Housing the Criminally Mentally Ill Offender- IT AIN'T EASY by chenleihor


									Understanding and Ending
              the Cycle of
         Homelessness &
   Incarceration Through
   Permanent Supportive
                        John Fallon
        Program Manager- Re-Entry
 Corporation for Supportive Housing
                    February 1, 2008
What are the barriers at release for
someone leaving jail or prison?

    No identification, SSI, birth certificate
    No medical funding, disability determination
    No psych services- services are not where person needs them
    No health care services except expensive emergency rooms
    Parole or probation rules
    No housing, no affordable housing
    No income
    Prejudice because of record, MI, substance use, homeless,
     poor, race
    Family relationships damaged
    Hopelessness, despair
    Release planning period, parole-technical violations
    Lack of misa programming- drug testing
Today I will talk about…

      I will talk about
       –   Me
       –   Criminal Justice and Homelessness
       –   Changing mental system
       –   Permanent Supportive Housing
       –   Policy
       –   CSH
       –   Harm Reduction
I want you to care about this

       I truly believe that we can spend money more
        wisely to solve problems related to institutional
       I had the pleasure to supervise a wonderful
        program at Thresholds where I worked with and
        supervised wonderful residents and staff
       I love the members I worked with and am so
        saddened to see people lost in the system due to
        non-integrated systems.
What‟s the Problem?

       Thousands of people with chronic health
        conditions cycle in and out of jail, prison, mental
        health institutions, detox, emergency rooms,
        shelter and the streets.

       Recidivism rates for this group are extremely high

       This group is largely ill-served by these crisis
        systems of care.
What‟s the Problem?

       There is an immense public cost for these poor

       This group needs support that is comprehensive
        to succeed.

       Housing, mental health, employment and other
        components are inter-dependent, but the systems
        that provide them are separate.
Priced Out of Housing

     In 2002, for the first time ever, the national average rent for an
      efficiency or 1-bedroom exceeded the income of a person with a
      disability receiving Supplemental Security Income (SSI).

     In 2002, there was not one single housing market in the country
      where a person with a disability receiving SSI benefits could
      afford to rent a modest efficiency or 1-bedroom unit

     Because of their extreme poverty, the 3.5 million non-elderly
      people with disabilities receiving SSI benefits cannot afford
      decent housing anywhere in the country without some type of
      housing assistance

         Source: Technical Assistance Collaborative, Priced Out in
How Big is the Problem?

     Right now, across the nation,
     2,385,000 people are locked up
       in county and state custody
How Big is the Problem?

The United States also has the highest incarceration rate at 737 per 100,000
people, compared to nearest country Russia's 611 per 100,000
The United States has 5 percent of the world's population and 25 percent of the
world's incarcerated population. We rank first in the world in locking up our fellow
citizens," said Ethan Nadelmann of the Drug Policy Alliance,

Texas               200,000             22,860,000      1035*
US                2,385,000            296,400,000      737
China             1,548,498          1,308,700,000      118
Russia              869,814            142,300,000      611

Source- International Centre for Prison Studies at King's College London Oct 2006
How big is this problem?

        Nationally, there will be
       672,000 releases from state
       and federal prisons this year
       That is 1,840 people a day

    There are more than 5,000,000

     people on probation or parole.
Who Is In Jail?

      Dept. of Justice estimates that up to 16% in jails
       & prisons have a mental illness
      About 6 to 12% have a serious and persistent
       mental illness
      The incidence of SMI is about 12% in female
      In Texas, a random survey in 2004 by the state
       legislature found 15% of admissions identified
       but 34% had been identified and treated
       previously by the public mental health system.
      Texas has the second largest prison population in the
       United States
        – There are 172,116 people in prison (152,889 (TJCJ)(28,543
          in 1980)
        – There are 15,091 people in jails
        – There are 18.627 people in private facilities
      That is more than 205,000 people according to DOJ
      In 2004, 55,183 people returned to communities from
       prison and felony jails- a five fold increase since 1980
      There are 51 prisons, 3 pre-release facilities, 3 psychiatric
       facilities, 1 MR facility, 16 jails, 13 transfer facilities……
      There are more than 430,000 on probation and 101,000
       on parole. In 2002, 53% of admissions were because of
       parole and probation revocations.
In Harris County

   Harris County now has 9,834 people in a jail that holds 11,000.
    At its present growth rate, it will likely pass Cook County as the
    third largest jail in the country.
   58% of paroled releases in 2004 went to 5 of 254 counties. No
    other county had more than 2%.
   26% went to Harris County and 23% to Houston
   26% of Houston‟s group went to 7 neighborhoods- Alief, East
    Houston, East Little York/Homestead, Kashmere Garden,
    Trinity/Houston Gardens, Third Ward/. And MacGregor- 196-
    538 supervised releases- 52% were unsupervised
   87% male, 45% AA, 41% White, 14% Hispanic
   Community- 18% AA, 41% White, 33% Hispanic, 6% Asian
Why do we care?

     In 1982, we spent as a nation less than 36 billion dollars on
      law enforcement costs (prison, jail, courts, supervision)
     In 2003, we spent 185.5 billion dollars (417% increase, or
      7.7% a year)
     In 2005, we spent 204 billion dollars or $660 per person
     This would operate 11,3 million units of supportive housing
      for a year
     The National Point in Time Count for this year was
      754,147. The number of chronic homeless was listed as
Why do we care in Texas?

     In 2005, Texas spent $10,673,000,000 on
      Criminal Justice Expenses
     This would operate 592,949 units of supported
      housing (18,000 per year)
     This is real money that could be invested
     There are 43,000 homeless individuals identified
      in the point in time count for Texas
Corrections has become the primary
national mental health system

     Deinstitutionalization
     More rigid criteria for civil commitment
     Lack of adequate housing
     Difficulty in gaining access to community based
     Attitude of society in general
                                    Mental Health and Correctional Trends Since 1970



                                                                                            Persons Receiving Treatment in the State
Number in Institution

                                                                                            Persons Receiving Treatment in the Private
                                                                                            Persons Receiving Psych Care in Gen
                                                                                            Persons in Custody in Jail
                                                                                            Persons in Custody in Prison



                                    1970   1976   1980   1986   1990   1998   2000   2004
      National Mental Health Treatment- 1970


                                      Persons Receiving Treatment
                                      in the State Hospitals
                                      Persons Receiving Treatment
                                      in the Private Hospitals
                                      Persons Receiving Psych
                                      Care in Gen Hosp
                                      10% of Persons in Custody in

      National Mental Health Treatment- 2004

                                       Persons Receiving Treatment
                                       in the State Hospitals
                        10%            Persons Receiving Treatment
41%                                    in the Private Hospitals
                                       Persons Receiving Psych
                                       Care in Gen Hosp
                                       10% of Persons in Custody in
                        15%            Jail
                                       10% of Persons in Custody in

Why we need to increase services for
the MI repeat offender population

      We are paying for these folks now through
                emergency services
           and have been for a long time.

       Here are long-term institution costs and
      averages for just two of the Thresholds jail
                project members….
The cost of non-treatment

    Client 1: 21 years
     – 3,758 days of hospital time
     – 399 days of jail time (six years is all we have)
     – Does not include private hospitals, court or
The cost of non-treatment

Client 1 Math: 21 Years
  3,758 hospital days * $400 a day   = $1,503,200
  399 Jail Days * $70 a day          = $   27,930
        TOTALS                       = $1,531,130
        Annual Total                 = $   72,910
The cost of non-treatment

Why this is all-important from a policy

     Client 2: 30 Years
      – 3,958 days of hospital time
      – 561 days of jail time
      – Does not include private hospitals, VA, court,
        or arrests
The cost of non-treatment

Client 2 Math: 30 Years
   3,958 hospital days * $400 a day = $1,583,200
   561 jail days * $70 a day       =$    39,270
         TOTALS                    = $1,622,470
         Annual Total              =$    54,082
The cost of non-treatment

Institution costs while in Thresholds program

    Institution time, Client 1: 4 Years
            – 14 days in jail * $70 per day = $980.00

    Institution time, Client 2: 3 Years    $   0.00
Penny Wise Can Be Pound Foolish

       Intensive Long Term Outreach Services in the home are
        what is generally needed to help break the cycle for the
        most difficult to engage persons

       Without comprehensive services, taxpayers will likely
        continue to pay large amounts of money in repeated
        incarcerations, emergency room visits, arrests, psychiatric
        hospitalizations, and decreased public safety. They will
        also miss a chance to enjoy the friendship of people who
        can become good and interesting community members.
The cost of non-treatment

    These programs are cost effective and if the most
     recidivistic clients are selected, society is already
     paying these costs
    The problem is the costs are in several places
     (OMH, county, department of corrections)
    Our task as policy makers is to recognize existing
     costs and redistribute current expenditures in a way
     that better serves the clients and the community
    Our current system is not optimized
An Exciting Social Experiment

      The President said we
         want to eliminate
     homelessness in 10 years.
An Exciting Social Experiment

     This is known as
      the „10 Year Plan
            to End

    The idea of the 10 year plan is to concentrate on
     the most frequent users of emergency services
     and provide less expensive, more focused, more
     intense, and more effective services for
     predictable crisis
    This will free emergency services for the
     intended purpose of transitory emerging
     problems in crisis
    This will save money, improve lives, and increase
     a sense of public safety
    Ill Goals:
     – About 7000 households
     – 3257 individuals in prisons and jails need PSH
A Cost-Effective Solution

 U. Penn. study of 5,000
 mentally ill homeless people
 in New York:

   Supportive housing created an
    average annual savings of $16,000
    per person, per year, by reducing
    use of public services
NY/NY: Background

    Agreement between NY State and NY City
    Funds capital, operating, and service costs for
     3,600 supportive housing units in NYC
    Placement recipients must have an SMI
     diagnosis & a record of homelessness
    Data available on 4,679 NY/NY placement
     records between 1989-97
Research Question

 How do NY/NY housing placements affect the use
       City shelters
       State psychiatric hospitals
       State Medicaid services
       City hospitals (HHC)
       Veterans Administration hospitals
       State prisons
       City jails
Data Sources

    NY/NY Housing Placements: 1989-97
    Single Shelter Users and Stays: 1987-99
    State Hospital Users & Stays: 1990-96
    Municipal Hospital Users & Stays (non-Medicaid): 1989-96
    Medicaid-Reimbursed Inpatient Hospital Stays: 1993-97
    Medicaid-Reimbursed Outpatient Visits: 1993-97
    Veterans Hospital Stays: 1992-99
    State Criminal Justice Prison Use & Convictions: 1987-97
    City Jail Use: 1987-99
Research Method #1

            Pre-Post Analysis

          2 Years       2 Years

         Pre-NY/NY     Post-NY/NY
         Placement     Placement
Research Methods #2

        4,679        Control
      Persons w/      Pool
      Placement     (observations
                    from services
                                       Matched Pair Case-
                       system)         Control Design

   P re-Match         Matched
    Matched On:
                    Best Match on:
                    Pre Intervention
   Race; Sex; Age    Services Use
    SA & MH Use
The Cost of Homelessness

                        Mean Days Used (2-     Per Diem   Annualized
    Service Provider     year pre-NY/NY)         Cost       Cost
NYC DHS – Shelter                      137          $68          $4,658
NYS OMH – Hospital                     57.3       $437          $12,520
NYC HHC – Hospital                     16.5       $755           $6,229
Medicaid – Hospital                    35.3       $657          $11,596
Medicaid – Outpatient          62.2 (visits)        $84          $2,612
VA – Hospital                           7.8       $467           $1,821
NYS DCJS – Prison                       9.3         $79            $367
NYC DOC – Jail                           10       $129             $645
Total                                                           $40,449
NY/NY Savings

Per Housing Unit Per Year
                  Service           Annualized Savings per
                                         NY/NY Unit
   DHS Shelter                              $3,779
   OMH Hospital                             $8,260
   HHC Hospital                             $1,771
   Medicaid – Inpatient                     $3,787
   Medicaid - Outpatient                   ($2,657)
   VA Hospital                              $595
   NYS Prison                               $418
   NYC Jail                                 $328
                            Total          $16,282
Why Permanent Supportive Housing?

    Supportive Housing breaks the cycle of
      homelessness, especially for those
     people who have been homeless and
         also deal with mental illness.
The Corporation for Supportive

      Three Core Lines of Business:
       – Project Specific Assistance
       – Capacity Building
       – Policy and Systems Change
      Resources
       – www.csh.org
What Is Supportive Housing?

A cost-effective combination of
permanent, affordable housing
with services that helps people
live more stable, productive lives.
Who is Supportive Housing for?

             People who are homeless or
             at-risk for homelessness
             - and -
             face persistent obstacles
             to maintaining housing,
             such as mental health issues,
             substance use issues,
             other chronic medical issues,
             and other challenges.
Who lives in Supportive Housing?

   People with long histories of homelessness

   Long-term poverty coupled with persistent health problems,
    including mental illness, substance abuse and HIV/AIDS

   Those with repeated engagements with temporary,
    institutional settings and crisis care services

   Histories of trauma, abuse and violence

   Single adults, families and unaccompanied youth
Features of
Permanent Supportive Housing

   Permanent Rental Housing
       Each resident holds lease on his/her own unit
       Resident can stay as long as he/she pays rent and
        complies with terms of lease (no arbitrary or
        artificial time limits imposed).

       Tenants usually pay no more than 30% of income
        for rent.
Features of
Permanent Supportive Housing

   Flexible Services
       Participation in a “program” is not a condition of
       Services are designed project by project for the
        target population and the housing setting
       Services are flexible and responsive to individual

   Cost Effective
       Costs no more,and often much less, than the cost
        of homelessness and produces better outcomes
        than the expensive system of crisis care
Supportive Housing Types

    Apartment buildings exclusively housing
     formerly homeless individuals and/or families.
    Rent subsidized apartments leased in open
    Apartment buildings with mixed income
     households, including the formerly homeless.
    Long-term set aside of units within privately
     owned buildings.
    Services integrated within existing affordable
     housing developments.
    Single family homes, including shared housing
Funding to Develop Permanent
Supportive Housing

      Capital
       – Bricks and Sticks
       – One time funds
      Operating
       – Funding to support building operations
       – Typically a Subsidy
      Supportive Services
       – Grants to fund staff salaries
A Proposed Model for Financing
Supportive Housing

   The Current Funding Model

      Capital
       – Existing affordable and supportive housing development
         sources (Housing Trust Funds, HOME, bond financing)
      Operating
       – Other operating subsidy/rental assistance stream to “take-
         out” bridge subsidy (McKinney, Sec 8)
      Social services
       – Existing service streams from human service systems
         (mental health, substance abuse, TANF, Medicaid, etc.)
St. Andrew’s Court

                  42 units of supportive housing, 30 for homeless ex-
                   offenders with disabilities and 12 for parolees.

                Includes integrated financing from HUD McKinney
                 Homeless grants, Low-income Housing Tax Credits, IL
                 Dept. of Human Services, IL Dept. of Corrections, and

                Conducts “in-reach” into correctional facilities to
                 provide a smooth transition into supportive housing.

                Delivers tailored, comprehensive support services to all
                 residents, including mental health, substance abuse,
                 and employment services.

                Recidivism rates decrease from 50% to 20% for
                 participants in their programs.
Sanctuary Place

                     63 SRO Units
                     6 3-bedroom
                     For women who
                      are formerly
                      incarcerated and
                      have a history of
                      domestic abuse,
                      substance abuse
                      or mental illness
Grais House- Chicago, IL

                            The 44-unit
                           residence gut-
                           building provides
                           housing and on-
                           site supportive
                           services for
                           individuals with
                           psychiatric and
                           substance use

                           Target- SMI Dual

                           Service Provider
Rowan Trees- Chicago, IL
                            45 units: 6 one-bedroom units
                           that are handicap accessible
                           and 39 efficiency studios
                           Target- SMI Dual Diagnosis

                           Service Provider Thresholds
Sanctuary Place SRO – 320 foot
studio apartments
What makes Good Housing That
Can Serve Ex-Offenders?

      First rule- Have it fit into the neighborhood
      Balance the need for specialized services with
       the need to have it fit into the neighborhood
      Make it a home with services and not a program
      Help people to live and integrate into the
      Encourage your house to enhance the
       neighborhood and participate in the
      Block clubs, picnics for your neighborhoods
What makes Good Housing That
Can Serve Ex-Offenders?

   Like other permanent housing but incorporates
    Case management and Counseling Linked with a

      continuum of services beginning inside the
      correctional facility
    Prison and jail-based transition planning services

      provided in coordination with reentry
    Blend with parole- Use Law Enforcement

      Positively and Collaboratively
A Range of Services to Support
Tenants in Their Goals

     A broad array of services needs to be available:
      – Mental health and substance use management and
      – Vocational and employment
      – Money management & benefits advocacy
      – Coordinated support / case management
      – Life skills
      – Community building and tenant advocacy
      – Medical and wellness
      – Parenting and child custody supports
      – Educational and psychological support and other
        family services
Most good programs do not
require abstinence

      The most effective programs use a harm
       reduction approach starting where a person is at
       and meeting their needs in the order the person
      Slower but more effective in the long run
      Requires that services be available when
Stages of Change Define Substance
Use, Mental Health, & CJ Involvement

       Willingness to change or accept and use services
        varies among individuals and across time within
       This willingness follows predictable patterns and
        can be labeled as stages of change
The Stages of Change

 •   Pre-Contemplation-Who, me?
 •   Contemplation-I can handle it.
 •   Preparation-I have a goal.
 •   Action-I am doing this.
 •   Maintenance-Hey, it works!
 •   Lapse (Relapse)-Here’s what worked.
Eviction Free Living is a goal of
good programs

    There is a tremendous emphasis on avoiding
    eviction in good programs
    Focus is on meeting the person‟s needs using a

     team approach- increased outreach and active
     listening and problem solving
    A Case-work approach

    Private funding to assist with rent- Focus on

     staying housed no matter what- Build services
     around the person- Volunteers can do this-
     Consumers can do this- Mission based.

     Aftercare needs to be designed to ensure continued
      treatment and duplication of the necessary components of
      inpatient hospitalization while eliminating unnecessary
     Members need their medication all the time- Jail and
      criminal justice interventions interrupt this access
     Good Case Management figures out how to use existing
      resources and to examine available resources to fit a
      person into his environment.
     Boundary Spanners (Steadman)
Medication Means

    Access to Medication (Before Jail, After Jail, In Prison, After
     Prison, Private, Shelters…)
    Access to Payment for Medication
    Access to Understanding of Medication
    Access to Necessary Supervision of
     Administration ad Storage of Medication
    Access to Necessary Monitoring of Side Effects
     and Adjustment of Medication on Demand
National Examples of

                City of New York
                   State of Ohio
             Los Angeles County
          Cook County/Chicago
               State of California
     Supportive Housing Projects
And so CSH Began the Returning Home to
help develop PSH for Ex-Offenders

    Begun in Spring of 2006, and largely funded
     through grant from Robert Wood Johnson

    Primary focus on Los Angeles, Chicago, and New
     York City

    Additional work in Michigan, New Jersey, Ohio,
     Rhode Island, and Minnesota

    $2.4 million to be re-granted to partners “on the
    Goal is to create at least 1,000 units of permanent
     supportive housing in three years- 400 in Illinois

    Advisory Board includes Assistant IDOC
     Commissioner Deanne Benos and Judge Biebel
     from Cook County.
State of Texas

      State of Texas refused to invest in building new
      This is known as the Texas Justice Reinvestment
       Initiative informed by a collaboration with the
       Council for State Governments
      Instead invested in mental health and substance
      Expect 65.1 million dollar savings by 2012
City of New York

   Frequent Users Service Enhancement (FUSE) pilot program serving
    100 “frequent users”

   Rigorous data integration efforts to identify “frequent flyers”

   Collaboration between homeless services, corrections, mental health
    and housing authority.

   Targeted in-reach and outreach to engage them and place them in
    supportive housing. A network of providers created to engage and
    house the frequent users.

   JEHT Foundation and multiple public sources of financing

   Cost evaluation by John Jay College
Ohio Dept. of Rehabilitation and Corrections

       ODRC-led pilot focused on placing 85 people
        with mental illness exiting prison into supportive

       $3 Million Investment over three years

       Targeted prison in-reach programs

       CSH coordination SH provider network

       Engagement of mental health and housing
Los Angeles County

LA County Sheriff’s Dept. Pilot Program ($1.5M)

   LASD investment to support the integration of
    corrections, housing, and human services

   Extensive jail “in-reach” to identify inmates with serious
    mental illness and link to community

   Network of supportive housing providers to collaborate
    with LASD and mental health agencies

   Accessing rent subsidies
Cook County, Illinois

   Pilot targeted at 120 frequent users of Cook County Jail and

   Collaboration between Sheriff‟s Office, IL Dept. of Mental Health,
    City of Chicago.

   Data integration and client identification efforts underway. In-
    reach conducted by providers and Cook County Jail.

   Housing subsides from the City of Chicago, mental health
    services from the state.

   Rigorous random assignment study with Urban Institute
State of California

   Pilot program included in FY08 budget with bi-partisan support
    and support from Governor‟s office.

   To be administered by CA Department of Corrections &

   Pilot target approximately 225 homeless, mentally parolees from
    state prison.

   Focus on stabilizing parolees in housing with the necessary

   Working to coordinate and leverage resources with county
    mental health and supportive housing providers.
   Thanks for your Interest and Attention to this
   You can make a difference by making your
    –   Safer in the long run
    –   Saving money over repeated institutionalization
    –   Improving lives
    –   Doing the right thing
Examples of Resources
Available on CSH Website

      “A Guide to Reentry Supportive Housing: A Three Part
       Primer for Non-Profit Supportive Housing Developers,
       Social Service Providers, and Their Government
      “New Beginnings: The Need for Supportive Housing for
       Previously Incarcerated People”.
      “Preventing Homelessness through Discharge Planning”.
      “Reentry Policy Council Report”
      Link to HUD Resource
       – www.hud.gov/offices/cpd/homeless/library/bibliobyauthor.pdf
Useful Resources

   National Institute for Corrections
     – ABT- Transition from Prison to Community
   US Department of Justice
   GAINS Center- Technical Institute on Co-Occurring
    MISA Disorders- Jails- 800-311-4246
        www.prainc.com, Hank Steadman
   Corporation for Supportive Housing (www.csh.org)
   SAMHSA- 800-729-6686
     – Best Approach to Re-Entry
     – Continuity of Offender Treatment
   Bazelon Center for MH Law- 202-467-5730
Useful Resources

   American Jail Association / American Correctional
   Urban Institute- Policy and Profile Papers on Prison
    Re-entry Issues
   Human Rights Watch- www.hrw.org
   Center for Mental Health and Criminal Justice
   TAPA Center / National Alliance to End
   Criminal Justice / Mental Health Consensus Project-
For more information, contact:

   John Fallon
   Program Manager, Re-Entry
   “Returning Home Initiative”
   Corporation for Supportive Housing
   203 N. Wabash, Suite 410
   Chicago, IL 60601

   T 312.332.6690 x21
   C 773.719.4601
   E john.fallon@csh.org

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