POLICY ISSUE ANALYSIS

Mental health and housing

What is the policy issue?

For those Australians who experience mental ill health, living in safe, secure and stable housing is an important part of their road to recovery. Determining housing policies for people with mental ill health of course means considering people with a broad range of illnesses that may present at different intensity levels at different times, resulting in quite diverse outcomes.

Housing which fosters meaningful relationships for individuals, both in the home and the community, is associated with improved wellbeing and quality of life, and decreased symptoms and service use. In addition, being in control of one’s housing can deliver positive mental health outcomes through feelings of empowerment and belonging, both of which are associated with greater resilience and ability to cope with stressors among people with severe mental illness. Furthermore, to access needed health services and supports an individual may need a fixed address or stable housing.

On the other hand, not being able to find affordable housing has been found to be detrimental to mental health for lower income householders, while there was no such association for higher income households. Where householders experiencing mental health disorders have been able to access housing which has a stable tenure, they have been able to focus their attention on mental health treatment and rehabilitation.

Key fact

In the year before they accessed support, clients of Specialist Homelessness Services (SHS) were heavy users of non-homelessness services such as health, justice and welfare services when compared with the Australian population average.

Every year, 1 in 5 adult Australians are estimated to experience mental ill health (equating to about 3.8 million Australians in 2015). Overall, 45.5 per cent of Australian adults (about 8.5 million people based on 2015 population) will experience a common mental health issue at some point in their lifetime.

Of those experiencing mental ill health, around 720,000 Australians (3% of the 2015 population) have a severe mental health disorder or illness, with a further 1.2 million having a moderate disorder (4–6% of population) and 2.5 million having a mild disorder.

With such a large number of people affected by mental ill health, the subject demands serious policy considerations beyond the health portfolio, with housing and homelessness solutions being very relevant. In 2016–17, 77,569 clients of SHS (being 32% of all SHS clients that year) had a current mental health disorder, and of those clients 47.8 per cent had been homeless at some point in the previous 12 months.

People presenting to medical services with mental ill health have a huge impact on government service demands, and on budgets. In 2015–16 over 2.3 million people received mental health-specific services through Medicare, while 244,934 overnight hospitalisations were for mental health care, amounting to nearly 4 million patient care days. In total, Australian Commonwealth, State and Territory Governments spent $9 billion on mental health related services.

Policy development options

The policy options presented here are drawn from the limited evidence-base of mental health and housing.

1. Explanatory statement

Property managers and housing workers, in both social housing and the private rental sector (PRS), are often among the first people to observe that their tenants are experiencing a mental health disorder. However, managers may not recognise tenants’ behaviours as originating from a mental health disorder, and instead may impose sanctions such as evicting the tenant.

A very practical policy solution would be to develop education programs for social housing and PRS property managers so they can recognise mental health disorders in tenants at an earlier stage and know what support services they can steer tenants towards. In particular, such programs could help connect social housing providers with mental health services so that state and territory housing anti-social behaviour policies (such as eviction) are not inappropriately applied to tenants suffering from mental ill health.

Research into anti-social behaviour in public housing identifies that anti-social behaviour is often an indicator that a tenant who suffers from mental health problems person is unwell or that their support programs have ceased. If housing policies enforce eviction it can mean individuals move to private rental in the same community or to another government or community supplied dwelling elsewhere where the anti-social behaviour may continue, or in a worst case the individual may become homeless.

2. A real world example

While there are no examples of education programs specifically targeted for property sector workers, as part of a previous 'Taking action to tackle suicide' program,  the Commonwealth Government provided funding for ‘mental health first aid training for frontline community workers in the financial and legal sectors, relationship counsellors, and healthcare workers. These sectors interact with people who may be in financial, legal or relationship crisis where the risk of suicide is increased.’

As part of the program, specialised training organisations, such as Mental Health First Aid Australia (MHFA),  were contracted by the Department of Health to train people in how to identify people at risk of suicide and how to respond appropriately. Such education programs could be expanded to cover real estate professionals (in both social housing and the PRS).

3. Scope of the practice

Not applicable.

4. Effectiveness/impact

An evaluation of MHFA Australia programs published by the National Center for Biotechnology Information (part of the US Government National Library of Medicine) found that ‘MHFA increases participants' knowledge regarding mental health, decreases their negative attitudes, and increases supportive behaviours toward individuals with mental health problems.’ Similar courses targeted to the housing sector are very likely to achieve similar positive results.

5. Guide to evidence

Not applicable

1. Explanatory statement

Many people who have been hospitalised as a result of a severe mental health disorder face a significant risk of becoming homeless when they are discharged. A survey of 2,388 people attending psychiatric clinics in inner Sydney homeless hostels found that 21 per cent of patients identified that being discharged from hospital was a key step to them becoming homeless.

Although it is common practice in Australia for those exiting hospital to be monitored by a hospital discharge liaison officer, there can be long delays between discharge and follow up. In addition, follow up services may only be possible if the person has been discharged to a fixed address. If a person becomes homeless after discharge they may slip through any provided support programs.

Government legislation should require that no person is discharged from a hospital psychiatric ward into inadequate housing or homelessness. However, such legislation would rely on social housing providers (both governments and community housing providers) having sufficient quantities of housing available for people to access when they are discharged.

2. A real world example

Transitional housing treatment programs (THT) supply short-term housing options for patients who are deemed to be at risk of becoming homeless when they are discharged.

One example currently operating in Australia is the Housing and Mental Health Pathway Program (HMHPP) delivered by Launch Housing in Victoria. This program is for adults aged 18 to 64 who have been discharged from psychiatric wards at either St Vincent’s or The Alfred Hospital, who are not currently case managed and are experiencing or at risk of homelessness after being discharged.  HMHPP has both short and longer term clients. It provides longer term case management support to clients who become tenants in social housing and short-term assistance to others to find emergency accommodation and referrals to local support services.

In the UK, the National Institute for Health and Care Excellence (NICE), which is part of the UK Department of Health, publishes guidelines to help patients with mental health issues after they discharge from National Health Service (NHS) hospitals.

Within 24 hours of the patient being discharged the hospital psychiatrist should ensure a discharge letter and copy of the patient's latest care plan is sent to the patient’s GP, to the patient, and other specialist services if appropriate.

Within a week, a discharge summary is sent to the GP and others involved in developing the care plan, subject to the patient’s agreement. This should include information about why the patient was admitted and how their condition has changed during the hospital stay. Such documentation is to identify any risk of suicide and incorporate appropriate actions into care planning.

The patient is to be contacted again by the discharge team within seven days. If the patient has been identified as being at risk of suicide they are to be followed up within 48 hours.

3. Scope of the practice

The Victorian HMHPP inpatient service comprises a number of wards; one for the City of Yarra and one for the City of Boroondara, in addition to the Koori Mental Health Service. In total there are 44 beds available.

4. Effectiveness/impact

There is no available evaluation of the current Victorian HMHPP program, however there was an evaluation in 2015 of four preceding programs as part of St Vincent’s Hospital Melbourne homeless services: Assessment, Liaison, & Early Referral Team (ALERT); Clarendon Homeless Outreach Psychiatric Service (CHOPS); The Sister Francesca Healy Cottage (The Cottage); and Prague House. In all, 359 clients identified as homeless or at risk of homelessness accessed one or more of the services, with 431 episodes of care provided.

As each of the four services offered differing styles of support, the average length of an episode care was quite different; ALERT (95 days), The Cottage (9 days), CHOPS (997 days; approximately 2 years and 9 months) and Prague House (2,505 days; approximately 6 years and 10 months). Across the four services, there was a 28 per cent reduction in the number of clients who accessed the hospital emergency department (from 232 to 168 people) and a 13 per cent reduction in the total number of emergency department presentations (from 667 to 581) in the six months period following support.

Unplanned inpatient admissions that occurred as a result of an emergency department presentation reduced by 34 per cent (from 320 to 210 admissions) and the number of total days spent in unplanned inpatient admissions also reduced, from 2,316 to 1,612 days in total, representing a decrease of 30 per cent. A comparison of pre- and post- support reveals St Vincent’s Hospital services had a $4,203 ($ 2015) reduction in costs per client for the six month period.

In addition, evaluation of a similar THT program in Queensland showed that individuals who accessed the program between 2006 and 2009 reduced their psychiatric in-patient bed-days by 20.76 days per participant compared to those who were not in the program.

A 2017 UK inquiry report into suicide found that for ex-NHS hospital patients who went on to commit suicide within the first week of discharge, 21 per cent died on the third day and 19 per cent on the second day.  In addition, 12 per cent of all ex-NHS hospital patients who committed suicide did so before their first follow up appointment. The inquiry report suggests that patient follow-up should occur within three days of discharge from a mental health facility in hospital.

5. Guide to evidence

Not applicable

1. Explanatory statement

For people experiencing mental health disorders that restrict their ability to find and maintain employment, supported housing programs may prevent them falling into homelessness. Together with housing, such supports may also include drug and alcohol counselling; employment training; financial budget training, and medical support such as help to take medicines regularly.

2. A real world example

Supported housing programs can work for people in public or community housing, and those living in private rental.

The Housing and Accommodation Support Initiative (HASI) operates in NSW and is a three‐way partnership in service delivery:

  • accommodation support and rehabilitation associated with disability is provided by NGOs (funded by NSW Health);
  • clinical care and rehabilitation is provided by specialist mental health services; and
  • long‐term, secure, and affordable housing and property and tenancy management services are provided by public and community housing (funded by Housing NSW).

The Doorway pilot program is a Victorian State Government initiative, and links people with persistent mental ill-health who are at risk of, or experiencing homelessness with private rental housing and psychosocial support. The program provides time limited rental subsidy, brokerage and tenancy support.

The model diverges from the predominant model of providing housing via social housing providers, in favour of the private rental market. Doorway program participants rent their housing directly from the real estate agents rather than through head leasing.

3. Scope of the practice

An evaluation in 2012 revealed that HASI supported over 1000 mental health consumers in social and private housing and ranging from very high support (8 hours per day) to low support (5 hours per week) levels. Slightly more men (53 per cent) than women (47 per cent) were in the HASI program and the median age of current consumers was 40 years old. Nine per cent of consumers identified as Aboriginal or Torres Strait Islander.

New HASI clients who require social housing apply through Housing Pathways for public or community housing. They are prioritised according to relative need, and are housed in existing social housing stock when a suitable property becomes available. Waiting times to access priority housing assistance varied depending on the location and needs, and was for periods ranging up to many months.

The Doorway program has been funded by the Victorian Government to deliver supportive housing to 100 people.

4. Effectiveness/impact

HASI clients had significantly fewer and shorter mental health hospital admissions after joining HASI: improvements included a 59 per cent decrease in the average number of days spent in a mental health inpatient hospital per year; and a 24 per cent drop in the number of admissions to hospital per year.

Among those who were admitted to hospital at least once both before and during HASI, the average number of days hospitalised per admission decreased by 68 per cent. The NSW Government has potentially avoided over $30 million per year on the hospitalisation of HASI consumers (in $2010).

An evaluation of the first Doorway program in 2013 showed 77 people had been accepted into the program, of whom 59 were housed (with 50 still housed at the end of that program). In addition, The average time in bed-based clinical mental health services per participant per year has decreased from 20.4 before housing to 7.5 days in the 12 months since being housed – with the biggest decrease occurring with acute inpatient services (13.9 to 6.6 days)

The mental health of one-third of participants improved to the point where they were discharged from their Area Mental Health Services to the care of their GP, with participants attributing their improved mental health outcomes to having stable accommodation and an integrated support team.

At the end of the first year, 31 participants have been offered and accepted 12 month lease extensions of their private rental housing. An additional three participants have elected to renew their lease on a monthly basis. In addition, 27per cent of participants were engaged in paid and unpaid work, an increase from the 16 per cent at the beginning of the program.

The program’s costs of $19,300 per participant per annum included $10,136 in housing costs and $7,937 in Home-Based Outreach Support. As participants were eligible for social housing, the program avoided or lessened government costs associated with providing social housing (between $9417 and $26,802 p.a.) and crisis accommodation costs (between $16,060 and 28,105 p.a. (in $2011)).

The program also saved the Victorian Department of Health an estimated $11,050 in avoided costs per annum per participant through reduced use of mental health services, presentations to emergency departments and hospital admissions. The estimate may be higher if reductions in the use of ambulances, drug and alcohol services and community health services were included.

5. Guide to evidence

The evaluations of HASI and Doorway show these programs can be very effective in supporting people with mental health disorders and preventing episodes of homelessness. Replicating and scaling up these programs would be of real benefit to Australian communities.

1. Explanatory statement

Assertive Outreach programs may engage actively with homeless people who have mental health issues to connect them with mental health services. The programs also attempt to end a person’s homelessness by working with them over a long timeframe in order to support, not only their transition from rough sleeping to housing, and stabilise their tenancy to avoid tenancy failure and a return to homelessness. The programs often use a Housing First philosophy, and feature an integrated approach that requires multi-disciplinary teams and access to specialist health professionals.

Assertive Outreach programs target the most vulnerable rough sleepers who generally have a high degree of complex needs. They may offer health services, such as mental health and harm minimisation services. These supports may be delivered through Assertive Community Treatment (ACT) teams, which have ‘a strong focus on the delivery of psychiatric services to all people in the broader community, but the ACT philosophy on engaging with people disengaged from the mainstream health sector means that they often provide mental health services to people who are homeless.’

2. A real world example

Street to Home programs, which have operated in several Australian states and territories, deliver moderate health and wellbeing outcomes including improvements in the experience of physical pain, stress, depression and anxiety, the use of support services, and engagement with friends, family and community.

In addition, Queensland’s Homelessness Health Outreach Teams (HHOT) were established on the mental health principles from the (assertive outreach) ACT model. These programs ‘provide comprehensive case management, assessment and intervention for homeless people who are experiencing mental illness. HHOT also develops strong links with local health and mental health providers.

3. Scope of the practice

The evidence from the first year (starting in 2010) of ‘Street to Home’ type programs run in Brisbane and Sydney showed 121 rough sleepers were helped into stable housing, but it also reveals limitations in the programs effectiveness. For example, the two Sydney service providers engaged with 291 people but were only able to house 42 individuals as there was a shortage of suitable, available housing. The Brisbane service provider was able to house more individuals (79 people) with 93 per cent of the tenancies being sustained. Seven per cent of the tenancies were not sustained, which was attributed to the service provider’s limited capacity to deliver multidisciplinary health services (particularly long-term health and drug and alcohol support) directly into the tenants’ homes or to access necessary services from elsewhere.

A HHOT program in the Gold Coast (QLD) in 2009 assessed 123 clients and 140 in the first few months of 2010.

4. Effectiveness/impact

The evidence shows that rough sleepers engage best with assertive outreach services when there is a trusting professional relationship with the worker; when the relationship is purposeful and goal-orientated; when the rough sleeper feels they are listened to, having ultimate say in determining their personal goals and the pace of change; and when workers are able to provide practical and meaningful assistance, resources and follow through on what they say they will do. This is where access to health services and long-term housing are crucial in making assertive outreach programs work.

Service providers stress that for some ‘ex’-rough sleepers, getting a job, undertaking education and training, having good health, and being connected to the community are difficult objectives, and as a result, to sustain their tenancies some will need ongoing support for many years, if not the rest of their lives.

5. Guide to evidence

Further information on assertive outreach is available in AHURI Final Report 179: The role of assertive outreach in ending 'rough sleeping'

1. Explanatory statement

Enabling people who are experiencing or have experienced a severe mental health disorder to access or remain in private housing is a benefit for all in the community. However, research finds that only 27 per cent of people with a mental illness own or are buying their own home, which compares poorly with 70 per cent of the general Australian population who own or are buying their own home.

Policy options for government could consider different strategies to prevent people with a mental illness who are buying their home from losing their home, for example, such as when illness prevents them being able to work for periods of time. In these cases, government assistance could include tailored housing finance, deposit assistance and shared equity contribution initiatives. These strategies could involve flexibility in levels and timing of housing repayments, so that fluctuations in income or gaps in employment are managed more responsively by financial providers.

Government could also consider a number of different strategies to help families who are prepared to purchase a property to accommodate a relative with mental illness. When families take housing responsibility for family members with a mental illness, this reduces the welfare housing cost burdens for governments. There may also be benefits in that living in owner occupied housing provides stability, independence and safety, which in turn may improve the ability to maintain employment.

Incentives could include low interest loans or tax offsets for families prepared to make a long term economic commitment to housing a family member who is experiencing an ongoing mental health disorder.

2. A real world example

Currently there are no real world examples of house purchase support for either people experiencing mental health disorders or their supporting families.

3. Scope of the practice

Not applicable

4. Effectiveness/impact

Not applicable

5. Guide to evidence

Not applicable

Background to the policy issue

Understanding what is mental ill health

In general, the broad definition of mental ill health is that it is a health issue where a person’s ‘cognitive, emotional, or social abilities are diminished but not to the extent that the criteria for a mental illness are met’.

A mental illness has a more serious impact on the individual, being a clinically diagnosable disorder that significantly interferes with an individual’s cognitive, emotional, or social abilities. A mental illness is diagnosed in reference to the classification systems of the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases, and includes illnesses such as bipolar disorder, depression, schizophrenia, anxiety, eating disorders and personality disorders.

A mental illness can reduce a person’s functioning in different aspects of their life, such as the ability to live independently, maintain friendships and employment, and participate meaningfully in the community.

The impact of mental ill health on an individual’s housing needs

Policy solutions need to take into account how mental health diagnosis affects an individual’s experience with housing, including:

  • Mental illness can be cyclic, in that they may reoccur a number of times over months, years or decades.
  • Mental illness can affect basic abilities required to access and sustain tenancies, such as completing an application form for housing or paying rent/mortgage on time.
  • Mental illness can lead to employment instability, which affects ability to access housing.
  • A person’s capacities for independent living and needs for support can fluctuate and be unpredictable.
  • People may need support with diverse areas of their life, assistance with coordination of many services may be required.
  • When a person is unwell they are usually heavily reliant on others to ensure required support is available and coordinated.
  • Homelessness can lead to mental health disorders: research that indicates 31 per cent of homeless Australians experience a mental health issue, but that only 15 per cent had a mental health issue prior to becoming homeless.

Relevant AHURI research