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.

1. Coming up this Wednesday: Public Conversation #4 — Mental healthcare services delivery. The TYP will hold its next public conversation on 6pm Wednesday, July 21 at the Cansler YMCA.

2. Reminder: Neighborhood meeting about Flenniken Housing. The TYP will dialog with residents of the neighborhoods close to the Flenniken School about safety on Thursday, July 29 at the South Knoxville Community Center.

3. In the news: Transport of people who are homeless to Knox County. The TYP’s response.

The TYP will hold its next public conversation at 6pm Wednesday, July 21 at the Cansler YMCA. The topic will be mental healthcare services in the context of permanent supportive housing. Sheryl McCormick, Coordinator, Recovery Training Services at Peninsula, will present for the first half-hour with Q & A to follow.

Ms. McCormick, as a person who has experienced homelessness and who lives a full and active life with a psychiatric disorder, brings a unique and extremely well-informed perspective to this conversation. McCormick says that recovery would not have been possible for her if she’d been warehoused or otherwise segregated. Community integration, with housing built out in the community, is critical for the success of people with mental illness.

We encourage you to attend this important conversation and to invite people you know to attend with you. This is an excellent opportunity to gain a more complete understanding of how mental healthcare services are delivered in our community and why they are such a vital component of our own Ten-Year Plan’s strategy to end chronic homelessness.

2. Reminder: Neighborhood meeting about Flenniken Housing

The TYP will dialog with residents of the neighborhoods close to the Flenniken School about safety on Thursday, July 29 at the South Knoxville Community Center.

The last time we met was on June 21. At that meeting we discussed establishing a regular meeting concerning Flenniken Housing. Attendees agreed that a monthly meeting on Monday* evening would be appropriate, and that the meeting should continue to take place at the South Knoxville Community Center. Attendees also generated a list of potential topics for those meetings. It became apparent at that time that the most significant concerns shared by Flenniken’s neighbors are related to the over-arching issue of safety, and that is what the meeting on the 29^th will be about.

*Please note that this meeting had previously been scheduled for Monday, July 19. It was changed to Thursday, July 29 at the request of a City Councilmember whose schedule did not permit attendance on the previously-scheduled date.

Again, we encourage you to attend this meeting and to invite others to join you. Safety for residents of permanent supportive housing, as well as for their neighbors, is of vital concern no matter where it’s built.

3. In the news: Transport of people who are homeless to Knox County

We spoke this week with reporters for local television stations about the recent news that officials from some counties surrounding ours have been sending people who are homeless to Knox County. We sent them the following information:

• The TYP’s reaction to news that some surrounding counties send people who are homeless who get discharged from jail to Knox County so they can obtain shelter.
  • To keep this in perspective, Knoxville is a mid-sized city situated within an area that’s historically rural. We have all kinds of resources here. That’s true of any city like ours.
  • People come to Knoxville from surrounding counties for a lot of different reasons: healthcare, jobs, educational opportunities, and more.
  • Are people who are homeless from surrounding counties going to come to Knoxville to gain access to services here? Sure. I’d probably want to do the same thing if I had no family, friends and other resources available to me if I fell into homelessness nearby.
  • Contrary to an often-repeated myth, we are not a unique magnet for homeless people from all over the country. Over 60% of the people who experience homelessness in Knox County list an address in Knox County as their last permanent address, with just under 80% having their last permanent address in Knox or one of the counties that surround Knox.
  • Our situation is very similar to most other cities of our size in our part of the country.

• The TYP’s reaction to the Sheriff’s response to learning that KCSO employees were meeting their colleagues from other counties and bringing people discharged from jails to homeless shelters in Knox County.
  • Sheriff Jones was very responsive and acted fast to resolve the situation just as soon as it came to his attention.

The July 9, 2010 edition of the Knoxville News Sentinel ran a front page article titled Ashe against idea for park to be future site for homeless residence. This article contains some elements that are unfortunately misleading. We have spoken to the reporter about our concerns. We want to make it clear that we are not pursuing any development of permanent supportive housing at Lakeshore Park and have no plans to pursue a Low-Income Housing Tax Credit application for Lakeshore in 2011.

2. Reminder: Public Conversation #4

The TYP will hold its next public conversation on 6pm Wednesday, July 21 at the Cansler YMCA. The topic will be mental healthcare services in the context of permanent supportive housing. Sheryl McCormick, Coordinator, Recovery Training Services at Peninsula, will present for the first half-hour with Q & A to follow.

1. Flenniken Housing: Parking variance request withdrawn. Southeastern Housing Foundation, the TYP’s nonprofit real estate development partner and developer of proposed permanent supportive housing at the old Flenniken School, has withdrawn its request for a zoning variance that would have permitted a smaller parking lot than what zoning requires. The project will go forward with a 58-space parking lot.

2. Recap: Compassion Coalition’s Salt & Light Luncheon. On Thursday, June 24, over 150 attendees at this luncheon learned about the Ten-Year Plan and how the faith-based community is engaging with its movement to help end chronic homelessness.

3. Recap: TYP Advisory Board Meeting. The TYP’s AB held its quarterly meeting on Friday, June 25, five days prior to the beginning of a new fiscal year. There was an update on housing placement numbers for the past two years (302 formerly chronically homeless people remain in housing), a discussion of next year’s goals, and a presentation by and dialog with Stephanie Matheny, a Knoxville resident with over a decade of experience developing affordable housing, including permanent supportive housing, in Seattle.

4. Preview: Public Conversation #4. The TYP will hold its next public conversation on 6pm Wednesday, July 21 at the Cansler YMCA.

Southeastern Housing Foundation, the TYP’s nonprofit real estate development partner and developer of proposed permanent supportive housing at the old Flenniken School, has withdrawn its request for a zoning variance that would have permitted a smaller parking lot than what zoning requires. The project will go forward with a 58-space parking lot.

Here’s the press release, dated June 29, 2010:

The Office of the Ten-Year Plan to End Chronic Homelessness announced today that Southeastern Housing Foundation, a non-profit affordable housing development organization, is withdrawing a request for a zoning variance for the old Flenniken School project following a public meeting with area residents. The public meeting was held June 21 at the South Knoxville Recreation Center. Residents clearly felt that there were parking issues with other developments in the area.

“We wanted to build fewer parking places because we believe they won’t be used and that the money to build them could be better spent. We also were concerned about unnecessary concrete which could be green space. However, the number of spaces is clearly an issue with the people who live nearby,” said David Arning of Southeastern Housing Foundation. “District Councilman Nick Pavlis also expressed his concerns. Therefore we are withdrawing the request for variance and will build all 58 parking places required by Codes.”

“We are committed to communicating more with the entire community and to listening to what they say,” said Jon Lawler, Director of the Ten-Year Plan. “If we can make adjustments based on what we hear, we will. That’s an important part of the process.”

The TYP has also committed to a monthly meeting with residents of the neighborhood close to Flenniken. The next one is scheduled for Thursday, July 29 at 6pm at the South Knoxville Community Center.

2. Recap: Compassion Coalition’s Salt & Light Luncheon

On Thursday, June 24, approximately 200 attendees at this luncheon learned about the Ten-Year Plan and how the faith-based community is engaging with its movement to help end chronic homelessness. Grant Standefer, Compassion Coalition’s Executive Director, pointed to some of the successes of the TYP.

• Knox County CAC’s Homeward Bound housed 255 homeless persons in 2009, 80% (202) of whom have remained in housing after one year. 99 of these were chronically homeless, and of those 77% (76) remain in housing after one year.
• Volunteer Ministry Center has housed over 250 previously chronically homeless in permanent supportive housing since July 1, 2007. 91.2% remain in housing.
• Prevention is a focus of the TYP. Four CAC case managers have worked with 263 residents of KCDC public housing units. None of these residents have been to the streets. Prior to CAC’s efforts in this area, an average of 67 per year were being evicted to the streets.

Jon Lawler described the TYP, the fact that it seeks to end homelessness by providing otherwise inaccessible resources to people who are chronically homeless (disabled individuals who have been homeless for a long time) mostly through the means of permanent supportive housing, and that the end goal is to empower people to integrate into the community. He underscored that this approach is demonstrated to be effective by research and also by our own local experience. He mentioned that the TYP is aligned with the federal government’s approach to the issue of homelessness.

Lawler encouraged members of the faith-based community to focus their attention on efforts that contribute to ending homelessness and helping formerly-homeless people to form healthy relationships (Circles of Support), to support those who are doing the work, and to attend public meetings and advocate for housing.

Jessica Bocángel shared three stories of Circles of Support teams. Circles of Support is a mentoring program sponsored by The Compassion Coalition. It pairs one resident of permanent supportive housing, a “neighbor,” with a team of five “mentors” who meet with their neighbor on a regular basis for an agreed-upon period to build friendships. It’s not always easy, but the program is successful. Circles of Support mentor teams are increasing in number, and are helping people who had spent years living on the streets to build healthy relationships and experience “wholeness, reconciliation, and reintegration into the community.”

Standefer encouraged the faith community to respond to the TYP by keeping communication respectful, honest, and open. He encouraged patience as the TYP seeks to implement a “complex, complicated process.” He also offered a handout with several specific ways to for faith communities to connect and get involved in the work.

In addition, Stephanie Matheny announced that she is working to form a pro-TYP group called Citizens for the Ten-Year Plan. They plan to be the citizen voice in support of the plan, and against the referenda if they end up on the ballot. The group was founded by Bill Snyder, Sheryl McCormick, Ray Abbas, and Stephanie Matheny.

Matheny is in the process of collecting a list of names of people who support the TYP.  She plans to put the list on a website — only names and zip codes, not their other information. Citizens for the Ten-Year Plan will also use the emails to form a listserve to announce meetings, ask people to write to council members, etc. She said, “This is not a “petition” – it is not directly related to the referenda and has no legal significance. We just want to be able to demonstrate that there are many of us who would like to see the TYP succeed.”

Ms. Matheny got about 60 signatures at the Compassion Coalition event (as of July 6, 115 people have signed up) and she would like to get several hundred before the website goes live.

3. Recap: TYP Advisory Board Meeting

The TYP’s AB held its quarterly meeting on Friday, June 25, five days prior to the beginning of Year 5 of the TYP’s implementation. There was an update on housing placement numbers for the past two years (over 300 formerly chronically homeless people remain in housing), a discussion of next year’s goals, and a presentation by and dialog with Stephanie Matheny, a Knoxville resident with over a decade of experience developing affordable housing, including permanent supportive housing, in Seattle.

Three over-arching goals for Year 5 were discussed.

1. All stakeholders in the plan will be effectively engaged regarding the plan’s ongoing implementation.
2. The original version of the TYP will be updated to reflect the specific systemic improvements resulting from the TYP’s work with Brad Greene (the conceptual design will be developed into a specific working document via the involvement of all the stakeholders).
3. Increase the housing options available to the entire homeless population.

There was a brief discussion of how these goals would be shaped with Advisory Board input (see item 1 above) and of other stakeholders who should be invited into the discussion. Advisory Board members pointed out that this goes beyond an “update” to the TYP. We’re at a natural halfway point, a great deal of progress has been made, especially in the area of interagency communication and cooperation, and this is a good time to open up the discussion to a lot of input from the public. There was also strong agreement among Advisory Board members about their desire to increase the level of discussion, reflection, and input from the Advisory Board.

The Advisory Board requested a weekly update from the TYP office. (An update will also be prepared for City Council, County Commission, and for the Homeless Coalition. It will be published on the Ten-Year Plan’s website, too.)

Stephanie Matheny addressed the Advisory Board of her eleven years’ experience developing affordable housing, most of it serving the homeless, in and around Seattle/King County, Washington.

• King County’s efforts to address the need for supportive housing began in 1992, when their health department realized that the same people were cycling over and over through detox.
• There was housing available at the time, but all of it required sobriety and was not effective, and they came to realize that they could house people and at the same time reduce public cost and public inebriation.
• When Matheny’s group began planning the Wintonia Apartments in King County, they held dozens of public meetings which were invariably painful and difficult.
• They made changes to their plan along the way, with public input, began operation in 1994, and has achieved great acceptance by its neighbors, which include a private school.
• Residents still drink, but far less than when they were homeless, and costs to the public have been reduced significantly.
• Case management to client ratio was approximately 1:25 in the beginning.
• Seattle has voted a housing levy to make more local funding available for affordable housing development.
• Seattle developed and still uses a detailed public notification process for affordable housing developers.

Three top lessons from Seattle about supportive housing development:

1. Expect opposition to any proposed supportive housing development. It will be significant at the outset, and some folks will never come around.
2. Mistakes will happen. The development process is extremely difficult.
3. You can’t give up just because people in the community are not happy about it.

Matheny also offered these suggestions:

• Help people understand that there’s a big difference between site control and a finalized purchase. Site control does not equal “done deal.” Contingencies are wide open before purchase.
• Do as much due diligence as possible before announcing site control—there is no sense in arousing concern before developer knows he’s interested in moving forward with the site.
• Outreach to the community must happen before closing the purchase, but not before obtaining site control.
• Tout the successes of the TYP. The interagency coordination achieved is a huge success.
• Try to figure out a way to de-stigmatize residents of supportive housing. They are not homeless anymore, after all.

There was some interaction between Advisory Board members and Ms. Matheny, and the next two Advisory Board quarterly meeting dates were announced.

4. Preview: Public Conversation #4

The TYP will hold its next public conversation at  6pm Wednesday, July 21 at the Cansler YMCA. The topic will be mental healthcare services in the context of permanent supportive housing. Sheryl McCormick, Coordinator, Recovery Training Services at Peninsula, will present for the first half-hour with Q & A to follow.

We’re thinking ahead about potential topics for these public conversations, which have been quite well-attended. We are considering addressing the subject of substance addiction treatment at the next one, which will happen in August. As always, we value your input on this. Please let us know what you think.

The TYP held its third Public Conversation tonight, Wednesday, June 23, 2010 at the Deane Hill Recreation Center about the origins of our own Knoxville and Knox County Ten-Year Plan to End Chronic Homelessness (TYP). Dr. Bill Lyons, the City of Knoxville’s Senior Director of Policy & Communication, acted as moderator. Dr. Roger Noose, Professor (Emeritus) UT College of Social Work; Linda Rust, Knox County Community Development; and Mike Dunthorn, TYP Project Manager, delivered a presentation about the process by which the TYP was developed in our community, the forces that drove its development, and its rationale. The meeting was quite well attended (probably just over fifty folks came out), and the conversation, once again, was respectful and quite informative.

I’ve transcribed my notes from the conversation below, edited only for clarity.

Notes

[These are my notes. 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.]

Attendees included several City Councilpersons: Vice Mayor Bob Becker, Marilyn Roddy, Brenda Palmer, Nick Della Volpe and former Councilman Barbara Pelot. County Commissioners Amy Broyles, Finbarr Saunders and Ed Shouse were in attendance. Also in attendance were several members of the staff of the City’s and the County’s Community Development department–Madeline Rogero (Director City of Knoxville Community Development)  and Grant Rosenberg (Director Knox County Neighborhoods and Community Development). 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. The meeting ran longer than one hour; I think it ended at about 7:15 or 7:20pm, but I’m not sure.

Dr. Lyons, in his role as moderator, focused this meeting’s topic on the formation of the TYP, the thinking behind it, the process of developing it, and its logic and goals. He also mentioned that this meeting is the third in a series to fully explain and dialog about the components and strategies connected with our community’s efforts to end chronic homelessness. Dr. Lyons mentioned that the presentation half of the conversation would focus on the long process we went through to develop the Knoxville/Knox County response to homelessness.

Dr. Nooe led off with background. To understand our TYP, you have to look back to the 1980s. There was at that time a growing awareness that homelessness was increasing across the country. In Knoxville at that time there were six shelters, and lots of groups who were providing food and other resources to homeless people. The causes of homelessness were beginning to be better understood, and included a national trend towards significant reductions in low-income housing that was partly brought about by urban renewal; deinstitutionalization, a movement to close or greatly reduce mental institutions in favor of residence and treatment in the community; increasing substance abuse; a job market whose competitiveness was increasingly growing; rising domestic violence, and other factors.

In 1986, Mayor Kyle Testerman and County Executive Dwight Kessel appointed a task force to study homelessness. The first biennial study happened that year, and showed 1000 homeless persons in any given month. By 2006, that number had jumped to 1900 homeless persons in any given month. This trend made it ever more clear that we were losing ground. Several issues during this period became much more obvious. (1) Service delivery was extremely fragmented. Agencies did not communicate with each other, nor did they coordinate service delivery. This made our “system” extremely inefficient. (2) Most services were were geared towards increasing the comfort of people who were still living in the streets. Well-intentioned groups offering these kinds of palliative services were mostly concerned with things like delivering blankets, soup, clean socks, restroom facilities.

In 1996, a group came together with the intention of developing a plan to address these issues, but it never generated much momentum and fell through. But in 2003, the United States Interagency Council on Homelessness (USICH) came onto the scene nationally, and in 2004 Knoxville Mayor Bill Haslam and Knox County Mayor Mike Ragsdale appointed a homelessness task force with 17 members and four staff members. This Task Force kicked off our TYP. The Task Force developed four working groups: (1) Housing, (2) Mental Health/Social Services, (3) Employment, and (4) Community Concerns.

Mike Dunthorn discussed the reformation of the mission of USICH under the leadership of Philip Mangano. Dunthorn emphasized the “interagency” component of USICH, which really did focus on bringing together different agencies to tackle the issues around homelessness using research and best practices. It began to become clear it was especially important to begin doing things differently regarding chronic homelessness, and Mangano embarked with USICH upon a mission to promote ten-year plans nationwide. More than 200 communities joined this movement.

Research was starting to suggest that the continuum of care model did not work very well for the chronically homeless population because it essentially asked them to attain sufficient stability to succeed in housing while still living on the streets. [Note: people who are chronically homeless are defined by HUD as unaccompanied disabled adults who have been homeless for at least a year or who have experienced four episodes of homelessness in the past three years. Research demonstrates that although they may make up only 10-15% of the homeless population, they consume about 50% of all the resources communities expend on all homeless persons.] Research was also beginning to demonstrate that housing first works very well with the chronically homeless population, and people were beginning to see housing alone was giving people who had been homeless for long periods of time the kind of stability that leads to positive life change and success. We were seeing good things happening in New York City, Seattle, and other cities, and people here started saying, “Let’s focus on the chronically homeless population, and do something different, because what we’ve done up to now isn’t working.”

Dr. Nooe mentioned at this point that housing is very important, but it’s not all there is to the TYP. He said that he gets very passionate about discharge of homeless people from jail, hospitals, or mental institutions to the streets. There should at least be some kind of coordination between a shelter and a discharging institution. And our TYP also recognized the importance of coordinating services. A homeless person doesn’t need five different case managers—there should just be one. And let’s use technology more effectively. We should also seek permanent solutions to homelessness instead of doing all of this recycling of people through the jails and emergency service providers. And get our churches involved in this solution, and work hard to prevent homelessness from occurring in the first place. Those things are all reflected in our TYP, which is not just about housing.

Linda Rust spoke to the process of developing the TYP. It started in September 2004 with the two mayors doing the Walk the Walk/Talk the Talk event, in which they got to interact with people in shelters and camps. This event had a profound impact on Mayors Haslam and Ragsdale, and the Homeless Coalition, which was forwarding the development of the TYP, wanted to take advantage of this “bigger leadership” represented by the City’s and County’s executives.

Working Groups started later that fall, and Ms. Rust was in the Community Concerns Working Group, which included representatives from the Council of Involved Neighborhoods (COIN), Center for Neighborhood Development (CND), 4^th & Gill Neighborhood Association, Fort Sanders, Knox Area Transit, Knoxville Police Department, and several other organizations. The group discussed  gaps, problem areas, and grappled with the question, “Why are we failing in re: homelessness?”

The Community Concerns working group recognized that, in the past, we had measured success by the number of beds in shelters, the number of meals served, but that we were not helping in a permanent way. They examined and discussed: the impact of homelessness on Knoxville’s downtown; methods for assessing the true cost of homelessness (taking into account more than just the cost of shelter beds, feeding programs, and other services operated specifically for the homeless population); better tracking of numbers of homeless people via improved utilization of the Homeless Management Information System database; the perception that the neighborhoods closest to downtown carry more of the burden associated with the issue of homelessness than they should; the issue of integration into the community; the fact that homelessness is really a community problem that crosses geographic barriers (noting the large number of camps distributed throughout Knox County). The Community Concerns working group also recognized that housing first and permanent supportive housing needed to be a priority in the emerging TYP.

This group also discussed ways to engage neighborhoods, and the Center for Neighborhood Development appeared poised to take the lead on that issue when it went out of existence in 2006.

The Community Concerns working group looked at several different communities, including Louisville KY, Chattanooga, and Maricopa County AZ, and how they were developing their own approaches to homelessness.

Members of all of the working groups recommended that both mayors (City and County) would take responsibility for and ownership of the TYP. An Advisory Board would meet quarterly, and the TYP would need a director, someone who would wake up every day thinking about the implementation of the plan. The Plan itself was always discussed as a living document that would evolve during the course of implementation.

Mike Dunthorn mentioned that there was a great deal of discussion about ownership of the plan. It was super-important to everyone involved in developing the plan that it not just gather dust on a shelf somewhere.

Dunthorn spoke to the TYP’s emphasis on prevention of homelessness. Knox County Community Action Committee (CAC) operates a prevention program in four KCDC properties. They provide case managers there who have reduced evictions into homelessness from an average of 67 per year to zero evictions into homelessness during the first 18 months of the CAC program’s operation. Prevention works, and we know it. Properly-resourced case management works, and we know it.

Coordination is also hugely important. Prior to implementation of the TYP, coordination between agencies was not very good. Now, it’s quite good and getting better all the time, and the change we see in our effectiveness as a community is profound. Coordination was something we developed in our plan and that is one of its main pillars.

Bill Lyons mentioned that some have said that there wasn’t much knowledge of, or community engagement in, the formation of the TYP. He pointed to copies of news stories from the time the TYP’s development process was getting underway, and acknowledged that now that the TYP’s implementation is touching neighborhoods and becoming more visible, people are learning more about it and getting more involved with it. Some of that involvement is critical of the TYP, of course, but even that is good. We need the hard questions. But notwithstanding all that, this plan was not developed in a vacuum.

Dr. Lyons opened the meeting up for questions and comments, asking that participants stick to the broad topic being discussed tonight.

An attendee asked how many homeless people have been housed? Mike Dunthorn responded that 287 people who used to be chronically homeless have been placed in permanent supportive housing in existing apartment units.

Someone then asked for the total number of homeless people in Knox County. Dr. Nooe responded. That’s a hard question to answer because the homeless population is very changeable. The number you’re asking about is never a static number because the people you’re counting don’t have addresses and they move around from place to place a lot. In the past we relied on statistical analysis of estimates based on data collection methods that were at the time the best we had. For example, in February 1986 it was estimated that the number of homeless in Knox County that month was around a thousand. Now, we estimate that between 7000 and 8000 people will experience homelessness in Knox County in one year. Most of those people will be homeless for less than six months, and that’s a good thing. People who are chronically homeless face a very different reality because the issues that have led to their homelessness are so profoundly difficult to address while they’re still living on the streets. It’s very hard to count homeless people and communities always struggle to do it, but our biennial study is really very good compared to other communities’ studies of the same issue. Dr. Nooe also related that back in 1992, a group of people connected with Whittle Communications had asked Dr. Nooe to locate some folks in the community who had escaped longterm homelessness. At that time, Dr. Nooe could only located five people in Knox who fit that description. He pointed out that now we’re placing people in housing in huge numbers [the average rate in Knox County is over 8 per month with one-year retention rates of better than 90%, which is better than the national average].

Jessica Bocángel asked the presenters to discuss what it means to not discharge people to the streets and into homelessness. She also asked how churches used to be engaged, and how they’re being engaged now. Mike Dunthorn responded that discharge to the streets is tough. Funding for hospitals, mental healthcare facilities, jails, etc., is beyond our immediate control, and those organizations serve other people besides just the homeless. They’re not equipped to get people into housing. We are working with them to develop better protocols. You start with simple solutions, like making sure there’s interaction between the discharging organization and the local shelter, so the shelter folks at least know that someone’s coming their way and can anticipate their needs. But it will require changes at the state and federal levels to really improve this problem significantly. The faith community has always been engaged with the issue of homelessness, largely focused on providing for the needs of people who are still homeless. The Compassion Coalition’s Circles of Support, which is a mentoring program specifically for people who live in permanent supportive housing, is a groundbreaking program that seeks to engage the faith based community in a different way, one that leverages the ability and mission of that community to provide healthy friendships so that people who’ve left the streets can more easily rebuild their lives where they live.

Joe Minichiello asked why there is no “cap” on the number of chronically homeless people served in our community. He said that according to Dr. Nooe’s research, 45% of the homeless in Knox County aren’t from here. Why wasn’t that addressed in the plan? Mike Dunthorn asked attendees to raise their hands if they were born here. He said “That’s the issue.” He went on to say that Dr. Nooe’s survey asks “Where were you born?” whereas the Homeless Management Information System database asks “What is the zip code of your last permanent residence?” In our community, over 60% of respondents list a 379 zip, with just under 80% coming from the counties that surround Knox. Dunthorn said that every one of his colleagues around the country gets asked the same question: “Why does our community attract all these homeless people? We’re the destination of choice for them from all over the country.” and that the situation is probably very similar everywhere else. If we’re all creating plans to effectively address the issue of homelessness, we’re all going to be attracting people to our communities about equally.

Brandon, a resident of the neighborhood surrounding the Cox Street permanent supportive housing development built and operated by Helen Ross McNabb Center, raised the issue of security, asking “What do you do with repeat offenders?” He said that he and his neighbors have been dealing with this at Cox Street since October 2009. He went on to say that he realizes that these kinds of facilities are going to be owned and operated by private entities, but who enforces accountability? Mike Dunthorn responded that it is important to recognize that people who are homeless are in the community already. We’re aware of this issue, and are taking steps to see that it’s resolved. In fact, you contacted the TYP to seek resolution and we got on it right away. That wouldn’t have been an available option before the TYP existed. The issue is very important to us, and we are working hard to resolve it. Brandon asked “What is being done about illegal drug use in the neighborhood?” Dunthorn responded that first of all the lease is enforced. That’s the side of the equation controlled by providers of permanent supportive housing. If a person is using illegal drugs on the property, they’re subject to immediate eviction, not to mention arrest. Engaging in violent or threatening behavior will also result in rapid eviction. However, it is important to note that the whole purpose of the TYP is to end homelessness, and that means working very hard with people who need a lot of help. You don’t just want to be kicking them out of their housing the first time they mess up–that would defeat the purpose. Case managers and other staff will be onsite, and they will work with residents to prevent eviction if possible.  If they get evicted, will they just get dumped out in the neighborhood, evicted to the street? No. The case manager would work very hard to place that client in a more appropriate housing setting, perhaps one with more supervision if that’s appropriate.

[Note: TYP director Jon Lawler engaged this situation as soon as he heard about it and offers this account.]

At the South Knoxville Meeting on Monday (6/21/10) and at the Deane Hill Community Center Meeting on Wednesday (6/23/10) a gentleman named Brandon made repeated references to Helen Ross McNabb’s mismanagement of its Cox Street Development.  This issue came to my attention on Monday afternoon when Brandon called my office.  I agreed with Brandon that his concerns were very valid, and I encouraged him to speak with Jana Morgan at Helen Ross McNabb.  I also asked him to call me back on Tuesday (6/22/10) by 2:00 p.m. to give me an update on his conversation with Helen Ross McNabb.

I did not hear from Brandon on Tuesday.  On Wednesday morning I called Andy Black (CEO of Helen Ross McNabb) to inquire about this issue and to determine what action had been taken.  He was unaware of the problem but told me that he would follow up and call me back.

Andy Black immediately called me back to let me know that Brandon had spoken with Jana Morgan on Tuesday afternoon.  Jana had been on vacation on Monday, so she was unable to return Brandon’s call until Tuesday.  Andy communicated to me that while Jana was on vacation the resident manager quit.  This left no nighttime presence at the facility.  Jana communicated to Brandon that Helen Ross McNabb was giving this issue its immediate attention, and Jana also communicated to Brandon that Helen Ross McNabb would schedule a neighborhood meeting to address its current and future methodology for responding to the neighborhood’s concerns.

Brandon knew all of this before he attended the meeting on Wednesday.  In fact, when I spoke to him after the meeting, he expressed his satisfaction at Helen Ross McNabb’s response and their plan for moving forward.  I am not sure why he chose to speak on Wednesday night as if Helen Ross McNabb had been unresponsive.

It should be noted that Helen Ross McNabb has been operating permanent supportive housing in Knoxville as long or longer than anyone else (Child and Family has also been operating PSH for a long time).  Helen Ross McNabb’s model is different than the model that has been proposed at Minvilla and Flenniken.  The Cox Street (15 units plus a resident manager unit) development has a case manager that visits during the day, and a resident manager that is on call during the night.  Cox Street is two buildings, and the main entrance is not monitored by a full-time staff person.  This model has worked well for McNabb in the past, and I am certain that it will work well at Cox Street.

Ron Peabody asked for the total number of homeless persons in the USA in the year 2000. Dr. Nooe responded that he could look that up, but didn’t know it off the top of his head. Suffice it to say that the numbers today are better than they were in 2000. Mr. Peabody said that our “best numbers” were between 1,200,000 and 1,500,000 in 2000, and that President Obama’s new homelessness plan which has just been released stated that there had been a 10% reduction in chronic homelessness in the last ten year, and that that doesn’t sound like success. Dr. Nooe responded that the results vary quite a bit from city to city, and that a 10% reduction would seem like a very good start. Mike Dunthorn held up a copy of the new homelessness plan Mr. Peabody had referenced, Opening Doors Federal Strategic Plan to Prevent and End Homelessness, and corrected Mr. Peabody’s figures by citing this from page 17: “After declining 30% between 2005 and 2007, the number of persons who experienced chronic homelessness remained essentially the same in 2008, but dropped 11% in 2009.” Dunthorn added, “I’d call that successful.”

Scott Smith said that he now understands permanent supportive housing and how it’s necessary to solve this problem, but wondered why sobriety is not a condition of the lease. Linda Rust responded that based on her experience working at Helen Ross McNabb Center, when a case manager encounters a client, the case manager has to meet that client on the level of the client, and clients are not homogenous–they are in all different kinds of places. It’s the case manager’s responsibility to determine needs and find resources to help the client address those needs. To make sobriety a condition of the lease would be very counterproductive for a lot of people, because they would perceive that condition as coercive. Research demonstrates that clients are more likely to get services if they make a choice to do it, and don’t feel coerced. The stability provided by housing is therapeutic in and of itself. It provides a level of peace that helps residents be in a better place to get the services they need to help them confront their issues. Scott Smith replied that at Cox Street, the case manager quit, so surely it would be better to have addressed sobriety in the lease. Bill Lyons said that we have to make sure case managers are present. We must ensure that people living in permanent supportive housing don’t do harm to residents of the surrounding neighborhoods. We need to strengthen all of the functional relationships so that communication between all the constituents is really good. A woman who lives near the Cox Street property said that the neighbors do not have anyone that they can call. Bill Lyons responded that we are aware of this situation, and that we are taking steps to ensure that proper relationships are established and maintained. Dr. Nooe suggested that neighbors contact Andy Black at Helen Ross McNabb Center.

Dave Gartner asked for the name of the Council of Involved Neighborhoods rep in the Community Concerns working group. Linda Rust said that they were Whitney Stanley and Polly Doka.

Brandon said that a Helen Ross McNabb staff person had told him that there is no requirement that they have 24/7 awake staff on site at Cox Street. He said there should be such staff anyway. Linda Rust said that that’s why she was on the phone to Helen Ross McNabb the moment she heard Brandon’s story. Nobody’s happy about the kind of situation he described and everyone involved wants to find out what’s going on get it resolved as soon as possible.

Dave Gartner said that there is no enforcement mechanism in place to ensure that operators of permanent supportive housing do things to an agreed-upon standard. Mike Dunthorn pointed out that while there’s no specific enforcement mechanism, any operator who does poor work puts his or her organization at risk of loss of funds. It’s not like we’re completely without leverage in a situation like what’s being described here. Whatever’s going on, we’ll find out about it and make sure it gets addressed.

A gentleman asked who bears the cost burden of permanent supportive housing residents. Linda Rust replied that many qualify for Social Security disability, which is a federal program, and that people in permanent supportive housing have to pay some portion of their housing expenses. She gave the examples of group homes, permanent supportive housing–you qualify for those kinds of housing because of your disability. Dr. Lyons mentioned that some expense is borne locally, too. Dr. Nooe said that we’ve got to solve this problem, and that we can. He discussed a group that meets every other Tuesday to address the most challenging of our community’s chronically homeless individuals. This meeting is about assigning responsibility, and it’s one of the best things we’re doing to coordinate our efforts and take responsibility for individuals who are out on the streets. He pointed out that not everyone is capable of living in the community, and that we will always need to screen people carefully and help them gain access to appropriate housing.

Next meeting

The next public conversation will be held at the Cansler YMCA from 6-7pm on Wednesday, July 21. The topic will be mental healthcare delivery 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.

The third installment in the series, which aired on May 24, continues with its three subjects, Robert Carmichael, Emmett Howard, and Shaun & Sue Buckarma. The first story ran in February, and you can watch it here. Click here to watch the second story.

The idea behind this series is to give viewers an opportunity to get to know more about some of the people in our community who are rebuilding their lives in PSH, which is such a critical part of our community’s strategy to end chronic homelessness.

What keeps a person living on the streets for years? How big a factor is mental illness? Addiction? What difference does it make to have a safe, secure place of one’s own? What about the role of case managers? How does housing with support change the life of a person who’s been on the street for long time?

Stay tuned. This series should touch on all of those questions, and more. We appreciate WBIR’s interest, and Alison Morrow’s in-depth and interesting reporting.



Small teams of mentors are invited from congregations throughout Knox County to participate. The program’s coordinator provides training so that the teams will understand the basic purpose, expectations, and goals of a mentoring team and provides an understanding of the issues faced by the chronically homeless. Here’s a glimpse:

Each mentor team is matched with a formerly homeless neighbor and is partnered with a professional case manager and other social workers. Mentor teams are focused on helping their neighbor understand and relate to the community at large. This could be anything from simple housekeeping, decorating an apartment, understanding basic money management, or engaging in social and recreational activities. Each mentor team is matched with a formerly homeless neighbor and is partnered with a professional case manager and other social workers. Mentor teams are focused on helping their neighbor understand and relate to the community at large. This could be anything from simple housekeeping, decorating an apartment, understanding basic money management, or engaging in social and recreational activities.

The TYP held a public conversation last night, Wednesday, May 19, 2010 at the Cansler YMCA about the cost of permanent supportive housing (PSH). Bill Lyons, the City of Knoxville’s Senior Director of Policy & Communication, acted as moderator. Jon Lawler, Director of the TYP, delivered a presentation about the cost of PSH in the context of the Flenniken Housing development. The meeting was well attended, and the conversation, once again, was respectful and helpful on several different levels.

I’ve transcribed my notes from the conversation below, edited for clarity, with absolutely no concern for brevity. I’ve incorporated information from the PowerPoint slideshow Jon Lawler used to support his presentation.

Notes

[These are my notes. 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.]

Attendees included several City Councilpersons (Marilyn Roddy, Nick Pavlis, Nick Della Volpe) and at least one County Commissioner (Finbarr Saunders). Apologies if I’ve missed anyone. Also in attendance were several members of the staff of the City’s Community Development department. The format of this meeting was one hour. The first half hour was mostly used for presentation, the second half hour was for conversation with attendees.

Bill Lyons, Senior Director of the City’s Policy & Communications Department, acted as moderator. He focused this meeting’s topic on the cost of permanent supportive housing (PSH), and mentioned that this meeting is the second in a series to fully explain and dialog about the components and strategies connected with our community’s efforts to end chronic homelessness.

Dr. Lyons also mentioned that it would be inappropriate to begin this discussion without mentioning that we have a baseline of cost already. We’re not starting from zero. The costs we presently incur are counted in places like the Knox County Jail, hospital emergency rooms, etc., and the tax dollars presently being spent in our community to cover those costs. Part of the impetus behind the TYP, and behind the development of more supportive housing in the community, is the great cost we already bear.

Jon Lawler presented the agenda:

1. Introductory Comments by Dr. Bill Lyons
2. Presentation of the Cost Components of Permanent Supportive Housing (PSH)
   1. Development Cost
   2. Operational Cost
   3. Case Management Cost
3. Questions from the Audience

The majority of those who’ve been placed in housing in connection with the TYP have been placed in already-existing housing in the community. Our TYP has the ambitious goal of ending chronic homelessness in ten years, mainly by providing housing with support. We have enough affordable housing stock to meet some of the need, but not all. New housing will need to be developed. Since housing with support is the means to end chronic homelessness, we want to address the cost of providing housing with support, and we’ll do this by examining what it will cost to develop and operate a new PSH project.

PSH is essential to end chronic homelessness, but the TYP does not have access to unlimited resources to develop affordable housing. Our office must ensure that PSH units could be developed by an entity that could utilize all of the sources of funding that are available for this type of development. Southeastern Housing Foundation (SHF), a 501(c)(3) non-profit affordable housing developer, offers its services as development partner of the TYP. A key part of SHF’s role is to increase the stock of PSH by aggressively assembling multiple layers of funding for each development.

This task is very challenging, and is undertaken by developers with a mission to develop this type of special needs housing. SHF has a deep commitment to that mission. What is the methodology SHF or any other PSH developer uses to fund the development cost of PSH? Flenniken Housing is a good example of how these developments are put together.

Development Cost: The Flenniken Example (Cost: approximately $7,050,000)

Low-Income Housing Tax Credits (LIHTC): $3,100,000
The federal government created the LIHTC program in 1986 to stimulate the development of affordable housing. Developers compete for award of tax credits which they then sell to a for-profit tax credit investor. These are typically banks and other financial institutions like them. This investment becomes equity in the development, so the investor is a financial stakeholder in the development.

Federal Home Loan Bank (FHLB) Grant: $1,000,000
The FHLB system is composed of 12 regional FHLBs with many member banks. “[Its] Affordable Housing Program (AHP) is one of the largest private sources of grant funds for affordable housing in the United States. It is funded with 10% of the Federal Home Loan Banks’ net income each year. The AHP allows for funds to be used in combination with other programs and funding sources, like the Low-Income Housing Tax Credit. These projects serve a wide range of neighborhood needs: many are designed for seniors, the disabled, homeless families, first-time homeowners and others with limited resources. More than 623,000 housing units have been built using AHP funds, including 391,000 units for very low-income residents.” (Here’s the source link for the quoted material.)

Federal Pass-thru Dollars
These funds are appropriated by Congress and come to local governments as federal grants to be spent at local discretion within established parameters in support of federal spending priorities. Flenniken has the following federal monies in its funding mix:

• CDGB (Community Development Block Grant) Funds: $100,000
• HOME (HUD’s HOME Investment Partnerships Program) Funds: $250,000
• NSP (Neighborhood Stabilization Program) Funds (Stimulus Funds): $800,000

TCAP/Monetization Funds: $1,500,000
TCAP (Tax Credit Assistance Program) provides funds directly to state housing finance agencies, like the Tennessee Housing Development Agency, to disperse to existing tax credit developments in need of additional gap funding. This program came into existence in response to bad conditions in the tax credit market that began to create serious difficulties back in 2009 for developers with tax credits in their developments. TCAP funds make up the difference between the value of tax credits and what those tax credits could actually be sold for in the market subsequent to the economic troubles of late 2008 and thereafter.

First Mortgage (CITC Loan): $300,000
This will be the only permanent debt carried by Flenniken.

Jon stopped at this point for questions, acknowledging that this had been a very complex part of the presentation. This is fairly typical of an affordable housing development’s funding package. All of these funds must be on the table to make deals like this work, and it is very difficult to put all of this together.

Barbara Disney asked which of these funding sources has to be paid back. Jon said that every source here is a grant, except for the first mortgage. That is the one source that, like any loan, must be repaid.

Joe Minichiello asked how else the money represented here could have been used. Jon replied that all of the funding represented here except the federal pass-thru dollars have to be used to develop affordable housing. David Arning added that affordable housing development was a focus of the NSP program.

Will these developments always be this expensive?

Jon next addressed the issue of costly developments. Will PSH projects always carry the high price tags associated with Minvilla and Flenniken? No, they won’t. But let’s look at why these two are particularly expensive compared to new construction.

Minvilla: The old 5th Avenue Motel was designated as a historic rehab before it ever was considered as a site for PSH. Historic preservation creates design inefficiencies that increase cost. PSH in general, and Minvilla specifically, has more common area than typical affordable housing, and this adds cost. There’s also more office space necessary due to the onsite presence of case managers and a management company.

Flenniken: Classified as an adaptive reuse project: an old school is being converted into apartments. Adaptive reuse commonly generates a higher per-foot rehab cost than new construction. KCDC’s Eastport School development (elderly housing) has a similar if not higher price per square foot. Certain design elements also add cost: 12 foot corridors, generous community space (gymnasium), and extra office space. Certain construction factors add cost: the dilapidated condition of the building and the extensive amount of environmental abatement work that needs to be done there.

New construction of PSH will not be as expensive as these two exceptional examples. New PSH can be developed at very close to the done at market rate for typical affordable housing plus a little more for necessary additional common area.

Who are the residents and what do they pay?

It is estimated that:

• 40% to 50% of the chronically homeless population qualify for Supplemental Security Income (SSI), which currently pays $674 per month
• 10% of the chronically homeless do not qualify for SSI but earn an income equal to or greater than SSI
• 40% of the chronically homeless do not qualify for SSI and earn less than what SSI pays.

None of our residents have sufficient income to pay fair market rent on their own, which means they need rental assistance. This rental assistance is provided in the form of a Section 8, Tenant-based voucher. In our community, the Section 8 program is administered by Knoxville’s Community Development Corporation (KCDC).

Operating Costs

Operating costs are a little bit higher in PSH than they are in typical affordable housing. On average, it costs about $3,200 per year to operate a typical affordable housing unit. It costs closer to $4,500 to operate a typical PSH unit for a year. Why is this? It costs more to staff PSH because the needs are a bit more intensive. For example, at Flenniken, an overnight staff presence every day adds cost. Utilities, repair and maintenance, and taxes and insurance would be very similar to typical affordable housing. The management cost will be higher than typical because of the level of expertise required to manage a PSH development. The role of the manager is to maximize revenue, control expenses, and preserve the value of the physical asset.

About developer risks and rewards

Jon mentioned that it’s been said that developing PSH is about easy money and no risk. Quite the opposite is true. This is very hard work, and it’s also quite risky. Tenant revenue is highly unpredictable, and the majority of expenses are fixed as opposed to variable. Folks who have been chronically homeless means are tenants who never have enough personal income to pay fair market rent, and even fair market rent does not ensure cushiony surpluses of funds. PSH providers in Knoxville/Knox County are dependent upon a working relationship with KCDC to have access to tenant-based assistance when it is needed. If assistance isn’t available, then providers are going to be housing someone without the ability to collect sufficient rent, which decreases operating reserves. Additionally, PSH providers are staffing and operating a property with higher than normal fixed operating costs and must maintain higher than normal reserves so they can do things like fund those tenants who are still working on gaining access to sufficient funds to pay rent. This is an extremely challenging operational model, and it takes a special kind of mission-driven company to meet it.

Case management cost

Case management cost is an expense beyond the operating budget of a PSH development, Funds for case management come largely via philanthropic support from the community. HPRP (HUD’s Homeless Prevention and Rapid Re-Housing program) funds; other grants from government sources like SAMHSA (the Department of Health and Human Service’s Substance Abuse and Mental Health Services Administration); and, potentially, pay for performance from the Knox County Sheriff’s Office based on savings realized by the jail (the largest provider of mental health services in Knox County) through housing people who have been chronically homeless.

Discussion

Bill Lyons moved the conversation into its second half. There aren’t many ground rules here, but let’s keep this more to questions and less to extended comments.

Bill Murrah spoke. A lot of concern has been expressed by people saying “not in my back yard.” Wouldn’t it be wonderful if we could have access to people who live in neighborhoods close to the kinds of people and facilities we’re talking about? I’m one of those people who lives in a neighborhood like that. I raised my kids in 4^th and Gill and nobody has ever bothered them. Our area is not a high crime area, and I challenge anyone to find an area whose property values have increased more than ours have. Our neighborhood is safe, even though it’s right next to the mission district. I have a brother who is schizophrenic, and who lived in a supportive housing situation. He lived as full a live as possible because of the support he got there. I want to allay the fears that people attach to this issue.

Joe Minichiello said that the $800,000 development fee for Flenniken was a lot, and that it seems that Southeastern Housing Foundation will become the owner of Flenniken without incurring any risk. Who determines what kind of development fee a developer is entitled to? Bill Lyons replied that the fee is suggested by THDA (Tennessee Housing Development Agency, the agency that administers the Low-Income Housing Tax Credit program, the Housing Trust Fund, and many other programs designed to stimulate development of affordable housing). The developer fee is essential to maintain and operate PSH facilities. SHF is a nonprofit, and their developer fee has to be channeled back into their mission, which is development of affordable housing. David Arning stated that the developer fee cannot exceed 15% of “eligible expenses” as stipulated by the IRS, and that these expenses are less than the total project cost. This fee looks fat on paper, but there’s a risk that you’ll never see it. The risk is in the recapture of funds. The developer makes certain guarantees to investors and if the developer fails to deliver on those, the investors will come after the developer. LIHTC is the single most important incentive to the development of affordable housing, and the developer fee is the lone incentive to the developer, besides the fulfillment of a charitable mission. These fees are critical to building reserves and are the sole source of income for a non-profit developer like SHF.

Nick Della Volpe asked whether or not it was easier to get money for Flenniken and Minvilla because the buildings were old. Jon Lawler responded that their age really didn’t’ have anything to do with making it easier to get money into the projects. He mentioned that Minvilla has Historic Tax Credits, but that Flenniken does not. Bill Lyons said that the City tried without success to find private developers for Minvilla. The development of PSH there will preserve a significant structure that will be a very attractive gateway between downtown and the surrounding neighborhoods.

Dan Smith asked a question about the ratio of clients to case managers in PSH. He said that we seem to have moved from a 10:1 to a 25:1 ratio and seemed to be asking if, even with this higher ratio, we could afford to pay all of the required case managers. Bill Lyons said that these developments don’t happen at that kind of pace. They come online one at a time at the rate of about 50 units per year or so, which means two new case managers at a time, and that organizations providing case management services in them have to step up and meet the challenge of raising funds to support case management delivery. If at some point over time an organization reaches what it believes to be the limit of its capacity to support this activity, we will not try to push beyond that. Sustainability is addressed on an ongoing, project-by-project basis. How do we know we can always raise the money to provide these services? We don’t have a guarantee that we can do any of these things going forward. Nothing comes with that kind of assurance attached to it, but we still move forward and do the very best that we can.

A gentleman named Tim spoke about the need to address the spiritual needs of people who experience homelessness. You can’t just give them a place to stay. People become homeless because of very bad things that occur in their lives, and we must show them compassion.

Ron Peabody asked how many chronically homeless people have been identified in HMIS (Homeless Management Information System, the main database used by service providers to gather data about homeless people in our community). Jon Lawler replied that approximately 1000 people designated in the database as chronically homeless received services in the last year. Mr. Peabody asked what the goal for PSH development is. Jon said that SHF can do one project per year, and that existing stock is being used on a regular basis, and that we’re developing a better understanding of what we need to develop in our community. Mr. Peabody said that 500 people are on KCDC’s waiting list for Section 8 vouchers. Jon responded that the wait list has been revised to a smaller number since Mr. Peabody got his information from KCDC two weeks ago, and that there is not a limitless supply of vouchers. [We met with KCDC the morning of May 19 and the wait list has been revised to approximately 270.] There is an art to making vouchers work. KCDC is not simply handing them out. This is one reason the developer of PSH must have sufficient reserves—to cushion against the unpredictable revenue from PSH tenants.

Stephanie Matheny asked David Arning what SHF has risked, so far, at Flenniken? David replied that SHF has $95,000 in Flenniken so far, of non-recoverable dollars that would be lost if the project fails to go forward.

Someone asked if any surplus funds would be reinvested in local projects, or would SHF develop outside the Knoxville/Knox County community? David Arning responded that SHF’s focus is on this community.

Nick Della Volpe asked if we could mimic the nursing home care continuum, in the sense that residents of a relatively costly kind of supportive housing could be helped to the extent that they’d be capable of moving into less-expensive housing. Jon Lawler answered that PSH isn’t the only kind of supportive housing and that it’s not appropriate for everyone. Tenants are not just put into housing, and residents of a particular development are not all at the same place with regard to the level of their disability and need. Barbara Disney added that residents who have Section 8 vouchers can take those vouchers with them to less expensive environments if they want to.

Duane Grieve asked if it is realistic to think that we can do away with existing cost as we fulfill the mission of the TYP. Jon Lawler responded that the TYP calls upon us to end chronic homelessness, but that it also calls upon us to do a lot of work to prevent homelessness in the first place. Mr. Grieve asked if we wouldn’t be adding new chronically homeless people each year. Bill Lyons responded that it’s not like there are slots that people move out of when they’re housed that are immediately occupied by some new chronically homeless person. Every person who is not stuck in the cycle of chronic homelessness is one person who is not adding to the cost borne by the community. We want to minimize the number of disabled people stuck in homelessness because it’s the right thing to do and because when they’re living on the street they are utilizing so many costly services.

Dave Gartner expressed disappointment that we didn’t provide a spreadsheet with costs of actual operations broken down into dollar figures.

Ron Peabody mentioned that TennCare is making major cuts and dropping people from its rolls. He asked how this will effect service delivery for mental health and basic healthcare. Ginny Weatherstone acknowledged that this places a burden on the service provider community. She indicated that she had been in contact with Cherokee Health Systems and Helen Ross McNabb Center to discuss this issue and that both of them are committed to continuing to serve their patients and clients who lose insurance provided by TennCare. She said that all agencies like these will continue the aggressive pursuit of other sources of funding, as in the example of the City’s recent submission of a Mental Health Transformation Grant to SAMHSA in partnership with Volunteer Ministry Center and Helen Ross McNabb. The bottom line is that there are people in the community who need this kind of help, and those who are committed to serving them will have to work harder to make sure they can deliver that help.

Suggestions

I had a very good conversation with an attendee after the meeting. She recommended, among other things, that a good topic for a meeting like this one might be the rationale behind the scattered site approach to PSH development. That approach is advocated in the TYP. There are good reasons for it, and she would like to hear them explained and opened up for dialog.

Another attendee offered some recommendations about presentation and materials that might be made available at these public conversations. We employed far too many acronyms in our speech and presentation materials, and this creates confusion and misunderstanding. Acronyms hurt. Spell things out. Point taken.

Some folks (I don’t think Dave Gartner was alone in this) wanted to see much more financial detail. This kind of material should be put on our website, along with images and reports on progress. Minvilla’s budget info has been up for a while. I need to update it, I’m sure. I’ll check on that and adjust as appropriate. I’ve not created a similar resource for Flenniken, but I will have it up within the week.

We need to create a handout for each of these meetings, and it seems reasonable to think we should make the same content available online.  The suggestion is for a two page piece printed double-sided on one sheet that contains links to additional information online.

All good suggestions. I’ll follow through on them.

Next meeting

The next public conversation will be held at the Deane Hill Recreation Center from 6-7pm on Wednesday, June 23. The topic will be how the Ten-Year Plan came about. Dr. Roger Nooe, our community’s recognized expert on the subject of homelessness, Mike Dunthorn of the Ten-Year Plan office, who helped write the plan, and Linda Rust, of Knox County’s Community Development Department, who facilitated Community Concerns working groups’ input in the TYP’s formation for a period of about a year, will present as a panel. We’ll follow the same basic format. First half hour presentation, second half conversation about the subject.

Subject: Ten-Year Plan public conversation: Cost of permanent supportive housing

Meeting date and time: Wednesday, May 19, 2010, from 6:00-7:00pm

Meeting location: Cansler Family YMCA , 616 Jessamine St., Knoxville, TN 37917

Contact: Robert Finley 215-3071

The Office of the Ten-Year Plan to End Chronic Homelessness would like to invite the public to a public conversation on Wednesday evening, May 19, 2010 from 6:00-7:00pm at the Cansler Family YMCA (616 Jessamine St., Knoxville, TN 37917; 637-9622). We’ll be discussing the cost of permanent supportive housing. Bill Lyons, Senior Director of Policy and Communications for the City of Knoxville, and Jon Lawler, Director of the TYP, will present during the first half of our time. The second half will be reserved for questions and conversation related to the subject of costs related to PSH.

This is the second in a series of similar public conversations. The Ten-Year Plan office (TYP) has heard from community members in many different venues that we need to be more open and transparent in our communication about the work we’re doing to end chronic homelessness. We agree, and are committed to an open dialog and a clear and open process of developing and implementing solutions to chronic homelessness.

We would like to keep these meetings concise, to respect the time commitments made by attendees. We’ll offer them on a regular basis, and invite presenters who can speak to their areas of expertise and to the roles that they play in support of the TYP. We’ll open up the floor for questions and conversation on the specific issue being addressed, and we’ll ask attendees for ideas about subjects they’d like for us to address in future public conversations.

The TYP held a public conversation on Wednesday, April 28, 2010 at the Cansler YMCA about case management in permanent supportive housing. Bill Lyons, the City of Knoxville’s Senior Director of Policy & Communication, acted as moderator. Ginny Weatherstone, CEO of Volunteer Ministry Center, and several members of VMC’s staff along with a resident of the Jackson Apartments, a PSH apartment building owned by VMC, presented led the discussion about case management in PSH as practiced by VMC. The meeting was well attended, and the conversation was very good.

I’ve transcribed my notes from the conversation below with very few minor edits for clarity.

Meeting Notes

[These are my notes. 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.]

Attendees included all City Councilpersons except one who was recovering from a medical procedure. Two Knox County Commissioners were present.

Bill Lyons, Senior Director of the City’s Policy & Communications Department, acted as moderator. He defined this meeting’s topic as being focused on case management in permanent supportive housing (PSH), and said that this meeting will be the first of a series to fully explain and dialog about the components and strategies connected with our community’s efforts to end chronic homelessness. The format of this meeting was one hour. The first half hour was mostly used for presentation, the second half hour was for conversation with attendees.

Ginny Weatherstone, CEO of Volunteer Ministry Center (VMC) presented. VMC views case management as the road from homelessness into housing. case management is a very big topic. Other agencies do case management, and there are many ways to do it. Tonight we will skim the surface, and our discussion will be focused on how we do case management at VMC.

We believe in the effectiveness of the case management we do. It works. Case management for us is facilitated coordination of services at a community level. Case managers connect their clients with the resources they need to take control of their lives, and are focused on the goals of the individual client. Case management is about empowering them to meet their goals. Case management is a way for you to go from one place to another place that you could not have gone on your own.

Homelessness is characterized by chaos, noise, uncertainty, lack of safety, lack of privacy, proximity to illicit substances, lack of trust, no autonomy, little responsibility and very little accountability. This is the environment within which a homeless person must work to regain control of his or her life, and to gain the stability necessary to live a good life in the community. For some people, it is impossible to cope with the challenges of life on the street, and with the challenge of trying to get off the streets.

Housing changes this environment completely. Life in one’s own apartment is characterized by safety, security of person and possessions, calm, privacy, autonomy, high levels of responsibility and accountability because residents pay rent and must abide by the terms of a lease agreement. All of can be very positive, but can also be extremely difficult for a person who has been homeless for a long time. Not all of them can get there without help.

Case management is about building and maintaining relationship, and this happens in steps.

• It begins with an individual’s expression of the desire to leave homelessness.
• An individual assessment is performed and the person is matched with a case management. At VMC, the end goal is always housing and becoming a part of the community.
• Secure the documents that are necessary for gaining access to housing. This can involve many different kinds of agencies and can be very daunting. case managers help  their clients navigate the bureaucracies involved.
• Apply for housing. In our community, there’s not a huge supply of appropriate housing. There’s usually a wait, and that lag time is productively used. It lets the case management client relationship build.
• Once housing is obtained, case managers help clients get the stuff they need and help them move in and get established.
• Case managers help clients to find and get to all of the services they need to help them meet their individual recovery goals and stay successfully housed.
• Case managers facilitate basic skills development. These can be related to many different things, such as skills related to successful employment, managing money, healthy diet, etc.
• Case managers engage in advocacy on behalf of their clients.
• Case managers visit clients often in the client’s apartment. This is a critical component of the ongoing assessment. It lets the case management know immediately if the client is experiencing any kind of issues that might affect his or her ability to remain successfully housed on the path to recovery.
• Case managers help clients find people who will help them feel good, have fun, and do things that are interesting and fulfilling. We’re really talking about helping them find and make friends with people who are different from their old associates.

Case management delivery is cost efficient when clients live close together. Sometimes the first case manager engaged by a client will make a “handoff” of that client to another case manager who is attached to the residence.

Case managers also plan and conduct activities that foster a sense of community. This helps residents decide that their housing is something that they really want to keep, to decide that “I want this to be my life and it’s worth working to maintain it.”

Two case managers, Megan Lappas and Matt Nance, and one of their clients, James Johnson, comprised a panel.

Challenges: Megan Lappas: One of the biggest challenges faced by case managers is that there is not enough housing. it is hard to instill hope when move-in is far away. Navigating bureaucracies is hard enough for case managers—imagine how challenging that is for a person who lives in the chaos of the streets. Matt Nance: The case manager’s fight is the fight against the tide of the chaos of the streets.

Megan Lappas: Our presence helps to keep people calm at Jackson Apartments, but so does the sense of community among the residents. Matt Nance: Community is a strong reinforcer of cohesion. “Don’t do bad things here because that will mess up what we’ve all built and are doing here.”

James Johnson: We depend on case managers for good advice. They’re not too authoritative. They’re kind of like family members. You can trust them. My apartment at Jackson Apartments is a blessing. I don’t know what I would do or where I’d be without it.

Dr. Lyons established ground rules for the second half. No reason for anyone to exceed 3 minutes with their comments/questions. Stay on the topic for this evening. Other than that, there are very few rules.

Della Volpe: Will the family atmosphere translate to 57 units? Matt Nance: It’s like a dorm experience in college. Lots of small interactions create the sense of community. That doesn’t happen necessarily because of big events.

Joe Minichiello: Does federal money restrict zero tolerance policies?  Ginny Weatherstone: Good case managers know what is in a lease. Most leases address disruptive behavior, not alcohol consumption per se. If a case manager suspects that a person is going to be a disruptive presence because of issues related to any addiction, then that person will not be placed in that housing. Not all homeless people are addicts, though, and not all are alcoholics. It is very important to note this. Only about half the residents at Jackson Apartments, for example, are mentally ill. Members of this population are all disabled, but they are also very diverse.

Dan Smith: Where does the sustaining funding for case management come from? Bill Lyons: It doesn’t all get secured at once or from one source. Ginny Weatherstone: We get grants from the City and the County for case management funding. Plus, VMC has embraced this as what we do. We fundraise. We’re increasing our pursuit of grants. We do much else to raise money for this work. Also, we will not provide ALL of the case management for everyone in PSH. Helen Ross McNabb, for example, does a great deal of excellent case management in the community, and they seek funding in many of the same ways we do. It’s just what you have to do.

Ginny Weatherstone: We know that what we do will save the community money, but that the effect of that savings will be cumulative and will not be immediately apparent. We will see it down the road when the jail doesn’t have to build another pod, for instance. You’re not going to immediately notice a savings to the community when just one person is housed, though.

Whitney Stanley: Are there separate approaches to case management and separate restrictions for people who are chronically homeless as opposed to those who are just down on their luck? Ginny Weatherstone: The latter would not be housed in a PSH development. Are there tighter restrictions on people in PSH? A better way to think of it is that there is a lot more supervision.

Is disability income used to pay for treatment? Ginny Weatherstone: Yes, part of the treatment.

Is this housing really permanent, or is it more transitional? Ginny Weatherstone: It is whatever the resident needs it to be. One of our folks at Jackson has been there for 15 years and will probably be with us for the rest of his life. Others have moved out much faster. It all depends on their needs.

How diverse is the chronically homeless population? Ginny Weatherstone: Very. They are disabled, but their disability is not always caused by addiction and it’s not always caused by mental illness. I mentioned before that only about half of the residents at Jackson have mental illness. We have some residents whose disability is simply the result of a physical impairment. Some are very young and some are elderly.

Nancy Mott: I have a concern about our progress moving forward. The old way was very expensive and it was less effective. I have brought some resources to help people understand this and would like to hand them out. They address myths about Ten-Year Plans, statistics on savings. You cannot treat addiction in people who are living on the streets.

Ron Peabody: Can disability recipients work? Ginny Weatherstone and Matt Nance: They can work, which scales back the disability payments for which they’re eligible.

Joe Minichiello: I’d like to ask James if I may where he is from and why he is here. James Johnson: I’m originally from Florida. I came here looking for work, and after I got here, I couldn’t find work and found myself homeless.

How are case managers trained? What kind of turnover do they experience? How stressful is the work environment? Megan Lappas: We have very low turnover at VMC. Our training occurs on a constant basis. The stress is pretty high, but the work is very rewarding.

Is two hours per week per client a sufficient amount of time for case management delivery? Megan Lappas: Different clients have different needs. I might have a client that I need to see on a daily basis, and I might have others who become self-sufficient enough that I might check in with them once a month. They’re very diverse in their needs and that affects the intensity of engagement. Matt Nance: We also maximize our efficiencies. For instance, I might wait until I’ve got a group of 4 or 5 clients who need to go to the Social Security office, and then get a van and take them all there at one time. We look for ways to do that kind of thing whenever we can.

Commissioner Brown: How do you make sure that meds are being taken? Megan Lappas: Some clients are responsible enough to take them on their own. Some get PACT (Programs of Assertive Community Treatment) supervision, which is for people who need more intensive mental healthcare. Sometimes the solution is as simple, and effective, as getting them an alarm watch to remind them of when they should take their medication. Matt Nance: The home visits we do let us check very closely on how this is going. We can see if a bottle of medication is being consumed at an appropriate rate. We can check on the condition of their apartment. All of those things will tell us if we have an issue that we need to deal with. Ginny Weatherstone: Also, not all  PSH residents are mentally ill. There is also a very high incidence of diabetes, hypertension, and we have to watch those things too.

The last question related to cost, and I didn’t really get much on paper about it. I think someone asked how we “arrived at a figure of $7M.” Someone else asked why Minvilla was not bid, I believe. The answer to the latter is that Minvilla’s construction contract was bid twice. (The contractor is making excellent progress on Minvilla, btw.)

Bill Lyons wrapped up our time by pointing out that the pro forma for Flenniken was presented at a recent City Council meeting, and it shows that no local tax dollars are in its funding mix, which is made up of private dollars invested via purchase of tax credits, grants, and federal dollars already appropriated for like purposes, allocated by the City and the County. He thanked everyone for taking the time to come out, and for the good dialog.

The next public conversation will be held at the Cansler YMCA from 6-7pm on Wednesday, May 19. The topic will be cost of PSH. We’ll follow the same basic format. First half hour presentation, second half conversation about the subject.