HomeMy WebLinkAboutMINUTES - 07121994 - H.3 H.3
THE BOARD OF SUPERVISORS OF
CONTRA COSTA COUNTY, CALIFORNIA
Adopted this Order on .July 12, 1994 , by the following vote:
AYES: Supervisors Smith, Bishop, DeSaulnier, Torlakson and Powers
NOES: None
ABSENT: None
ABSTAIN: None
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SUBJECT: Mental Health Commission 1993-1994 Annual Report
The members of the Mental Health Commission appeared and orally reviewed their .
1993-1994 Annual Report which included a follow up of the Ad Hoc Plan Recommendations,
the planning efforts for the Children's Plan, and their goal for services for older adults and
linkages between the children's, adult and older adult plans to establish a continuity of care as
part of the planning, priority to community-based housing, and to effectively fulfill their
Commission responsibilities.
The Commission advised that it had developed a Mission Statement, as follows:
The Mental Health Commission has a dual mission: First, to ensure that the County's mental
health system delivers quality services which are effective, efficient, culturally relevant and
responsible to the needs and desires of the clients it serves; and, second, to advocate with the
Board of Supervisors, the Mental Health Division and the community on behalf of all Contra
Costa County residents with mental disabilities.
Board members expressed their appreciation to the members of the Mental Health
Commission; ACCEPTED the 1993-1994 Annual Report of the Mental Health Commission;
REFERRED the report to the Finance Committee to work with the Commission to find a way
to accomplish the recommendations in the report and to facilitate public education relative to
Mental Health, including the use of the community access television channel; and
AUTHORIZED a letter to the cities informing them of the availability of the report.
1 Hereby certlty that this is a true and correct copy of
an action taken and entered on the minutes of the
Board of Sui!=the date shown.�
ATTESTED:
PHIL BAT LOR fork oft the Board
of Supero and County Administrator
cc: Finance Committee .
County Administrator
Mental Health Director
se L CONTRA COSTA COUNTY
. = MENTAL HEALTH COMMISSION
595 CENTER AVENUE,SUITE 200
n�
MARTINEZ,CALIFORNIA 94553-4639
o. G!iuu'+A Z Phone(510)313-6414
�OST4 COUNT
MISSION STATEMENT
of the
Contra Costa County Mental Health Commission
INTRODUCTION:
The State of California has mandated the development of Mental Health Commissions in
each County so that consumers,family members and other citizens gill have ars.
opportunity to be involved and influential in the planning and implementation of the
public mental health services delivery system.
MISSION:
The Mental Health Commission has a dual mission: First, to ensure that the
County's mental health system delivers quality services which are effective,
efficient, culturally relevant and responsive to the needs and desires of the
clients it serves; and, second, to advocate with the Board of Supervisors, the
Mental Health Division and the community on behalf of all Contra Costa
County residents with mental disabilities.
ACT IV IT IES:
To this end, the Contra Costa County Mental Health Commission gill review and assess
the County's mental health services system,report on the performance of the mental
health system to the Board of Supervisors, provide a forum for public input regarding
the concerns and needs of persons with mental disabilities, participate in relevant
planning activities,and advocate for appropriate and needed services and the rights of
persons with disabilities. -
Adopted by the Mental Health Commission
Jaw.x%ry 25,1994
sEa� CONTRA COSTA COUNTY
MENTAL HEALTl COMMISSION
595 CENTER AVENUE,SUITE 200
MARTINEZ,CALIFORNIA 94553-4639
Phone(510)313-6414
6¢ 'VN
TO: Board of Supervisors
FROM: Mental Health Commission
DATE: July 5, 1994
Attachments to be made part of the report of the Commission to the Board
of Supervisors on Tuesday, July 12, at 11 am:
Information on the Commission:
*Roster of Commission membership
*Commission Mission Statement
*Commission Goal Statement
Follow-up on Ad hoc Plan prepared by the Commission one year
ago:
*Summary of the Ad hoc Plan for adult services, June, 1993
*Progress Report from Mental Health Director describing
actions in response To Plan recommendations
Housing Report of the Mental Health Commission, June, 1994
A351 (6/93)
Health Services Department
sE-� c MENTAL HEALTH DIVISION
i 595 Center Ave.,Suite 200
ice _ ,• Martinez,CA 94553
M' _ Director (510) 313-6411
Medical Director (510)313-6415
Operations Manager (510) 313-6418
�o.� =_ .•i✓4~ Ethnic Services (510)313-6413
srA cotIT Adult Program Chief (510) 313-6419
Children Program Chief (510) 313-6408
May 19, 1994
To : Mental Health -C7 Cmission
� � I
From: Lorna Bastin -�
Mental HealtH Director
Subj : Progress Report
I have prepared the following report on the changes the Mental
Health Division has made since the Ad Hoc Planning Committee
report was presented to the Board of Supervisors in June 1993 .
As the new Mental Health Director, the Ad"Hoc Planning Committee
Report, an up-to-date overview .and evaluation of the adult mental
health system from the perspective of the various stakeholders ,
was of considerable value to me. I have noted many times that
the report will provide a good starting point for a comprehensive
reevaluation of our services .
A full-scale System of Care/Managed Care planning process is just
now getting underway with the arrival of Alan Stein, our new
Director of Planning and Management Support .
We have addressed changes or progress in the mental health system
in the following general recommendation areas of the Ad Hoc
report :
1) Decrease reliance on State Hospital and IMD beds;
2) Identify strategies to reduce the utilization and length of
stay on I & J Wards at Merrithew Memorial Hospital;
3) Expand crisis intervention capabilities;
4) Involve consumers, at all levels of the system, in
developing their treatment plans, evaluating services,
working as staff and serving as members of boards or
committees;
5) Enhance and strengthen the case management system;
6) Evaluate all current clinic services and day treatment in
light of the possibilities offered by the Rehab Option and
other funding sources .
A-371 (9/91)
Contra Costa County
Mental Health Commission
Progress Report
Page 2
1) DECREASE RELIANCE ON STATE HOSPITAL & IMD BEDS
• Number of State Hospital beds decreased from 71 39 .
• Housing consultant under contract to provide advice on
supported housing programs, to identify outside funding
sources for transitional and permanent housing and to
develop a strategy for increasing the number of board
and care facilities .
• RFP sent out 5/16/94 for augmented board and care with
community support .
• Addition of one 10-bed augmented board and care home .
• Contract with Telecare Corporation to utilize 10 beds
at their three sub-acute, locked treatment facilities .
• Bed Review Committee meets .weekly to review clients
appropriate for movement to a lower level of care.
• A Clinical Nurse Specialist has been reassigned to
monitor patient care for Contra Costa County residents
at the Crestwood facilities, Westwood, Highview, the
Telecare facilities and Napa State Hospital .
• Have applied, via Housing Authority, for 30 Section 8
vouchers with Division commitment to hire 3 part-time
consumer employees to provide support to voucher
recipients.
• RFP being developed for a 10-bed residential treatment
facility with an average length of stay of 12 months .
This facility will be an alternative to acute
psychiatric hospitalizations and IMDs.
2) IDENTIFY STRATEGIES TO REDUCE THE UTILIZATION AND LENGTH OF
STAY ON I & J WARDS AT MERRITHEW MEMORIAL HOSPITAL
• Bay area counties contract with Guardian Corporation
for a Neurobehavioral Program at Highview (in Alameda
County) for organic brain syndrome (OBS) clients .
Contra Costa County has 13 beds in that facility.
• The Ad Hoc Planning Report referenced FY 92/93 average
length of stay as 22 (V and 31 (J) . FY 93/94 average
length of stay, through March, were : 21 (1) and 22 (J) .
Mental Health Commission
Progress Report
Page 3
• Weekly Bed Review Committee regularly considers clients
located on Inpatient Wards .
• Consideration being given for future uses of Napa State
Hospital facilities for dual diagnosis and other
populations .
3) EXPAND CRISIS INTERVENTION CAPABILITIES
• Consolidated management of Crisis Services in both
Central and West County.
• Insufficient space and additional staff costs preclude
development of an East County Crisis Unit at this time .
This will be reconsidered if the Pittsburg Medical
. Clinic moves to Los Medanos . The East County
Outpatient Clinic does crisis intervention on a drop-in
basis . However, they do not receive 5150 ' s .
• The concept of providing mobile crisis services will be
looked at more closely as part of the System of
Care/Managed Care Planning process .
• Admissions to Nierika House are now coordinated through
Merrithew Memorial Hospital E Ward to ensure these
services are utilized by the target population.
• The concept to develop a pilot that adapts the ISA
concepts will be considered in the System of
Care/Managed Care Planning process .
4) INVOLVE CONSUMERS AT ALL LEVELS
• Four consumers were recently selected as Mental Health
Community Support Workers . These are permanent, full-
benefitted County positions .
• Two additional consumer employees will be hired July 1,
1994 to provide supportive services to H. I . P. housing
programs .
• Consumers and family members were involved in designing
the implementation plan for Coordinated Services .
Mental Health Commission
Progress Report
Page 4
• Approved a proposal by Mental Health Consumer Concerns
to develop a self-help center.
Coordinated Services implemented in April 1994 .
Providers, clients and family members were active
participants in designing the process to implement the
new system.
5) ENHANCE AND STRENGTHEN CASE MANAGEMENT SYSTEM
• Reassignment of staff increasing number of case
managers from 9 to 15 during the past year.
• Four consumer Mental Health Community Support Workers
have been hired to assist case management effort .
• A volunteer program under development that will
incorporate consumers throughout the mental health
division.
• one of the major objectives of Coordinated Services is
to make the mental health system more responsive to the
changing needs of individuals by improving coordination
of services and establishing a single point of
coordination for each person receiving services .
Implementation of Coordinated Services has resulted in
a strengthening of the case management system.
• Linkages between case managers and the Conservatorship
Unit have improved. Not only do conservators
participate in the weekly Bed Review Committee, bi-
monthly meetings are held between the Mental Health
Director and Conservatorship staff to improve
communications .
• Conservators participate as members of the coordination
teams, thereby improving coordination between case
managers and conservators .
6) EVALUATE ALL CURRENT CLINIC SERVICES AND DAY TREATMENT IN
LIGHT OF THE POSSIBILITIES OFFERED BY THE REHAB OPTION AND
OTHER FUNDING SOURCES
• Contract and County day treatment providers are now
meeting monthly to explore revenue enhancement via
Medicare billing. Providers are also looking at
programmatic issues around day treatment and looking at
future system directions in terms of the needs of the
client population.
October 26, 1993
_ MENTAL HEALTH COMMISSION GOALS
1993-1994
FOLLOW-IIP ON AD HOC PLAN RECOMMENDATIONS
1. Actively follow-up with the Mental Health Division to
ensure that progress is being made in implementing the Ad
Hoc Plan recommendations. (Mental Health Commission and
designated representatives)
2. Participate in the Mental Health Division's planning to
create a more consumer-centered system. (Mental Health
Commission and designated representatives)
3 . Regularly secure and review information on the Mental
Health Division's implementation of Performance Outcome
Measures. (Mental Health Commission)
4 . Report to the Board of Supervisors on the Ad Hoc Plan
recommendations which have been implemented and those yet
to be implemented. (Mental Health Commission and
designated representatives)
COMPLETE THE PLANNING EFFORT
5. Complete the Children's Plan. (Suzanne Strisower and the
Children's Committee)
6 . Develop Mental Health Commission goal(s) regarding
services for older adults. (Marie Goodman)
7. Plan linkages between the children's, adult, and older
adult to establish a continuity of care as part of the
planning.
GIVE PRIORITY TO COMMUNITY-BASED HOUSING
8 . Advocate for the maintenance of currently funded housing
resources. (Joan Sorisio and Adult Committee)
9. Building on the Ad Hoc Plan and prior housing plans,
develop a detailed 1993-94 Housing Plan which spells out
a range of housing options and a targeted number of units
to meet the array of housing needs. (Joan Sorisio and
Adult Committee)
10. Propose and advocate for an organizational mechanism for
accomplishing the housing goals. (Joan Sorisio and Adult
Committee)
EFFECTIVELY FULFILL MENTAL HEALTH COMMISSION RESPONSIBILITIES
11. Develop a mission statement pertaining specifically to
Contra Costa County Mental Health Commission. (Mini Ad
Hoc Committee)
12. Perform the duties specified in AB 14. (Mental Health
Commission)
Mental Health Commission Goals
October 26, 1993
Page 2
KEEP CURRENT ON RELEVANT INFORMATION
13 . Revisit AB 904 and develop a summary. (Wayne Simpson and
Jay Mahler)
14. Keep abreast of Federal/State/Local mandates, changes,
developments, etc. (Mental Health Commission)
15. Review the County's budget and policies and advocate for
Mental Health services throughout the budgeting process.
(Mental Health Commission)
EXECUTIVE SUMMARY
OF THE AD HOC PLANNING COMMITTEE REPORT
Approved by the Mental Health Commission, 6/24/93
INTRODUCTION:
The Ad Hoc Planning Committee of the Contra Costa County Mental Health Advisory
Board was formed in early 1993 to provide a vehicle through which a broad array of
mental health constituencies could provide input into planning and developing the
County's mental health services. The full report details the Committee's guiding
philosophy, a description of the County's mental health services for adults*, and
extensive recommendations.
MAJOR FINDINGS:
As a consequence of limited and shrinking resources, the County has restricted the
potential service population to those with the most severe impairment and reduced
community- based services geared to prevention,early intervention and support.
This-has produced a disproportionate reliance on costly, restrictive institution-based
programs and increasingly heavy usage of acute hospital and crisis services. The
projected distribution of expenditures is graphically shown below.
PROJECTED COST OF ADULT PROGRAMS FOR FY 92-93
BY PROGRAM TYPE
Total Costs
` Net County Costs
Crisis Community
Crisis Community
1394 Based 13% Based
28% Ifetrithew 2494
Mcnithcw 15%
26% 1MDs IHDs
r.
State Hospitals 10% a State Hospitals 13%
23%
?c
PROGRAMS TOTAL COST COUNTY COST
COMMUNITY BASED SERVICES (County and contractors)including:
Client advocacy/self-help,Case Management,Supported Housing,
Day Treatment/Socialization, Vocational and Employment,
Medication Management,Outpatient Psychotherapy,Board and
Care Supplement,Homeless Services,Residential Treatment,
Forensic and Monolingual/Bilingual Services. .............................$9,046,645 $5,108,562
INSTITUTES FOR MENTAL DISEASE(DADS)[73 beds] .............................$3.265,479 $2,727,335
STATE HOSPITALS [72 beds] ..........................................................................57,226,900 $7,226,900
MERRITHEW HOSPITAL(I&J WARDS) [35 licensed beds].............................$8,225,145 $3,069,763
CRISIS SERVICES,'including E Ward,Nierika,West County Crisis,and............$4,030,807 $2,735,592
Crisis&Suicide Intervention
"Due to time constraints and the fact that adult services receive nearly 80%of allocated mental health
funds, the Committee elected to focus on this age group. We hope that future planning efforts will address
children's and geriatric programs and follow-up on adult issues not fully covered in this report
EXECUTIVE SUMMARY
We find the system spending most of its meager resources to care for a relatively small--- .
number of patients in institutions,a form of care that is the least desirable as well as the
most costly. A decade of experience,bolstered by solid research, has shown that
individuals with serious and persistent mental disabilities as well as frequent users of
mental health acute and crisis services,can make successful adjustments to community
living IF they are given adequate supports.
BASIC APPROACH:
Given the current National, State and County fiscal and political realities, the only viable
option is to radically reconfigure existing resources to change the system. These changes
must be accompanied by a corresponding political shift, as stated in the AB904 Master
Plan, that empowers clients, focuses on their strengths and encourages them to live full,
productive lives in the community.
The direction proposed in this report-- MEASURED MOVEMENT AWAY FROM
INSTITUTIONAL CARE AND TOWARD A COMMUNITY SUPPORT SERVICES
SYSTEM -- is fully consistent with National, State and County philosophy and trends. It
holds the promise of providing better services to more people in need at less cost to the
County.
In order to accomplish this goal:
-Mental Health Services must share equal status, priority and financial support
with medical services.
-Dollars saved from the reduction of state hospital and IMD beds must be
designated for local community mental health services in order to avoid repeating
the historical deinstitutionalization disaster.
•A case management system (individual or team) must be proactive in securing,
arranging and/or providing needed services and supports as clients transition to
the community.
-Clients must be involved in all decisions affecting their lives.
•A full range of appropriate housing options with sufficient supports from case
managers and other services must be available within the community.
-Pilot programs -- including proven models like Integrated Services Agency and
Mobile Crisis -- must be implemented as a means of exploring the options for
reconfiguring the system.
These components will make it possible to develop a system,which is cost effective,
client centered and community based.
RECOMMENDATION HIGHLIGHTS:
Decrease the reliance on State Hospital and IMD beds:
Work closely with residents to determine their preferences and needs and to
prepare them for returning to the community.
Identify and develop a full range of alternative placements in the community.
ii
Strive to upgrade the services provided in State Hospitals and IMDs for the
benefit of those who will require these services until sufficient and adequate
alternatives are available.
Identify strategies to reduce the utilization and length of stay on I and J wards in
Merrithew Hospital:
Enhance the system's ability to provide needed supports before the clients'
problems escalate to the acute stage.
Work with other counties to develop specialized facilities for populations that are
not appropriately served by acute inpatient services.
Increase efforts to divert patients to other programs and hospitals.
Begin discharge planning, in cooperation with the patient's case manager, as soon
as possible.
Strive to preserve the client's living situation and ties to the community during
hospital stays.
Expand crisis intervention capability:
Increase crisis residential resources.
Develop a mobile crisis service pilot program.
Retain the West County Crisis Service and pilot a crisis walk-in service in East
County.
Develop a system for sharing Crisis and Suicide Intervention's computerized data
base on community resources.
Consider integrating all crisis services under one administration.
Involve consumers,at all levels of the system,in developing their treatment plans,
evaluating services, working as staff and serving as members of boards and
committees:
Contract with a consumer group to conduct a survey of State Hospital and IMD
clients and assist in transitions to the community.
Develop an action plan to implement a client-centered service delivery system and
train all staff in client-centered methods. Implement the Coordinated Services
System.
Support the development of a consumer-run self-help center.
Develop a pilot project that adapts the Integrated Service Agency/AB 3777
program to Contra Costa County and include the components necessary to focus
on client needs,choices and wants.
iii
EXECUTIVE SUMMARY
Enhance and strengthen the case management system:
Recognize case management as a therapeutic modality and the case manager as
the advocate and facilitator of the provision of community-based treatment.
Assure system-wide knowledge of expectations and capabilities of case
management services.
Limit case loads to a size that enables staff to meet client needs by increasing
existing case management services.
Augment the case management system to include consumers, contractors and
families.
Provide case management priority access to (and exit from)services needed by
their clients.
Evaluate all current clinic services and day treatment in light of the possibilities
offered by the Rehabilitation Option and other funding sources:
Provide supports necessary to enable clients to remain in their own homes, using
24-hour services only when a person needs a more structured situation.
Assign staff to coordinate and advocate for housing and for vocational and
employment services.
�.. ']Keep funds saved from reducing hospital, IMD,and local inpatient services
available for the maintenance and development of community services--for ALL
AGE GROUPS -- to the fullest extent possible.
Develop an integrated system to identify and monitor potential grants and to
coordinate grant-writing and other activities to generate additional revenues.
FOLLOW-UP:
The Ad Hoc Planning Committee recommends that this preliminary planning effort be
followed by a substantial ongoing planning process led by County Mental Health
Administration which includes clients, families,contract administrators, front-line
County and contract staff, and union representatives. One-half of.the committee should
be comprised of consumers and families.
A planning process of this nature will enable Contra Costa County to continue to move
toward a more cost effective,client centered,community based system. We look forward
to having a new Mental Health Director who will continue the open door policy of
inclusion and the serious development of ongoing working relationships among all
_ groups and constituencies. We,believe that our County has the will to offer critically
needed support to our most vulnerable population.
iv
Ml
MENTAL H%ALTH COMMISSION
595 center Avenue, Suite 200
Martinez, CA 94553
NAME PHONE POSITION APPTD, TERM E_N_D
pistrict I
Joan Bartulovich H: 529-1134 Family Member 6/22/93 6/30/94
7102 Donal Avenue
E1 Cerrito, CA 94530
Taalia Hasan H: 234-7590 Family Member 6/22/93 6/30/95
1300'Amador St, 118 O: 215-4670
Richmond, CA 94804
VACANCY (Miller) H: At Large 6/22/93 6/30/96
0:
District 2
Marie Goodman H: 372-0545 Family Member 6/22/93 6/30/95
3331 Brookside Dr.
Martinez, CA 94553
Cynthia Miller H: 372-7678 At Large 6/22/93 6/30/94
105 Jose Lane O:
Martinez, CA 94553
Pat Risser H: 671-4886 Consumer 6/22/93 6/30/96
141 Golf Club Road
Pleasant Hill, CA 94523
District 3
Ralph Hoffmann H: 837-4498 Consumer 6/22/93 6/30/96
69 St. Timothy Court
Danville, CA 94526
Wayne Simpson H: 820-2163 Family Member 6/22/93 6/30/94
897 Dolphin Court
Danville, CA 94526
Suzanne Strisower H: 930-8778 At Large/ 6/22/93 6/30/95
3159 Lippizaner Ln. O: 943-2347 Child Advocate
Walnut Creek, CA 94598
District 4
Violet Smith H: 680-1632 At Large 6/22/93 6/30/94
1103 Temple Drive
Pacheco, CA 94553
Joan Sorisio H: 672-2292 Family Member 6/22/93 6/30/95
F.O. Bax 612 O: 825-1921
Clayton, CA 94517
Veronica Vale H: 676-5313 Consumer 6/22/93 6/30/96
4819 Clayton Rd. 116
Concord, CA 94521
District 5
Anne Mc Laurin H: 625-7330 Consumer 6/22/93 6/30/94
99 Adams Court O: 933-0990
Oakley, CA 94561
VACANCY (Puente) H: At Large 6/22/93 6/30/96
0:
Linda Trowedale H: 754-1199 Consumer 6/22/93 6/30/95
2824 Honeysuckle Circle
Antioch, CA 94509
Supervisor Representative
Jeff Smith H: 646-2080 Bd. of Supes 6/22/93 6/30/96
651 Pine St. 1108A
Martinez, CA 94553
The Mental Hea th commission meets on the Fourth Tuesday of the mouth. from 4130-600
at 595 Center Avenue Suite 200 Martinez.
4
HOUSING REPORT
OF
THE CONTRA COSTA COUNTY
MENTAL HEALTH COMMISSION
Adopted by:
THE MENTAL HEALTH COMMISSION
595 Center Avenue, Suite 200
Martinez, CA 94553
June 28,1994
ACKNOWLEDGEMENTS
The ad hoc Plan for Adult Mental Health Services which was
developed by the Mental Health Commission in FY 92-93 emphasized
the critical importance of stable living conditions and expressed
concern about the limited availability. within Contra Costa Counly. o
both needed and preferred housing options for people with mental
disabilities. Since there was insufficient opportunity to explore this
subject in depth, it was recommended that the Special User Housing
Plan of November, 1988, be revisited and updated.
Responding to that recommendation, the ADULT COMMITTEE OF THE
MENTAL HEALTH COMMISSION undertook a study of existing and
needed housing within Contra Costa County during FY 93-94.
Members of the Commission, family members, and consumers --
from the Commission, from the Alliance for the Mentally III (AMI)
and from the Contra Costa Network of Mental Health Clients -- who
participated in the study included:
Joan Bartulovich, Edith Benjamin, Pat Fuqua,Lawrence Gault,
Ralph Hoffman, Monica Larsen,Jay Mahler, Herb Putnam,
Pat Risser, Wayne Simpson,Joan Sorisio, Violet Smith, and
Veronica Vale.
They were greatly aided by the active participation of knowledgable
staff members from the County Division of Mental Health, from the
county's Conservatorship program, and from contract agencies,
including:
Diane Frary, Benita Harris, Sharon Lundholm,
Barbara McCullough, Julie Peck, Carol Sebilia, and Vicki Smith.
We wish to express our deep appreciation to all of the above-named
participants and to the many others who shared information with the
committee, reviewed the draft and provided valuable input.
Joan SorisioC6r, Adult Committee
Violet Smith,Chair, Mental Health Commission
TABLE OF CONTENTS
Acknowledgements .............................. ................. .................Inside cover
Summary ........................................................................ ...............................I......I - Ix
Introduction ... 1
.......................................................................................................
HousingIssues ........................ .................*...........................................................6
Population to be Served* .............................•---••--------•---•---............--. .......... 12
LivingSituations: ........................................................ ........ .................14
Living with Family Members ...................... ....................................15
Permanent Independent Living Situations.............................................16
Special User "Housing" ..................................................*...... 19
Licensed Board and Care Homes .............................................22
Supported Independent Living (SIL).........................................
...*........***......*....*...**...26
Single Room Occupancy (SRO) ...............................................2 9
Transitional Housing ................................................................3 0
Residential Treatment ........................................................3 0
Crisis Residential Treatment 32
................................................
State Hospitals and Institutes for Mental Disease....................3 3
Homelessness ....... ......................... ........ ................................ ....3 6
Conclusion ................................................................................................... ...40
There are a great many terms used to describe the people who use mental health
services. We have tended to use the terms "consumer" and "client" interchangeably,
although the former is generally preferred. Perhaps the best term,though
awkward,is the phrase"person with mental disability",since it places the focus on
the person and not on the disability; we have therefore used this term frequently
thoughout the report.
**There are also a vast number of terms which are used to describe and/or categorize
residences of all types. We have attempted to rely on terms in general usage and to
define them in the appropriate sections,as indicated above,but it is important to
acknowledge that there is no universally-accepted vocabulary or categorization of
housing targeted for people with mental disabilities. For example,we have included
Residential treatment and Institutions under the Special User"Housing"category but
quotation marks were used to highlight the fact that these programs do not constitute
housing in the sense of permanent homes.
CONTRA COSTA COUNTY MENTAL HEALTH COMMISSION
HOUSING REPORT -- JUNE, 1994
SUMMARY
INTRODUCTION
The need to ensure the availability of safe, affordable, independent
housing for people with a mental disability has become a top priority
for mental health systems throughout the nation, due to:
First, the recognition that: (a) housing is a right and necessity
for all people; (b) having a decent place to live should be
independent of treatment or compliance with non-housing-related
issues; (c) frequent moves are unsettling; and that, therefore, (d) a
stable, permanent living situation is necessary for the successful
treatment and rehabilitation of persons with serious mental
disabilities;
Second, the commitment to a client-driven system, which
respects clients' preferences, and extensive survey information
which documents the fact that clients strongly favor independent
living over institutional or semi-institutional placements;
Third, concern that limited availability of Special User Housing
makes it impossible to meet the needs of more than a small
proportion of consumers of mental health services and that the
unavailability of alternative housing resources results in increased
use of costly inpatient and crisis services; and
Fourth, a growing recognition that effectively addressing the
problem of homelessness requires the provision of acceptable,
affordable housing options AND the provision of adequate support
services for persons with special needs who are homeless.
The Ad Hoc Plan adopted by the Commission last year identified the
lack of adequate, affordable, community housing as cne of the most
important missing links in our County's ability to meet the needs of
Contra Costans with mental disabilities.
I
In order to aid Contra Costa County in planning a response to this
important challenge, the Mental Health Commission undertook to
study the housing situation and prepare a report which:
• Identifies the current and future needs of Contra Costa County
residents with mental disabilities;
• Describes the housing programs and resources which are (and
are not) now available in our county; and
• Offers recommendations to strengthen and expand the quantity
and variety of housing options in order to more adequately meet the
housing needs of the county's diverse population of mental health
clients/consumers.
FINDINGS
1) POPULATION: Approximately 7,200 mentally disabled adults (18 to
60 years old) are served by the County's mental health system each year.**
2) INCOME RESTRICTIONS: The vast majority (estimated at 70%)
of persons with mental disabilities receive only Supplemental Security
Income (SSI), placing them at 27.6% (!) of the median per capita income
in Contra Costa. With incomes substantially below the poverty level, SSI
recipients have little chance of securing adequate housing, especially
when the median monthly apartment rent exceeds 100% of the total
monthly SSI payment.
3) LIVING SITUATIONS:
A. LIVING WITH RELATIVES:
• Approximately 3,400 mentally-disabled persons (47% of the
county's adult clients) are living with relatives, generally their parents;
• More than half of the caregiving parents are over age_65:
• 59% of those who live with relatives would prefer to live elsewhere;
• Those who wish to move are prohibited from doing so by a lack of
adequate alternatives and/or insufficient personal financial resources.
* Sources for all numbers contained in the Findings are documented in the full
sport.
**Based on data provided by the Mental Health Computer system(known as
PSP)and including clients served by the county's Mental Health clinics,
contract service providers,Mental Health Crisis Service,Merrithew Hospital
psychiatric wards, Institutes of Mental Disease,and Napa State Hospital.
II
B. LIVING INDEPENDENTLY:
• Nearly 2,250 (almost 32%) of the County's clients are currently
living on their own, without any formal supervision and, most often,
without any housing-related support (other than that provided by their
families);
• About 1,450 are living alone in apartments or houses scattered
throughout the community;
• The remaining 800 are living with unrelated persons, including
about 100 who are living in unlicensed group homes;
• Both consumers and their families strongly favor apartments over
group settings, despite the limitations imposed by poverty and the
potential social isolation which results from living alone.
C. LIVING IN SPECIAL•USER "HOUSING":
Approximately 800 adult clients (11%) five in "housing" (including
permanent housing, residential treatment, supervised homes, and
institutions) which has been specially-designated ,and funded or
licensed by the government) for use by persons with mental disabilities,
as decribed below:
1. Board and Care Homes:
• Over 500 clients (7% of the total and two-thirds of those in special
residential programs) live in Board and Care homes; Board and Care
Homes are licensed by the State to provide care and medication
supervision;
• There is currently a shortage of Board and Care operators who will
accept persons with mental disabilities at the SSI rate, particularly in
East County;
• 33 of the 40 Board and Care homes serving persons with disabilities
are small homes, licensed to serve 6 or fewer people;
• Due to economic considerations, Board and Care Homes often have
environmental, programmatic and/or staff deficiencies;
• Board and Care operators currently have no incentive to prepare
and/or encourage their residents to move into independent living
situations.
2. Supported Independent Living (SIL):
• Supported Independent Living (SIL) provides rental subsidies and
supportive services to residents of apartments which have been
especially developed and targeted to serve persons with mental
disabilities;
• When several recent changes are fully implemented, there will be 70
beds in Supported Independent Living units, an increase of 33 beds
since the 1989 Special User Housing Report;
- Supported Independent Living is the preferred housing of a great
many clients and families;
• Only about 1% of all consumers can be served by the present SILs.
3. Single Room Occupancy (SRO):
- Since the 1989 Special User Housing report, 25-30 slots have been
added in a Single Room Occupancy Hotel, but no housing-related support
services were provided;
- Needed support services are currently being developed.
4. Transitional Housing and Residential Treatment:
- Transitional housing and residential treatment programs are
necessary parts of the continuum, diverting clients from hospitalization
and providing a brief respite from situational stresses;
- There are 19 transitional housing beds, 22 residential treatment
beds, and 9 crisis residential treatment beds in the County.programs;
* Because stays are time-limited, the 50 beds were able to
accommodate approximately 200 people (under 3% of the total client
population) during the past year.
5. Institutional Settings:
- Approximately 1.5% of clients spent sometime in State Hospitals and
Institutes for Mental Disease (IMDs) during the past year;
* As part of the plan to decrease the State Hospital census by 34
persons, the Mental Health Division contracted for 10 additional slots in
IMI)s last year, a net (and welcome) decrease of 24 institutional slots.
D. HOMELESS SHELTERS:
- Estimates of homeless Contra Costans with mental disabilities range
from 2,000-5,000 per year;
- About 374 clients (5% of those receiving billable mental health
treatment services during the past year) were homeless;
- Approximately 2/3 of the mental health clients who were homeless
were seen in the Crisis Center, and 1/3 received ongoing help from
clinics;
# Additional hundreds of homeless persons with mental disabilities
received limited mental health services in homeless shelters and multi-
purpose centers (but these persons are not currently included in the
computerized data base because the services provided are not Medi-Cal
reimbursable).
IV
RECOMMENDATIONS
o Survey consumers to ascertain their preferences and
needs and to ensure that housing planning is client-directed.
o Develop alternative housing options for adult clients
living at home. The need for alternative housing will become
critical when large numbers of elderly parents are no longer able to
provide at-homecare. Varied housing options should also be
available whenever the needs/desires of adults living at home would
be better served by other forms of housing.
o Collaborate with cities, planning commisisions and
housing developers to urge/encourage the extensive development
of affordable housing, including units targeted for persons with
mental disabilities.
o Increase access to existing community housing, by:
- Working with communities and landlords to secure
increased access to housing located throughout the county;
- Securing additional rental subsidies, especially Section 8
vouchers and certificates earmarked for persons with special needs;
and
- Providing other financial supports to persons with mental
disabilities, including, for example, a rotating fund for first and last
months' rent (as proposed by Mental Health Consumer Concerns).
o Provide a full range of support services, on-site when
necessary, to help maintain people in their own homes in the
community, including: help in locating and securing access to
rentals; help in dealing with landlords, neighbors and roommates;
and training in skills necessary for independent living.
o Include more consumers as housing support staff
members (an action which has already been initiated by the Mental
Health Division in relation to several Special User Housing programs).
V
o Help Board and Care Operators to: (a)upgrade their
services and (b) encourage/prepare clients to move on to
independent living situations by:
- Providing monetary incentives, augmentation, and/or
mental health staff assistance to Board and Care Operators, and
Developing standards for, and increasing monitoring of,
both large and small Board and Care Homes serving people with
mental disabilities.
o Provide supportive services to persons residing in
SROs to aid them in adapting to this form of high-density housing,
(Such a program is currently being developed by the Mental Health
Division for the River House hotel).
o Retain and expand transitional housing and residential
treatment programs, as needed, to divert clients from
hospitalization and provide a brief respite for clients and caregivers.
o Place emphasis on preserving permanent residences
and preventing homelessness, by:
- Intervening and offering support when an individual with
mental disabilities is at risk of losing his/her home, and
- Making every effort to secure and/or preserve clients'
permanent residences during the time they are in short-term
residential programs.
o Focus on upgrading programming at IMDs and
continuing to develop alternative placements so that the
lengths of stay can be reduced. Continue all efforts to reduce
reliance on institutional placements by providing adequate
alternatives.
o Strengthen the provision of mental health services to
homeless people who have mental disabilities, by:
- Extending the permitted length of stay at the East County
shelter for people with mental disabilities who are homeless;
- Expanding the mental health supportive services provided
at the generic homeless shelters; and
- Providing substantial follow-up services to aid homeless
persons with special needs to secure and maintain stable housing
when they are discharged from the shelters.
VI
Together, these recommendations will provide measured movement
toward our goal of increasing and maintaining a diverse supply of
safe, affordable,permanent community housing, together with the
supportive services which are needed to maintain clients in the
housing of their choice.
These recommendations will also serve to strengthen and improve
those special residential services which are, and will continue to be,
needed until both the clients and the system are fully prepared for
independent living.
IMPLEMENTATION RECOMMENDATIONS
The foregoing recommendations can become reality if everyone
shares in the vision and makes the required commitments. We
therefore recommend that:
I. THE BOARD OF SUPERVISORS AND COUNTY
ADMINISTRATORS:
o Endeavor to ensure an adequate, stable and dedicated
funding source for mental health services. This is essential if the
Division is to provide the array of programs and supports which are
needed to divert persons with mental disability from costly hospital-
based care and to maintain them in less expensive, community-based
programs which foster independence.
o Dedicate State and Federal funds, generated by the
billing for mental health services, to the provision of
mental health services rather than using these funds to offset
General Fund dollars;
o Work with the State to see that realignment funds are
maintained intact for mental health;
VII;
o Restore the past, and allocate the future,dollars
saved by the reduction in State Hospital usage to the
County mental health budget. Because of the lead time that it
takes to develop housing alternatives, these funds should be trusteed
beyond the current fiscal year and beyond the reach of the General
Fund.
H. CITY AND COUNTY GOVERNMENTS, and all of the planning
commissions and housing departments under their jurisdiction:
o Develop housing that persons with very limited
incomes can afford, by actively participating and collaborating
with each other and with federal agencies and appropriate
developers;
o Support development of targeted units for persons with
mental disability throughout the community;
o Join in advocating for an end to NIMBYism.
III. THE MENTAL HEALTH DIVISION:
o Designate a person with on-going responsibility for
housing development so that housing planning and implementation
can go forward with added impetus;
o Make the provision of housing supports a top
priority, continuing and expanding the recently-implemented
program in which consumers are employed to provide housing
supportive services to clients residing in varied housing throughout
the community; and
o Continue to collaborate with community-based
providers to implement, to the fullest extent possible, the
foregoing recommendations in relation to Supported
Independent Living, Board and Care homes, residential treatment,
and other targeted programs.
IV. THE ADVOCACY GROUPS, (Mental Health Commission,
Alliance for the Mentally I11, and Contra Costa Network of Mental
Health Clients):
t
VIII
o Fully support the government and the Mental Health
Division in the foregoing efforts;
r
o Maintain vigilance in ensuring that safe and
affordable housing becomestremains a priority in our County;
o Actively work to educate communities to a greater
receptivity to clients as neighbors and to counteract the "Not-
in-my-backyard" syndrome and all other efforts to thwart the
development of affordable housing for special needs populations.
The Contra Costa County Mental Health Commission believes that the
Mental Health Division of the Health Department has made very
important progress during the past year, progress which derives
from inspired and responsive leadership and a solid commitment to
the principles expressed in this report.
As Commissioners, we pledge to do all that we can to continue this
forward movement, to strive to ensure that mentally-disabled people
in Contra Costa have access to safe, affordable, permanent homes and
the supportive services which they need to retain and maintain those
homes. We hope that the Board of Supervisors and all segments of
the community will join us in support of this important effort.
IX
Y
INTRODUCTION
BACKGROUND: Early in the 19th Century, people with mental illness
"who were confined to poorhouses and jails or held without care in
their family's homes were viewed as in need of treatment in a
benevolent environment. An era of institutionalization ensued that
was to last more than a century. During this period, large 'asylums'
were created" .
These asylums, generally far-removed from their communities, were
intended to be short-term and treatment-oriented, but they quickly
deteriorated into custodial, long-term "homes", providing for all basic
needs but creating institutionalization (a passive condition of
habituation to an institution and a corresponding inability to function
outside of it).
By the 1970's, aversion to the effects (as well as the cost) of
institutionalization led to the de-institutionalization movement
wherein clients were to be discharged to model community facilities.
Unfortunately, adequate funding for these facilities was never '
provided. In addition, Supplemental Security Income (SSI) rules.
became more stringent and federal housing subsidies were
drastically reduced. As a result, "most ex-patients were simply
discharged to their families, or to custodial board and care and
nursing homes...or they were left to fend for themselves in the open
market"* .
CONTINUUM OF CARE: During the 70's and 80's, the mental health
system developed the "continuum of care" concept. This model
involves the development of residential facilities with different
levels of service, supervision, and restrictiveness, including, for
example, nursing homes, board and care settings, halfway houses,
quarterway houses, and supervised apartments.
*Ridgway,Priscilla and Zipple,Anthony M.,The Paradigm Shift In Residential
Services: From the Linea Continuum to Supported Housing Approaches.
Psychosocial Rehabilitation Journal, Vol.13,No.4,April,1990.
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Mental Health Commission Housing Report-June,1994
The programs are organized developmentally, and the client moves
to progressively less (or, occasionally, more)restrictive settings along
this continuum as his/her level of functioning changes. The goal is for
the client to move upward through the continuum until, finally,
he/she achieves fully independent living and requires no further
support.
In spite of the general acceptance of the continuum concept and
concerted efforts within the mental health community to provide
sufficient specialized services, there is a growing belief that the
continuum alone cannot fulfill the housing needs of people with
mental disabilities. This is reflected in a growing movement which
advocates for the provision of supportive services to enable people
with mental disabilities to reside in ordinary housing scattered
throughout the community -- the new Supported Housing model.
REASONS FOR THE SHIFT TO A SUPPORTED HOUSING MODEL:
FIRST: due to funding shortages, very few communities have a
complete continuum of services available and even those that do can
serve only a small fraction of the population in need. The
unavailability of subsidized, affordable housing often means that
clients cannot "graduate" from the residential treatment continuum
to the desired independent living but can only be discharged to
custodial boarding houses, inner-city residential hotels, shelters, or
the streets.
"Gridlock" is p—rWuced in the system as programs stop requiring
people to move on, permitting them to stay in settings that are less
than ideal for them, because there is no other place for them to go.
Even costly inpatient services are sometimes pressed into service as
housing when patients have no housing and no prospects of acquiring
housing. Faced with these practical problems, "many systems have
intensified their efforts to develop residential programs but found
their way blocked or slowed by community opposition and the lack
of funding for congregate residential facilities."
SECOND, the emergenct-, of family and client movements during
the 1980's also focused attention on critical housing issues. The
Alliance for the Mentally Ill (AMI) gave voice to the concerns and
needs of the many families whom deinstitutionalization had forced
Ibid.
- 2 -
ti
Mental Health Commission Housing Report-June,1994
into the role of primary caregiver. The empowerment movement
among consumers was even more significant, with clients strongly
communicating the message that housing needs are of paramount
importance in the lives of persons with psychiatric disabilities -- that
they wanted regular housing,jobs, income, relationships, and a place
in the community.
THIRD, major pressures have been produced by the rapidly-
growing.incidence of homelessness. This has been of particular
relevance to the mental health system because a substantial
proportion of homeless persons have serious mental disabilities. The
lack of residential alternatives for this population has produced the
socially and politically unconscionable situation where vulnerable
individuals have NO place to live. It has also been reflected in
increased demand for acute inpatient and emergency services as
more and more homeless individuals are admitted to the hospital or
emergency room as the housing of last resort. And we, as a State and
as a County, have contributed to this unconscionable situation by
reducing the number of institutional beds without, concurrently,
making financial provisions for an adequate number of supported
beds in the community.
FINALLY, there is a growing body of research showing that
Supported Housing works, that even persons with very serious
mental disabilities can live independently if they receive adequate
support. This research has also shown that stability and satisfaction
in one's housing can contribute to the effectiveness of rehabilitative
interventions without having housing and treatment tied together.
DESCRIPTION OF SUPPORTED HOUSING: The shift to a
Supported Housing model rests on two fundamental principles;
namely, (a) that having a home in the community is a right for all
persons, including persons with severe mental disabilities, and (b)
that a stable home is a prerequisite for effective treatment and
psychosocial rehabilitation.
Major components of the Supported Housing model include:
(1) A real "home", not just a residential treatment setting or
"guest" status in someone else's home. Supported housing promotes
the use of regular housing stock within the community, including all
- 3 -
r
Mental Health Commission Housing Report-June,1994
of the typical kinds of housing used by nondisabled community
members-- a private room and bath, a private or shared apartment,
a mobile home, even the hope of owning a condo or house of one's
own;
(2) Consumer choice, not placement;
(3) Social integration rather than homogeneous grouping by
disability;
(4) A shift from staff to client control and a separation of
treatment from housing. The client "carries the keys" and can make
decisions about the rhythm of life, including whether or not to accept
treatment. "The supported housing model decouples the services
from the building or facility and links them to the client as an
individual...As each client's needs change, the services and supports
can be introduced into or withdrawn from the environment. The
client does not move as his or her needs change, but remains in
stable housing while the services are altered", ;
(5) An emphasis on permanent, rather than transitional,
housing; and
(6) Most importantly, the provision of flexible supports --
whatever is needed for however 1"it is needed -- to enable the
client to achieve and maintain a permanent independent home.
Because of the serious long-term nature of psychiatric disabilities,
few people with such disabilities can make a fully successful
adjustment without some supports and ongoing services, although
the nature, magnitude, and duration of the supports will differ
significantly from individual to individual.
THE "SUPPORT" PART OF SUPPORTED HOUSING: Because of the
emphasis on tailoring services to the needs of individuals, a very
broad range of support services has been identified -- ranging from
rental subsidies to homemaker services and from medication
monitoring to skills training. In a consumer survey undertaken by
Mental Health Consumer Concerns in Contra Costa in 1989, clients
were asked to specify the supports they would need for success in
*Ibid.
- 4 -
Mental Health Commission Housing Report-June,1994
independent living. Their top priorities were money (75%) and
affordable housing (73%) followed by emotional supports (56%) and
training in living skills (54%).
Activities suggested for support personnel, as described in the
literature, include: training in such living skills as cooking, shopping,
managing money, and securing transportation; helping to secure and
move furniture; working with roommates on task-sharing;
providing crisis intervention during periods of stress; negotiating
with landlords and utility companies; locating community support
groups; and numerous other activities to help the client acquire and
maintain a home. There is general agreement that the support must
be flexible and that it is preferable to provide it in the client's own
home, insofar as possible.
As noted, the quantity of service will vary tremendously from client
to client and from time to time. Some may require daily visits for
medication monitoring and ongoing support while, for others, a call
once a month may be sufficient. As a result of this anticipated
diversity, it is difficult to project a cost, but data from a national
evaluation of the Housing Demonstration Projects supported by the
National Institute for Mental Health (NIMH) suggested a range of
approximately $4,000 to $12,400 per client per year.*
IN SUMMARY, it is clear that no one approach can accommodate the
full spectrum of diverse housing needs. Historically, the continuum
of care model has not been able to produce enough housing to meet
the needs of all; and in some instances, programs which were
intended to be transitional ended up serving as "defacto long-term
housing" because the independent living options needed at the end of
the continuum were unavailable.
Similarly, "supported housing cannot, nor should it be expected to,
subsume all of the roles that specialized residential treatment can
play in an overall system of community support" ** . In the sections
which follow, we will explore both independent living and the
varied Special User Housing programs which grew up under the
continuum of care model.
*Livingston,et al.,1991,cited in Innovations and Research. Vol. 2,No. 3,1993.
**Ridgway and Zipple, op. cit.
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Mental Health Commission Housing Report-June,1994
HOUSING ISSUES
The need for a greatly expanded housing program--including both
special user housing and supported housing-- was acknowledged and
supported in two Contra Costa County Special User Housing Plans* ,
developed in 1988 and 1989. The implementation of the many
recommendations contained within those reports has been impeded
by multiple factors:
o Shortage of funds;
o Failure to designate a full time person to advocate and plan for
housing for persons with mental disabilities;
o An all-too-persistent discriminatory attitude within the
community--the Not-In-My-Backyard syndrome (known as
NIMBYism); and
o An insufficient commitment to affordable, specialized housing,
by all levels of government.
As a result, the pressing needs for affordable and special user
housing which were identified in the 1988-89 housing reports have
remained virtually unchanged. During the intervening 6 years,
however, the total population and the number of homeless in our
County have grown substantially, so that the need for housing is
even more urgent today. This is not a problem which can be solved
by Mental Health, or Health, or any other department alone -- it is a
problem which will require the best efforts of all segments of our
community. We hope that this report will help provide the impetus
for change.
*The 1988 report was prepared by Housing for Independent People(HIP),
under contract to the Contra Costa Health Services Department; the 1989 report
was a follow-up draft prepared by the Alcohol/Drug Abuse/Mental Health
(A/DA/MH)Division of the Health Services Department. A/DA/MH is the
forerunner of the present Division of Mental Health.
- 6 -
Mental Health Commission Housing Report June,1994
MISSION: The mission statement which guided the Special User
Housing Plan of 1988 is equally relevant to the current effort. les
stated goal is:
"To increase and maintain county-wide a diverse supply of
a&, sant r_and decent housing (which is)&DElab&I ,
acce5sible and appropriate for low-income individuals...who
have a persistent mental disability...by providing long-term
stablenormalizedcommunity living situations...accompanied
by the design and delivery of appropriate supportive services
aimed at maintaining clients in their housing of choice"
(underlining added)
SAFETY: Let us examine each of these component elements in turn.
First, we note that considerations of safety. sanitation, and
accessibility late to the neighborhoods in which the housing is
situated as well as to the condition of the properties. Economically
depressed housing is generally of sub-standard quality,poorly
maintained, and crowded; in addition, it is most often located in
unsafe, multi-problem neighborhoods, with little access to
transportation, services, or other amenities.
AFFORDABILITY: Access to safe, sanitary and accessible housing is
clearly related to a&Wabilily. And, because most persons with
disabilities are poor, they are almost always forced to live in
economically depressed, generally sub-standard housing, and, at the
same time, they are paying a disproportionately large share of their
incomes for this housing.
Available information sources* suggest that approximately 70% of
persons with psychiatric disabilities have SSI as their sole income
source. The current SSI paymentthe total income on which
.- .ents must subsist. is $603.40 per month ($7.240.80 per year)
DOWN from$646 peri in 1992.
According to the 1989 Special User Housing Report, economists use
the median income of a particular area to define income status. The
The housing study conducted by the Contra Costa Chapter of the Alliance for
the Mentally III and preliminary data developed as part of the State of
California Outcome study.
- 7 -
Mental Health Commission Housing Report-June,1994-
median annual income per person in Contra Costa County was $26,215
in 1991, the fourth highest per capita income in the State. This places
SSI recipients in Contra Costa in the y=VERY LOW income category
since "very low" is defined as "under 50%",and Contra Costa SSI
recipients are FAR UNDER the 50% which is characterized as "very
low"; in fact, SSI recipients are receiving only 27.6% of the median
Wr capita income in Contra Costa.
The median rent in Contra Costa County in 1993 ranged from
$628/month in West County to $650/month in Central County, more
than the TOTAL monthly SSI payment. The median rent in the lowest
10th percentile in West County was $535/month.* . It is clear that
SSI recipients simply cannot afford apartments in Contra Costa
County. unless they receive subsidies or find housemates. Being poor
also dramatically impacts a person's quality of life, making it next to
impossible to have a telephone, take a bus, go to a movie -- or
engage in any of life's "normal" and pleasurable activities.
Assistance in accessing subsidies, locating and getting along with a
roommate, managing money and finding recreational opportunities
are all forms of support which could prove very helpful to an SSI
recipient struggling to maintain an apartment.
SUBSIDIZED HOUSING: According to the Housing Authority, there '
are approximately 6,000 low-cost, subsidized housing units in Contra
Costa, although the only ones with relevance for people with mental
disabilities are the Section 8 programs targeted for the Elderly/
Disabled populations.
There are two types of Section 8 Housing which "exemplify the
federal government'sdecision to turn away from building public
housing in favor of providing assistance that allows poor people to
rent housing in the private market"**:
(1) The Section 8 Certificate Program, enacted in 1974, provides
that tenants will pay 30% of their adjusted income toward rent, with
the Public Housing Authority paying the remainder directly to the
owner, and
(2) The Section 8 Voucher Program, implemented in 1988, "has
no absolute limits on rents, and the percentage of the tenant's income
* Annual Report on Housing in the Bay Area. 1993,Bay Area Council.
- 8 -
Mental Health Commission Housing Report-June,1994
paid toward rent is not fixed ...Voucher holders may lease a unit
renting for more than the payment standard, but they must make up
the difference themselves , thereby paying more than 30% of
adjusted income for rent—This can cause trouble later, particularly
for people receiving Supplemental Security Income (SSI) and others
with very limited incomes."
Figures for 1992**indicate that there are approximately 1500 Section 8
units targeted for senior and/or disabled persons in Contra Costa
County. Precise figures on distribution of these units are not
available, but it is estimated that there were no more than 150
subsidized units occupied by 1&rsons with mental disabilities las
year, The demand for Section 8 vouchers and certificates far exceeds
the supply and waiting lists are very long and very frequently
closed.
Shelter, Inc. now has funding to establish and support 80 Supported
Housing units; these units, to be subsidized for one year, will be
available to persons with mental disabilities if they meet the other
McKinney Homeless program qualifications. The Housing Authority
of Contra Costa County has also received a grant to provide 100
vouchers for families and individuals who are homeless and
mentally-disabled; and it is anticipated that an additional 40-50
vouchers will become available for mentally-disabled persons who
are homeless or in transitional shelter settings.
The additional vouchers are a welcome response to the urgent need
for these subsidies for mentally-disabled persons who are, or are at
risk of becoming, homeless. Nonetheless, it is apparent that a rnuch
more substantial increase in the number of targeted Section 8
vouchers is needed if the hundreds of SSI recipients with mental
disabilities who desire independent living are to be able to afford
safe and decent housing. It is essential that every effort be made to
help consumers access as many certificates and vouchers as possible,
by advocating for more vouchers and by taking advantage of the
HUD regulation which "requires PHAs to provide 'reasonable
accommodation' to people with disabilities in their Section 8
*The Housing Center Bulletin, Vol. II, No. 4, January, 1994
**Provided verbally by staff of the Contra costa County Housing Authority.
- 9 -
Mental Health Commission Housing Report-June,1994
application procedures. One type of reasonable accommodation could .
include case management staff assisting with the application process"
(Ibid., the Housing Bulletin)
APPROPRIATE HOUSING OPTIONS: The issue of appropriateness
is of paramount concern, since the population served by the mental
health system is by no means homogeneous, despite the fact that the
system is limited to persons with "severe and persistent" disabilities.
Within this general population are older persons who have spent
many years in institutional settings, settings which have ill prepared
them for life "on the outside". Within this population are young
adults who have been homeless and rootless and desperate and
surviving any way they could. Within this population are also
persons who have children and jobs and the skills they need for
independent living.
The individual variations are endless, but the significant point is that
all people, including persons with disabilities, differ in skills, in social
aptitude, in adaptability, in tolerance for various situations, and in
the need for supervision. Most particularly, everyone differs in the
types of housing they choose to live in. Being able to choose your
place of residence is part of what makes a house a home. Our plan
must provide the full array of options required to fulfill the needs
and preferences of all of the diverse individuals with mental
disabilities.
THE NEED FOR SUPPORT: Since there are people who are
conditioned to restrictive living conditions and others whose
impairment is so severe that they seem to require extensive
supervision, it is essential to retain a variety of structured. special
user housing--at least until both the clients and the system are
FULLY PREPARED for success in independent living situations.
What would it take to be fully prepared? There is a growing body
of research showing that people tend to live up to expectations (both
positive and negative) and that most clients -- including those with
very severe impairments -- can and do succeed in stable, long-term,
normalized, independent housing PROVIDED THAT THEY RECEIVE THE
SUPPORTS THEY NEED FOR AS LONG AS THEY NEED THEM.
What is required, then, is access to appropriate, affordable,
permanent "regular" housing AND all necessary supports. And, it
must be emphasized that, for clients whose disability is severe
- 10-
Mental Health Commission Housing Report-June,1994
and/or for those who have had little opportunity to develop needed
skills, there will be need for a high level of support.
As indicated on page 4, the nature, duration and magnitude of
support will differ from time to time and from client to client, and
the cost will fluctuate in relation to these factors. The challenge is to
find methods which enable the system to be flexible enough to
respond to changing needs, adding and withdrawing supports as
changes occur.
According to Carling*: "Often agencies find it initially difficult to
make the transition...to working on resource coordination and
housing development. Many local programs have made this
transition either through extensive development of apartment living
options, through creating a housing assistance program, or through
routinely dealing with housing as a part of the case management
function." Several communities in California have
developed experimental models, called Integrated Service Agencies
(ISAs), which are designed to provide a variety of services in a
flexible manner, including supportive services, on-site, at the homes
of their clients.
Providing permanent, support-enriched independent living
opportunities for every person with mental disabilities is the goal.
The danger is that, if we fail to provide su #icien support, we will
repeat the tragic mistakes of deinstitutionalization, that of pushing
people out to a promised "better place" and then failing to ensure
that the promised place is really there. And failing to provide
adequate living options to meet the needs of people with mental
disabilities translates into a continuing use of expensive institutional
care and/or the very visible presence in our communities of large
numbers of people who are homeless and disabled.
* Carling,Paul J., Ph.D. , A Psychiatric Rehabilitation Approach to
Housing, John Hopkins University Press, 1985)
- 11 -
Mental Health Commission Housing Report-June, 1994
POPULATION TO BE SERVED
Today's limited mental health resources are directed toward serving
those characterized as having a serious and persistent mental
disability; ie, having a "DSM-HI-R diagnosis that may lead to chronic
disability and functional limitations in major life activities which
require treatment and services over an extended time -- sometimes
throughout a lifetime"*
Based on projections from national data, we may estimate that there
are approximately 16,000 persons in Contra Costa County (2% of the
total population) who may be characterized as having a "serious and
persistent mental illness" as defined above. National data also
suggest that 50% of these persons never utilize the public system. On
this basis, we might expect to find a population of 8,000 people
(including children and adults) who are in need of public mental
health services, and the actual population which is served by public
mental health approximates this estimated number.
The total number of adults who are currently being served by the
county's mental health system is 6,971 ** In addition, there are an
estimated 260 clients being served by the county's conservatorship
program, for a total of 7.231 persons with mental disabilities who
receive publicly-supported services.
In addition, there are a great many people who have mental
health problems and significant housing needs but who are presently
outside the system's service population, for the following reasons:
1) The definition of eligibility has been limited to the most
seriously impaired as a result of funding restrictions,
2) Homeless persons generally do not receive (or may not
accept) ongoing services from the Division; they are, therefore,
significantly under-represented in the Division data,
*Definition in use in Contra Costa County
** Based on the system's computer compilation of billable cases for the period
May 1, 1993 through April 30, 1994.
- 12 -
Mental Health Commission Housing Report-June,1994
3) Persons with a primary diagnosis of substance abuse are
not eligible for services under the present definition; yet a great
many of these persons have mental disabilities and are in need of
housing;
4) Some people move in and out of the system and may not
be included in the count at any given time;
5) Persons with substantial work histories, who are receiving
Social Security for the Disabled (SSDI) and Medicare rather than SSI
and Medi-Cal, may be using private, rather than public, mental
health resources and would therefore be unknown to the system;
while SSDI recipients receive higher benefits than SSI recipients,
they are still in need of affordable housing; and
6) Some families have been instrumental in moving their
family member to other locations in order to secure housing and
services that are not available here.
These factors would make it difficult to estimate the precise extent of
the unmet housing need, even if full information on the housing
needs of current clients were available. While these data are not
now available, the recently-implemented Coordinated Services, in
which all clients are being asked about their housing situation and
their housing goals, will provide definitive data about the housing
needs of the client population within the next year.
We need not wait for additional data, however, since the information
contained in the following sections makes it abundantly clear that
there is a very large already-identified population with urgent
housing needs. Developing plans and strategies which will enable us
to provide an adequate and anp_rQpriate range of housing options for
this population is the goal toward which we must strive. These plans
and strategies can be fine-tuned when additional information
becomes available.
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Mental Health Commission Housing Report-June,1994
LIVING SITUATIONS
OF CONTRA COSTA COUNTY CLIENTS
The following chart portrays the proportion of adults with mental
disabilities* who were living in each of the major housing categories
in the year from March 1, 1993, through February 28, 1994. Specific
housing categories have been clustered to convey the larger picture.
Living with family�
member 47%
i
.rl�¢.Fes.. +i'.�.yy'�',�."Y." h`y•v
®
These findings generally correspond with those of a national study
by the National Alliance for the Mentally Ill (NAMI)** in which
respondents reported that 42% of their mentally disabled relatives
lived with family members and 14% lived in supervised housing in
the community.
* Information from the mental health system's computer, including all persons
who received billable mental health services during the year May 1, 1993,
through April 30, 1994.
**Steinwachs, Kasper, and Skinner, 1992.
- 14 -
Mental Health Commission Housing Report-June,1994
LIVING WITH FAMILY MEMBERS
As shown above, approximately 3.400 persons with mental
disabilities (47% of the county's current caseload) are residing with
some member of the immediate or extended family. This is clearly
an extremely significant part of the housing picture, yet it has been
given very little attention.
We know from our Contra Costa data that nine-tenths of those who
live with family members are living with members of their
immediate family and the balance are living with members of their
extended family, but we have no speck information on which
family members are involved. It may be presumed that some clients
are living with their spouses and/or minor children, some are older
persons living with grown children, and some, perhaps, are residing
with siblings.
All indications are, however, that the vast majority of clients living
with family members are adults residing with their parents. The
National Alliance for the Mentally Ill (NAMI) study cited earlier
notes that most of the caretakers were parents and that more than
half were over 65 years of age. This situation is a tremendous
source of concern and anxiety for the elder parents -- because they
live in fear of the day when they can no longer cope with the day-to-
day needs of their loved ones and, often, because they are aware that
living with parents is not the optimum housing arrangement for
adults -- and it must be of equal concern to the county.
In 1992, the Alliance for the Mentally Ill in Contra Costa County
(AMI-CC) conducted a survey of families'perceptions of the housing
situations and preferences of family members with a mental
disability. They reported that 41% of those who were living with
family members were satisfied with the arrangement whereas 5901b
would have preferred another housing situation. The AMI-CC study
also found that those who wished to leave the family home were
unable to do so because they either could not find, or could not
afford, suitable alternatives.
Considering the movement toward increased independence in living
situations, respect for client preferences, and the reality-based
concerns of caretaking parents as they grow older and die, i i
imperative, when developinghousing_plans, to include the needs --
- 15 -
Mental Health Commission Housing Report June,1994
and anticipated needs — of the adult clients who are currentlyli
with the ren s.
PERMANENT INDEPENDENT LIVING SITUATIONS
Independent living situations are preferred by a substantial majority
of all mental health clients, by as much as 70-90%, according to local
surveys*journal articles," and anecdotal input from consumers.
Based on the living situation categories and data in the system's
computer base, we have identified 2,286 clients (32% of the total)
who are living in a variety of permanent, independent situations,
including:
1,448 persons who live alone in,a house or apartment,
701 who live with unrelated adults,
39 who live in a Single Room Occupancy hotel (SRO), and
98 who live in unlicensed "group homes".
We do not know from the data how many of these persons are living
in Supported Independent Living (SEL) situations nor how many of
the units are subsidized, but we know there were no more than
222-227 ** independenA living situations in which aome suI212ort(i.e.,
subsidy or housing-related service) was pEovidgd. It is therefore
apparent that some 90% of the mental health consumers who are
living indeDendently are living in regular, unsubsidized, widely-
scattered community housing; they are receiving no housing-related
support from the mental health system although they may be
receiving substantial support from members of their families who
live in the community.
Surveys of consumers residing in Board and Care Homes and in Institutes for
Mental Disease(IMDs),conducted by Mental Health Consumer Concerns of
Contra Costa County, in January,1989.
**Survey results reported by Jonathan Keck and Paul J.Carling,Journal of
Social Rehabilitation, April, 1990.
***As will be seen later, the independent living situations which provided
some degree of support during the past year included: 47beds with both
subsidies and housing supports in SELs; 25-30 beds with subsidies but no
housing-related supports in SRO's;and approximately 150 units, with Section 8
subsidies and no-housing related supports.
- 16 -
Mental Health Commission Housing Report-June,1994
The AMI survey of 102 families reaffirmed this finding and included
a further breakdown of the living situations and preferences of their
disabled relatives, as perceived by the family. The following table
shows the findings with reference to persons in independent living
situations.
AMI-CCCSTUDY OF HOUSING 5M TATTONS AND PREFERENCES,
Independent Rousing Situation Current Number Preferring
Number (Multiple 4's
permitted)
Supported Independeni Living 3 41
Own apartment 21 29
Shared apartment 3 18
Mobile home 3 3
Room in private home 7 6
Single room 4 2
Unlicensed home 6 1
Approximately half of the clients living independently are living in
apartments. Given the impoverished status of most clients and the
high rents being charged for apartments in Contra Costa County, it is
very likely that most of their apartments are small, run-down,
located in poor neighborhoods, and lacking in amenities.
Nonetheless, apartments are very highly preferred over rooms in
other people's homes, and a room in an unlicensed group home is the
least preferred. While this fording is based on a local survey of
families, rather than consumers, it corresponds with a national study
of consumer preferences which found that 43% of consumers living
in their own apartments were very satisfied with their situations
compared with only 17% of those living in group homes (Levstek and
Bond).
According to the AMI-CC study, Supported Independent Living was
over-whelmingly favored by families of persons with a mental
disability, and this is also consistent with the national trend.
Furthermore, it can be anticipated that this form of housing will
show a progressively increasing dominance over time, as clients and
families have more opportunities to be exposed to the concept and to
experience the benefits of Supported Independent Living.
IF we are truly interested in developing a client-driven system, one
which is responsive to the desires, as well as the needs, of mental
health consumers, and IF we intend to follow the State's Master Plan,
then the development of Sup2med Independent Housing will have
to assumeVriority,status.
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Mental Health Commission Housing Report-June,1994
SPECIAL USER "HOUSING"
Special User Housing was defined in the 1989 Special User Housing
Plan as:
"Housing specifically designed, supported and maintained to provide
community residences for members of a particular group of
individuals who share a common characteristic, disability or special
need. And who may... require specialized support services in order
to maintain that residence."
As used here, the term Special User Housing has been broadened to
encompass all of the residential settings/programs which have a
governmental connection (i.e., which receive funds from the county
or other governmental agency and/or which are licensed by a
government agency)* and which are specially targeted for persons
with mental disabilities, including:
(a) Permanent housing for persons with mental disabilities,
such as Supported Independent Living (SII.) units and Single Room
Occupancy (SRO) hotels;
(b) Those which are more appropriately characterized as long-
term supervised group settings (i.e., Board and Care homes);
(c) Residentially-based treatment programs, and
(d) Institutions, including Institutes for Mental Disease (IMDs)
and State Hospitals.
Many of the above programs, while not strictly "housing" are
relevant to our analysis since they are included in the system's
computerized listing of living situations and may, in fact, be the
person's only "home".
785 persons (approximately 11% of the mental health system's clients)
are living in some form of Special User "Housing", as described
above.**
` Non-licensed room and board and other strictly private facilities are not
included.
** The "system's clients", as the term is used here,includes all of the clients
who received billable mental health services from public or publicly-
supported agencies during the year from February 28, 1993 to March 1. 1994.
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Mental Health Commission Housing Report-June,1994
The distribution of slots which were available in each of the Special
User "Housing" categories, during the past year, is displayed in the
first column of the table below. The second column shows the
proportion of clients who lived in each "housing" category during the
one year period.
DISTRIBUTION OF SPECIAL USER "HOUSING" SLOTS
Special User "Housing" Categories Number Percent of Special
of Beds User Clients in Each
(93 - 94) Category
Board and Care Homes 231 58%
Supported Independent Living 47 5%
Special-User SRO's 25-30 4%
Transitional Housing (3 - 24 22 2%
months)
Community Based Residential
Treatment
Nierika (Crisis) House - 30 day 9 11%
limit
Nevin (Transitional) House 12 4%
Institutes for Mental Disease 82 10%
State Hospitals 39 6%
TOTALS 497-472 100% of the 785
persons in Special
User "Housing"
[Information was drawn from the Mental Health Division's computerized
data for the year from February 28,1993 -March 1,1994. Some
extrapolation was required because the computerized categories do not
exactly correspond with the categories being used in this report. It
should also be noted that some of the short-term programs(notably
Nierika,the Crisis Residential program which has a 30 day limit per
stay, and several transitional programs)serve many more persons than
their slots would suggest,because multiple persons fill a single slot in
the course of a year].
- 20 -
Mental Health Commission Housing Report-June,1994
A comparison of the current picture of community-based programs
with that shown in the Special User Housing Plan of 1988 reveals
little net gain, despite the concerns expressed at that time and
substantial growth in the County's population over the past 5-6
years. Specifically:
o 14 Supported Independent Living (SIL) slots were developed
in response to the Plan's recommendations; 6 of these are now in the
process of being restructured as a 10-bed residential treatment
program; and 25 are being added -- so, for next year, the net gain in
the SII. category will be 33 slots; while the number of slots in
residential treatment will be increased by 10.
o 25-30 slots in an Single Room Occupancy (SRO) hotel were
made available to persons with mental disabilities; and
o A treatment facility for dual diagnosis clients was changed to a
transitional residential treatment program.
o Funding for the prior "SB 155" program, which regulated the
augmentation of Board and Care Homes, has been discontinued, and
the homes which were certified to receive a funding augmentation
(known as a "patch") in 1988 have not received any augmentation in
recent years. During the past few months, ten augmented care beds
in Board and Care homes have been reinstated, and an additional 20-
30 are planned.
In the following sections, we will examine all of the types of Special
User "Housing" within Contra Costa County in greater depth, including
for each: a definition, an inventory of the resources, the number of
Contra Costans who can be served, a discussion of the issues, and our
recommendations for improvement.
- 21 -
Mental Health Commission Housing Report-June,1994
A. LICENSED BOARD AND CARE HOMES
DEFINITION: Board and Care Homes are licensed by the State to
provide room and board and 24-hour care and supervision of
residents, and to store medications and monitor their usage. Board
and Care Homes are designated either as Adult Residences, for .
persons from 18 through 59, or Elderly Residences, for persons 60
and over. Licenses specify whether Board and Care Homes may
serve persons who are not ambulatory, but there is no specific
licensure by tape of disability; ie, the operator may specify a
preference for mentally disabled, developmentally disabled or other
disability category or the operator may serve persons from various
categories.
Not all Board and Care providers accept persons with mental
disability and even those who do sometimes "pick and choose" their
residents. Elderly Residences are permitted to fill 25% of their beds
with residents under the age of 60, but only a small portion actually
do so.
PROGRAM & REGION CAPACITY COMMENTS
PROVIDER
2 Adult Board and Care East 22 beds 11 beds each,one owner
Homes in East County
9 Adult Board and Care Central 65 beds Some prefer develop-
Homes in Central mentally disabled but
County will accept a few
mentally disabled
residents
29 Adult Board and Care West 152 beds Some prefer develop-
Homes in West County mentally disabled but
will accept a few
mentally disabled
residents
TOTALS: 40 homes 239 beds NOT ALL of the beds
are for mentally
disabled
DISCUSSION: Board and Care Homes constitute the predominant
form of Special User "Housing", providing the only environment in
which long-term 24-hour-a-day supervised residential care is
- 22 -
Mental Health Commission Housing Report-June,1,994
provided in a community setting. As such, it is frequently the only
allowable option for placement of people leaving State Hospitals or
Institutes for Mental Disease (IMDs).
During the past year, a total of 538 mental health clients' reportedly
lived in Board and Care Homes, 377 in the 33 homes with 6 beds or
less and 161 in homes which are licensed to serve 7 or more clients.
Small homes, those serving 6 residents are less, generally are
operated by one person, or a couple, who live on the premises. The
large homes, 7 in our County, range from 7 to 14 residents at a single
site.
SPECIAL ISSUES: A number of concerns have been identified, as
follows:
(1) Most, but not all, Board and Care operators accept the specified
SSI rate, an amount which takes virtually all of the client's income.
Despite this hardship for clients, however, the net income to
operators of small Board and Care homes is generally very low. In a
county like Contra Costa, where housing costs are high, this produces
a difficult situation in which:
(a) It has been difficult to maintain an adequate supply of
providers. In East County, there has been a decline from 12
homes and 42 beds in 1988-89 to 2 homes and 22 beds
today. Central and West County counts are similar to those
reported in 1988-89** , but the numbers fluctuate and not
all of the beds in our count are specifically ear-marked for
the mentally disabled.
'The number of residents exceeds the number of beds because: (a)a single slot
may be filled by a number of different persons at different times, as residents
move from one living situation to another, and(b)those reporting the data
may not always differentiate between licensed Board and Care and unlicensed
group homes, causing some inflation in the number reportedly living in Board
and Care homes.
**The Special User Housing report of 1989 reported that there were 213 Board
and Care beds designated for mentally disabled persons. Our current figure
includes some homes that serve varied populations and some that will not
accept the SSI rate, we don't have the precise numbers but it appears that a
fully adjusted current total would closely approximate the 1989 figure.
- 23 -
Mental Health Commission Housing Report-June,1994
(b) Most small Board and Care Homes are located in multi-
problem neighborhoods, generally with poor transportation
and inadequate community facilities;
(c) Small Board and Care Homes are frequently physically
uncongenial, with two persons generally required to share a
small room, no private bathroom or other provisions for
privacy, inadequate space for socializing, etc.;
(d) There is no way for a single provider of a small Board and
Care home to provide 24 hour supervision without some
assistance.
(e) When a single person provider leaves the premises, he/she
will often lock client(s) out of the home during his/her
absence. This practice is illegal and grounds for license
revocation; nonetheless, there is substantial anecdotal
evidence that it does occur. A Mental Health Consumer
Concerns survey of 67 Board and Care residents (January,
1989)reported that clients said they were "quite often"
required to leave the home for the day. This, along with.an
occasional designation of the home as a "guest house" and
the fact that the owners often live on the premises,
contributes to the residents' feeling that it is not reallyIt leir
"home".
(2) In both large and small Board and Care homes, the services
provided, apart from medication monitoring, are generally minimal
unless a special augmentation is provided;
(3) Board and Care homes serving 7 or more residents generally
employ staffs, increasing their potential for offering on-site programs
and activities and decreasing operator burnout. However, if their
sole source of income is the SSI reimbursement rate, their funds will
be limited and their staff members are likely to be low-paid,
sometimes poorly qualified, and, frequently, non-English speaking;
(4) SB 155, which was available to provide augmented funding (a
patch) for Board and Care homes in the past, has not been available
since Realignment went into effect. Without a patch, Board and Care
Homes must make do with the meager income derived from SSI, hold
- 24 -
Mental Health Commission Housing Report-June,1994
out for private-pay clients at higher rates, switch to serving
developmentally disabled clients (who do provide a patch of at least
$220/month), or discontinue their operation.
The Division has begun to address this issue. One large (10 bed)
Board and Care Home in our County -- the Lee Care Home in San
Ramon -- is receiving additional funding from the Mental Health
Division to provide augmented care for 10 persons. Such augmented
care includes: a weekly "Health and Medication Group" for residents;
an on-site psychiatrist four hours a month to provide treatment,
monitor medications, and educate staff and residents about
psychotropic medications; a weekly "Personal Milestone" group for
residents, and a weekly group focused on activities of daily living. In
addition, structured physical activities (walking, exercises, athletic
games) occur daily and outings.planned by the residents occur on a
monthly basis.
Proposals from Board and Care Homes willing to provide augmented
services are being solicited, and it is anticipated that the number of
augmented beds contracted in Board and Care homes will be
increased by 20-30 in FY 94-95.
RECOMMENDATIONS:
(1) Explore the possibility of providing monetary incentives to Board
and Care home operators in order to stimulate them to encourage
and facilitate their residents' moving to independent living
situations. At present, the operator has a disincentive to accomplish
this, since he/she will lose the resident's rent and will have to
exchange a known resident for an unknown --possibly more difficult
-- resident when the current resident moves on;
(2) Provide a monetary patch in order to upgrade services in Board
and Care Homes, particularly in the larger homes which have the
most potential. As noted earlier, this is being done or planned in a
few homes at the present time. Since Board and Care Homes are
heavily used, particularly for persons leaving institutions, we would
like to see a substantial expansion of augmented beds. The
possibility of enlisting non-profits in the development of high-
quality Board and Care homes has also been suggested.
(3) Consider developing some form of non-monetary assistance (in
lieu of a patch) in order to upgrade services in Board and Care Homes
- 25 -
Mental Health Commission Housing Report-June,1994
which do not receive augmented funding. Such support might be
particularly helpful in small Board and Care homes, where single
person operators are more subject to burnout and more prone to
shut residents out of the home when they leave the premises.
(a) One strategy might be for the mental health system to
assign personnel (without cost to the operator) to provide: respite
care for the Board and Care operator, on-site instruction for clients in
household maintenance and cooking, client group meetings and
activities, or other targeted supports to the Board and Care provider
and/or the clients in the Home; and
(b) Another might be a cluster strategy, whereby a group of
operators are connected to a core program which offers joint
purchasing, medication education, and a variety of other services
supportive of the operator as well as the clients.
In addition to upgrading services, the proposed funding
augmentation and/or the provision of staff assistance might facilitate
recruitment of Board and Care operators in all sections of the County.
(4) Develop standards and a more active monitoring system,
including regular surveys of client satisfaction, so that: .
(a) operators know that their programs are being evaluated,
(b) placement of clients in poor situations can be avoided, and
(c) the best programs and/or potential models can be
identified.
B. SUPPORTED INDEPENDENT LIVING (SIL)
DEFINITION: Special-user Supported Independent Living (SIL) is one
of the terms used to describe independent living in specially-
targeted apartments or houses. Other terms which are sometimes
used for S]Ls include: Clustered Apartments, Member-supportive
Communities, Service-enriched Housing, Targeted Housing, and
Congregate- Supported Housing.
There are two forms of support provided in SILs: first, there is'a
rental subsidy which is linked to the property (rather than to the
tenant as it is under Section 8), and, second, there is supportive
nearby, or available, to provide assistance with issues relating to
- 26 -
Mental Health Commission Housing Report-June,1994
living in an independent or shared unit within,a larger community.
Directly linked to the housing program, the support staff generally
involves clients in providing peer support and making program.
decisions related to their housing community.
The current status of County-supported SIL programs is shown
below:
PROGRAM & REGION CAPACITY COMMENTS
PROVIDER
Clayton Way,HIP Central 6_11,adr_ One six-bedroom house
[THIS PROGRAM IS BEING for homeless adults;rent
CHANGED to residential at 30%of adjusted income
treatment--see Discussion] I
Santa Fe, HIP East 8 beds Two two-bedroom units
and one four-bedroom
unit for homeless adults;
rent is 30%of tenant's
adjusted*income.
Kirker Court, HIP Central 25 beds 13 one-bedroom and 6
[NEW--ANTICIPATED two-bedroom for
OPENING WELL BE THE adults/families;
BEGINNING OF FY 94-95] rent will be 30%of ten-
ant's adjusted income.
Phoenix Apts.,Phoenix Central 11 beds Eleven one-bedroom
units,for individuals or
couples
Rubicon Homes,Rubicon West 10 beds Rent is 30%of tenant's
adjusted income
Virginia St.,Rubicon West 12 beds Rent is 30%of income
9th St. Apts.,Rubicon West 4 beds Mentally-disabled
homeless
TOTAL 70 beds
DISCUSSION: The HIP programs were initiated in response to the
Special User Plans developed in 1988 and 1989. This resulted in 14
additional Supported Independent(SIL) beds being available to
Contra Costars during the past several years. With the addition of
the Kirker Pass units, scheduled to be open in July, 1994, the total
SEL capacity would have reached 76.
However, the Clayton units are being converted from Supported
Independent Living (SIL) units to Residential Treatment units, so
there will be an off-setting loss of 6 SIL beds. The total number of
SEL beds will be 70 when all of the changes are complete. While this
progress is welcome, the number is unacceptably small, given the
- 27 -
Mental Health Commission Housing Report-June,1994
marked preference for Supported Independent Housing and the large
number of clients who are currently living in independent housing
without any support.
RECOMMENDATIONS:
(1) Explore all of the possibilities for increasing the number of
Supported Independent Living (SIL) units/beds in our County,
including:
(a) Identifying and/or encouraging the development of
Special-User Housing Development Corporations with a commitment
to building affordable housing units, including units targeted for
persons with mental disabilities;
(b) Supporting the efforts of identified Housing Development
Corporations to secure community acceptance and project funding;
(c) Collaborating in County efforts to identify and secure
funding for any subsidized housing programs which may have
applicability to persons with mental disabilities; and
(d) Endeavoring to increase the availability of Section 8
vouchers and certificates targeted for the mentally disabled;
(2) Work with appropriate County Departments to ensure that the
Master Plan's Housing Elements adequately provide for Special User
Housing for all lands under the County's jurisdiction;
(3) Continue active collaboration with the County's Housing
Authority, housing developers, and cities to increase the supply of
safe affordable housing; and
(4) Fund services to provide needed supports, to the fullest extent
possible, to all persons who are living independently and who
require assistance in order to maintain their independent living
situations.
- 28 -
Mental Health Commission Housing Report-June,1994
C. SINGLE ROOM OCCUPANCY (SRO)
DEFINITION: SRO's are simply rooms for individuals to rent. They
may or may not have a dining hall, common kitchen and community
room. Generales they are converted hotels/motels that provide
private rooms with baths. or shared baths, to clients who have
difficulty living with other people in shared housing or who prefer to
live alone.
PROGRAM&PROVIDER REGION CAPACITY COMMENTS
River House Central 75 rooms-- Available to elderly
total for all and/or disabled adults,
(HIP owns the property populations with no planned ratios;
and it is managed by preference is given to
Eden Housing's 25-30 rooms homeless.
Management Service) (33%)were Rent is based on room
occupied by size; all have bathrooms
mentally and kitchenettes,with
disabled in one full kitchen on each
January, '94 1 floor.
DISCUSSION: Many of the mentally disabled residents in River House
were formerly homeless persons, and some of these individuals have
found it very difficult to conform to the behavior required for living
in a building with a lot of other people, resulting in their being
evicted. It is strongly felt that these difficulties could have been
avoided if adequate support, as well as opportunities for
participation in structured activities, were provided.
RECOMMENDATION:
In cooperation with a consumer organization, arrange to provide all
needed support and activities to enable residents in SRO's to
successfully maintain their residence in these living situations and to
access more fully independent living situations when the person is
ready for such a move.
Note: As this report is being prepared, we understand that
the County is actively developing a consumer-staffed
support program at River House, as well as at the Santa Fe
and Kirker Court Apartments. This is a much-needed and
most welcome development!
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Mental Health Commission Housing Report-June,1994
D. TRANSITIONAL (TIME-LIMITED) HOUSING
DEFINITION: Transitional programs generally provide for a length of
stay ranging from three to twenty-four months, based upon the
client's needs and desires. Except for their temporary nature, they
are similar to Supported Independent Living programs which
provide both housing and staff support. They are primarily designed
to prepare residents for independent living in the community.
PROGRAM& PROVIDER REGION CAPACITY COMMENTS
Pine House,Phoenix West 5 beds Coed;can serve people
from all regions of
count
Maple House,Phoenix Central 5 beds Coed;can serve people
from all regions of
count
San Joaquin I,Rubicon West 3 units/
9 beds
TOTAL 19 beds
DISCUSSION: These programs provide a useful transition for
mentally disabled persons being discharged from more restrictive
settings and their function is particularly valuable during this period
when every effort is being made to bring people from State Hospitals
and IMDs into community housing. Additional transitional housing
units are needed to serve a population the size of Contra Costa's,
particularly during a time of change.
RECOMMENDATION: Retain, support and, if possible, expand these
programs.
E. RESIDENTIAL TREATMENT
DEFINITION: Residential Treatment Services provide a structured
program, available day and night, seven days a week in a non-
institutional residential setting. Individuals are supported in their
efforts to restore, maintain and apply interpersonal and independent
living skills and to access community support systems.
This is a time-limited treatment service for individuals who would
be at risk of hospitalization or other institutional placement if they
were not in a residential treatment program. No particular time
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Mental Health Commission Housing Report-June,1994
limit is specified in the contract for Nevin House, but the average
length of stay has been approximately three months during this past
year.
Since it is considered to be a TREATMENT program, rather than a
housing program, it is billable under MediCal.
PROGRAM & PROVIDER REGION CAPACITY COMMENTS
Nevin House, Phoenix Located 12 beds Serves men and
in West women from the
entire count
Clayton House (NEW)* Central 10 beds
TOTAL 22 beds
DISCUSSION: As noted earlier, *Clayton House, which had been used
as a Supported Independent Living (SII.) program for homeless
persons, is being converted to a Residential Treatment program for 10
persons. With the existing Nevin House and the re-structured
Clayton House, the county will have 22 beds for Transitional
Residential Treatment. While the loss of supported independent
housing is always regrettable, this virtual doubling of our county's
transitional residential treatment capability is a necessary
component in the effort to reduce reliance upon costly institutional
and hospital services.
RECOMMENDATIONS:
(1) Support the County's effort to utilize Clayton Way as a residential
treatment program for clients at risk of hospitalization or other
institutional placement.
(2) Provide active encouragement and support to clients who choose
to move out of residential treatment to permanent independent
living situations. If they already have permanent housing, aid them
in retaining their housing during the time-limited periods when
residential treatment is necessary.
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Mental Health Commission Housing Report-June,1994
F. CRISIS RESIDENTIAL TREATMENT
DEFINITION: Crisis Residential Treatment is an alternative to
hospitalization for individuals who are experiencing an acute
psychiatric episode or crisis and who do not present medical
complications requiring nursing care. It offers a structured program,
with services available day and night, seven days a week.
Stays are limited to a maximum of 30 days per episode. The time
limitation on stays, and the consequent turnover, made it possible to
serve the 98 different people who were reportedly served in this 9-
bed facility during the past year. This is a TREATMENT program,
billable under MediCal.
PROGRAM & PROVIDER REGION I'CAPACITYT COMMENTS
Nierika House, Phoenix County- 9 beds For men and
wide I I women
DISCUSSION: This small 9-bed facility is the only crisis residential
treatment program for adults with mental disabilities in the County;
and its services are essential to our community. In addition to
providing a viable alternative to hospitalization, it provides a
necessary respite for both the client and the caregiver during crisis
periods. However, it would be inappropriate to consider Nierika a
"housing" program, since it does not provide a permanent place to
live.
ISSUES: While the program can theoretically serve 150 people for
30-day stays, it is much too small to accommodate-the numbers of
people who are in need of this service as an alternative to costly
hospitalization during periods of acute crisis.
RECONtIVIENDATIONS:
(1) Contract for the additional three beds for which Nierika is
licensed. This will bring the total number of crisis beds available in
our county,to 12, and it will make it more possible to provide access
to residential crisis beds whenever they are needed.
(2) Do everything possible to ensure that clients maintain their own,
permanent housing while they are in the crisis residential treatment
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Mental Health Commission Housing Report-June,1994
program or help them to access such housing if they don't already
have it.
G. STATE HOSPITALS AND
INSTITUTES FOR MEENTAL DISEASE (IMD's)
DEFINITIONS:
State Hospitals are state-operated facilities which provide food,
shelter, medical care, mental health treatment and other basic
services in locked, institutional settings,removed from the
community. As utilization of State Hospitals has declined, virtually
the only persons remaining in State Hospitals are those who are very
severely disabled (frequently with physical as well as mental
disabilities), self-destructive and/or violent.
Institutes for Mental Disease (IMD's) are the psychiatric equivalent
of Skilled Nursing Facilities (SNP's). They are institutional, locked
facilities, generally ranging in size from 64 to 199 beds. Mm's are
specially licensed and accredited as psychiatric non-acute facilities
for adults with "mental diseases which require treatment".
The following table shows the number of institutional beds which are
being contracted/purchased by Contra Costa County during the
current fiscal year:
PROGRAM&PROVIDER REGION CAPACITY COMMENTS
Napa State Hospital County- 39 beds for Contracted beds for FY'94
wide Contra Costa
Crestwood IMD's County- 52 beds San Jose 30
wide Vallejo 17
Modesto 2
Stockton 3
Westwood IMD County- 20
wide
Telecare,Alameda Co. County- 10 Gladman 2
wide Villa Fairmont 4
Garfield 4
SUB TOTALS: 39 Hospital
82 IMD's
INSTITUTIONAL 121 TOTAL
TOTAL:
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Mental Health.Commission Housing Report-June, 1994
DISCUSSION: There is general agreement that it is desirable to
provide clients with community-based permanent housing in non-
institutional settings whenever possible, and our county has made
significant progress in reducing our reliance on institutional care.
Our use of Napa has been reduced by nearly half in the past year,
from 72 to 39 beds. The total number of IMD beds was increased by
10, to help serve the clients returning from the State Hospital.
While the institutional census has declined substantially, there were
still approximately 100 clients housed in 11VIDs in the course of the
year. Similar numbers will most likely be served in these facilities
for the foreseeable future, so that concerns about the quality of care
must be addressed. Particular concern has been expressed about the
adequacy of space and programming and the qualifications and
English-speaking capability of aides and other low-paid, entry-level
staff within the IMD's.
RECOMMENDATIONS:
(1) Endeavor to improve the quality of IMD's, as recommended in the
ad hoc Plan of the Mental Health Commission;
(2) Invite input from families and clients about available/desired
programming at IMI)s to assist in developing IMD performance
contracts;
(3) Continue to develop the housing alternatives and supports which
are needed to maintain persons with severe disabilities in the
community, as recommended throughout this housing report, and
(4) Continue to strive, as expeditiously as possible, to move clients
from IMDs into less restrictive types of care
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Mental Health Commission Housing Report-June,1994,
SPECIAL NOTE ON THE COUNTY JAIL:
Before leaving the discussion of institutional care, it is important to
mention that there is another institution in our county -- the county
jail -- which, unfortunately, "houses" a substantial number of
persons with mental disabilities. There are 50 beds in a special
psychiatric wing, known as the M-Module, in the Martinez Detention
Facility. These 50 beds are all-too-often filled with people whose
mental disability and lack of resources have combined to produce
behaviors which result in their incarceration.
The Mental Health Division provides limited mental health services
at the jail, although mental health services provided in jails are not
reimbursable by Medi-Cal and the Sheriff s Department does not
contribute to the cost of these services.
The incarceration of persons with mental disabilities, who require
treatment and not punishment, is a very serious issue, but it is
beyond the scope of this housing report. It is hoped that future
studies and reports will give this important subject the attention
which it most certainly warrants.
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Mental Health Commission Housing Report-June,1994
HOMELESSNESS
Deinstitutionalization and the.lack of adequate community resources
to house persons with mental disabilities has contributed
significantly to the growing problem of homelessness within the past
decade. It has generally been stated that over 30% of homeless
persons have a mental disability. Shelter, Inc., the County's operator
of generic homeless shelters estimated that there were 15,000
homeless persons in Contra Costa in 1990.
If the estimates and projections are correct, there may be as many as
5,000 homeless persons with some degree of mental disability
and/or dual diagnosis in our county in any given year. Even if we
were to use the most conservative estimate of homelessness (6,000
total for the County), we would still have an estimated 2,000
homeless in need of mental health services in Contra Costa County.
Data from the Mental Health computer system identified 374 mental
health clients as homeless during the year from February 28, 1993,
through March 31, 1994. Of the 374 homeless persons who were
receiving billable services from the mental health system, 112 (30% )
were receiving ongoing treatment at County clinics; 217 (58%) were
seen by Mental Health Crisis Services; and 45 (12%) spent time in
Merrithew's psychiatric wards. This pattern is consistent with
national findings that homeless persons with mental disabilities
rarely receive ongoing mental health treatment and are frequently
seen by Crisis Services.
Further, contrasting the several hundred homeless persons served by
mental health with the estimated several thousand who are homeless
and mentally disabled, it seems apparent that mental health services
to the mentally disabled homeless consist primarily of the time-
limited help which they receive at multi-purpose centers and at the
generic and special user shelters described below.
Delays in the provision of adequate, long-term mental health
treatment generally costs more in the long run, since homeless
persons who are untreated often end up in crisis services and acute
psychiatric hospitals. While this population is frequently resistant to
seeking mental health services, they are accessible when they are in
contact with shelters and Multi-service Centers. Therefore,
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Mental Health Commission Housing Report June,IGA
91—
expanding mental health treatment services at the shelters and
following discharge can provide an opportune means of reaching and
helping to stabilize hard-to-reach people who are homeless.
DEFINITION OF HOMELESS SHELTERS: The provision, generally in
group settings, of emergency and transitional housing for persons
who are homeless. - Emergenry housing is defined as housing where
the length of stay is limited to NO MORE THAN THREE MONTHS.
Transitional housing programs generally permit residents to stay
from THREE TO TWENTY-FOUR MONTHS.
PROGRAM & REGION CAPACITY COMMENTS
PROVIDER
Ease CQunty Shelter for County- 20 beds Emergency shelter for
people with mental wide homelQss persons who
disabilities, Phoenix have a mental
(SPECIALIZED,supported disability; stays limited
by Mental Health) to 30 days; served 325
peop-e last year
Contra Costa County County- 60 beds Emergency shelter for
Shelter in North_Canoa wide (for all; all persons who are
Shelter Inc. number for homeless- including
(GENERIC,supported by those with mental
CCC Housing Authority) MI isn't disabilities,dual-
specified) diagnoses and HIV
Contra Costa County County- 56 beds Emergency shelter for
Shelter in NDXlh wide (for all; all persons who are
Richmond,Shelter Inc. number for homCless.including
(generic,supported by those with mental
ccr, MI isn't disabilities,dual-
Housing Authority) specified) diagnoses and HIV
Mt. View,Shelter Inc. Central 12 beds Transitional shelter,
(GENERIC,supported by dormitory style,for
CCC Housing Authority) homeless women;may
include mentally
disabled
5=Damiano, Shelter Inc. Central Cottage for Transitional shelter for
(GENERIC, supported by two women empluygd homeless
CCC Housing Authority) women;may include
mentallY disabled
TOTAL 150 NOT ALL for persons
with mental disabilities
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Mental Health Commission Housing Report-June, 1994
Additional emergency shelter beds in Contra Costa County are
designated for the following population groupings:
200 beds for persons who are homeless(most of these are at
the Richmond Rescue Mission)
100 beds for substance abusers,
24 beds for battered women and their children,
Motel vouchers for homeless persons/persons at risk of
homelessness (generally funded by FEMA,the Federal
Emergency Management Agency, and limited to 3 nights),
18 beds for persons with HN/AIDS
These shelters and motel vouchers can be utilized by persons with
mental disabilities if they meet the programs' other criteria.
It should also be noted that there are three Multi-purpose Centers,
one in each region of the county, which serve people with mental
disabilities who are homeless or at risk of becoming homeless.
Funded,by Contra Costa County Mental Health and operated by
Phoenix, Inc., these Centers provide: assistance in securing financial,
medical and housing resources; showers and laundry facilities;
counseling; referrals to the East County Shelter; and other services.
Approximately 900 people received services at the Multi-purpose
Centers last year. County Mental Health has assigned a case manager
to each of the Centers for six hours per site per week.
DISCUSSION:
The demand for housing assistance for homeless persons greatly
exceeds the capacity of the shelter programs.
The emergency shelter programs which serve persons with mental
disabilities (East County,North Concord and North Richmond) tend to
serve the same persons over and over--a revolving door
phenomenon-- because:
o The length of stay at the East County shelter is limited to 30
days, too short a time to develop and implement a long-range plan
o There are insufficient mental health services* available to
residents of the Shelter, Inc. programs which are operated by the
County Housing Authority. County Mental Health provides one
mental health professional for all of the Shelter, Inc. programs, an
*The need for substance abuse treatment and treatment for those with dual
diagnoses is equally compelling. While these subjects are beyond the scope of
the present report, we recognize that effectively addressing the problems of
homelessness will require collaboration with the Departments and agencies
who are involved with subtance abuse issues.
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Mental Health Commission Housing Report-June,.1994
allocation of 6 hours of mental health services per week per site. At
the Concord shelter, there are a group of professionals who provide
mental health services on a volunteer basis, but there is no similar
volunteer program available in Richmond; and
o There is insufficient funding to provide follow-up services after
persons leave any of the shelter programs.
RECOMMENDATIONS:
(1) Work to_develop more early intervention programs which could
help to prevent homelessness, including, for example:
- Identifying persons at risk of homelessness, (e.g., people who
have been served with eviction notices) and providing them
supportive services before they lose their homes;
- Ensuring that people who have housing do not lose that
housing when they are temporarily hospitalized or in a treatment
program;and c
- Helping mentally-disabled people who are about to be
discharged from hospitals, treatment programs,jails, and other
temporary "residences" arrange permanent housing prior to their
release;
(2) Advocate with the county for more shelters;
(3) Increase the maximum length of stay permitted in the East
County Shelter;
(4) Increase the mental health services which are provided: (a) at
the generic homeless shelters that serve substantial numbers of
persons with mental disabilities and (b) at the Multi-service Centers;
(5) Increase linkages between shelters and case managers to ensure
more adequate provision of critically-needed follow-up services; and
(6) Involve clients in planning and preparing for services and
housing alternatives which are acceptable to them since people who
are homeless "may have had many negatives experiences in the past
with the mental health system, or may have simply become so
rootless as to have enormous.difficulty in staying within a particular
housing setting". (Carling, Paul J., 1993)
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► Mental Health Commission Housing Report-June,1994
CONCLUSION
The approach presented in the foregoing pages reflects the Mental
Health Commission's commitment to developing and implementing a
comprehensive array of community-based housing options,
responsive to the needs and desires of the heterogeneous population
served by the mental health system It reflects our belief that we
must retain, and improve, a variety of special user housing until both
the clients and the system are fully ready to move into supported
independent housing. It reaffirms the commitment of both the
Commission and the Division to a client-driven system, one which
respects the desire of clients to have what most other people have
and to live the very best lives tiat they can.
An extensive body of literature, as well as data from our state and
county, has shown that most clients want to live in permanent,
independent, affordable homes in ordinary neighborhoods, alone or .
with roommates of their own choice.* That literature has also shown
that they can do so successfully, even if their disabilities are severe,
PROVIDED THAT ALL NEEDED SUPPORTS ARE AVAELABLE.
Needed support may mean help in finding a place, applying for a
rental subsidy, and arranging for utilities and furniture; it may
involve being available for crisis intervention or medication
monitoring; it may include training in cooking, money management,
and other independent living activities; it may involve helping the
client to access other supports and resources within the community;
or it may involve helping a client prepare for, secure and retain
employment.*
In order.to truly stabilize permanent independent living situations,
these supports must be available, preferably on-site at the client's
*The literature has also emphasized the importance which consumers place
upon having real jobs and social interactions within the community. Both of
these are of utmost importance, and,as pointed out in previous sections,the
income to be derived from paid employment can be a key element in one's
ability to secure decent housing. But,like independent housing,regular
employment requires the provision of adequate training and supports. We
believe that this is a vital aspect of community living for persons with mental
disabilities, and we hope that it will be addressed in subsequent planning
efforts.
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w
Mental Health Commission Housing Report-Jun,,LwN :.
residence, FOR AS LONG AS THEY ARE NEEDED. Since staff members
(either County employees or contracted staff) are the ones who
provide these supportsf there would have to be a commitment to
fund additional positions, or reassign staff, to provide.the necessary
supportive services.
By and large, neither permanent, affordable housing nor the above-
described supportive services are now available to the majority of
clients in the mental health system in Contra Costa(or elsewhere in
the country). Placing major emphasis on the development of housing
and the provision of requisite supportive services will require
profound changes in the mental health system. As stated in the
Psychosocial Rehabilitation Journal devoted to this subject(April,
1990): "In order to implement supported housing on a broad scale,
most mental health systems and agencies will have to change their
mission and values, as well as the way they relate to clients and
communities. Such fundamental changes must occur if the right to a
home and life in the community is to move out of the realm of
rhetoric and become a reality in the lives of people who experience
psychiatric disabilities".`
Key to this process is the commitment on the part of the Mental
Health Division to assign priority status to allocating, or contracting
for, staff to provide the supportive services which are required to
maintain people in independent living situations.
It is essential that our county and city leaders take the lead in seeing
that more affordable units are built throughout our county and that
more of these units are made available to people with mental
disabilities.
It is critical that any savings which derive from our system's
reduction in State Hospital and other institutional usage be retained
within the mental health system for application to urgent housing
and supportive service needs.
And, finally, the Mental Health Commission and other advocates for
persons with mental disabilities must continue to promote these
concepts and actively work to enlist communities in our efforts.
If we all work together, we CAN move from rhetoric to reality!
'Ridgway and Zipple,op. cit
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