1. AB 109: Realignment and MHSA Housing
Anne Cory Corporation for Supportive Housing
MHSA Housing Program TA Webinar January 25,

2. What to Expect Today Not a full explanation of Realignment
Focus on MHSA Housing Program impact
How to apply what we’ve learned in the Housing Program to meeting your community’s needs under realignment
Housing lens

3. Agenda for Webinar Introduction to Realignment
Criminal Justice Realignment
Other Realigned Programs
Opportunities for Mental Health Staff
Why We Should Care About Housing?
CSH Programs: Returning Home Initiative and FUSE

4. Introduction to Realignment
The 2011 realignment plan shifts responsibility and funding for numerous programs from state to local levels.
Revenues for local management of programs exceed $6 billion per year.
Realignment revenues are deposited into a complicated series of accounts in the new Local Revenue Fund 2011.
Counties are agitating for commitment of adequate revenues long term.

5. Criminal Justice Realignment
Realigned Criminal Justice Programs include:
Adult offenders and parolees;
Court security;
Pre-2011 juvenile justice realignment;
Misc. local public safety grant programs.
This is the largest programmatic and financial element of 2011 realignment.

6. Realignment of Health and Human Services Programs
Mental Health Managed Care
EPSDT
Drug and Alcohol Programs
Foster Care and Child Welfare Services
Adult Protective Services
CalWORKS/Mental Health Transfer

7. What Does Realignment Look Like at the Local Level?
Need for substance abuse treatment services
Need for mental health services
Numbers are not matching projections
No benefits sign-ups before return to community
Dropping off offenders at Mental Health Department
Law enforcement lacks knowledge to assess and refer appropriately
Intense focus on criminogenics and recidivism
In planning documents, counties estimate that much of the prison population (60% to 80%) will require substance abuse treatment services;
Counties estimate that 20% or more of the prison population has a serious mental illness. Counties providing integrated behavioral and primary health care.
Numbers are not matching projections.
No eligibility screening before return to community.
Dropping off offenders at Mental Health Department.
Law enforcement lacks knowledge to assess and refer appropriately.

8. How Does it Look in Your Communities?
Challenges
Loose ends
Collaboration
Successes
What are your experiences with realignment so far?

9. What Issues Can You Address at the Local Level?
Discharge Plan: The discharge plan should include probationers’ or parolees’ treatment and other service needs.
Probation and parole conditions should be the least restrictive necessary.
Probationers and parolees with mental illness or co-occurring disorders should be supervised by probation officers and parole agents with specialized mental health training and reduced caseloads.
Discharge Plan: The discharge plan should include probationers’ or parolees’ treatment and other service needs as well as risks associated with public safety, recidivism, and danger to self. AND it should be followed.\ by all.
Probation and parole conditions should be the least restrictive necessary and should be tailored to the probationers’ or parolees’ needs and capabilities, understanding that successful completion of a period of community supervision can be particularly difficult for offenders with mental illness.

10. What Issues Can You Address at the Local Level?
Probation officers and parole agents should should:
reorient the supervision process from enforcement to intervention and ensure that it is community-based.
ensure that probationers and parolees with mental illness receive the services and resources in their discharge plans and are connected to a 24-hour crisis service.
Develop working agreements with community-based service providers to increase coordination of supervision and treatment goals and to ensure continuity of care once supervision is terminated.
Specialized mental health probation officers and parole agents should conduct their supervision and other monitoring responsibilities within the communities, homes, and community-based service programs where the offender with mental illness spends most of his or her time. This approach should reorient the supervision process from enforcement to intervention.
Specialized mental health probation officers and parole agents should work closely with mental health treatment providers and case managers to ensure that probationers and parolees with mental illness receive the services and resources specified in their discharge plans, and that released offenders are connected to a 24-hour crisis service.88

11. What Issues Can You Address at the Local Level?
Benefits enrollment – asap
Access to psychiatric medications
Enrollment in service programs (probationers are eligible for MHSA services, parolees are not)

12. What are the Barriers at Release?
No identification, SSI, birth certificate
No disability determination
Definitions of homelessness can exclude people coming from correctional settings
Hard to access health or mental health services
Lack of affordable housing resources and access issues
Limited income
Legal and illegal discrimination (criminal record, mental illness, substance use, homelessness, poverty, race)
Post traumatic stress disorder, difficulty reintegrating
Family reunification issues, particularly for women

13. Opportunities for Mental Health Staff
Planning through Community Corrections Partnerships
Community Corrections Partnership recommends local plan for realignment implementation to county board of supervisors.
Executive Committee of CCP: Chief Probation Officer, Chief of Police, Sheriff, District Attorney, Public Defender, Superior Court Presiding Judge, County health & human services representative.

14. Opportunities for Mental Health Staff
Counties have a lot of discretion on how to use funds:
State providing per parolee amount, per inmate amount, plus additional funding for “innovative” alternatives to incarceration.
Opportunity to weigh in to influence how funding is spent (i.e., diversion programs, housing, services, etc.)

15. Why Should We Care About Housing?
Task Force for Criminal Justice Collaboration on Mental Health Issues: Final Report
RECOMMENDATIONS FOR CHANGING THE PARADIGM FOR PERSONS WITH MENTAL ILLNESS IN THE CRIMINAL JUSTICE SYSTEM
APRIL 2011

16. Why Should We Care About Housing?
Many individuals with mental illness are released from jail and prison without housing arrangements, making it nearly impossible to succeed in managing their mental illness.
The California Department of Corrections and Rehabilitation (CDCR) reports that, at any given time, 10 percent of the state’s parolees are homeless.
The percentage of parolees who are homeless ranges from 30 percent to 50 percent in major urban areas such as San Francisco and Los Angeles.
Statistics are pre-realignment

17. Why Should We Care About Housing?
Appropriate housing in the community at the time of release is critical for successful reentry for offenders with mental illness since it serves as the foundation from which this population can access treatment and supportive services. Every offender with mental illness leaving jail or prison should, as a part of his or her discharge plan, have in place an arrangement for safe housing.

18. What Can We Do About Access to Housing?
Take on the role of housing advocate for the releasee, and ensure that community partners are doing so as well.
Establish agreements with housing programs, including supportive housing, to develop a housing referral network.
Courts, prisons, jails, probation, parole, and community partners should be prepared to assume the role of housing advocate for the releasee, recognizing that there are explicit as well as implicit prejudices and exclusions based on either mental illness or the criminal history of the releasee.
Courts, prisons, jails, and community partners, including law enforcement, discharge planners, service providers, probation, and parole, should establish agreements with housing programs, including supportive housing, to develop a housing referral network to coordinate stable housing placements for offenders with mental illness who are returning to the community.

19. What Can We Do About Access to Housing?
Make MHSA Housing Program units available to offenders with mental illness.
Ensure that your county plan includes equal access to MHSA housing for offenders with mental illness.
Mental Health Services Act (MHSA) funding dedicated to housing should be leveraged with other funding sources to ensure equal access to housing for offenders with mental illness, including those on probation. The state Director of Mental Health and the Mental Health Oversight and Accountability Commission (MHSOAC) should ensure that county plans include provisions to secure equal access to housing paid for with MHSA funding for offenders with mental illness.

20. AB 826 Sponsored by CSH & Housing California Authored by Toni Atkins
Funding since FY for program Department of Corrections & Rehabilitation (CDCR) calls the “Integrated Services for Mentally Ill Parolees” program.
RFP in 2009:
Mental health services for mentally ill parolees in community.
Unclear whether housing costs could be funded.
We can also learn about – and advocate for – legislation that will address the need for housing and services for the reentry population.

21. AB 826
Bill would use funds now used for ISMIP to create a supportive housing programs for parolees with mental illness at risk of homelessness.
Specifically, would—
Identify inmates at risk of homelessness and parolees who are currently homeless as potential participants;
Offer services to some participants before release to parole; and
Provide housing subsidies and services to participants

22. CSH Work: Housing for Criminal Justice-Involved Individuals
Looking at the larger picture of how communities benefit from their work providing housing for reentry individuals, especially those with mental illness and other special needs.

23. Corporation for Supportive Housing
CSH is a national non-profit organization that helps communities create permanent housing with services to prevent and end homelessness.
CSH advances its mission through advocacy, expertise, innovation, lending, and grantmaking.
Some of you are familiar with CSH. For those who are not, here is the one-slide introduction.

24. Why We Do It: Lavelle’s Story
Lavelle has been arrested more than 150 times, largely for quality-of-life crimes
He suffers from schizophrenia, depression, and drug addiction
Has had inconsistent mental health care and multiple encounters with drug treatment programs
He has spent most of the last 12 years on a revolving door between streets, shelter, hospitals, and jail

25. CSH’s Frequent User Systems Engagement (FUSE) Initiative

26. The FUSE Premise
Thousands of people with chronic health conditions cycle in and out of crisis systems of care and homelessness - at great public expense and with limited positive human outcomes. Placing these people in supportive housing will improve life outcomes for the tenants, more efficiently utilize public resources, and likely create cost avoidance in crisis systems like jails, hospitals and shelter.

27. The Beginning: New York City FUSE
Demonstration program matching “frequent fliers” with permanent supportive housing and enhanced services.
190 frequent users of jail and shelter, identified through pre-generated data match
Demonstration program designed to test whether PSH with enhanced engagement services can break cycle of homelessness and incarceration among individuals who are known “frequent flyers” of jail and shelter
Supportive housing with “front-loaded” intensive case management services for 190 frequent users of jail and shelter, identified through pre-generated data match
DHS
DOC
Neither System

28. The Blueprint for FUSE

29. Three Pillars, Nine Steps
Data-Driven Problem-Solving
Cross-system data match to identify frequent users
Track implementation progress
Measure outcomes/impact and cost-effectiveness
Policy and Systems Reform
Convene interagency and multi-sector working group
Troubleshoot barriers to housing placement and retention
Enlist policymakers to bring FUSE to scale
Targeted Housing and Services
Create supportive housing and develop assertive recruitment process
Recruit and place clients into housing, and stabilize with services
Expand model and house additional clients

30. Cross-System Data Match Provides Recruitment List
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NAME
CLIENT_ID
DOC_LOS
DHS_LOS
SHELTER
DOCFacility
Zeilinger, L. 45 98
USICH
EMTC
Hobson, B. 64
132
DESC
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Kanis, B. 75
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CSH

31. Results of Cross-System Data Match
DHS
DOC
Neither System
Source: Urban Institute (2009)

32. Implementation through Collaboration
Partner
Role
NYC Dept of Correction
Data matching, program oversight, policy advocacy, service enhancement funding, facilitate jail in- reach
NYC Dept of Homeless Services
Data matching, program oversight, policy advocacy, service enhancement funding, facilitate shelter in-reach
NYC Dept of Health and Mental Hygiene
Services and operating funding and program oversight
CSH
Program design, assembled and coordinated funding, program oversight and troubleshooting, TA/training,
NYC Housing Authority / Housing Preservation and Development
Provide Section 8 vouchers
JEHT Foundation / Langeloth Foundation
Provided funding for service enhancements and evaluation
NYC Office of Management and Budget
Program oversight
John Jay College / Columbia University
Program evaluation

33. Assertive Recruitment Through Jail, Shelter, Hospital In-Reach
Courts
Jail/Prison
Street
Hospital
Detox
Alcohol/Drug Treatment
Shelter
Psychiatric Hospital

34. Supportive Housing
Section 8 Housing Choice Vouchers (or State rental assistance programs) + Mobile Intensive Case Management Services
Unit set-asides in new supportive housing buildings or existing supportive housing with turnover
Providers trained in Motivational Interviewing, navigating criminal justice system, harm reduction, recognizing “symptoms” of incarceration

35. Stabilization through Services
Low case manager-to-client ratio (1:10 – 1:15)
Case manager role as “client advocate” and “failure preventer”
Emphasis on reduction of “risky behaviors”
Non-judgmental, client-centered counseling
Team approach to services delivery

36. “Systems Change” Through Case Coordination
Monthly implementation monitoring meetings to track recruitment, housing placement, housing retention, and recidivism prevention
Case conference and intervention in cases of re-arrest or re-hospitalization
Wraps “system of care” around tenants with supportive housing provider in central coordinating role

37. Measure Outcomes and Cost-Effectiveness
Crisis services use ($) 2 years before FUSE — Crisis services use ($) 2 years after FUSE — FUSE cost over 2 years = Net Savings of FUSE over 2 years

38. Getting to Policy Adoption and Scale
Bringing FUSE from pilot to full policy:
Early engagement of policymakers, budget officials around the FUSE “experiment”
Communication of outcomes and cost-offsets
Advance redirection of public spending from jails, shelters, etc. to supportive housing

39. Sites Implementing or Planning FUSE Replications
Implementing FUSE
Planning FUSE

40. Prior Research on High / Frequent Users
Hopper et. al. (1997) found that long-term homeless persons with severe mental illness experienced an “institutional circuit” that includes shelters, jails, ED, detox
Kuhn and Culhane (1998) found that approximately 10% of shelter users in New York City were ‘episodic’ users of shelter
These individuals are “more likely to be non-White, and to have mental health, substance abuse, and medical problems.”
“Much of the periods they spend outside of shelter may be spent in hospitals, jails, detoxification centers, or on the street. Indeed, one could argue that part of the very reason that these individuals do not become chronically homeless or long-term shelter residents is their frequent exit to inpatient treatment programs, detoxification services, or to penal institutions. Nevertheless, these clients often find their way back to shelters.”
Culhane et. al. (2002) found that homeless persons with serious mental illness cost $41,000 annually through usage of emergency public systems
Ford (2005) identified 61 frequent flyers of a FL county jail, of whom 82% were homeless,100% had substance abuse history, and 51% had a mental health history
Gladwell (2006) described individual who cost roughly $1 million in public service utilization

41. Characteristics & Service Needs of Jail-Shelter Frequent Users
Believed to have high rates of co-occurring and complex issues:
Alcohol and substance use (approx. 80%); earlier data matches found high utilization of crisis drug treatment services (i.e. Medicaid-reimbursed detox)
Mental health issues (est %), including serious mental illnesses (est %)
Criminal offenses largely consists of low-level misdemeanors (i.e. “quality of life” crimes), with minor felony histories

42. Characteristics & Service Needs of Jail-Shelter Frequent Users
Histories of transience and high level of involvement in multiple systems and services
Providers report:
Lack of trust in service providers and inconsistent benefits enrollment
Comparatively high occurrence of behavioral issues and lower degrees of independent living skills
Individuals are difficult to keep in one place and need nearly constant hand-holding as they navigate systems involvement

43. Research Suggests that Housing with Services Can Break the Cycle
Intensive service models such as Assertive Community Treatment or Intensive Case Management reduce recidivism
Supportive housing significantly reduces involvement in jails and prisons (along with shelter, hospitals, etc.) among homeless persons with serious mental illness
Intensive service models such as Assertive Community Treatment or Intensive Case Management reduce recidivism to local corrections (Lurigio et. al., 2000; Ventura et. al, 1998; Hartwell and Orr, 1999; Lamberti et. al, 2004.)
Recidivism and homelessness among persons with serious mental illness is higher among individuals with social disadvantage (poverty, lack of education, etc.)
Suggests that economic supports such as housing and employment services are as important as mental health treatment and case management services (Draine et. al., 2002)
Supportive housing significantly reduces involvement in jails and prisons (along with shelter, hospitals, etc.) among homeless persons with serious mental illness (Culhane et. al., 2002)

44. Health and Behavioral Health
Fractured Systems
Social
Services
Employment
Criminal Justice
Health and Behavioral Health
Housing
More than 10% are homeless before or after incarceration
For people with mental illness, it is 20%
More than 2/3 of those returning home have a history of substance abuse
49% of homeless adults spent 5 or more days in city or county jail, and 18% had been state or federal prison (CA)
More than 30% of single adults entering shelters are recently released from correctional facilities (NY)

45. Aligning Multiple Systems for Better Results
Criminal Justice
NYS DOC
NYC DOC
PAROLE
PROBATION
Bridge Rental Support
Client Identification
Transitional Case Management
Housing
HUD
Shelter + Care
Public Housing Authorities
Section 8
Social
Services
Shelter Plus Care
NY/NY III
Service Contracting through Criminal Justice/Human Service Agencies
Health and Behavioral Health
Mental Health Support Services
Housing Support
ACT Teams
Employment
Employment Initiatives both Federal and Local
Supportive Housing

46. CSH Returning Home Initiative
CSH's Returning Home Initiative started in 2006 and applies the FUSE model in communities across the country.
Initiatives integrate the systems and resources of criminal justice, behavioral health, and housing agencies.
CSH partnered with a number of leading researchers, including the Urban Institute, the John Jay College of Criminal Justice, the University of Minnesota and Columbia University.
CSH partnered with a number of leading researchers, including the Urban Institute, the John Jay College of Criminal Justice, the University of Minnesota and Columbia University to evaluate and measure the impact of these supportive housing interventions and document the systemic and programmatic lessons we have learned.

47. CSH Returning Home Initiative: Early Findings
A 39% reduction in the number of days in county jail for participants in Hennepin County.
A 50% reduction in the number of days in jail for participants in New York, compared to a comparison group.
A 43% reduction in the number of nights spent in shelter by participants in Hennepin County over the course of 22 months.

48. CSH Returning Home Initiative: Early Findings
Preliminary findings from New York show that after 12 months, only 16% of the program group had any shelter admission compared to 98% of the comparison group.
Preliminary findings from New York show lower rates of alcohol and drug abuse—specifically injection drug use—among people in the program.
In addition, the proportion of people with earnings and/or entitlements is much higher for people in the program.

49. To Learn More About CSH, FUSE and Returning Home
Anne Cory
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And help with the
MHSA Housing Program