The trend these days is to shift from "monster units" that house 20 or more people to Community Based and Teaching Family Programs.
On one hand, having smaller case loads makes programming easier and the number of behavioral incidents get substantially reduced by having less crowded buildings. If it's hard to live with just one person under the same roof, imagine living with 20 (with psychological issues). Moreover, staffing big units is not always an easy task and supply of qualified staff has surprisingly shrunk during the past months. We were expecting a surge in demand due to the recession but for some reason (unknown to me) this hasn't happened.
Another advantage of having smaller units is that the stress levels that staff are subject to are greatly reduced (which helps decrease turn-over rates) as a consequence of having fewer incidents and a slower paced environment.
Even though the legal client to staff ratio is 8:1 big units need to have at least a 5:1 ratio to ensure proper coverage during crisis situations and daily programming. This greatly impacts budgets and is one of the main problems that service providers are having across the country. Unfortunately there's no way of reducing FTEs without affecting service quality, the latter being often the loser in this battle since budgets are the priority. I think this is mainly why funding agencies are pushing towards more home-like settings.
Additionally, mental health care facilities have been reticent to expand their community based programs for a simple reason: less beds means less money. But empty beds are starting to pile up so it makes no sense keeping a big building fully operational if you are going to operate at half capacity. It's a waste of resources. Furthermore, if you think about it, TFP and Community based programs give more flexibility and are better suited for growth. If you plan to expand your business it's easier to buy a small house or sign in a family for a TFP than building a big facility from scratch. You are also not constricted to available (physical) space on your campus or center, thus there's basically unlimited possibilities for expansion.
Having smaller units also means lower maintenance costs, and the opportunity to develop more and more diverse programs to fit the different populations.
Something that cannot be stressed enough is the importance of having a homogeneous population in each building. Usually, the bigger the unit the more diverse the conditions it serves. This can make daily activities a nightmare since clients' preferences and needs greatly vary. By having small and homogeneous groups this can be avoided.
While some organizations have reacted faster to the new environment and are currently expanding at a frantic pace, others have been more skeptical and tried to stay on course, crashing into the reality wall. They have realized that the near future doesn't look so bright and therefore, they have started to lay out plans to expand into the community. The fate of some will depend on how fast they can deploy. Other organizations, which enjoy a big enough financial cushion, will have time to make this transition in a tidy manner.
Fernando Tarnogol is an Argentinean psychologist, currently working as Program Coordinator at the Devereux Foundation in West Chester, Pennsylvania.