Statement of Need and Recommendations

Recommendation 2:
Plan, invest, build, and support a continuum of housing for people residing in ASH  

Therapeutic and residential housing is needed as alternatives for people residing at ASH. Just as each work group recommended salary increases for hospital staff, each work group mentioned the need for more and varied housing in the continuum of care. A summary of each work group’s recommendation is provided here with more details listed in each work group’s report in Appendix 5 - 9. 

Competency Restoration Work Group – Campus housing that supports people with a history of criminal charges, mental health needs and competency restoration to offer the opportunity to discharge from the hospital when a lower level of care is needed, but competency has not been restored. 

Academic and Area Experts – Housing in a campus hub setting where students, residents, fellows, and peers can work collaboratively in a multidisciplinary setting for individuals who have discharged from ASH but are not clinically appropriate to return to a community setting. 

Peer and Family – Housing units located on the campus and throughout the continuum that are peer-run. Specific to the campus, a respite facility run by peers for people in need of short stays between 3 – 5 days would be a good next step. From the work group’s research, an example from Massachusetts found that a day bed rate of $305 – less than half the cost of the ASH bed day rate of $806 (HHSC, 2022) – be provided by such a facility. 

The Housing Work Group examined the individuals that are residing at ASH with barriers to discharge, called the 365+ day list; this list represents people who have been at ASH for over a year. Figure 5, shows the fluctuation of people at ASH greater than 365 days, ranging from 75 to 100 between October 2020 through September 2022. At the time of the work group, there were 85 people residing at ASH for over a year. Figure 6 provides the general characteristics of the population. The work group determined that not just one type of housing is needed, but a variety of options to support individuals as they transition and work through their recovery. 

Figure 6: All Catchment LMHA 365 General Characteristics

Campus Housing – Each work group in Phase III recommended building housing directly on the ASH campus. The master plan (Appendix 3) developed in 2018 planned a campus for several partners to support brain health recovery through all stages of a person’s journey and HHSC posted a request for information (RFI) from interested organizations to build out the master plan in Fall 2021. One of the spaces on the campus indicated housing or a residential facility. Many individuals on the 365+ day list need a secure setting with 24/7 care, but at a lower level of care than ASH provides. People with these needs would benefit from a residential facility on the ASH campus. As recommended in Phase I and Phase II, a standalone residential facility with 48 – 72 beds would allow people needing a lower of level care to move to a more appropriate facility and, hopefully, more clearly delineating ASH as an acute and subacute facility only (for which is designed, and its cost structure supports). 

In 2018 a 48-72 bed residential facility was estimated to cost $15M - $45M; with recent price escalation, a facility of this size in 2024 would cost $30M - $90M, see Table 3. 

With a residential facility on ASH’s campus, 48 – 72 beds in the new hospital would become available that can be used to support more people in need of acute and subacute mental health care. Individuals without longer term needs currently stay at ASH 90 – 120 days, at times without clear rationale for why ongoing inpatient level care is clinically necessary. With the addition of a 72-bed residential facility to support longer term care and opening beds for individuals even with a longer than 120 average day stay, ASH could then serve about 200 more people per year. As the continuum of care creates more available discharge or step-down options, the number of people served by ASH will increase through shorter acute hospitalizations and more effective, less intensive and less expensive community residential and outpatient mental and physical care. 

Bridging Hospital to Community – A variety of housing supports are needed to create multiple alternatives out of the hospital. Not everyone will discharge from ASH back to their community; some may need a gradual return, but not a long-term care facility. The Peer and Family and Housing Work Groups recommend more peer-run houses on campus and in the continuum of care. An example of a peer-run respite facility is the Kiva Centers’ Karaya in Massachusetts that offers 24/7 support for people in crisis and a place stay on average of 5 – 7 days. Karaya is designed as a psychiatric hospital diversion program and also decreases the potential for law enforcement engagement. A service like Karaya located on ASH’s campus as part of the continuum of care will assist people in crisis with short-term needs and decrease their chances of hospitalization or involvement with the criminal justice system. More peer-run services continue with the person-first approach and increases peer services within the continuum. 

Along with peer-run respites for a shorter-term care, the Housing work group recommends increasing step-down housing through the Step-Down Housing Pilot overseen by the Behavioral Health Services Division. At the time of this report, there are two step-down pilot homes in the ASH region managed by Bluebonnet Trails Community Services. As this program continues to prove successful in assisting people discharging from ASH and other state hospitals, HHSC can replicate the program throughout the State. 

Right Size the need – data collaboration

There are several local and state efforts that strategize solutions for housing needs, and yet improvements have been elusive. The efforts made are not unrecognized, but are stacked up against large demand. Appendix 10 provides a Housing Matrix for the ASH service area that looks at what was available in continuum services during calendar year 2022. Programs and services may have changed over time as new programs opened and others closed. The matrix describes what is available in the service area, but it is a complicated system to navigate. Therefore, a collaborative effort is needed to identify, distribute and maintain available housing services for people with mental illnesses. By sharing the available services for housing with community and state mental health care agencies, use of these facilities can be optimized. Nonetheless, even with this optimization, the supply of alternative care options (to hospitalization) is underdeveloped in Central Texas. 

Funding 

Phase II of the ASH Redesign reviewed the Network, a supportive housing network of New York that has a funding guide to support expanding housing through multiple funding sources. This funding guide is a valuable tool for organizations interested in building housing options into the continuum of care. In research and conversation with the Network, the group explained the funding guide is the most visited portion of their website, highlighting the value it brings to their community. The funding guide is relatively low maintenance and requires less than 1 full time employee to update. A list like the Network’s funding guide was created for resources available in Texas for funding housing options. The list can be found in Appendix 11. Although much shorter than the Network’s list, it is a starting point for interested organizations looking to fund housing opportunities for Texas. It is recommended HHSC consider maintaining a similar list and offering this resource on their website for organizations to use in the future. 

Delaying investment into a variety of therapeutic housing options for people with mental health illnesses puts ASH under pressure to serve as a residential facility. This pressure is in contrast to its better role in the continuum as a subacute care facility. Better would be a broader range of therapeutic housing options to allow people to continue their recovery in more appropriate settings when inpatient level care is no longer needed; moreover, these resources would then permit ASH to serve more people needing acute and subacute clinical care, i.e., requiring hospital level support. Housing options are required to create an efficient and wise investment in the new ASH.