MENTAL HEALTH 5 YEAR HOUSING PLAN

Transcription

1 MENTAL HEALTH 5 YEAR HOUSING PLAN

2 ACKNOWLEDGEMENTS This housing plan was developed by the Mental Health Housing Plan task group which formed in January 2005 to provide leadership and recommendations toward the planning, development, implementation, and evaluation of a Fraser Health Housing plan for Mental Health Services. This committed group of individuals provided valuable input and debate on much of the information contained within this plan. It should also be noted that a significant amount of information was obtained from previous strategic housing plans that had been developed prior to the formation of Fraser Health. The work and information that was contained within these plans has been utilized and must also be acknowledged. Please note the term consumer and client is used interchangeable throughout this document

3 TABLE OF CONTENTS Executive Summary 4 Summary of Recommendations 4 Housing Plan Supports Strategic Planning 7 Vision, Purpose, Values, Guiding Principles 8 Goals and Objectives of Mental Health Housing Reform 9 Page Historical Perspective of Residential Care for the Mentally ill 11 Best Practices in Mental Health Housing and Residential Care 11 Understanding our Clients and their Residential and Housing needs 14 Continuum of Mental Health Residential Care & Housing Programs 16 Projected Residential & Housing Needs over the next 5 years 19 Facility Upgrades / New Residential Resources, 23 Build or Develop Unlicensed Models Supported Housing Models, Add to existing Rental Subsidy and Support capacity. Development of Specialized Housing and Residential Resources 30 Additional recommendations to facilitate Mental Health Housing Reform 33 Evaluation and Research 51 Summary and Conclusions 53 References 55 Appendices A. Glossary 57 B. Principles of Psychosocial Réhabilitation 59 C. Benchmark comparisons from other jurisdictions 60 D. Mental Health Housing Capacity by Health Authority 61 E. Members of the Housing Plan Task group 62 F. Housing Plan Consultation Day Feedback 63 G. Consumer & Family Focus Group Feedback

4 Executive Summary During the past century there have been many changes in how residential care has been provided to persons with mental illness. In the early 1900 s, residential care for the mentally ill was provided in large centrally located institutions. This type of care has evolved over the past many decades to more community based residential resources where clients live closer to their families and are provided with more community based opportunities. Over the past 15 years as mental health reform has taken shape across Canada, housing and residential care has received increased attention. Health Authorities have realized the significance in providing safe and secure housing options for persons with mental illness. Proper housing is considered a major determinant of ones physical and mental health and has significant impact on health care costs in the long term. Numerous health authorities have reshaped and expanded housing resources to not only include 24 hour licensed residential care but have developed a broader continuum of housing options that includes supported housing. Supported housing is a model of care that provides clients with greater independence and on-site supports. The goal to build a broader continuum of mental health housing is important and has only just begun in Fraser Health. The recommendations within this housing plan outline the steps necessary to continue the development of this continuum. The Mental Health housing plan recommends three major areas of development to increase capacity and expand on the range of resources. It is projected that by 2011, Fraser Health will need an additional 790 licensed residential, supported housing and crisis stabilization beds combined. The housing plan recommends the development of 135 specialized licensed residential beds, 255 supported housing units, and 525 additional subsidized rental units to address this anticipated shortfall. This three pronged approach will enable mental health housing reform to move forward in Fraser Health and ensure sustainability and an adequate housing supply in the years ahead. In addition, this housing plan also outlines specific recommendations that will improve the quality of programming currently in residential care, will ensure that clients are being placed in the most appropriate resources, will provide appropriate levels of support for clients living in the community, and will move toward a housing and residential program that is integrated and accessible. Following is a summarized list of the housing plan recommendations. Full descriptions of these recommendations are contained within the housing plan document itself. It should be noted that the recommendations in this plan have no committed financial resources at this point. To ensure the successful implementation of the recommendations, necessary funding will be required. Summary of Recommendations: o o Build nine 15 bed licensed Specialized residential facilities over 5 years. (p. 25) Build seventeen 15 unit supported housing apartment projects over 5 years. (p. 27) o Professional Support for supported housing projects (17 FTE s over five years). (p. 27) o Health Care Worker / Community Living Support Worker for Supported housing projects (63 FTE s total over five years). (p. 27) o Develop an additional 525 subsidized rental units. (p. 29) (Add 105 subsidies per year each year for 5 years)

5 o Health Care Worker / Community Living Support for rent subsidies (35 FTE s total over five years). (p. 29) o Capital Improvement / contingency fund. (p. 24) o o o Increase the number of rehabilitation specialists across Fraser Health. (15 FTE s) (p. 33) Establish a quality improvement / risk management position for the Mental Health residential and housing program. (p.34) Residential / Housing project coordinator 5 year term position. (p. 35) o Project management support. (p. 35) o o o Incrementally increase per diem funding to $110/ day for Licensed Mental Health residential facilities. (p. 37) Make available funding for facilities willing to provide complex care to residential clients. (5 facilities) (p. 37) Supported Independent Living (SIL) program guidelines review. (p. 38) o SIL subsidy annual cost pressure funding. (p. 38) o o o o o Increase after hour supports to clients living in the community. (12 Professional & 12 Non Professional FTE s) (p. 39) Assessment / referral tool development to ensure client needs are matched to available resources. (p. 40) Development of a standing committee for the Housing and Residential program. (p. 41) Develop improved communication and linkages between service areas. (p. 42) Ongoing educational opportunities. (p.43) o Utilization of Information technology. (p. 44) o Update Mental Health Policy & Procedure manual. (p. 45) o o Mental Health Service provider contract review and contract language revision. (p. 46) Increased participation of consumer and family members in decision making committees. (p. 47) - 5 -

6 o o o Development and enhancement of partnerships with municipalities, apartment owners, non-profit agencies, current service providers. (p. 48) Development of consultative as well as collaborative processes to ensure input is obtained from affected parties. (p. 49) Development of a communication plan to ensure all interested parties are informed about the upcoming changes and new developments in the Housing and residential program. (p. 50) o Evaluation & Research (p. 51) The following list is a summary of the identified specialized populations that will require specialized housing and residential resources. o Clients requiring minimal barrier housing. (p. 30) o Youth or younger adults. (p. 30) o Individuals with a dual diagnosis of mental illness and other mental disorder including developmental disabilities, organic brain syndrome, or acquired brain injury. (p. 31) o Support to Inpatient psychiatry and step down. (p. 31) o Individuals with eating disorders. (p. 31) o Concurrently disordered clients whose primary issue is substance use. This could be in the form of second stage housing following support recovery (p. 32) o Aging in place and medically complex mental health clients. (p. 32) These recommended changes are complex and impact many individuals. The actions required to make mental health housing reform a reality and move the housing and residential program forward requires commitment from Fraser Health. Combined with the commitment comes the passion of the mental health staff and dedicated community service partners who truly believe improved housing for persons with mental illness is of the utmost importance. Together we will work together to ensure housing reform does become a reality

7 Housing Plan Supports Strategic Planning In October 2003, a three year Strategic Plan for Fraser Health was developed setting out Fraser Health s long term direction and vision for health care. This plan outlined four strategic directions that would be implemented to move towards the vision of Better Health, Best in Health Care. These four strategic directions included; an integrated health system, people development, partnerships, and performance improvement. The core business for Fraser Health was to develop an integrated health system, with the other strategic directions aligning with and providing support to this first initiative. Goals were identified to support these strategic directions, and strategies to achieve these goals were outlined in the strategic plan. One of the major initiatives identified in the Fraser Health strategic plan supporting an integrated health system was to develop a plan for the redesign of residential and supportive housing for mental health clients. 1 Along with the Fraser Health Strategic plan, the Mental Health & Addiction strategic plan developed in December 2003 also supported this initiative. 2 The Mental Health & Addiction strategic plan identified four strategies required to move toward the broader Fraser Health initiative of an integrated health system. These strategies included: standardization based on evidence and best practice, target services for populations at risk, redesign clinical services to achieve a continuum of care and ensure the right care is provided in the right location, and a focus on chronic disease management, health promotion, and strategies to build healthier communities. Mental Health housing redesign is a major initiative identified in the Mental Health & Addiction strategic plan of redesigning clinical services. The 2003 Mental Health & Addiction strategic plan also identified that one of four major initiatives outlined in the Ministry of Health Services 2005/2006 performance agreement, was to implement the Mental Health residential and housing redesign plan. The development of this housing plan is in keeping with the strategic directions of the Fraser Health strategic plan, the Mental Health & Addiction strategic plan, and in meeting the 2005/2006 performance targets identified by the Ministry of Health Services. These strategic directions provide the broader support to the housing plan. The vision, purpose, values, and guiding principles outlined in the housing plan provide the direction

8 Vision, Purpose, Values, & Guiding Principles Vision To provide safe, secure, and accessible housing and residential care while promoting it within a recovery oriented system. Purpose To provide housing and residential care from a population health perspective which promotes illness stabilization and recovery to individuals with emerging mental illnesses as well as individuals with longer term serious and persistent mental illness. Values We provide care and service that is compassionate, respectful, and encourages individual growth. Guiding Principles Mental Health housing and residential care services will be directed by evidence based best practices which support independent living and recovery, consumer choice, flexible supports and service accountability. This supports a shift from the current residential care model to a better range of housing options. Supported housing will be considered a first choice in housing options for clients when available. This will be dependant on client choice and need. Licensed residential care will be considered if client needs are unable to be met through other community mental health housing programs. Psychosocial rehabilitation principles and a recovery oriented system of care will be used to guide housing and residential care programs. This program orientation will assist clients to move into the least restrictive environment of residential care or housing. The Mental Health Housing and Residential program will be planned and coordinated in an integrated manner across Fraser Health. Access to Mental Health Housing and Residential care will be equitable across Fraser Health taking into consideration the unique needs of each client and considering the resources available in each community. A variety of (re)development options will be considered including public/private, nonprofit, and for profit partnerships. The Mental Health, Housing and Residential program will support other related services or programs such as Community Mental Health Centres, Inpatient Psychiatric Units, and tertiary rehabilitation programs being developed through the Riverview Redevelopment project. Performance indicators will be used to measure processes and outcomes. Clinical effectiveness will be a primary consideration in the development of a range of housing options while being cognizant and mindful of cost effectiveness. Clients will be able to access the housing continuum at any point. Continuous quality improvement will be used to evaluate and improve upon program delivery. Ongoing advocacy and relationship building will occur between Fraser Health and other agencies and service providers to improve housing options

9 Goals & Objectives of Mental Health Housing Reform Goals Beds/units will be developed consistent with Best Practice recommendations towards supported housing. Housing will be designed to support independent living and recovery, including access to employment, educational, socialization or social opportunities, and leisure activities. Rehabilitation services will play a significant role in the residential and housing program. Support services will be creative, flexible and developed to meet individual needs. A planning process will be established that includes consultation and active participation with key stakeholders: including clients, families, staff, service providers, and advocacy groups/agencies. Licensed residential facilities will be reshaped where possible to meet specialized residential program needs including caring for residents with complex needs. Licensed residential facilities will meet Mental Health clinical and physical plant standards. Facilities that cannot meet program standards may be considered for upgrading, downsizing, or closure. Any newly developed licensed residential facilities will meet Licensing standards. New licensed residential facilities will range in size from beds. Specialized residential facilities may be larger or smaller depending on Fraser Health s community needs and the specialty focus of the program. Supported housing will be developed with accompanying support. The long range goal is to increase the available supply of supported housing units, specialized licensed residential beds and rental subsidies. Facilities will be supported to develop bridging or transitional beds wherever possible. Single rooms will be the standard in new residential facilities and supported housing projects. Services will be timely, well communicated, and accessible, allowing consumers and family members to obtain information and make informed decisions regarding their housing and residential care choices. Housing and residential facility redesign projects will complement other mental health planning initiatives wherever possible. e.g.) Early Intervention, Riverview redesign, Assertive Community Management review. The planning process will use relevant, valid and timely information to support decision making. A measurement system will be developed that ensures ongoing performance monitoring and system accountability. Linkages will be developed with other housing service providers and program partners to enhance housing and residential opportunities. e.g.) BC Housing, Licensing, non profit / profit service providers

10 Objectives Using the data from the completed Colorado Client Assessment Records (CCAR) of 2003 and current benchmarking standards, develop bed / unit targets for residential services and supported housing within Fraser Health. Using the physical plant reviews and other supporting information, identify facilities for upgrading, downsizing, or potential replacement. This will be done in partnership with service providers following a consultation process. Develop a financial plan that identifies resources needed to shift service emphasis from residential care to supported housing taking into consideration increased support and rehabilitation needs. New and/or recouped funding in the housing and residential program will be reinvested in developing additional supported housing capacity, rebuilding existing residential facilities, providing funding for capital repairs, developing rehabilitation / support services, increasing SIL capacity, and improving per diem rates to current residential facilities. To work together with the Rehabilitation & Recovery specialists within Fraser Health to identify resources needed for the development of community based rehabilitation services. Develop a transitional funding plan to address anticipated service impacts during rebuilds and bed redistribution. Review the Supported Independent (SIL) program and implement program changes as required. Develop a standardized policy manual for the housing and residential program. Performance indicators will be developed to evaluate services against the following quality dimensions: access / referral to housing/residential services, individualized service, recovery focus, consumer involvement, clinical performance and service delivery. Develop a communication plan for staff, consumers, family members, service providers, key stakeholders, and the public

11 Historical Perspective of Residential Care for the Mentally ill. Over the course of the past one hundred years, the type of treatment and care for persons with mental illness has gone through many changes. In the late 1800 s and early 1900 s, people with mental illness were admitted to large mental hospitals where they were housed with little treatment or rehabilitation in mind. These hospitals were often located hundreds of kilometres from family and home communities often resulting in isolation, loneliness and a disconnection from familiar surroundings. Treatment for mental illness in those days was very rudimentary with little understanding of the illnesses and minimal medical treatment available to adequately address psychiatric symptoms. This resulted in hospitalizations of many years duration often resulting in chronic institutionalization. In the early 1960 s, medical breakthroughs with medication took place which allowed for better control of psychiatric symptoms. This resulted in the ability to discharge patients back into their communities and downsize large institutions. Riverview Hospital in British Columbia was one of these large institutions that was downsized at that time. As large hospitals reduced their populations, community mental health centres were established to provide community treatment for discharged individuals. Due to the fact that many Fraser Health communities are in close geographic proximity to Riverview Hospital, many residents discharged from Riverview Hospital chose to remain living in the Fraser Health area. Boarding homes in Fraser Health communities were developed to provide residential care for these discharged residents due to their ongoing care needs. Many of these residents could not return home to their families. The early boarding homes provided little in the way of rehabilitation. Treatment consisted of custodial care and symptom management. Little recovery was expected. The early 1990 s saw a significant shift in how residential care was provided. The voice of the consumer became stronger and it was clear individuals wanted a say in how they were to receive treatment and services. Consumers indicated they preferred to live in less restrictive care settings where they were in control of their daily living activities. They wanted more access to employment, education, and support services. Above all they wanted to take control over their lives and the illnesses affecting them. In the mid 1990 s, Mental Health reform was occurring in many jurisdictions across Canada and British Columbia was embarking on its own Mental Health plan. Best Practices in Mental Health Housing & Residential Care In 1998, the British Columbia Mental Health Plan was unveiled. This plan identified a need to change service delivery methods to meet the complex and changing needs of individuals with serious and persistent mental illness. Housing was identified as one key area requiring change, and Health Authorities were encouraged to consider best practices as they redesigned their housing and residential programs In 1997, a review of Best Practices in Mental Health Reform was prepared for the Federal / Provincial / Territorial Advisory Network on Mental Health. This report indicated that over the past decade there had been an ongoing shift from residential custodial models of care to supported housing. The report stated today many experts view the supported housing model approach as a key element in Mental Health Reform 3. This shift towards the development of supported housing was supported by evidence based research indicating consumer preference for less restrictive environments. This model also worked well due to the fact that clients were able to receive rehabilitation services within their own community from community mental health teams

12 Supported housing can be described as a model of housing where clients are assisted to live as independently as possible in housing of their choice, with adequate community supports. Usually rent subsidies are provided. The move from residential care to supported housing allows consumers to gain much more independence in their lives, often indicating their quality of life is much better. The development of supported housing is identified as a best practice for housing reform and a model of housing that is supported extensively throughout the literature. 4 In 2000, the BC Ministry of Health, Mental Health Services in collaboration with representatives from the health authorities, prepared seven Best Practice documents to guide BC s Mental Health reform. Housing was one of these seven best practice documents. The housing document stated that housing was a basic right of all individuals and an important determinant of a person s health. Individuals could be expected to have diminished health status and reduced quality of life without adequate housing options. It was noted that a lack of adequate housing for persons with mental illness has a direct result in increased costs for the health care system and increased costs in providing emergency and other supplementary services. The literature points out that individuals who have control over the type and quality of their housing, have much better control over their illness and their quality of life improves. The Ministry of Health document stated the strongest emphasis in any mental health housing program must be on supported housing: affordable, secure, independent housing in the community that provides a consumer with access to associated support services as requested. 5 This best practice model is the preferred type of housing identified by consumers and it fits within a recovery oriented system of care. The Best Practice housing document states that as mental health reform progresses and more supported housing options are available, the need for more intensive and expensive types of residential services such as licensed residential care will be reduced for some individuals. The BC Ministry of Health best practice document also identified a number of favorable outcomes associated with the development of supported housing. Reductions in hospitalization rates, reduction in symptoms, increased residential stability, increased consumer satisfaction, increased independence, personal empowerment, gains in role achievement, and improved community integration were all indicators of the successes supported housing could bring. The evidence suggests that supported housing should be the first offered choice of housing options for clients versus residential care. Only if the client does not have the necessary skills to live in an independent setting or illness symptoms are too severe, should residential care be considered. Even then, in most cases, residential care should be considered as a flow through to prepare for future supported housing or more independent type living and not as the clients permanent place of residence. Best practice also recommends that when developing new housing units and residential beds, location is important. Supported housing should be non-segregated and located in ordinary residential areas. Licensed residential facilities should be designed on smaller scales that are homelike and provide a level of privacy, especially a level of privacy that is provided through single room occupancy. 6 New housing developments should be close to community resources and transportation services. This will assist consumers in meeting their social, educational, and vocational goals. Housing should also be developed in the communities in which consumers live, close to friends and family. This decreases social isolation, loneliness, and maintains an already established network of support

13 As supported housing is developed, it is important to ensure adequate supports are available for clients to access. D. Rog stated in a journal article that the most common reason for supported housing placements to break down was due to inadequate amounts of available supports. 7 Young adults with concurrent disorders had the most difficult time succeeding in supported housing when proper supports were not in place. Placement in supported housing was considered to be a success if it lasted a year or more and usually if the placement was to fail it would fail within the first four months. Other aspects to consider when developing supported housing are the socialization and recreational needs of the client. Clients consistently identify loneliness and isolation as one drawback to supported housing. Clients living by themselves in supported housing arrangements have commented on feeling isolated especially in the evening. In Fraser Health focus groups held for consumers and family members in December 2004, this issue was raised as well. Future support services will need to be planned and developed taking these issues into consideration. Consumers also want to do more recreational things individually or on a one to one basis. Consumers also want to be involved in meaningful activities, ones that they have had significant input into. Going out in large groups is not favorable. It should be noted that even with a range of supports available, the single most determinant of a successful placement is the availability of a rental subsidy which enables choices of safe, secure, and affordable accommodation. The 1997 Review of Best Practices also indicated that a move to strictly a supported housing model may be ill advised as some communities may not have the appropriate resources and supports necessary to make supported housing a viable option. 8 This may leave clients vulnerable to an unsuccessful community placement with greater chance of illness relapse. Best practice indicates that a transition period should be established between the reduction of residential beds within the system and the buildup of supported housing capacity. This will ensure a smooth transition period that limits increased pressure on the residential and housing system. Over the past five years, the previous health service areas of Fraser North, Fraser South, and Fraser East have all developed individual housing plans while separate health authorities. These housing plans all indicated a need to develop more supported housing opportunities. Fraser North and Fraser South have started to move forward with their housing redesign initiatives. Fraser East has also developed a number of bridging beds. As best practices and the literature indicates, supported housing is an important model of care to develop and there is a need across all Fraser Health to increase supported housing capacity to provide a broader continuum of housing options for consumers. While supported housing is a model of care that has been identified as a best practice, there is a need as well to develop a continuum of housing options that provide a variety of models and levels of supports. This menu of housing options allow clients to find the most appropriate type of housing required based on their individual needs. A fully developed Mental Health housing and residential program will provide this range of housing options

14 Understanding our Clients and their Residential and Housing Needs To understand the types of supported housing and residential care required, it is important to understand the clients and their housing and residential care needs. Licensed residential care client Community Residential Program (CRP) Not all mental health clients are able to live independently in the community. Many clients require a more supervised setting where staff is available on a 24 hour basis. Mental Health Centres operate the Community Residential Program (CRP) within Fraser Health and have approximately 647 licensed residential beds in the program dispersed throughout the communities in Fraser Health. Most clients who are referred to the CRP program have a serious and persistent mental illness and may have ongoing psychiatric symptoms which limit them from living more independently in the community. In many situations, medication management is a problem. Clients living in residential care have case managers assigned from the Mental Health Centres. For many clients, the expectation should be that they remain in residential care only long enough to develop independent living skills that will enable them to live more independently in the community. Over the past few years, many CRP teams have made significant efforts to move clients into more independent living situations within the community. Unfortunately, one of the limitations of being able to move more clients into the community is a lack of alternative housing. One creative option that has been developed in recent years to assist clients to move into the community has been the development of transitional and bridging homes. Transitional and Bridging Housing Transitional housing is described as communal living homes or apartments where individuals have their own rooms but share the other amenities in the home or apartment. A support worker assists with community living skills and the length of stay is time limited, usually six months to two years. This time period allows the client to adjust to independent living prior to moving into more permanent living arrangements. Bridging is described as congregate living situations where individuals have their own room and again share other amenities in the home. This is similar to transitional housing although the clients usually are placed from licensed residential facilities and are bridged into community living from the residential facility. Supports are provided usually from the residential facility but this is not always the case. Clients referred to transitional or bridged housing generally have achieved stability with their illness and are ready for a more independent living environment. Over the past few years Fraser Health has developed a number of bridging and transitional houses with good success and should continue to build capacity in this area. Supported Independent Living (SIL) The Supported Independent Living (SIL) program is a very successful program that was first introduced by Mental Health Services, Ministry of Health in the early 1990 s. The SIL program provides Mental Health clients with a monthly rental subsidy and access to a community support worker on a regular basis. This support worker assists them with many day to day activities including client advocacy, assistance with activities of daily living, medication support, and liaison with the Mental Health Centre case managers and psychiatrists. These activities are outlined in individual service plans, which are developed jointly between the client, case manager, and support worker

15 Case loads for the community support workers range on average between individuals and they may see their assigned clients anywhere from once a day to once every two weeks. There is also a variation to the SIL program called Super SIL where the amount of support time is significantly increased and case loads may be smaller. This allows for more intensive support by the support worker for clients who have significantly greater needs. Clients who are placed on the SIL program are registered clients of Mental Health and may have an emerging mental illness or an ongoing serious and persistent mental illness. They may or may not have substance use issues. Clients work well within the program guidelines and many have achieved illness stability with their mental illness. These clients are well known to the Mental Health Centre and in many cases have had case management services for many years. Many of these clients participate in rehabilitation activities as well. One advantage of the SIL program is that it allows clients to find and move into a variety of apartments that are available throughout the community. Clients feel much more part of their community and enjoy the fact that they can blend in with others in the apartment building. Many enjoy the freedom that accompanies living alone, but at times find it lonely. To address this issue, support services should be designed to include recreation and socialization activities. Another significant strength of the SIL program is that clients can generally afford safer & cleaner accommodation. For some, it allows them to live in more desirable areas of the city, away from the downtown core where crime and drug usage is common. With safe, affordable, stable housing, illness stability is maintained and there is a noticeable decrease in the frequency of hospitalizations and the use of crisis services. Unfortunately due to increasing rents in many communities, the ability to obtain better accommodation even with a rental subsidy is diminishing. The popularity of the SIL program far outweighs the availability of SIL units and many Mental Health Centres in Fraser Health have clients on waitlists. In May 2005, a survey of SIL utilization within Mental Health was conducted. 317 clients were identified as currently needing SIL, with another 383 clients identified as requiring a rental subsidy only. Currently there are 900 supported housing / SIL units available throughout Fraser Health and unfortunately there is not much turnover for these units so the wait lists grow. Because of the limited number of SIL units available, many individuals are forced to live in accommodations of a lower standard as they cannot afford the higher costs of rent. Many clients are on disability income which provides them with a total income of approximately $856 per month. Most rents for single bedroom apartments range from $450 to $700 depending on which community you live in. This leaves many clients short of money for proper nutrition and limits their ability to participate in recreational and social activities. This impacts significantly on their physical and mental health. The SIL program is an extremely cost effective program and on average costs about $ 6,000 per client per year depending on which community you live in. Due to the significant number of clients that would benefit from the SIL program, the housing plan is recommending that a significant increase in the number of SIL units be made available in Fraser Health over the next five years. Family Care Homes At this point in time, Fraser Health will not be developing a program to enhance or broaden the current Family Care Home model. Individual contract arrangements may still be undertaken with individual care providers at the local community level to provide a specific specialized residential resource when required

16 CONTINUUM OF MENTAL HEALTH RESIDENTIAL CARE & HOUSING PROGRAMS M O R E E X P E N S I V E LESS SUPPORT TRANSITIONAL HOUSING SUPPORTED HOUSING (On site support) MORE SUPPORT 24 Hour Licensed Residential Care Family Care Homes CONGREGATE HOUSING BRIDGING L E S S E X P E N S I V E SUPER SIL SIL (Supported Independent Living) COMMUNITY SUPPORT Provided by: Assertive Community Management Teams, Case managers, Rehabilitation therapists, Psychiatrists Community Support Workers, Peer Support Workers

17 Homelessness The issue of homelessness has gained a significant level of interest throughout all levels of government within the past few years. In the fall of 2004, the Premier s Task Force on Homelessness was formed in British Columbia in an attempt to address the issues surrounding homelessness. It has been identified that an increasing number of people are living on the streets in Vancouver and throughout the lower mainland. In the recently released 2005 Greater Vancouver Homeless Count report, it was shown that the number of homeless people within the Greater Vancouver area has almost doubled between 2002 and A total of 2,057 people were identified as being homeless (sheltered homeless (952), street homeless (1,105)) during the count on March 15, % of the homeless were found to be living in the Vancouver, Surrey, and Langley areas, although the Tri-Cities area experienced the largest percentage increase in the number of homeless since People with Aboriginal identity were over represented in the count compared to their share of the overall population (30% versus 2%). Poor health conditions were commonly identified in many of the homeless individuals. 74% of those counted identified one or more health conditions. These health conditions were listed as addictions, medical condition, mental illness, or physical disability. Addiction was the most common health condition identified with over half the street homeless indicating they had problems in this area. One third of the homeless counted also indicated they had both an addiction and mental illness. In another homeless survey conducted in the Upper Fraser Valley (Mission, Abbotsford, Chilliwack, Hope, Agassiz, Boston Bar) on August 19 & 20, 2004, over 411 homeless people were identified. Of those who responded, almost half reported having health concerns including drug and alcohol addiction, mental health issues, or other physical problems. 10 Due to the growing number of homeless individuals with mental illness and other health conditions, housing and support services need to be considered as part of the housing plan. The problem of homelessness is a complex and a difficult issue to solve in isolation. It will require the cooperation and partnership between all levels of government, Fraser Health, and community service partners to fully address this growing trend. One possible solution to addressing the growing homelessness problem is to develop minimal barrier housing using a housing first approach. Clients needing minimal barrier housing Minimal Barrier housing is defined as access to flexible and non-judgmental service based on need, without restrictions to lifestyle, condition (e.g. Intoxicated), eligibility or number of times receiving the service, in a building that is accessible to everyone regardless of physical condition. It is also acknowledged that acuteness of health needs, behaviour or level of intoxication may limit the ability of the provider to give service. 11 Mental Health Services provides service to a diverse population of individuals in Fraser Health. People with a serious and persistent mental illness generally receive the highest priority for placement in supported housing or residential care. Examples of the types of mental illnesses considered to be serious and persistent include schizophrenia, bi-polar disorder, major depression, or other mental disorders where their illness impacts on their judgment and day to day functioning. This group of individuals is considered to be the most vulnerable and may require a significant amount of support to assist them to manage their activities of daily living. Many of these individuals are unemployed and on disability income

18 There are also a number of individuals who may refuse or cannot be maintained in traditional supported housing and residential care resources due to lifestyle and behaviour. They require less restrictive minimal barrier models of housing. Many of these individuals have both mental illness and substance use problems (concurrent disorders). A significant number of homeless individuals have concurrent disorders as well as other complicating medical conditions. As a result, it is often more challenging for them to find appropriate housing. Broadly speaking, this group of homeless individuals could be described as a population whose multiple diagnoses impede their ability to secure housing because they are deemed problematic by housing providers. 12 These individuals can pose challenges as they may not want assistance from Mental Health. They are reluctant to participate in the mental health system as they view it as restrictive and confining. As a result of this reluctance, services are difficult to provide. They often have limited insight into their illnesses or the need for treatment. They tend to be frequent users of services provided through hospital emergency departments, emergency services, and the court system. Many times these individuals are brought into the hospital by the police under the Mental Health Act due to behaviour in the community. Many of these individuals are often under housed or homeless, and not able to keep adequate housing for any length of time. Housing is often an ongoing issue as they tend to lead transient lifestyles, regularly use alcohol and drugs, behaviourally are challenging and have limited financial resources available to them. Judgement is commonly impaired with little to no insight into their situation. Many have been blacklisted by landlords in their communities due to disruptive behaviour which makes renting any accommodation very difficult. Assertive Case Management (ACM) teams are one approach in providing services to these challenging groups of individuals. Eight Mental Health Centres within Fraser Health utilize ACM teams. These teams carry low client to case manager caseloads at a ratio of 10:1 and can provide clients with more intensive support. Unfortunately, a lack of appropriate housing regularly becomes an issue with ACM clients. Another approach in connecting with this group of individuals is to use non professional outreach workers who work specifically with street homeless or those at risk of being homeless. Relationship building, support, and service linkages are main goals of the outreach worker. The use of outreach workers in working with the homeless has proven to be quite successful in a few communities within Fraser Health. In Fraser Health, few communities have the proper housing resources available to provide safe affordable housing for these individuals with multiple problems. If clients have been able to find accommodation, it is usually in the downtown core where crime and drug related activities are high. In many instances accommodation standards are low. This type of environment is not conducive to establishing a safe environment for clients where they can regain a sense of stability with their illness and their lives. In Fraser Health, the number of clients requiring minimal barrier housing is steadily increasing. These clients are reluctant to live anywhere other than their home community. Many younger clients fall into this category, and many times their illnesses are compounded by the use of alcohol or drugs. Many of these clients either refuse to live in residential facilities due perceived restrictive environments or are not appropriate placements as they would pose significant risks to other clients already in care. Fraser Health has little purpose built housing for these mental health clients. There is a need for each community in Fraser Health to develop minimal barrier housing resources that provide safe, secure, and affordable housing. This type of housing would fall into the category of supported housing and be non-licensed care. Support workers would be available to provide support either on site or through an outreach capability

19 One example of a successful minimal barrier housing resource that currently operates in Vancouver is the Portland Hotel project. Portland Hotel The Portland Hotel is one model that is used in the downtown eastside of Vancouver to provide housing for individuals with complex medical and psychiatric problems. Affordable subsidized apartments are provided with onsite support. This model is one to consider when developing new resources in Fraser Health. The Portland Hotel program follows a minimal barrier housing model and uses a housing first approach. Housing first can be described as giving people who are homeless direct access to permanent housing without going through a continuum of shelter and transitional housing. A housing first approach assumes that factors that led to an individuals homelessness can be remedied or stabilized once the individual is stably housed. This model has proven to be very successful, housing some of the most challenging clients with the most complex of problems. Many communities in North America are using this approach as it places people in permanent housing quickly and provides links to needed services. The housing first model builds relationships and trust with the tenants which paves the way for future involvement with other support services. 13 Clients requiring minimal barrier housing generally are not appropriate for the Supported Independent Living (SIL) program due to the difficulty in providing service to them and their reluctance to participate in treatment plans. Finding landlords willing to rent to clients requiring minimal barrier housing also poses its challenges. Housing options are limited, which is why it is important to develop purposely designed supported housing that is tailored to this challenging and complex group of individuals. Projected residential and housing needs over the next 5 years To get a better understanding of Fraser Health s future housing and licensed residential bed needs, it is important to understand what resources are currently available and where these resources are located. Tables 1&2 on the following pages show the inventory of current licensed beds, numbers of supported housing units, and the number of regional crisis stabilization and emergency housing beds available in Fraser Health. Using benchmarks developed by Fraser Health in March 2005, the projected needs for licensed residential beds and supported housing are shown. 14 These benchmarks provide a starting point in identifying where resources may be needed in the future, especially where there are significant gaps in resources. All communities will continue to need resources to build up housing capacity as it is recognized that adequate mental health housing is in short supply throughout all of Fraser Health. It is estimated that by 2011, Fraser Health will be short 243 licensed residential beds, 102 supported housing units, and 24 crisis stabilization beds. This does not include an additional 63 benchmark projected beds under the Family Care Home category if this program was to be developed further. Total shortages across all categories will be 432 beds/units by Benchmarking numbers in Tables 1 & 2 are considered to be conservative estimates of the required beds and housing units needed in Fraser Health between 2006 and This benchmark model has been developed using current residential and housing supply and not on future demands. Taking into consideration SIL waitlists identified in May 2005, Alternate Level of Care (ALC) days for Fraser Health Inpatient psychiatric units from the years 2003/2004, and the impact the closing of Riverview Hospital may have on Fraser Health housing resources, a demand model estimates that an additional 358 beds / units may be needed in addition to the

20 beds / units already identified. 15 Health by Therefore a total of 790 beds / units will be required in Fraser To address this anticipated shortfall, the housing plan is recommending an increase in 135 licensed residential beds, 255 supported housing units, and 525 supported independent living (SIL) units over the next five years. It must also be kept in mind that best practices recommend shifting from licensed residential care to developing a broader continuum of supported housing models of care when implementing Mental Health housing reform. Therefore bed numbers in the end may favour a higher proportion of supported housing development versus new licensed residential beds. Work has begun to address some of these shortfalls as Fraser Health has allocated $1.12 million of annualized funding in the 2005/2006 budget toward Mental Health housing. This funding has been used to add an additional 50 SIL units, develop 46 new supported housing spaces, and increase the number of licensed residential beds by 14. These additions are included in the 2006 inventory. The benchmarks were developed using a number of set indexes (human economic hardship, crime, health problems, education, children/youth at risk). They do not take into consideration the variable that some communities have access to other forms of housing not provided through Mental Health services. As an example, some communities have access to subsidized housing through BC Housing or other non profit agencies, whereas other communities may have no access to these additional resources. These variations in housing availability will need to be taken into consideration when allocating future resources for each community. It is also worth noting that there is currently work being done at the provincial level to establish province wide benchmarks for Mental Health tertiary & residential services. How does Fraser Health housing capacity compare to other British Columbia Health Authorities? In January 2006, the Ministry of Health surveyed the five health authorities throughout British Columbia to assess Mental Health housing capacity in licensed residential care, supported housing, and family care homes. Based on this data, the number of available beds per 10,000 population (19 years of age and older) was calculated for each Health Authority. (See appendix D) In 2006, Fraser Health ranked first in the number of available licensed residential beds per 10,000 populations compared against the other four health authorities. Unfortunately, Fraser Health ranked last when available supported housing capacity was reviewed. Fraser Health has only 7.9 beds available per 10,000 population of supported housing, the lowest of the five health authorities. Vancouver Coastal ranked the highest with 15.3 beds of supported housing available per 10,000 population. As previously stated, supported housing is a direction Fraser Health would like to build more capacity in. It becomes evident when compared against the other Health Authorities, how important it will be to focus new resources in this area