Addressing the Housing Needs of Peope using Menta Heath Services A GUIDANCE PAPER Prepared by a muti-agency advisory group for the HSE Nationa Vision for Change Working Group
Addressing the Housing Needs of Peope Using Menta Heath Services A GUIDANCE Paper Prepared by a muti-agency advisory group for the HSE Nationa Vision for Change Working Group 2012 Uses: This is our master fu coour ogo which shoud appear on a white backround. A Vision for Change ADVANCING MENTAL HEALTH IN IRELAND 1
Contents Introduction......... 4 Part 1 Defining the Roe of Menta Heath Services in Housing of Peope with Menta Heath Difficuties Introduction... 7 Conceptuaising the Links Between Housing, Menta Heath Difficuties and Socia Excusion... 8 Determining the Service User Perspective... 9 Housing of Individuas with Menta Heath Difficuties Genera Considerations... 9 Long-Stay Inpatients and Discharged Long-Stay Patients... 10 New Long-Stay Service Users and New Service Users with Severe and Compex Menta Heath Probems... 10 The Spectrum of Housing Requirements in the Context of Menta Heath Needs... 11 In-Patient and High Support Accommodation... 11 Assessment of Housing Need... 12 Ongoing Engagement in Reation to Housing Needs of Individua Service Users... 13 Preventing Homeessness... 13 Patients Leaving Hospita and Menta Heath Care... 14 Access to Socia Housing... 14 Forma Links with Loca Authorities... 15 Forma Links with Housing and Support Services... 15 Participation in Loca Forum on Housing for Peope with a Disabiity... 15 Part 2 Modes of Housing and Housing Supports Appropriate to the Needs of Those with Menta Heath Probems Introduction... 17 Housing Forum... 19 Modes of Housing Provision... 22 Housing Mode Description... 23 Case Studies... 24 References... 26 Appendices... 28 3
Introduction The guidance provided in this document is designed to assist menta heath services in deveoping appropriate poicies and procedures for addressing, from a menta heath service deivery perspective, the housing needs of service users, and integrating the provision for this eement of need with other eements of ongoing menta heath care for both those who currenty reside in residences provided by or through the HSE and those who are newy presenting to menta heath services who have a housing need. Housing is a basic human need. Adequate and appropriate housing is a key component of estabishing and maintaining human webeing. Chapter 4 of A Vision for Change addresses the issues of beonging and participating the socia incusion of peope who experience menta heath probems and the adequacy or otherwise of ones housing provision is a very significant determinant of both socia incusion and menta heath. The Convention on the Rights of Persons with Disabiities (CRPD) guarantees a human rights and fundamenta freedoms to a persons with disabiities. It promotes a socia mode of disabiity and outines genera principes which incude respect for individua autonomy and independence of persons, and fu and effective participation and incusion in society. In respect of iving arrangements Artice 19 affirms the right of persons with disabiities to ive in the community and among other things to have the opportunity to choose their pace of residence and where and with whom they ive. The provision of socia housing is the responsibiity of the Loca Authority. Menta heath services shoud work in iaison with Loca Authorities to ensure housing is provided for peope with menta heath probems who require it. A Vision for Change is unequivoca. Responsibiity for the provision of housing rests with oca authorities and they are required to fufi their obigations in this respect. Recommendation 4.7 states: The provision of socia housing is the responsibiity of the Loca Authority. Menta heath services shoud work in iaison with Loca Authorities to ensure housing is provided for peope with menta heath probems who require it. The Department of the Environment, Community and Loca Government has recenty aunched a Nationa Housing Strategy for Peope with a Disabiity 2011-2016 in accordance with its responsibiities under the Nationa Disabiity Strategy. A specific aim in the Strategy addresses the housing needs of peope with a menta heath disabiity as foows: To address the specific housing needs of peope with a menta heath disabiity, incuding through the deveopment of frameworks to faciitate housing in the community, for peope with ow and medium support needs moving from menta heath faciities, in ine with good practice. This is supported by a commitment to estabish a management framework between the two government departments of Environment and Heath, the HSE and Loca Authorities to oversee the phased movement of peope out of HSE menta heath faciities whie continuing to ensure the provision of appropriate speciaist menta heath care as required. In the context of such poicy aignment at government eve there is now an obigation on service deivery agencies, specificay the HSE and Loca Authorities to work coaborativey on making appropriate and adequate provision for both the housing and menta heath care needs of those who use menta heath services and to ensure that supports are congruent with their rights as citizens, sufficient for their webeing and conducive to persona recovery. 4
This guidance was prepared by a muti-agency advisory group drawn from a range of stakehoders incuding service user and carer representation, peer and poitica advocacy representation, Loca Authorities, a socia housing provider and the HSE. Part 1 of the guidance outines the respective roes of menta heath services and housing authorities addressing such issues as: The right of the service user to choose where and with whom they ive The roe of menta heath services in the assessment of housing and support needs and in providing speciaist support The requirement on both menta heath services and housing authorities to coaborate with services users and carers and each other to ensure integrated provision The roe of housing authorities in conducting housing needs assessments, providing accommodation options through a variety of housing schemes and providing tenancy support where this is required. Part 2 describes some modes of housing and housing support currenty avaiabe in Ireand to address the needs of those with menta heath difficuties. 5
1 PART 1 Defining the Roe of Menta Heath Services in Housing of Peope with Menta Heath Difficuties. Uses: This is our master fu coour ogo which shoud appear on a white backround. 6 A Vision for Change ADVANCING MENTAL HEALTH IN IRELAND
Introduction The guiding principes reevant to the housing needs of individuas with menta heath difficuties incude citizenship (equity of access), community care, incuding speciaist menta heath support, coordination of supports and incusiveness. The recovery approach as the cornerstone of A Vision for Change poicy is particuary reevant. Recovery in this context refects the beief that it is possibe for a service users to achieve contro over their ives, to recover their sef-esteem, and move towards buiding a ife where they experience a sense of beonging and participation (Department of Heath and Chidren 2006). Aong with difficuties in securing empoyment, imited access to appropriate housing represents a structura barrier to menta heath and is recognised as a key factor maintaining the cyce of [socia] excusion experienced by many peope with menta heath difficuties in Ireand (Department of Heath and Chidren, 2006). Menta heath services have traditionay provided housing to certain individuas with menta heath difficuties with the regrettabe resut in some cases, that access to oca authority housing was impeded despite the provisions of the Housing Acts 1966 to 2009. In addition to reinforcing socia excusion this has aso tended to divert menta heath funds away from providing menta heath treatment and care. Ensuring proper provision for the housing needs of individuas with menta heath difficuties represents both a means for greater efficiency in care as we as increasing community invovement and breaking the cyce of socia excusion. Gaining contro over one s own housing is considered a critica step towards achieving socia incusion. Government and HSE poicy, A Vision for Change, envisages a substantia reduction in the number of beds, incuding those in community residences operated by the menta heath services and the redepoyment of associated resources to the deveopment of a range of integrated community menta heath services. The Vaue for Money and Poicy Review of the efficiency and effectiveness of ong-stay residentia care for aduts within Menta Heath Services (2009) concuded that a considerabe proportion of those currenty in residentia care coud manage with ower eves of support or they coud access suitabe independent accommodation. Athough most of those who use menta heath services wi ive independenty with itte or no specia housing support needs, there is a cohort of service users who, because of their menta heath difficuties require supports across a spectrum spanning housing and menta heath. For some this requirement wi be short term. For others the requirement may be onger term though not necessariy continuous and wi require fexibiity in respect of the nature and eves of support required at any particuar time. For yet others there is a ifetime need for continued support by menta heath services in order to hep them maintain their tenancy and in addition, a requirement for fexibe provision of housing and other benefits which takes account of their changing needs over the ifespan. Current poicy requires oca authorities to fufi their obigations under the Housing Acts 1966 to 2009 to provide housing to a peope who require it, incuding those with menta heath difficuties and obiges menta heath services to work in iaison with oca authorities to ensure service users can access housing that is appropriate to their needs. In this context there is an urgent need to deveop a framework of guidance for oca menta heath services to assist them in making pans for the suitabe engagement of menta heath services in matters concerning the housing of service users who have housing and reated needs. 7
Conceptuaising the Links Between Housing, Menta Heath Difficuties and Socia Excusion Tabe 1. The inks between housing, menta heath iness and socia excusion. Key Eements of Housing Reationship to socia excusion for peope with menta heath iness Outcomes Cost/Affordabiity Capacity to meet housing costs out of avaiabe income and have sufficient income for other basic needs Rent setting poicies/practice if renta payments in reation to income too high: Reduced income for other needs e.g. heath, food, supports service Participation in consumption & recreationa activities compromised Inabiity to pay rent-arrears Eviction/homeessness Hospita/institution/prison Trapped on benefits Negative impact on menta and physica heath Accessibiity/Avaiabiity Whether or not appropriate housing is avaiabe Lack of access to affordabe housing Needs based aocation poicies for socia housing potentiay incusive but eads to stigma, poverty concentrations Homeessness Poverty Residuaisation Feeings of not fitting into community Revoving door of hospitaization due to ack of housing Discharge from hospita directy to homeessness Remaining in congregate housing where no other viabe option is avaiabe Negative impact on menta heath Stabiity of Housing Extent to which guaranteed continued occupation of housing Where no security of tenure may have to move sporadicay housing at risk Insecure accommodation affects abiity to maintain supports, empoyment Educationa outcomes compromised Income eves ikey to be affected adversey Socia isoation (oss of natura supports) Appropriateness Whether housing meets needs of occupants in terms of: Appearance Locaity Quaity Suitabiity: househod size/age of occupants, congregate/independent Safety Choice over housing, who to ive with Housing aggravates person s iness e.g. phobia Concentrated with ow income groups Lack of services e.g. shops Reiabe support not avaiabe for medication and other informa support Poor socia/physica environments due to poory maintained housing Overcrowding Disruptive behaviour Housing at risk Access to empoyment & education and other services compromised Poor heath, educationa, empoyment prospects Breakdown in reationship with neighbours, confict with neighbours Stigma Adapted from Arthurson and Jacobs (2003) Housing pays a key roe in whether or not peope with menta heath probems can make successfu transitions from institutiona to community care or sustain meaningfu community iving. Tabe 1 provides an overview of the connections between housing, menta heath and socia excusion based on research findings in this area (Arthurson & Jacobsen, 2003). 8
Determining the Service User Perspective In his work, Descriptions of Homeess Menta Heath Service Users in Dubin (Unpubished Dissertation 2008) John Cowman references the iterature on menta heath service user preference studies reating to housing and support needs. Service user preference studies provided evidence that peope with menta heath difficuties woud prefer to ive in their own house or apartment, to ive aone or with a spouse or romantic partner and not to ive with other menta heath consumers. Consumers reported a strong preference for outreach staff support that is avaiabe on ca, few respondents wanted to ive with staff (Tanzman 1993:450). These and simiar findings, from service users, provided evidence which was in turn used to support the deveopment of the most evidence based and best practice housing modes for peope with menta heath disabiities, incuding Housing First....Preferences expressed by homeess menta heath service users (incuding from a range of menta heath settings) in Dubin (Cowman 2008) were for independent iving for reasons of autonomy and choice. Most stated that they woud need support from the menta heath services to be abe to ive in their preferred iving situation. In addition, most preferred to ive with their reatives and a minority woud choose to ive with other service users. The findings of this Dubin study confirm the findings of simiar internationa studies athough the study sampe was overrepresented with participants from ong term menta heath settings. See appendix 1 for extended text and references. Housing of Individuas with Menta Heath Difficuties Genera Considerations The majority of individuas with menta heath difficuties who use menta heath services ive independenty and require imited or no specia housing supports. It is anticipated that the deveopment of eary intervention services for peope with serious menta heath probems and the expansion of youth menta heath initiatives wi impact positivey on the course of major menta inesses and provide the opportunity to heighten pubic awareness and inform primary care service providers of the importance of community based menta heath interventions, such as outreach support and the need for suitabe, stabe housing. Adequate individuaised care and treatment panning on the part of menta heath teams shoud ensure that particuar needs in reation to accommodation and appropriateness of housing are addressed at the primary or secondary care eves in consutation with service users, carers and reevant agencies in their oca community. There is aso a roe for community menta teams in the provision of speciaist information and support to primary care and non-statutory agencies in reation to the recovery approach in genera and specificay in this context, in regard to the need for mainstream housing to promote persona recovery in those with emerging menta heath probems. Opportunities for independent housing shoud be provided by appropriate authorities with due regard for service user s needs. Individuas with menta heath difficuties who have a greater need for housing support fa into five main groups: 1. ong-stay in-patients: peope who have been continuousy in menta hospitas or units for proonged periods of a year or more. 2. discharged ong-stay service users: peope who were previousy discharged from ong-stay wards and who now ive in staffed community residences or supported housing in the community. 3. new ong-stay service users: peope who, in recent times, have passed from acute to ong-term care. Some have been retained in hospita for ong periods because of the nature and severity of their iness. Some are ong-stay on acute units, though in some services they are transferred to ong-stay wards. 9
4. new service users with severe and compex menta heath probems: peope who have presented with severe iness since the deinstitutionaisation programme began. They may never have been in a ong-stay ward, but some wi have had mutipe admissions to acute wards. If iving with carers, the effects of their disorder may pace considerabe burden on their famiy/carers. Some may never have been admitted to hospita but are particuary at risk of becoming homeess or spending time in prison. 5. New service users with ess severe symptoms in the famiy home: peope, particuary those young peope who deveoped menta heath probems whie sti in the famiy home, who remain dependent within their famiy and are at risk of requiring ifetime high dependency iving arrangements if not supported/encouraged to ive independenty. Long-Stay Inpatients and Discharged Long-Stay Patients Most ong-stay patients can successfuy eave psychiatric hospitas and ive in community settings (Barbato et a, 2004). Suitabe housing is a key aspect of the reintegration in their community of deinstitutionaised individuas with psychiatric disabiity, whereby they can, potentiay, be provided with some choice and contro over where and with whom they ive (Arthurson, 2007). To date in Ireand, rehabiitation services have been based on resettement programmes foowing hospita cosure programmes. Providing shetered housing in the community for the ong-term patients of arge psychiatric institutions was one of the first steps of deinstitutionaisation. There is cear evidence from the UK that, because of a ack of panning and provision for continuing care foowing the resettement programmes associated with the cosure of arge psychiatric institutions, a significant number of peope with severe and enduring menta iness with compex needs were reaocated to out of area treatments. A consequence of this was that ties with famiies and oca communities and socia networks were disrupted, with peope being paced in in-patient settings far from their homes because of ack of oca provision (Department of Heath, 1984). Without investment in appropriate oca provision, there is a danger of a simiar phenomenon emerging in Ireand. There is now compeing evidence from the Irish context of the importance of continued investment in speciaist inpatient and community services for peope with compex and onger term menta heath probems and shows that despite the severity of their probems, rehabiitation services faciitate improvement in socia functioning and successfu community discharge (Lavee, E et a, Menta Heath Rehabiitation and Recovery Services in Ireand: A muticentre study of current service provision, characteristics of service users and outcomes for those with and without access to these services. Menta Heath Commission, 2011) There is a ack of patient data on the unmet needs of peope with severe and enduring menta iness in Ireand, particuary in reation to the new generation who are being referred and who ive in the community. Community menta heath services are not we deveoped with regard to the avaiabiity of eary intervention, whie assertive outreach and speciaist rehabiitation and recovery services are sti poory deveoped at a nationa eve. New Long-Stay Service Users and New Service Users with Severe and Compex Menta Heath Probems The phenomenon of new ong-stay patients residing on acute admission units for proonged periods has attracted attention in the UK for the past 30 years. Litte is known about the nature of the new ong-stay popuation in Ireand. The UK experience is that, foowing deinstitutionaisation, new ong-stay patients are a heterogeneous group of individuas with a range of compex needs, who often exhibit chaenging behaviour that makes their care outside the hospita setting probematic (Leiott et a, 1994; Hooway et a, 1999). These patients are ceary disenfranchised and are often 10
inappropriatey paced on acute admission units, where the focus of treatment is towards the management of acutey i patients and rapid patient turnover. At present there is a serious ack of adequate housing and accommodation options for enabing service users to move through the different stages of recovery and progress towards the goa of independent community based iving. As community based secondary menta heath services deveop, the need for the current accommodation resources in menta heath services (such as high, medium and ow support community residences and group homes) shoud diminish. These resources shoud then become avaiabe to the rehabiitation and recovery team. A oca pan for the transitiona arrangements to achieve this shoud be drawn up by the catchment area management team with the primary objective of enabing service users to move to independent iving with supports as and when feasibe. The majority of new service users with severe menta iness wi not require community residentia faciities, but wi need varying degrees of support to ive in individuaised, independent accommodation. As the statutory responsibiity to provide this housing rests with the oca housing authorities there is a need for cose cooperation between these agencies, the HSE and oca menta heath services. A poicy of fexibiity in addressing varying eves of individua needs shoud be adopted by oca menta heath teams as service users progress through different housing arrangements in the course of their recovery. This requires staff to be fexibe and recovery-oriented, encouraging movement by service users within the system of avaiabe housing and support options towards independent iving. The Spectrum of Housing Requirements in the Context of Menta Heath Needs The foowing indicates the range of accommodation required to faciitate the provision of comprehensive menta heath care services at both in-patient and community eve, based on the needs of the target service user popuation. Options 1 3 wi be the responsibiity of the HSE, whie responsibiity for 4 6 wi aready be or wi transfer to the appropriate statutory body or vountary sector agency. The atter wi require consideration of existing estate management arrangements. 1. in-patient intensive rehabiitation unit 2. continuing-care rehabiitation unit 3. high-support community unit (24-hour nursing care) 4. medium-support community unit (generay care assistant at night, supported by community menta heath/ rehabiitation team during the day) 5. ow-support/group home unit (with input from the community menta heath/rehabiitation team during the day, but no staff at night) 6. independent, own door, accommodation (with visiting support as determined by individua care pan) In-Patient and High Support Accommodation The statutory authority for community high-support residentia units shoud remain under the remit of the menta heath services and the HSE, in order to meet the needs of the target cient group who have enduring menta iness with significant eves of disabiity. The emphasis in the Vision for Change strategy document in reation to deveoping rehabiitation and recovery services is currenty on community rehabiitation services. Whie this is wecome, there is 11
a ack of panning, based on the needs of target popuations, for in-patient provision for patients with severe enduring menta iness with compex needs who need a onger term approach to their case management. In deveoping rehabiitation and recovery services there is a need to provide a comprehensive range of residentiay based services from in-patient intensive rehabiitation/continuing care and short term rehabiitation to community-based rehabiitation services. It is anticipated that once the housing needs of the cohort of former ong stay hospita service users has been catered for the requirement for the current eve of 24 hour high support accommodation wi decrease. A Vision for Change outines a requirement of approximatey 30 paces per 100,000 popuation. These residences shoud have a maximum of ten paces to foster a non-institutiona environment. Some may be designated to provide socia respite care. There is a requirement to deveop a standardized set of poicies and procedures at HSE eve for the optima operation of high support hostes which is outside the scope of this guidance. Assessment of Housing Need This guidance assumes the competence of the menta heath team in respect of hoistic assessment of need with service users and focuses on the issue of assessment of housing need. The assessment of housing need is a statutory function of oca authorities and in recent times they have deveoped a standardized format and process for assessment of housing need across the country. Trained housing aocations officers conduct assessments with assistance from skied socia workers in the assessment of more compex needs. Roe of the Menta Heath Team 1 An assessment of the housing and support needs of a person with a menta heath disabiity can pose significant chaenges. The identification and articuation of persona preference and expressed need can be difficut for a person with severe and enduring thought disorder, heightened anxiety, deusions, demotivation or extreme mood swings. Yet this work, of heping the person to consider and express their choices and preferences, is the most essentia way in which the menta heath team can assist. This is the foundation work and a core ski for menta heath professionas. If the person s fet need is not buit into the assessment of need, i.e. both the individuaised care pan and service needs deveopment, then the service runs the risk of seeking soutions that are not aigned to the service users needs and continuing to deveop services into the future that ikewise fai to meet the needs of service users. Warner (1997:5) expressed simiar concern. If accommodation issues are overooked when packages of care are being panned for this cient group, then a vita component is being missed, without which any programme of therapeutic intervention is bound to be ess effective. Simiar evidence emerges from consumer preference studies. It is essentia that consumers are fu partners in panning treatment if reevant services are to be provided (Kein et a 2007). Studies which have compared the preferences of professiona and users have noted that professionas emphasised compiance and menta heath treatment whie service users emphasised practica needs ike money and accommodation (Cohen et a 1999, Godfinger and Schutt 1996, Schutt et a 2005). Case managers favoured a more gradua transfer to community iving and more support than the service users did (Piat 2008). Focusing on a housing and support preference assessment can go a ong way to remedying this. The goa of assessment in the area of housing and supports is to enabe the service user to accuratey identify the type and ocation of housing, what housemates (if any) are preferred, and the range and eve of supports he/she fees are needed to maintain their preferred accommodation. Identification of individua choice/preference is the core work of the assessment of housing and support needs with the utimate aim of a stabe and affordabe pace to ca home. The incusion of choice and preferences increases the opportunity of the house becoming a home rather than a pacement 1 This section has been provided by John Cowman based on his work Descriptions of Homeess Menta Heath Service Users in Dubin (2008) and Cowman, Gough and Cunningham (2012) Housing Preference and Assessment Survey. 12
or programme (Padgett et a 2006, St. Vincents Menta Heath Service 2005, Tsemberis et a 2004). Perceived choice and contro over housing is aso positivey associated with perceptions of quaity of ife, whie both quaity of housing and choice/contro over housing are important contributors to quaity or ife (Neson et a 2007) 2. In addition increasing choice is shown to decrease psychiatric symptoms and homeessness (Greenwood et a 2006), and to increase satisfaction with where peope ive (O Brien et a 2002, Neson et a 2007, Syvestre et a 2009, Tsai et a 2009). The ack of research and evidence in reation to the success of the traditiona/continuum of care mode reinforces this evidence based on increasing choice. Shepherd and Macpherson expressed this succincty, apart from expressed preferences, there is itte evidence to assist in the judgement as to which service users wi fare we in which different kinds of accommodation. (Shepherd and Macpherson 2011:184). The Housing Preference and Assessment Survey (Cowman, Gough and Cunningham 2012) is a too which eicits service user s subjective housing needs, support needs, housing preferences and support preferences. Deveoped as part of a arger service improvement project in Dubin WSW Menta Heath Service it can be used as an individua needs assessment too or as a survey instrument to assist menta heath services to pan for the housing needs of its service users. Each menta heath service can change or adapt it to their own needs and purposes. It is avaiabe on enus the Irish Heath Repository at http://www.enus.ie/hse/hande/10147/250793 <http://www.enus.ie/hse/hande/10147/250793%20%20it> It is proving a very effective and reevant method to carify desired options, increasing engagement and partnership working and at advocating for peope with housing authorities and housing services. For exampe, one particuar outcome was assisting three service users to access their preference for shared private rented accommodation in the community where one of them receives frequent and reguar support from our Assertive Outreach Team. This is a version of the housing first mode in practice. Within services and oca authority areas where there is a significant eve of socia housing need among menta heath service users there is an argument to be made for the aocation between the oca authority and the menta heath service of a support worker to work directy with service users, the menta heath service and the housing department of the oca authority to ensure that the processes for assessment of need, aocation of housing, and supports to faciitate maintenance of tenancies are deveoped and maintained appropriatey. Ongoing Engagement in Reation to Housing Needs of Individua Service Users The comprehensive assessment of housing need, identifying and securing appropriate accommodation, moving and setting in, are intensive and chaenging processes for many menta heath service users and aso require a substantia investment of ski and time from the menta heath team aong with a commitment to high quaity interagency coaboration with housing authorities housing support officers in particuar. However in most cases this is ony a beginning and the successfu maintenance of stabe housing wi require ongoing engagement by a stakehoders. Initia quaity individua care and treatment panning, discharge panning and community foow up pans incuding crisis management pans need to be reviewed and updated on a reguar basis by the menta heath team to ensure that the appropriate eves of support continue to be provided to the service user to enabe him/her to continue to ive independenty with whatever supports their changing circumstances require. Preventing Homeessness A range of practices shoud be adopted by a menta heath services and teams to prevent service users becoming homeess. These might incude an assessment of the housing need and iving circumstances of a peope referred to menta heath 13
services, inking with oca housing authorities as appropriate, and the impementation of discharge panning and poicies with a specific focus on accommodation. A Vision for Change p145. The Housing Act 1988, sets out the ega definition of homeess persons to incude those for whom no accommodation exists which they coud be reasonaby expected to use, or those who coud not be expected to remain in existing accommodation and are incapabe of providing suitabe accommodation for themseves from their own resources. The HSE Code of Practice for Integrated Discharge Panning (2008) is the HSE poicy for a admissions and discharges since November 2008. Section 11 addresses the issue of peope who are homeess. Since January 2010, a guidance document from the Menta Heath Commission, Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre, has been in pace. This makes specific reference to the discharge of those who are homeess from the psychiatric services. These documents offer guidance on the discharge of peope from the psychiatric services. Patients eaving Hospita and Menta Heath Care In the specific area of preventing homeessness in the mentay i it is important that peope discharged from in-patient care shoud have a comprehensive care pan agreed by the mutidiscipinary team, a key worker and a detaied foow up pan. In addition there shoud be a check to ensure that the patient is registered on the housing or homeess ist and that whoever is foowing them up checks to ensure that they remain on this ist. Centra to a, of course, is the necessity of providing residentia accommodation. Whie menta heath services provide over 3,000 community residentia paces for mentay i persons oca authorities have a cear responsibiity for housing mentay i persons under current poicy and egisation. A checkist of best practice in risk assessment and prevention of homeessness in discharged patients shoud incude: a documented discharge pan a check that the patient s housing conditions are satisfactory and that the next of kin is aware of the patient s pending discharge a ink with the homeess service to obtain suitabe accommodation a check to ensure patient has a current medica card a mutuay agreed care pan and key worker Discharged service users shoud remain the responsibiity of the service that treats them and, if against a the precautions, homeessness shoud ensue, they shoud return to receive care from their parent service. A care pan shoud be put in pace for a service users invoving frequent service contact as a critica ingredient eading to positive engagement and concordance with treatment pan and better housing outcomes. A Vision for Change, Annex 15.2.2. p 253 Access to Socia Housing Considerabe fexibiity is needed to enabe individuas with enduring menta iness to move towards independent iving in the community, depending on their individua needs and taking into consideration their varying eves of disabiity and compex probems. Some may need a onger time in in-patient rehabiitation units before they can progress to community iving, whie others may need the option of moving back into an in-patient rehabiitation setting from the community during a period of iness reapse. 14
The focus in recovery oriented menta heath care is on encouraging service users to pursue the same avenues for accommodation needs as everyone ese in the community. Menta heath teams have a very particuar roe in faciitating the assessment of housing and support needs reated to the menta heath requirements of the individua service user. As outined by Cowman service user preference is a key factor in estabishing successfu housing arrangements and the skis of the menta heath team are critica in heping service users to comprehensivey determine and articuate those preferences on an individua basis. Menta heath teams have a broader roe in inking service users with advocacy services in the community to assist with the chaenging task of sourcing appropriate accommodation or in providing this service where no suitabe aternatives exist. Furthermore menta heath services have a roe in heping to determine the eve and range of housing need for the popuation of menta heath service users in their oca area. This requires an ongoing reationship with those responsibe for the provision of socia housing within the functiona area. One mode of working that has been successfu is where forma 6-monthy meetings take pace between the Menta Heath Service and oca County Counci housing authorities and reevant vountary sector agencies in a housing forum, to update on identified housing needs, current socia housing provision, and the processes in pace for assessment, aocation and ongoing support. Forma Links with Loca Authorities Menta heath services and oca authorities need to have a forma reationship to address and progress matters of common interest. They need to engage in estimating and panning for the provision of an adequate stock of suitabe iving accommodation for menta heath service users who have specia needs in reation to their iving environment and the deveopment of mechanisms to ensure equity of access for peope with a menta iness to the housing aocations process. They aso need to engage on the deveopment of robust mechanisms for responding appropriatey to crises occasioned by the onset of acute episodes of menta iness in oca authority tenants who are users of the menta heath service. Menta heath services and oca authorities shoud engage in reguar monitoring of current and emerging modes of housing provision for users of menta heath services and conduct evauations of such modes to inform decisions on the effectiveness, efficiency and continued use of such modes. See appendix 2 for the protoco outined in the current Nationa Housing Strategy for Peope with a Disabiity. Forma Links with Housing and Support Services The range of supports required by persons with a menta iness to maintain a tenancy varies consideraby and the knowedge, expertise and capacity to provide those supports often resides in vountary housing agencies or agencies providing independent iving supports Where such providers are invoved in providing services to peope with a menta iness the menta heath service needs to have a forma reationship with such providers to deveop, maintain and review appropriate and adequate poicies, protocos and where reevant Service Leve Agreements governing service provision. Participation in Loca Forum on Housing for Peope with a Disabiity The Nationa Housing Strategy for Peope with a Disabiity (2011) recommends the estabishment of oca fora on housing for persons with a disabiity. The menta heath service must participate as a partner in such fora to keep other partners appraised of ongoing eves of housing need among its service users, types of housing required, deveopments in menta heath care practice and to contribute to the overa achievement of the objectives of the forum. 15
2 PART 2 Modes of Housing and Housing Supports Appropriate to the Needs of those with Menta Heath Probems Uses: This is our master fu coour ogo which shoud appear on a white backround. 16 A Vision for Change ADVANCING MENTAL HEALTH IN IRELAND
Introduction Foowing on from Part 1, this section of the guidance addresses modes of housing and housing supports for those with menta heath probems and in particuar those using menta heath services. Traditionay menta heath services in Ireand have been a major provider of housing and accommodation for peope using menta heath services. That wi change in ine with A Vision for Change. Menta heath poicy identifies the primary roe of oca authorities in reation to the provision of housing for those with menta heath probems in the context of a recovery oriented, service user focussed reform of menta heath services. There is a penitude of housing authorities in Ireand within which a vibrant socia housing sector addresses the needs of a wide variety of groups at risk of socia excusion and marginaisation. Some socia housing associations have deveoped speciaist housing and housing support services for peope with menta heath probems either as a singe focus or as part of a wider network of at risk cient groups. These services seek to meet the housing needs of a but a sma cohort of those with menta heath probems who require round the cock care, treatment and supervision in a speciaist menta heath faciity for extended periods. This cohort wi be accommodated in in-patient settings or high support community residences. In the context of the guidance being provided it was considered appropriate to showcase some of the modes of housing for peope with menta heath probems avaiabe in Ireand as iustrative of the provision that can be panned and deivered when seeking to transition responsibiity for the housing needs of service users from menta heath services to oca authority provided services. Community housing traditionay operated by menta heath services is broady categorised into high, medium and ow support. High support residences provide 24 hour staffing, usuay a combination of nursing and care staff and possiby some housekeeping staff, faciitating the pacement of service users with high care support needs. Medium support provides daytime staffing, usuay a combination of nursing and care staff but no night-time presence. Low support has no staffing associated and is sef managed by residents with some visiting care and/or tenancy support. Service users requiring 24 hour supervised care wi continue to be accommodated by the menta heath service in high support community residences. Service users with care and support needs short of 24 hour supervised care are entited to access socia housing with appropriate supports. Terminoogy varies from area to area and service to service but most accommodation options operated by socia housing providers for peope with menta heath probems fa into the foowing categories: A. One-off own door individua units (scattered housing), either private rented or socia housing tenancies, with visiting care and/or tenancy supports B. Own door individua units within a housing scheme with singe or muti-cient focus-visiting care and/or tenancy supports C. Sma custer with caretaker visiting care support if required D. Shared care scheme i.e. either shared community residence or custer with significant heath service engagement There are a number of steps invoved in accessing socia housing which seek to address the issues pertinent to successfu and sustained housing tenancy for those at risk of socia excusion and marginaisation incuding peope with menta heath probems. In broad terms these are as foows: 1. Appication: Mandatory housing authority appication for housing accommodation (assessment of housing needs) form must be competed by a service users requiring housing pacement. This assessment shoud be competed by the appicant themseves. It is carried out in the reevant Loca Authority Office. The appicant can bring their advocate/famiy member with them to support them in the process of competing the form. Since this 17
wi constitute the basis for an assessment of eigibiity it may aso be appropriate for the appicant to incude information from their menta heath service provider on their menta heath probem, treatment and care pan. 2. Assessment of eigibiity: this wi be made by the housing authority officia charged with that responsibiity based on the information provided on the form and conversation with the appicant (and advocate/famiy member in attendance). 3. Assessment of tenancy supports: this wi generay be considered in the context of the overa assessment of eigibiity but focused on identifying if there are particuar tenancy sustainment issues arising and how these might be addressed in the housing aocation process (e.g. invovement of socia housing provider or housing support agency). 4. Aocation of housing: this wi be determined by the housing authority and where appicabe with a commitment from a socia housing provider or tenancy support agency. 5. Contract: a tenancy agreement outining the rights and obigations of the housing authority and the tenant is signed by both parties. 6. Occupation: tenant takes up residence in property. What is cear from the above process is that currenty there is no structura provision for coaboration between oca authorities and heath services on ensuring that the housing entitements and tenancy sustainment requirements of menta heath service users are addressed and met. There are however exampes of good practice in this area around the country, often on the initiative of socia housing providers who have deveoped modes of practice in response to presenting needs. Some of these wi be described ater in this paper. As part of the work of preparing the new Housing Strategy for Peope with a Disabiity the DOE working group identified the need for a protoco between oca authorities and the HSE on this matter and such a protoco was agreed (Appendix 2). Based on this and the modes of practice currenty in operation we recommend that each oca authority and menta heath service estabish a forum to faciitate the integrated provision of appropriate housing, tenancy and care support to peope with menta heath probems. The roe and purpose of such a forum is outined here. 18
HOUSING FORUM Purpose To promote independent iving by supporting menta heath service users who have a housing need to access and maintain suitabe accommodation as appropriate. The Forum wi faciitate the reevant agencies to act as a gateway so that the housing needs and supports of service users wi be addressed in a coaborative, efficient and effective way. Terms of Reference Deveop required interagency protocos Map avaiabe housing units Identify and monitor the eve of housing need among menta heath service users Match peope with suitabe units of accommodation Foster the integrated provision of services to promote the optima eve of independent iving with specia reference to crisis management in the community and the management of specia housing projects Deveop individua management strategies and pans for tenants/service users with compex needs. Composition of Forum Service User/Carer representative HSE Rehabiitation co-ordinator 2 HSE Socia Worker Aocation Officer from Loca Authority/County Counci Senior Management from Loca Socia Housing Providers (where reevant). Roe of Members Service User/Carer Representative To represent the voice of the peope who use the menta heath services with housing needs. HSE Rehabiitation co-ordinator Main access point for and iaison between the menta heath services and the forum in particuar the oca authority housing aocations personne To map the eve of housing need through assessment by the mutidiscipinary team To provide the assessment outcomes/care pan to the forum Ensures the care pan incudes for those who need it an eement of pre tenancy independent iving preparation To maintain a ist of those ready for independent iving To maintain contact with housing and tenancy support services in the community. 2 Where this post is not in pace, a member of the community menta heath team shoud be assigned. 19
HSE Socia Worker (where different from above) To support rehabiitation coordinator in tasks To ensure socia workers on menta heath teams prioritise supporting service users in making housing appications as appropriate To monitor the housing need of service users and advise the forum accordingy To support the service user moving to independent iving in iaison with CWO re financia entitements and supports, furnishing an apartment, arranging budget panning etc. Aocation Officer Conduct housing needs assessments with service users Identify suitabe properties for the service user group Act as advocate for the provision of housing for peope with menta heath needs Ensure that estate management issues in reation to the tenant are reported in a timey manner to the rehabiitation co-ordinator and monitor foow up. Senior Management from Loca Socia Housing Providers Identify suitabe properties for the service user group Act as advocate for the provision of housing for peope with menta heath needs Ensure that estate management issues in reation to the tenant are reported in a timey manner to the rehabiitation co-ordinator and monitor foow up To ensure that the appropriate support service is in pace to support the tenancy for the service user. Assessment process Service user/carer representative wi monitor service user experience of assessment process and provide continuous feedback oop into the process Aocations officer wi faciitate effective service user engagement in housing needs assessment process through information provision, practica assistance with appication and accommodation of service user supports (advocate, famiy member etc) Rehabitation co-ordinator/socia worker wi arrange for menta heath service etter of support, information on support pan etc once approved by the service user (Data Protection) Socia Housing Manager wi provide information on tenancy support pan (where reevant) once approved by the service user (Data Protection) Assessment process and stakehoder engagement around it wi be reviewed on an annua basis by the forum 20
Support requirements A recent ongitudina study of the experience of 400 singe homeess peope who moved into independent accommodation in a variety of tenures indicated that the eary settement period and pre move preparation are vitay important for independent iving to succeed. The move and eary settement period is a stressfu time for anyone but for those with an enduring menta heath difficuty may ast onger and perhaps act as a trigger for a more serious episode of i heath. Post move support was required by fewer than expected. However it was observed that onger term support was poory reated to need. If a foating support mode is to be effective ongoing monitoring and assessment of need is necessary and is an important function of the forum. Menta Heath Service roe: The service user remains with their menta heath team and care pan refects arrangements for reguar ongoing care Care pan detais ongoing outreach supports to be provided by the menta heath team Care pan detais coaborative arrangements with socia housing/tenancy support provider Crisis pan detais more intense re-engagement of menta heath team and incudes contact detais for menta heath team Discharge pan (when/where appropriate) negotiated with service user (and supports) and G.P./primary care team and housing provider consuted as appropriate. Loca Authority/Housing association roe: Tenancy support pan agreed with service user, activated and monitored. One to one support is not time imited but can foat away and re-engage as required Tenancy support pan detais coaborative arrangements with menta heath team Tenancy support pan incudes customized community integration programme incuding guidance and advice on the socia activities and support networks avaiabe in the community Tenancy support pan incorporates a monitoring and review mechanism invoving partner services and the cient/tenant so that crisis can be recognized and appropriate preventative measures put in pace Tenancy support pan incudes crisis pan provisions. 21