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​​ISSUE BRIEF:  Adult Residential Facilities (ARFs)
The critical need for “Board and Care” facilities.  

Adult Residential Facilities (ARFs) are a critical component of California’s housing continuum.  Lack of ARFs impacts individuals, families and local communities.  The social and financial cost is high as adults with severe mental illness enter revolving doors between crisis facilities, psychiatric facilities, emergency rooms, homelessness and incarceration.  Local budgets are impacted due to crisis management, expensive placements and incarcerations when the appropriate placement would be an ARF with service offerings for adults with severe mental illness.

What is an ARF?

Names and acronyms include:

• ARF: Adult Residential Facility
• RCFE: Residential Care Facility for the Elderly
• Board & Care (often called “Enhanced” or “Augmented” Board & Care)
• Assisted Living​

ARFs are licensed to provide care and services sufficient to support needs resulting from an inability to perform Activities of Daily Living or Severe Cognitive Impairment.  ARFs provide services that allow people to maintain independence and receive individualized care in a home-like environment, to include:
1. 24 Hour Care
2. Trained Staff
3. Three meals/day (must accommodate special dietary needs)
4. Access to a physician/nurse in case of emergency
5. Assistance with managing medications

Funding

FUNDING:  Current ARF funding for adults with severe mental illness is limited to the SSI rate, approximately $1069 per month. Some counties bolster this rate, providing “patches” to large-scale ARFs, often located hours away from the consumer’s community.  Patches range from $64/day to $125/day.  It is worth examining a different funding model, such as the one available for adults with developmental disabilities. This model provides several tiers of funding based on the needs of the consumer.  Funding ranges from $1,069 to $9,288 per month per consumer, allowing for community-based, appropriately staffed ARFs.  Dept. of Developmental Services Community Care Facility Rates:  www3.dds.ca.gov/Rates/docs/CCF_Rates_January2020.pdf

Three Key Challenges

1. Financial: ARFs cannot survive on a small scale without substantial subsidies. On a larger scale (45+ beds), a supplemental rate (known as ‘patches’) from counties ranging from $64/day to $125/day is required  for fiscal stability.(1)
2. Staffing: Providing and retaining a professional, trained and experienced staff requires proper management, appropriate salaries and ongoing training.
3. “Not In My Backyard” (NIMBY) opposition from communities for new construction or attempts to rezone a property for ARF (required for more than 6 beds).

Costly Consequences

• Psychiatric hospitals & facilities range from $350 - $775/day.
• Prison costs appr. $222/day (2)
• County jail costs appr. $155+ per day (Alameda County, 2014)
• Transitional Programs cost appr. $150/day per resident

Hundreds of Beds Lost

Among 22 counties reporting to a 2016 CA Mental Health Planning Council survey, 907 beds were needed with 783 beds lost in the last 10 years. The respondents represented 1/3rd of the state. This trend has continued into 2020.
It is clear there is a high need for this housing option for facilities that provide board and care for adults with severe mental illness in every county. 
CBHPC 2016 ARF Issue Paper: www.dhcs.ca.gov/services/MH/Pages/CBHPC-Reports.aspx

A Call for Immediate and Long-Term Solutions

It  is in the best interest of adults with mental illness, and in the best financial interest of the State of California to increase access to appropriate community-based, long-term residential options that include the necessary supports to address mental illness and other co-occurring physical health conditions.  ARFs (and RCFEs) are a critical component of this housing continuum. Solutions must be both immediate and long-term:
A) Immediate—Funding to prevent closures and increase offerings
B) Long-Term—Address key challenges: 

1. Financial: Changes to current licensing structure to accommodate a tiered level of care system
2. Staff Support: Technical assistance, training and support for staff and owners to: a) Successfully work with this complex population; b) Maintain fiscal stability; c) Sustain licensing.
3. NIMBY Advocacy toolkit to increase understanding of mental illness and the effective use of ARFs/RCFEs in order to overcome NIMBY (Not in My Backyard) opposition.

 

End Notes

1. RCFs that provide residential care to adults with mental illness survive at a larger scale (45+ beds), with “patches” provided by counties. Psynergy Programs, Inc. and Davis Guest Home offer examples of companies that operate RCFs with a financial model that works due to “patches” paid by counties (added to resident’s SSI).  Even with the additional revenue, this financial model requires a minimum of 45 residents.  These are considered “Enhanced” or “Augmented Board & Cares” as they provide needed supports to the residents, including team leaders, activities, dietary staff, access to a psychiatrist and more. Psynergy additionally provides:  Medication Support, Mental Health Services, Crisis Intervention, Case Management and Collateral (all Medi-Cal billable.)
2. CA Legislative Analyst’s Office:  http://www.lao.ca.gov/PolicyAreas/CJ/6_cj_inmatecost 
3. The Price of Jails:  Measuring the Taxpayer Cost of Local Incarceration (Page 26, Vera Institute of Justice.)
4. Rates found on-line from 2016-17 San Luis Obispo County Contracts with Psynergy Programs, Inc (page 9) and Davis Guest Home (p. 6).