Does the IMD Exclusion apply to secure residential treatment facilities? 

          No.   The IMD exclusion, which is found in section 1905(a)(B) of the Social Security Act, applies to “institutions for mental diseases” with more than 16 beds and to individuals between ages 21-65.  The IMD exclusion was intended to ensure that states, not the federal government, be responsible for funding psychiatric services and substance use disorder residential treatment.  Secure residential treatment facilities will not be IMDs as they will have less than 16 beds.  

 How does Olmstead relate to the Secure Treatment?

The landmark Supreme Court decision,Olmstead v. LC, 527 U.S. 591 (1999), protects the civil rights of people with disabilities from being inappropriately institutionalized. Olmstead requires that individuals reside in the “most integrated” setting that the individual’s treatment professionals agree is clinically appropriate. Olmstead at 597.  ACMI envisions secure residential treatment facilities as providing a more integrated setting to hospitalization, jail, or prison for individuals who have not been successful in other community living arrangements. 

All individuals who are referred to and accepted in a secure residential treatment facility will have been committed by a Title 36 civil court.  And Arizona law is actually more protective than Olmstead because it mandates that individuals be provided services in the least restrictive placement: “The court shall order the least restrictive treatment alternative available.” See ARS 36-540.  Consistent with Olmstead, Title 36 also requires that a treatment professional to conclude that a less restrictive traditional community placement is not appropriate.

Does Olmstead forbid secure settings other than a psychiatric hospital?

No.Importantly, the Supreme Court explained that admission to any facility always depends, first, on the treating professionals’ assessment that the facility is appropriate for the individual either as an alternative to a more restrictive setting such as a hospital or a less restrictive setting such as housing in the community.  Olmstead at 597. 

Second, secure residential treatment facilities are the kind of option that the Supreme Court seemed to anticipate and encourage when it said that states “need to maintain a range of facilities for the care and treatment of persons with diverse mental disabilities …”  Olmstead at 597 (emphasis added).   Individuals with chronic serious mental illness face unique challenges and may benefit during their recovery from services delivered in a clinically appropriate, secure residential setting.  Such a setting is “more restrictive” than other community-based housing options, but “less restrictive” than inpatient care or incarceration.  It can offer an alternative to jail, prison, the state hospital, or life and death on the street.      

Will secure residential treatment facilities meet due process requirements. 

Yes.  Olmsteadrequires, first, that treatment professionals determine what is appropriate clinically for each person. Second, all due process protections apply as to who may be admitted and why. No person will be admitted to a secure residential treatment facility except under a court-order.  The court order must be based on and follow an assessment and recommendation by an individual’s treatment professionals that (i) the secure facility is the most integrated setting appropriate for the individual’s clinical needs, and (ii) the individual likely cannot succeed in a less restrictive community placement.  Individuals considered for admission generally will have been unsuccessful in other types of housing and treatment settings.   Third, there will be periodic review of appropriateness of continued stay and criteria for discharge and the ability at any time to petition for discharge.  Fourth, there must be ongoing, periodic reviews about whether transfer to a less restrictive setting is clinically appropriate.  The individual can petition for discharge at any time.

Will secure residential treatment facilities provide comprehensive services?

          Yes.  Olmstead requires that states offer services, programs, and activities in the most integrated setting appropriate to the clinical needs of the individual.    Secure facilities can provide all needed services and support, including the full range of clinical and therapeutic services and peer support consistent with an individualized treatment program.  Personal choice and independent living skills will be promoted consistent with maintenance of a therapeutic and safe environment for all residents.  There will be a full range of recreational and educational opportunities.  All residents will have ongoing contact with an assigned outpatient clinical team who will follow the individual after discharge to a lower level of care.  In short, secure residential treatment facilities can be the most integrated and most appropriate setting for people who are struggling in their recovery journey in other outpatient settings.

This post was edited 8/6/2019 to ensure that you have the most up to date information!

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Lighthouse Model community homes are a form of long-term housing for people with serious mental illness (SMI). They are located in safe neighborhoods and run smoothly and efficiently resulting in a good relationship with the neighbors. The program is centered around the needs of the individual rather than a program (one program fits all).

They are distinguishable from other forms of housing by their capacity to respond to SMI symptoms without threats of evictions for behaviors that are related to their illness. Other housing programs, even those designed to aid individuals with SMI, may evict a member on the grounds of substance abuse, unpredictable behavior due to their mental illness, disregard for program schedules and/or other violations of rules. Due to their serious mental illness, these individuals are more likely to be hospitalized, evicted to the streets and/or incarcerated. The lighthouse model approach is person centered not program centered. Staff recognize behaviors that are symptomatic of SMI and assist the individual to manage their symptoms while retaining their housing.  Staff are available 24 hours a day with on-site behavioral technicians who are trained to respond to behaviors associated with SMI symptoms and who make an effort to de-escalate any situation that occurs. Their whole goal is to help the person remain successfully in the community in order to develop a real and meaningful life. If, for example, a person has to be taken to the hospital, or if they end up in jail due to behaviors related to their mental illness that were determined uncontrollable in the current setting, the member will retain his or her place in the Lighthouse when they return. Members all sign individual leases and pay 30% of their income. There is not a time limit on the length of lease and occupancy.

Advocates of the Lighthouse community home model believe that:

  1. This is an efficient cost-effective program that provides the support and safety that enables people to be permanently housed many of whom would otherwise  become homeless or repeatedly cycle through other housing programs, hospitalizations and incarcerations.
  2. The traditional short-term traditional housing model is insufficient for the chronically mentally ill (a small subset of the SMI population that have not achieved recovery and have failed to demonstrate the ability to successfully live independently.
  3. For these individuals there is currently no other form of suitable housing available that meets their needs to successfully live in the community.

Characteristics of the target population for Lighthouse Model housing:

  1. All referrals should have serious mental illness too severe to live with family or friends.
  2. Failed multiple attempts at living independently.
  3. May have been unsuccessful at other programs and housing settings.
  4. Have had many contacts with fire paramedics, police and the judicial system.
  5. They also may suffer from addiction which often is grounds for eviction from other programs.
  6. The target population may improve under supervised treatment, but often relapse when released too soon to have benefited from a supportive and therapeutic environment.

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Today over 200,000 Arizonans live with serious mental illness (SMI); more than 13 million individuals nationwide. Most are adequately served by our statewide Medicaid system commonly known as AHCCCS (Arizona Health Care Cost Containment System). But, many of those with the most serious mental illnesses live on our streets and in and out of our jails and prisons, primarily because of a lack of appropriate housing. They’re not safe, they lead lives filled with misery, fear, and danger because our current system is not able to meet their special housing needs.

The Association for the Chronically Mentally Ill (ACMI), a non-profit organization, was founded by a group of passionate parents whose adult children shared a similar experience with Arizona’s behavioral health system. The families of ACMI are working hard so that future families will not have to endure the multiple and unnecessary hospitalizations, incarcerations and homelessness that their sons and daughters have experienced. People with serious mental illness prematurely die 25-30 years earlier than the average person without serious mental illness. Indeed, the purpose of ACMI is to not only shine a light on this reality, but to advocate and work with our State’s leaders in health care, public safety, and government to implement practical solutions that are both compassionate and effective for our chronically and seriously mentally ill population.  ​

How Can You Help?
You can help by continuing to engage with our communications, share about this work, and partner with ACMI financially. The vision is to improve the well-being of the Chronically Seriously Mentally Ill population through filling the gaps in the current continuum of care with:

  • More “Lighthouse-like community living” homes.
  • Secure Treatment Facilities. 

We will work with all persons and organizations who share our deep concern for the well-being of this population. Please join us as we seek to ensure that the most vulnerable mentally ill can achieve a life with dignity!