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Supportive Housing for Homeless Adults with Seriou ...
Presentation Q&A
Presentation Q&A
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Dr. Rosenknecht, one of the first questions that came in was, do you feel like there should be a different approach for those who are chronically homeless versus those who are recently homeless? Yes. Much of what I've discussed is of relevance to people who are chronically homeless and seriously mentally ill. Most homeless people are homeless for a short period of time. There also are what are called shallow subsidies to help people who have become homeless, to help them make their next rent payment. Differentiating those two cases can be a challenge, but yes, not everybody needs intensive support and housing of the kind I've described. It's very important programs, and this has been true to some extent in the VA, get doctrinaire and say everybody must be seen by their case manager once a week in a sort of community treatment style. The fact is not everybody needs that. Individualizing the care is, of course, as always, very important. There was a question related to this, which is, it's been easier to work with homeless men because the homeless women often have children, and that makes it much more complicated. Can you speak a little bit to that? Well, as someone who's done most of my work in the VA, I have to admit we haven't had very many women and not very many with children. However, I've worked in other non-VA programs, and what we showed was that when you housed women, there was the possibility of reuniting them with their children. We showed us, I don't remember what the percentage was, that that does happen, but obviously, as I understand it, the Section 8 program, no, I think it is available to families. It's not available to unrelated adults, which can be a problem. So yes, I agree it's a challenge. It's not an area in which I have a lot of expertise. Great. Someone just wrote in and said, do you find that chronically homeless people that move from city to city have severe mental illness? I'm thinking about those individuals that are sometimes described as transient. Well, it turns out, I don't know that there's been much study of this recently, but there was a lot of study of this early on in the 90s. And it turned out that the myth that homeless people are wandering around the country, which may have been true in the 1930s, is much less true. That most people who were homeless or in shelters are in the city in which they were residing before they became homeless. There are some, there's a kind of famous story about the I-5 corridor on the West Coast, and we did some studies, and there is a proportion, I don't know the exact proportion, of people who move, who are mobile. They tend to be less interested in services, but I don't think that's a major phenomenon in this population as far as I know from research. Terrific. This person said, thank you for this excellent talk, Dr. Rosenheck. If housing doesn't help people's mental health and functional outcomes substantially, what do you think are the most effective evidence-based approaches for improving these outcomes? Well, that's a big question. I have to admit that I was raised a psychiatrist and I, you know, for serious mental illness, if there was one thing I could do for people, it would be to get the medication. You know, there's the whole need for wraparound services, for rehab, for all those other things. But I've done some work in Ghana, in Nigeria, and I've seen what life is like for people who cannot afford antipsychotic medication. And it's just, you know, that's step one, as far as I'm concerned, that's step one. That doesn't solve anything. We still have lots of homeless people living in squalor. But I think that's the most effective treatment we have for severe mental illness. But it's not everything they need, and it's not everything that we have to offer. Could you speak on your thoughts about the work of Dr. Jeff Brenner and his, quote, hotspotting model of providing care to high-need, high-cost patients? I don't. I don't know Jeff Brenner. I'm familiar with certainly the idea of targeting high-cost patients. You know, the VA is such a big system with five million patients and one and a half million people with mental health problems that you can take the top 100 and those patients are costing, you know, $5 million a year. And it's been a, you know, it's been an idea that's been around for at least, you know, the 30 or 40 years I've been working in the field to target the high-cost patients. And that is what we do in the VA with assertive community treatment. We, you know, we take the most expensive patients, those who stay in the hospital who need the most services, and we focus intensive treatment on them. And this is, like most things, is partially effective, but it doesn't solve the problem. So this person wrote in a comment, and I think it's, you know, I just read it. It's long, but I think it's worth reading. I think it will resonate with some of the things you said early on. So I just want to read it. It says, Medicare plus Medicaid account for $800 billion or more. For adults, Medicare and Medicaid has not included SDOHs as part of what they will pay for for people with SMI. In fact, Medicaid will not recognize tenancy support as a clinical service, though they are awakening to what SDOHs can do to reduce costs, but more importantly, help people recover the lives interrupted by SMI. People just having mortgage interest credits on their taxes pales in comparison to what can be done with 2% of Medicare and Medicaid monies for housing plus case management plus tenancy support. Just some ideas. Well, let me share one other idea with you while we're talking about a world that could be. I spent part of my career studying atypical antipsychotics, and at the peak, we were spending $10 billion a year on atypical antipsychotics. And as far as I could tell, and I'm sure many of you will disagree with me, as far as I could tell from the research, they had little or no benefit over older, less expensive medications. And people would say, so what's $10 billion? And for $10 billion, well, $10 billion is $2 billion more than we spend on the whole profession of psychiatry in America. And for $10 billion, you could hire 150,000 social workers, which is three times as many as there are, and you could provide every person with serious mental illness in America with assertive community treatment, which I think would be an advantage over what we're providing now. How funds get allocated in this country is not necessarily the way everybody would like it to be. Let me leave it at that. But I think I'm supporting the perspective and the concern of that comment. Right. I think we're all in the same choir. So I need to wrap up now.
Video Summary
In this video, Dr. Rosenknecht discusses different approaches for chronically homeless individuals versus those who are recently homeless. He emphasizes that not everyone needs intensive support and housing and that individualized care is important. He also addresses challenges in working with homeless women who have children and mentions the possibility of reuniting them with their children when housed. Dr. Rosenknecht also talks about the misconception that homeless people wander around the country, stating that most homeless individuals are in the city where they were residing before becoming homeless. He highlights the importance of medication for severe mental illness and mentions the effectiveness of targeting high-need, high-cost patients. The video concludes with discussions on the allocation of funds for housing and mental health services.
Keywords
chronically homeless
recently homeless
individualized care
medication for severe mental illness
allocation of funds
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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