broome county mental health department

Broome County Mental Health Department

RESIDENTIAL SERVICES FOR MENTALLY ILL ADULTS IN BROOME COUNTY

AN ASSESSMENT OF WHAT EXISTS AND SERVICE GAPS

By Zachary R. Collins, MA

Broome County Mental Health Department State University of New York at Binghamton

Arthur R. Johnson, LMSW Commissioner

Broome County Mental Health Department One Hawley Street

Binghamton, NY 13901

2/3/05

2

Key Findings Funding from the New York State (NYS) Office of Mental Health (OMH) has not

kept up with the increased cost of operating residential programs. (Page 27) Catholic Charities certified residential programs all received the highest level of

certification possible from the NYS OMH in 2003 Three year certification. (Page 6) Satisfaction of Catholic Charities residents is high across all housing programs. (Page

6) Percentage of Residents that are Mentally Ill (Page 9)

Catholic Charities and Greater Binghamton Health Center 100% Fairview Recovery Services - 40-50% YMCA, YWCA, & Renaissance Plaza 25-40% Volunteers of America - 15-25%

In the last four quarters the Occupancy rate for the Catholic Charities Certified Apartment Program was 76%. It was between 83-86% from 1999-2003. (page 10)

17 (6%) of the 274 referrals to Catholic Charities Housing in the last four quarters

were denied. (page 14) The median length of stay for the Catholic Charities Certified Apartment Program is

less than half the New York State Average. (page 16) Broome is one of few counties with a lower percentage of Community Residence

beds than of Certified Apartment beds. Most other counties have a higher percentage of Community Residence beds, which provide a referral base for their Certified Apartments. (page 19)

The Stepdown model is not an accurate description of how residents move through

Catholic Charities Residential Services. (page 20) Housing for high risk clients is an issue in Broome County (Page 22) Renaissance Plaza had the lowest occupancy rate of all agencies surveyed, 57% in the

last four quarters. (Page 12) The Section 8 Housing program in the Town of Union has a 400 person waitlist.

(Page 7)

2

3

Acknowledgements

The author would like to thank my supervisor, Dr. Robert Russell, staff psychologist and Broome County Mental Health Commissioner Arthur R. Johnson for all of their guidance and support on this project. Thanks are also due to Lynne Esquivel, MPA.

This report would not have been possible without the contributions of many individuals who were generous with their time and provided the information upon which this report is based. Thanks to Lawrence Mennig from Renaissance Plaza Ltd., Fran Hall, Joe Gosney, and Kathleen OConner from Catholic Charities, Michele Napolitano and Patrick Haley from Fairview Recovery Services, Inc., Lynne Webb from Volunteers of America, John Burke from the Greater Binghamton Health Center, Nancy Johnson from YWCA, Jack McAndrew from YMCA, Michael Atchie from the Binghamton Housing Authority, Paul Nelson from the Town of Union and Toni Lasicki from the Association for Community Living. Much thanks to all the staff at the Broome County Mental Health Department for their invaluable assistance.

3

4

Key Findings ..2 Acknowledgements .........3 Table of contents ......4

I. Introduction .6 Goal 6 Background ...6 Current housing providers ..6

Catholic Charities ...6 Greater Binghamton Health Center .7 Fairview Recovery Services .8 YMCA ...8 YWCA ...8 Volunteers of America .......9 Renaissance Plaza .....9 Section 8 Housing ..9

II. Method ...10 Data Collected .10

Table 1 - Housing Providers Capacity & Percentage of Mentally Ill Residents 10

III. Results .12 Occupancy Rate ..12

Figure 1 - Catholic Charities Occupancy Rate .12 Figure 2 Certified Apartment Occupancy Rate by County and Year ..12

Table 2 Occupancy Rate by County, Year and Level of Care ....13 Table 3 - Housing Providers Capacity & Occupancy ......14

Referral Sources.15 Figure 3 Catholic Charities Referral Sources ....15

Referral Outcomes ..16 Figure 4 Catholic Charities Referral Outcomes 16 Referral Distribution 16

Table 4 Outcomes of Referrals to Certified and Non-certified programs .17 Figure 5 Outcomes for referrals to Certified Programs....17 Figure 6 - Outcomes for referrals to Supported Housing ...17

Median Length of Stay ...18 Figure 7 Median Length of Stay for

Certified Apartment Program ......18 Figure 8 Median Length of Stay for Supported Housing Program ..19

4

5

Figure 9 Median Length of Stay for Community Residences ...20

Broome vs. Other Counties ....21 Figure 10 Number of Beds by County

and Program Type ..21 Table 5 Ratio of beds between program levels by county ......21

Stepdown model vs. What Actually Happens ...22 Figure 11 Stepdown model .22 Figure 12 Stepdown model with Referral Data 22 Table 6 Discharges for Catholic Charities by Location ..23

IV. Discussion..24 Agency Feedback ..24

Best Aspects of Residential Services ...24 Renaissance Plaza ..24 Accessibility of Services .....24 High-Risk Clients .....24 Why CA Underutilized .....25 Changing Client Profile ...25 Changing Model ...25 Possible Solutions ...26

List of Issues .....26 Certified Apartment Program Underutilized..26 Unmet Community Needs ..26 Step-Down Model 27 Erosion of the Fiscal Model ...28

Summary of Results .28 V. Appendices .30

Appendix A Broome County Residential Program Evaluation Reports Appendix B SPMI Criteria Appendix C Catholic Charities Certified Programs Operating Certificates Appendix D Catholic Charities Housing Programs Satisfaction Data Appendix E Case Management Services for Supported Housing Residents Appendix F Blank Housing Program Questionnaire Appendix G Completed Housing Program Questionnaires Appendix H Association for Community Living Housing Report

5

6

Introduction Goal This study assessed residential services for mentally ill

adults in Broome County. Information gathered included a detailed listing of residential services currently available including utilization data and patterns of referral among county agencies. The purpose of this study is to determine if the level of residential services is matched to community needs. A specific issue to be examined was why the Catholic Charities Certified Apartment program is under-utilized

Background Catholic Charities is the primary provider of NYS OMH

approved housing for mentally ill adults in Broome County. They are the contract agency for three levels of housing, Community Residence (CR), Certified Apartment (CA), and Supported Housing (SH). The Certified Apartment program and two of the Community Residences have been underutilized compared to the other programs as well as comparable programs in other counties (See Appendix A). Catholic Charities has proposed reducing the number of CA beds and increasing the number of SH beds.

Current housing providers Catholic Charities Catholic Charities (CC) Transitional Living Services (TLS)

is a New York State (NYS) Office of Mental Health (OMH) certified and funded program that uses Medicaid as a source of funding. All residents must meet Severely and Persistently Mentally Ill (SPMI, see Appendix B for complete list of criteria) criteria and have a DSM IV Diagnosis.

The program has 88 certified beds, of which 40 are in the Community Residence (CR) program. There are three Community Residences: Madison House that has 14 beds, Damon Hall that has 14 beds, and Bridgeway that has 12 beds. Madison House offers residents a Certified Alcohol and Substance Abuse Counselor (CASAC) for 30 hours per week. There is also the Twin Rivers Certified Apartment (CA) program that has a 48-bed capacity of primarily two bedroom apartments located in and around Binghamton.

6

7

People in the certified program have service plan goals and each resident is required to participate in four units of service a month to be Medicaid reimbursable. All four of the Catholic Charities certified programs were inspected by the NYS OMH in 2003 and licensed for three years, the highest level of certification possible. This indicates the quality of these residential services and the fact that they are complying with all state regulations (see Appendix C for copies of operating certificates). Also Catholic Charities collected satisfaction data from clients, which suggests a high level of client satisfaction with all of their residential services (See Appendix D).

The Catholic Charities Certified Housing Programs were all given the highest level of certification by NYS OMH at their last review in 2003.

The non-certified Supported Housing (SH) program is designed to place people in independent living in their own apartment. It is a NYS OMH funded program with a 108-unit capacity. However the program routinely exceeds this capacity because all residents are not served by all components of the program. The Supported Housing program has three components, startup, rental stipend, and support services. The startup includes Catholic Charities providing furnishings and supplies for the apartment. The rental stipend is given to assist with rent until residents can get section 8 housing support. The residents choose an eligible apartment within either the City of Binghamton or Town of Union. The program also provides staff support for people who require it, including education about daily living, groceries, food stamps, and other housing related matters. There are four support staff in the Supported Housing program. Because the Supported Housing is non-certified there is no mandated level of support program participation, residents participation is based on need and interest. Catholic Charities staff notes that due to its popularity, this program typically exhausts its funding in early fall and cannot place new residents until the next year. They further point out that supported housing is not exclusive to low risk, low need individuals and the majority of residents have case managers (see Appendix E).

Due to high demand, the Catholic Charities Supported Housing Program typically exhausts its funding in early fall and carries a waitlist into the next year.

Greater Binghamton Health Center The Greater Binghamton Health Center (GBHC) is a 154-

bed inpatient psychiatric facility. In addition they offer case management and outpatient services. GBHC recently opened a transitional living unit (TLU) which is a 21 (soon to be 24) bed unit to facilitate discharged patients moving

7

8

to less restrictive settings. The TLU replaced the Community Preparation Unit (CPU) which had a similar function but which was an inpatient unit. The model of the TLU is based on the psychiatric rehabilitation model of care. All residents of the TLU have been discharged from the hospital and deemed safe as are all patients discharged. Therefore, TLU residents are outpatients who can leave the program at any time. Every resident has a goal of securing living arrangements outside TLU within roughly six months.

GBHCs TLU is an outpatient rehabilitation residence program with the goal of securing outside living arrangements within six months.

GBHC also has a network of 13 family care homes to care for some discharged patients. The total certified capacity of the homes is 65. The operators of these homes are paid $692.48 per month per patient and they provide meals, laundry, transportation and other related services. The typical patient in this program has multiple functional deficits and would be unable to live independently. They are also very low risk patients.

Fairview Recovery Services Inc. Fairview Recovery Services provides residential and

support services for chemically dependent individuals. These services are certified by the NYS Office of Alcoholism and Substance Abuse Services (OASAS). They provide these services along a continuum of care including an 18 bed addictions crisis center which provides medically monitored withdrawal, two community residences with a total of 36 beds, 40 beds in a supportive living program, 25 Shelter Plus Care apartments, addiction case management and career counseling. They also provide a Mentally Ill Chemical Abuser (MICA) Case manager funded by reinvestment money. All treatment occurs outside of the agency at an area treatment provider. Residents in these programs need at least a moderate level of functioning.

YMCA The YMCA has 87 beds and offers its residents on site

caseworkers, referral, meals and YMCA membership. No clinical services are provided on site.

YWCA The YWCA has four housing programs and offers a full

time social worker. Their housing options include a 10 bed emergency shelter, 14-16 beds of adult long term supportive housing in communal living apartments, and an intensive independent living program which offers 3-4 long-term housing beds for 18-23 year olds.

8

9

Volunteers of America The Volunteers of America (VOA) operate several housing programs in Broome County. Their funding is from city, state and federal grants, as well as private funding. They have two case managers and offer lifeskills groups. Residents only requirement is to pass police clearance. VOA housing includes a mens shelter which has 30 beds, in single, double, and triple rooms, seven transitional apartments for women and families, eight transitional beds for men, 10 permanent housing beds for very low income individuals and Family emergency housing.

Renaissance Plaza Renaissance Plaza is a Level 2 convalescent care adult

home with 316 licensed beds. Currently there are 180 residents of which an estimated 30-40% are mentally ill. Two in-house service providers offer psychological and social work services to residents. Additionally, they are attempting to set up a UHS satellite clinic to run groups including depression, impulse control, and MICA.

Section 8 Housing Section 8 Housing is a federal program to provide

assistance for people who would not be otherwise able to afford adequate housing. There are two Section 8 programs in Broome County, the city of Binghamton and the town of Union.

The City of Binghamton Section 8 program has 427 units. Priority for the program is determined by lottery, with some preference given to disabled individuals. The Binghamton Housing Authority administers the Section 8 program and they are not involved in any service package for mentally ill residents. When asked the director estimated that 10% of the residents are mentally ill but emphasized that they do not keep track of that information.

The Town of Union Section 8 program currently has 460 units. They have recently closed their waitlist at 400. 60% of Section 8 residents in the town of union are elderly, handicapped or disabled, but they do not track mental illness apart from its inclusion in that statistic. They also do not collect data on referral sources or service package for mentally ill residents. They did note that Catholic Charities and the Southern Tier Independence Center do refer to them.

There are a total of 887 units of Section 8 Housing in Broome County and the demand is greater than the supply.

9

10

Method Data There were several sources of data used in this report.

NYS OMH Residential Program Indicators Reports for 2001-2003 These reports list statistics on all OMH housing in New York State by county.

Catholic Charities Transitional Living Service Database 2003-2004 A working list of referrals with identifying information deleted was provided. This file included referral source, placement outcome, dates, etc. Surveys of housing statistics for last four quarters (Oct 03-Sept 04) All housing providers for mentally ill adults in Broome County were surveyed for information about capacity, services offered, referrals, and utilization. Eleven of the fifteen programs surveyed returned the survey. For an example and the complete surveys see Appendices F & G. The following table (Table 1) details the residential programs surveyed.

Interviews with program directors The researcher met with a director from each of the housing programs listed, with the exception of the YMCA. These interviews greatly informed this project as well as generated comments that were included in the discussion section.

10

11

Table 1 Agency Program Capacity % Mentally Ill Catholic

Charities Madison House 14 beds 100%

Community Residence

Catholic Charities

Damon Hall 14 beds 100% Community Residence

Catholic Charities

Bridgeway 12 beds 100% Community Residence

Catholic Charities

Certified Apartment Program

48 beds 100%

Catholic Charities

Supported Housing

108 units 100%

GBHC TLU 21 beds 100%

GBHC Family care homes

13 homes 100% 65 beds

Fairview Recovery Services

Addictions Crisis Center

18 beds 40-50%


Fairview Community Residence

24 beds 40-50%


Merrick Community Residence

12 beds 40-50%


Supportive Living

40 beds 40-50%

YMCA Housing Program

87 beds ~25%

YWCA Emergency Housing

10 beds + up to 8 children

~33%

Renaissance 316 beds 30-40% Plaza

Volunteers of Mens Shelter 30 beds ~15%

America

11

12

Results Occupancy Rate Over the last four quarters (Oct 03 Sept 04) the

occupancy rate of the Certified Apartment (CA) program was 76%, while the Community Residence (CR) was 90% and the Supported Housing (SH) program was 122%.

Catholic Charities Occupancy Last Four Quarters

020406080

100120140

oct dec 03 jan mar 04 apr june 04 july sept 04

Quarter

Occ

upan

cy R

ate

CRCASH

Figure 1

The Certified Apartment program has been underutilized for several years. According to a previous report by Griffith it was 85% for 1999 and according to New York State data it was 86%, 84% and 83% for 2001, 2002, and 2003 respectively. This is below the occupancy rate for two similar counties as well as the New York State average.

Certified Apartments Occupancy

0

20

40

60

80

100

120

Broome Orange Oneida NYS

County

Occ

upan

cy R

ate

200120022003

Figure 2

Source: NYS OMH Residential Program Indicators Reports

12

13

The occupancy rate for the Catholic Charities Certified Apartment Program has been lower than similar counties and the NYS average for several years.

Over the past three years, the occupancy rate in the Certified Apartment program is below that of similar counties and the NYS Average. The Community Residence or Congregate Care level has been near or at the occupancy level of similar counties and the NYS average. Conversely the occupancy rate of the Supported Housing program has been substantially higher than similar counties and the NYS average (See Table 2).

Table 2 Occupancy rate by county, year, and level of care 2001 2002 2003 Community Residence Broome 94% 91% 93% CR Orange 96% 97% 103% Oneida 93% 93% 93% NYS 95% 95% 96% Certified Apartments Broome 86% 84% 83% CA Orange 92% 104% 104% Oneida 97% 98% 95% NYS 93% 93% 97% Supported Housing Broome 112% 125% 122% SH Orange 120% 108% 113% Oneida 102% 101% 105% NYS 84% 98% 102%


Table 3 provides a complete list of the occupancy rate for each housing provider in Broome County over the last four quarters. Renaissance Plaza had the lowest occupancy rate overall, as well as the largest capacity, which may indicate pressure on them to increase their occupancy level. The Fairview Addiction Crisis Center and the GBHC family care homes are the next lowest. The Family Care homes level reflects the total licensed capacity but it is unknown if the homes wish to reach that level or even if suitable residents exist. The next lowest is the Catholic Charities Certified Apartment program and then one of their Community Residences, Madison House. Every other program seems to be running near or at capacity.

Renaissance Plaza had the lowest occupancy rate overall, as well as the largest capacity, which may lead to economic pressure to increase their occupancy level.

13

14

Table 3 Agency Program Capacity Occupancy Rate Catholic

Charities Madison House 14 beds 83%

Community Residence

Catholic Charities

Damon Hall 14 beds 93% Community Residence

Catholic Charities

Bridgeway 12 beds 93% Community Residence

Catholic Charities


48 beds 76%

Catholic Charities

Supported Housing

108 units 122%

GBHC TLU 21 beds 100%

GBHC Family care homes

13 homes 79% 65 beds



18 beds 71%


Fairview Halfway House

24 beds 92%


Merrick Halfway House

12 beds 95%


Supportive Living

40 beds 94%

YMCA Housing Program

87 beds 93%

YWCA Emergency Housing


85%

Renaissance 316 beds 57% Plaza

Volunteers of Mens Shelter 30 beds -

America

14

15

Referral Sources There were 255 referrals to the Catholic Charities housing

program in the last four quarters (there were also 54 internal transfers not included in this analysis). The three largest referral sources for the Catholic Charities transitional living services were UHS, GBHC and Catholic Charities (case management and other programs). These three agencies accounted for almost two-thirds of all referrals. Other sources included the Broome County Mental Health Clinic, rehabilitation facilities such as Fairview or Addiction Center of Broome County, self-referral, or any other such as private providers and agencies from another county.

Catholic Charities Referral Sources Last 4 Quarters

UHS 63

GBHC 62

CC CM 24

CC programs 15

BCMH 29

Rehabs 15

Self 13

Other 34

Figure 3

Source: 2003-2004 TLS data

15

16

Referral Outcomes Of the 274 referrals processed in the last four quarters (including transfers), 130 were admitted to the housing program and 104 were withdrawn. Withdrawn referrals include clients no longer interested, withdrawn by the referring agency, and individuals whose housing needs have been met. Of all the referrals 23 were found to be ineligible and 17 were denied. The ineligible referrals were those who did not meet SPMI criteria, usually due to a primary diagnosis of substance abuse. Referrals were denied when Catholic Charities decided that they were unable to provide adequate supervision due to either complex medical needs, a safety risk for self/others, or sexual offenders.

Figure 4

CC Referral Outcomes Last Four Quarters

admitted48%

withdrawn38%

ineligible8%

denied6%


Referral Distribution The pattern of referral outcome was similar between referrals to the Certified Programs (CR & CA) and the Supported Housing (SH) program (see Table 4). There were slightly more accepted and withdrawn referrals in the SH program while the Certified Program had more ineligible and denied referrals.

16

17

Table 4 Total Outcome Certified Program CR+CA

Supported Housing SH

130 Accept 90 40 48% 46% 51% 104 Withdraw 71 33 38% 36% 42% 23 Ineligible 20 3 8% 10% 4% 17 Denied 15 2 6% 8% 3%

Total 196 78 274 72% 28% 100%

Figure 5

Outcome of 196 referrals to Certified Program (CR+CA)

admit-90

withdrawn-71

ineligible-20

denied-15

Outcome of 78 referrals to Supported Housing

admit-40withdrawn-33

ineligible-3

denied-2Figure 6

17

18

Median Length of Stay The median length of stay in the Broome County Certified

Apartment program is much less than that in two comparable counties and the New York State average. This could be contributing to the low occupancy rate of the certified program.

Figure 7

median length of stay CA

0

200

400

600

800

1000

1200

2001 2002 2003

year

days

BroomeOrangeOneidaNYS


18

19

While the Certified Apartment program has much shorter median length of stay than Certified Apartments in other counties, the Supported Housing program has experienced increases in the median length of stay that put it closer to the New York State average. This pattern may be related to the extremely high levels of occupancy in this program.

Figure 8

Supported Housing Median Length of Stay

0

200

400

600

800

1000

1200

2001 2002 2003

year

days



19

20

The Community Residences also have a median length of stay that is below that of similar counties and the New York State Average. This is an indication that residents are progressing quickly through the Community Residence level of care. This suggests that people staying too long in the Community Residence is likely not one of the causes of the under-utilization of the Certified Apartment program.

Figure 9

Community Residence Median Length of Stay

0

200

400

600

800

1000

1200

2001 2002 2003year

days



20

21

Broome vs. other counties Broome County has fewer Community Residence (or Congregate Treatment, CR) beds than any of the other counties measured. The levels of Certified Apartments (CA) and Supported Housing (SH) are comparable to the similar counties.

Figure 10

2003 Number of Beds

020406080

100120140160180

Broome Oneida Orange NYS avg

CRCASH


However the ratio of Congregate Treatment to Certified Apartment beds in Broome County is the almost the reverse of the pattern found across similar counties, the central Region and New York State. As the congregate treatment level is the largest single source of referrals (46%) to the Certified Apartments, this may be a factor in the underutilization of the Certified Apartments.

Table 5 Congregate Treatment CR

Certified Apartment CA


Total # of Beds

Broome 40 48 108 196 20.4% 24.5% 55.1% Oneida 86 41 107 234 36.8% 17.5% 45.7% Orange 94 52 116 262 35.9% 19.9% 44.3% Central 495 393 1,031 1,919 Region 25.8% 20.5% 53.7% NYS 87 65 167 319

Broome is one of few counties in NYS with fewer community residence beds than certified apartment beds.

average 27.2% 20.4% 52.5%

21

22

Stepdown model vs. What Actually Happens Catholic Charities Transitional Living Services was

organized upon the step-down model. According to this model residents should come out of the psychiatric center or some other agency and enter the community residence. Once they have obtained more ability to live independently they would transition to a Certified Apartment and when they no longer need the structure of a certified program they would be placed in the supportive housing program which would allow then to obtain their own apartment and live independently.

To examine if the movement of residents matched the step-

down model, the amount of referrals from inside and outside of Catholic Charities was plotted.

CR

CA

SH

Figure 11

At the Community Residence level 92 of the total 103 referrals were from outside agencies, which is in line with the model. (However, 11 referrals were from the Certified Apartment program.)

At the Certified Apartment level 21 of the 46 total referrals were from the community residences, the other 25 were from outside agencies, which is contrary to the step-down model.

At the Supported Housing level only 32 of the total 86 referrals were from the Certified Apartment program. Fifty-one were from outside agencies, which is also contrary to the step-down model. Three were from the Community Residence level.

21

32

CR

CA

SH

92

25

51

Outside referral

11

3

22

23

Table 6 Discharges from Catholic Charities in the last four quarters by location. Discharge

Location

Community Residence

Certified Apartment

Supported Housing

Own Apartment 23 6 38

Community Residence

- 4 0

Certified Apartment 13 - 0

Supported Housing 2 8 -

Family 13 4 1

Renaissance Plaza 5 0 0

Rehabilitation 1 0 0

Left County 0 1 1

Other housing program

5 1 0

UHS inpatient 7 1 0

GBHC 1 0 2

Jail 1 1 0

Deceased 0 1 1

Unknown 0 1 0

Total 69 27 43


23

24

Discussion

Agency Feedback The following are summaries of themes that emerged from the interviews with agency directors and program directors.

Best Aspects of Residential Services There are a wide variety of residential services in Broome

County. These housing programs provide a safe place to stay while getting services. The amount of services varies by program, ranging from focusing on mental health or addictions, to case management. In addition to housing people, these programs facilitate treatment because treatment attendance of residents is better than that of outpatients.

Renaissance Plaza Renaissance Plaza would like to work more closely with

agencies in communities to provide in house services and would like to get more referrals from community agencies. They seek to provide entire medical and psychological services in house, or as a total care package, while other agencies are set up to utilize existing community services.

Accessibility of Services Several providers expressed concern that it was difficult to

get mental health services for residents. Some expressed a need for more mental health options and a desire to let residents be more involved in choosing providers.

High-Risk Clients Two agencies felt that some of their referrals were too low

functioning for their residential programs. They indicated that their level of staffing was not appropriate for more high-risk residents. All providers indicated that there was a great deal of difficulty placing high-risk clients. While all agencies agree that the safety of all congregate setting residents and staff is a paramount concern, there is disagreement about what constitutes a safety risk.

Clients with a history of violence are a particular area of

concern. Patients must be judged safe to be discharged from an inpatient facility, but those facilities have much greater supervision, availability of restraint and ready medication to deal with violence. Agencies with much lower staffing levels are looking for evidence that a resident will not become violent in a much less controlled setting. This evidence is hard to obtain while a client is still in a controlled setting, which has become a point of contention in the past.

All providers interviewed indicated that there was a great deal of difficulty placing high-risk clients in residential services.

24

25

The availability of housing for high-risk clients seems to be an issue. Those interviewed felt that, for high-risk clients, finding residential services is a bigger issue than finding treatment. Everyone interviewed recognized that inpatient facilities need to get housing for their discharged patients, but some feel that housing providers are sometimes too conservative about the risk of particular patients. Others maintain that nearly half of their referrals have a forensic history and they only deny a small percentage of all referrals. These providers indicate that even when they admit a high-risk individual they frequently are unsuccessful and stay a short time. In any case all agreed that the options for a high-risk individual who is denied housing are not good. Some facilities will accept such individuals, but do not provide the level of services that a high-risk individual requires.

Providers disagree about the level of risk posed by certain clients. Evidence of risk is difficult to gather while clients remain in controlled settings.

Why CA Underutilized Those interviewed report a steady decrease in CA

enrollment for the past five years. They cite the addition of Supported Housing and case management as factors that have eroded interest in the Certified Apartment program because residents could receive the same level of care in a less restrictive setting and while living in their own apartment. In addition these alternatives have lead to shorter lengths of stay for those who do enter the Certified Apartment program.

Changing Client Profile Several service providers reported that residents stay less

time and are unwilling to participate as much as in the past. Residents used to be higher functioning and now more high need cases are being seen. For example, residents are more likely to have a violent record or substance abuse problem compared to 10-15 years ago. Also current residents have more healthcare issues and many more medications than in the past. As more lower functioning and higher risk residents are enrolling in these programs, some agency managers believe that current staffing is inadequate. A typical Community Residence has one counselor per eight hour shift, typically with a high school diploma, for 12-14 residents.

Changing Model Catholic Charities managers reported that the step-down

model for movement through different levels of housing is no longer accurate because people are not transitioning down the continuum of care. Instead people spend shorter amounts of time and often only at one level of residential

25

26

care. Some service providers indicated that although their programs are voluntary, some residents have received pressure from their discharge agency or their parole officer to stay in the program. Catholic Charities staff emphasized that a referral to an appropriate level of care does not necessarily mean that clients will accept or stay for the recommended time period.

Possible Solutions Catholic Charities has proposed eliminating 12 Certified

Apartment beds and using the money saved to create more slots in the Supported Housing Program.

Some providers suggested that the Catholic Charities ACT flex team could provide services for high-risk individuals in a Supported Housing setting. This would eliminate the risk to other residents in a congregate setting, but provide a higher level of care that is needed.

One possibility is that the Catholic Charities ACT flex team could provide services for high-risk individuals in a Supported Housing setting.

Another provider suggested that if a Community Residence were designed to respond to higher need individuals from inpatient settings it would be easier to get these individuals housing.

List of Issues Certified Apts. Program Underutilized The Certified Apartment program is currently underutilized

and has been for at least five years. The primary reason for this seems to be that people prefer to live in their own apartment. While the Certified Apartment program has openings, there are individuals on the waiting list for the Supported Housing program, which puts residents in their own apartment. Other issues that may contribute to the seeming lack of interest in the Certified Apartment program is that individuals must have a roommate, that significant others are not able to live with them, and that attendance in treatment programs is highly recommended. In addition, services provided in the Certified Apartment program may overlap with existing case management.

The primary reason for the underutilization of the Certified Apartment program seems to be that people prefer to live in their own apartment.

The CA has a very short median length of stay compared to similar counties that may be contributing to its low occupancy rate. The CRs also have a relatively short median length of stay, suggesting that residents are not staying too long at that level when they should move to the CA.

26

27

Another factor that may contribute the underutilization of CA beds is the ratio of 40 CR beds to 48 CA beds. Not all of the people coming out of the CRs go in to the CA program. The CRs are the largest source of referrals to the CAs. Having more beds to fill than beds that ostensibly feed into the program may be a factor. Based on the occupancy rate of the CR program, adding additional CR beds is not currently indicated. However the system as it is currently is unable to fill 48 certified apartment beds.

Unmet Community Needs There appear to be two groups of mentally ill adults who

are currently not having their subsidized housing needs met. The first group is adults who want to live independently and are capable of doing so. These people are currently served by the Supported Housing Program that is routinely over 100% capacity and usually has a waiting list. This program has been successful at putting SMPI adults into their own apartment. This is the ultimate goal for transitional housing programs and it is also more cost effective than other housing programs. This trend is matched by the overall demand for Section 8 Housing. For example the waitlist in the Town of Union was recently capped after it reached 400. It should be noted that these people could rent their own apartment as roughly 10% of apartments in Binghamton are vacant. Catholic Charities points out that without rental assistance SPMI adults frequently live in substandard apartments in unsafe neighborhoods.

The housing needs of two groups of mentally ill adults seem to be not being met, people who desire independent living and high-risk, high need people.

The second group that seems to be under-served in terms of housing is high need adults who have significant history of high-risk behavior such as violence or sexual offenses. Agencies may differ on what amount of risk is too much, but there is little doubt that the highest-risk patients need a greater level of care and supervision than is currently available outside of inpatient hospitals. In the four quarters 15 referrals were denied from Catholic Charities due to a history of violence, sexual offense or both. Catholic Charities as well as other housing providers are not staffed to handle violence. When high-risk patients are denied they have few options. No housing exists to provide the level of care needed to house high-risk individuals.

Step-down model The step-down model is not an accurate depiction of the movement of residents through the levels of Catholic

27

28

Charities residential services. The model predicts entry into the Community Residence and progression through the Certified Apartment and Supported Housing program toward the goal of independent living. However many referrals are made directly to the Certified Apartment and especially the Supported Housing program. Also the majority of discharges from the CR and CA levels are to housing outside of Catholic Charities. The current pattern is much more fluid than would be suggested by the model. According to Catholic Charities the step-down or continuum-of-care model no longer meets the needs and interests of recipients. They maintain that placement directly into the most appropriate level of care better meets the needs of individuals.

Erosion of the Fiscal Model Funding for NYS OMH supervised residential

programming is a complex combination of deficit funding, Medicaid and SSI congregate care payments. The NYS OMH has not provided annual cost of living increases to residential programs since the inception of these programs. Essential program costs go up every year but funding usually does not. In the 2004-2005 state budget the NYS OMH did award a 12% increase in Medicaid funding to Community Residences and Certified Apartments based on direct care salary line. This translates to an approximate increase of $95,000 to Catholic Charities in 2005. For a more complete discussion of this issue see Appendix H.

Summary of Results Many housing options for mentally ill adults exist in

Broome County. There is a great deal of diversity across these housing providers. While Catholic Charities is the sole NYS OMH certified program that exclusively serves mentally ill adults, other housing programs which serve larger populations contain a significant percentage of mentally ill adults. The data collected show that overall the residential services are operating near capacity. Two notable exceptions are Renaissance Plaza and the Catholic Charities Certified Apartment program. As one of the largest providers Renaissance Plaza has the lowest occupancy rate and also has had concerns about the availability of mental health services for their residents. Meanwhile, the Certified Apartment program has been operating below capacity for several years. This may reflect a capacity greater than the demand for this level of housing. While the majority of mentally ill are being served by this system, there seems to be two groups whose

Currently Catholic Charities are unable to fill 48 Certified Apartment beds. This may reflect capacity being greater than demand for this level of housing.

28

29

housing needs are not being met, a small number of high risk individuals and a large number of people who want supported housing.

29

30

Appendices Appendix A Broome County Residential Program Evaluation Reports, 5/03 & 7/04

(26 pages) Appendix B SPMI Criteria (1 page) Appendix C Catholic Charities Certified Programs Operating Certificates (4 pages) Appendix D Catholic Charities Housing Programs Satisfaction Data (1 page) Appendix E Case Management Services for Supported Housing Residents (1 page) Appendix F Blank Housing Program Questionnaire (2 pages) Appendix G Completed Housing Program Questionnaires (16 pages) Appendix H Association for Community Living Mental Health Supported Housing

Report (48 pages)

30

Key Findings Acknowledgements The author would like to thank my supervisor, Dr. Robert Russell, staff psychologist and Broome County Mental Health Commissioner Arthur R. Johnson for all of their guidance and support on this project. Thanks are also due to Lynne Esquivel, MPA. Key Findings ..2 Acknowledgements .........3 Table of contents ......4 I. Introduction .6 II. Method ...10 III. Results .12 IV. Discussion..24 V. Appendices .30 Introduction

Background Catholic Charities is the primary provider of NYS OMH approved housing for mentally ill adults in Broome County. They are the contract agency for three levels of housing, Community Residence (CR), Certified Apartment (CA), and Supported Housing (SH). The Certified Apartment program and two of the Community Residences have been underutilized compared to the other programs as well as comparable programs in other counties (See Appendix A). Catholic Charities has proposed reducing the number of CA beds and increasing the number of SH beds. Current housing providers

Volunteers of America The Volunteers of America (VOA) operate several housing programs in Broome County. Their funding is from city, state and federal grants, as well as private funding. They have two case managers and offer lifeskills groups. Residents only requirement is to pass police clearance. VOA housing includes a mens shelter which has 30 beds, in single, double, and triple rooms, seven transitional apartments for women and families, eight transitional beds for men, 10 permanent housing beds for very low income individuals and Family emergency housing. Renaissance Plaza Renaissance Plaza is a Level 2 convalescent care adult home with 316 licensed beds. Currently there are 180 residents of which an estimated 30-40% are mentally ill. Two in-house service providers offer psychological and social work services to residents. Additionally, they are attempting to set up a UHS satellite clinic to run groups including depression, impulse control, and MICA. Section 8 Housing Section 8 Housing is a federal program to provide assistance for people who would not be otherwise able to afford adequate housing. There are two Section 8 programs in Broome County, the city of Binghamton and the town of Union. Method Results Over the past three years, the occupancy rate in the Certified Apartment program is below that of similar counties and the NYS Average. The Community Residence or Congregate Care level has been near or at the occupancy level of similar counties and the NYS average. Conversely the occupancy rate of the Supported Housing program has been substantially higher than similar counties and the NYS average (See Table 2). Table 2 Table 3Table 4Total

Source: 2003-2004 TLS data Discussion

Agency Feedback The following are summaries of themes that emerged from the interviews with agency directors and program directors. Renaissance Plaza Renaissance Plaza would like to work more closely with agencies in communities to provide in house services and would like to get more referrals from community agencies. They seek to provide entire medical and psychological services in house, or as a total care package, while other agencies are set up to utilize existing community services. Changing Client Profile Several service providers reported that residents stay less time and are unwilling to participate as much as in the past. Residents used to be higher functioning and now more high need cases are being seen. For example, residents are more likely to have a violent record or substance abuse problem compared to 10-15 years ago. Also current residents have more healthcare issues and many more medications than in the past. As more lower functioning and higher risk residents are enrolling in these programs, some agency managers believe that current staffing is inadequate. A typical Community Residence has one counselor per eight hour shift, typically with a high school diploma, for 12-14 residents. List of Issues

7

5


0

20

40

60

80

100

120

Broome

Orange

Oneida

NYS

County

Occupancy Rate

2001

2002

2003


0

20

40

60

80

100

120

140

oct dec 03

jan mar 04

apr june 04

july sept 04

Quarter

Occupancy Rate

CR

CA

SH

Key Findings

Funding from the New York State (NYS) Office of Mental Health (OMH) has not kept up with the increased cost of operating residential programs. (Page 27)

Catholic Charities certified residential programs all received the highest level of certification possible from the NYS OMH in 2003 Three year certification. (Page 6)

Satisfaction of Catholic Charities residents is high across all housing programs. (Page 6)

Percentage of Residents that are Mentally Ill (Page 9)

Catholic Charities and Greater Binghamton Health Center 100%

Fairview Recovery Services - 40-50%

YMCA, YWCA, & Renaissance Plaza 25-40%

Volunteers of America - 15-25%

In the last four quarters the Occupancy rate for the Catholic Charities Certified Apartment Program was 76%. It was between 83-86% from 1999-2003. (page 10)

17 (6%) of the 274 referrals to Catholic Charities Housing in the last four quarters were denied. (page 14)

The median length of stay for the Catholic Charities Certified Apartment Program is less than half the New York State Average. (page 16)

Broome is one of few counties with a lower percentage of Community Residence beds than of Certified Apartment beds. Most other counties have a higher percentage of Community Residence beds, which provide a referral base for their Certified Apartments. (page 19)

The Stepdown model is not an accurate description of how residents move through Catholic Charities Residential Services. (page 20)

Housing for high risk clients is an issue in Broome County (Page 22)

Renaissance Plaza had the lowest occupancy rate of all agencies surveyed, 57% in the last four quarters. (Page 12)

The Section 8 Housing program in the Town of Union has a 400 person waitlist. (Page 7)

Acknowledgements

The author would like to thank my supervisor, Dr. Robert Russell, staff psychologist and Broome County Mental Health Commissioner Arthur R. Johnson for all of their guidance and support on this project. Thanks are also due to Lynne Esquivel, MPA.

This report would not have been possible without the contributions of many individuals who were generous with their time and provided the information upon which this report is based. Thanks to Lawrence Mennig from Renaissance Plaza Ltd., Fran Hall, Joe Gosney, and Kathleen OConner from Catholic Charities, Michele Napolitano and Patrick Haley from Fairview Recovery Services, Inc., Lynne Webb from Volunteers of America, John Burke from the Greater Binghamton Health Center, Nancy Johnson from YWCA, Jack McAndrew from YMCA, Michael Atchie from the Binghamton Housing Authority, Paul Nelson from the Town of Union and Toni Lasicki from the Association for Community Living.

Much thanks to all the staff at the Broome County Mental Health Department for their invaluable assistance.

Key Findings ..2

Acknowledgements .........3 Table of contents ......4

I. Introduction .6

Goal 6

Background ...6

Current housing providers ..6

Catholic Charities ...6

Greater Binghamton Health Center .7

Fairview Recovery Services .8

YMCA ...8

YWCA ...8

Volunteers of America .......9

Renaissance Plaza .....9

Section 8 Housing ..9

II. Method ...10

Data Collected .10

Table 1 - Housing Providers Capacity & Percentage

of Mentally Ill Residents 10

III. Results .12

Occupancy Rate ..12

Figure 1 - Catholic Charities Occupancy Rate .12

Figure 2 Certified Apartment Occupancy Rate

by County and Year ..12

Table 2 Occupancy Rate by County,

Year and Level of Care ....13

Table 3 - Housing Providers Capacity & Occupancy ......14

Referral Sources.15

Figure 3 Catholic Charities Referral Sources ....15

Referral Outcomes ..16

Figure 4 Catholic Charities Referral Outcomes 16

Referral Distribution 16

Table 4 Outcomes of Referrals to Certified

and Non-certified programs .17

Figure 5 Outcomes for referrals to Certified Programs....17

Figure 6 - Outcomes for referrals to Supported Housing ...17

Median Length of Stay ...18

Figure 7 Median Length of Stay for

Certified Apartment Program ......18


Supported Housing Program ..19


Community Residences ...20

Broome vs. Other Counties ....21

Figure 10 Number of Beds by County

and Program Type ..21

Table 5 Ratio of beds between program levels

by county ......21

Stepdown model vs. What Actually Happens ...22

Figure 11 Stepdown model .22

Figure 12 Stepdown model with Referral Data 22

Table 6 Discharges for Catholic Charities by Location ..23

IV. Discussion..24

Agency Feedback ..24

Best Aspects of Residential Services ...24

Renaissance Plaza ..24

Accessibility of Services .....24

High-Risk Clients .....24

Why CA Underutilized .....25

Changing Client Profile ...25

Changing Model ...25

Possible Solutions ...26

List of Issues .....26

Certified Apartment Program Underutilized..26

Unmet Community Needs ..26

Step-Down Model 27

Erosion of the Fiscal Model ...28

Summary of Results .28

V. Appendices .30

Appendix A Broome County Residential Program Evaluation Reports

Appendix B SPMI Criteria

Appendix C Catholic Charities Certified Programs Operating Certificates

Appendix D Catholic Charities Housing Programs Satisfaction Data

Appendix E Case Management Services for Supported Housing Residents

Appendix F Blank Housing Program Questionnaire

Appendix G Completed Housing Program Questionnaires

Appendix H Association for Community Living Housing Report

Introduction

Goal This study assessed residential services for mentally ill adults in Broome County. Information gathered included a detailed listing of residential services currently available including utilization data and patterns of referral among county agencies. The purpose of this study is to determine if the level of residential services is matched to community needs. A specific issue to be examined was why the Catholic Charities Certified Apartment program is under-utilized

BackgroundCatholic Charities is the primary provider of NYS OMH approved housing for mentally ill adults in Broome County. They are the contract agency for three levels of housing, Community Residence (CR), Certified Apartment (CA), and Supported Housing (SH). The Certified Apartment program and two of the Community Residences have been underutilized compared to the other programs as well as comparable programs in other counties (See Appendix A). Catholic Charities has proposed reducing the number of CA beds and increasing the number of SH beds.

Current housing providers

Catholic CharitiesCatholic Charities (CC) Transitional Living Services (TLS) is a New York State (NYS) Office of Mental Health (OMH) certified and funded program that uses Medicaid as a source of funding. All residents must meet Severely and Persistently Mentally Ill (SPMI, see Appendix B for complete list of criteria) criteria and have a DSM IV Diagnosis.

The program has 88 certified beds, of which 40 are in the Community Residence (CR) program. There are three Community Residences: Madison House that has 14 beds, Damon Hall that has 14 beds, and Bridgeway that has 12 beds. Madison House offers residents a Certified Alcohol and Substance Abuse Counselor (CASAC) for 30 hours per week.

There is also the Twin Rivers Certified Apartment (CA) program that has a 48-bed capacity of primarily two bedroom apartments located in and around Binghamton. People in the certified program have service plan goals and each resident is required to participate in four units of service a month to be Medicaid reimbursable.


UHS 63

GBHC 62

CC CM 24

CC programs 15

BCMH 29

Rehabs 15

Self 13

Other 34

All four of the Catholic Charities certified programs were inspected by the NYS OMH in 2003 and licensed for three years, the highest level of certification possible. This indicates the quality of these residential services and the fact that they are complying with all state regulations (see Appendix C for copies of operating certificates). Also Catholic Charities collected satisfaction data from clients, which suggests a high level of client satisfaction with all of their residential services (See Appendix D).


admitted

48%

withdrawn

38%

ineligible

8%

denied

6%

The non-certified Supported Housing (SH) program is designed to place people in independent living in their own apartment. It is a NYS OMH funded program with a 108-unit capacity. However the program routinely exceeds this capacity because all residents are not served by all components of the program. The Supported Housing program has three components, startup, rental stipend, and support services. The startup includes Catholic Charities providing furnishings and supplies for the apartment. The rental stipend is given to assist with rent until residents can get section 8 housing support. The residents choose an eligible apartment within either the City of Binghamton or Town of Union. The program also provides staff support for people who require it, including education about daily living, groceries, food stamps, and other housing related matters. There are four support staff in the Supported Housing program. Because the Supported Housing is non-certified there is no mandated level of support program participation, residents participation is based on need and interest. Catholic Charities staff notes that due to its popularity, this program typically exhausts its funding in early fall and cannot place new residents until the next year. They further point out that supported housing is not exclusive to low risk, low need individuals and the majority of residents have case managers (see Appendix E).

Greater Binghamton

Health CenterThe Greater Binghamton Health Center (GBHC) is a 154-bed inpatient psychiatric facility. In addition they offer case management and outpatient services. GBHC recently opened a transitional living unit (TLU) which is a 21 (soon to be 24) bed unit to facilitate discharged patients moving to less restrictive settings. The TLU replaced the Community Preparation Unit (CPU) which had a similar function but which was an inpatient unit. The model of the TLU is based on the psychiatric rehabilitation model of care. All residents of the TLU have been discharged from the hospital and deemed safe as are all patients discharged. Therefore, TLU residents are outpatients who can leave the program at any time. Every resident has a goal of securing living arrangements outside TLU within roughly six months.

Outcome of 196 referrals to Certified Program

(CR+CA)

admit-90

withdrawn-71

ineligible-20

denied-15

GBHC also has a network of 13 family care homes to care for some discharged patients. The total certified capacity of the homes is 65. The operators of these homes are paid $692.48 per month per patient and they provide meals, laundry, transportation and other related services. The typical patient in this program has multiple functional deficits and would be unable to live independently. They are also very low risk patients.

Fairview Recovery

Services Inc.Fairview Recovery Services provides residential and support services for chemically dependent individuals. These services are certified by the NYS Office of Alcoholism and Substance Abuse Services (OASAS). They provide these services along a continuum of care including an 18 bed addictions crisis center which provides medically monitored withdrawal, two community residences with a total of 36 beds, 40 beds in a supportive living program, 25 Shelter Plus Care apartments, addiction case management and career counseling. They also provide a Mentally Ill Chemical Abuser (MICA) Case manager funded by reinvestment money. All treatment occurs outside of the agency at an area treatment provider. Residents in these programs need at least a moderate level of functioning.

YMCA The YMCA has 87 beds and offers its residents on site caseworkers, referral, meals and YMCA membership. No clinical services are provided on site.

YWCA The YWCA has four housing programs and offers a full time social worker. Their housing options include a 10 bed emergency shelter, 14-16 beds of adult long term supportive housing in communal living apartments, and an intensive independent living program which offers 3-4 long-term housing beds for 18-23 year olds.

Volunteers of AmericaThe Volunteers of America (VOA) operate several housing programs in Broome County. Their funding is from city, state and federal grants, as well as private funding. They have two case managers and offer lifeskills groups. Residents only requirement is to pass police clearance. VOA housing includes a mens shelter which has 30 beds, in single, double, and triple rooms, seven transitional apartments for women and families, eight transitional beds for men, 10 permanent housing beds for very low income individuals and Family emergency housing.

Renaissance PlazaRenaissance Plaza is a Level 2 convalescent care adult home with 316 licensed beds. Currently there are 180 residents of which an estimated 30-40% are mentally ill. Two in-house service providers offer psychological and social work services to residents. Additionally, they are attempting to set up a UHS satellite clinic to run groups including depression, impulse control, and MICA.

Section 8 HousingSection 8 Housing is a federal program to provide assistance for people who would not be otherwise able to afford adequate housing. There are two Section 8 programs in Broome County, the city of Binghamton and the town of Union.

The City of Binghamton Section 8 program has 427 units. Priority for the program is determined by lottery, with some preference given to disabled individuals. The Binghamton Housing Authority administers the Section 8 program and they are not involved in any service package for mentally ill residents. When asked the director estimated that 10% of the residents are mentally ill but emphasized that they do not keep track of that information.


admit-40

withdrawn-33

ineligible-3

denied-2

The Town of Union Section 8 program currently has 460 units. They have recently closed their waitlist at 400. 60% of Section 8 residents in the town of union are elderly, handicapped or disabled, but they do not track mental illness apart from its inclusion in that statistic. They also do not collect data on referral sources or service package for mentally ill residents. They did note that Catholic Charities and the Southern Tier Independence Center do refer to them.

Method

Data

There were several sources of data used in this report.

NYS OMH Residential Program Indicators Reports for 2001-2003

These reports list statistics on all OMH housing in New York State by county.

Catholic Charities Transitional Living Service Database 2003-2004

A working list of referrals with identifying information deleted was provided. This file included referral source, placement outcome, dates, etc.

Surveys of housing statistics for last four quarters (Oct 03-Sept 04)

All housing providers for mentally ill adults in Broome County were surveyed for information about capacity, services offered, referrals, and utilization. Eleven of the fifteen programs surveyed returned the survey. For an example and the complete surveys see Appendices F & G. The following table (Table 1) details the residential programs surveyed.

Interviews with program directors

The researcher met with a director from each of the housing programs listed, with the exception of the YMCA. These interviews greatly informed this project as well as generated comments that were included in the discussion section.

Table 1

Agency

Program

Capacity

% Mentally Ill

Catholic Charities

Madison House

Community Residence

14 beds

100%

Catholic Charities

Damon Hall

Community Residence

14 beds

100%

Catholic Charities

Bridgeway

Community Residence

12 beds

100%

Catholic Charities


48 beds

100%

Catholic Charities

Supported Housing

108 units

100%

GBHC

TLU

21 beds

100%

GBHC

Family care homes

13 homes

65 beds

100%



18 beds

40-50%


Fairview Community Residence

24 beds

40-50%


Merrick Community Residence

12 beds

40-50%


Supportive Living

40 beds

40-50%

YMCA

Housing Program

87 beds

~25%

YWCA

Emergency Housing


~33%

Renaissance

Plaza

316 beds

30-40%

Volunteers of

America

Mens Shelter

30 beds

~15%

Results


0

200

400

600

800

1000

1200

2001

2002

2003

year

days

Broome

Orange

Oneida

NYS

2003 Number of Beds

0

20

40

60

80

100

120

140

160

180

Broome

Oneida

Orange

NYS avg

CR

CA

SH

Occupancy RateOver the last four quarters (Oct 03 Sept 04) the occupancy rate of the Certified Apartment (CA) program was 76%, while the Community Residence (CR) was 90% and the Supported Housing (SH) program was 122%.

The Certified Apartment program has been underutilized for several years. According to a previous report by Griffith it was 85% for 1999 and according to New York State data it was 86%, 84% and 83% for 2001, 2002, and 2003 respectively. This is below the occupancy rate for two similar counties as well as the New York State average.


0

200

400

600

800

1000

1200

2001

2002

2003

year

days

Broome

Orange

Oneida

NYS


0

200

400

600

800

1000

1200

2001

2002

2003

year

days

Broome

Orange

Oneida

NYS


Over the past three years, the occupancy rate in the Certified Apartment program is below that of similar counties and the NYS Average. The Community Residence or Congregate Care level has been near or at the occupancy level of similar counties and the NYS average. Conversely the occupancy rate of the Supported Housing program has been substantially higher than similar counties and the NYS average (See Table 2).

Table 2

Occupancy rate by county, year, and level of care

2001

2002

2003

Community Residence

Broome

94%

91%

93%

CR

Orange

96%

97%

103%

Oneida

93%

93%

93%

NYS

95%

95%

96%

Certified Apartments

Broome

86%

84%

83%

CA

Orange

92%

104%

104%

Oneida

97%

98%

95%

NYS

93%

93%

97%

Supported Housing

Broome

112%

125%

122%

SH

Orange

120%

108%

113%

Oneida

102%

101%

105%

NYS

84%

98%

102%



UHS 63

GBHC 62

CC CM 24

CC programs 15

BCMH 29

Rehabs 15

Self 13

Other 34

Table 3 provides a complete list of the occupancy rate for each housing provider in Broome County over the last four quarters. Renaissance Plaza had the lowest occupancy rate overall, as well as the largest capacity, which may indicate pressure on them to increase their occupancy level. The Fairview Addiction Crisis Center and the GBHC family care homes are the next lowest. The Family Care homes level reflects the total licensed capacity but it is unknown if the homes wish to reach that level or even if suitable residents exist. The next lowest is the Catholic Charities Certified Apartment program and then one of their Community Residences, Madison House. Every other program seems to be running near or at capacity.

Table 3

Agency

Program

Capacity

Occupancy Rate

Catholic Charities

Madison House

Community Residence

14 beds

83%

Catholic Charities

Damon Hall

Community Residence

14 beds

93%

Catholic Charities

Bridgeway

Community Residence

12 beds

93%

Catholic Charities


48 beds

76%

Catholic Charities

Supported Housing

108 units

122%

GBHC

TLU

21 beds

100%

GBHC

Family care homes

13 homes

65 beds

79%



18 beds

71%


Fairview Halfway House

24 beds

92%


Merrick Halfway House

12 beds

95%


Supportive Living

40 beds

94%

YMCA

Housing Program

87 beds

93%

YWCA

Emergency Housing


85%

Renaissance

Plaza

316 beds

57%

Volunteers of

America

Mens Shelter

30 beds

-

2003 Number of Beds

0

20

40

60

80

100

120

140

160

180

Broome

Oneida

Orange

NYS avg

CR

CA

SH

Referral Sources There were 255 referrals to the Catholic Charities housing program in the last four quarters (there were also 54 internal transfers not included in this analysis). The three largest referral sources for the Catholic Charities transitional living services were UHS, GBHC and Catholic Charities (case management and other programs). These three agencies accounted for almost two-thirds of all referrals. Other sources included the Broome County Mental Health Clinic, rehabilitation facilities such as Fairview or Addiction Center of Broome County, self-referral, or any other such as private providers and agencies from another county.



admit-40

withdrawn-33

ineligible-3

denied-2

Referral Outcomes Of the 274 referrals processed in the last four quarters (including transfers), 130 were admitted to the housing program and 104 were withdrawn. Withdrawn referrals include clients no longer interested, withdrawn by the referring agency, and individuals whose housing needs have been met. Of all the referrals 23 were found to be ineligible and 17 were denied. The ineligible referrals were those who did not meet SPMI criteria, usually due to a primary diagnosis of substance abuse. Referrals were denied when Catholic Charities decided that they were unable to provide adequate supervision due to either complex medical needs, a safety risk for self/others, or sexual offenders.

Figure 4


Referral DistributionThe pattern of referral outcome was similar between referrals to the Certified Programs (CR & CA) and the Supported Housing (SH) program (see Table 4). There were slightly more accepted and withdrawn referrals in the SH program while the Certified Program had more ineligible and denied referrals.

Table 4

Outcome

Certified Program CR+CA


Total

Accept

90

46%

40

51%

130

48%

Withdraw

71

36%

33

42%

104

38%

Ineligible

20

10%

3

4%

23

8%

Denied

15

8%

2

3%

17

6%

Total

196

72%

78

28%

274

100%


0

20

40

60

80

100

120

Broome

Orange

Oneida

NYS

County

Occupancy Rate

2001

2002

2003

Figure 5


admitted

48%

withdrawn

38%

ineligible

8%

denied

6%

Figure 6

Median Length of StayThe median length of stay in the Broome County Certified Apartment program is much less than that in two comparable counties and the New York State average. This could be contributing to the low occupancy rate of the certified program.

Figure 7


0

200

400

600

800

1000

1200

2001

2002

2003

year

days

Broome

Orange

Oneida

NYS



0

200

400

600

800

1000

1200

2001

2002

2003

year

days

Broome

Orange

Oneida

NYS

While the Certified Apartment program has much shorter median length of stay than Certified Apartments in other counties, the Supported Housing program has experienced increases in the median length of stay that put it closer to the New York State average. This pattern may be related to the extremely high levels of occupancy in this program.

Figure 8


The Community Residences also have a median length of stay that is below that of similar counties and the New York State Average. This is an indication that residents are progressing quickly through the Community Residence level of care. This suggests that people staying too long in the Community Residence is likely not one of the causes of the under-utilization of the Certified Apartment program.

Figure 9


0

20

40

60

80

100

120

140

oct dec 03

jan mar 04

apr june 04

july sept 04

Quarter

Occupancy Rate

CR

CA

SH



0

200

400

600

800

1000

1200

2001

2002

2003

year

days

Broome

Orange

Oneida

NYS

Outcome of 196 referrals to Certified Program

(CR+CA)

admit-90

withdrawn-71

ineligible-20

denied-15

Broome vs. other counties Broome County has fewer Community Residence (or Congregate Treatment, CR) beds than any of the other counties measured. The levels of Certified Apartments (CA) and Supported Housing (SH) are comparable to the similar counties.


However the ratio of Congregate Treatment to Certified Apartment beds in Broome County is the almost the reverse of the pattern found across similar counties, the central Region and New York State. As the congregate treatment level is the largest single source of referrals (46%) to the Certified Apartments, this may be a factor in the underutilization of the Certified Apartments.

Table 5

Congregate Treatment CR

Certified Apartment CA


Total # of Beds

Broome

40

48

108

196

20.4%

24.5%

55.1%

Oneida

86

41

107

234

36.8%

17.5%

45.7%

Orange

94

52

116

262

35.9%

19.9%

44.3%

Central

495

393

1,031

1,919

Region

25.8%

20.5%

53.7%

NYS

87

65

167

319

average

27.2%

20.4%

52.5%

Stepdown model vs. What

Actually HappensCatholic Charities Transitional Living Services was organized upon the step-down model. According to this model residents should come out of the psychiatric center or some other agency and enter the community residence. Once they have obtained more ability to live independently they would transition to a Certified Apartment and when they no longer need the structure of a certified program they would be placed in the supportive housing program which would allow then to obtain their own apartment and live independently.

To examine if the movement of residents matched the step-down model, the amount of referrals from inside and outside of Catholic Charities was plotted.

At the Community Residence level 92 of the total 103 referrals were from outside agencies, which is in line with the model. (However, 11 referrals were from the Certified Apartment program.)

At the Certified Apartment level 21 of the 46 total referrals were from the community residences, the other 25 were from outside agencies, which is contrary to the step-down model.

At the Supported Housing level only 32 of the total 86 referrals were from the Certified Apartment program. Fifty-one were from outside agencies, which is also contrary to the step-down model. Three were from the Community Residence level.

Table 6Discharges from Catholic Charities in the last four quarters by location.

Discharge Location

Community Residence

Certified Apartment

Supported Housing

Own Apartment

23

6

38

Community Residence

-

4

0

Certified Apartment

13

-

0

Supported Housing

2

8

-

Family

13

4

1

Renaissance Plaza

5

0

0

Rehabilitation

1

0

0

Left County

0

1

1

Other housing program

5

1

0

UHS inpatient

7

1

0

GBHC

1

0

2

Jail

1

1

0

Deceased

0

1

1

Unknown

0

1

0

Total

69

27

43


Discussion

Agency FeedbackThe following are summaries of themes that emerged from the interviews with agency directors and program directors.

Best Aspects of

Residential Services There are a wide variety of residential services in Broome County. These housing programs provide a safe place to stay while getting services. The amount of services varies by program, ranging from focusing on mental health or addictions, to case management. In addition to housing people, these programs facilitate treatment because treatment attendance of residents is better than that of outpatients.

Renaissance PlazaRenaissance Plaza would like to work more closely with agencies in communities to provide in house services and would like to get more referrals from community agencies. They seek to provide entire medical and psychological services in house, or as a total care package, while other agencies are set up to utilize existing community services.

Accessibility of ServicesSeveral providers expressed concern that it was difficult to get mental health services for residents. Some expressed a need for more mental health options and a desire to let residents be more involved in choosing providers.

High-Risk ClientsTwo agencies felt that some of their referrals were too low functioning for their residential programs. They indicated that their level of staffing was not appropriate for more high-risk residents. All providers indicated that there was a great deal of difficulty placing high-risk clients. While all agencies agree that the safety of all congregate setting residents and staff is a paramount concern, there is disagreement about what constitutes a safety risk.

Clients with a history of violence are a particular area of concern. Patients must be judged safe to be discharged from an inpatient facility, but those facilities have much greater supervision, availability of restraint and ready medication to deal with violence. Agencies with much lower staffing levels are looking for evidence that a resident will not become violent in a much less controlled setting. This evidence is hard to obtain while a client is still in a controlled setting, which has become a point of contention in the past.

The availability of housing for high-risk clients seems to be an issue. Those interviewed felt that, for high-risk clients, finding residential services is a bigger issue than finding treatment. Everyone interviewed recognized that inpatient facilities need to get housing for their discharged patients, but some feel that housing providers are sometimes too conservative about the risk of particular patients. Others maintain that nearly half of their referrals have a forensic history and they only deny a small percentage of all referrals. These providers indicate that even when they admit a high-risk individual they frequently are unsuccessful and stay a short time. In any case all agreed that the options for a high-risk individual who is denied housing are not good. Some facilities will accept such individuals, but do not provide the level of services that a high-risk individual requires.

Why CA UnderutilizedThose interviewed report a steady decrease in CA enrollment for the past five years. They cite the addition of Supported Housing and case management as factors that have eroded interest in the Certified Apartment program because residents could receive the same level of care in a less restrictive setting and while living in their own apartment. In addition these alternatives have lead to shorter lengths of stay for those who do enter the Certified Apartment program.

Changing Client ProfileSeveral service providers reported that residents stay less time and are unwilling to participate as much as in the past. Residents used to be higher functioning and now more high need cases are being seen. For example, residents are more likely to have a violent record or substance abuse problem compared to 10-15 years ago. Also current residents have more healthcare issues and many more medications than in the past. As more lower functioning and higher risk residents are enrolling in these programs, some agency managers believe that current staffing is inadequate. A typical Community Residence has one counselor per eight hour shift, typically with a high school diploma, for 12-14 residents.

Changing ModelCatholic Charities managers reported that the step-down model for movement through different levels of housing is no longer accurate because people are not transitioning down the continuum of care. Instead people spend shorter amounts of time and often only at one level of residential care. Some service providers indicated that although their programs are voluntary, some residents have received pressure from their discharge agency or their parole officer to stay in the program. Catholic Charities staff emphasized that a referral to an appropriate level of care does not necessarily mean that clients will accept or stay for the recommended time period.

Possible SolutionsCatholic Charities has proposed eliminating 12 Certified Apartment beds and using the money saved to create more slots in the Supported Housing Program.

Some providers suggested that the Catholic Charities ACT flex team could provide services for high-risk individuals in a Supported Housing setting. This would eliminate the risk to other residents in a congregate setting, but provide a higher level of care that is needed.

Another provider suggested that if a Community Residence were designed to respond to higher need individuals from inpatient settings it would be easier to get these individuals housing.

List of Issues

Certified Apts. Program

UnderutilizedThe Certified Apartment program is currently underutilized and has been for at least five years. The primary reason for this seems to be that people prefer to live in their own apartment. While the Certified Apartment program has openings, there are individuals on the waiting list for the Supported Housing program, which puts residents in their own apartment. Other issues that may contribute to the seeming lack of interest in the Certified Apartment program is that individuals must have a roommate, that significant others are not able to live with them, and that attendance in treatment programs is highly recommended. In addition, services provided in the Certified Apartment program may overlap with existing case management.

The CA has a very short median length of stay compared to similar counties that may be contributing to its low occupancy rate. The CRs also have a relatively short median length of stay, suggesting that residents are not staying too long at that level when they should move to the CA.

Another factor that may contribute the underutilization of CA beds is the ratio of 40 CR beds to 48 CA beds. Not all of the people coming out of the CRs go in to the CA program. The CRs are the largest source of referrals to the CAs. Having more beds to fill than beds that ostensibly feed into the program may be a factor. Based on the occupancy rate of the CR program, adding additional CR beds is not currently indicated. However the system as it is currently is unable to fill 48 certified apartment beds.

Unmet Community Needs There appear to be two groups of mentally ill adults who are currently not having their subsidized housing needs met. The first group is adults who want to live independently and are capable of doing so. These people are currently served by the Supported Housing Program that is routinely over 100% capacity and usually has a waiting list. This program has been successful at putting SMPI adults into their own apartment. This is the ultimate goal for transitional housing programs and it is also more cost effective than other housing programs. This trend is matched by the overall demand for Section 8 Housing. For example the waitlist in the Town of Union was recently capped after it reached 400. It should be noted that these people could rent their own apartment as roughly 10% of apartments in Binghamton are vacant. Catholic Charities points out that without rental assistance SPMI adults frequently live in substandard apartments in unsafe neighborhoods.

The second group that seems to be under-served in terms of housing is high need adults who have significant history of high-risk behavior such as violence or sexual offenses. Agencies may differ on what amount of risk is too much, but there is little doubt that the highest-risk patients need a greater level of care and supervision than is currently available outside of inpatient hospitals. In the four quarters 15 referrals were denied from Catholic Charities due to a history of violence, sexual offense or both. Catholic Charities as well as other housing providers are not staffed to handle violence. When high-risk patients are denied they have few options. No housing exists to provide the level of care needed to house high-risk individuals.

Step-down modelThe step-down model is not an accurate depiction of the movement of residents through the levels of Catholic Charities residential services. The model predicts entry i

broome county mental health department

Documents