Frequent reference has been made throughout this paper to specialized mental health services. These may include a variety of service structures that serve or focus on chronically homeless people with SMI, including assertive community treatment (ACT) teams, structures in which a mental health agency is in the lead, and structures that integrate mental health, physical health, and substance abuse services with funding to cover care coordination and integration. Among the specific services that the homeless people in Group 3 may receive, but that usually are not available to people in Groups 1 and 2, are:
Monitoring and therapeutic interventions that help clients achieve and maintain mental health-related goals.
Helping clients develop functional, interpersonal, family, coping, and community-living skills.
Using evidence-based techniques such as motivational interviewing to help clients use appropriate health and behavioral health services, change behaviors associated with health risks, and avoid crises that lead to loss of housing.
Helping clients with co-occurring substance abuse disorders develop plans and strategies to prevent relapse.
6.2.1. Assertive Community Treatment and Similar Teams for People in Group 3
Some mental health agencies working with PSH tenants with SMI use ACT or similar models of team-based services. In Illinois, for instance, Medicaid reimbursement is available for ACT teams, which are supported by a psychiatrist and include at least one nurse, one person in recovery, and team members with training or certification in substance abuse treatment and rehabilitation counseling.
Illinois also provides Medicaid reimbursement for services provided by CSTs. CSTs have staffing similar to ACT but without a nurse as part of the team and with more flexibility in training or certification requirements for other team members. CSTs and their equivalents are less expensive than ACT teams because of these staffing differences.
California counties use state funding provided through the states MHSA to establish a similar team model called Full Service Partnerships (FSP). FSPs may include case managers, a peer counselor, a psychiatric nurse practitioner, a physicians assistant (often from a partnering FQHC), an employment specialist, housing staff, a supervising social worker, and administrative support.
In the communities visited, team models for PSH tenants with SMI often incorporate a psychiatrist or psychiatric nurse practitioner who can prescribe and monitor medications. Usually, at least one team member will have a specialized role and expertise in addictions recovery or employment promotion. Team members share responsibility for a group of clients, and team meetings are used to share information and develop collaborative strategies for providing services. Staff-client ratios are usually kept at 1:10 to 1:15.
In the communities visited, mental health service-providers most often use team models such as ACT, CST, and FSP with scattered-site housing in which PSH tenants hold their own lease. The providers help their homeless clients qualify for rent subsidies in the form of Shelter Plus Care certificates, local rent subsidies, HCVs, or, most recently, Supportive Housing (VASH) vouchers for homeless veterans. Some mental health agencies and other PSH providers master-lease apartments that give landlords greater assurance that the agency will provide backup and tenant-landlord liaison services. These arrangements allow the providers to house homeless people with very poor credit and eviction histories or criminal backgrounds that would deter most landlords from renting to them.
Mental Health Agencies in the Lead: Thresholds and Trilogy in Chicago
Two CMHCs in Chicago operate PSH programs to end homelessness and support housing retention for their clients with SMI. Thresholds and Trilogy are Medicaid providers under the states regulation for Medicaids Rehabilitation Option. Most formerly homeless clients of these programs live in scattered-site housing throughout the community, with rents most commonly subsidized by Shelter Plus Care. These two agencies also operate some facility-based projects for which HUD SHP grants support the housing and some of the services. Both offer integrated mental health and addictions recovery services.
These two CMHCs have long histories of serving homeless people with SMI and helping them secure and retain housing. Their work has become increasingly difficult to fund, however, due to changes in Medicaid and state funding that limit reimbursement for the time it takes to establish and maintain trusting relationships with clients. In addition, even with sophisticated providers such as these, the mental health-related care they give is not usually integrated with primary health care. Trilogy recently received a SAMHSA grant to integrate its mental health services with primary care and will be working with Heartland International Health Center (HIHC) to do so. HIHC will add a primary care provider to one of Trilogys mental health service sites.
6.2.2. Mental Health Agencies as Leads for PSH for People in Group 3
Among the most common combinations of housing and services for chronically homeless people with SMI are structures in which a mental health agency takes the lead, as shown in the following examples.
A mental health service agency develops and operates9 its own dedicated PSH projects (i.e., it owns and manages the housing), uses these PSH units to house its own homeless clients with SMI, and directly provides those clients with nearly all the community-based mental and behavioral health services they need.10
A mental health service agency has access to rent subsidies that it uses to help its homeless clients get apartments in the private market, and directly provides those clients with community-based mental health/behavioral health services. Sometimes, the scattered-site units are located within an affordable housing complex (the mixed-use or integrated model). The rent subsidies are usually Shelter Plus Care and sometimes HCV or state or locally-funded rent subsidies for scattered-site models.
For many mental health organizations, providing supportive services in PSH has been a logical extension of their services to support recovery for their SMI clients, and an evolution of practice to incorporate PSH as a SAMHSA-approved Evidence-Based Practice for persons with SMI.
6.2.3. Integrated Care for People in Group 3
Integrated care may be said to exist when mental health, substance abuse, and primary care are delivered by staff who work together to provide PSH tenants with comprehensive care delivered with attention to the whole picture. The staff may be from a single agency or from different agencies. Dental and eye care and clinical pharmacy services are also sometimes part of the mix. Many practitioners consider integrated care to be the gold standard, particularly important when caring for people whose many complex and interacting conditions often do not improve unless all aspects of the clients situation are taken into account simultaneously.
From a housing perspective, integrated care also needs to assure that caregivers consider housing issues as factors when making decisions about how to help a patient or client, or else the decisions will not really be based on the whole picture. In many of the programs visited, housing case managers were part of the team in completely integrated approaches to supporting PSH tenants.
Providing Substance Abuse Services to Chronically Homeless People with Serious Mental Illness
Challenges of integrating care for mental illness and substance use disorders are examined here, in relation to people in Group 3, because many chronically homeless people with SMI also have substance use disorders. From the clients perspective, if both mental health treatment and treatment for co-occurring substance use disorders are needed, offering them in an integrated way is the most likely to produce improvement in both conditions. Too often, mental health providers want a persons substance use to be cleared up before they will work with the person on mental health issues, and substance use treatment providers do not want to work with anyone whose mental illness is not controlled. The result--many chronically homeless people do not get any treatment at all.
It can be challenging to provide housing for chronically homeless people with both SMI and substance use disorders, as housing providers traditionally screen out people whose substance abuse is current. Therefore, many PSH service-providers have integrated harm reduction principles into low demand or Housing First models of PSH. In this type of PSH, sobriety or participation in substance abuse treatment is not a requirement for getting or keeping housing. It is often a goal of individual treatment plans, however.
Using Harm Reduction Principles
Heartland Alliance and HHO in Chicago and its partner, AIDS Housing of Chicago, have been working with local university faculty to develop a strategy based on Harm Reduction principles. The assessments and service protocols derived from these principles are incorporated into all program practices and make it possible to address client issues and measure progress quite precisely along dimensions of mental health, substance use, and primary care, as well as employment and other important dimensions.
Mental health service-providers working with PSH tenants nearly always incorporate some care for co-occurring substance use disorders because so many of their clients have both. ACT and similar team models usually include both mental health and substance abuse treatment expertise, and they give consideration to how the two conditions are interacting when working with clients. Funding sources sometimes cover both mental health and substance abuse care. Some states have created behavioral health carve-outs in their Medicaid programs, one rationale for which may be to allow integrated treatment. Nonetheless, PSH service-providers who want to integrate mental health and substance abuse services often face challenges:
The mainstream funding and Medicaid reimbursement mechanisms for mental health services often do not provide payment for services that focus on substance use problems.
Funding mechanisms for substance use services are usually limited to services provided in designated substance use treatment facilities or treatment programs. This makes it impossible to blend these sources of funding into more-flexible models that integrate attention to substance use problems with other services provided in PSH or in other settings that are not substance abuse treatment facilities.