Conservative estimates peg the number of disabled adults in Napa Valley at about 20,000. This excludes a few thousand adults living in institutions, such as Napa State Hospital and the Yountville Veterans Home. By "disabled," we mean anyone living with: a physical impairment (about 15,000); severe mental illness (roughly 3,000 people); or, cognitive or developmental limitations (about 2,000). Within each category, there is a tremendous variety of types of disability, each of which offers its own set of challenges for daily living. For instance, physical disabilities can mean a sensory impairment, such as blindness or deafness, or confinement to a wheelchair due to paralysis. People with cognitive or developmental disabilities can have brain injuries, cerebral palsy, or other genetic conditions, like Down syndrome, that result in learning deficiencies. Diagnoses of severe mental illness can include schizophrenia and anxiety disorders.

Fifty years ago, life for disabled people was radically different. They frequently were separated from society and relegated to living in state-run institutions. In the 1960s, things began to change. New clinical treatments, medications and adaptive technologies surfaced and quickly became more commonplace. A combination of grassroots efforts and federal and state legislation established funding streams to pay for some health and social services, so disabled people could move out of institutions and live within the community, with varying levels of support. In the 1980s, California's government, seeing the economic benefit of outsourcing housing and support services to nonprofits and private facilities, downsized or closed many of its state-run hospitals. For instance, Napa State Hospital shrunk its staff and the number of mentally ill people it served, and the county's Health and Human Services Agency boosted its out-patient services and contracted with specialized nonprofits to provide housing and case management.

As a result, Napa County's disabled adults have more choices of where and how to live and work. The vast majority of disabled adults lives on their own or with family, and often relies on private nursing or in-home support services. Many with physical disabilities just need adaptive fixtures, like ramps or grab bars, or the help of a service dog, to live and work in the community. Clients with severe mental illness or mild cognitive disabilities can often live independently, provided they get help managing medications, attend weekly support groups, or a case worker assists them with household budgeting. Other disabled adults require supervised living, in which staff dispense medications or assist with household chores.

There are some two dozen nonprofits and agencies that provide a range of living skills, work and activity programs, as well as housing arrangements. Each year, these organizations reach more than 1,000 of our disabled residents with their services. Health professionals agree that more choice frequently results in better quality of life. At the same time, accessing and paying for these services has become increasingly complex.

In Napa County, households with a disabled adult are twice as likely to live in poverty. Here's why: Disabled individuals often live on a fixed income, have limited capacity to work, cannot drive a car, and have more health care needs. Our Valley also is an expensive place to live. Average monthly rent for a two-bedroom apartment is $1,214. While disabled adults receive government aid, called "disability benefits," a typical allotment for one person is $830 per month. Even for those splitting rent with a roommate, little remains to pay for utilities, food, clothing or bus fare. The City of Napa administers a federal subsidy program that reduces rents by 30 percent for disabled, low-income residents. The wait list is one to two years. For clients that live in nonprofit or privately-run, for-profit housing programs, disability benefits pay for those services; but, almost nothing is left to buy clothing, go on a field trip or eat out at a restaurant.

In spite of cost pressures, Napa Valley offers a robust menu of housing options for disabled people, especially given that we are a rural community. Privately-owned, for-profit licensed facilities (called "board and care") provide food, handle medications and around-the-clock supervision. Nonprofit housing programs fall into three categories: residential; transitional housing; and scattered-site housing, which also is known as independent or supported living. About 250 developmentally disabled adults and 110 clients with severe mental illness live in these three types of housing in Napa County.

Residential programs own one or more houses, which are typically shared by multiple adults. Meals and 24-hour supervision are provided. Some clients leave during the day to attend life-skills programs; others work at local businesses, bagging groceries or assembling packages for shipping. Most clients in these programs live here permanently.

Transitional housing agencies provide shelter for a limited time, and train clients how to live on their own. The range of skills taught depends on residents' needs. Examples include managing finances, grooming, socializing skills, or how to take medications. Graduates of these programs move on to an apartment and continue to receive periodic visits from the agency.

Nonprofits that offer scattered-site housing offer a more mainstream experience called independent or supported living. Clients live in a single-unit apartment, or shared apartments or homes that are regular housing stock in our neighborhoods. A nonprofit case worker visits weekly to check-in, and assists the client with health management issues, budgeting or light housekeeping.

A combination of federal, state and county dollars pays, only partially, for certain supervision, living-skills and work-coaching services. These reimbursements pass through Napa County's Health and Human Services Agency or North Bay Regional Center, and then funnel to the nonprofit or to the disabled client. Legislated reimbursement rates are determined by complex formulas based on the individual's diagnosis, and the type and level of service provided.

Changes. That's the forecast for the disabled population and the nonprofit programs that assist them. First, the population is increasing: The number of Californians with developmental disabilities rises five percent a year, as compared to a 1.5 percent increase for the overall population. Children born with autism now account for one in 150 births; it was one in 10,000 about 15 years ago. In addition, disabled people's conditions are more complex. For example, many developmentally disabled adults have multiple diagnoses, like depression, on top of their disability. People with severe mental illness can also be challenged by drug and alcohol abuse. Advances in medical science have improved survivability, especially among cognitively and developmentally disabled adults. Many are now living into their 60s and 70s and some are developing dementia or Alzheimer's disease. Programs skilled at working with developmentally disabled clients typically don't have the expertise to work with these newer health complications. Plus, government funding streams aren't designed to reimburse nonprofits for services that fall outside the scope of the originally diagnosed disability.

The second big trend is decreased funding. While it's true that federal and state governments reimburse nonprofit organizations for the support and living services they provide to disabled adults, the per- person rate has remained flat for more than a decade. That means charitable programs already have been absorbing rising operating costs like office space and health insurance benefits. To cope, many nonprofits have kept staff wages low. It typically costs nonprofits providing housing $3,000 to $4,500 per individual per month, and reimbursement rates cover anywhere from 30 to 50 percent. But, this year, rates were reduced three percent, and an additional seven- percent cut is looming. The result: greater pressure on nonprofits to fill larger and larger gaps with foundation grants and gifts from individual and corporate donors.

Please note: This list is not comprehensive; it does not include all types of services, or programs for disabled or special needs populations, such as children, the elderly or those in recovery for addiction.