HOPWA Housing Plans

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 PreferencesUnit SizeLocationTenure (lease/own)

Housing Stability Related Goals

IncomeEarned income goalsBenefits sought

Education/Skills goalsDegree relatedJob Training

Supportive Service Required

Access to primary health care Behavioral health needs

Mental HealthSubstance Abuse

Child Care/Support Needs

Goal Setting

Client establishes goals for :Housing to be obtainedIncome/EmploymentIndependent living skillsMental health/substance abuse

treatmentFamily connections

Plan for Achieving Goals

Key ElementsTime FrameSpecific outcome to achieveSupport needed to achieve goalTasks to be accomplished by client

and case manager

Role of the Case Manager

Identify assistance needed to accomplish planSkills deficitsBudgeting supportNegotiation 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 NeedsCurrently homelessCannot 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 housedCriminal justice background

• Prior offenses• Currently on parole/probation

Credit problems• Poor credit history• Bankruptcy

Assessment – 3

Other issues related to housing instabilityCo-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 issuesIllness/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 NetworkPositive contributions

• Counter loneliness• Financial support• Other assistance

Negative contributions• Drug use• Violence• Anti-social behavior

Assessment - 7

Daily living skills and resources for housing stabilitySelf careTransportationMaintaining an apartmentFinancial literacyManaging nutrition

Assessment – 8

Income and access to benefitsSource of incomeReceiving any benefitsEligible for any mainstream programsExpect to receive benefits in the future

Assessment – 9

Family and social supportsConnections to familyOther significant people

Assessment – 10

EmploymentWork historyCurrently employed?Skills/education for potential

employmentPrior 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