The Ten-Year Plan to End Chronic Homelessness

Monday, May 21st, 2012

Overview

The TYP held its fourth Public Conversation at 6pm on Wednesday, July 21, 2010 at the Cansler YMCA about mental health services and the role they play in relation to the TYP. Mary Thom Adams, a supporter of the TYP who works in development with Positively Living Park Ridge Harbor, Knoxville’s largest dedicated permanent supportive housing facility, acted as moderator. Sheryl McCormick, Coordinator, Recovery Training Services at Peninsula, delivered a thorough presentation about the nature and effects of mental illness, with a primary focus on treatment options in the community . The meeting was attended by approximately 45 people and the conversation, once again, was respectful and extremely informative.

Notes

[These are my notes combined with material presented by Ms. McCormick. I tried to capture as much of what was said as I could. If I've misrepresented anything here, or left out something you believe to be significant, please mention that in the comments below this post. Please tell us who you are and where you live.]

Attendees included several City Councilpersons: Vice Mayor Bob Becker, Daniel Brown, Nick Della Volpe and former Councilman Barbara Pelot. County Commissioner Finbarr Saunders was present, too.  Also present were several members of the staff of the City’s and the County’s Community Development departments–Madeline Rogero, Director City of Knoxville Community Development; Grant Rosenberg, Director Knox County Neighborhoods and Community Development; Linda Rust, also with Knox County Community Development. Several members of the mental healthcare provider community were present. My apologies if I’ve missed anyone. The format of this meeting was one hour. The first half hour was used for presentation, the second half hour was for conversation with attendees.

Ms. Adams, in her role as moderator, focused this meeting’s topic on mental illness and chronic homelessness. She also mentioned the date and topic of the TYP’s next public conversation, which will take place at the Cansler YMCA on Wednesday, August 25, and will focus on the subject of addiction treatment. She introduced Ms. McCormick and her topic. Ms. McCormick coordinates recovery services at Peninsula. She is also a respected mental health advocate. Ms. Adams described the format of the meeting: Ms. McCormick will speak for one half hour and share a PowerPoint presentation during that time. The following half hour is reserved for discussion. We’ll stick to the topic: mental illness and chronic homelessness, and limit each question and answer in the discussion to three minutes so that everyone who wants to has the opportunity to participate.

Ms. McCormick introduced herself and said that tonight we’re going to talk about mental health services for people in permanent supportive housing. She started off with background about the nature of mental illness. [Note: Much of the following material comes from Ms. McCormick’s PowerPoint presentation and is interspersed with her remarks.]

What is mental illness?

• A mental illness is a disease that causes mild to severe disturbances in thought and/or behavior, resulting in an inability to cope with life’s ordinary demands and routines. Symptoms may include changes in mood, personality, personal habits and/or social withdrawal.
• Mental illnesses cause more disability than any other class of medical illness in America.
• Mental illness is very common and is in no way limited to people who experience homelessness. In Knox County, 106,000 of 389,327 residents (about one in four) have a diagnosable mental illness of some type.
• More than half of these have more than one mental illness.
• Co-occurring mental health and substance abuse disorders are common.
  • 52 percent of people diagnosed with alcohol abuse or dependence have also experienced a mental illness.
  • 59 percent of people with a history of other drug abuse or dependence have experienced a mental illness.
• Mental illness frequently predates substance abuse problems by a period of four to six years. Alcohol or other drugs may be used by people who don’t know they have a mental health problem as a form of self-medication to alleviate the symptoms prior to diagnosis and effective treatment.
• People with serious mental illness die 25 years earlier than the general population. Their increased morbidity and mortality are largely due to treatable medical conditions and inadequate access to medical care.
• Although certain diagnoses do have lower treatment success rates, all mental illnesses respond to treatment, especially if the person participating in treatment accepts the need for change and is actively involved in his or her own recovery.
  • Treatment for mental illness is actually more effective than treatment for cancer, diabetes, and other chronic conditions.
• In a given year, only approximately 1/3 of people in the community with mental illness will receive treatment services.
  • Some people with mental illness suffer from a disorder called anosognosia. People with anosognosia do not recognize that they are ill, and therefore do not seek treatment. Once this challenge is overcome, they too can experience recovery.

Treatment providers

Community Mental Health Agencies

• Cherokee Health Systems
• Helen Ross McNabb Center
• Peninsula- A Division of Parkwest Medical Center

Other Providers

• Lakeshore Mental Health Institute
• Child and Family Tennessee
• Mercy St. Mary’s
• Various private mental health professionals

Adult services

• Crisis services
• Mobile Crisis Unit: Crisis services are provided by MCUs when there is a perception of a crisis by an individual, family member, law enforcement, hospital staff or others. MCUs are frequently actuated by law enforcement officers and are available regardless of ability to pay. Slide 14.
• Crisis Stabilization Unit: CSUs are accessible 24/7 by telephone and/or walk-in services with face-to-face crisis service capabilities including triage, intervention, evaluation/referral for additional services/treatment, and follow-up services. Helen Ross McNabb’s Crisis Stabilization Unit provides assessment, triage, medication management, group and individual therapy, and the opportunity for clients to work with a peer specialist. CSUs are cost effective, offering up to 72 hours of intensive, 24/7 mental health treatment in a less restrictive setting than a psychiatric hospital. Funding is provided partly by the Tennessee Department of Mental Health and partly by TennCare
• Inpatient hospitalization is provided in a physically secure setting in a licensed general hospital (Mercy St. Mary’s); Psychiatric hospital (Peninsula); or state-operated psychiatric hospital (Lakeshore). Inpatient hospitalization offers a full range of diagnostic, educational, and therapeutic services with the capability for emergency life-saving medical and psychiatric interventions. Average stays are three to seven days. Admission into this level of care results from a serious or dangerous condition that requires rapid stabilization of psychiatric symptoms. This service is generally used when 24-hour medical and nursing supervision are required to provide intensive evaluation, medication, symptom stabilization, and intensive brief treatment. It has been discovered that the vast majority of people who are hospitalized don’t need to stay in the hospital for long periods of time. The usual goal is to stabilize in the hospital and then provide ongoing treatment in the community.
• Intensive Outpatient services is more intensive than traditional outpatient services; is designed to achieve short-term stabilization and resolution of immediate problem areas; is offered by a team of professionals which may include a doctor, licensed therapists, nurses, and program specialists; is a time-limited program for people working on similar issues.
• Psychiatric Assessment is a process of gathering information about and from a person within a mental health service for the purpose of making a diagnosis, the assessment is usually the first stage of a treatment process, but psychiatric assessments may also be used for various legal purposes. The assessment includes social and biographical information, direct observations, and often data from specific psychological and lab tests.
• Medication Management is a service that includes psychiatric assessment with recommendations for treatment; medication evaluation and management– prescription and review of therapeutic effects and possible side effects; laboratory services and referral(s) to other specialists; and clinical documentation in an individual’s care record. Most provider agencies offer this service. Sometimes, a person receiving this service will see his or her service provider only four times a year for fifteen minutes at a time. There is a serious emphasis on this service now because it is especially cost effective and is extremely efficacious for many people.
• Therapy is offered by many providers and are especially helpful for people who have developed maladaptive coping mechanisms over long periods of time.
  • In individual therapy the client meets face to face with a therapist to talk about the things that are bothering the client, to help clarify and put problems and issues in perspective.
  • Group therapy is a form of psychotherapy in which a small, carefully selected group of individuals meets regularly with a therapist to assist each individual in emotional growth and personal problem solving.
• PACT (Program of Assertive Community Treatment). Helen Ross McNabb Center has the only PACT in East Tennessee for adults with severe mental illnesses. PACT is designed to help people reduce or eliminate symptoms, function in the community, live independently, and reduce hospitalization. PACT provides intensive, direct care and services 365 days a year, primarily in the home and in the community, which enhances accessibility and the comfort level of clients. There is no time limit on program participation. PACT is very effective for people who are very ill.
• Continuous Treatment Teams. Adult CTT is an intensive outpatient treatment program that is comprehensive in nature. CTT offers case management, medication management, crisis intervention, advocacy and goal-oriented therapy services. CTT clients have on-call crisis services 24 hours a day, seven days a week.
• Case management is a range of services to assist and support persons receiving mental health services to develop skills to gain access to needed medical, behavioral health, and other services/ supports. Case managers assess needs, link to services, train on use of community resources, and monitor overall service delivery. Case management is intensive, relationship based care coordination for people who have ongoing support needs in areas such as housing, employment, social relationships, and community participation.
• Psychiatric rehabilitation is self directed treatment for people who want to be in recovery. It reinforces and emphasizes hope, personal responsibility, self advocacy, support and skills development. It is extremely important that people with mental illness know that they have a voice because many of them have been so beaten down and forced into silence, resignation, and hopelessness. Some people who had been hospitalized twenty times per year or more have completed a program of psychiatric rehabilitation and do not have to be hospitalized any more as a result. Psychiatric rehabilitation promotes recovery, full community integration and improved quality of life for persons who have been diagnosed with any mental health condition that seriously impairs their ability to lead meaningful lives. Psychiatric rehabilitation provides independent living and social skills training, psychological support to clients and their families, vocational rehabilitation, social support, and access to leisure activities. Psychiatric rehabilitation services are collaborative, person directed and individualized.
• Transportation is provided to covered services for TennCare enrollees with no other means of transport through contracted transportation vendors, such as ETHRA and CAC. In a crisis, transportation to a psychiatric facility may be provided by a law enforcement officer if the person is deemed to need restraint or a secure vehicle.
• Peer support is run by peers for peers. Peer support promotes recovery through one-on-one peer support sessions or through group interactions. The service may include resource sharing, recovery education, support groups, and training about how to obtain and use services and supports. Peer support is offered at no cost through Helen Ross McNabb’s Friendship House and Peninsula’s Knoxville Wellness Recovery Center. Friendship House has operated in the Fourth and Gill neighborhood for twenty years.

Recovery refers to the process in which people are able to live, work, learn, and participate fully in their communities. For some people, recovery is the ability to live a fulfilling and productive life. For others, recovery implies the reduction or complete remission of symptoms of their mental illness. Recovery is very much an individually-determined thing. Contrary to what many people believe, recovery from mental illness can be complete and often is. For example, some people with psychiatric disorders like schizophrenia, bipolar disorder, and other severe forms of mental illness have experienced recovery from their mental illness to the point that they have been able to enter challenging and rewarding professional fields such as psychiatry, engineering, the law, and others.

Stigma plays a huge role in the lives of people with mental illness. It interferes with people accessing treatment; has a profoundly negative impact on their self-esteem; shapes public policy, including funding for research, treatments, and services, and for housing, in inappropriate and damaging ways; decreases the  likelihood of a person with mental illness admitting  that he or she has a mental health problem, which interferes with their accessing the treatment they need to recover. Stigma interferes with society’s acceptance of individuals who suffer from brain illnesses through no fault of their own.

Myths. Ms. McCormick discussed myths about mental illness and related them very powerfully to her own story.

The first myth she discussed was this one: There is no hope for people with mental illness. The fact is that there are more treatments, services, and community support systems than ever before, and more are being developed. People with mental illnesses lead active, productive lives. Ms. McCormick disclosed that she is one of them. “I am in recovery from bipolar disorder,  and severe anxiety. I’ve been delusional. I’ve been self destructive. And I’ve been homeless. I was able to get treatment, education, tools and resources that helped me in recovery. I’ve had people around me to help me who helped me.”

The second myth is that people with mental illness are violent and unpredictable. Actually, the vast majority of people with mental health conditions are no more violent than anyone else. People with mental illnesses are much more likely to be the victims of crime than the perpetrators of it. You probably know someone with a mental illness and don’t even realize it.

The third myth is this: I can’t do anything for a person with with mental illness. Ms. McCormick said that you can help, starting with how you act and speak. Don’t focus on people’s disabilities. Instead, create an environment that builds on people’s strengths and promotes understanding. For example:

• Don’t label people or define them by their diagnosis.
• Learn the facts about mental illness and share them with others.
• Treat people with mental illness with respect and dignity.
• Respect the rights of people with mental illness and don’t discriminate against them when it comes to housing, employment, or education.

The fourth myth is that people who develop mental illness can never recover. The fact is that most people with mental illness get better, and many recover completely. There are now approximately a hundred  people at any given time in the hospital at Lakeshore [Note: At its highest capacity, Lakeshore, which used to be called Eastern State Mental Institute, had approximately 2,500 beds.] and another hundred at Peninsula. There are not all that many people in institutions anymore. They’re in the community, everywhere, and many of them are integrated into the community and doing quite well.

Hope! Ms. McCormick emphasized that hope plays a key role in recovery. People who live in permanent supportive housing have a very good shot at recovery because they are living living somewhere safe that provides them with a support network. She said that recovery is almost impossible when you’re stressed out and living on the street.

Ms. Adams opened up the second half of the meeting for questions and comments, asking everyone to stick to the topic and to keep their interactions to three minutes or less. She expressed her willingness to help the conversation stay on track.

Councilman Della Volpe asked how many people with mental illness in the community seek or get treatment? Ms. McCormick said that about a third of them do, and that not all of those who seek and receive treatment have a severe, persistent mental illness–it runs the gamut.

Jerry Askew asked if we have stats that show how important it is for people seeking to recover from mental illness to be in housing as opposed to living on the streets. He said that it seems like it’s more likely that treatment is more effective for people who are in housing. Mike Dunthorn answered that studies show that housing has a tremendous positive effect on the efficacy of treatment and the ability of people to recover. Housing takes a person out of the chaos of the streets and out of survival mode and provides the stability a person needs to focus on the work of recovery.

A woman mentioned that she had seen the night before this meeting a television show on schizophrenia. That show said that the largest mental health facility in the nation is the Los Angeles county jail. 30% of inmates there have some kind of mental illness. Ms. McCormick said that if you want to get definitive information about this for our community that you can contact Ben Harrington at Tennessee Department of Mental Health. Leann Human-Hilliard of Helen Ross McNabb Center said that 18-20% of inmates in the Knox County Jail are on medication for psychiatric disorders, and reiterated that Ben Harrington would know precise statistics.

A man asked if mental illness leads to homelessness, or vice versa? Ms. McCormick’s response essentially was “Yes.” If you are mentally ill, that definitely places you at much greater risk of losing your housing than if you are not mentally ill. Too, being homeless can cause post-traumatic stress disorder, anxiety, depression. The chaos, fear, danger and abuse that goes along with homelessness can trigger mental illness in anyone who is predisposed to it.

A woman asked if people are kicked out of Peninsula when their insurance runs out. Ms. McCormick said that she doesn’t know, but she does know that Peninsula provides Safety Net services. Another woman said that Cherokee Health Systems takes up slack, providing services for those who are indigent. Safety Net was created by the State legislature when TennCare was being downsized. Ms. McCormick contrasted the cost of $853 per day to be hospitalized at Lakeshore versus the cost of $750 per year to provide services in Safety Net.

Councilman Della Volpe said that lots of times people get stabilized on medication, then they quit. He asked why this happens. Ms. McCormick’s response was “Because we’re human beings.” She went on to explain that when people start to feel better they stop taking meds, or they forget to take them, or they start to think that they don’t really need the meds. Anosognosia is a factor too. This is one reason why supportive housing is so important. Case managers and peer specialists on site can recognize these kinds of things when they start to happen and get people back on track before it becomes a real problem.

Joe Minichiello asked for Ms. McCormick’s assessment of the 48 to 2 ratio of clients to case managers proposed at Flenniken Housing. Ms. McCormick said that that ratio sounds about right.

Councilman Bob Becker mentioned that people with mental illness are more likely to be victims of crime than perpetrators. He asked for Ms. McCormick to discuss that in context. Ms. McCormick said that so many of us get our identity from work, where we live, and also from the people we associate with. A person’s identity can get really messed up by being adrift in homelessness. You’re worried all the time. You don’t know who to trust. Many times, other homeless people become your support network. Most predators are just passing through, but still they’re common enough and are a source of constant worry. And of course, when you’re homeless, some things happen to you that are pretty awful. Therapy can help you recover from the damage, but it doesn’t do anything to prevent it happening in the first place.

An attendee asked Ms. McCormick to discuss moving from negative coping mechanisms to positive ones. Ms. McCormick said that people who are homeless often cope by learning to live by manipulation. They have not been taught legitimate skills that they need to live legitimately in society. Also,  the mental health system forces some people to become manipulative so they can get into the hospital—they know they need to get somewhere safe, so they learn how to work the system. Once you move out of homelessness, you’re not just surviving anymore, and you have to learn how to function in a new way. You need to be taught the appropriate skills to do that, and services like therapy, among others, help with that. It takes the right services, hard work, and time, but it’s doable. People do it all the time.

Ron Peabody asked if Peninsula is a committed provider of treatment to residents of permanent supportive housing. Ms. McCormick said that she didn’t know how to answer that question. She said that she is sure Peninsula would provide services to people in permanent supportive housing. Mr. Peabody said that these meetings are supposed to be about providers who are providing services to residents of permanent supportive housing. Ms. McCormick mentioned that Peninsula used to provide a lot of services in rural communities and that their location in Knox County is a mile from the Knox Area Transit busline. Jerry Askew suggested that relevant relationship is the one between the TYP and Peninsula, and that most people aren’t mentally ill who are chronically homeless, although some are. If we can help them get into housing, we know that they’re going to do better. We also know that in absence of housing with good case management support, bad stuff happens. People in housing are far more likely to be treated well. Dr. Osborne with Peninsula said that housing increases effectiveness of the kinds of treatment Peninsula delivers. Sometimes it takes a time, and trial and error, to find the right combination of medications and other treatment, but it’s much better to be working on that with someone who is in housing than with someone who is trying to address mental illness while they’re still living on the street.

Bob Fischer suggested that the 1:24 ratio [the case manager to client ratio proposed for Flenniken Housing] seems like a stretch. 1:10 to 1:12 seems to be the norm elsewhere. Ms. McCormick replied that there are different kinds of case managers. Ms. Human-Hilliard affirmed that, and added that  the definition of case management is very broad. When you talk about onsite case management, a lot of those ratios are very small. Some of the intensive services offered by Helen Ross McNabb have case manager to client ratios closer to 1:10. But McNabb also has programs with ratios that exceed 1:30. It really depends on the level of severity of need.  Mr. Fischer suggested that unless our community makes a commitment to provide these services over the long run, we won’t succeed. A woman in attendance suggested that in fact the  ratios proposed for Flenniken Housing are really good. She went on to point out that a person might have three or four case managers from different programs at one given time working in a collaborative way, and that that is a dynamic thing that is responsive to the needs of the person in treatment.

Madeline Rogero suggested that the purpose of tonight’s conversation is to discuss the array of services available in the community to those seeking treatment for mental health issues. She asked, “If a person needs to be at Peninsula they can go, right?” Ms. McCormick said that yes, of course they could. Ms. Rogero said that that had not been clear in the foregoing discussion. Ms. McCormick went on to say that a person in supportive housing, or any other kind of housing, really, can stay where they live and get services from any of these providers being discussed tonight.  She added that people are not in crisis all the time. Some of these client to case manager ratios are what they are because not everyone is in crisis at the same time.

Ron Peabody said that it is not accurate to believe TennCare will provide for all of these folks. He pointed out that until April 2 of this year, the Safety Net was about to be cut, and was only saved by being re-funded. He asked how the TYP can guarantee that these services will be paid for in an ongoing way. A woman in attendance mentioned that a whole lot of people with mental illness in Knox County will receive services just because they’re here, they’re indigent, and/or they get put in jail. Michael Dunthorn pointed out that helping people gain access to supportive housing does not create more mentally ill people and does not increase the burden on our service delivery systems. In fact, people in housing place much less demand on those systems and make resources go further and serve more people who need them. It’s just much more cost-effective. Grant Rosenberg mentioned that Knox County spends, right now, five million dollars per year for indigent care, and that those are all local dollars, not federal pass-through. He also said that if we can help more homeless people find housing, their use of these dollars will decrease. Right now, he said, it’s the status quo that is not sustainable.  A provider who works at Peninsula said that Peninsula takes TennCare and Medicare recipients. Cherokee Health Systems delivers care to the indigent, and our jails and emergency rooms take the overflow. In Peninsula, we can use resources much more efficiently when we’re treating people who are in housing.

Jessica Bocangel, with The Compassion Coalition’s Circles of Support, said that she has had much conversation with a psychiatrist who constantly underscores the need to for our community to focus not so much on mental illness, but to focus instead on mental health. She posed this question: “Will we we become the kind of community that encourages mental health or will we be one that talks only about our fear of the mentally ill?”

Ms. Adams closed the meeting a few minutes after 7pm. She encouraged anyone with further questions to contact the TYP office.

Next meeting

The next public conversation will be held at the Cansler YMCA from 6-7pm on Wednesday, August 25. The topic will be addiction treatment in the context of the TYP. We’ll publish more information here about that as we get closer to the date of the meeting. We’ll follow the same basic format. First half hour presentation, second half conversation about the subject.