DHSHOUSING FOR HEALTHHousing For Health 101 and The Whatever It Takes Model

Agenda and Objectives

Agenda:➢Housing For Health 101➢15 minute break➢Whatever It Takes Model

At the end of the training participants will be able to:➢Understand better the world of Housing for Health and know all the programs/ resources available.➢Understand the “Whatever It Takes” approach and be able to operate under this philosophy as an ICMS provider.

WHAT IS PSH ?

What is Permanent Supportive Housing?

“Permanent Supportive Housing is an intervention that combines affordable housing assistance with voluntary support services to address the needs of chronically homeless people. The services are designed to build independent living and tenancy skills and connect people with community-based health care, treatment and employment services.” – National Alliance to End Homelessness

Housing First Model

Housing First is an approach to quickly and successfully

connect individuals and families experiencing

homelessness to permanent housing without preconditions and barriers to entry, such as sobriety,

treatment or service participation requirements.

Harm Reduction

Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences. Traditionally associated with drug use

and other risky behaviors.

HOUSING FOR HEALTH TOOL BOX

INTENSIVE CASE MANAGEMENT SERVICES

HOUSING SUBSIDIES HOUSING STABILITY

What is Intensive Case Management Services?

Homeless services agencies contracted to work with DHS to provide on-site and scattered

site support services for medically/behaviorally complex

individuals and families experiencing homelessness using a harm reduction and

housing first approaches

What are Housing Subsidies and which ones does HFH use?Housing subsidies make housing units affordable

so people do not pay more than 30% of their income towards rent.

HFH uses federal subsidies and locally funded

subsidies to house our population.

96% Retention rate in permanent supportive housing after 1 year in

housing

Federal Subsidy

Section 8

Local Subsidy “FHSP”

HOUSING FOR HEALTH 101

HFH Goals

1. Create 10,000 units of housing quickly

2. End homelessness in LA County

3. Reduce inappropriate use of expensive health care resources

4. Improve health outcomes for vulnerable populations.

Homeless Initiatives and Measure H

➢ 51 Strategies to Combat Homelessness

➢ March 2017 voters approved a quarter cent sales tax dedicated to funding homeless services.

➢ Strategy D7 “Permanent Supportive Housing” has a goal of providing subsidies and services to 2500 people experiencing homelessness.

Flexible Housing Subsidy Pool

FHSP

Los Angeles County Dept. of Health

Services

503(c) nonprofit coordinating community-

based partner

Property owners throughout Los Angeles County

LAC-DHS Supportive Housing Rental Subsidy

Program

High and Low Acuity

Client lives in PSH for 3 years

(automatically steps down to low acuity)

Client enters PSH as a high acuity slot and case

managed at high acuity level , paid out at

$450 reimbursement rate

Client is case managed at low acuity

level of services and paid out at $225

reimbursement rate

Street-Based Engagement

Permanent Supportive

Housing and Services

FIELD BASED OUTREACH: E6

Vision of Homeless Initiative Strategy E-6

To develop a coordinated outreach system to reduce duplication of services and increase efficiencies through the investment of resources for:

➢CES Outreach Coordinators

➢Centralized Call/Referral Center – LA HOP

➢Generalized Outreach Workers

➢Multidisciplinary Outreach Teams

INTERIM HOUSING

Interim Housing Services

Who is eligible for Interim Housing?➢Individuals exiting institutions such as jails, prisons, foster care, hospitals, urgent care centers and other medical, behavioral health, and substance abuse treatment facilities.

➢Individuals currently on the streets

Interim housing can be requested in CHAMP and the referral is added to

queue for review and assessed for appropriateness.

Stabilization Housing

Provides bridge housing and support for homeless DHS patients prior to permanent housing placement.

Medically and psychiatrically stable individuals who may be vulnerable to decompensation if not placed into shelter housing.

• HIV/AIDS• Diabetes• Hepatitis• Mental Health (e.g.

Schizophrenia, Depression, Bipolar, etc.)

• ETOH

Recuperative Care

Provides short-term care and medical oversight to homeless DHS patients who are recovering from an acute illness or injury or have conditions that would be exacerbated by living on the street or in

shelters.

Medically and psychiatrically stable patients requiring low-level medical oversight for:

✓ Wound care✓ Recovery from surgical procedure✓ Additional time to recuperate from

illness and/or injury

Common Health Conditions:✓ End Stage Renal Disease✓ Congestive Heart Failure

(EF > 20%)✓ Cancer✓ Decubitus (Stages I-III)

PERMANENT SUPPORTIVE HOUSING

HFH Permanent Supportive Housing

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PSH is a department of HFH that contracts service agencies in LA County to provide Intensive Case Management Services (ICMS) in a project based and/or scattered site model. PSH is governed by the Statement of Work (SOW).

➢ We provide our ICMS contractors a defined model of case management.

➢ We work closely with our all the other units at HFH to coordinate housing services for clients.

➢ Within our unit, we have 5 teams that work on PSH placement and delivery of services to PSH clients within our system.

Statement of Work

- Outlines and dictates our expectations for how services will be delivered to clients

- Outlines our case management “ whatever it takes” model and all the training requirements needed to learn and adopt this model

- We monitor to the SOW

Access, Referral & Engagement Team

• Refer clients to PSH opportunities • Manage ICMS PSH resources matched

through CES• Complete Reverse Referrals• Provide TA to ICMS providers • New project set up/lease up calls• Special projects

New Agencies

• Building the foundation/orientation

• Statement of Work

• Determine Start Date/Initial Slot allocation/Subsidy

• Billing/Documentation Overview

• Documents (review and collect)

• Implementation Plan

• Policies and Procedures

• Client Satisfaction Survey

• Quality Control Plan

• Clinical Supervision Policy

• On-Call Procedures

PSH- Project Based• Project Based means that all the units are

located in one building or facility.

• Project based units are often tied to federal and local subsidies. There are two types of subsidies in project based: Project based with tied to units and Tenant based which is tied to the tenant as the move.

• DHS Program Mangers work with ICMS agencies to provide weekly ongoing support and technical assistance.

• We work with developers of PSH to build in ICMS slots in new upcoming project based sites and we are engaged in the lease up process with the developer, ICMS provider and property management company.

PSH-Scattered Site

• Scattered sites means that all the units are not located in one building or facility but rather units are scattered across several different properties in LA.

• ICMS works with the local housing authorities and Brilliant Corners.

• ICMS develops relationships with community landlords.

• DHS Program Mangers work with ICMS agencies to provide weekly ongoing support.

OFFICE OF DIVERSION AND REENTRY (ODR)

ODR Mission

Develop and implement county-wide criminal justice diversion for persons with mental and/or substance use disorders, including persons who are homeless.

➢Goal to provide 2500 units of permanent supportive housing to the justice population

Why housing?

• At least 20% of jail population is homeless

• Over a quarter have a mental illness

• Housing key to maintaining connection to treatment

• Almost 58,000 people experience homelessness on any given night in Los Angeles

ODR Housing Program

LA Superior

Court

Jail In-

Reach

Services

Conditional

Release

Bridge

Housing

Permanent

Supportive

Housing

Criminal Justice System Interim PSH

PSH PROGRAMS

In- Home Care Giving (IHCG)As part of Housing for Health’s mission to end homelessness and reduce unnecessary health costs, HFH established a program with the help of the Flexible Housing Subsidy Pool to provide In-home caregiving services to clients who DO NOT QUALIFY for State of California IHSS services. IHCG is a “ last resort” program for clients that do not meet eligibility for the state program.

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Housed but Need

Care

In-Home Care

Giving

Stably Housed

ERC- Higher Level of Care

Clients who are not thriving in their independent living situation due to an extreme change in medical or physical condition may need to be considered for a higher level of care, our Enrichment Residential care unit (ERC).

Legal status and income are notrequired to apply for ERC. Once a client is placed in a ERC facility, the ICMS provider continues to meet with the patient and provide services as in any other type of housing setting.

Unstably Housed

OR

Extreme Change in Medical or

Physical Condition

ERC

Medical Case Management Program

Description of Program: The medical case management program is comprised of 8 SPA based nurses ( 2 per SPA) that do assessments, light medical care and connection to a medical home and/or more intensive medical services within LA County’s medical system.

PurposeThis program is meant to be there to support ICMS in the work they are doing with the client, the nurses are an addition but they do not supplant your role as case manager. We ask that you work closely with the nurse as a team member.

How do you access these services ? Complete the Medical Assistance Request form, send to your assigned HFH PM, they will forward to medical team.

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COUNTYWIDE BENEFITS ENTITLEMENTS SERVICES TEAM ( CBEST)

Built upon the foundation of benefits advocacy in LosAngeles:

• HOPE, BEST, SOAR, DPSS GR to SSI (SSIMAP)

New Program design is a holistic approach:

• Submit full and complete SSI/SSDI/CAPI applications to SSA and DPSS

• Benefits advocacy and linkage to housing and services

• “Whatever it takes” approach

• Based on SOAR Best Practice

What is CBEST?

C.B.E.S.T Providers

• SPA 1- The Catalyst Foundation

• SPA 2- Tarzana Treatment Center

• SPA 3 & 4- Volunteers of America

• SPA 5- St. Joseph Center

• SPA 6- Special Services for Groups (HOPICS)

• Watts Labor Community Action Committee

• SPA 7- People Assisting the Homeless

• SPA 8- Lutheran Social Services

• Help Me Help You

• Co-located in 14 GR District Offices

• Community based locations in each SPA

• Jail facilities located in SPAs 2, 4, and 6

• Benefits Advocate teams are mobile

Service Locations

How to Refer into C.B.E.S.T

Fax/Scanned Referrals• Community organizations can refer potential

applicants via a referral form.

Appointments and Walk-ins• Potential applicants can schedule an appointment or

walk-into the community based locations during walk-in hours.

CONNECTING CLIENTS TO PRIMARY CARE

Connecting To Primary Care• Connection to Primary Care

• Be the liaison between clinical staff and clients• Providing/Assisting with transportation services

• Connection to MediCal• Check for expiration dates on card• Assist with recertification

• Connection to Mental Health• Takes some advocacy• Call DMH helpline

MOST COMMON CONDITIONS:

Hypertension

Diabetes

Asthma

Heart disease

Congestive heart failure

Cancer

HIV/AIDS

Hepatitis

Depression

Bipolar disorder

Schizophrenia

PTSD

Most HFH clients have MULTIPLE, POORLY CONTROLLED CHRONIC PHYSICAL AND MENTAL HEALTH CONDITIONS. Assume they all need

care ASAP!

10 minute break, please be back on time.

Thank you!

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THE WHATEVER IT TAKES MODEL

Whatever it Takes Do what is necessary to assist and support the client to most effectively reach the goals, resources and/or needs in ways that foster a client’s own sense of agency, self –efficacy, and quality of life within an ethical professional case management framework.

Qualities of ICMS:

➢Tenacity

➢Motivated

➢Client Centered

➢Strengths focused

➢Creative

➢Collaborative with client and team mates

➢Flexible as changes come up

➢Willing to learn and accept support

➢Strong Advocate

Traditional Case Manager vs. ICMS?

Intensive case management is a client-centered, strengths-based approach aimed at empowering and working in partnership with clients to effectively meet their individual needs and become self-sufficient. ICMS is not a traditional case management. We employ Whatever It Takes approach to case management.

V.S

Core Functions of ICMS

- ICMS begins work with the client from the moment they receive the

referral.-Intake and Assessment and addresses any immediate needs- Linking them to Interim Housing -Working with clients to find permanent housing units-Once client moves into PSH, move-In Activities and linking clients to resources to that will give them everything they need in their new home- Support and assist Client to stay housed and improve and maintain

and overall quality of life in all life domains:- Physical Health- Mental Health- SUD- Life Negotiation Skills- ADLs and iADLs

ICMS Interim Housing:

• Coordinate with Department of Health Services (DHS) Housing for Health (HFH)’s Access Referral and Engagement (ARE) team for client move-in.

ICMS Permanent Housing:

•Contact client within 2-5 business days. If client is unreachable, call referral source.•Meet with the client at a location convenient to them, (e.g., shelter, park, hospital or restaurant/cafe).

Outreach and Engagement

Warm Hand Off- Ensuring Continuity of Care

➢Two members from different agencies working with the same client meet to transition plan of care. Client is part of this meeting.

➢It’s about connection and making everyone feel comfortable about the transition.

➢Communication breakdowns within the health care team or between the team and the client can result errors of care transition

➢What does this look like?➢ Where is the client at currently?

➢ Client goals

➢ Client’s MH and medical history

➢ Calling the referring party ( interim case manager) weekly to check in with the client before warm handoff meeting 49

Intake and Assessment

• Work with Interim Housing Case

Manager (if applicable) to conduct a

“warm hand-off” and transition the

client over to your caseload.

• Obtain appropriate consents and

authorizations for client’s

participation.

• Conduct assessment of client’s

immediate and long-term needs.

• Develop an individualized case

management services plan.

CHAMP Referral shows client’s

medical history; which can

assist with conducting the

biopsychosocial assessment

during intake.

THIS CAN HELP YOU WITH

DEVELOPING A HOLISTIC CASE

PLAN and in turn, assist you

with your case management

and housing retention

Re-assessment Tool: 5 X 5

•A tool to help risk stratify HFH clients

•A tool to track progress of clients over time

•Looks at 5 domains of life; Physical Health, Mental Health, Substance Use, Life Negotiation Skills and Activities of Daily Living (ADL), Independent Activities of Daily Living ( IADL)

•Score of 1-5 within each domain➢ 1 is THE BEST

➢ 5 is HIGH NEED

➢ So…the higher the score, the more vulnerable the client

➢ But also remember that a 4 or 5 in any given domain can also make the client very vulnerable (so vulnerable even if total score is low)

➢ There is no culminative score for all the 5 domains. The scores should not be added together, the 5 scores should be considered separate but related

Client Support Needs

BOTH ICMS Interim Housing and Permanent Housing Teams must do the following:

•Go above and beyond “How are you feeling today?”•Ensure linkage to health, mental health services and specialty care.•Ensure clients with maintaining medication and treatment regimens.•Provide transportation, as needed, by means of bus fare/pass, agency vehicle(s), or private vendor. •Monitor and follow-up with clients and communicate clients needs

Let’s work out our brains!

Break up into small groups-3-4 people per group

Mr. Ramsey BoltonRamsey is a 35 year-old man. He has been homeless for the last 10 years living on the streets and in out of hospitals for various lengths of time in the last few years. Ramsey has a weak liver. He is an active cocaine user but denies using drugs or drinking. DHS has just referred Ramsey to you for housing at your PSH site and in the email it says he is connected to a therapist at DMH. You call him on the phone # listed and he agrees to meet at your office, he shows up to the appointment. You begin your assessment with him and he gets very upset and tells you he does not want to do the assessment and he will not sign any paperwork. He tells you he had a bad experience with the authorities. He has told he trusts no one except his 5 dogs. You know he needs the housing desperately.

***How do you handle this case as an Whatever It Takes Intensive Case Manager?

Housing SearchAssist client to complete rental subsidy applications with necessary documentation.

Accompany client to all housing-related interviews/meetings.

Assist client with locating permanent housing.

Unit location is between YOU and the client, not Brilliant Corners or any housing authority, though they may offer support.

Keep in mind vacancy rate is at an all-time low (~2%)

Advocate on client's behalf with landlord.

Attend unit showings with client.

Move-In Activities

• Conduct move-in orientation and ensure client has access items (e.g., toiletries, kitchen utensils, linens).

• Provide supportive services on life skills, rental responsibilities, etc.

• Assist clients with daily independent living, social/leisure, budget management, and personal hygiene skills.

• Increase visits around move-in. Clients are incredibly vulnerable during times of transition.

• Once stable, encourage community participation, and/or provide group programming onsite.

Let’s work out our brains!

Ms. Cersei LannisterCersei is 59 year old woman. She is living at your PSH site and has been there for 1 year. She’s diagnosed with bi-polar II disorder and reports seeing a psychiatrist. Her psych. is Dr. Littlefinger at Westeros Medical and she reports getting a refill prescription for her psychotropic medication every month. Cersei also has Hep C. she has admitted to self-medicating with wine in her past.

She was paying her rent on time for a long time then stopped paying her rent the last two months. Also within the last two months, her neighbors who live around and below her have complained to Property Management about loud music coming from her apartment late into the night. When you inquired about her drinking, she denies it. You notice Cersei often smells like alcohol and looks very disheveled during her case management meetings. Last week, she was issued 2 warnings from property mgmt. for threatening her neighbors and urinating on the community room couch. Property Management has told you that they want to evict her for non-payment of rent and her recent behavior.

***How do you use the Whatever It Takes approach to help keep Cersei housed?

COMPREHENSIVE HEALTH ACCOMPANIMENT MANAGEMENT

PLATFORM (CHAMP)

CHAMP Learning Objectives

➢ Understand basic functionality of CHAMP including workspace, menu options and dashboard functionality.

➢ Submit an Referral in CHAMP.➢ Create and Add Case Notes, Permanent Housing Updates, and Client Profile Updates.➢ Accept Referrals➢ Find and download authorization (PHI) forms.➢ Identify where the user guide can be downloaded.

Who gets trained in CHAMP?Providers who have a Contract/Work Order with Housing for Health to work with men, women and families who are homeless.

CHAMP Trainings

CHAMP Training Workgroups:➢CHAMP 101 Trainings- HFH ICMS Permanent Housing, Whole Person Care (WPC), Office of Diversion and Reentry (ODR), HJC and CBEST providers.

➢CHAMP REFERRER Trainings- DHS Hospitals, Nurses, Social Workers/Case Managers and Street Outreach and Engagement teams.

➢Interim Housing Trainings- Interim providers which includes; Intake specialist, Case Managers, Program Managers, Program Directors, and Psychiatric Staff.

➢ CHAMP 102 Trainings-

• Submitting Interim Housing/Higher Level of Care applications and completing unsubmitted applications or updating existing applications

• Exiting clients, transferring clients

• Assigning tasks

• Editing draft and saving final case notes

• Reports: Case note Summary Reports, active Roster Reports, clients W/O updates report, ICMS weekly reports and Updating employment and income for rapid Re-Housing Clients (If applicable)

If you have questions , please

come up to us individually after

the training.

Thank You for all you do in this effort to

resolve homelessness!!!

The TeamNew Agencies Team

Josh Legere

Sareena Kanji

Scattered Site Team

Karen Hamilton

Joey Aguilar

Alejandrina Jurado

Ana Rios

Silva Sepanian

HFH PSH Director

Leepi Shimkhada

Project Based Team

Alsalon Williams

Christin Doyle

Dalina Sasayama

Renee Williams

Connie Mitchell

Office of Diversion & Reentry Team

Tootsa Farrington

Oisin O’Shaughnessy

Michael Williams

Access, Referral and Engagement Team

Richy Myers

Roxanne Calimeris

Alsalon Williams

Keith Smith

CHAMP Trainings

Veronica Love

Data & Invoice Team

Kendra Purnell

Daniel Tirado