Introduction
The purpose of this paper is to highlight critical issues in housing
for people with mental illness and to suggest new approaches. The overall
importance of housing is well established and is founded on a combination
of research, consumer experience, and common sense. Consumers need safe,
affordable places to live and the right level of support to make their
tenure a success.
This paper will briefly review some of the more recent research findings
but in general assumes that the case for good housing as an essential
component of community support has been made. In addition, the case for
a current crisis in housing can also be taken as made. The crisis has
two dimensions: the absolute shortage of affordable units and the lack
of a range of models that are reflective of best practice and the diversity
of consumer need. In Toronto, the absolute shortage has been documented
by the Mayor's Homelessness Action Task Force (1999) and other studies.
The report of the Task Force outlines, among other things, the plight
of people with mental illness who have no permanent housing. Although
focused on Toronto, its overall findings and description of the negative
fundamentals of the housing market are considered to be generally applicable
across much of the province. The lack of a sufficient range of models
is reflected in a number of ways. Mental health clinicians and planners
are in agreement that many consumers do not get the type of housing and
support they need. Some settings are in short supply, while others do
not offer state of the art models of housing and support. Ontario continues,
for example, to fund large numbers of custodial beds concentrated in the
Homes for Special Care, Habitat, Approved Homes, and Domiciliary Hostel
programs. Homes of this type do not provide care that is in line with
current best practice evidence and consumer needs.(1)
These problems stand in sharp contrast to the solutions that are now
available to us. Research on housing models and consumer preference has
yielded a range of approaches that are proven to work. The Report on Best
Practices in Mental Health Reform (1997) summarizes this work and calls
for a range of flexible models. More recently, programs have been developed
that allow even very disabled consumers to be supported in rehabilitation
oriented, non-custodial settings. The gap between the current crisis and
its solution is, therefore, based on the need for organized and concerted
action, not a lack of knowledge of what needs to be done.
The importance of housing is widely recognized as a priority in mental
health policy documents. These include the national policy of the Canadian
Mental Health Association (A New Framework for Support for People with
Serious Mental Illness 1993) and more recent Ontario policy statements
(Making it Happen 1999).
The widespread recognition of housing as a key issue raises the question
of who it is for. The focus of this paper is people with mental illness,
and here the situation is complex. Significant numbers of people manage
some type of mental health problem, but the majority will not want or
need specialized housing. They use their own resources to live in the
community like any other citizen. In some cases, however, especially where
the illness is more serious, the need for a specialized resource comes
into play. People who need this extra help are typically, but not always,
identified along three dimensions: a diagnosis of a serious mental
illness like schizophrenia or bipolar affective disorder; a significant
duration of illness; and a marked level of disability. Known
in the field as the three Ds, diagnosis, duration, and disability
are not defined in an exact way in day to day practice, but form the basis
of clinicians' decisions to recommend specialized housing. The absence
of exact definitions is important given the broad heterogeneity of the
expression of mental illness. Some consumers, for example, have persistent
psychotic symptoms such as hearing voices, but are still able to live
successfully on their own. In other cases, the symptoms are less severe
but more disabling in their impact on daily life. Some consumers may need
housing support for a long period of time, possibly for life, while others
need temporary help. For some groups, all of the 3 Ds may not be
present. A good example is people in the early stages of psychosis, who
may not have a significant duration of illness, but for whom timely support
can help prevent a worsening of the impact of schizophrenia or bipolar
affective disorder.
Moving Forward
Strategies for improving the current housing situation need to be based
on three things. First, remembering; developing an understanding
of the strengths and weaknesses of past programs and models can bring
to light what has worked and what has not. Secondly, knowing;
putting in place the kind of knowledge and information that are needed
to shape a responsive and flexible system, and finally, doing;
developing concrete ways of going forward.
Part I
Remembering: A Critical History
Appropriate housing has long been considered essential to the process
of deinstitutionalization, and the absence of such housing is rightly
seen as one of the central failures of the process. Ontario has two basic
housing traditions that continue to shape and influence the field. Recognizing
these traditions and understanding their ongoing influence is essential
to moving forward.
Tradition I: Custodial Models
The first supportive housing strategy in Ontario was the Approved Homes
Program that was launched in the 1930s (Simmons 1990). Approved Homes
were based on foster-care and boarding home models and were privately
operated. All residents remained registered as inpatients of the hospital
which referred them and could be returned immediately if necessary, a
situation which was not changed until the 1980s.
The next major development in housing people with mental illness was
the Homes for Special Care Program (HSC), developed in the mid-1960s.
HSC was intended to support bed closures by offering safe and secure housing,
and was developed with three levels: residential, intermediate, and nursing
care. Over the years, the nursing home portion of the program has, in
most areas, been gradually eliminated, leaving residential homes and one
intermediate home. There are now 1775 HSC beds in Ontario (Ministry of
Health 1999). HSC is perhaps best seen as a combination of models; many
are large enough to be classed as boarding homes, while others are small
and operate as foster-care settings.
Unlike most community mental health programs in Ontario, HSC is regulated
by provincial legislation. Over the years, this has made the program particularly
resistant to change and innovation. Despite this, the efforts of staff
and operators have made the best of a difficult situation and have led
to a number of important improvements over the years. The constraints
of the program, however, both financial and administrative, have maintained
it as an essentially custodial option.
In custodial homes, the operator is required to provide a common basket
of services to all residents. From the perspective of the present day,
with a greater base of research and emphasis on psychiatric rehabilitation,
the important lessons of the custodial sector relate to its broad conceptualization
of the basic program model. This conceptualization reflects a dynamic
referred to in the literature as transinstitutionalization.
Key to this dynamic is the inappropriate application of institutional
thinking outside of institutions. In a custodial approach the emphasis
is placed on a single set of standards governing such things as meals,
supervision, and laundry services. These must typically be provided to
all residents in the same way. This makes sense from a custodial perspective;
disabled people who are unable to take care of themselves are ensured
basic care.
On the other hand, if viewed from a rehabilitation perspective, this
approach is very problematic. A consumer living in a custodial setting,
for example, may want to work towards independence. In many cases, this
involves learning to cook, to do laundry, and to take care of oneself
in general. In a custodial setting, this may be impossible. Cooking for
oneself, for example, is a violation of the expectations of funders. Another
example is provided by a 1996 review of the HSC program. The reviewers
found that some of the very best settings in terms of quality were in
small family-scale homes, sometimes housing only one or two residents.
In most cases, these settings were actually in violation of the provincial
standard for 24-hour supervision of the home. Such supervision was not
needed and providing it would have made the homes untenable financially.
The review of Homes for Special Care also pointed out that the legislative
structure of the program discourages rehabilitation and creates substantial
obstacles for operators who want to move in this direction.
What, then, can be done about the way in which custodial programs operate
and are monitored? The issue is not monitoring itself; all housing programs
in receipt of public funds need to be carefully monitored. The issue is
how to do this in a way that supports best practice. We will see below
that alternative housing programs are monitored in a different way, but
the main point here is that the custodial model is only one approach,
and in our view, the wrong one.
The essentially institutional model of HSC has had other negative consequences
as well. It has made the large size of many homes seem acceptable. The
1996 review indicated that 8 homes have over 30 beds. It has also legitimated
crowded conditions and lack of privacy. In some homes, for example, rooms
are shared by four people.
In addition to its institutional foundations, HSC established a tradition
of under-funding housing programs. Despite a recent large increase, operators
receive approximately $40.00 per diem, or about 8% of the costs of an
inpatient day at a hospital. This is the case despite the fact that many
HSC residents are very disabled by their mental illness and have very
high needs.
The institutional nature and the inadequate funding levels of HSC have
had a significant impact on other approaches to housing people with mental
illness in Ontario. The basic level of HSC funding has acted as a benchmark
for newer programs such as domiciliary hostels and Habitat Services (a
subsidized boarding home program in Toronto).
In addition to inadequate funding levels, the basic custodial model of
HSC has also been replicated in newer programs. Domiciliary hostels and
Habitat Services are essentially custodial in nature and mimic the HSC
approach in the types of facilities they fund and the services they expect
to be provided by operators. It is sobering to realize that these custodial
options, despite the contradiction they represent with the Ministry's
basic policy position as expressed in Putting People First, account for
4,864 beds in Ontario, or about 44% of the total dedicated beds. Non-custodial,
or alternative models account for 6,214 bed. (2)
The major problems with the custodial models described above are balanced
by one major strength: effective targeting. Despite inadequate funding
and other problems with the models, the capacity of these programs to
target people with very serious mental illness is consistently good. They
focus the resources they have on the most needy as a result of the mandates
imposed by funders and the commitment and skill of their operators. This
is a significant accomplishment.
Tradition II: Alternative
Housing
In the mid-1970s a second approach to housing began to appear in Ontario.
Referred to as 'alternative' housing, the name itself expressed the attempt
to develop a new approach. When compared to custodial models, alternative
programs tend to be smaller and to focus on skills training and community
integration (Trainor, Morell-Bellai, Ballantyne, and Boydell 1993). They
are typically operated by non-profit agencies within a rehabilitation
framework and encourage residents to be involved in decision-making. In
most cases, and in contrast to boarding homes, individuals with training
in social work or psychiatric rehabilitation make up at least part of
the staff.
Alternative housing can be broken into two main categories: supportive
and supported. Supportive models were the first to be developed and typically
take the form of co-operatives and group homes. The support provided is
tied to the facility and the people living there are seen as program clients.
More recently, a different approach to alternative housing has emerged.
This approach, encouraged by the provincial government, grew out of concerns
about the tenancy rights of individuals in all kinds of supportive housing.
Some individuals no longer needed or wanted the support services that
were provided in their particular housing environment, or wanted services
that could follow them when they moved. Called 'supported' housing, the
new approach de-links the housing and support functions. Support services
are provided from outside the home, often by a different agency than the
housing provider, and are portable, in that they can move with
the client. The client is a regular tenant in a house or apartment that
is ideally obtained on the open market, although many clients are supported
within non-profit or cooperative social housing projects.
A number of factors about alternative housing are critical for the development
of future programs. The first is the knowledge and experience that has
developed in the area of rehabilitation oriented, non-custodial support
and program monitoring. Alternative models are enabling in that they attempt
to enhance consumer skills and are monitored by funders to support this
approach. By using a psychiatric rehabilitation framework and a more flexible
approach than the custodial programs, they are successful in supporting
consumers without resorting to an overly standardized approach that results
in providing each client with an identical basket of services. Experience
has shown that the skills and techniques applied in this flexible and
non-custodial model can be used successfully with clients who have very
high levels of disability.
The approach used by the Ministry of Health and Long-Term Care to monitor
the activities and service standards of alternative housing programs is
appropriate for non-custodial models in several ways. Agencies are globally
funded and encouraged to provide flexible, custom designed support. Rules
are not embedded legislatively in an act or regulations and are able to
change as new approaches emerge. However, alternative housing programs
have not been required to follow clear selection procedures when choosing
tenants. In many cases, tenants must meet the eligibility criteria for
social housing (e.g. income criteria, immigration status, age) but there
has not been a clear articulation of eligibility in terms of the degree
of disability or support needs.
Alternative housing programs, then, have left an important legacy. They
have pioneered non-custodial models of support and have operated with
both linked and de-linked housing and support services. While their operating
agreements with the Ministry of Health and Long Term Care have not required
them to house and serve the most disabled clients, they have effectively
supported consumers with a range of needs, including those with serious
mental illness. The absence of clear access criteria for alternative housing
is something that needs to be addressed to ensure that the needs of the
most seriously mentally ill are centrally addressed in these programs.
It is also important to note that alternative models are better funded
than their custodial counterparts. Some models are quite inexpensive,
while others, such as high support group homes, have secured funding ranging
from $100 to $140 per diem. This is in contrast to the approximately $40
per diem paid to custodial operators.
Summary and Implications
for the Development of Housing
This brief look at the development of housing in Ontario can be summed
up with a number of points that are relevant to planning for the future.
Any new models will be influenced by the traditions of existing programs
and, therefore, planners must be aware not only of the strengths of these
traditions but also of their weaknesses, in order to avoid repeating past
errors. New strategies will need to:
-- make maximum use of rehabilitation oriented, non-custodial models
of support, including programs for consumers with very high needs,
-- ensure that support levels match consumer needs,
-- secure adequate levels of funding,
-- be fully integrated with other mental health and community services,
and
-- target resources to those most in need.
One point above, adequate funding, is of particular importance. Looked
at objectively, it is striking that so few options exist between the very
high levels of inpatient spending and the very low levels of funding for
housing. The most disabled consumers from psychiatric hospitals, for example,
are frequently discharged to HSC or other boarding home models. As we
have seen, the funding in these settings is only a small fraction (8%)
of the cost of inpatient care. If we compare the clinical condition and
support needs of many psychiatric hospital inpatients with the residents
of a typical Home for Special Care, this funding disparity is clearly
unjustified. A concerted effort will need to be made by planners to break
through the underlying perceptions and assumptions that have made this
state of affairs seem reasonable.
Part II
Knowing: Getting and Using the Right Information
Best Practices in Housing:
The Research Evidence
A foundation of research on housing for people with serious and persistent
mental illness has been building since the early 1980s. Although gaps
in knowledge still exist, the important elements of successful housing
and support programs for people with mental illness are clear. These elements
encompass a range of housing and programmatic support features that must
be implemented to provide the best opportunities for recovery and success
in the community.
The Review of Best Practices in Mental Health Reform, produced
in 1997 by the Health Systems Research Unit, Clarke Institute of Psychiatry,
reviewed research evidence relevant to the reform of mental health systems.
Despite some methodological weaknesses in the research to date, numerous
studies show that:
-- community residential programs can successfully substitute for long-term
inpatient care,
-- supported housing can successfully serve a diverse population of
persons with psychiatric disabilities if support networks are in place
and monitored,
-- consumer choice is associated with housing satisfaction, residential
stability and emotional well-being, and
-- consumers prefer single occupancy units with support available on
request.
Best Practices also notes the importance of case management to
the success of supported housing approaches. Evidence from numerous studies
indicate that consumers with serious mental illness can improve in a number
of life areas and live successfully in various types of community housing
when supported by assertive community treatment and other case management
services.
The Best Practices report recommends a shift of resources and
emphasis to supported housing options that incorporate the following key
elements:
-- use of generic housing dispersed widely in the community,
-- provision of flexible individualized supports which vary in type
and intensity,
-- consumer choice,
-- assistance in locating and maintaining housing,
-- no restrictions on the length of time a client can remain in the
residence, and
-- case management services that are not tied to particular residential
settings but are available regardless of whether the client moves or
is hospitalized.
This endorsement of supported housing is balanced in Best Practices
by the recognition that a range of options is needed. People with
severe and persistent mental illness vary considerably in their needs
and preferences, and no single housing model can be expected to successfully
accommodate everyone.
Since Best Practices, Parkinson, Nelson and Horgan (1999) and
Newman (2001) have summarized evidence of the qualities and features of
housing settings that produce positive outcomes for people with serious
mental illness. This evidence demonstrates that social support, good housing
quality, favorable locations in the community, privacy, a small number
of residents, and resident control and choice all contribute to overall
satisfaction and emotional well-being. These housing characteristics are
typically features of alternative models and are rarely observed in custodial
housing programs.
Most custodial housing does not conform to good practice, let alone best
practice. Steps have been identified to re-develop these settings so that
they can reflect some of the practices associated with alternative housing
models (Pulier & Hubbard, 2001). These include:
-- an upgrade of the physical plant, including issues such as
location, access to transportation and community services, improved
physical quality and safety, improved accessibility, a reduction in
the number of residents, introduction of more common areas, and the
introduction of personal storage areas,
-- the introduction of home-like amenities, including personal
decorations and comfortable furniture,
-- in house programming, including group and personal empowerment,
skills development, and
-- Collaboration with a psychosocial rehabilitation centre,
including vocational services and rehabilitation.
The most basic reform, however, remains the transformation of these settings
away from the custodial model.
In thinking about various housing strategies, it is essential to note
that a subgroup of the most seriously mentally ill has been unable to
live in the community in any of the housing models that now exist in Ontario.
A survey of long-stay clients in British mental hospitals (Wykes, 1982)
describes these individuals as having one or more of the following characteristics:
-- active symptoms of schizophrenia or bipolar affective disorder that
are unresponsive to medication,
-- fixed delusional beliefs or patterns of behaviour that are unacceptable
within conventional housing programs,
-- the need for long-term medical or nursing care to deal with security
issues and the severity or instability of the clinical condition,
-- a tendency towards self-neglect and wandering, and
-- co-occurring physical disabilities, including deafness, blindness,
epilepsy, brain damage, physical disability, and developmental delay.
Several jurisdictions that have faced mental hospital bed closures
have developed very high support facilities in the community to address
the complex needs of these individuals. These programs are for individuals
who require very high support if they are to leave inpatient care. In
their review of high support facilities, Trainor & Ilves (1999)
note that, despite the very high level of client need, many of these
programs successfully use psychosocial rehabilitation (PSR) models instead
of custodial support. Their success underscores the need for a wider
range of program models and support strategies.
Program Evaluation and
Monitoring
Program evaluation and program monitoring are critical elements of mental
health reform in order to determine whether programs and services have
been implemented successfully and to document the effects of change (Review
of Best Practices in Mental Health Reform 1997). These activities
should occur at the program level as well as at the systems level. At
the program level, program evaluation and ongoing monitoring must be built
into the development of housing programs. These activities can contribute
to a process of continuous learning and program improvement.
There are two main approaches to the evaluation and monitoring of systems:
internal and external. The internal approach relies
on the capacity within the system to generate and analyze information
to achieve quality assurance and manage services in accordance with desired
goals. The external approach relies on the creation and support
of external monitoring and evaluation by stakeholder groups with a vested
interest in holding providers and management accountable and/or by investigators
with interests and technical expertise in health services research. Both
approaches can help to identify effective practices, identify new and
emerging needs, and monitor system performance.
New Knowledge
With extensive knowledge of innovative housing models now in place and
documented in Best Practices and other places, the question arises
of what information is still needed? This question has at least two answers:
a fine-grained knowledge of the actual housing needs of consumers in different
regions of the province and an ongoing exploration with consumers of how
housing and support models should change over time. Information in the
first area is needed if we are to plan and implement programs now
for consumers who need support, and in the second area so that we can
develop what will become tomorrow's best practices.
A fine-grained knowledge of the housing needs of consumers in a particular
region needs to be based on the routine collection of information. This
information becomes the foundation for planning and resource allocation.
The process of collecting information should be broadly conceived to encompass
the many dimensions of consumer need and preference. This requires more
than simply counting those who need support. Ontario's many diverse communities
and cultures are both an important resource and a challenge to housing
development. The collection of information should be sensitive to diversity
of all types. This information can inform planning and lead to better
programs.
A number of other issues are also important to keep in mind when developing
an information base. Many consumers, for example, have families and this
trend is expected to increase. Putting in place housing units that can
accommodate them will be an important part of planning. Another fundamental
issue is the state of the generic housing market. The generic market forms
a backdrop that will directly influence the need for designated units.
If rents are above the amounts paid by the income sources many consumers
rely on, the result will be an increased demand.
In Ontario, the current approach is not based on the organized collection
of information and its use as the basis for ongoing planning and development.
Instead, occasional proposal calls result in spikes of activity followed
by inaction. Current information has typically not been available on how
many beds of certain types are needed and on what new trends are emerging.
This situation can be compared to the provision of other medical services
such as dialysis. By monitoring need and the available treatment capacity
on an ongoing basis, the required services are in place. People who need
dialysis are not told to wait for the next proposal call in the hope that
service may some day be available. This approach reflects a basic attitude
about the importance of a service. Although the crisis in housing for
people with mental illness does not have the immediate dramatic consequences
of a failure in the dialysis system, it is nonetheless an issue of the
highest priority. Housing is a fundamental determinant of health and is
essential to survival in the community.
The second kind of information required to put in place an excellent
housing system is oriented towards the future. Our knowledge of best practices
is adequate for action now, but best practices can and should change.
This requires ongoing innovation and exploration. The mental health field
is rapidly changing with new developments in treatment, community support
and self-help. These will inevitably influence housing.
Part III
Doing: Strategies for Action
Enhancing housing resources is a complex task. The most important action
items can, however, be grouped under two headings: re-thinking and re-regulating
the custodial stock and developing an adequate range of new supportive
and supported housing.
1. Re-thinking and transforming custodial stock is essential to
moving forward. These units do not meet best practice expectations and
do not fully support a rehabilitation agenda.
The common response to criticisms about the absence of a rehabilitation
focus in custodial settings is that the clients living in them do not
need, or would not benefit from, such a focus. It should be noted that
there is no evidence for this. In fact, our current knowledge of the course
of mental illness and the ability of consumers to move forward and recover
directly contradict this myth. In addition, a review of Homes for Special
Care residents conducted by the Health Systems Research and Consulting
Unit at the Centre for Addiction and Mental Health demonstrated that residents
form a heterogeneous population with a range of needs. The single level
of support offered by the homes is not appropriate for many residents.
The provincial government issued a 'Discussion Backgrounder' on
the four custodial programs in 2000. This paper called for an administrative
consolidation of the programs and their regulation under one set of provincial
standards. The new approach to regulation was, however, still custodial
and the paper described the residents as people who have 'reached their
maximum level of functioning'. The Backgrounder did not propose
a way to modify the custodial programs in line with best practices and
the principles of psychiatric rehabilitation. In this critical sense,
it did not address the limitations of the custodial programs identified
in this paper.
In our view, the points raised by CAMH in response to the Backgrounder
continue to form the foundation of needed action. It is essential that
we:
-- recognize that, in the case of the four programs to be consolidated,
Ontario has a tradition of supporting custodial models that violate
current best practice,
-- recognize the heterogeneous nature of the clients living in the
4 programs to be consolidated,
-- recognize that there is no basis in fact to assume that the population
of the 4 current programs -- will not benefit from a rehabilitation
oriented approach, and
-- secure adequate levels of funding which are structured to provide
incentives for operators to move away from custodial models.
2. Developing an adequate range of supportive and supported housing
The range of models that is now established in best practices and more
recent research is the foundation for developing new housing programs.
For these models to be articulated when and where they are needed will
require a change in the current approach to planning and funding housing.
As above in Part II, a regular flow of information is needed to fine-tune
program development. Instead of occasional proposal calls, a continuous
planning model is required, based on a redefinition of the priority given
to housing. There are two key aspects of this: regular surveys of housing
requirements carried out in each region of the province and a new business
and funding model adopted by the Ministry of Health and Long-Term Care.
A new approach to planning and development must be supported by new approaches
to funding. Key to this will be new ways of involving the private sector.
Examples include apartment subsidy schemes (already introduced by the
Ministry) that support the use of private sector units. These programs
improve the ability of the system to be expanded if necessary. Although
they do not add to the supply of housing in a tight market, they can be
put in place quickly and are an essential part of a more responsive system.
In addition, the current funding approach must be modified to allow for
a wider range of financing schemes to support housing. At the present
time, long-term commitments that permit the full involvement of private
sector partners are not possible. A commitment to long-term arrangements
including leaseback and turnkey models will increase the flexibility of
the system.
Two Action Steps
Ontario is fortunate in having a significant pool of talented people
with the skills and energy to successfully confront the housing problems
that we now face. These people include consumers, families, professionals,
government officials, and private and non-profit housing operators. In
addition, Ontario has made significant commitments to funding new housing,
research, and evaluation. These factors are the foundation for effective
action. There is no doubt that the knowledge and human resources are in
place to build an excellent housing system to meet consumer needs.
We believe that it is the responsibility of the Ministry of Health and
Long-Term Care, with the full support and involvement of other key stakeholders,
to launch a housing action strategy to harness these resources.
Two direct steps can be taken now to move ahead.
1. Transform custodial stock into supportive housing that reflects
best practice. It is recommended that the Ministry of Health and
Long-Term Care convene a provincial working group of consumers, families,
private operators, and professionals to plan the conversion of custodial
stock to supportive housing. This will require addressing issues beyond
those identified in the Homes for Persons with Special Needs Discussion
Backgrounder. The working group should be charged with two fundamental
tasks.
-- Develop a new approach to monitoring and funding that will put in
place a model that reflects the principles of best practice and psychiatric
rehabilitation.
-- Ensure that the interests and talents of private operators are respected
and that, subject to operator cooperation, the new model supports the
transition of existing homes and offers operators a viable economic
model.
2. Create and implement new approaches to planning and funding
housing for people with mental illness. If step 1 above is implemented,
the need for different strategies for custodial and alterative stock (as
reflected, for example, in the Phase I and II Homelessness Initiative
and the Homes for Persons with Special Needs strategy) will end. Instead,
each region of the province can develop a single coordinated strategy
for all the housing resources in its area. Given the different tasks involved
in developing a single strategy, it is recommended that the Ministry of
Health and Long-Term Care convene two working groups to deal with planning
and funding respectively. Consumers, referral source staff, housing researchers,
Ministry operational, policy, and regional officials, and operators are
essential for the first group. The critical tasks are as follows:
-- develop a strategy that will allow all regions of Ontario to collect,
on an ongoing basis, data on housing needs,
-- develop a common method for the analysis of data and its translation
into development targets, and
-- develop a method of regularly assessing new ideas and concepts in
housing to create tomorrow's best practices.
The second working group, focusing on funding, needs the same membership
categories as the first group with the important addition of private sector
developers. The critical tasks are as follows:
-- outline a funding and business model that will allow the full participation
of both the private and non-profit sectors in the development of new
housing, and
-- develop a funding model that will allow for continuous development
and adjustment of the mix of housing -- programs to meet the changing
needs of consumers.
Conclusion
People with mental illness need safe and affordable places to live. They
also need the right kind of support to live successfully in these settings.
To work for consumers and for a health care system that faces high demands
and limited resources, a coordinated housing strategy needs to be driven
by good information and to utilize models that respect the capacities
of consumers and offer only the support that is needed.
Ontario has developed two approaches, or traditions, to providing housing
for people with mental illness. Although the development of good housing
faces a single set of challenges, and is governed by a single set of best
practices, custodial and alternative models are planned, funded, and monitored
in different ways. This split reflects historical, policy, and administrative
factors, but it does not reflect the needs of consumers.
The ingredients for change are in place. The knowledge of best practices
and the talents of consumers, families, government officials, providers,
and referral sources can be galvanized to create the needed reform. With
its current emphasis on reform, the province is ideally situated to take
action. This paper has outlined a series of steps that can shape this
action.
The key factor that can start the process is leadership from the Ministry
of Health and Long-Term Care. The Ministry alone can create the needed
context and coordination. With this in place, it will be the responsibility
of all stakeholders to fully support the process and bring it to a successful
conclusion.
The Centre for Addiction and Mental Health is committed to working in
partnership with the Ministry and all other stakeholders to develop a
new vision and to make it a reality. Excellent housing that brings dignity
and supports recovery is a goal we can all share.
References
Health Systems Research Unit, Clarke Institute of Psychiatry. (1997).
Review of Best Practices in Mental Health Reform. Ottawa, ON: Ministry
of Public Works and Government Services.
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Footnotes
(1) A recent discussion of these programs is contained in the document
Homes for Persons with Special Needs: Consultation Backgrounder (2000).
This document calls for administrative restructuring, but in its conceptualization
posits a homogeneous group of consumers who have reached their maximum
level of functioning and a program model that remains custodial. The usefulness
of the paper is limited by the fact that this characterization is at odds
with three things: best practice evidence in housing, clinical evidence
regarding the course of serious mental illness, and actual assessments
of the consumers involved.
(2) Source: Ministry of Health and Long-Term Care, 2002. The figure for
alternative beds breaks down as follows: 238 are federally funded Canada
Mortgage and Housing supported units and 5,976 are with the Ministry of
Health and Long-Term Care. Of the latter group, 2,376 are in the dedicated
supportive housing portfolio, 1,000 are phase I homelessness beds and
2,600 are in phase II of the same program. Over 1,000 of these beds are
still being developed as of February 2002.
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