Prior to 1981 and the Arnold vs. Sarn class-action lawsuit, Arizona had a backwards approach in regards to mental health services for individuals with Serious Mental Illness (SMI). The state ranked 52nd in per capita funding for mental health services (behind the other 49 states, Puerto Rico, and the District of Columbia), and every other state in the nation except Arizona participated in the federal Medicaid program.
My, how times change.
Today, Arizona is a behavioral health leader. The state, which now participates in Medicaid, was last to join, but benefited from this by evaluating other states’ adoption hurdles and learning from them. Unencumbered by startup pitfalls and “unlearnings,” Arizona advanced quickly, creating a very sophisticated, interdependent system with the Medicaid authority, referred to as AHCCCS (Arizona Healthcare Cost Containment System), the Arizona Department of Health Services, and the state’s capitated health plans and Regional Behavioral Health Authorities (RBHAs). With it grew a network of specialty behavioral health organizations.
In 2015, the state ranks seventh among states in per capita mental health funding, and boasts some of the most advanced and integrated systems of care in the country, with an extensive array of crisis options, over a thousand peer and family roles, and children’s programming that is trauma-informed and inclusive of toddlers. In addition, the Mercy Maricopa Integrated Care RBHA is recognized as one of the most innovative and sought after models in the country and is being replicated in northern and southern Arizona.
It wasn’t until 2014, though, that the Arnold vs. Sarn litigation was finally put to rest. The agreement to terminate the case was made with an eye to solidify the gains of the last decades, but also to continue advancing the system into the future.
To satisfy the agreement, the state must show an increase in service, capacity and fidelity in four key SAMHSA best practices:
- Assertive Community Treatment
- Supported Employment
- Supportive Housing
- Peer and Family Services
The needs of individuals with serious mental illness are multi-variable and complex, and these four interventions are key to a behavioral health system that can accomplish the trifecta of better care, a better experience, and reduced costs.
In the area of Supportive Housing, Recovery Innovations has taken the lead.
Available, safe, and stable housing is a key component in a person’s wellness and recovery journey. However, housing is often unavailable when people are in the most need, wait lists are long due to a lack of inventory, and eligibility requirements may create barriers. People leaving the hospital may be discharged to the streets, as they have nowhere else to go. For others, they may be held in hospitals longer than what may be clinically indicated due to a lack of housing when they are discharged.
While there are housing programs nationwide, many may require a person go through multiple steps in order to “earn” his/her own place to live and/or to prove that he/she is “ready.” For example, the individual must be clean and sober for a certain length of time and at least seem mentally stable before being considered. On the off-chance housing options are available, they are often in congregate living arrangements with little privacy. Their roommates and neighbors are all people experiencing similar challenges and there is usually not enough support to go around. Furthermore, “house rules” restrict when they can come and go, who can visit, and what they can and can’t do.
The SAMHSA guidelines encourage us to put ourselves in these individuals’ shoes. Imagine living on the streets and struggling with co-occurring challenges. You are in a constant fight for survival and live in fear of being assaulted or arrested. Each day is a struggle as you seek to find shelter, food, water, and a way to escape the misery and despair of your circumstances. You may feel disenfranchised. You may feel traumatized by past and current experiences. You want some sense of hope and a refuge from your pain and living circumstances. You seek support from a housing program…and it’s really, really important.
Now, imagine being homeless and offered a chance to start over in a place of your own and of your own choosing. The lease is in your name and you live there as anyone else within the community – by the terms of the lease. You are now in your own safe and private environment of your choice.
And, what if the person supporting you in the process of finding a home also has lived experience with homelessness and co-occurring challenges? They have found his/her own wellness and have learned how to navigate the system and find relevant resources. They provide an example to you of hope and self-efficacy and are proof that anyone can defy their previous circumstances.
In addition to your own place to live, substance use treatment services, education, and vocational services are available to you. You’re inspired by peers, the services, and classes you choose and you find a desire to live free from subsidies and entitlements as you graduate from the support of the program.
The SAMHSA ideal sounds too good to be true, right?
Chris Bartz thought so, too, but as a former service recipient of Recovery Innovations’ housing program, that was his story. Now, as the Program Administrator of the Community Building supportive housing program, he has repeatedly witnessed similar stories of other individuals.
The Recovery Innovations’ Community Building Program utilizes a Housing First approach. Housing First programs aim to end homelessness by providing people with housing as quickly as possible and then providing additional services as needed. This gives individuals immediate access to housing despite substance use and/or mental health challenges. This approaches echoes SAMHSA’s Permanent Supportive Housing Evidence Based Practices.
Recently, a team from the the Western Interstate Commission for Higher Education (WICHE) visited Recovery Innovations. WICHE was commissioned by the state and Mercy Maricopa Integrated Care to conduct quality service reviews utilizing the SAMHSA fidelity standards, and Recovery Innovations’ Supportive Housing program was the focus (as part of the Arnold v. Sarn settlement conditions). All results are posted to the ADHS website, including the Recovery Innovations report.
Chris shared his experience leading the program with the WICHE reviewers: “In the near decade of working as a behavioral health service provider and almost 20 years of living with co-occurring challenges, I believe I have a unique perspective of the system. Providing Housing first and Supported Housing is not only the right thing to do for people, it works, and it saves the system a tremendous amount of money.”
Lawsuits are not about cost savings or public safety. They are invariably about social justice and human rights. At the core of SAMHSA’s models is the idea of zero exclusion for these services, individualized and integrated support services, as well as mental health and substance use services within the service mix, along with the idea that recovery is possible. Arnold v. Sarn has brought this foundation to housing for individuals with serious mental illness.
Housing may be the key in starting a person on his/her path to wellness. In addition, peers have the ability to make a tremendous impact in the lives of people they work with by demonstrating and providing a role model of what recovery and wellness look like.
Arnold v. Sarn will continue to positively shape a comprehensive Arizona community mental health system of care for decades to come. Expanding housing opportunities and the peer workforce in the SAMHSA arenas of Supportive Housing, ACT, Supported Employment, and Peer and Family Services is not just a good idea, but an important part of promoting individuals in their unique recoveries.
Notes: Dimension 6 of the SAMHSA fidelity model looks at the Indicator of the “extent to which tenants are required to demonstrate housing readiness to gain access to units.” The highest score of a ‘4’ in this area may be obtained for those programs which do not have any requirements for a person to first demonstrate housing readiness in order to obtain housing; meaning that there is not a need for an initial screening or review to determine a person’s readiness.
RI News Flash
On March 29th, Sue Ann Atkerson joins Recovery Innovations as Chief Operations Officer, bringing 19 years executive management experience from leading Arizona behavioral health agencies Southwest Behavioral & Health and TERROS. She is pictured above alongside Chris Bartz and Arizona Regional Director Marleigh O’Meara.
Velvet Elvis Update: Chris Bartz is the third individual at Recovery Innovations to join the ranks of Velvet Elvis recipient. The king transitions back to Arizona from Washington State and prior holder Liz Timko for her work in the Lakewood Recovery Pathway Evaluation and Treatment program. Congratulations, Chris!