Statements of Need and Recommendations

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IV. Increase residential care and supported housing capacity

Gap Addressed

As noted, over 25% of ASH’s current capacity is filled by individuals staying in the hospital longer than a year and many of those significantly longer. Maintaining these individuals in a hospital setting is perhaps the least effective and most expensive approach toward meeting their needs. Alternative care settings are critically needed.


1. Foster better use of the HCBS-AMH 1915(i) State Plan Amendment program.

As described in the “Financing” section of this report, the 1915(i) Home and Community Based Services – Adult Mental Health Program within the state’s Medicaid plan was specifically developed to assist long-term state hospital residents to transition to the community. However, the program has encountered operational barriers described by the Meadows Mental Health Policy Institute in Appendix 15. In this biennium, we recommend creating a regional work group, funded by HHSC that engages the relevant stakeholders to evaluate and overhaul the 1915(i) HCBS-AMH program so that community providers believe that it is financially and clinically viable as an alternative to ASH for long-term patients. As noted previously, Meadows Mental Health Policy Institute analyzed this program, and they provide a framework to address these barriers (Appendix 15). These proposals will need to consider older individuals who need complex medical and mental (including memory) support as well as younger individuals suffering from severe and persistent mental illnesses that cannot be safely released to their own care in the community based upon their illness.

2. Finance expansion of evidence-based residential care and supported housing.

Although these individuals remain hospitalized for many reasons, including some caught up unnecessarily in long-term competency restoration (as previously discussed), the major barrier to discharge is a lack of long-term residential care and supported housing options. Residential care refers to long-term care given to adults or children who stay in a residential setting rather than in their own home, family home or a hospital. There are various residential care options available, depending on the needs of the individual, including skilled nursing facilities and small community-based group homes. Supported housing encompasses a wider array of options. One example is a therapeutic housing facility in which the community itself, through self-help and mutual support, is the principal means for promoting recovery. Other examples include group homes, supported living residencies, and halfway houses. In these types of facilities attached staffing, such as a house manager, helps residents remember to attend appointments or take medications. Often residents of supported housing have a case manager employed by the Local Mental Health Authority. Home-health care can provide similar support for individuals who own a home. All of these approaches are specifically designed to provide long-term, chronic care and recovery support much less expensively and more effectively than an inpatient setting. There are both open and locked facilities that could meet a wide variety of these needs, and they are less expensive to build and operate than an inpatient setting. Increasing availability of both residential care and supported housing throughout the ASH Service Area would help LMHAs to manage the region’s mental health needs much more efficiently than continuing to expand inpatient facilities; some individuals needing care might be referred to these facilities from short-term acute care settings and never need a long-term subacute inpatient admission at ASH.

A number of private and community organizations provide these types of services for older individuals suffering from Alzheimer’s disease and other dementias. These facilities are typically only available to people with insurance or financial capacity to afford the residential care. This type of care, however, as well as private skilled nursing facilities, might provide relatively immediate alternatives for some individuals residing at ASH. There is considerable skilled nursing capacity in the Service Area (see “Current State: Inpatient Facility Utilization” section). To do so, the state would need to provide either direct (e.g., CPB for long-term care) or indirect (e.g. tax credits) financial incentives to these community partners. Alternatively, the state might invest in building residential care or therapeutic housing that it manages through Local Mental Health Authorities. Based upon the $4.6M needed to operate a 24-bed inpatient unit, it would support only 24 people residing for up to one year on the inpatient unit. In contrast, that same $6.5M would support, at a minimum, 125 individuals in residential care and that many or more in supported housing (depending on the structure). Additionally, home health agencies specializing in brain health could support individuals in their homes; again, at this same expense, with 4 hours per day of home health support, over 200 individuals could be supported for a year.

With these considerations in mind, we recommend: 1) release the Request for Information referred to previously to include developing a residential care facility on the ASH campus as a test of partnering opportunities with either private companies or LMHAs; and 2) request HHSC develop a comprehensive proposal within the Office of Transformation to develop residential care, supported housing, and home health capacity for the state.

Recommendations Summary: Increase Residential Care and Supported Housing

• HHSC to fund a regional work group to eliminate perceived and real barriers to better use of 1915(i) HCBS-AMH funding to expand supported housing.

• HHSC to develop a comprehensive plan for expanding residential care, supported housing, and home health capacity in the state (including the ASH Service Area).