have to plug the gaps in fragmented systems in order to ensure the necessary supports are in place. Identifying skills and support needs Each individual in a supportive housing arrangement will have unique skills and unique support needs. Some needs, such as assistance with arranging utilities setup or housekeeping services, will be directly related to housing. Other needs, such as medication management or transportation, might not be directly related to housing but have a major impact on living successfully in the community. A supportive housing program should identify what steps will enable a person to obtain and retain housing in the community. For each necessary step, it is important to ask what skills the person has in this area and what supports he or she will need. A person’s skill level will help to determine the degree of staff involvement that is necessary. Staff can take the following roles, which range from minimal to extensive involvement: State of Florida Guidelines for Supportive Housing 1. Doing or delegating a task when the individual does not want to do the task or it is impractical to teach the skill. 2. Teaching a task when the individual wants to do the task, but cannot do it and has no experience doing it. 3. Reviewing and practicing a task when the individual wants to do the task and has experience doing it, but cannot do it at the time. 4. Supervising a task when the individual wants to do the task and can do it but is not confident in his or her ability to do the task. 5. Monitoring a task when the individual wants to do the task and can do it. This may also involve periodic reminders to help the individual sustain their independent task performance. Some of the many areas in which individuals might require support include: Apartment search. Using the above framework and individual preferences to help determine the level of staff involvement, services can include educating people about neighborhoods and apartment hunting strategies, actively conducting a search with the person, or supporting the individual as they conduct the search on their own. Landlord negotiations. Supportive housing staff should advocate and intervene to ensure that people receive a standard lease with no extra provisions. Examples of supports include explaining lease Page 36 of 67 terms to the tenant, reviewing the lease, practicing interviews, etc. Prior to landlord negotiations, staff should help individuals deal with sensitive issues—such as past housing instability—and plan appropriate responses. Credit reports, references, security deposits, utilities, phone, insurance, etc. Some people might need assistance gathering necessary information to present to landlords and other third parties, filling out forms, arranging payments, etc. In many cases, supportive housing staff and individuals together will meet with landlords to address reliability and stability concerns. Furnishings. Depending on a person’s interest level and preferences, he or she might want to take an active role in furnishing his or her apartment, if resources are available. Often, however, the program provides furnishings on an interim basis, until the individual purchases the furnishing or alternate furnishings. Housekeeping. People might be able to maintain their household in a safe and healthy manner without any supports. Some people might need assistance with major chores, such as cleaning floors, bathrooms, and windows; others might need help with more routine activities such as laundry. Food shopping and preparation. People making the transition from institutions or congregate living might need supports to help them prepare their own meals. These supports could include teaching skills or actually arranging for shopping, meal preparation, and eating some meals at another location. Financial management. People’s financial skills will vary greatly; some people who live in supportive housing can manage their own finances, but others might require help paying bills, balancing checkbooks, etc. Medication management. Although symptom reduction is not essential for successful housing, a supportive housing program can offer help with medication issues, such as helping an individual develop strategies for taking medications as directed, or talking to doctors about symptoms and side effects. It is important to work with the individual to understand any relationship that might exist between their use of medications and when they may have lost their housing in the past. Help should be available for those who have trouble managing their medication regimen because of cognitive limitations. Natural supports. Some people might have more difficulties than others in developing a natural support system. Examples of solutions might include counseling people in developing social skills— e.g., communication, assertiveness, and self-esteem— and cultivating friendships, linking people to formal social activities or companionship, assisting with organizing social events or leisure activities, or setting up family gatherings. State of Florida Guidelines for Supportive Housing Page 37 of 67 Transportation. Some people might need instruction on how to use public transportation. In other instances, supportive housing might have to arrange transportation so that people can access needed services and supports. Medical and dental care. People might need help as basic as locating providers who participate in their health care programs. However, some people might need help monitoring their own health and knowing when to visit a doctor or dentist, and following health care regimens. Job search. A person might need assistance with locating job openings, preparing a resume, and defining employment goals based on interests, experiences, and the current job market. Activities might be relatively straightforward, such as writing or editing a resume, or openended, such as helping a person to develop skills needed for a desired job, talking with potential employers, etc. Job interviews. Supports needed for the interview process could include advice on how to dress, practice interviews, developing responses to sensitive issues (such as a long gap in work history), and could extend to accompanying a person on an interview. Workplace accommodations. A person might need assistance obtaining accommodations based on specific symptoms or limitations caused by his or her illness. Activities might range from educating a person about reasonable accommodations to actively negotiating with an employer. Workplace performance. Supportive housing staff can provide informal supports, links to peer supports, or links to more formal services such as job coaches. Self-help and peer support Self-help and peer support are critical elements of supportive housing because a desired outcome is for people to maintain stable housing with the least amount of professional supports needed. Peer support is especially critical for people living in scattered site housing because people accustomed to congregate living might feel isolated. Peer support groups are voluntary and usually small, and they accomplish their goals through mutual aid. They offer the opportunity to bring both personal and social change, to assume personal responsibility for treatment, to recover and to be productive, and to find solutions with the help of others. Individuals have continually found the groups to help them better themselves in many areas of their lives: • The act of joining together with others who have “walked in their shoes” enables individuals to State of Florida Guidelines for Supportive Housing Page 38 of 67 • • • recognize that they are not alone, that other people have had similar experiences and feelings. Individuals in the mental health system often do not have the support of family and friends. Self-help groups can provide the support that may be missing from these other systems. Self-help groups offer a safe place for self-disclosure. Self-help groups encourage personal responsibility and control over one's own treatment. Because group members are actively helping others, they gain a sense of their own competence. In a landmark report on mental health issued by the Surgeon General, a section was devoted to self-help groups: As the number and variety of selfhelp groups has grown, so too has social science research on their benefit. In general, participation in self-help groups has been found to lessen feelings of isolation, increase practical knowledge, and sustain coping efforts. Similarly, for people with schizophrenia or other mental illnesses, participation in self-help groups increases knowledge and enhances coping. Various orientations include replacing selfdefeating thoughts and actions with wellness-promoting activities, improved vocational involvement, and social support and shared problem solving. Such orientations are thought to contribute greatly to increased coping, empowerment, and realistic hope for the future.11 Self-help and peer support are services that—by their very nature— a professional cannot provide. However, it is important for support staff to facilitate self-help and peer support through such methods as: • • • • • • • Promoting the value of self-help and peer support Providing places for peer support groups to meet Publicizing existing peer support groups. Providing self-help materials. Training individuals in group facilitation skills Providing technical assistance to group leaders Sponsoring specialized dualrecovery groups for co-occurring disorders Systems advocacy As discussed in Chapter 3, it is important that supportive housing staff advocate not only for individuals, but also for greater availability of affordable housing and wrap-around services. For advocacy efforts to be successful, it is State of Florida Guidelines for Supportive Housing Page 39 of 67 important that the individual voice be heard. Organizing a day in which people with disabilities meet with their legislators is a powerful method of sending the message that community supports are essential. It is important for the entire group to prepare for a day meeting with legislators. When the group goes to the capitol, it is important for all of the participants to understand why affordable housing is important. Personal stories are the key to success: Role playing, in which more experienced advocates play legislators, can be helpful in teaching people how to tell their stories more effectively.12 Eviction prevention and housing retention Supportive housing requires a change of mindset from traditional models of housing for adults with serious mental illness. Traditional models relied on shortterm funding, transitional housing, and expectations of moving through a residential “continuum.” Under the supportive housing approach, a person sets goals in areas such as housing, employment, etc., and the program helps the person achieve and maintain the roles that he or she has set for himself or herself. A desired outcome of supportive housing is that a person keeps his or her chosen roles with the least amount of professional support possible. For supportive housing, this involves: • Maintaining supports through contact with the person • • Monitoring progress and recognizing achievements as they happen Monitoring peril and mobilizing services and supports to prevent role deterioration In order to maintain housing stability, it is especially important that supportive housing providers help people to maintain housing through actively preventing problems. The service should be active in preventing eviction, as well as helping people maintain other chosen roles, such as employee and friend. Some of the ways in which supportive housing staff might help a person retain his or her roles include: • • • • Negotiating reasonable accommodations with landlords (or employers) Consulting with landlord (or employer) if problems develop. Intervening in times of crisis and providing linkages to crisis services Monitoring benefits—e.g., SSI, Social Security, Medicaid, and Medicare—and advocating for a person to obtain or retain benefits Mediation with others, such as neighbors (or co-workers) Skills instruction and monitoring. Examples include cleaning, maintenance, etc • • State of Florida Guidelines for Supportive Housing Page 40 of 67 Notes to Chapter 4 Olmstead and Supportive Housing: A Vision for the Future. 2 Personal Outcome Measures in ConsumerDirected Behavioral Health, 121. 3 See generally, http://www.iapsrs.org/; http://www.bu.edu/cpr/; http://www.psych.uic.edu/uicnrtc/. 4 William A. Anthony, “A Recovery-Oriented Service System,” 165. 5 William A. Anthony, “Recovery from Mental Illness,” 12. 6 William A. Anthony, “A Recovery-Oriented Service System,” 161. 7 William A. Anthony, “A Recovery-Oriented Service System,” 165. 8 William A. Anthony, “A Recovery-Oriented Service System,” 164. 9 William A. Anthony, “A Recovery-Oriented Service System,” 164. 10 William A. Anthony, “A Recovery-Oriented Service System,” 160. 11 United States Surgeon General, Mental Health: A Report of the Surgeon General (1999), 289. 12 Participants’ Guide, Community Integration Now, 48-49. 1 State of Florida Guidelines for Supportive Housing Page 41 of 67 Chapter 5 - Supportive Housing Management and Operations: A new management philosophy “Embrace new roles, tolerate ambiguity, encourage creative conflict, stay on message” Agencies that undertake new supportive housing roles often discover that the “old way” of doing business is no longer adequate or appropriate. Managers and staff both realize quickly that in order to be successful in this new environment, they must assume new roles, develop new skills, perform very different tasks, forge relationships with different groups of people, and challenge some of their basic assumptions. Many of the principles and practices outlined in the first four chapters of this guide are very different from those taught to mental health professionals in the recent past. This can be very humbling for staff who are more used to traditional roles and expectations. Working in partnership with individuals, and with their natural support system, supportive housing staff learn as much from service recipients and their families as they do from more formal educational and supervisory systems. Managers and staff need to learn very quickly that the supportive housing approach requires one to assess each situation according to the particular needs and circumstances of the individuals involved. Unwavering rules and regulations don’t work well in these; in fact, they contradict many of the core principles and values discussed in chapter one. Sometimes, the “right” answer or the best decision is not clear; it may take a while to emerge, and often requires compromise between competing points of view or priorities. Case in point: Jennifer has been admitted 12 times in the past five years to a psychiatric hospital, due primarily to stress that is directly related to relationships with people in her living environment. She has lived in assisted living settings, group homes, and supervised apartments, always with one or more roommates or housemates. She has never lived alone because she is unwilling to ever throw anything away, including household garbage, leftovers, etc., due to the symptoms of her obsessive compulsive disorder. However, this has also made it very difficult for others who are living with her. She has been determined a health hazard if left alone, but she is able to manage all other necessary independent living tasks. A traditional approach to resolving this issue would focus on symptom reduction or elimination-e.g. helping her to overcome her fear of throwing things State of Florida Guidelines for Supportive Housing Page 42 of 67 away, while providing a protected and supervised living situation, with periodic crisis intervention when roommate conflicts exacerbate. Instead, a supportive housing program could help her to live alone, while investing contingency funds to pay someone to take out her garbage three times a week with her permission, while she is at her clubhouse program. In order to make the best day-to-day and policy decisions, managers must take the time to explore the underlying assumptions and implications of all program structures and activities. This means providing frequent opportunities for debate or “creative conflict” among staff, openly exploring options to make sure that the decisions being made, or the structures being implemented, are consistent with the values, principles, and goals of supportive housing. The absence of such a planning and problem-solving approach can lead to the program’s “death by a thousand cuts”. In other words, it’s the little decisions that can gradually erode the foundation of the program. Leadership in this type of environment means inspiring staff and service recipients to take on challenges that they might otherwise be daunted by, even when there is enormous pressure to back away from core values. This is what is meant by “staying on message”. Sometimes there is great pressure to abandon these values because they are perceived to be inconvenient or risky. Sometimes compromise is necessary and advisable. Often, there are more options than are immediately obvious or available. Staff competencies Supportive housing staff need to have a set of core competencies in order to be effective at their jobs. These competencies fall into three general categories: knowledge, skills, and attitudes. Knowledge There are many specific things that a supportive housing coach must know about in order to help individuals choose, get, and keep their housing. These are sometimes technical matters, and sometimes interpersonal, as in who is in charge of the Housing Authority. Supportive housing Coaches are often working within the housing field for the first time, and have to learn a whole new language along with the housing system. It’s usually a rapid learning curve, and once orientation is complete, staff and supervisors have to make a commitment to continuous learning. Most updated information will be only available outside of the training resources and programs typically provided within community mental health centers or their affiliates. This is another reason why collaboration with local homeless and housing agencies is so important. State of Florida Guidelines for Supportive Housing Page 43 of 67 Some of the specific knowledge areas for staff include: 1. Local housing market: Staff should invest significant time in understanding what rental housing is available in their community. Maintaining a complete knowledge of the housing market will be important throughout the process of helping people to choose, get or keep their housing. Staff should be able to provide individuals with a thorough and current description of what is generally available, what are the advantages and disadvantages of specific locations and types of housing, anticipated costs, etc. This will help individuals to make informed choices about their preferred housing. With such current knowledge, staff will also be a valuable resource to individuals in the search process, whether or not they accompany them to visit apartments. 2. Neighborhood/area features: Staff also must intimately know the communities and neighborhoods of their service area. Again, this is to help individuals make informed choices, and also to support them to become fully integrated into the community. This means knowing about community amenities such as transportation, stores, medical facilities, places of worship, recreational facilities, etc. Other neighborhood features such as safety, privacy, or easy access to contraband are often a concern for individuals and families. 3. Landlords, Public Housing Agencies, Community Housing Development Organizations: Once staff have developed a general understanding of the local housing market, then it becomes critical to learn who is in control of the housing, e.g. who owns or manages it. Obviously, in most communities it would be impossible to get to know each individual landlord. However, in most communities there are usually numerous individual landlords or real estate companies that control large blocks of rental housing. Similarly, many landlords hire property management firms to oversee their units on a daily basis, including tenant screening. Developing a close working relationship with these individuals and companies can make a huge difference. In communities where a positive track record exists, landlords reach out to supportive housing when they have available units. o According to the Florida Housing Coalition, in Florida there are 122 Public Housing Agencies (PHA’s). One hundred of these PHA’s administer Housing Choice Section 8 vouchers that total State of Florida Guidelines for Supportive Housing Page 44 of 67 over 89,000 vouchers, including 2,100 targeted to persons with disabilities. These are very important people to know! There is no substitute for a collaborative working relationship with a local PHA, and it is important to invest time and energy in this relationship. This includes getting to know the individuals who work in the PHA, and the programs sponsored by the PHA. This knowledge will assist in efforts to collaborate on an individual level (e.g. making a reasonable accommodation for a specific individual), a system level (e.g. developing a memorandum of understanding between the PHA and the community mental health center), while also opening the door to new resources that only the PHA can apply for (e.g. targeted Housing Choice rental assistance vouchers). o Finally, HUD’s Home Investment Partnerships Program (HOME) requires that 15% of all HOME funds be given to a local community housing development organization (CHDO) approved by HUD. Staff should find out if there are any CHDO’s in their community, and try to develop a similar working relationship. Many CHDO’s manage property, and can agree to notify supportive housing staff when units become available. Additionally, community mental health agencies can establish partnerships with CHDOs to develop new units, with a certain number setaside for supportive housing recipients. 4. Homeless service providers and coalitions. Organizations that have historically served or advocated on behalf of people who are homeless have a long history of working to increase affordable housing for all people. While agencies serving the homeless do not just work with people who are diagnosed with a mental illness, most agencies serve a significant number, with national statistics ranging between 30 – 40%. As discussed in Chapter 4, homeless coalitions have access to specialized funding that can be used to buy, rehabilitate, or lease affordable housing. Members of these coalitions can also be great sources of information, referrals, and wisdom. In turn, supportive housing staff can be resources to homeless providers when they are seeking additional mental health services. 5. Mainstream community services organizations, faith-based organizations, drug and alcohol treatment agencies, self-help and peer-support groups, natural supports. Similar to State of Florida Guidelines for Supportive Housing Page 45 of 67 case managers, supportive housing staff must be familiar with all community health, mental health, and rehabilitation services, along with various government benefit and entitlement programs. In addition, with an emphasis on full community inclusion and integration, staff must “break out of their boxes” and develop collaborative relationships with individuals and organizations throughout the community who will be important in supporting the individual in their home. 6. Municipal services, building departments and utility companies. At times, supportive housing staff may need to enlist the help of various municipal departments, including building and codes, fire, water, sanitation, and public safety. Having a basic understanding of how these functions are organized is important, along with contact information. Similarly, staff will often have to assist individuals with making initial utility hook-ups, and a clear understanding of the process is critical. interpersonal. Some of these critical skills are: 1. Active listening: In order to fully engage individuals in making good choices, staff must be willing and able to spend sufficient time with them, and with involved family members. Active listening involves being interested and engaged with the person, asking clarifying questions, and coaching the individual through a problem-solving process, when necessary. It also means setting aside one’s own judgments and biases, and walking in the others’ shoes, while still retaining objectivity. 2. Effective communication: Supportive housing staff and managers are communicating, in some way, the vast majority of their work-day. Whether in person, or on the telephone, the ability to communicate clearly, directly, and honestly is the hallmark of a competent worker. Additionally, since there are numerous paperwork requirements for all staff, an ability to write clearly and concisely is important. 3. Networker: As described above, supportive housing staff must form and maintain many new working relationships. Over the years, a successful staff person will develop a giant Rolodex filled with contact information that is of great value to individuals and colleagues. Skills Supportive housing staff needs to utilize a variety of skills in their work with individuals, colleagues, natural support networks, and other community agencies. The most important of these skills are State of Florida Guidelines for Supportive Housing Page 46 of 67 4. Teacher: With an emphasis on psychiatric rehabilitation and skill development, staff will spend a great deal of time with some individuals teaching specific tasks and skills. One of the core premises of psychiatric rehabilitation is that skills are taught most effectively in real world setting, rather than simulated environments. Therefore, based upon individual needs and preferences, staff is frequently involved in teaching and modeling new skills, and providing direct and supportive feedback. The teaching approach will vary for each individual, so no “one size fits all” approach is effective. many places all over the community. Each day is different than the next, and brings new challenges and opportunities. People who are more comfortable with a predictable routine would probably be happier in a different type of program. 3. Self-confident: It takes a certain degree of self-assurance to enter into the new types of relationships required of staff. Additionally, working successfully in partnership requires one to set aside the protective position of “professional” or “expert” and relate as a person. Relying on one’s personal qualities, rather than power, role or status requires a special kind of confidence and sincerity. 4. Hands-on: This is not an office job! Staff must be willing to do whatever it takes to help people keep their homes. This means everything from helping to pay bills, doing laundry, or going to AA meetings. Staff must be out in the community, visiting apartments, job-sites, and day programs. With the use of cell phones and pagers and laptop computers, many programs function with minimal office space and shared desks for staff to discourage unnecessary time in the office. 5. Inventive: It may be an overused phrase, but staff must “think out of the box”. Brainstorming sessions, led by skilled supervisors, can help staff to Attitudes Of all of the core competencies, the right attitude is the most critical. Knowledge and skills can usually be taught, but individuals bring their personal perspectives, experiences, personalities, world-views, and motivations to their jobs. Sometimes these are congruent with the program; sometimes not. A good match is critical. 1. Shared values: It is critical that staff believe in the core values of supportive housing: recovery, integration, empowerment, choice, and individualization. These are the foundation of the program, and are non-negotiable. 2. Flexible: Not everyone is comfortable with the flexible and sometimes ambiguous nature of the supportive housing. Staff members wear many hats in State of Florida Guidelines for Supportive Housing Page 47 of 67 come up with fresh ideas to persistent problems. 6. Tenacious: In spite of barriers, missteps, and the pessimism of others it’s still important to keep trying. Many people refer to this as “do whatever it takes”. People notice and remember, even when it doesn’t seem that way. 7. Patient, compassionate, and encouraging: For many individuals, growth will be slow and incremental, with periodic relapses. Others may have cognitive impairments that require repeated teaching and intervention. For most, recovery is a long and bumpy road filled with both joy and heartache. Recent research on supportive housing has confirmed that the single most important factor in a person’s success is the quality of their relationship with staff. If a staff member is consistently there, offering hope and encouragement, the barriers will not seem as formidable. Balance and flexibility Although a specific number of home visits or individual contacts is not mandatory for each person, managers and staff have to make reasonable estimates of service levels for budgeting and planning purposes. Some supportive housing are funded on a fee for service basis, which also presents a paradox for staff. If the program is going to receive sufficient funding to cover costs, and funding is based upon units of service, then it will be very tempting for managers to require each person to accept a minimum number of contacts per week or month. This is a good example of an administratively efficient decision that can erode the values foundation of the services. Instead, the key to effective planning is to maintain a heterogeneous mix on each team. If a supportive housing coach is working alone, then balance will be achieved through managing the admissions process. In practice, this means working with people who have varied levels of need and tenure in the program. When a program is first starting, this will be more difficult since everyone will be new, and both staff and service recipients are likely to need greater levels of support. Therefore, when a program is first starting, or a new individual caseload or team is being implemented, it is essential to phase up gradually to full capacity. The tone for the program is set in the Service management One of the most challenging aspects of supportive housing is achieving the right mix of people that any individual housing specialist or team is responsible for. Since service delivery is driven by individual needs and preferences, planning and time management are critical, yet difficult. Again, flexibility and communication are key among all team members, with the leader ultimately responsible for making decisions between competing priorities. State of Florida Guidelines for Supportive Housing Page 48 of 67 beginning, and “being there” for people will be impossible if individual need outstrips staff availability. Some “rules of thumb”: New tenants need the most intensive services. Initially, substantial time should be invested with each individual (based upon their level of need and preference) to help them develop the apartment search plan, schedule visits, meet with landlords, complete paperwork, deal with all moving details, set up the apartment, and assist with neighborhood orientation. Sometimes there are friends or family members who can help with some of these activities, but don’t make that assumption. Moving is hard work and stressful for everyone! Plan at least 2 – 4 visits or contacts each week for at least the first few months. • Plan a gradual reduction of services after the third month, but this will vary for each person. In other words, for caseload planning purposes, it is reasonable to assume individuals’ needs will decrease once they are settled into their new homes. However, this does not mean support should automatically decrease after a specific time period. Some will need less support, but for a longer time. Others may need frequent visits for 6 months or longer. A person’s ongoing need for services will be affected by many individual and environmental factors, and will fluctuate over time. Staffing plans must be able to accommodate these changes, and should therefore not “creep” up to a level that makes it impossible for staff to provide intensive support to an individual when it is needed. Some of the factors that will affect an individual’s need for services include: o Stressful life events, such as a new job, a new relationship, loss of a loved one. Expect that people will need additional support during these times, and plan for it. We all need extra help at times like this! o The effectiveness and availability of other service providers in the individual’s support team and in the local mental health system. In reality, supportive housing staff often have to “plug the gaps” that exist in the rest of the system. Again, it is important to strike a balance. Staff should help the person to advocate for and access services if they are available and supportive housing staff should participate actively as members of the treatment team. However, staff should also be careful not to be ‘all things to all people”. In the long run, that will defeat the goal of full community integration. In rural areas, where the formal service system is limited, it is especially important to • State of Florida Guidelines for Supportive Housing Page 49 of 67 consider available natural supports as long-term alternatives to formal services. o Individual coping skills and functioning may fluctuate based upon changes in treatment or increase in symptoms. A change in medication may prompt a need for additional support, as will a relapse. Someone with a co-occurring disorder may have a relapse in drug or alcohol use, and need intensive support to get back on track with his or her recovery program. Whenever possible, it is essential to help people through these changes, without requiring them to leave their homes. If residential treatment is necessary, contingency funds should be used to retain their apartment if needed. These changes illustrate why it is important for the supportive housing coach to be a member of the treatment team. supportive housing approach is that it can be tailored to work with any special population, by adjusting level and type of service, and assisting people to select the most appropriate housing type and location. Smaller caseloads will allow for more frequent and intensive support services. With flexible and accessible on-site support, most people can live in supportive housing. In general, a typical supportive housing caseload should be 12-15 individuals per staff member. This will provide an average of 1- 2 visits per tenant per week, depending upon length of visits, travel time, etc. Again, some people may need less, others more. The factors outlined above will also affect these ratios. Specialized supportive housing have proven to be effective alternatives to homelessness or institutional care for people with high levels of need. In order to provide seven-day/week staffing and the option of daily home visits, a maximum staffing ratio of 6 tenants per staff member is needed. This ideal option is particularly effective for people who have limited daily living skills, and minimal experience living on their own. Knowing that staff are available every day can be very reassuring to individuals who have been living in hospitals or residential treatment for extended periods, and can help to prevent crises. Medication management can be a particular challenge at first, especially for people on multiple types and doses. More intensive Staffing ratios: Understanding profiles and needs The size of an individual or team caseload should be determined by the known or anticipated profiles of the individuals served. The beauty of the State of Florida Guidelines for Supportive Housing Page 50 of 67 staffing can allow for daily assistance in this area, if needed. Team approach A team approach is one of the most important keys to success, especially if the supportive housing program is providing services seven days a week, or providing after hours oncall. A team approach also provides backup to individual staff who may need additional help for a period of time. A team can also draw upon the varied skills of its members, so as individual needs evolve, different staff may respond. peer mentoring. Training should include topics specific to supportive housing, and other general areas of knowledge essential to community mental health workers. Some suggested topics include: 1. Recovery and empowerment principles and practices 2. Psychiatric rehabilitation principles and practices, e.g. establishing rehabilitation goals, functional assessments, goaloriented service planning, direct skills teaching 3. Working with families and collaterals 4. Ethical decision-making; 5. Overview of Affordable Housing Programs 6. Components of local community mental health and social welfare system 7. Fundamentals of major mental illnesses 8. Co-occurring disorders, and selfhelp/mutual support strategies 9. Crisis prevention/intervention; and 10. Team building Building Organizational Capacity Personnel policies When implementing a supportive housing program there are some critical elements that should be in place to support its operations. First, job descriptions and performance review systems should be revised as needed to reflect the new expectations of staff. Job duties and performance measures should be tied to the goals and values of supportive housing, including the individual outcomes discussed in chapter one. Additionally, with the new competencies expected of staff, the agency has an obligation to offer staff a variety of opportunities for training and development. Operating Policies, Procedures, and Tools Program Managers must provide clear policies and procedures that outline expectations of staff, and facilitate their achieving the objectives of the program. This is both art and science, as the goal is to have no more and no less than what is needed to ensure clarity, effectiveness, and efficiency. The following tools and related policies are recommended for each program: Staff training Direct care staff need access to tailored in-service training on an ongoing basis. This should be a combination of formal classroom training, individual and group supervision, guided reading, and State of Florida Guidelines for Supportive Housing Page 51 of 67 1. Housing quality standards checklist 2. Tenant rent payment worksheet 3. Furnishings agreement (if program is supplying furniture) 4. Sample lease 5. Confidentiality agreement 6. Housing preference questionnaire 7. Individual plan for services 8. On-call plan Quality assurance Practice Standards Without practice standards and benchmarks, there is no way to determine whether supportive housing is fulfilling the values and achieving the outcomes discussed throughout these guidelines. Practice standards can be established by states, by national accreditation bodies, by professional organizations, and by individual agencies. The Commission on Accreditation of Rehabilitation Facilities (CARF) has established standards for supportive housing. The Center for Mental Health Services, through a national services research project, established a fidelity model that has been used to study supportive housing across the country. Individual agencies may establish standards of practice that exceed those of third parties. In general, practice standards for supportive housing will cross into multiple sectors of an organization. Standards and related policies should address at least the following core areas: 1. Individual rights, selfdetermination 2. Recovery outcomes and satisfaction 3. Family involvement and satisfaction 4. Ethics and code of conduct 5. Program operations 6. Environment and safety 7. Psychiatric Rehabilitation 8. Personnel Management 9. Administrative Practices and record keeping 10. Community relations Quality indicators The following dimensions and indicators for supportive housing have been identified by the Center for Mental Health Services: CMHS Housing Initiative: Fidelity Dimensions and Indicators Housing Choice o Exploration of housing options/preferences o Choice of units o Choice of living arrangements o Florida’s operational definition is “the process and extent of offering different housing choices.” Housing/Services Separation o Legal separation o Functional separation – distinct roles of housing and service staff o Functional separation – service providers based offsite o Florida’s operational definition is “ensuring that the roles of housing staff and service staff are distinct.” State of Florida Guidelines for Supportive Housing Page 52 of 67 Housing Affordability o Extent to which tenants pay a reasonable amount of their adjusted income toward rent + utilities (+ food, for congregate housing) o Perception of affordability o Florida’s operational definition is “determining each applicant’s monthly income and establishing a personal budget to determine what amount of subsidy is needed.” Integration o Mixed populations in the building(s) o Florida’s operational definition is “promoting scattered-site housing and identifying provisions that may offset the impact of more segregated housing.” Rights of Tenure o Full rights of tenancy consistent with tenant/landlord law o Independence, i.e. program/house rules consistent with tenant/landlord law o Permanence, i.e. length of stay o Florida’s operational definition is “ensuring that the individual has full rights of tenancy consistent with the tenant/landlord law.” Service Choice o Services & supports determined by resident choice o Florida’s operational definition is “absence of any requirements to participate in activities or treatment as a condition of residence.” Service Individualization o Services reflect needs/preferences of residents o Extent of agency flexibility in meeting changing resident needs o Florida’s operational definition is “informing the individual of choices; determining the extent that the individual is receiving the services of his/her preference.” Community-Based Service Availability o Array of services available in the community o Extent to which available services are accessible to residents o Extent to which crisis services are available o Extent to which services are bundled within the housing program o Florida’s operational definition is “providing access to community mental health and other services and supports.” Quality o Perceived safety/quality o Extent to which housing meets objective standards of quality o Florida’s operational definition is “the extent to which housing supports meet the individual’s stated goals and objectives and conforms to programmatic requirements.” State of Florida Guidelines for Supportive Housing Page 53 of 67 Structure o Extent to which group and/or recreational activities are planned by the housing program & attendance is expected o Extent to which residents are expected to eat meals together o Florida’s operational definition is “individuals will plan their own daily schedule of activities.” Privacy o Extent to which resident has private living quarters o Extent to which resident controls access to unit o Perception of privacy o Florida’s operational definition is “individuals will have private living quarters and control access to their home.” Risk Management At the core of risk management is the process used by an organization or individual to make decisions. The process for making good decisions in housing involves a dynamic interplay among the following three key elements: o Individual choices and needs o Standards of practice o Program purpose and expected outcomes In most cases, tough decisions do not have an obvious answer, such as when a potential violation of regulation or law is the issue. Most often, it is a matter of considering different and conflicting points of view, weighing multiple options, and then moving forward with diligence and good faith. Some Guiding Values for risk management are: Do no harm Share the responsibility Communicate Gather objective information Respect others’ views share the decision-making promote good judgment and self-determination o act, when necessary o o o o o o o “Good judgment is a product of understanding the environment in which one is working, the values that are important, the risks that are present, and the outcomes that are desired. People make good decisions when they are prepared for and understand the decisions they must make, and their responsibility to make them.” (Sundram, 1994) Individuals as staff and peer models Supportive housing providers should make special efforts to include mental health service recipients among their staffs. Some of the many demonstrated benefits of having service recipients as staff members are: Provides direct peer support. Staffs who are also service recipients can “provide social support and nurturance. Individuals State of Florida Guidelines for Supportive Housing Page 54 of 67 often feel that they are connected to a more supportive network, that fulfills their emotional and social needs, and that provides empathy by having individuals available who better understand their history and their current situation.”1 Provides first-hand guidance in problem-solving skills. Because service recipient staff have “been there,” they know first-hand how to overcome some of the frustrations of navigating the mental health and social service systems. Provides hope for recovery. By seeing peers working as staff in supportive housing programs, individuals see first-hand that recovery is possible, and this often acts as an inspiration that aids recovery. Provides a method of recruiting and retaining dedicated employees. When service providers often have a difficult time recruiting and retaining employees, individuals with mental illnesses often have a personal mission that enables them to become dedicated and loyal employees. Notes Chapter 5 Carol T. Mowbray and David P. Moxley, “Consumers as Providers: Themes and Success Factors” in Consumers as Providers in Psychosocial Rehabilitation. 1 State of Florida Guidelines for Supportive Housing Page 55 of 67 Chapter 6 - Increasing the Supply of Affordable Housing For a supportive housing program to be successful, it is important that program staff take an active approach to improving access to affordable housing. A study of the elements of supportive housing conducted by the University of Kansas School of Social Welfare concluded: “The extreme poverty of the target population, due to low levels of employment and low entitlement income provided by government programs for people with disabilities, makes it difficult to afford a place to live. The lack of low income housing, both within the private market and through government-assisted programs, makes decent affordable housing a very scarce commodity in almost all areas of the country. Stigma and discrimination, fragmentation of services and supports, and the general lack of housing, social welfare and mental health programs add to this problem.”1 In your efforts to develop affordable housing, remember that the federal government, through the Department of Housing and Urban Development (HUD), provides the state and local communities with a substantial amount of funds for housing each year. However, “HUD data show that people with disabilities use only 12 percent of HUD’s subsidized resources, but represent at least 25 percent of the households with ‘worst State of Florida Guidelines for Supportive Housing case’ housing needs.” Therefore, disability advocates must work hard to ensure that more HUD funding is designated to help people with disabilities. The state of Florida also offers programs that can be used to provide housing to consumers. People with serious mental illness are part of a larger community of people with disabilities and their advocates who share common experiences, needs and dreams. Working together, these crossdisability coalitions can significantly increase the percentage of resources available to invest in supportive housing. Providing rental assistance A key resource that enables people to obtain and retain affordable housing is rental assistance. The need for rental assistance for people with disabilities is primarily a function of poverty rather than disability. Many people with disabilities rely on Supplemental Security Income (SSI) as their only means of financial support. Statistical analysis2 provided by the Housing Center for People with Disabilities paints a grim picture: • People with disabilities continued to be the poorest people in the nation. As a national average, SSI benefits in 2000 were equal to only 18.5 percent of the oneperson median household income. Page 56 of 67 • “Housing wage” data from the National Low Income Housing Coalition shows that people with disabilities who received SSI benefits needed to triple their income to be able to afford a decent one-bedroom unit. On average, SSI benefits are equal to an hourly rate of $3.23, only one third of the National Low Income Housing Coalition’s housing wage, and almost $2 below the federal minimum wage. • • • development of natural supports and recovery. Is associated with positive outcomes. Is flexible and can move with the individual from place to place. Is less expensive than residential care or the development of housing stock. According to the study, SSI recipients in the state of Florida would have to spend an average of 104.4% of their monthly income in order to afford a modest onebedroom apartment;3 in some areas of the state, this figure was as high as 123%.4 Obviously, it is impossible for a person relying solely on SSI to find decent housing; this figure is particularly disturbing in light of federal standards for housing affordability, under which housing is considered affordable if 30% or less of household income is used toward rent and utilities.5 However, rental assistance allows people with disabilities to afford their own housing. According to the National Association of State Mental Health Program Directors (NASMHPD),6 rental assistance is an effective means of providing housing because rental assistance: • Is consistent with principles of community support and recovery. • Maximizes choice. • Results in natural integration of individuals into the community and fosters acceptance and Supportive housing can provide short-term rental assistance, but linking individuals to permanent rental assistance is needed to achieve the goal of supportive housing—a permanent home of one’s own. Moreover, due to the current shortage of affordable housing slots, supportive housing must play a role in developing additional affordable housing through working with private landlords and housing authorities as well as advocating for the use of state and federal housing funds for supportive housing. Improving access to housing One method for helping individuals acquire and maintain permanent housing is to help them access the stock of affordable housing that is currently available, especially housing that might not yet be accessible to people with mental illnesses. State of Florida Guidelines for Supportive Housing Page 57 of 67 Working with landlords A key function of supportive housing is working with landlords who privately rent housing; this is especially important when a rental subsidy is being used to help pay a portion of an individual’s rent. Supportive housing staff can also play an integral role in identifying and maintaining a list of landlords who offer private housing that is affordable for people with low incomes. Staff also can play an important role in overcoming the discrimination that mental health service recipients often face when seeking housing on the private market, especially if they are relying on rental assistance, which many landlords may initially reject. Keys to reducing discrimination and increasing access to privately run housing include: • Educating landlords about common misconceptions about mental illness, e.g., perceptions of violence or lack of self-care skills. Reaching out to civic groups that landlords are frequently associated with (e.g. Chambers of commerce, landlord associations) and offering to speak at a meeting, or distribute program material. Using the vast personal networks of staff and board members to identify potential landlords and make introductions as necessary. • • • • • Reassuring landlords that supports are available to clients on an around-the-clock basis, and delivering on that promise. Making staff accessible to landlords and neighbors on an ongoing basis to prevent potential problems. Educating landlords about technical issues, such as how representative payee programs operate. If the agency is providing a rental subsidy, making payment in a timely manner. Assisting the person to be a good tenant, to pay their share of the rent on time, maintain their home well, and be a good neighbor. After time, well run supportive housing develop a group of dedicated landlords who prefer to rent to their tenants, and seek them out when apartments become available. This takes time and hard work, but it is well worth it. Accessing subsidized housing Federal government funding is used to create a great deal of housing; the problem is that people with disabilities have not been able to access this housing easily. Public housing authorities (PHAs), nonprofit organizations, and private landlords offer housing that has been created using governmental subsidies of some sort. Additionally, HUD offers tenant-based rental assistance through the Section 8 program and other programs. Listed below are some strategies for improving access to subsidized housing through systems advocacy efforts. • • State of Florida Guidelines for Supportive Housing Page 58 of 67 Developing affordable housing Because the existing supply of affordable housing is not sufficient for people with disabilities, it is important that supportive housing staff join with individuals and other housing advocates to develop additional sources of affordable housing. Advocating for more funds Despite having access to federal funding, local and state governments have traditionally not done enough to help people with disabilities secure affordable, accessible, and appropriate (“Triple A”) housing. Although a small percentage of HUD funding goes to programs specifically for people with disabilities, it is not enough, and people with disabilities lose out on other HUD-funded housing for reasons including: • Income. Local and state governments often choose to use HUD funding to create housing for working-class families, and people who rely on disability income cannot afford this housing.7 This is largely due to the fact that it is more expensive to make housing affordable for persons with the lowest incomes. (In the housing industry this is referred to as a “deep” subsidy.) These households require the greatest subsidy; therefore fewer people can be served with the same dollars. To illustrate, a family earning 60% of median income may only need a low interest below market mortgage and a small grant for down payment assistance in order to qualify for an affordable “first time homebuyers” loan. In contrast, an individual living on SSI at 18% of median income will probably need a grant to cover all of the costs of a unit, and perhaps some rental subsidy to cover ongoing operating costs. Sometimes, government officials are reluctant to invest more funds to serve fewer people, even though these people are among the most vulnerable in their communities. • Age. Local housing agencies can designate HUD-funded housing as “elderly only,” thus excluding younger people with disabilities. According to the Consortium for Citizens with Disabilities Housing Task Force, this policy has resulted in the loss of over a quarter of a million housing opportunities for non-elderly people with disabilities.8 For your supportive housing program to be able to ensure that individuals have access to affordable housing, you must become an advocate for increased system funding of housing for people with disabilities. Some specific strategies are discussed below. When advocating for a fair share of housing resources, it is essential to work in coalition with other organizations. Remember: Because access to housing is primarily a poverty issue rather than a disability issue, it is important to build as broad-based a coalition as possible. State of Florida Guidelines for Supportive Housing Page 59 of 67 Examples10 of groups with whom to work include: • • • • • • • • Homeless coalitions Affordable housing task forces Mental health self-advocacy organizations Low-income assistance organizations (e.g., ACORN) Local housing non-profit organizations Public officials Anti-poverty or anti-hunger organizations Other service providers Shelter Grants, and Housing Opportunities for People With AIDS (HOPWA). The “Con Plan” lays out local priorities and a three-to-fiveyear strategy that the jurisdiction will follow in implementing HUD programs. In addition, an annual action plan provides the basis for assessing performance.11 The Consolidated Plan must contain a Citizen Participation Plan, and it is extremely important for disability advocates to take advantage of this requirement and to become involved in the planning process. For effective participation in the Consolidated Plan process, it is important to document the need for additional housing for people with disabilities. Through disability advocacy networks, gather information about the housing needs of people with disabilities. Identify types of public housing that are designated as “elderly only” and therefore exclude many people with disabilities. Try to identify how many people on waiting lists have disabilities. Work with other service providers to determine how many individuals are homeless or living in substandard housing.12 You can use this information to create a more complete needs assessment for the Consolidated Plan, as discussed below. Each local and state Consolidated Plan controls vast amounts of money, and disability advocates must be involved in order to be sure that people with disabilities are considered a priority group to receive federal housing funds. Full participation13 includes: Federal funding sources If you want to be an effective housing advocate, you should familiarize yourself with some of processes going on at the local and state level that determine how HUD funding will be used. In order for local communities and the state to apply for federal funding from HUD, they must create plans that address housing needs in a more coordinated way. A. Consolidated Plan Each local community and state must complete a Consolidated Plan in order to receive funding from four HUD programs: the Community Development Block Grant Program, the HOME Program, Emergency State of Florida Guidelines for Supportive Housing Page 60 of 67 • • • • • • • • • Getting to know who is in charge of the local or state Consolidated Plan. Getting a copy of the complete Consolidated Plan (and related documents) and reviewing these documents thoroughly. Getting a copy of the Citizen Participation Plan and reviewing it thoroughly. Getting a copy of any performance reports and reviewing them thoroughly. Submitting written comments. Writing a draft needs assessment for people with disabilities. Speaking at public hearings. Expressing your concerns directly to HUD if needed. Most importantly, engaging individuals with mental illnesses in all of these activities. People with disabilities lose out on much of the housing funded with block grants because they cannot afford it. Block grants are often used to create housing that working-class families can afford but people living on disability income cannot.14 (Again, this is related to the “deep subsidy” issues outlined above.) In order to help people with disabilities, some of the block grant funds must be used to create housing for people with the lowest incomes. ► The Consolidated Plan should allocate a significant percentage of federal HOME funds to Tenant-Based Rental Assistance for people at the lowest income levels, including people with disabilities. Each year, HUD gives over a billion dollars to local communities and states to increase the availability of affordable housing through the Home Investment Partnerships Program (HOME). As with the Community Development Block Grant program, communities and states can use HOME funds to create “affordable” housing that people living on disability income still cannot afford.15 However, HOME funds can be reallocated to fund supportive housing. HOME funds can be used for: Loans and grants for rental housing production and rehabilitation. Assistance to first-time homeowners. Homeowner loans for repairs. Tenant-based rental assistance. Advocacy efforts during the planning process could include: ► The Consolidated Plan should designate a significant percentage of federal Community Development Block Grant funds to creating housing for extremely low-income people, including people with disabilities. Nationally, the block grant program gives billions of dollars each year to local and state governments. The funds can be used in many ways, including renovating housing, building new housing or community facilities, purchasing land or buildings, making housing accessible, and providing public services. State of Florida Guidelines for Supportive Housing Page 61 of 67 ► The Consolidated Plan’s needs assessments should address the needs of people with disabilities who are not homeless or in need of supportive housing but need appropriate, accessible, and affordable housing. Each local and state Consolidated Plan must contain a housing and homeless needs assessment, with separate sections for people who are homeless and people with disabilities who are in need of supportive housing. Remember that supportive housing can be successful for any adult who has a disability, needs supportive services, and wants to live in the community. Therefore, the “needs statement should also describe the needs of people with disabilities in residential settings, such as group homes, who may desire more independent housing options”16 such as their own homes in conjunction with supportive housing. In order for the housing needs assessment to be accurate, the disability community must be active in discovering, documenting, and reporting the housing needs of people with disabilities. According to the Technical Assistance Collaborative: “The disability community can also utilize data from management information systems of service providers to document the need for housing among the people they serve. Useful information includes the number of people on the waiting list for residential services or PHA housing assistance (including public housing and Section 8); the number of people who are living at home with aging parents, homeless, rent burdened, “doubled up” or living in substandard housing. Service providers should be asking these questions in order to develop comprehensive housing needs data.”17 ► The Consolidated Plan’s housing market analyses should address the additional housing needs of people with disabilities caused by the designation of publicly assisted housing as “elderly only.” Each local and state Consolidated Plan must contain a housing market analysis, which covers the cost and availability of housing. Disability advocates must ensure that a misleading picture is not created by the availability of housing units that have been designated as “elderly only.” It should be made clear in the housing market analysis what percentage of affordable housing units are not available to most people with disabilities.18 B. Public Housing Agency (PHA) Plan The PHA plan covers two extremely important HUD programs for lowincome people: Public Housing and Section 8 Housing Choice rental assistance. Public Housing is maintained by local PHAs; the Section 8 program makes private housing affordable by paying a portion of the rent on behalf of the eligible tenant. The PHA Plan also State of Florida Guidelines for Supportive Housing Page 62 of 67 covers some programs specifically designed for people with disabilities, such as Access Housing and Section 8 Mainstream Housing. The PHA plan covers many issues of great concern to people with disabilities, including eligibility and preference guidelines. The local PHA must draft its plan in “consultation with affected groups,” such as Resident Advisory Boards composed of people who live in public housing or participate in the Section 8 program. It is important that supportive housing staff and people with disabilities participate in this process, including advocating for positions on Resident Advisory Boards.19 Advocacy efforts during the planning process could include: ► The local Public Housing Agency (PHA) Plan should give priority for available public housing to people with disabilities. Over 1.3 million people live in public housing according to HUD statistics;20 however, the demand for public housing exceeds the supply, adding to the problem of homelessness in the United States. Each local PHA plan determines which low-income people get priority for the limited amount of public housing that is available in the local community. People with disabilities, especially those leaving institutions, often have the greatest need for housing, yet many advocates believe that PHAs steer away people with disabilities or place them in the worst available units. In some places, advocates have tried to document these problems and have fought to convince PHAs that they should give preference to people with disabilities when units become available.21 Remember: It is important that people with disabilities are not segregated from people who do not have disabilities! ► The local Public Housing Agency (PHA) Plan should devote a significant percentage of federally funded housing choice vouchers(Section 8) to people with disabilities. The housing choice voucher program (Section 8) is an important federal resource that allows people to rent privately owned apartments: according to HUD, approximately 1.5 million people use Section 8 vouchers. As with public housing, when the demand for Section 8 vouchers in a given area exceeds the supply, the PHA plan determines who has priority access to the vouchers. Some advocates have taken the position that a third of all Section 8 vouchers that become available should go to people with disabilities.22 Specialized programs (described below) exist to provide rental assistance specifically to people with disabilities. However, these programs can help only a small percentage of people with disabilities; even though at least 23 percent of people receiving Section 8 vouchers have disabilities, many more people with disabilities have unmet housing needs. HUD gives State of Florida Guidelines for Supportive Housing Page 63 of 67 preference to PHA plans that devote at least 15 percent of Section 8 housing vouchers to people with disabilities, but an even higher percentage would be needed to meet the needs of people with disabilities. ► The local Public Housing Agency (PHA) Plan should include programs specifically designed to provide rental assistance to people with disabilities, in addition to targeting increased percentages of general choice voucher to very low income people with disabilities. HUD has developed rental assistance programs targeted specifically for people with disabilities. However, the number of vouchers is small in comparison to the overall number of Section 8 vouchers available, and the PHA plan should not limit assistance to people with disabilities to these specialized programs.23 HUD disability programs include: Access Housing: Provides Section 8 housing vouchers to PHAs, in partnership with state Medicaid agencies, to help transition nonelderly people with disabilities from nursing homes into the community. Section 8 Mainstream Housing Opportunities: Provides vouchers to people with disabilities. Section 811 supportive housing programs (which can be used for scattered-site housing) Several other smaller programs. C. Continuum of Care Plan (McKinney Homeless Assistance programs) The Continuum of Care Plan is a strategy for dealing with homelessness at the local and state levels. It also serves as the application for HUD’s Supportive Housing Program, Shelter Plus Care, and the Section 8 Moderate Rehabilitation Program for Single Room Occupancy Dwellings. Any local or state government applying for funding under the Continuum of Care Plan must develop strategies for preventing people who are discharged from institutions from becoming homeless; however, the funding may not be used for homelessness prevention activities.24 Unlike the Consolidated Plan and the PHA Plan, the Continuum of Care Plan is not necessarily developed by a government agency. A coalition or nonprofit organization might take the lead role in developing a Continuum of Care Plan. Various organizations and providers can apply for funding as part of the same plan; in fact, HUD ranks plans that include widespread involvement more favorably than plans that do not.25 Advocacy efforts during the planning process could include: ► Local communities and the state should develop Continuum of Care Plans, emphasizing the use of Supportive Housing Program (SHP) funds to create permanent housing for people State of Florida Guidelines for Supportive Housing Page 64 of 67 with disabilities who are homeless. The Supportive Housing Program (SHP) provides funding to local and state governments, PHAs, and nonprofit organizations. It is designed to provide housing and supportive services to people who are homeless. People with disabilities are identified as a priority population. SHP funds can be used for the following types26 of programs, among others: Permanent housing for people with disabilities. Supportive services for people who are homeless. ► Local communities and the state should develop Continuum of Care Plans that include providing tenant-based rental assistance under the Shelter Plus Care (S+C) program to people with disabilities who are homeless. The state should provide funding for supportive services in order to qualify for S+C funds. The Shelter Plus Care (S+C) program enables local and state governments and PHAs to provide rental assistance to people with disabilities who are homeless. The funding must be matched dollar-fordollar at the local or state level with funding for supportive services for the people who receive S+C rental assistance. This can be new or existing supportive services funding. For people with significant support needs, it is advisable to target additional funds to tenants who receive S+C to ensure that they receive sufficient support to retain their housing. State funding sources The state of Florida offers several programs that can be used to create affordable housing for individuals receiving supportive housing. These programs27 include: The Department of Children and Families offers a monthly supplement of $212 to people who participate in Florida Assertive Community Treatment (FACT) programs. The SAIL program (low-interest loans for creating low-income housing). Five percent of SAIL funds (approximately $1.8 million in 2002) are reserved for creating housing for people who are homeless. Challenge grants for Continuum of Care programs. Continuum of Care lead agencies can apply for matching funds from the state (up to $500,000 each) for supporting their programs. A total of $4 million was advocated for 2002. Capital costs for constructing or rehabilitating supportive housing for people who are homeless. Up to $5 million is available for 2002; each project must be within the area’s Continuum of Care. A maximum of 2 projects can be funded per continuum, at up to $500,000 per project. State of Florida Guidelines for Supportive Housing Page 65 of 67 Private funding sources Although many individuals must rely on publicly funded rental assistance in order to afford housing, supportive housing is not just for people who require rental assistance. It is important to maximize housing resources by providing support services to people who have other sources of funding for housing, but still require support services in order to maintain their homes. Examples might include people who already own their own home or have received assistance from their families or from programs such as Habitat for Humanity. Employment also provides a potential source of housing funds. A focus of supportive housing is helping people return to work. With programs created by the Ticket to Work and Work Incentives Improvement Act (TWWIIA), it is possible for people with disabilities to earn income while continuing to receive benefits. In conclusion, supportive housing is grounded in the core philosophy that persons with mental illnesses and all Floridians should have choice and access to safe, affordable and decent housing. Persons with mental illnesses should have the same right of tenancy as all citizens and be offered individualized support services tailored to their own changing needs. Expanding the supply of supportive housing requires information sharing, coordination and collaboration State of Florida Guidelines for Supportive Housing among various mental health organizations, people who receive services and housing partners. The State of Florida's Mental Health Program Office is pleased to be affiliated with a wide range of housing advocates who are developing strategic plans to expand supportive housing for persons with mental illness. These "Guidelines" offer direction, hope and optimism that supportive housing plays a central role in recovery and community integration for persons with mental illnesses. Notes to Chapter 6 Priscilla Ridgway and Charles A. Rapp, “The Active Ingredients of Effective Supported housing: A Research Synthesis” (January, 1997), 3. 2 Ann O’Hara and Emily Miller, Priced Out in 2000: The Crisis Continues, Housing Center for People with Disabilities (June 2001), 4-5. Available online at http://www.tacinc.org 3 Priced Out in 2000, 12. 4 Priced Out in 2000, 15. 5 Priced Out in 2000, 12. 6 National Association of State Mental Health Programs Directors, Best Practices in Housing, 45. 7 Overcoming Barriers: 30-31. 8 Overcoming Barriers: 28. 9 Ann Denton, “Community Housing Plans: An Opportunity for Advocacy.” 10 Ann Denton, “Community Housing Plans: An Opportunity for Advocacy.” 11 See http://www.hud.gov. 12 Piecing It All Together: 22-25. 13 Piecing It All Together: 16-25. 14 Going It Alone: 14. 15 Going It Alone: 15. 16 Piecing It All Together: 23. 17 Piecing It All Together: 23. 18 Piecing It All Together: 8. 19 “Affordable Housing in Your Community: What you need to know! What you need to do!” Opening Doors (Sept. 1999): 4, 7. 20 See http://www.hud.gov/. 21 Piecing It All Together: 27-28. 1 Page 66 of 67 22 23 Going It Alone: 34. Going It Alone: 13. 24 How to Be a “Player” in the Continuum of Care: 2-4. 25 How to be a “Player” in the Continuum of Care: 21. 26 How to Be a “Player” in the Continuum of Care: 10-11. 27 “Landmark Homelessness Bill Passes Florida Legislature,” Florida Homelessness: Issues and Ideas 6(1) (May 2001), 1 State of Florida Guidelines for Supportive Housing Page 67 of 67 State of Florida Guidelines for Supportive Housing Page 68 of 67