HMHS Supported Housing/Employment Services (l to r): Holly Combs, peer support specialist; Mike Donegan, program manager; Meghan Szczebak, employment specialist; Rena Elkin, housing & employment specialist; Teri Jo Punteney, peer support specialist; Nancy Dow-Witherbee, consumer computer lab manager; Martha Lindner, housing specialist; and Susanna Lovin, employment specialist. Photo by Topher Jerome
David, age 49, had been living on Seattle's streets for three years when he was brought to Harborview Medical Center's ER after attempting suicide. He spent three weeks on the inpatient unit, where he was stabilized on medication, provided cognitive-behavioral coping strategies and life skill assessments and training, and given assistance to apply for Social Security and Medicaid benefits. Yet his life was far from stable. He still was homeless and jobless, and he had symptoms of depression and psychosis.
Fortunately, David was in the right place. When he was referred to Harborview Mental Health Services (HMHS), he had access to an integrated housing and employment program that put him on the path to recovery. Upon discharge from the hospital, David entered a transitional home that partners with HMHS. In addition to receiving individual counseling from both his Harborview case manager and his housing specialist, David attended group meetings at the clinic and in his new home. In these sessions he explored ways to improve relationships with his housemates, keep his room clean, monitor his symptoms, and engage the community.
While the housing team helped David search for permanent housing, the employment team quickly arranged a volunteer job in the community that reflected David's ultimate goal of working in customer service. Later, with their continued support and a reference from his volunteer job's supervisor, a hotel hired David as a desk clerk.
As David's goals evolved, the employment team provided ongoing support through several job changes. Eventually, a local mental health agency hired him as a peer counselor. “It's great to see people seeking solutions to their needs,” David says. “It's real gratifying work. You see people change over a period of time, getting better. In certain situations, they're trying to follow in your footsteps, to become a peer counselor.”
David credits his success to the integration of Harborview's housing and employment programs. “I've been in other programs, but they didn't have housing and employment connected like Harborview does,” he says. “There were programs that helped me get ready for jobs, but they didn't help me with housing. I think that having housing and employment work together gave me empowerment.”
Integrating Housing and Employment Programs
HMHS offered long-term services to 1,384 consumers in 2007. When they entered the long-term programs, more than 60% were homeless and more than 98% were unemployed. In Harborview's integrated program the housing team begins working with homeless consumers immediately to help them qualify for subsidized housing and choose the type of housing that best meets their needs. Once a consumer is housed, the team makes frequent home visits and offers support groups at eight community housing sites.
As a public institution, Harborview does not own any housing units. Instead, the supported housing program partners with a wide array of providers, including private apartment managers, church groups, and large housing providers and housing authorities. With more than 200 subsidized units reserved for Harborview consumers, HMHS consumers have an overall homeless rate of less than 6%.
The employment team often meets with consumers before they move into their apartments and regularly attends housing support groups. Employment specialists work closely with the Washington State Division of Vocational Rehabilitation (DVR) to assist consumers. These practices have resulted in a 77% job placement rate for consumers with DVR plans and an average job search of 54 days. These results are even more remarkable when one considers that 16% of HMHS clients meet the county Medicaid guidelines for the highest level of care based on a GAF (Global Assessment of Functioning) score under 31, with a recent history of hospitalizations and/or incarcerations. In contrast, only 4% of clients in the regional mental health system qualify for this level of service. Overall, the rate of employment for HMHS consumers is 21%, compared to 12% for consumers of the regional mental health system. For consumers living in the buildings served by the supported housing and employment programs, the employment rate increases to more than 40%.
Combining Treatment and Rehabilitation
In traditional mental health services, treatment and rehabilitation often are considered distinct categories. While treatment involves psychopharmacologic interventions for “acute” consumers, rehabilitation involves psychosocial interventions for “stable” consumers. However, increasing evidence points to the benefits of using an integrated service delivery system that addresses mental illness as a chronic condition requiring ongoing and simultaneous psychiatric and support services.1