Transitional residences: effectiveness and system transformation.
There is considerable evidence that transitional residences play an important role along the continuum of post-discharge residential settings for (1) recipients of intermediate and long-term inpatient psychiatric services, (2) the homeless, and (3) the chronic medically ill. For this continuum to perform optimally, transitional residences should be structured as short-term, cost-effective rehabilitation centers with expedited referral and placement (Geller & Fisher, 1993; Hewett, Ryan, & Wing, 1975; Hunter, Buick, Wellington, & Dzerovych, 1993; Sadowski, Kee, VanderWeele, & Buchanan, 2009; Yanos, Barrow, & Tsemberis, 2004). The social environment of transitional residences has been shown to be a powerful predictor of multiple outcome variables in terms of health, employment, and quality of life due, in part, to high levels of social involvement (Schutt, Rosenheck, Penk, Drebing, & Seibyl, 2005).
Further along the continuum, long-term outcomes of residential placements in supported housing include successful community tenure and improvements in cognitive and social functioning. Such housing is typically implemented as community residences or supported apartments for former psychiatric inpatients. Findings also indicate that former patients prefer settings with low restrictiveness and increased independence along the continuum (Wong, Poulin, Lee, Davis, & Hadley, 2008). Therefore, it is important to describe the functions and outcomes of transitional residences, as well as the features of transitional residence implementation and interventions, in order for model replication to lead to beneficial care outcomes (Fakhoury, Murray, Shepherd, & Priebe, 2002; Okin, Borus, Baer, & Jones, 1995).
This article describes the functions and outcomes of two transitional residences, the South Beach Transitional Living Residence (SB-TLR) and the Ocean View Lodge Transitional Placement Program (OVL-TPP). These two residences, which differ nominally, and to some extent programmatically, are operated by South Beach Psychiatric Center (SBPC), a New York State Office of Mental Health (NYS-OMH) facility. The SBPC serves a catchment area of 2.5 million individuals in Brooklyn, and Staten Island, NY. This facility, which serves adults and children, operates as an integrated mental health care system that offers intermediate and long-term inpatient services, comprehensive outpatient treatment, rehabilitation and wellness services, and case management, along with transitional residential services. The facility currently operates 280 inpatient beds and 48 transitional residential beds, and has approximately 3,400 outpatients registered and receiving highly personalized care at varying service intensities.
The Transitional Residences
The SBPC SB-TLR and OVL-TPP are located on the main campus of the facility and serve consumers discharged from one of eleven inpatient units who are transitioning to community care and supported housing placements. These transitional residences are located in former inpatient units, designed as short-term college-campus-like settings. Architectural and interior design renovations include removal of the nurses' station, repositioning of interior walls, and creation of common living room and dining room spaces complete with noninstitutional furniture, electronic entertainment, and computers. The term transitional residence is used to refer to both facilities.
The SB-TLR and OVL-TPP are part of the OVL Service, which includes inpatient, outpatient, transitional, and supported housing services. The SB-TLR program evolved from a psychiatric rehabilitation framework with emphasis on community skills development, wellness self-management, self-advocacy, and vocational services (Anthony, Cohen, & Farkas, 1990; Bond, Evans, Salyers, Williams, & Kim, 2000; Bond et al., 2007). The OVL-TPP added many principles of the Fairweather Lodge model, stressing peer supports and mutual aid, in a unique and caring residential environment (Haertl, 2005; Schoenwald & Hoagwood, 2001). The two residences have similar programming in terms of health services, substance abuse services, case management, and medication self-administration. They also perform crisis and respite functions for outpatients who require symptom stabilization or certain medication starts, tapering, or monitoring. The respective program focus of each of the transitional residences offers clients a choice and helps to optimize the residential setting to maximize their strengths. The transitional residences provide twenty-four-hour coverage for residential, rehabilitation, and case management services, provided by professional and paraprofessional staff.
The SBPC maintains identical and professionally enhanced staffing standards in both programs. The programs are administratively integrated under the general direction of the chief of the OVL Service and the outpatient and inpatient deputy directors, who are executive leaders of the facility.
The residences prioritize recovery from co-occurring substance abuse disorders, vocational planning, and medical case management. They also provide a graduated training program for medication administration that culminates in self-administration as an essential community readiness skill. These dimensions of wellness and recovery are also identified as key elements of the SBPC mission and vision (Bond et al., 2007; Dickey, Normand, Weiss, Drake, & Azeni, 2002; Dixon, Postrado, Delahanty, Fischer, & Lehman, 1999; Drake, Mueser, Brunette, & McHugo, 2004; Minkoff, 2001). Figure 1 lists many of the tasks and functions performed by the transitional residence case management staff.
Integration with Outpatient Care
Transitional residence clients receive mental health, medical, and case management services through the OVL outpatient clinic, other SBPC outpatient departments (OPDs), and community medical providers. Clients work from a strengths-based perspective through individual service plans that emphasize medication self-management, psychotherapeutic services, social affiliation, community skills, wellness self-management, and advocacy. Client choice is a guiding principle at SBPC OPDs because there is considerable evidence that client satisfaction is related to respect for preferences in terms of medication regimens, psychotherapy, programs, and groups (Klein, Rosenberg, & Rosenberg, 2007). Outpatient clients choose from a menu of treatment, rehabilitation, and support groups, in collaboration with their primary therapists, as components of their individual service plans. Having a good fit with community services has been found to enable clients to live in the community successfully, with increased tenure and improved quality of life (Cohen, Gantt, & Sainz, 1997; Rosenberg & Rosenberg, 2006). The transitional residences facilitate clients making such a fit because they are fully integrated with outpatient and community care. This integrated approach offers many opportunities for clients to select from an array of mental health, residential, and employment services with input from professionals.
Substance abuse and dependence treatment and support services are also core services provided through each OPD. Hiring of certified alcohol and substance abuse counselors (CASACs) has been prioritized, and Dual Recovery Anonymous (DRA) twelve-step self-help programs have been made available to all outpatients. Employment services include supported/competitive employment, job search and placement support, skill building internships, and individual employment grants. Medical case management includes primary health care, specialty consultations, colocated medical services, cardio-metabolic monitoring, and preventive care. The tight linkages between transitional residence case managers, SBPC OPD clinicians, and SBPC Department of Community Services administration facilitates the delivery of these services for all members of the transitional residences, and indeed all outpatients.
This integration is further enhanced through an advanced electronic health record system that includes the medical record; pharmacy, laboratory, and case management applications; and HIPAA-HITECH-compliant e-mail and file sharing systems. In addition, the facility has developed CARENET, a secure intranet-based system for monitoring, tracking, and event notification at all levels of care including the transitional residences.
Although the SB-TLR was already licensed and operational, the OVL-TPP was implemented as the SBPC response to the NYS-OMH plan for system transformation, which called for eliminating 325 inpatient beds statewide, replacing them with TLR and TPP programs (NYS-OMH, 2010). The SB-TLR was the first facility to be licensed and accept patients for transition under this initiative, and the establishment of the OVL-TPP permitted a realignment of SBPC services, reducing inpatient beds by 25 (the former inpatient unit) and increasing residential beds by 24. Operational integration with the SB-TLR under the new initiative was designed to achieve specific benchmarks for admissions and placements, and represented an important opportunity to achieve system transformation.
The transitional residences address system transformation at three levels, first by providing a short-term living option, therapeutic affiliation, and community skills training for clients ready for discharge from inpatient services but awaiting new housing; secondly by facilitating clients' community integration, in close coordination with SBPC OPDs; and thirdly by increasing inpatient admissions and discharges while decreasing inpatient beds, achieving cost reductions and efficiencies.
This article reports on twenty-seven months of implementation (January 2009 to April 2011) with tracking and movement data for 192 clients who were admitted to the transitional residences from inpatient or outpatient settings and were subsequently discharged. The former inpatients had received maximum benefit from inpatient treatment, and the outpatients required crisis or respite transitional care and were assessed to potentially benefit from transitional residence programming. In addition, this article reports on outcomes related to system transformation, efficiency, and cost effectiveness.
The chief outcome measures of the transitional residences include (1) attainment of community-based housing; (2) substitution of residential services for inpatient services, minimizing length of stay at both levels of care; and (3) improved efficiency of inpatient services by facilitating increased inpatient admissions and discharges through a decreased number of inpatient beds.
The NYS-OMH Mental Health Automated Record System (MHARS) data portal was used to track and aggregate movements including (1) discharges from the inpatient units to the transitional residences, (2) discharges from the transitional residences to longer term placements, and (3) admissions to inpatient from acute settings and community hospitals associated with increased efficiency in the utilization of existing beds. In addition, median and mean inpatient length of stay prior to transitional residence admission and length of stay in the transitional residence were calculated. Frequency and percent for primary diagnosis, race, age, and gender were also calculated for admissions to the TLRs. Each case was reviewed to determine the nature of the placement, current community tenure, and inpatient interventions needed since placement at a transitional residence. Inpatient hospitalizations following TLR discharge were tracked, along with several dimensions of individualized service planning, including utilization of case management, employment, and substance abuse services.
To estimate the impact of the TLRs on system transformation, several other indices were examined. These included changes in the overall number of admissions to SBPC inpatient units during the study period compared to the previous twenty-seven months from October 15, 2006, until January 14, 2009. Discharge of longer term inpatients to the residences was expected to create vacancies that would lead to more efficient use of remaining inpatient beds. Finally, data are presented to compare staffing, medication, and non-personnel-related expenses associated with inpatient beds with those for transitional residence beds. All quantitative analyses were performed using SPSS 18.0.
The TLRs admitted 173 clients from intermediate and long-term inpatient settings and 19 outpatients diverted from inpatient admission for crisis or respite care during the study period (n = 192). Gender, age, and ethnicity/race demographics for the TLR admissions cohort were calculated and tested for differences from the overall inpatient admission cohort for the study period. For gender, male n = 136 (70.8%), female n = 56 (29.2%), and a chi square test of independence and Cramer's V for gender revealed modest significant differences ([chi square] = 6.192, df = 1, significance. = .013, V = .070, significance. = .003). The proportion of males in the TLR cohort was significantly greater (70.8%) than the proportion of males in the overall admission cohort (61.4%), and the proportion of females was smaller (29.2% for TLR vs. 38.6 for overall). For age, the mean = 43.72 years, median = 45.00 years, skewness = -.138, standard error of skewness (SES) = .175, a nonsignificant skew from normal distribution between ages 19 and 73. For age stratified into age groups: <22 years, n = 4; 22 to 30 years, n = 29; 31 to 40 years, n = 37; 41 to 50 years, n = 61; 51 to 64 years., n = 57; [greater than or equal to] 65 years, n = 4; a chi square test of independence for grouped ages revealed small significant differences ([chi square] = 18.34, df = 5, significance = .003, V = .121, significance = .003). Specifically, the TLR admissions cohort had fewer patients than expected in the youngest groups (<22 and 22 to 30 years), and more patients than expected in the 41- to 50-year-old group compared to the all inpatient admission cohort. For race/ ethnicity, white n = 87 (45.3%), African-American n = 68 (35.4%), Hispanic n = 29 (15.1%), Asian/other n = 8 (4.2%). The chi square test of independence for ethnicity/race revealed no significant differences ([chi square] = 7.84, df = 3, significance = .049, V = .079, significance = .049) between the cohorts.
The inpatient admissions to the transitional residences had a median length of stay (LOS) of 173.00 days, mean LOS of 296.36 days (SD = 384.757 days, skewness = 3.429, SES =.187) on inpatient units prior to their transitional residence admission. This distribution of admissions is highly positively skewed by long-stay cases, with thirty-one clients having an inpatient LOS of 1 to 3 years, five having an inpatient LOS of 3 to 5 years, and four having an inpatient LOS greater than 5 years. Clients' five highest inpatient LOS ranged from 4.04 to 6.92 years.
Those 192 residents who were admitted to the TLRs were discharged with median LOS of 104.00 days and mean LOS of 149.05 days (SD = 169.84, skewness = 3.582, SES = .175). This distribution is also significantly positively skewed due to clients' five highest LOS, ranging from 331 to 428 days (0.91 to 1.17 years) due to difficulties securing benefits and undocumented immigration status. These discharged clients selected from an array of housing options shown in table 1.
As the table indicates for discharges to the community (n = 133), community residences were the most popular housing option, with many individuals choosing apartment treatment programs, private residences, or adult proprietary homes. A substantial number of patients were not discharged to the community (n = 59) because they returned to inpatient care or left against clinical advice. Small numbers of patients were discharged to nursing homes or family care, on a criminal justice warrant, or transferred between the TLRs. During and after the course of their TLR stay, outpatient individualized service plans included case management services for thirty-eight (20%) clients, substance abuse treatment for seventy-nine (41%), and employment services for thirty-eight clients. Nineteen (10%) clients were competitively employed upon follow-up.
The current disposition status as of July 15, 2011, for all of the 192 TLR discharges, considering the intent to treat, was also reviewed. The current disposition of the discharged clients, with at least three months of community follow-up, is displayed in table 2.
On follow-up, 13 7 patients were still living in the community; some had changed settings. Most were living in community residences, apartment treatment programs, private residences, and proprietary adult homes. Of those not living in the community (n = 55), inpatient facilities (n = 29) and TLR (n = 12) were the most common settings. Current status was unknown for 3 clients, and 1 had died. Preliminary results on follow-up indicate that 119 (62%) of TLR discharged patients had not been admitted for further inpatient services, 50 (26%) had a single hospitalization, and 14 (7.3%) had two or more hospitalizations; data on hospitalization was missing for 9 (4.7%) discharged patients. In addition to the benefits to clients of residing in less restrictive environments and spending far less time in inpatient settings, multiple cost benefits accrue to the facility and payers such as Medicaid and Medicare, which pay for hospital stays through several reimbursement mechanisms.
There was an increase of 112 admissions (11.7%) to SBPC inpatient units from acute care community hospitals during the study period (n = 979 from January 15, 2009, to April 15, 2011) compared to the previous twenty-seven months (n = 867 from October 15, 2006, to January 14, 2009). Preliminary cost estimates comparing the operation of two TLRs relative to two typical facility inpatient units indicate considerable savings. The estimated annual salary and fringe benefits for the two TLRs is $2,369,888; for comparable inpatient units, it is $5,860,784, a savings of $3,490,896 per year. Estimated annual overtime costs for the two TLRs are approximately $155,154; for two comparable inpatient units, the estimate is $514,514. In terms of medication costs, most TLR patients have Medicare D or Medicaid pharmacy benefits as outpatients, whereas the inpatient units are full charge to the NYS-OMH budget. This is essentially cost shifting to the outpatient benefit, but it saves the facility approximately $631,436 in operating costs. Other costs such as food, medical contracts, and utilities are essentially identical as the residences are housed in former inpatient units.
Clients admitted to the transitional residences were broadly reflective of the South Beach inpatient admission population with some differences. Males were admitted at a higher rate, possibly due to higher levels of functional disability, socially adverse illness behavior, and lower levels of social integration. Similarly, males were overrepresented in the SBPC inpatient long-stay population compared to the general admission population. Age differences between the TLR cohort and the general population were not surprising in that the youngest clients typically have involved families, whereas the middle-age population group, forty-one to fifty years old, are increasingly alienated, with few family or social resources and many more years of inpatient hospitalization and disability (Hafner, 2003; Walkup & Gallagher, 1999). There were no differences based on ethnicity or race between the TLR admission cohort and the general inpatient admission population. The differences between the TLR admission cohort and the general inpatient admission cohort suggest that the most functionally disabled individuals have been targeted for admission to the TLRs.
The results of this study suggest that the transitional living residence model as implemented at SBPC is clinically effective, is a minimally restrictive environment, and makes efficient use of facility resources. Many clients, including those with long-stay hospitalizations, attained community-based housing with excellent rates of community tenure and low rates of inpatient hospitalization following their TLR discharge. Clients received highly effective and integrated outpatient care during their TLR stay, which included a full array of treatment modalities, as well as substance abuse, medical, and employment services. A small but growing number of these clients are now competitively employed despite dislocation from the workforce due to inpatient hospitalization. Clients discharged from the TLRs selected from an array of high-quality community placements broadly reflective of their preferences. These placements are largely in the voluntary nonprofit sector, supported by the NYS-OMH, and are targeted to discharges from inpatient facilities.
The TLRs also contribute to system transformation and reduce costs. The SBPC has significantly increased bed vacancies and capacity for admissions. This in turn has reduced pressure on acute care hospitals in SBPC catchment areas because these facilities can more readily accommodate inpatient admissions. This has been accomplished despite reducing capacity by twenty-five inpatient beds. In addition, multiple cost benefits accrue to the agency and facility through reduced personnel and non-personnel allocations. There are also reduced costs for payers such as Medicare, Medicaid, and commercial insurers that pay for certain state hospital inpatient stays through various benefits.
There are significant limitations to the results and conclusions of this study. Because this is not a controlled study, there are important threats to validity. It is possible that the TLR cohort differs from the general admission inpatient population in unaccounted for ways. For example, the TLR cohort may have high disability but low behavioral risk. Clients may also have experienced clinical changes over time that are unrelated to gains made through residence in the TLRs. It is also possible that institutional history has had an effect because SBPC has administratively emphasized community placements and reductions in length of stay for all units and programs at the facility. Because SBPC is an integrated mental health care system, exposure to treatments elsewhere in the system, such as through facility outpatient departments, may have had a major effect in terms of supporting clients in the community, independent of living in the TLRs.
Nevertheless, the accumulation of evidence appears to support the efficacy and efficiency of the TLRs for many SBPC inpatient clients including those who had been long stay and for outpatients in terms of preventing inpatient hospitalization. Inpatient lengths of stay have been reduced, and many clients who had resided on inpatient units have benefited from living as outpatients in environments with few restrictions. The majority of former TLR residents are successfully living in the community and in housing of their choice. Low rates of TLR post-discharge inpatient hospitalization have been observed for former residents. System transformation priorities have been realized by providing increased capacity for inpatient admissions with fewer occupied beds. Discharging longer term inpatients to the residences has created vacancies that have led to more efficient use of remaining inpatient beds.
The implementation of the TLRs has dramatically reduced costs for the facility and the agency, making resources available for new investments in community, residential, and employment services. Considering all the benefits realized at SBPC, the authors believe that the TLR model is a best practice and should be implemented nationally.
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Thomas Uttaro, Martin Erman, Gary Klemuk, Eileen Klein, William Henri, Karin Wagner, Jacqueline Guddemi, and Doreen Piazza
Thomas Uttaro, PhD, is director, Adoption Programs and Services, at New York eHealth Collaborative, New York, NY. Martin Erman, PhD, is chief of service, Oceanview Lodge, and Gary Klemuk, MA, is chief of service, Fort Hamilton at South Beach Psychiatric Center, Staten Island, NY. Eileen Klein, PhD, is assistant professor at Ramapo College of New Jersey, Mahwah, NJ. William Henri, MPA, is mental health program specialist at the New York State Office of Mental Health Field Office, New York, NY. Karin Wagner, PhD, is deputy director, Community Services; Jacqueline Guddemi, MSW, is team leader, Oceanview Lodge OPD; and Doreen Piazza, MSN, is deputy director, Inpatient Services (Acting), at South Beach Psychiatric Center, Staten Island, NY.
Table 1 Frequencies of Disposition Types from the Transitional Residences Frequency % 1 Community residence 67 34.9 2 Inpatient unit 41 21.4 3 Apartment treatment program 21 10.9 4 Private residence 21 10.9 5 Adult home 19 9.9 6 Left against clinical advice 16 8.3 7 Nursing home 3 1.6 8 Family care 2 1.0 9 Criminal justice system 1 .5 10 Transfer between TLRs 1 .5 Total 192 100.0 Table 2 Frequencies of Current Dispositions from the Transitional Residences Frequency % 1 Community residence 71 37.0 2 Inpatient unit 27 14.1 3 Apartment treatment program 23 12.0 4 Private residence 22 11.5 5 Adult home 16 8.3 6 Left against clinical advice 9 4.7 7 OVL-TPP 7 3.6 8 SB-TLR 5 2.6 9 Unknown 3 1.6 10 Family care 2 1.0 11 Nursing home 2 1.0 12 Second Chance program 2 1.0 13 Deceased 1 .5 14 Criminal justice system 1 .5 15 Single room occupancy 1 .5 Total 192 100.0 Figure 1 Tasks and Functions Performed by the Transitional Residence Case Management Staff Daily transitional visits by clients to the residence from their inpatient unit. Education of clients and families about housing options; helping consumers select housing that best optimizes their recovery. Helping clients establish Medicaid, Medicare, Supplemental Security Income, Social Security Disability, and other financial benefits. Helping consumers enroll in the optimal Medicare D plan based on their medication regimen and the plan formularies. Nutrition education, meal planning, shopping, and training in cooking skills. Budget planning reflecting and aligned with projected income. Travel training to access community resources and participate in leisure activities. Medication training to identify benefits and risks, to track renewals, and to support reliable self-administration. Education in personal scheduling for residents to make and keep mental and physical health appointments. Training of residents to organize their living space and recognize the rights of coresidents. Increasing interpersonal skills and mutual support. Education of residents and families regarding mental illness and community resources. Training in laundry, ironing, and personal care. Training in interview and resume development skills. Development of referral packets for housing, case management, and program referrals. Liaison with mental health clinics, general health providers, case management programs, legal system, and family.