Housing Services

• What evidence is available to support the service?
• The Current Reality
• The Call For State and Local Leadership
• The Cost Effectiveness of Supported Housing
• Contact Information

Is there research, evidence-based practice, best practice, or literature to support Housing Services?
There is a wealth of literature, both national and Tennessee-specific, to support the essential role of stable, safe, quality, and affordable permanent housing in the recovery process for persons with mental illness and co-occurring disorders. Research indicates the absolute necessity of financial assistance/rental subsidies and support services to ensure that consumers have the opportunity to live independently in integrated community setting. As well, research indicates that not only are consumers served more effectively by supported housing, but they also are served more efficiently. Emerging evidence shows significant cost savings due to reduced use of high cost service by persons residing in housing that includes wrap-around support services.

The key writings and quotes from those writings that are presented here, are only a small sample of current literature, research and best-practice models that have informed and shaped the philosophy and expansion of the Department of Mental Health and Development Disabilities’ Housing and Homeless Services programs. This section should be referenced as all or part of the answer to the question above (in bold) for each of the program descriptions in the housing/homeless services category that follow.

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The Current Reality
Mental Health: A Report of the Surgeon General stated that “housing ranks as a priority concern of individuals with serious mental illness. Locating affordable, decent, safe and appropriate housing is often difficult, and out of financial reach. Stigma and discrimination also restrict consumer access to housing.”

The President's New Freedom Commission Final Report confirmed that “the lack of decent, safe, affordable, and integrated housing is one of the most significant barriers to full participation in community life for people with mental illnesses.”

By comparing SSI monthly income (equal to $545 in 2002) to the U.S. Department of Housing and Urban Development Fair Market Rents across the United States, the Technical Assistance Collaborative’s Priced Out in 2002 documented that:

• In 2002, for the first time ever, the average national rent was greater than the amount of income received by Americans with disabilities from the SSI program. Specifically, the average rent for a modest one-bedroom rental unit in the United States was equal to 105 percent of federal SSI benefit amounts – up from 98 percent as reported in Priced Out in 2000.
  
• In 2002, people with disabilities were priced out of every housing market area in the United States. Of the nation’s 2,702 market areas, there was not a single area where modestly priced rents for efficiency or one-bedroom units were affordable for people with disabilities receiving SSI.
  
• People with disabilities continue to be the poorest people in the nation. As a national average, SSI benefits in 2002 were equal to only 18.8 percent of the one-person median household income.
  
• Rental housing costs continued to increase much more rapidly than the income of people with disabilities. From 2000 to 2002, rental housing costs rose at twice the rate of SSI cost-of-living adjustments. In some high-cost housing market areas, increases in rental housing costs were six times higher than SSI benefits increases.
  
• People with disabilities receiving SSI benefits needed to triple their income to afford a decent one-bedroom unit in 2002. This finding is based on the National Low Income Housing Coalition’s 2002 Housing Wage of $12.08 per hour, which is approximately 3.5 times higher than the SSI equivalent hourly wage of $3.43.
  
• In Tennessee, a person on SSI disability will need 80.8% of their monthly income to rent a modest one-bedroom housing unit.

The Criminal Justice Task Force Report on Mental Health and Criminal Justice in Tennessee recommended that “the TDMHMR (now TDMHDD) through the Office of Housing Planning and Development (now Office of Housing and Homeless Services) work toward increasing appropriate housing options for persons with serious mental illness who are engaged with the criminal justice system.”

Findings of the THDA SJR 279 Housing Report in 2000 concluded:

• Approximately 15% of persons with severe and persistent mental illness receiving case management are housed inappropriately. One can assume that this percentage might be considerably higher among those other segments not receiving services at all, such as homeless persons.
  
• In all areas of the state and among every subgroup of the population surveyed, the primary barrier to appropriate housing was insufficient income to pay for monthly expenses.
  
• The type of housing most appropriate for the majority of the consumers surveyed is independent living units.
  
• A large proportion of persons awaiting release from Regional Mental Health Institutes cannot be discharged because there are not enough spaces available in appropriate licensed facilities.

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The Call for State and Local Leadership
The National Technical Assistance Center for State Mental Health Planning’s Housing for Persons with Psychiatric Disabilities: Best Practices for a Changing Environment established that:

• State and community mental health systems have a responsibility to focus on housing as a necessary component of recovery and community support.
• Housing planning should focus on permanent housing that is affordable.
• Planning for housing should be closely linked to planning for the supports that people need for recovery, and people with psychiatric disabilities and their families should have a central role in the planning process.
• The most effective approach to promoting recovery and integration is to combine professional services staffed by people with and without histories of psychiatric disabilities with peer support and consumer-operated services and natural support systems in the community.
• The leadership of the state mental health agency (SMHA) must view rental assistance as part of a larger strategy designed to increase access to integrated housing.
• Rental assistance activities should be developed in the context of an overall housing policy that supports a variety of activities designed to increase the availability of integrated housing. Helpful activities include assembling groups of stakeholders to assist in the development and oversight of state policy regarding housing and residential services.
• Housing discrimination against people with psychiatric disabilities is a major national problem that requires urgent attention.
• Legal protections and tools, such as those found in the Fair Housing Amendments Act, Section 504 of the Rehabilitation Services Act, and in provisions of the Americans with Disabilities Act, are often overlooked within both mental health and housing systems should be utilized as important tools for assisting people with psychiatric disabilities and to meet their housing needs.
• Education, information and training in these protections are of critical importance to consumers and family members as well as to housing and mental health staff.
• State and local mental health agencies should develop partnerships with housing finance and development agencies to increase housing access and supply.
• State mental health agencies should support the development of knowledge and skills necessary for accessing mainstream housing resources.
• Creative use of mainstream housing resources both new and existing (e.g., Community Development Block Grant, HOME funds), should be a priority of mental health and housing authorities.
• The leadership of the state mental health agency (SMHA) must view rental assistance as part of a larger strategy designed to increase access to integrated housing.
• Rental assistance activities should be developed in the context of an overall housing policy that supports a variety of activities designed to increase the availability of integrated housing. Helpful activities include assembling groups of stakeholders to assist in the development and oversight of state policy regarding housing and residential services.

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The Cost Effectiveness of Supported Housing
Results of a recent groundbreaking study by Dennis Culhane and his colleagues Stephen Metraux and Trevor Hadley, published by the Fannie Mae Foundation as Public Service Reductions Associated with Placement of Homeless Persons with Severe Mental Illness in Supportive Housing concluded that:

• “Supportive housing"—permanent housing with attendant social services—was in the past often considered prohibitively expensive, but has emerged as a good investment because it is shown to substantially reduce the use of other publicly funded services. For example, New York City established a comprehensive supportive housing program for homeless people with severe mental illness. A major study of the program calculated that long-term homeless people with severe mental illness used an average of $40,500 a year in public shelter, corrections, and health care services. For those placed in the permanent supportive housing program, the reduced use of acute care services nearly offset the costs of the supportive housing. Evaluations of similar programs nationally have found that most supportive housing programs for homeless people with mental illness boast retention rates of 80 percent up to one year following placement, while leading to significant reductions in hospitalizations and shelter use.
  
• The costs of providing supportive housing are nearly made up in reductions in expenditures for providing care in homeless shelters, acute psychiatric and medical services, and the public costs of incarceration. And the savings from reduced demand for services are only conservatively estimated, as a variety of nutrition and social services used by the study group were not tabulated. The equation also does not include the many non-financial benefits of providing supportive housing, such as the benefit from residents of supportive housing being more likely to secure voluntary or paid employment and an improved quality of life. Similarly, the social value of reduced homelessness, and of providing greater social protection for the disabled, is not included in this financial analysis.
  
• Persons with SMI could also be expected to reduce their use of hospital services following a housing placement, because persons who are receiving services would be in a better position to engage in regular outpatient regimens that would replace the need for hospitalization. Furthermore, if they are hospitalized, access to housing and support could reduce the length of stay in the hospital.

A 2003 study by Rosenheck, Kasprow, Frisman, and Liu-Mares titled Cost-Effectiveness of Supported Housing for Homeless Persons with Mental Illness showed that:

Supported housing, integrating clinical and housing services, is a widely advocated intervention for homeless people with mental illness. In 1992, the U.S. Department of Housing and Urban Development (HUD) and the U.S. Department of Veterans Affairs (VA) established the HUD-VA Supported Housing (HUD-VASH) program. Homeless veterans with psychiatric and/or substance abuse disorders or both were randomly assigned to one of three groups: HUD-VASH, with Section 8 vouchers (rent subsidies) and intensive case management; case management only, without special access to Section 8 vouchers; and standard VA care. Primary outcomes were days housed and days homeless. Secondary outcomes were mental health status, community adjustment, and costs from four perspectives. During a three-year follow-up, HUD-VASH veterans had 16 percent more days housed than the case management only group and 25 percent more days housed than the standard care group. The case management only group had seven percent more days housed than the standard care group. The HUD-VASH group also experienced 35 percent and 36 percent fewer days homeless than each of the control groups. There were no significant differences on any measures of psychiatric or substance abuse status or community adjustment, although HUD-VASH clients had larger social networks. From the societal perspective, HUD-VASH was $6200 more costly than standard care. Incremental cost-effectiveness ratios suggest that HUD-VASH cost $45 more than standard care for each additional day housed. Supported housing for homeless people with mental illness results in superior housing outcomes than intensive case management alone or standard care and modestly increases societal costs.

The Corporation for Supported Housing has been a forerunner in not only preparing leaders to commit to and direct efforts to develop supported housing, but also in supporting and publishing research to measure the cost effectiveness of supported housing nationwide. In remarks delivered at National Press Club launch of the Partnership to End Long-Term Homelessness, given on November 23, 2004, Carla Javits, President & CEO said, “Over the past 13 years, the data increasingly demonstrates that supportive housing is in fact a powerful solution. It has been shown to cut use of hospital emergency rooms and jails in half, double rates of tenant employment and improve health and mental health status.”

“New data from the Lewin Group also dramatizes the cost comparison. Lewin looked at the relative costs in nine states of a day in jail, a hospital bed, a mental hospital and a shelter as compared to a day in supportive housing -- a day in supportive housing costs $30 in Los Angeles, whereas a day in a mental hospital costs $607. And in Boston, a day in jail costs nearly three times as much as a day in supportive housing.”

“While everyone who is homeless for the long term obviously does not spend 365 days a year in jail—there is evidence that too many spend almost all their time bouncing among institutions without becoming stable. A recent study in New York City found 909 people who each spent on average 397 days out of two years in either shelter or jail.”

“The benefits of supportive housing are obvious—to the taxpayer, as a more humane solution, and to encourage people to be as independent and engaged in work and community as possible.”

The Lewin Group examined the daily cost of supportive housing in San Francisco, Los Angeles, Atlanta, New York City, Columbus (OH), Chicago, Boston Seattle, and Phoenix. The results of their financial analysis indicated that:

• A day in supportive housing cost significantly less than a day in a shelter, jail or psychiatric hospital.
  
• For example, in New York City, a day of supportive housing costs $31.23, compared to a day in jail at $164.57, a psychiatric hospital at $467 or a community hospital at $1,185.
  
• Studies have shown that when formerly homeless individuals us supportive housing, they experience a 58 percent reduction in emergency room visits; 85 percent reduction in emergency detoxification services; 50 percent decrease in jail time; and a 50 percent increase in earned income. More than 80 percent stay housed for at least one year.

Another study published in February 2005 by the Corporation for Supportive Housing titled How Public Leaders Change Multiple Systems: Reducing Costs and Improving Outcomes through Supportive Housing showed that:

• While supportive housing is a proven remedy for interrupting and ending cycles of homelessness, this social innovation is also an approach for improving the performance and impact of services provided by mainstream systems such as healthcare, child welfare, and criminal justice.
  
• The current systems for health care, mental health, housing, criminal justice, child welfare, and addiction treatment do no work well for people with especially complex health and social service needs. Because no single agency is primarily responsible for these individuals and families, different service systems struggle in isolation to manage high costs and service demands. The relative isolation of multiple human service systems makes it exceedingly difficult to ensure that an individual leaving one system will transition smoothly to another.
  
• A supportive housing system can produce far superior, long-term results with minimal additional cost to existing programs. Such a system combines elements of today’s disparate mechanisms for housing, health care, mental health, social services, employment, criminal justice, addiction, and child welfare services without depending for its success on the voluntary cooperation and creativity of separate, independent actors in these arenas.

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