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Healthcare and Housing (H2) Systems Integration Initiative - State and Community Action Planning

To better meet the needs of people who are homeless and people living with HIV/AIDS who have low incomes, HUD's Office of Special Needs Assistance Programs (SNAPS) and the Office of HIV/AIDS Housing (OHH), in collaboration with the U.S. Interagency Council on Homelessness (USICH) and the U.S. Department of Health and Human Services (HHS) sponsored a technical assistance (TA) initiative to support states and communities in undertaking the systems changes needed to enhance integration and collaboration between the housing and healthcare systems. The goal of the TA initiative was to maximize care coverage for the target populations and increase access to comprehensive healthcare and supportive services that can be coordinated with housing.

20 communities were selected from a pool of applicants to receive on-site direct TA in the form of 1.5-day action planning sessions. TA providers, including expert facilitators and subject matter experts, worked with the TA recipients to plan, design, and deliver customized action planning sessions focused on integrating healthcare and housing systems and services. 20 sessions were held around the Country from December 2014 to May 2016. Planning session participants included representatives from Continuums of Care and ESG programs, HIV/AIDs providers and networks, local/state healthcare agencies, HUD and HHS regional and field offices, and other interested parties. For more information, view the TA announcement. Note: Applications are no longer being accepted for this TA.

This page provides an overview of the action planning session for each of the 20 participating states and communities, as well as community-specific resource information, contact information for each community's H2 Leadership Team, and the community's action plan overview and/or completed plan.

Access materials and resources to support communities in working to increase and improve housing and healthcare coordination and systems integration.

H2 Toolkit

Key features of the action planning sessions:

  • Participation by key stakeholders from both the Homeless Assistance and Health Care systems, including participants from all levels: agency and program staff, from front-line workers to Executive Directors; city, county, and state-level government representation, Federal Agency representatives (HUD, SAMHSA, HRSA, USICH, CMS)
  • Knowledge exchange across the homeless assistance and health care systems, including baseline knowledge of each system's structure, operation, and funding, as well as opportunities for connection and integration, including review of case studies and best practices being explored in states around the country
  • Subject matter experts and experienced, effective facilitators working with diverse group of stakeholders
  • Facilitated breakout discussions to elicit strategies and action steps for a customized H2 action plan, which the TA Team compiled into a draft action plan overnight. On the second day, participants were directly involved in reviewing and revising the emerging draft action plan
  • Consideration of and alignment with existing complementary structures, strategic plans, and initiatives
  • Each community also received remote follow-up TA to revise and finalize its H2 action plan and work toward implementation.

Community outcomes from action planning sessions:

  • Connections among people and organizations serving the same populations
  • Increased knowledge of existing housing and healthcare resources and how to help programs, organizations, and clients access those resources
  • Increased knowledge of potential local and national funding sources to leverage
  • A draft action plan to improve health and housing outcomes and stability for people who are homeless and people living with HIV/AIDS who have low incomes by integrating housing assistance and health care systems.

View Action Planning Session Information by State

Connecticut

Fairfield County, Connecticut's action planning session was conducted March 18-19, 2015 and was attended by approximately 80 people, representing federal and local government (including HUD, HRSA, and SAMHSA); homeless, HIV/AIDS and veterans providers; housing and healthcare agencies (including Health Care for the Homeless and Federally Qualified Health Centers); and other interested parties.

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"The beauty of [this planning session] is that providers are being informed on the small picture and the big picture."

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A draft Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term. Connecticut's H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan's overall objective of integrating Fairfield County's housing and healthcare systems to improve outcomes for persons experiencing homelessness, particularly those struggling with substance abuse and severe mental health issues.

"During our last breakout session, one table mate was able to get an appointment for a client by speaking to another person at our table." – Marti Knisley, Facilitator

Fairfield County's H2 Action Plan implementation will align with other related initiatives in Fairfield County and Connecticut, including Connecticut's Frequent Users' Service Enhancement (FUSE) Program and Connecticut's SIM grant implementation work. The H2 Leadership Team will coordinate with Opening Doors of Fairfield County's Health and Housing Committee to implement the Action Plan, keeping an eye on ongoing work of other state-wide programs such as the Partnership for Strong Communities and the Connecticut Coalition to End Homelessness.

The 4 goals of Fairfield County, Connecticut's H2 Action Plan are:

  1. Fill key gaps in housing, treatment, and services to facilitate better health and housing outcomes for the target population.
  2. Facilitate expanded system and service level integration and coordination of care.
  3. Enhance data quality, analysis, and sharing to improve client outcomes and system efficiency.
  4. Secure stable funding to support provision of integrated housing and health and behavioral health services and treatment.

For additional Connecticut-specific information, including the details of Fairfield County's H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Florida

"The incredible linkage between housing and health care struck me in 2011 when we did our first 100K homes registry week. We had 4 people who had cancer and were receiving chemo while still living on the street. That’s when it struck me that we are very siloed." - Dawn Gilman, CEO of Changing Homelessness in Jacksonville, FL

Jacksonville’s action planning session – which focused on Duval, Clay, and Nassau Counties – was conducted February 23-24, 2016 and was attended by nearly 30 people, representing federal and local government (including representatives from HUD and SAMHSA); homeless, HIV/AIDS, and veteran providers; housing and healthcare agencies (including Health Care for the Homeless and Managed Care Organizations); and other interested parties.

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"We need the right kind of services, with the right kind of expertise."

A draft Action Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on action steps that can be carried out or at least started in the short term. Jacksonville’s H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating Jacksonville’s housing and healthcare systems to improve outcomes for persons experiencing homelessness.

The implementation of Jacksonville’s H2 Action Plan will involve coordination among multiple departments and agencies, including the Duval County Department of Health and the Florida Department of Children and Families; hospitals and other health care providers, including Baptist Health, Lutheran Services Florida Health Systems, and the I.M. Sulzbacher Center for the Homeless; non-profits such as Ability Housing; and CoC-funded agencies, among others. The H2 Leadership Team is dedicated to creating an Action Plan that is responsive to the unique housing and health care needs of Jacksonville’s most vulnerable populations.

The 4 goals of Jacksonville's H2 Action Plan are:

  1. Use Data to Prioritize the Most Vulnerable Members of Our Community that Frequently Use Multiple Systems for Housing and Health Care Services.
  2. Better Understand and Leverage Resources Across Systems to Improve Coordination.
  3. Increase Enrollment and Access to Housing and Services.
  4. Maximize Use of Medicaid and Other Resources to Support Housing and Healthcare Access, Retention, and Stability.

For additional community-specific information, including the details of Jacksonville's H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Georgia

Athens, Georgia’s Action Planning Session was held in Athens on October 20-21, 2015, and was attended by nearly 40 people, representing local, state, and federal government; homeless, HIV/AIDS and veterans providers; housing and healthcare agencies (including Health Care for the Homeless and Athens Regional Medical Center); and other interested parties, including Advantage Behavioral Health Systems and the Georgia Department of Human Services, Division of Family and Children Services

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"In light of insufficient service dollars, how can we collaborate as a community to still serve clients’ needs?"

Housing and Health Initiative Action Planning Session - Georgia 4A draft Action Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term. Athens’ H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating Athens’ housing and healthcare systems to improve outcomes for persons experiencing homelessness.

"Currently, health delivery for our vulnerable populations is more reactive. We need to work together to change that."

The implementation of Athens, Georgia’s H2 Action Plan will involve coordination among multiple state departments and agencies, including Athens-Clarke County Housing and Community Development; hospitals and other health care providers, including Athens Regional, St. Mary’s Hospital, and Advantage Behavioral Health Systems; non-profits such as AIDS Athens; and CoC-funded agencies, among others. The H2 Leadership Team is dedicated to creating an Action Plan that is responsive to the unique housing and health care needs of Athens’ most vulnerable populations.

The 4 goals of Athens, Georgia's H2 Action Plan are:

  1. Improving Data Utilization
  2. Integrate Housing, Health Care, and Other Services.
  3. Closing Gaps in Access to Services and Treatmen
  4. Maximizing Resources

For additional Athens-specific information, including the details of the Athens, Georgia H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Hawaii

"Health care is only a small percent of a client’s well-being. The built environment, food security, and housing are all critical determinants of health."

Honolulu’s action planning session was conducted February 2-3, 2016 and was attended by approximately 70 people, representing federal and local government (including representatives from HUD, HHS, and USICH); homeless, HIV/AIDS, and veteran providers; housing and healthcare agencies (including Health Care for the Homeless and Managed Care Organizations); and other interested parties, including Hawaii State Senator Susie Chun Oakland.

Housing and Health Initiative Action Planning Session - Hawaii 1

"I want to see how Medicaid funding could trickle down to FQHCs to help provide additional outreach, case management, care coordination, and assistance in receiving people from hospitals and getting them into housing."

A draft Action Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term. Honolulu’s H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating Honolulu’s housing and healthcare systems to improve outcomes for persons experiencing homelessness.

The Leadership Team is looking into potential existing structures and plans into which the Honolulu H2 Action Plan can be incorporated, including HIC Task Force #4, Partners In Care’s recent strategic plan, and the Department of Health’s strategic plan.

"The unique thing about Hawaii is that all the resources we have are on the island. On the mainland, if you’re in a city and need something 100 miles away, you can get on a bus. Here, it’s either here or not here. How can we be creative with the resources we have on the island?"

The 4 goals of Honolulu's H2 Action Plan are:

  1. Create a Fully Functional Homeless Management Information System (HMIS) that Supports Effective and Efficient Client Care Across Systems; and Develop the Infrastructure Required to Facilitate the Secure Sharing of Information to Support Comprehensive, Consistent and Accurate Analysis and Planning.
  2. Close the Gaps Between Members of the Target Population and the Housing, Health Care, and Services They Need.
  3. Foster Collaboration Between Housing and Health Care Systems to Reduce Barriers and Improve Health Through Greater Access to Health Care and Stable Housing.
  4. Maximize Medicaid Utilization and Tap Other Available Resources to Improve and Support Housing Access, Retention, and Stability.

For additional Honolulu-specific information, including the details of the Honolulu H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Idaho

"The overall missing piece is a place to live that’s safe."

Housing and Health Initiative Action Planning Session - Idaho 1Housing-and-Health-Initiative-Action-Planning-Session-Idaho-2Housing and Health Initiative Action Planning Session - Idaho 3

Idaho’s state-wide action planning session was conducted May 27-28, 2015 and was attended by over 40 people, representing federal, state and local government (including HUD, SAMHSA, and HRSA representatives and members of various state departments); homeless and HIV/AIDS providers; housing and healthcare agencies (including Federally Qualified Health Centers and behavioral health agencies); and other interested parties, including representatives from state hospitals and medical facilities such as Idaho State University and Portneuf Medical Center.

"From a hospital perspective, the integration model is critical due to the fact that millions of dollars are lost every year due to the care for homeless individuals on the street."

Housing and Health Initiative Action Planning Session - Idaho 4A draft Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the near term. Idaho’s H2 Action Plan encompasses 4 goals, which address areas of activity essential to integrating Idaho’s housing and healthcare systems to improve outcomes for persons experiencing homelessness and low-income people living with HIV/AIDS.

The implementation of Idaho’s H2 Action Plan will involve coordination among multiple state departments and agencies, including the Idaho Department of Health and Welfare; health providers, including hospitals, FQHCs, and primary health associations; the Idaho Housing and Finance Association; and CoC-funded agencies, among others. The H2 Leadership Team is dedicated to creating an Action Plan that is responsive to the unique health and housing needs of Idaho’s most vulnerable populations and that reduces the barriers to accessing integrated health and housing services.

"Creating awareness is the key to getting more resources involved and improving the wellbeing of the community."

The 4 goals of Idaho’s H2 Action Plan are:

  1. Close the Gap in Housing and Health Care Services and Treatment by Increasing Services, Reducing Barriers, and Facilitating Access for Idaho’s Most Vulnerable.
  2. Develop a Robust, Integrated Data-Driven System that Uses Data to Understand and Assess Needs, Evaluate Program Effectiveness, Demonstrate Cost Savings and Secure Funding, and Generate an Accurate Picture of Homelessness in Idaho.
  3. Establish Mechanisms for the Housing and Health Care Systems to Work Cooperatively, thereby Reducing Barriers and Improving Health Through Greater Access To, and Maintenance of, Health Care and Stable Housing.
  4. Minimize the Incidence of Homelessness by Housing People and Providing Health Care.

For additional Idaho-specific information, including the details of Idaho’s H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Illinois

Chicago’s action planning session was conducted July 8-9, 2015 and was attended by approximately 60 people, representing federal and local government (including HUD, HRSA, and SAMHSA); homeless and HIV/AIDS providers; housing and healthcare agencies (including Health Care for the Homeless and Federally Qualified Health Centers); and other interested parties, including managed care organizations and the Illinois Department of Corrections.

Housing and Health Initiative Action Planning Session - Chicago 1

“The integration of data needs to happen from the top down.”

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A draft Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on action steps that can be carried out in the short term. Chicago’s H2 Action Plan encompasses 9 goals across three key focus areas, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating Chicago’s housing and healthcare systems to improve outcomes for persons experiencing homelessness.

 

"[In the] ideal database, all data is synced so that everyone has a holistic picture of the client."

The implementation of Chicago’s H2 Action Plan will involve coordination among multiple state departments and agencies, including the Illinois Department of Healthcare and Family Services and the Department of Mental Health; non-profit housing and healthcare organizations such as All Chicago, the Center for Housing and Health, Heartland Health Alliance, and Thresholds; and managed care organizations such as AETNA, among others. The H2 Leadership Team is dedicated to creating an Action Plan that utilizes innovative funding strategies, particularly through Medicaid, to increase Chicago’s supportive housing resources.

The 3 key focus areas of Chicago’s H2 Action Plan are:

  1. Developing a Data-Driven System of Care: Identification, Stratification, Linkage, Coordination, Evaluation, Recommendations, and Implementation
  2. Improving Access to Coverage through Care
  3. Increasing Supportive Housing Resources

For additional Chicago-specific information, including the details of Chicago’s H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Michigan

"For our newly enrolled Medicaid populations, all they know is to go to the ER. It’s very important to help them connect to primary care – we cannot see cost savings until then."

Michigan’s action planning session was conducted April 5-6, 2016 and was attended by over 80 people, representing federal and local government (including representatives from HUD and HRSA); homeless, HIV/AIDS, and veteran providers; housing and healthcare agencies (including Health Care for the Homeless and Managed Care Organizations); and other interested parties, including representatives from local hospitals and the Michigan Primary Care Association.

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"We need to look at system-wide approaches, not agency by agency strategies anymore."

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A draft Action Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term. Michigan’s H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating Michigan’s housing and healthcare systems to improve outcomes for persons experiencing homelessness.

The Leadership Team is looking to coordinate the development and implementation of the Michigan H2 Action Plan with the Michigan Interagency Council on Homelessness 10-Year Plan to End Homelessness.

"There are many supportive services agencies across Michigan, and a key piece of bringing them together is patient education & cross knowledge. We need to work together to create a model that works, and replicate it."

The 4 goals of Michigan's H2 Action Plan are:

  1. Expand Community Capacity to Empower Data-Driven Decision Making to Support the Integration of Housing and Healthcare Systems.
  2. Optimize Existing Service Delivery Systems by Improving and Increasing Communication and Coordination to Create a Seamless Approach to Providing Housing and Related Services.
  3. Increase Capacity and Flexibility of Care Delivery to Improve Access and Utilization of Services that Support Housing Stability.
  4. Fully Utilize Current Capacity to Bill Medicaid for Health Care and Supportive Services and Identify Alternative Funding Sources to Fill Remaining Gaps.

For additional Michigan-specific information, including the details of the Michigan H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Montana

"I want to challenge all of us here that in six months we are a case study on housing and healthcare integration." – Marcia Armstrong, Department of Public Health and Human Services, Addictive and Mental Disorders Division

Montana’s action planning session was conducted May 12-13, 2016 and was attended by over 50 people, representing federal and local government (including HUD); homeless, HIV/AIDS, and veteran providers; housing and healthcare agencies (including Public Housing Authorities and Federally Qualified Health Centers); and other interested parties, including representatives from the Montana Primary Care Association.

Housing and Health Initiative Action Planning Session - Montana 1

"From both the housing and healthcare perspective, this is about human dignity. There are exciting things we can do to improve our housing and health outcomes together."

Housing and Health Initiative Action Planning Session - Montana 2An Action Plan has been developed and a Leadership Team appointed to begin implementation, focusing on state and local action steps that can be carried out in the short term. Montana’s H2 Action Plan encompasses three goals, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating housing and healthcare systems across Montana to improve outcomes for persons experiencing homelessness.

The implementation Montana’s H2 Action Plan will involve coordination among multiple state departments and agencies, including the Montana CoC Coalition; Montana Department of Public Health and Human Services; Montana Department of Commerce; and other state-level groups dedicated to serving Montana’s most vulnerable populations.

The 3 goals of Montana’s H2 Action Plan are: 

  1. Develop Data-Driven Service Interventions.
  2. Enhance Systems Coordination to Facilitate Meaningful Access to Housing, Health Care, and Other Support Services and Treatment.
  3. Maximize Use of Medicaid and Other Existing Resources to Support Housing and Health Care Access, Retention, and Stability.

For additional Montana-specific information, including the details of Montana’s H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Nevada

Nevada's H2 Action Plan encompasses 5 goals, each of which addresses an area of activity essential to achieving the Plan objective: "Building Housing and Healthcare Systems that Work Together."

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"Relationship building is key, as is following through, and intensive case management."
"We have to acknowledge the changing landscape. Balance specialization with diversification of funding sources."

Housing-and-Health-Initiative-Action-Planning-Session-Nevada-4Nevada's state-wide action planning session was conducted December 10-11, 2014 and was attended by over 40 people, representing federal, state and local government (including HUD and HRSA representatives); Medicaid; homeless, HIV/AIDS and veterans providers; housing and healthcare (including behavioral health) agencies; managed care organizations, criminal justice and court systems, and other interested parties. A draft Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term.

"Healthcare providers must recognize that they have a piece of the responsibility. The impact of housing on health outcomes and services is established."

The 5 goals of Nevada's H2 Action Plan are:

  1. Identify the priority target group of homeless persons and unstably housed people living with HIV/AIDS where a significant gap in housing and treatment exists.
  2. Identify the appropriate Medicaid payment mechanism linked to the care, treatment and housing proposed for the prioritized target sub-population.
  3. Build strong local relationships between MCOs, homeless housing providers and HIV/AIDS housing providers for a seamless service delivery system; integrated housing and treatment.
  4. Meet the existing gap in housing, discharge planning and recuperative placement.
  5. Meet the resource gap to support innovative treatment and housing partnerships.

For additional Nevada-specific information, including the details of Nevada's H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

New Mexico

"We are redefining what health care really looks like, because we finally folded in Behavioral Health diagnosis."

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"In rural areas, that problem is magnified. Even once you get Section 8 or public housing, if you don’t get supports, how long are you going to last?"
"Housing and services have to develop together as a comprehensive system."

Housing and Health Initiative Action Planning Session - New Mexico 6New Mexico’s state-wide action planning session was conducted May 14-15, 2015 and was attended by nearly 60 people, representing federal, state and local government (including HUD and HRSA representatives and members of various state departments); homeless and HIV/AIDS providers; housing and healthcare agencies (including Health Care for the Homeless and Managed Care Organizations); and other interested parties, including Gerald Ortiz y Pino, a member of the New Mexico State Senate.

A draft Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the near term. New Mexico’s H2 Action Plan encompasses 3 goals, which address areas of activity essential to integrating New Mexico’s housing and healthcare systems to improve outcomes for persons experiencing homelessness and low-income people living with HIV/AIDS.

"[We] Have to be a lot more innovative on this partnering. FQHCs under this new model will be the leaders, so we need to develop partnership with them."

The implementation of New Mexico’s H2 Action Plan will involve coordination among multiple state departments and agencies, including the New Mexico Department of Human Services and the City of Albuquerque Family & Community Services; non-profits such as The Life Link; and CoC-funded agencies, among others. The H2 Leadership Team is dedicated to creating an Action Plan that prioritizes populations that receive lower levels of services and that recognizes the state’s rural housing and service needs.

The 3 goals of New Mexico’s H2 Action Plan are: 

  1. Use Data to Demonstrate the Connection Between Housing and Health Care and Integrate Homeless Assistance and Health Care Systems to Improve Client Outcomes
  2. Leverage System Integration to Provide Ready Access to Stable, Affordable Housing and Comprehensive Health Care for People Experiencing or at Risk of Homelessness to Improve Housing Stability and Health Outcomes for New Mexico
  3. Maximize New Mexico’s Current Resources and Develop New Resources to Address the Housing and Health Care Needs of People Experiencing Homelessness.

For additional New Mexico-specific information, including the details of New Mexico’s H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Upstate New York

"This has been an amazingly productive use of our time. Getting this number of people from around the state was great. It feels like we actually accomplished something. This was a very unique opportunity to network, communicate, learn and go back with ideas to implement."

Upstate New York’s action planning session was conducted April 20-21, 2016 and was attended by over 100 people, representing federal and local government (including representatives from HUD and SAMHSA); homeless, HIV/AIDS, and veteran providers; housing and healthcare agencies (including Health Care for the Homeless and Managed Care Organizations); and other interested parties, including representatives from local hospitals and the New York State Department of Health.

Housing and Health Initiative Action Planning Session - New York 1

"Health care agencies and homeless agencies too often operate in silos - knowing ways to collaborate with Medicaid or hospitals would be a huge step in better serving our clients."

Housing and Health Initiative Action Planning Session - New York 2A draft Action Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term. Upstate New York’s H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating housing and healthcare systems across New York State to improve outcomes for persons experiencing homelessness

The Upstate New York H2 Leadership Team is looking to incorporate the H2 Action Plan into each Community Consolidated Plan and New York’s Plan to End Homelessness.

The 4 goals of Upstate New York’s H2 Action Plan are:

  1. Improve Data Quality, Strategic Integration, and Analysis to Better Understand the Comprehensive Needs of Clients to Reduce Client Burden and Improve Housing Stability and Health Outcomes.
  2. Foster Strategic and Intentional Partnerships Between Key Stakeholders at the Local, County, and State Levels to Create an Integrated Health Care and Housing System that Maximizes Resources and Improves Outcomes for People Experiencing Homelessness.
  3. Increase Access to and Effective Utilization of Health Care and Housing Services.
  4. Allow Providers of Homeless Services to Draw Down Medicaid and Other Sources of Revenue in Order to Sustain and Expand Services and Supports For People Experiencing or At Risk of Homelessness

For additional Upstate New York-specific information, including the details of the Upstate New York H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

North Carolina

North Carolina’s action planning session was conducted April 28-29, 2015 and was attended by approximately 120 people, representing federal and local government (including HUD, HRSA, and USICH); homeless, HIV/AIDS and veterans providers; housing and healthcare agencies (including nine Managed Care Organizations and four Federally Qualified Health Centers); and other interested parties, including the North Carolina Department of Health and Human Services and representatives from five local hospitals and medical facilities.

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"Had he stayed on the street, he would have been dead in two months. Now he has everything he needs. And the difference is housing." - Session participant, describing a client with complex needs who was placed in a Housing First program

Housing and Health Initiative Action Planning Session - North Carolina 5A draft Framework has been developed and a Leadership Team appointed to finalize the Framework and begin implementation, focusing on state and local action steps that can be carried out in the short term. North Carolina’s H2 Action Framework encompasses state and community level objectives, strategies, and action steps to achieve the overall objective of integrating North Carolina’s housing and healthcare systems to improve outcomes for persons experiencing homelessness and low-income people living with HIV/AIDS.

"Big hospitals and health care systems are speaking together to integrate better and also meet other needed services.."

North Carolina’s H2 Action Planning Session focused on four counties - Alamance, Durham, Forsyth, and Guilford - which will continue to focus on the Action Framework finalization and implementation. The goal of these four counties is to create a model for the integration of health and housing systems that can be scaled up to the entire state of North Carolina.

The State Level Objectives of North Carolina’s H2 Action Framework are:

  1. Create Partnerships and Integrate Housing and Health Care Treatment and Services to Increase Housing Stability and Health Outcomes for North Carolina’s Most Vulnerable
  2. Maximize Use of Medicaid and Other Resources to Improve Access to Health Care and Other Services that Support Housing Stability
  3. Engage with Managed Care System to Improve Health Outcomes and Housing Stability
  4. Improve Data Collection and Analysis Across Housing Assistance and Health Care Systems Throughout North Carolina.

The County Level Objectives of North Carolina’s H2 Action Framework are:

  1. Increase and Improve Meaningful Access to Health Care and Services that Support Housing Stability Through Education and Coordination
  2. Increase and Improve Data Collection, Sharing, and Analysis to Enable Data-Informed Education, Data-Driven Decision Making, and Data-Supported Funding Requests.
  3. Integrate Housing and Health Care Systems Interventions & Treatments Through Education, Relationship-Building, Coordination, and Innovative Collaborations.
  4. Maximize Medicaid and Existing Resources to Fund and Support Health Care and Services that Support Housing Stability for People Experiencing Homelessness.

For additional North Carolina-specific information, including the details of North Carolina’s H2 Action Framework, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

North Dakota

"We need to build the capacity to partner. We as a state are majorly lacking in mental health services, and that’s a big piece of why people are homeless. And it’s hard to do in a rural state – it’s hard to get where you need to go for the weekly meeting with your mental health case manager."

North Dakota’s action planning session was conducted March 8-9, 2016 and was attended by nearly 30 people, representing federal and local government (including representatives from HUD); homeless, HIV/AIDS, and veteran providers; housing and healthcare agencies (including behavioral health and public health agencies); and other interested parties, including representatives from the North Dakota Department of Human Services – the state’s Medicaid agency.

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"We know there is a connection between your health and where you live. Environment affects health, and mortality is affected by housing status."

A draft Action Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term. North Dakota’s H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating North Dakota’s housing and healthcare systems to improve outcomes for persons experiencing homelessness.

The Leadership Team is looking to coordinate the development and implementation of the North Dakota H2 Action Plan with existing structures and ongoing initiatives, including the Statewide Housing Services Collaborative, the North Dakota Interagency Council on Homelessness, and the Governor’s Council on Behavioral Health.

"What we want - and the clients want - is a warm hand-off between medical care, behavioral health, and housing providers."

The 4 goals of North Dakota's H2 Action Plan are:

  1. Strategically Collect and Analyze Data to Identify Needs, Facilitate System Planning, Measure Outcomes, and Advocate for Funding.
  2. Create a Person-Centered Integrated System to Improve Health Outcomes, Housing Stability, and Access to Social Services.
  3. Ensure North Dakota’s Most Vulnerable Residents have Sufficient Access to Needed Housing, Health Care, and Supportive Services.
  4. Maximize Utilization of Resources to Fund Affordable Housing and Services that Support Housing Stability.

For additional North Dakota-specific information, including the details of North Dakota's H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Pennsylvania

“The number one need is: we've got to get people housed and set them up to sustain themselves with income, services, and health care.”

Pittsburgh’s action planning session was conducted December 15-16, 2015 and was attended by approximately 70 people, representing federal and local government (including representatives from HUD and the Allegheny County Department of Human Services); homeless, HIV/AIDS, and veteran providers; housing and healthcare agencies (including Health Care for the Homeless and Managed Care Organizations); and other interested parties, including Operation Safety Net and Allegheny County APPRISE.

Housing and Health Initiative Action Planning Session - Pennsylvania 1

“Integrating housing and healthcare requires establishing initial trust, moving clients into housing and making sure they stay housed. We need to be able to house someone as soon as they are ready.”

Housing and Health Initiative Action Planning Session - Pennsylvania 2A draft Action Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term. Pittsburgh’s H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating Pittsburgh’s housing and healthcare systems to improve outcomes for persons experiencing homelessness.

"The amount of money it takes to neglect people is stunning. If the medical community better understood that, there would be a shift in perspective."

The implementation of Pittsburgh’s H2 Action Plan will align with the efforts of the Allegheny County Homeless Advisory Board to create a comprehensive plan to end homelessness by 2020.

The 4 goals of Pittsburgh's H2 Action Plan are:

  1. Collect and Use Data to Catalyze Systems Change by Demonstrating Cost Effectiveness, Remaining Client Focused, Informing Future System Planning, and Informing Resource Allocation.
  2. Create a Person-Centered, Integrated System to Improve Health Outcomes, Housing Stability, and Access to Social Services.
  3. Redesign Care Delivery System to be Trauma-Informed, Recovery-Oriented, and Strength-Based, to Increase and Improve Access to Needed Care by Members of the Target Populations.
  4. Increase and Improve Opportunities for People to Access and Retain Stable Housing Through the Promotion of Housing First and Maximized Understanding and Utilization of Medicaid and Other Resources in Allegheny County.

For additional Pittsburgh-specific information, including the details of Pittsburgh's H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Tennessee

"You are the people you've been looking for…It's people like you who will make this change happen." - Sernorma Mitchel, Director of HUD's Nashville Field Office

Nashville, Tennessee's action planning session was conducted June 9-10, 2015 and was attended by approximately 40 people, representing federal and local government (including HUD and the Tennessee Department of Health); homeless, HIV/AIDS and veterans providers; housing and healthcare agencies (including Health Care for the Homeless and Federally Qualified Health Centers); and other interested parties, including TennCare and representatives from local hospitals.

"We need to coordinate, share information and be on the same page about how to deliver those services and care…housing and health care all benefit when it works right."

Housing and Health Initiative Action Planning Session - TennesseeA draft Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term. Nashville's H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan's overall objective of integrating Nashville's housing and healthcare systems to improve outcomes for persons experiencing homelessness.

Nashville's H2 Action Plan implementation will align with other related initiatives in Nashville/Davidson County, including the How's Nashville campaign and Hospital 2 Home project.

"If you only concentrate on HIV issues and resources, you aren't going to really help the people you want to help. For many, it's the least of their problems. To solve their problems, we need to take a much more comprehensive approach- including mental health, housing, and nutrition."

The 4 goals of Nashville's H2 Action Plan are:

  1. Build and Enhance Cross-System Relationships to Foster Collaboration and Effective Data Sharing to Improve Housing Stability and Health Outcomes.
  2. Build Capacity for Integrating Health, Behavioral Health, Housing, and Social Services for People Experiencing Homelessness and Low-Income People Living with HIV/AIDS.
  3. Increase Collaboration Between Housing and Health Care Systems to Improve Communication, Education, and Access to Housing, Services, and Comprehensive Health Care by People Experiencing Homelessness and People Living with HIV/AIDS.
  4. Maximize Efficient Utilization of Existing Housing Assistance and Health Care Resources to Support Access, Retention, Stability, and Positive Outcomes for People Experiencing Homelessness and Low-Income People Living with HIV/AIDS.

For additional Nashville-specific information, including the details of Nashville's H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Texas

"The key is to bring the right people to the table and form partnerships. FQHCs are welcoming and can provide a holistic approach."

Texas’ Action Planning Session was held in Austin on September 16-17, 2015, and was attended by approximately 65 people, representing federal and local government (including HUD and the Texas Department of State Health Services); homeless, HIV/AIDS and veterans providers; housing and healthcare agencies (including Health Care for the Homeless and Local Mental Health Authorities); and other interested parties, including representatives from Medicaid and the criminal justice system.

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"Even with the demographic and geographic complexity of the state, many of us have the same goals. Having a general platform to work off of would do well."

Housing and Health Initiative Action Planning Session - Texas 4A draft Action Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term. Texas’ H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating Texas’ housing and healthcare systems to improve outcomes for persons experiencing homelessness.

"From the MCO perspective, where to focus includes the question of whether Coordinated Access exists. Collaboration among homeless and housing providers is the basis for managed care participation."

The Texas H2 Leadership Team has aligned the target population and timeline for Texas’ Action Plan with the goals of The U.S. Interagency Council on Homelessness (USICH)’s “Opening Doors: Federal Strategic Plan to Prevent and End Homelessness.” The Texas H2 Action Plan will prioritize ending homelessness for Veterans in 2015, for chronically homeless individuals in 2016, and for youth and families by 2020. In addition, Texas’ H2 Action Plan will build on the successes of the Mayor’s Challenge to end Veteran Homelessness in order to meet the housing and health needs of the state’s most vulnerable populations.

The 4 goals of Texas' H2 Action Plan are:

  1. Increase Access to Housing, Health Care, and Supportive Services throughout Texas by Maximizing Use of Mainstream Resources and Improving Coordination and Utilization of Existing Assets.
  2. Integrate Housing, Health Care, Behavioral Health, and Other Services to Improve Housing Stability and Ongoing Wellness.
  3. Maximizing the Use of Medicaid and Other Resources to Support Access to and Stability in Housing and Integrated Health Care.
  4. Use data to better coordinate services within and across systems.

For additional Texas-specific information, including the details of Texas' H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Utah

“Let’s focus our planning on what we can accomplish, which depends on interaction with elected officials. What can we come up with that captures their hearts, minds, and commitment?”

Housing and Health Initiative Action Planning Session - Utah 2Housing and Health Initiative Action Planning Session - Utah 3Housing and Health Initiative Action Planning Session - Utah 4Housing and Health Initiative Action Planning Session - Utah 5

“We need to make a better case for more funding; and, to do more with what we've got.”
"Community volunteers in our state are becoming exhausted with the depth, length, and frequency of need.”

Housing and Health Initiative Action Planning Session - Utah 6Utah’s state-wide action planning session was conducted March 4-5, 2015 and was attended by over 40 people, representing federal, state and local government (including HUD and HRSA representatives and members of various state departments); homeless, HIV/AIDS and veterans providers; housing and healthcare agencies (including Health Care for the Homeless and Federally Qualified Health Centers); and other interested parties, including Lloyd Pendleton.

A draft Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the near term. Utah’s H2 Action Plan encompasses 4 goals, which address areas of activity essential to integrating Utah’s housing and healthcare systems to improve outcomes for persons experiencing homelessness and low-income people living with HIV/AIDS.

“Like our 10 year plan, we will see real change in time.  We are at the start now on connecting housing and healthcare.  I am grateful to be a part of the creation, and proud of the difference we are making in people's lives.”

The 4 goals of Utah’s H2 Action Plan are: 

  1. Facilitate enrollment of homeless people in Medicaid, access to care and treatment, and appropriate use of medical services.
  2. Integrate housing, health care, and other services for housing retention and ongoing wellness to ensure that all homeless individuals have access to housing and appropriate support services to maintain housing, increase self-sufficiency, and decrease disparities in access and utilization of healthcare services.
  3. Develop a comprehensive, accurate, and timely data sharing system to implement data-driven service interventions.
  4. Maximize the use of Medicaid and other resources to finance services and treatment supporting housing access, retention, and stability.

For additional Utah-specific information, including the details of Utah’s H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Virginia

Virginia's Healthcare and Housing Integration Action Plan encompasses 5 goals, each of which addresses an area of activity essential to achieving their Plan objective "to improve client lives, health outcomes, and housing stability by transforming and integrating the housing and health care delivery systems."

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"Health care providers need to be educated on how to work with those who are experiencing homelessness and what questions to ask, especially in emergency situations."
"We have good ideas. What we lack is systems talking to each other."

Housing and Health Initiative Action Planning Session - Virginia 4Virginia's action planning session was conducted January 8-9, 2015 and was attended by over 80 people, representing federal, state and local government, homeless, HIV/AIDS and veterans providers; housing and healthcare agencies; and other interested parties. Norm Suchar, Roula Sweis, and Amy Palilonis from HUD attended, as well as Leah Suter from HRSA, Virginia's Secretaries of Health and Human Resources and Commerce and Trade, and representatives from Virginia's state Medicaid agency. A draft Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term.

"Part of the culture of Virginia is everything is local, which can be a problem. If we could get a statewide system that everyone would actually implement, that would be a tremendous help."

Oversight of Virginia's H2 plan will be conducted by the Solutions Committee of the Governor's Coordinating Council on Homelessness to ensure coordination with all complementary efforts and initiatives in the state. The H2 Leadership Team will also align its efforts with Virginia's State Innovation Model (SIM) grant implementation and changes to the state Medicaid Plan.

The 5 goals of Virginia's H2 Action Plan are: 

  1. Ensure that every person in the target population has access to housing and to the support services needed for ongoing residential stability.
  2. Enhance access to health and behavioral health services needed to maximize health, manage ongoing conditions, and facilitate housing retention.
  3. Improve coordination and collaboration between the housing and health care systems, at both the systems and service levels.
  4. Use data to inform decision-making in order to enhance system efficiency and improve quality of care and outcomes.
  5. Support H2 with complementary efforts currently underway in Virginia.

For additional Virginia-specific information, including the details of Virginia's H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

West Virginia

West Virginia’s Action Planning Session was held in Charleston on August 12-13, 2015, and was attended by approximately 40 people, representing federal and local government (including HUD and the West Virginia Department of Health and Human Resources); homeless, HIV/AIDS and veterans providers; housing and healthcare agencies (including Public Housing Authorities and Federally Qualified Health Centers); and other interested parties, including the Legal Aid of West Virginia and representatives from local hospital facilities.

Housing and Health Initiative Action Planning Session - Virginia 1Housing and Health Initiative Action Planning Session - West Virginia 2Housing and Health Initiative Action Planning Session - West Virginia 3

"Enrollment is good, but the bigger issue is to follow through for folks with complex health needs…they need access to care."

Housing and Health Initiative Action Planning Session - West Virginia 4A draft Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term. West Virginia’s H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating West Virginia’s housing and healthcare systems to improve outcomes for persons experiencing homelessness.

"[If] homeless housing providers are tied to FQHCs, clients will get better care and better outcomes."

The West Virginia H2 Leadership Team will forge strong partnerships for H2 Plan implementation, working with the state’s Rural Health Association, Behavioral Health Association, Primary Care Association, and Hospital Association, colleges and universities, State Medicaid, State Behavioral Health, and hospital facilities in order to meet the housing and health needs of West Virginia’s most vulnerable residents.

The 4 goals of West Virginia’s H2 Action Plan are:

  1. Collect, Organize, and Use Cross-System Data to Evaluate Need, Expand Awareness, and Demonstrate Cost Savings and Program Effectiveness to Improve Health Outcomes and Housing Stability.
  2. Foster Ongoing Collaboration Between CoC Housing and Health Systems, Integrating Care to Improve Lives.
  3. Transform Access and Delivery of Health Care and Housing as an Open System to Meet Client Needs, Conditions, and Abilities.
  4. Maximize Use of Medicaid and Other Existing Resources to Increase Access to Health Care and Other Services That Support Housing Stability.

For additional West Virginia-specific information, including the details of West Virginia’s H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

Wisconsin

“We are coming together across different parts of housing to plan. The gaps in our system create barriers and impact health.”

Wisconsin’s Action Planning Session was held in Madison on December 1-2, 2015, and was attended by approximately 40 people, representing local, state, and federal government (including SAMHSA); homeless, HIV/AIDS and veterans providers; housing and healthcare agencies (including Health Care for the Homeless); and other interested parties, including the AIDS Resource Center of Wisconsin.

Housing and Health Initiative Action Planning Session - Wisconsin 1Housing and Health Initiative Action Planning Session - Wisconsin 2Housing and Health Initiative Action Planning Session - Wisconsin 3

"I want to end homelessness. Any opportunities to get more resources for people who are homeless, I want to know about."

Housing and Health Initiative Action Planning Session - Wisonsin 4

A draft Action Plan has been developed and a Leadership Team appointed to finalize the Plan and begin implementation, focusing on state and local action steps that can be carried out in the short term. Wisconsin’s H2 Action Plan encompasses 4 goals, each of which addresses an area of activity essential to achieving the Plan’s overall objective of integrating Wisconsin’s housing and healthcare systems to improve outcomes for persons experiencing homelessness.

"Supporting health and housing integration makes sense from a health side. Not taking steps towards integration is expensive, and there are models we can look to for replication."

To support the implementation of Wisconsin’s H2 Action Plan, the Wisconsin Leadership Team will identify existing committees or work groups (including CoC committees) to take leadership of implementing priority H2 strategies. Committees being considered to help implement Wisconsin’s H2 priority strategies include the Dane County CoC Data Committee, Dane County CoC Mainstream Committee, Dane County CoC Coordinated Intake Committee, Madison Zero2016 Committee, and the creation of a new Healthcare Coordinating Committee.

The 4 goals of Wisconsin’s H2 Action Plan are:

  1. Move toward cross-system data matching across health, housing, and other service systems to facilitate improved client access and utilization of all needed services.
  2. Move toward an integrated system of housing services, medical health, and behavioral health for low-income people with HIV/AIDS and people experiencing homelessness
  3. Move toward elimination of housing and healthcare service gaps for low-income people with HIV/AIDS and people experiencing homelessness.
  4. Move toward using Medicaid and other mainstream funding for services that support housing stability to increase funds available for housing.

For additional Wisconsin-specific information, including the details of the Wisconsin H2 Action Plan, check out the following links:

Contact Information: Gillian Morshedi - 415-788-7961 ext. 301 - gillian@homebaseccc.org

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