The Housing and Homelessness Subcommittee made a number of recommendations on housing and homelessness issues that are key to effective mental health system transformation. Their recommendations sought to end chronic homelessness among people with mental illness, expand access to affordable housing resources for consumers, and promote evidence-based practices, including the use of Medicaid financing mechanisms, for people with mental illness who are homeless or at risk of homelessness.
Strategies to prevent and end chronic homelessness
In 2002 the Bush Administration announced its policy objective to end chronic homelessness in ten years. In the midst of the subcommittee's work in 2003, HUD, the U.S. Department of Health and Human Services (HHS), and the U.S. Department of Veterans Affairs (VA) in partnership with the U.S. Interagency Council on Homelessness initiated the first of three federal interagency permanent supportive housing initiatives targeted to chronically homeless people (
35 ). The subcommittee strongly endorsed the President's commitment to end chronic homelessness and recommended that this coordinated interagency approach—linked with appropriate incentives in federal "mainstream" housing and support services programs—could create a framework for the federal government's efforts to address the housing and support services needs of people with serious mental illness.
To support and advance the goal of ending chronic homelessness among people with serious mental illness, the subcommittee recommended that HUD—in partnership with HHS and VA—develop and implement a comprehensive plan designed to facilitate access to 150,000 units of permanent supportive housing for chronically homeless individuals over the next ten years. They called for the plan to include specific cost-effective approaches, strategies, and action steps to be implemented at the federal, state, and local levels.
Five years into the federal commitment to end chronic homelessness, progress to expand permanent supportive housing for chronically homeless people is evident. In addition to the federal interagency initiatives, HUD appropriations legislation since 2002 has included new McKinney-Vento Homeless Assistance funds to develop between 5,000 and 10,000 new units of permanent supportive housing for chronically homeless people (
36 ). Policy incentives have also been adopted to redirect existing permanent supportive housing units to people with disabilities who have been homeless for long periods of time (
37 ). At the state and local levels, communities are creating plans to end chronic homelessness that focus on improving outreach activities, discharge planning, and housing and community supports for people with mental illness and others who experience chronic homelessness (
38 ). Private philanthropic organizations and national homeless advocacy groups are actively promoting this agenda and providing financial support for these initiatives (
39 ).
Strategies to expand access to affordable housing
The Housing and Homelessness Subcommittee recognized that to end homelessness among people with mental illness, federal housing policy must also respond to the needs of consumers at risk of homelessness. Toward that end, the subcommittee's report included several recommendations designed to improve mental health consumers' access to government-funded affordable housing opportunities. These recommendations recognized the importance of federal housing policies in facilitating access to a complex array of federal housing programs administered through a myriad of state and local public and private housing agencies and providers. In particular, the subcommittee noted the important role that HUD could play through structured partnerships with HHS and other federal agencies and by providing guidance and technical assistance to state and local housing officials and public housing agencies. Unlike the sustained federal effort to create new housing opportunities for chronically homeless people, there has been very little response from the federal government to address the housing problems of the lowest-income consumers before they become homeless.
Housing experts agree that federal housing funds—including so-called "mainstream" housing programs as well as housing programs targeted to people with disabilities—are essential to close the housing affordability gap that affects people with mental illness with the lowest incomes. Flexible capital funding through programs such as the Low Income Housing Tax Credit and the HOME Investment Partnerships programs are core components of affordable rental housing strategies in local communities. However, for units in these types of properties to be affordable for consumers with extremely low incomes, permanent rent subsidies provided through programs such as the Housing Choice Voucher program and the Section 811 Supportive Housing for Persons With Disabilities program are also essential.
During the past five years federal support for the rent subsidy programs needed by people with serious mental illness has declined significantly. In 2002 a successful policy initiated in 1997, which provided approximately 50,000 new Housing Choice Vouchers for people with disabilities, was eliminated (
24 ). From 2003 to 2006 Congress and HUD created fiscal policies that contributed to the loss of more than 150,000 existing Housing Choice Vouchers and also weakened efforts to rejuvenate and preserve the nation's supply of housing for the lowest-income households (
23 ). During this same period, HUD also repeatedly proposed legislation that would have redirected existing voucher funds to households above 30% of median income (
25 ).
The Section 811 Supportive Housing for Persons With Disabilities program has also been adversely affected by recent federal housing policy (
16 ). Section 811 is the only federal housing program dedicated to expanding the supply of affordable and accessible supportive housing for people with serious and long-term disabilities. Recognizing the value and symbolism of this program, the subcommittee report called for reforms and improvements in Section 811, but none have been enacted. During the past four years the number of new rental units for people with disabilities produced through the Section 811 program has declined by more than 25% (
40 ).
As new federal housing resources for the lowest-income households have steadily declined, more state and local mental health authorities have elected to create policies and housing approaches that rely on mental health system resources to expand affordable and permanent supportive housing opportunities for consumers. During recent years the State of California has reduced hospitalizations, incarceration, and homelessness and achieved substantial cost savings through the development of permanent supportive housing. These outcomes prompted the passage of Proposition 63 and an unprecedented state commitment to finance the creation of 13,000 new units of permanent supportive housing over the next ten years (
41 ). Over the past decade state mental health-funded "bridge" subsidy programs have helped link thousands of consumers to Housing Choice Vouchers in Ohio, Connecticut, Oregon, and Hawaii. Given the recent cutbacks in the voucher program, the effectiveness of these bridge subsidies to link consumers to Housing Choice Vouchers may now be in question.
At the local level, counties and municipalities are also increasingly tapping discretionary mental health funds, such as savings from managed care, to leverage scarce government housing dollars. In 2004 and 2005 Arlington County, Virginia, and Allegheny County, Pennsylvania, both successfully implemented housing strategies for people with serious mental illness on the basis of this leveraging principle. Although these noteworthy state and local efforts have certainly helped some consumers obtain affordable housing, they are not sufficient to fill the gap created by declining federal support for housing programs that assist the lowest-income households.
The subcommittee's report emphasized that housing funding alone could not solve consumers' housing problems. Their recommendations reinforced the complexity of the housing issue for people with mental illness by calling for the creation of public-private partnerships between developers, landlords, housing agencies, and the mental health system. These types of partnerships were first modeled through the Robert Wood Johnson Foundation's Program on Chronic Mental Illness, which demonstrated the importance of housing planning and the important role of nonprofit housing corporations in mental health housing policy (
42 ). Today, mental health nonprofit housing development corporations in numerous states own and manage thousands of units of permanent housing permanently set aside for consumers. However, the scarcity of new housing funding from programs such as Section 811 may reduce the number of new units that these development corporations could otherwise produce each year.
Mental health systems that have made significant progress on affordable housing issues do so by strengthening linkages with the affordable housing system (
22 ). Strategies to implement this approach typically include dedicating one or more full-time staff members to work exclusively on housing and homeless issues. These mental health system staff must have the expertise to facilitate partnerships with housing agencies, track housing program and policy changes, obtain the scarce housing resources that are available, and provide training and technical assistance on housing issues. Today, Tennessee stands out as a strong example of this practice in action. The state has hired seven regional housing facilitators who have been instrumental in creating well over 2,000 units of affordable housing for persons with mental illness since 2002. Other state mental health authorities that have successfully used this model include Connecticut, Kentucky, Massachusetts, Ohio, and Oregon.
Strategies to promote evidence-based practices
Mental health care programs and practitioners often rely on clinical and service delivery practices that, although widely accepted in the field, are not evidence based (
43 ). The subcommittee recommended that HHS establish funding policies to ensure that initiatives related to evidence-based practices and the integration of federal and state funding resources are tailored to people with mental illnesses who are homeless or at risk of homelessness. Evidence-based practices that are known to be effective in assisting people with mental illnesses who are homeless (or at risk of homelessness) to gain and sustain independent living in the community include assertive community treatment, integrated services for people with co-occurring substance use disorders and mental illnesses, supported employment, and illness self-management.
Financing and implementation of evidence-based practices have been adopted as a core principle and objective of the Substance Abuse and Mental Health Services Administration (SAMHSA) mental health system transformation effort. Implementation of these practices poses a significant challenge for state and local systems electing to reconfigure mainstream resources. At the service delivery level, a lack of knowledge of evidenced-based practices, readiness issues, fiscal disincentives, and inadequate support for the change process can often derail potentially successful systems change activities (
43 ).
The subcommittee also recommended that HHS and its Centers for Medicare and Medicaid Services (CMS) improve and expand the ways in which Medicaid funding is used to maximum effect in serving people who are homeless, at risk of homelessness, or moving from homelessness to permanent supportive housing. Existing Medicaid statutes and regulations support some flexibility and ability to implement community-based services of importance to people with mental illnesses who are homeless or at risk of homelessness. However, best-practice services are optional as opposed to mandatory in state Medicaid plans, and thus states vary widely in how these service approaches are implemented. The subcommittee recommended that CMS exercise strong national leadership to engender the inclusion of best-practice services into state Medicaid plans and service requirements.
CMS has acted on these recommendations through its policy guidance to state Medicaid directors, through a set of system change grants to states designed to reduce institutional care and increase integrated community service provision, and through active participation in HHS's mental health transformation agenda. However, it should be noted that Medicaid resources are being restricted and curtailed at both the state and federal levels at the same time that efforts are being made to expand Medicaid coverage for best-practice services targeted to people with serious mental illness. Stringent eligibility requirements for Medicaid and difficulties navigating the SSI application process can restrict access to services, particularly for homeless people with serious mental illnesses (
4 ).
Housing as a key factor in transformation planning
To ensure that housing and other essential resources are available to consumers and families in a transformed mental health system, the commission called on states to develop comprehensive mental health plans to outline responsibility for coordinating and integrating programs. Through the accountability envisioned in the planning process, the commission postulated that states would have the flexibility to combine federal, state, and local resources in creative, innovative, and more efficient ways, overcoming the bureaucratic boundaries between the health care, housing, employment support, and criminal justice systems (
2 ). The background paper of the Subcommittee on Housing and Homelessness made note of a similar vision articulated in policies that apply to federally mandated housing planning activities (that is, the Consolidated Plan, the Public Housing Agency Plan, the Continuum of Care Plan, and the Qualified Allocation Plan) required of state and local government housing agencies as a condition of receiving federal affordable housing funding.
In 2005 SAMHSA awarded Mental Health Transformation State Incentive Grants (MHT-SIGs) to seven states to advance the vision and goals of the Commission's final report. These grants are intended to support an array of infrastructure and service delivery improvement activities to help grantees build a solid foundation for delivering and sustaining effective mental health and related services. It is too early in the MHT-SIG planning process to determine whether state mental health systems will build the housing capacity necessary to successfully leverage interagency partnerships and the limited resources that are available from state and local housing systems and this planning process. It is clear, however, that these collaborations are essential for a transformed system.