Health, Housing, and Service Supports for Three Groups of People Experiencing Chronic Homelessness. 6. Group 3: Eligible for Specialized MENTAL/BEHAVIORAL Health Services Under Medicaid


The condition known as “serious mental illness” differentiates Group 3 from Groups 1 and 2. SMI usually involves a diagnosis of psychosis or major affective disorder and duration of at least a year, either already experienced or anticipated. Along with these two elements, the condition must create substantial disability, meaning that it significantly impedes a person’s ability to function in the world, including earning enough to be self-sufficient and be able to take care of oneself.

Currently available housing and service structures appear to best serve chronically homeless people, with an SMI; many PSH programs serving Group 3 operate under the umbrella of public mental health systems, as opposed to providers in homeless assistance systems that provide most of the PSH serving Groups 1 and 2. Why, among chronically homeless people, are those with SMI best served by current structures? At least four reasons suggest themselves. First, public service agencies exist--state and local mental health authorities--that are charged with assuring the safety and well-being of this group of people. SMI is the standard against which state mental health authorities judge an adult’s eligibility for public mental health services. Eligibility carries with it access to specialized mental health services and, in some jurisdictions, also access to various types of housing.

Second, long-term residential care has historically been a responsibility of public mental health agencies, carried out (though not always necessarily well), through state or county mental hospitals or other residential care facilities. Only the U.S. Department of Veterans Affairs has responsibilities even roughly comparable to public mental health agencies and, until very recently, its responsibilities did not extend to providing permanent housing or ending homelessness. No other agencies with a similar charge exist for most other people with disabling physical conditions or substance use disorders.

Third, the SMIs of people in Group 3 qualify them for SSI--a critical source of financial support--in addition to the services of state and local public mental health systems.8 SSI gives people in Group 3 an income from the federal program, as well as supplements for certain types of housing arrangements in some states. Providers who serve the people in Group 3 often have the clinical documentation to help them establish eligibility for SSI. With SSI income, chronically homeless people with SMI can help pay for their own housing, making it more financially possible for mental health service agencies to offer housing.

Fourth and finally, SSI qualifies chronically homeless people with SMI for Medicaid and often for specialized mental health services, providing a funding source for services that supplements county mental health contracts and federal grants, if the service-providers already are or are able to become certified as Medicaid providers.

People with SMI and the mental health agencies that serve them were the focus of three major research-demonstration and systems-development efforts in the early days of PSH (1990-1995). Those efforts examined the question of what types of housing worked for people with SMI, as well as what aspects of public systems were best able to guide homeless people with mental illnesses toward supportive housing and help them to stay there. They were:

  • Demonstrations in five communities to examine promising practices in housing-plus-services for people with SMI (Shern et al., 1997), funded by the National Institute of Mental Health under a mandate included in the Stewart B. McKinney Act of 1987.

  • A complex demonstration program, the Robert Wood Johnson Foundation (RWJF) Program on Chronic Mental Illness, co-funded by the RWJF and HUD. In Ohio, the demonstration was a partnership with the Ohio Department of Mental Health (DMH) to establish PSH programs for homeless people with SMI in nine Ohio cities (Goldman, Morrissey, and Ridgeley, 1994).

  • The ACCESS demonstration in nine intervention and nine comparison communities had the same purpose (Randolph et al., 2002; Rosenheck et al., 2002; Rosenheck et al., 1998).

The results of all three demonstrations helped to establish PSH as a useful practice for homeless people with SMI. They had the additional outcome of helping the participating communities to establish working relationships among previously isolated agencies, many of which evolved into today’s most well-established and innovative integrated services models.

Also contributing to the focus on homeless people with SMI were large public investments such as the New York/New York Initiative, the Special Homeless Initiative in Massachusetts, and California’s Integrated Services for Homeless Adults with Serious Mental Illness program (known locally as “AB 2034” after the Assembly bill that created it).

  • The New York/New York Initiative, begun in 1991, is a city-state agreement, now in its third iteration and negotiating its fourth, to fund PSH for people with SMI in New York City. (Houghton, 2001).

  • Massachusetts’s Special Homeless Initiative began in 1992 with a $1 million legislative appropriation to the DMH to support a pilot housing-with-services program for homeless people with SMI. It grew to more than $20 million a year by the mid-2000s. Its funding has contributed to doubling the number of housing units for people with SMI in Massachusetts and simultaneously shifting the type of housing supported by the DMH from group homes and “treatment” settings to independent and semi-independent living in the PSH model (Burt, 2006).

  • In California, AB 2034 focused on homeless persons with SMI, and programs often provided immediate offers of housing as well as the services to keep people in it. Programs throughout the state were able to get more than 80 percent of their clients off the streets, demonstrating improved well-being as well as cost savings (Burt and Anderson, 2005; Mayberg, 2003).

The evidence from early demonstrations and the lead taken by pioneering states and communities have contributed to the situation prevailing today, in which a substantial portion of the PSH created across the country is specifically targeted to adults with SMI because the money for the housing, and often the services, comes from or through, mental health agencies. Much of the funding for capital and/or operating costs of the housing component of PSH comes from the budgets of state or local (usually county) mental health agencies, which often are legally restricted to serving people with SMI. In addition, many public mental health agencies control housing resources from HUD through successful applications for SHP funds as part of annual Continuum of Care submissions, including PSH projects and Shelter Plus Care subsidies. Control over entry into housing is often through a mental health system gatekeeper, who either must refer homeless people with SMI to the PSH (after first determining their eligibility against clinical criteria) or must give final approval for people referred for PSH from community-based service-providers.

In recent years, states and communities have launched initiatives to end chronic homelessness that add some special targeting priorities to the general category of homeless or chronically homeless people with SMI. Some of these initiatives focus on reducing chronic homelessness, some focus on reducing unnecessary and expensive use of crisis public services, and some do both. The targets include:

  • Very vulnerable homeless adults with SMI who are living on the streets or staying in emergency shelters. Many but not all have been homeless long enough to qualify as chronically homeless (County of Los Angeles, 2010; Moore, 2006; Strebnick, 2007).

  • Homeless frequent users of psychiatric emergency rooms, inpatient care, or sobering centers, or those who are being discharged from inpatient hospitals after relatively short stays for acute medical and/or psychiatric conditions (Corporation for Supportive Housing, 2010; Larimer et al., 2009; Linkins, Byra, and Chandler, 2008).

  • Homeless adults with SMI who are cycling among jails, shelters, and street homelessness (Burt, 2009, 2008b; Roman, Fontaine, and Burt, 2010).

  • Chronically homeless persons with SMI who “have not been engaged in or effectively served by the traditional mental health system.” This group is a priority for California’s Mental Health Services Act (MHSA) funding (Burt, 2008c; Burt and Hall, 2010).

  • Persons with SMI who have been living in restrictive settings (nursing homes, Institutions for Mental Disease, psychiatric hospitals, board and care facilities) and have no other housing options. Many are not homeless as defined by HUD, but may be eligible for PSH and other forms of housing assistance funded through their mental health system (Pathania, 2009).

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