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Housing for people with mental illness is as much a place as it is an ongoing process to engage and promote their recovery. Helping consumers easily access and maintain stable housing must remain at the heart of any service system.

The suitability of certain types of housing for people with mental illness is a discussion as relevant today as it was thirty years ago. Recently, a New York State judge made a landmark decision regarding the rights of people with mental illness residing in adult homes in New York City (Disability Advocates, Inc. vs. NYS Governor David A. Paterson et al, 2009). He ruled that the adult homes provide little opportunity for people with mental illness to integrate within the community. The judge also noted that keeping them in adult homes is more expensive by several thousand dollars per person per year than providing these individuals with supported housing and community services. The court ordered the state to create a plan to transition these residents from adult homes into supported housing or smaller group residences.

This decision, though right now limited to New York City, could set a nationwide precedent,particularly in states that rely heavily on board and care homes, as well as nursing homes, to house people with mental illness. Given the potential changes ahead, it is vital we understand the questions and issues posed by supported housing. What follows is a brief discussion of four critical questions that every mental health and housing provider must consider in order to create stable housing and successful community inclusion for people with mental illness.

What works best for different people?

The Housing First model has had an undeniable positive impact on how we approach housing for people with mental illness. This model unconditionally offers consumers an apartment of their own and then crafts personalized supports for them that range from flexible case management to community-based mobile treatment in the form of Assertive Community Treatment. Since not everyone wants to live in his or her own apartment, a range of options that includes small congregate housing programs and other alternatives with flexible supports is necessary and appropriate.

What clinical supports do clients need in communities and how best can these be provided?

A recent article in the New York Times (For Families of Mentally Ill, Mixed Feelings Over Push Away From Adult Homes, October 8, 2009) voiced concerns pertaining to the court’s ruling on adult homes. Relatives of people living in adult homes fear that their loved ones do not have the skills to survive in their own apartments and have previously failed in similar circumstances.

Supported housing that provides small studio apartments within congregate buildings might address those concerns. This type of congregate model has been shown to be very cost-effective and programmatically responsive for clients who otherwise might not be successful in a scatter-site apartment arrangement. These buildings generally consist of approximately 40 studio apartments and, while congregate, are small enough to foster a sense of community inclusion and privacy and maintain a very high retention rate. People who live in these small buildings typically have access to a front desk attendant round the clock.

How can supported housing and its necessary supports best be financed, especially in a recessionary economy?

Wrapping in appropriate supports for people with serious mental illness living in communities can be expensive — but by no means more expensive than the alternative. Most state budgets are strained and the largest single cost escalator is Medicaid, especially for people with serious mental illness. Medicaid costs are ballooning for people with mental illness because of the heavy utilization of hospital emergency rooms and subsequent hospitalizations due to avoidable medical and psychiatric emergencies.

In an effort to stabilize medical care received by people with mental illness in the community and reduce emergency costs, there is a national movement to create “medical homes.” Medical homes provide continuous and consistent medical care to people with mental illness. However, stable consumer housing is a necessary precursor to the implementation of an effective “medical home” intervention.

Supported housing is less expensive than all costs associated with adult home care. However, there needs to be a means of aggregating all available funding into a single payer silo and allocating a fair share to supported housing. Otherwise, it will be difficult to make supported housing universally available. One major barrier is that Medicaid defines eligible costs as those that are medically necessary, thereby limiting Medicaid participation to an illness model. It would be more productive and cost-effective to permit Medicaid’s participation in prevention planning and implementation. Additionally, supported congregate housing, in contrast to the general housing market, requires a capital investment to finance the building of efficiency unit-housing facilities and a long-term commitment to support affordable rents despite market escalations.

What types of risk management approaches most effectively respond to legitimate community safety issues?

It only takes one or two well-publicized allegations of crime to further ingrain the stigma against people with mental illness. Widespread use of supported housing will force community-based agencies to train case management staff differently and develop clinical support tools to assist in consumer risk assessment and monitoring. Additionally, for parents with mental illness raising their children in supported housing, case managers with family development skills will be required to ensure child safety within the context of supporting the whole family.

Many of the lessons we at the Institute for Community Living have learned about community-based housing were gained through our work with the people we serve. One of the most important design elements is to enlist consumer participation in housing decisions. It is the hope of all mental health care providers that an ongoing conversation surrounding these topics will raise more questions than provide answers, thereby fueling the national dialogue on how to help people with mental illness — an incredibly diverse population — best integrate within the community.