Seven Counties Services Housing First

Kentucky established the Personal Care Home (PCH) level of care in 1974. Today, Kentucky has 6,490 personal care home beds licensed statewide, with at least 1,500 occupied by persons with psychiatric disabilities. The Kentucky Department of Behavioral Health and Developmental and Intellectual Disabilities (DBHDID) funds the operation of three freestanding PCHs. Seven Counties Services (SCS), the regional community mental health center in Louisville, has managed one of these PCH’s on the grounds of the state hospital in Louisville since the fall of 1994. The home is known as the Center for Rehabilitation and Recovery.

Although not a proponent of personal care homes, SCS took the challenge to create something more than a warehouse environment for the new residents. The program’s mission and values are based on principles for a recovery-oriented service system. The programming and documentation follow psychiatric rehabilitation technology published by Boston University and the Center for Psychiatric Rehabilitation in Boston.

The center quickly produced significant reductions in hospitalizations and improved skill functioning for the residents. The center also witnessed the quick deterioration of individuals who moved from the PCH to the community due to the ‘support gap’ in the outpatient system’s continuity of care. There were also obvious barriers to recovery within the PCH itself, including the stress of congregate living and the perpetuation of learned helplessness.

Weighing the pressures from both ends, we began the push ‘de-congregation’ soon after opening. Our goal was to locate appropriate housing in the community and provide needed supports and services within the homes of the individuals we served. We heard naysaying from every quarter of our community: We could not afford to change the service model. We could not provide the support needed unless everyone was in the same building. The individuals served were far too ill to live outside of a PCH. Everyone leaving the state hospital needed a step-down environment before living in his or her own home. There were endless predictions of certain failure, many identical to arguments offered in similar efforts across the country.

Over the span of nearly two decades, we met with each new incoming DBHDID Commissioner to sell the idea that we could de-populate the home and support the residents in community living. We proposed providing our same “package of services” to those we serve whether their bed was in the PCH or in their own apartment. We described it simply as a staff transformation into a mobile support team providing in vivo skills training, medication assistance, physical health monitoring, supportive counseling, and 24/7 access and availability.

Since existing evidence from other states was unconvincing, we produced our own evidence. We assisted two male residents in a move to their own two-bedroom apartment near the PCH. We continued to serve them daily while operating the PCH at full census. We then invited DBHDID representatives to visit the apartment and listen as the men shared the profound positive change in their lives. They were eloquent spokespersons for the “intervention” of a chosen environment and the receipt of voluntary, flexible supports. As a result, our proposal was accepted and our contract renegotiated to accommodate our transformation to the evidenced-based practice of Permanent Supportive Housing. The Center for Rehabilitation and Recovery recently changed its name to Seven Counties Services Housing First, Your Home Team to accurately reflect our new structure for service provision.

To-date, we have moved twenty-two individuals into their own apartments. These individuals are doing well and are happy with their new lives. We anticipate moving eight more individuals at the end of 2012. Our goal is to move the remaining residents and close the PCH by the summer of 2013. Our state has significant Olmstead litigation exposure because of our use of institutions for housing persons with psychiatric disabilities. Interested parties have coalesced to explore possibilities for judicial remedies. We are confident that our success can play an important role in the development of more supportive housing options for people in Kentucky and serve as a model for the type of actions and decisions that are needed to satisfy the letter and intent of Olmstead. Our program provides compelling evidence that individuals of all abilities can live successfully outside of institutional settings.