What is a Comprehensive Housing Plan? • It is a tool for case managers and clients to outline and manage housing and supportive services needs and goals to achieve housing stability.
What is the purpose of the Comprehensive Housing Plan? • To help HOPWA clients achieve housing stability without long-term dependence on HOPWA assistance and improve clients’ access to medical care and supportive services associated with HIV/AIDS.
Is a Comprehensive Housing Plan required for all HOPWA clients? • Yes. All clients receiving HOPWA TRBA, STRMU, Permanent Housing Placement and Supportive Services must have a Comprehensive Housing Plan at enrollment.
What should case managers put in the Comprehensive Housing Plan? • Issues that led to housing instability and dates assessed • For STRMU, the emergency situation that led to the request for assistance and evidence of that emergency • Action steps to be taken to address housing issues and the dates these were completed • Referrals offered to client and document referrals utilized by client
Key Components of Housing Plan • Determine housing needs • Identify eligibility for other housing assistance • Supportive services needs to maintain housing stability • Eligibility for mainstream assistance • Client sets goals for housing and independence.
Plan Development • Developed jointly by client/case manager • Client develops own goals and commits to accomplishing them • CM confers with other providers • Plan is updated on regular basis or when client’s condition/needs change
How Plan Assists HOPWA STRMU • Creates a framework for addressing “conditions” that gave rise to short-term need • Establishes time frame to achieve stability within 21 week assistance period • Allows time to plan for and arrange longer term housing, if needed • Can avoid repeated 21 week cycles of assistance
How Plan Assists HOPWA TBRA • Assure that supportive service needs are met • Identify any resources, skill deficits or service needs that could lead to lack of housing stability • Mainstream rental assistance opportunities for long-term support • Develop strategies to avoid perpetual dependence on HOPWA rental assistance
Goal Setting/Housing Planning • Housing Preferences • Unit Size • Location • Tenure (lease/own)
Housing Stability Related Goals Income • Earned income goals • Benefits sought Education/Skills goals • Degree related • Job Training
Supportive Service Required • Access to primary health care • Behavioral health needs • Mental Health • Substance Abuse • Child Care/Support Needs
Goal Setting • Client establishes goals for : • Housing to be obtained • Income/Employment • Independent living skills • Mental health/substance abuse treatment • Family connections
Plan for Achieving Goals • Key Elements • Time Frame • Specific outcome to achieve • Support needed to achieve goal • Tasks to be accomplished by client and case manager
Role of the Case Manager • Identify assistance needed to accomplish plan • Skills deficits • Budgeting support • Negotiation health care of behavioral health • Encourage clients to develop future oriented goals
Evaluation and Plan Updating • Purpose • Identify changes in circumstances that could impact plan • Health status • Family composition • Income/employment • Behavioral health needs • Amended plan also includes time frames and client/CM responsibilities
Intervals for Updating Plan • If receiving time limited HOPWA services such as STRMU, whenever client applies for assistance • Otherwise, for clients receiving TBRA, plan should be updated when you talk to client.
Stages in Developing Housing Services Plan • Engagement • Assessment • Goal Setting and Housing Planning • Evaluation and Plan Updating
Engagement • Establishing clear communications • Active listening • Non-judgmental • Meeting client where they are • Capitalize on interest in housing : provide information, encourage client to make the choice • Will require multiple encounters to develop working relationship • Change the client’s role from passive to active
Assessment - 1 • Housing Needs • Currently homeless • Cannot afford current housing • Inappropriate or sub-standard housing • Not accessible or presenting other health related problems
Assessment - 2 • Issues that could impact ability to be housed • Criminal justice background • Prior offenses • Currently on parole/probation • Credit problems • Poor credit history • Bankruptcy
Assessment – 3 • Other issues related to housing instability • Co-Occurring disorders • Mental health issues • Connection to care/services • Able to manage care • Able to manage symptoms
Assessment - 4 • Other issues (continued) • Substance use/abuse • Use history • Awareness of relapse patterns • Treatment history • Interest in treatment/sobriety
Assessment - 5 • Other issues • Illness/disabilities • HIV confidentiality • Special housing needs related to disability • Equipment/furnishings • Live-in personal care attendant • Location requirements related to accessing health care/services
Assessment - 6 • Family or Social Network • Positive contributions • Counter loneliness • Financial support • Other assistance • Negative contributions • Drug use • Violence • Anti-social behavior
Assessment - 7 • Daily living skills and resources for housing stability • Self care • Transportation • Maintaining an apartment • Financial literacy • Managing nutrition
Assessment – 8 • Income and access to benefits • Source of income • Receiving any benefits • Eligible for any mainstream programs • Expect to receive benefits in the future
Assessment – 9 • Family and social supports • Connections to family • Other significant people
Assessment – 10 • Employment • Work history • Currently employed? • Skills/education for potential employment • Prior job training experience
Goal Setting and Housing Planning • Use the assessment items to set goals • Include assessment items and goals in housing plan
If a client does not comply with the Comprehensive Housing Plan? • Case managers should make a good faith effort to achieve client’s compliance and all efforts should be documented in the CHP. • The agency should have a termination policy and procedures that establish concrete requirements and procedure if a client is non-compliant with the CHP. • Termination of clients must comply with Section 14 of the HOPWA Manual and must be implemented in a uniform manner.
Evaluation and Plan Updating • Review housing plan and client’s progress • Review clients’ CHP at each contact with the client, assessing the current housing situation and update the CHP accordingly • Document all activities and efforts