Analysis of Integrated HIV Housing and Care Services. B. IHHP Housing Assistance and Care Coordination Models


The 2011 Notice of Funding Availability for the HOPWA IHHP grants announced that funds were available for projects that addressed “(1) direct housing assistance and service delivery to low-income PLWHA and their families, including homeless individuals and families; and (2) comprehensive planning and coordination of local resources in meeting the housing and service needs of the population.” It specified that the grants would support the NHAS goals of reducing HIV infection, increasing access to care, and improving the health outcomes of PLWHA through “improved cross-agency planning [and] resource utilization and service integration among mainstream housing and HIV-related agencies and providers.” Finally, the notice stipulated that “grant applicants must commit to increasing coordination among local partners in providing housing as a base for access to services that target the needs of PLWHA and their families.”31

The four IHHP sites we studied are fulfilling these requirements, working with a range of community  partners  to  provide  direct  housing  assistance  funded  by  HOPWA,  with  service coordination funded by their IHHP grants in collaboration with HIV medical case management funded by the RWP. In addition, they have developed and are starting to implement community-level integrated HIV housing planning efforts. Among the four IHHP sites, there is a gradient of service coordination in three areas: (1) direct housing assistance and housing service coordination, (2) coordination with employment services, and (3) linkage to HIV care through medical case management (See Figure III.1). In Figure III.1, the darkest oval represents the highest level of service coordination and collaboration. First, all four sites provide housing assistance (rental payments or housing units) directly to their clients. All four sites also fund “housing coordinator” positions, though two contract out that function. Second, of the four sites, only two fund “employment coordinator” positions, both contracted out. Third, the position of “medical case manager” is funded by none of the sites directly, but all four sites work closely and collaboratively with medical case managers funded by RWP to access medical case management for housing program participants.

Figure III.1. IHHP Service Components

Figure III.1. IHHP Service Components

FPC is the only grantee providing direct housing assistance. The other three grantees (RRHS, CARES, and PHB) are contracting with project sponsors to carry out housing assistance activities. All four include housing coordination services in the programs: identifying, recruiting, and enrolling program participants; assessing clients’ service needs; and linking clients to support services. Of the four sites, two (RRHS and FPC) used their IHHP funding to hire internal staff to provide housing coordinator, case manager, and/or peer support functions. The other two (PHB and CARES) funded community partners to provide those services (See Table III.2).

The sites also differed in their approach to employment services. Two sites (PHB and CARES) are using their IHHP funds to build employment services into their program models. CARES used an evidenced-based “considering work” model; the CARES FFL project is working to create “a seamless collaborative team approach to service planning that includes service integration and coordination with health care and other support services (such as mental health and substance abuse treatment), with vocational rehabilitation, workforce development, and employment programs.” PHB is expanding the Worksystems model of employment and vocational rehabilitation services for PLWHA. In contrast, the other two sites (RRHS and FPC) are using their housing coordinators to assess the education, employment, and training needs of clients and refer them to appropriate services, but are not funding employment services directly through IHHP funds.

Table III.2. IHHP Program Models

Program Goal(s) FUSE goals: to increase access to affordable housing for families headed by homeless PLWHA; to coordinate housing, HIV care, and other services; to integrate housing and HIV data; and to coordinate community planning to leverage public housing for PLWHA FPC goal: to increase statewide access to public housing for PLWHA, with linkages to HIV care maintained by local HIV medical case management services PHB goal: to improve health outcomes for PLWHA by leveraging collaboration among HIV housing and service providers in Portland and surrounding counties, and by adapting the Home Forward model to offer workforce development services to PLWHA FFL goals: to offer housing assistance and services to low-income PLWHA interested in employment; to link housing, HIV, and employment systems; and to improve comprehensive planning and coordination of local services to meet the needs of PLWHA
Primary Partners Ability Housing (AH); and Health Planning Council of NE Florida Maine State Housing; Bangor, Portland and Sanford Housing Authorities; Maine’s RWP Part B Grantee Cascade AIDS Project (CAP); The Multnomah County Health Department (MCHD) Part A Grantee and Worksystems, Inc. Albany Damien Center (ADC); Catholic Charities Community Services of Rochester (CCCS)
Staffing The FUSE project funds three full-time staff: a program manager, a services coordinator, and a peer specialist, with part-time support from an evaluator and a database integration specialist FPC funds an FT IHHP housing specialist and a portion of the program evaluator position, with in-kind assistance from FPC’s occupancy specialist and housing coordinator PHB funds an FT housing case manager and FT employment specialist at CAP; a PT position at Worksystems; a PT BHP consultant working with the S4H evaluation and data collection; and some BHP project management time The FFL program funds a program coordinator, FT employment coordinators at ADC and CCCS, a PT CCCS program developer; and in-kind rent assistance, HMIS, and evaluation services (CARES)
Program Model RRHS leases units in two AH apartment complexes. FUSE service coordinator and peer specialist work on site to enroll families in FFL, assess their needs, provide peer support and transportation to, and coordinate with RW-funded medical case managers on HIV care issues FPC offers TBRA, STRMU, and related support services to HOPWA-eligible clients, while working with local housing authorities to move them into mainstream public housing. Local providers or AIDS service organizations provide medical case management, linking PLWHA to medical care PHB coordinates the data collection, evaluation, and funds services provided by key partners: rental and homelessness prevention assistance (CAP); housing and employment case management (CAP); and linkage to employment (Worksystems), and coordinates with HIV-related care (MCHD) Region-wide, CARES facilitates CoC planning; administers the HMIS, and provides HOPWA-funded rental assistance; ADC and CCCS staff provide direct housing services, outreach, intake, housing and employment counseling, and HIV care coordination

The fourth IHHP component is medical case management. All four sites also include linkages to HIV care in their program models, and their housing coordinators are working closely and collaboratively with medical case managers who are employed in local HIV clinics, supported by RWP funds. The details of these health care linkages are described in more detail in the next section.

31  Department of Housing and Urban Development [Docket No. FR -5500-N-13 Notice of Funding Availability for HUD’s Fiscal Year 2011 Housing Opportunities for Persons With AIDS. Accessed August 11, 2013, at [].

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