HOUSING AND THE DEPARTMENT OF MENTAL HEALTH

Knowledge about Available Programs Can Lead to Appropriate Housing

by Larry Fletcher, Consumer Services, St. Louis Psychiatric Rehabilitation Center

Take a look at any needs assessment involving Missourians with mental illness and you will consistently find housing at or near the top of the list. Whether the need is for rental assistance for scattered-site apartments, congregate housing with specialized mental health services, semi-independent living arrangements or high quality assisted living, the common themes are affordability and limited supply. The Missouri Department of Mental Health (DMH) has taken a two pronged approach to the housing needs of its consumers: improved access and resource development.

Supported Community Living

The issue of access is addressed largely through the Comprehensive Psychiatric Service (CPS) Division’s Supported Community Living (SCL) Program. Through a network of contract providers including residential care facilities, assisted living facilities, scattered site apartment programs and skilled nursing facilities, SCL provides assistance with rent, room & board and other housing-related expenses.  Points of entry to the SCL program are the Department’s network of Administrative Agents and Community Psychiatric Rehabilitation Centers. In the Eastern Missouri Region, these providers are BJC Behavioral Health in St. Louis County and South St. Louis City; Hopewell Center in North St. Louis City; Crider Center in St. Charles, Franklin, Warren and Lincoln Counties; Comtrea in Jefferson County; and Places for People, Independence Center and Adapt of Missouri, all of which operate primarily in St. Louis City and County.  Professional staff at these agencies assess the consumers’ needs, including their housing needs. If assistance in accessing and funding suitable living arrangements is needed, the community-based agency completes some paperwork and refers the individual to the regional SCL office. Community-based providers are all familiar with SCL’s network of residential settings. Once the individual is placed, the staff of these agencies continue to provide them with clinical care and supports in whatever setting is most suitable.  Some of the housing settings more commonly used by SCL participants include:

• Residential Care Facilities and Assisted Living Facilities These are licensed residences that provide room, board and protective oversight, including 24-hour staffing. Residents share living space with as few as 5 and as many as 80 other residents. Medications are stored by the facility and administered by trained staff.  Residents may leave these facilities, but staff are required to be reasonably certain of where their residents are at all times. Payment sources for these settings are typically the individual’s SSI/SSA benefits (if applicable), a cash grant through the Department of Social Services and the DMH subsidy through SCL. The participant receives a personal allowance, usually $55 per month, and a transportation allowance, usually $38 per month. SCL also may pay for medications and medical supplies not covered by Medicaid. SCL contracts with 45 Residential Care and Assisted Living Facilities in the 7-county Eastern Region of DMH.

• Independent Apartment Programs Consumers who are capable of maintaining their own apartments (with supports as needed) can receive a rental subsidy through the SCL Program. Recipients of rental subsidies are required to register for HUD Section 8 vouchers whenever the waiting lists are open to new registrants, with the objective of “graduating” individuals from the SCL program to other housing subsidies. Two funding mechanisms are used to subsidize apartments:

HOUSING AND THE DEPARTMENT OF MENTAL HEALTH

• Housing Voucher Consumers with income at the level of basic SSI or more usually participate in the Housing Voucher program. This program is modeled after the HUD Section 8 program, whereby the consumer pays 30% of his/her income for rent and SCL pays the balance up to an established Fair Market Rent (FMR). Unfortunately, due to funding limitations the FMR used by SCL is lower than the HUD amount and does not include a utility allowance. Under the Housing Voucher program payments are made directly to the landlord by DMH. The participant can be his/her own payee for benefits or can designate a representative payee. Seven agencies in the Eastern Region can access SCL housing Vouchers.

• Traditional Apartment Program An individual without income also can participate in SCL, as long as an application for benefits is in process. In the traditional apartment program, monthly payments are made to the consumer’s community-based provider for rent (up to $335 for one bedroom), utilities (actual), food ($155), transportation ($38) and personal allowance ($51.50). Case managers work with the consumers to budget funds and pay bills. If the individual later becomes eligible for benefits and a back payment is forthcoming, the Department recovers the cost of care from these funds.  Seven contracted apartment providers are in the Eastern Region.

• Skilled Nursing Facilities These facilities are appropriate for consumers who have a high level of medical need in addition to their mental illness. Nursing care on a 24/7 basis is available at these facilities in addition to room, board and protective oversight.  Some nursing homes have locked behavioral units for individuals whose behaviors rule them out from residing in less restrictive settings.  Nearly all SCL residents of skilled nursing homes are on Medicaid, which serves as the primary funding source, with SCL providing an extra layer of oversight and maintaining availability in the event the individual can graduate to less restrictive environments.  Thirty-three skilled nursing facilities are in the Eastern Region with SCL contracts.

As director of a regional SCL office I am well acquainted with the challenges involved in administering these services. Chief among these is the one you would expect: limited financial resources. Efforts to keep as many roofs over as many heads as possible leads us to stretch the available dollars in such a way that results in unwanted side effects.  Despite these limitations, considerable effort goes into maintaining the quality of housing in all the settings we fund. All residential care and assisted living facilities that contract with SCL are licensed by the Division of Health and Senior Services, and nearly all are also licensed by the Department of Mental Health. Oversight by the licensure offices is supplemented by regular visits by community-based case managers as well as SCL monitoring staff. All facilities are required to self-report serious incidents and potential cases of abuse and neglect, and SCL staff regularly follow up to investigate these reports. Apartments must pass a housing quality inspection in order to qualify for DMH funding. A recent development in maintaining quality housing is the addition of an annual apartment inspection to ensure that conditions have not deteriorated over time.

Department of Mental Health Housing Team

Operating on a statewide as well as a regional basis, the Housing Team works with all three of DMH’s divisions to help link mental health services consumers to rental assistance through the Shelter Plus Care program. The Team also makes efforts to expand housing options; assists in creating partnerships between housing developers and non-profit agencies in developing affordable rental units statewide; and works to increase rental assistance and homeownership opportunities for mental health services consumers.  Shelter Plus Care (SPC) is a HUD-funded rental assistance program that brings together permanent housing and mental health services for people who are both homeless and disabled. SPC is rental assistance; program participants pay 30% of their income toward rent while SPC funds pay the balance. If a program participant has zero income, SPC pays 100% of the rent. SPC funds also can be used to pay for a security deposit up to the value of one month’s rent. While participating in Shelter Plus Care, program participants are expected to work on increasing their incomes through employment or by accessing mainstream resources such as Social Security or SSDI. Program participants must have some form of case management while in Shelter Plus Care.  The Housing Unit is also a resource for technical assistance for agencies seeking to develop affordable and/or supportive housing for people with disabilities anywhere in the state. Advice on housing options, funding issues and numerous other critical aspects of a project can be provided. 

Most participating apartment dwellers are paying substantially more than the recommended 30% of their income on housing. Throughout the state our subsidies for residents of residential care or assisted living facilities are kept low in order to stay within budget; this restricts our access to the higher quality, more expensive facilities. Budget restraints also hinder our efforts to expand our array of available housing options, such as semi-independent apartments, if those options are more expensive than our existing, more conventional housing models.  The Housing Unit maintains a website that provides further information as well as links to funding sources and other helpful housing information.  Visit them at http://www.dmh.mo.gov/ada/housing/housingindex.htm.

Conclusion:  On a number of fronts, some exciting developments are occurring in the area of housing for Missourians with mental illness. The efforts of the Housing Team are bearing fruit in the form of numerous projects springing up throughout the state. Of the 1400+ consumers supported by the SCL program, well over half are now in independent apartments, a setting that is usually preferred over congregate settings.  We have been able to develop several new facilities under the Intensive Residential Treatment Services model, including Psychiatric Individualized Supported Living settings and clustered apartments.   We hope to solicit the support of NAMI as these projects evolve.