Category: Housing

OLMSTEAD & THE HIGH END OF THE CONTINUUM OF CARE ---BEYOND CRISIS SERVICES

1/19/2021

WE'RE Focusing OUR 2021 COLORADO COGNITIVE DISABILITY Report on Olmstead

   We anticipate providing issue briefs on a Strength-Based Approach and Accommodations or Workarounds for Executive Functioning Issues later this year.
   It would appear that Colorado needs a lot more in Housing and Residential Services and Enhanced Services.
We need a system that is "RATIONAL" and "DATA-DRIVEN" and maintains "WAITLISTS MOVING AT A REASONABLE PACE."

   Some type of Crisis Services often are a part of many US Department of Justice Olmstead Settlement Agreements.

BUT they are HARDLY EVER the sole element of COMPLIANCE --- it's often also:

Housing
Assertive Community Treatment
Supportive Housing

States like Colorado often correctly say --- "Hey, we're doing that!" YEAH BUT ---- you need several thousand more slots.

Orchid's 2021 Colorado Cognitive Disability Report

State Governments: "Even though we know about those laws, still we don't comply with them" ---paraphrasing REO Speedwagon

5/3/2020

There are a lot of things that people with cognitive disabilities need and HOUSING is right up there.

We really need HUD to condition any money to States on COMPLIANCE WITH OLMSTEAD.

Specifically, that means:

Measurable Goals
Reasonable Time Frames
& Funding to Support the Plan

To bring Housing to SCALE for people who disabilities who are:

institutionalized
being released from incarceration
homeless
or otherwise at great risk of institutionalization.

REO Speedwagon 2010 -- about 30 years after "Keep on Loving You" (1980):
"And though I know all about those men
Still I don't remember"

This is pretty off the wall reference -- but whenever I think of Olmstead Compliance in this country -- this is what I think of.

Housing: A Conundrum for the States, A Nightmare for People with Mental Illness

2016: MLK Marade in Denver -- "Why is Michael Marshall Dead?"

Housing & Infrastructure

3/23/2020

While the Senate coronavirus Stimulus Plan does not address housing -- this is still in the early days of the emergency and there will likely need to be multiple ECONOMIC STIMULUS PACKAGES.

Supportive Housing is a FUNDAMENTAL aspect of our ECONOMY and SOCIETY.

It is crucial that DEMOCRATS and REPUBLICANS take this MOMENT to bring SUPPORTIVE HOUSING to SCALE.

Housing

Absent comprehensive and bold investment in our nation's housing infrastructure, the inequities in access to affordable, healthy housing will continue to grow.

[ Orchid: Further, housing is a primary SOCIAL DETERMINANT of HEALTH and lack of housing is a primary source of HEALTH INEQUITY.]

Infrastructure Equity

Council of Large Public Health Authorities

Public Housing IS Infrastructure

A Basic Need: American Infrastructure Must Include Housing

Document from Oregon Housing & Community Services.

Ethics & The Current System

7/27/2019

When we think about problems with the Mental Health System 2 Common issues that come up are:

Civil Commitment Statutes, and
HIPAA

Neither of these issues really gets to the root cause of most problems.

If there are sufficient:

housing
placements,
services, and
reasonable accommodations --

The rest is largely moot. When there aren't -- providers, family members and attorneys have a lot of hard choices to make.

We've learned the hard way how difficult it is to make the decision to file a petition for court-ordered evaluation even when the grounds may exist -- time, resources, unnecessary further upset, etc.

We've talked some on this page about what the goal is -- and not mistaking the "means" as the end. The goal is NOT certification.

The goal is adequate placements and services and avoidance of homelessness and criminal justice involvement.

That is not cut and dry. AND most importantly, are we going to do more harm than good?

That is the difficult problem many providers, family members and attorneys are faced with.

So the ultimate answer is not Civil Commitment Statutes that providers, family members and even attorneys may feel could make the situation worse.

But providers, family members, attorneys and the communities need VIABLE alternatives. Right now we don't have too many alternatives. That is why so many people rotate in and out of the Criminal Justice System despite being on Medicaid and often dumped by their providers.

HCPF [Colorado's Dept. of Health Care Policy & Financing] has not sufficiently addressed this.

BUILDING HOUSING, INFRASTRUC-TURE with skin in the game

7/24/2019

Affordable Housing is a big problem for people in Colorado and other large urban and rural areas in the US and around the world, and for people with physical and cognitive disabilities.

Further, HOUSING is one of the MOST IMPORTANT social determinants of health.

Social Impact Bonds are one way to seek financing, government funding, foundations, large donors, medium-sized donors, small donors, and micro donors should be part of the mix as well.

Imagine a world in which we're all more interested in HOME IMPROVEMENT & TAKING CARE OF EACH OTHER & EXPANDING OUR HOME IMPROVEMENT BUSINESSES & RELATED BUSINESSES.

Further, this new housing should take into account climate change -- not only what we build technologically but also where we build -- not along the coast of Florida or coast of Bangladesh.

Is that FANTASY going to pan out -- well probably not totally -- but things could be and should be a lot better than they are.

MAKING THE SUCCESSFUL HANDOFF FROM THE CRIMINAL JUSTICE SYSTEM TO INTEGRATED PHYSICAL & BEHAVIORAL HEALTH AND PUBLIC HOUSING OR RESIDENTIAL SERVICES

12/5/2018

Assertive Community Treatment & Flexible ACT Index

From my standpoint, the Criminal Justice System has been looking for alternatives to incarceration for decades.

I graduated from law school in 1988 and worked for 3 years @ the Oklahoma County District Attorney's Office. Even then in a conservative state, prosecutors were very open to considering drug or alcohol treatment or other appropriate treatment.

Later, in private practice, I represented a 16-year-old young man who was charged with Robbery with Firearms. He was certified to stand trial as an adult. The State recommendation was 25 to do. We entered a "Blind Plea" and the judge ordered him to a 90-day Program of "Regimented Inmate Discipline" [RID] and then a 5 year deferred sentence -- but if he came back the judge wrote that he was looking @ 45 years to do.

Guess what -- my guy ended up loving RID. The problem is many folks involved with the Criminal Justice System have extremely complicated difficult issues that are unlikely to get resolved in 90 days or even 180 days. In fact, my guy did end up picking up another charge.

When we make that hand-off to the Healthcare System we need to understand that we are making a potential LIFETIME COMMITMENT -- this isn't a term of years. That means using appropriate certification and substitute decision-making procedures when appropriate -- we don't want providers handing the person back to the Criminal Justice System. [There should also be an inclusive stakeholder group to oversee the use of such procedures]

It has been absolutely shocking to see Medicaid Mental Health Residential Service providers call law enforcement on minor matters when theoretically they should be able to initiate a 72-hour hold or petition the Court for an evaluation. Further, mental health patients who are just annoying as opposed to dangerous are @ great risk of this type of Mental Health Provider behavior.

Whether people with invisible disabilities or Mental Health Providers behaving badly -- in one sense, the problem is the same --- people are NOT getting enough support.

We can make this transition from INCARCERATION to HEALTHCARE -- BUT everybody needs to understand -- the State, providers, the Criminal Justice System, individuals, the Disability Community--that if providers do not seek appropriate certifications and or assisted/substituted decisionmaking when needed -- this is not going to work for many people.

On the other hand, providers must learn to deal with ANNOYING BEHAVIOR without resorting to the path of least resistance -- calling law enforcement. Note, most of this annoying behavior DOES NOT satisfy certification criteria for dangerousness; although most people in Medicaid Mental Health Residential arrangements probably do meet the criteria for "GRAVELY DISABLED" if they are not provided that residential support .

MOST PEOPLE WANT "HELP." MOST PROVIDERS WANT TO HELP. Not all providers are competent to handle every person. Throwing some providers in WAY OVER THEIR HEADS -- isn't helping anyone -- not the person, not the provider.

So we are aware of a situation in which the Mental Health Center washed its hands of the person, and a PROPERTY MANAGER was left to deal with someone with very complex needs.

We must provide a ROADMAP to providers to deal with these difficult situations & that probably needs to be in Volume 8 of the regulations for the CO Dept. of Health Care Policy & Financing.

Providers-- what support do you need to make the transition from Incarceration to Healthcare?

Complex Behavioral Problems are often NOT SOLVED on the Time Table provided by the Criminal Justice System

One of the reasons ACT is considered the GOLD STANDARD in Intensive Community Mental Health Treatment -- IT IS NOT TIME LIMITED

CO is in DESPERATE NEED of a STATEWIDE Olmstead Housing Plan for People with Disabilities

3/30/2018

The Proceeds of the Lakewood Property Sale Should Go To the CO Coalition for the Homeless

We have been BIG CRITICS of the Colorado Coalition for the Homeless' [CCH's] proposal for a Segregated Housing Project in Lakewood that could ultimately house 1,000 people who are homeless.
That is a pretty clear violation of the Integration Mandate of Title II of the Americans with Disabilities Act [ADA] and Section 504 of the Rehabilitation Act of 1973. Who is the violator?
Well, if approved it could be many entities:

CCH
US Dept of Human Services
the State of Colorado

On the other hand, what is CCH supposed to do?
Lakewood residents and even Disability Advocates like ourselves, are NOT giving them a lot of REAL ALTERNATIVES --- just moral support in varying intensities, mostly tepid.
CCH, people who are homeless in Jefferson County, Residents, and Disability Advocates need REAL INTEGRATED ALTERNATIVES.
Further, while most states' problems with homelessness are decreasing, Colorado's are increasing for many, many reasons.
If necessity was ever the Mother of Invention, Colorado's Homeless Problem could really be the catalyst to get a Statewide Olmstead Housing Plan for people with disabilities, including "invisible disabilities" such as mental illness, developmental disability, and brain injury that has:

Measurable Goals
Reasonable Time Frames, &
Funding to Support the Plan.

Now Olmstead is NOT going to cover every homeless person in Colorado, but it could be a HUGE step in tackling a problem that is confronting many people and communities with untold human misery.

We propose that the US General Services Administration [GSA] Sell the Property and Give the Proceeds to the Colorado Coalition for the Homeless to Provide Integrated Housing & Services to people who are Homeless in Jefferson County.

Is the provision under the McKinney Homeless Act requiring that any Homeless Provider use the Land in Whole -- a violation of Section 504 of the Rehabilitation Act
of 1973?

From the US Dept. of Health & Human Services --Discrimination Based on Disability
https://www.hhs.gov/civil-rights/for-individuals/disability/index.html#

We're Not Just Reaching A "Tipping Point" on the Provision of Integrated Housing & Services, We're Reaching A "Tipping Point" In Our Scientific Understanding of Many "Invisible" & "Cognitive Disabilities" --- & That Is Going To Revolutionize Our Society

3/15/2018

It's kinda FUNNY actually, that all the research that is coming out about our GUT & Microbiome could REVOLUTIONIZE our society -- but we think it will -- and like BOILING WATER -- the research and insights are coming FASTER & FASTER.
There are people who for thousands of years have understood that HUMAN BEHAVIOR is pretty complex, and maybe we should reserve judgment on our fellow human beings -- at the same time we do have to have Safety.
Some of our greatest Spiritual Leaders have voiced those views. Additionally, many Spiritual Traditions have a very strong component of "Social Justice."
When the World Health Organization says the best way to promote "Social Justice" is to ensure the "Social Determinants of Health" --- It sounds good. Can we quantify it? We have and --
We're on the cusp of REALLY being able to QUANTIFY it -- by looking at the individual's gut microbiome, among other things.
WE'RE STARTING TO BRING IT ALL TOGETHER:

The NEED for Individualized Medicine [understanding that INDIVIDUAL'S DNA, environment, etc.] -- Micro Approaches;
The Importance of our Social Environments to our Overall Physical & Mental Health -- Macro Approaches;
The Impact of "Social Stress" on our Gut & Microbiome
That the Gut & Microbiome Drive Auto-Immune Disease
That "Mental Illness" is often a complicated interaction of the Gut-Immune-Brain Axis.

So all that is pretty HEADY stuff -- back down to REALITY---
The 1000-Person Segregated Housing Project for Homeless People proposed by the Colorado Coalition for the Homeless.
First, if any of us had done a fraction of the GOOD that the Colorado Coalition for the Homeless has done -- WE WOULD ALL BE SAINTS.
The Colorado Coalition for the Homeless is just operating in a very difficult reality and trying to make it better. And that's probably true for everybody, including Lakewood officials, residents, and the Hickenlooper Administration.
Part of Gov. Hickenlooper's success as a politician is that he recognizes it is very difficult to get anything done without strong public support -- certainly in the political arena.
Colorado has a growing homeless population unlike most states -- and there are a lot of reasons for that, and not all people who are homeless in the State have:

"mental illness"
brain injury
developmental disabilities, and/or
substance issues

BUT many of them do.
And it is really in everyone's interests to do legally required Americans with Disabilities Act-US Supreme Court mandated Olmstead Inclusive Planning when we don't have sufficient Integrated Housing & Services to prevent unnecessary institutionalization, including incarceration, or the great risk of institutionalization inherent in homelessness.
We just bet if there was enough support for this -- even with the limited time remaining in the Hickenlooper Administration -- they would try to begin Inclusive Olmstead Planning to bring Integrated Housing & Services to Scale to Meet the Need for People with Disabilities.
Including in that process:

People with Disabilities
Law Enforcement
Residents & Homeowners
CO Counties
CO Municipalities
Family Members
Concerned Coloradans
Maybe even CU Researchers
Other Academic Researchers
The CU National Behavioral Health Innovation Center
Etc.

It's not just Lakewood and Jefferson County that are facing a homeless problem -- Denver, Pueblo, Ft. Collins, and many others are as well.
AND that homeless problem is often at least in part an "INVISIBLE DISABILITY" problem.
Colorado has the opportunity to LEAD the nation in addressing that.

Gov. Hickenlooper says among other things: "We're going to concentrate on finishing strong."

Social Determinants of health

New Science Is Amazing & It Has Huge Moral Implications -- NOW

Social Determinants of Health, Social Stress, the Gut & Microbiome & -- Mental Illness

Male Human Persons + Neuro-Disability & Anti-Social Behavior

3/5/2018

I think for at least some of us, this does come down to algebra ---

x + y + (others?) = z

If "z" is anti-social behavior which may or may not be evil --- what are "x" & "y"?
If "x" is a human person, maybe especially a male human person [although not always], what is "y"?
I would submit "y" is often "neuro-disability,"
especially those neuro-disabilities that affect:

self regulation;
emotional regulation
etc.

This may very well be a BIGGER problem for boys and men, because of our evolutionary history and that male human persons tend to be more "aggressive" than female human persons.
This is NOT meant to be sexist -- this is meant to recognize the fundamental need to treat people "equitably" and that often means recognizing real differences that affect life trajectories.
This also isn't meant to suggest that every male human person with a "neuro-disability" exhibits "anti-social behavior."
"Neuro-disabilities" are probably pretty widespread across the human population and account for a lot of "diversity." "Neuro-disabilities" can involve speech and movement.
It is probably identifying specific "neuro-disabilties" that can be particularly problematic such as neuro-disabilities affecting self-regulation and emotional regulation.
"Neuro-disability" is seemingly a much more functional category than "mental illness" or for that matter "brain injury" -- and at least suggests that the "neuro-disability" will be more specifically defined and that can lead to the "reasonable accommodations" necessary.
Maybe that is more of a "HOPE" than a "REALITY," but it could happen -- especially, if WE ALL PUSH FOR IT TO HAPPEN.
There are A LOT of parents and grandparents that may very well know that little or not so little Johnny has some behavior problems. Further, at some point, Johnny may know something isn't right.
They don't want to see Johnny locked up, Johnny doesn't want to be locked up. Further, the Jails & Prisons don't know what to do with Johnny.
The Community does have an obligation to provide Safety -- AND it has an obligation to Johnny and his family -- to make available community services and housing as well as institutional services to Johnny where necessary.

So There Are A Lot Of Issues For CO Medicaid Assertive Community Treatment: Parity, Network Adequacy, Adequate Planning, Provider Reimbursement, Etc. [& Olmstead]

2/10/2018

Things happen for reasons. Usually a lot of complicated factors.
We don't have Thousands of Coloradans with Mental Illness:

In Prisons & Jails
On the Streets, and
In Nursing Homes

by accident.
We've made some pretty HORRIFIC policy choices as a society, here in Colorado and across the Country.
AND at one time, we thought we could get away with those short-sighted choices refusing to:

adequately fund Housing for people with disabilities; and
refusing to do the REAL PLANNING and NETWORK ADEQUACY WORK for INTENSIVE COMMUNITY MENTAL HEALTH TREATMENT that people in this State need --- NOT just LIP SERVICE to it. [Remember, this is the same Administration that refused to do Olmstead Planning with measurable goals & refused to respond when asked about a waitlist for Assertive Community Treatment]

So our point is essentially without:

some type of specific measure of "Reasonable Medical Necessity" for Assertive Community Treatment
and applying that to the relevant populations

-- How is Colorado going to know if its Network is Adequate?
Of course, the rest of us already know that Colorado Housing and Medicaid mental health services are NOT sufficient to keep people out of:

prisons & jails
homeless shelters
nursing homes, and
mental institutes

This really isn't rocket science folks -- it can just be expensive. While this is going to mean an increase in Community Mental Health Costs, it will mean a decrease in:

Corrections Costs
County Jail Costs
Nursing Home Costs

We're willing to work with people on innovative solutions and we're tired of playing games.

CODE OF FEDERAL REGULATION SECTIONS ON: MEDICAID MANAGED CARE NETWORK ADEQUACY STANDARDS, ETC.

Does Colorado Medicaid NOT know that there are thousands of Coloradans with mental illness in Colorado Prisons, Jails, Homeless Shelters, Nursing Homes, & Mental Institutes, Etc. Okay -- not all of them need ACT -- but don't we need to figure out who does. [Amy Poehler on SNL]

Our Understanding of Medicaid Network Adequacy is:

Expected Utilization of Services
Based on Member Characteristics
& Health Care Needs

(at least that is the way Wisconsin is defining it)

So you can see why refusing to do Olmstead Planning is such a BIG DEAL -- IT ALSO IMPLICATES THE ADEQUACY OF THE STATE'S MEDICAID NETWORK.

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