Hawaii Homeless Policy Academy Strategic Plan

¹ The Manager is the individual responsible for coordinating each action.

PLANNING AND COORDINATION (Working Group Infrastructure)

² The Implementer is the individual (or entity) responsible for carrying out
each action.

Strategy 1.1
Summarize available data and resources to serve Hawaii’s chronically homeless.

Action 1.1.1
Gather statewide data on target population.

HCDCH

SMS Research

Gain a fairly accurate number of chronically homeless plus client profile.

Survey completed; Unmet needs determined; Results released.

8/30/03

Action 1.1.2
Gather statewide data on affordable and subsidized housing stock.

HCDCH

SMS Research

Severe shortage of affordable and subsidized housing will quantify the unmet need of the homeless.

Survey completed;
Unmet needs determined;
Results released.

8/30/03

Action 1.1.3
Identify and develop catalogue of mainstream services

HCDCH

Policy Academy

Improved access as the information is made available to providers and other line staff.

Improved understanding of available services, eligibility criteria, accessibility, and service gaps. Catalogue produced.

12/30/03

Strategy 1.2
Develop and implement a reliable homeless management information system (HMIS) to track clients and program utilization.

Action 1.2.1
Initiate the new HMIS with homeless provider agencies under the State programs.

HCDCH

Hybrid International

An integrated database will facilitate a more effective response to homeless needs; and provide data on homeless trends, demographics, service utilization and program effectiveness.

All contracted service providers will master inputting intake and progress data into the web-based system.
They will also be capable of creating reports from their data.

August 2003

Action 1.2.2
Expand the HMIS program to encompass federal, city and county programs.

HCDCH

Hybrid International

An integrated database will facilitate a more effective response to homeless needs; and provide data on homeless trends, demographics, service utilization and program effectiveness.

All service providers will master inputting intake and progress data into the web-based system.
They will also be capable of creating reports from their data.

12/31/03

Action 1.2.3
Solicit private homeless provider agencies that do not receive public funds to participate in the HMIS system

HCDCH

Counties and other provider agencies

An integrated database will facilitate a more effective response to homeless needs; and provide data on homeless trends, demographics, service utilization and program effectiveness.

All homeless providers will master inputting intake and progress data into the web-based system.
They will also be capable of creating reports from their data.

03/31/04

Action 1.2.4
Use HMIS to generate and publish placement outcomes and homeless success data.

HCDCH

Hybrid International

Higher community profile of homeless services and the effectiveness of the services.

Strong media attention initially.
Improved community understanding and support.

Ongoing

Strategy 1.3
Identify risk factors associated with becoming homeless and use the findings to develop prevention and intervention protocols.

Action 1.3.1
State agencies determine what segment of their clients are at high risk of homelessness.

State Policy Academy

Office of the Governor

Less persons become homeless

Agencies respond to findings with preemptive measures.

7/1/04

Action 1.3.2
Academy aids state agencies in identifying opportunities for collaboration and integration of prevention and intervention protocols.

State Policy Academy

HCDCH

Less persons become homeless

Academy prepares a curriculum for workshops. Workshops held.

7/01/04

Action 1.3.3
Each affected state agency needs to modify the reporting requirements of substance abuse providers to include the number of participants who are homeless as part of client demographics. (Include drug court)

ADAD

Elaine Wilson

Expect to find a large component of substance abusers are chronically homeless.

Amend contract requirements to include homeless demographic.
Include in reporting requirements from provider agencies.

7/01/04

Action 1.3.4
Review/adopt model programs or best practices in addressing the needs of the chronically homeless.

HCDCH

State agencies and counties

Improved services with evidence-based practices and proven success models.

Research practices.
Review and adapt for Hawaii.
Implement and track.

Ongoing

Strategy 1.4
Improve access by removing barriers to mainstream services

Action 1.4.1
Identify and document the barriers to accessing services

Policy Academy

Policy Academy and State Agencies

Barriers will be removed or modified to improve service access.

Barriers researched. Collaboration on how to solve the access problem.
Adoption of new procedure to accommodate better access.

Ongoing

Action 1.4.2
Address confidentiality concerns

Policy Academy

State and County agencies

A service network which is in compliance with privacy laws.

Research privacy laws. Adopt procedures to comply with privacy requirements.

12/31/03

Action 1.4.3
Develop and execute MOA for interdepartmental partnerships (get samples from various agencies)

State and Counties

State and Counties

More effective service delivery, resource sharing and coordination.

Identify areas where MOA would solidify roles in interdept. partnerships.
Develop MOAs.

Ongoing

Action 1.4.4
Identify processes and mechanisms to share information with staff, providers and clients on service to the homeless – no wrong door with coordinated services.

Policy Academy

HCDCH

More effective service delivery, resource sharing and coordination.

Develop a series of communication devices. Utilize each to determine which are most effective.

Ongoing

Action 1.4.5
Expand eligibility criteria from SMI to also include individuals who are chronically homeless due to co-occurring disorders

Adult Mental Health Division

Adult Mental Health Division

More services available to the chronically homeless, especially those who straddle jurisdictional lines.

Policy change by AMHD

12/31/03

Action 1.4.6
Implement model for co-occurring treatment.

Adult Mental Health Division

Adult Mental Health Division and ADAD

The most effective practices will be utilized to maximize benefit.

Research models.
Select the best practices from each and try out the model.

03/30/04

Action 1.4.7
Expand services to those with co-occurring disorders.

Adult Mental Health Division

Adult Mental Health Division and ADAD

Integrated services produce positive outcomes for clients.

Agreements on service pieces and integrated treatments.

01/01/04

Action 1.4.8
Increase accessibility to VA services.

Rick Velasquez

VA

More veterans will receive mainstream services.

Systems change in VA procedure

6/30/04

Action 1.4.9
Provide for intensive interventions such as acute medical care or psychiatric hospitalizations when needed.

Policy Academy

Hospital system and AMHD

Timely and appropriate treatment available to preempt emergency situations for the homeless.

6/30/04

Strategy 1.5
Discharge Planning

Action 1.5.1
Collect and analyze discharge plans and assess consistency with discharge actions.

HCDCH

HCDCH

Most discharge policies do not address housing.

Survey to assess discharge policies of all residential facilities.
Analysis of whether facilities’ actions are consistent with their policy.

10/30/03

Action 1.5.2
Work with discharge entities to effectuate appropriate discharge planning, if necessary.

Policy Academy

State and Counties

All facilities will have discharge plans that include housing upon discharge.

Identify potential solutions to the discharge dilemma when the client has nowhere to go but homelessness.

6/30/04

Strategy 2.1
Strengthen statewide homeless outreach.

Action 2.1.1
Increase homeless outreach staff so as to increase contact with the homeless and increase penetration into under served areas.

HCDCH

PIC to lead lobby for more funds; HCDCH to contract for more outreach staff.

More outreach teams for greater coverage;
Less time spent homeless.

Funding approved and released by State.
Additional outreach staff hired by contracted agencies.

July 2004

Action 2.1.2
Investigate adding advance practice nurses to health outreach teams.

DOH AMHD - Bernie Miranda

Case Management Services Director Pam Haina and Bernie Miranda

Prompt mental health assessment, immediate appropriate treatment, and less time homeless

Funding approved and released.
Nurses hired to support outreach teams.

July 2005

Action 2.1.3
Convene quarterly meetings of Honolulu outreach workers to implement collaboration.

Darlene Hein of Affordable Housing and Homeless Alliance

Darlene Hein

Information sharing;
improved communication;
better targeted services.

Quarterly meetings convened

Done

Action 2.1.4
Convene quarterly meetings of outreach workers in the rural counties to implement collaboration.

Adult Mental Health Division

Office of Social Ministry (Hawaii), Mental Health Kokua (Maui, Kauai)

Information sharing;
improved communication;
better targeted services.

Quarterly meetings convened

September 2003

Strategy 2.2
Establish a Mental Health Court with treatment services

Dept. of Public Safety Wendell Murakawa

Judiciary Branch, District/Circuit Court Judge

Connect the mentally ill offender with the appropriate treatment services.

Grant for funds approved and pending.

June 2004

Strategy 2.3
Achieve minimal clinician competency among line staff to achieve early intervention

DOH AMHD - Eva Kishimoto

DOH AMHD - Eva Kishimoto

Early screening and assessment aids in appropriate referrals and early intervention.

Training established for line staff in all disciplines.
Line workers use their new skills for early intervention.

June 2004

Strategy 2.4
Formalize veteran parolees benefit awareness

Action 2.4.1
Establish outreach for intake of incarcerated Vets.

U.S. Vets Inc. – Dwight Radcliffe

Outreach Coordinator of US Vets, Inc. and Public Safety

Vets will be linked with services and housing upon release

MOU executed between US Vets and Dept. of Public Safety

January 2004

Action 2.4.2
Provide information materials to incarcerated veterans on benefits and services prior to parole or probation.

Rick Velasquez, VA Homeless Program

Allan Kellogg

VA services will be available to help parolees and probationers reintegrate into the community.

Regular informational outreach visits scheduled at the correctional facilities.

January 2004

Strategy 2.5
Establish community aide centers in the rural counties.

Action 2.5.1
Collaborate with agencies and private sector to gain support for a site which will most serve the chronic homeless.

Office of the Mayor of each county.

Office of the Mayor of each county.

Additional resource available for providers and community agencies.
Place where the homeless may just BE in a low demand setting and assessed for needs.

Release of funding by the Mayor for development of a center.

July 2005

Strategy 2.6
Develop and improve inter-agency communication and agreements that can influence and enhance release plans for inmates being released by the Department of Public Safety

Action 2.6.1
Develop a discharge plan for exiting prisoners upon entry or well in advance of release date.

Dept. of Public Safety

Dept. of Public Safety

Discharge prisoners will have a smoother transition into the community and are less likely to become homeless and reenter prison.

An individualized plan is developed for each prisoner which outlines benefits to which he is eligible, support services he may access, housing accommodation on release, and job goals.

July 2004

Action 2.6.2
Coordinate with a variety of agencies, state and federal, to ensure eligible inmates receive available services and/or benefits. (SSI, Med-Quest, drivers licenses, veteran’s benefits, employment training, financial management, mental health services, and others)

Dept. of Public Safety

Dept. of Public Safety

Follow State Hospital model;
Specialized intake process developed for incarcerated

Establishment of specialized DHS procedure;
MOU between DPS and DHS, DOH and VA.

January 2005

Action 2.6.3
Collaborate to enhance inmate stability upon release including housing intervention and equipping inmates with a transition plan to receive a continuum of community care upon parole.

DOH Adult Mental Health Forensics Director, Dr. R. Kennedy

Adult Mental Health Division, Dept. of Public Safety

Incarcerated will be linked to a community service provider in the continuum of care.

Development of community plan for triage and referral to appropriate agency.

July 2004

Strategy 2.7
Incorporate the Comprehensive, Continuous, Integrated System of Care Model by Dr. Kenneth Minkoff into the approach to serve the chronically homeless.

Hawaii Policy Academy

AMHD, State Dept. of Health

Improved service to the chronically homeless will help them achieve a high level of long term success.

Workshops will be held to explain and implement the eight research-derived principles contained in the integrated system of care model.

July 2004

Strategy 3.1
Develop affordable supportive housing.

Action 3.1.1
Develop new supportive housing projects, first in one county, ultimately in each county. Note: Project hoped to serve as demonstration to other counties and community. Phased development will reduce competition for limited funds.

Action 3.1.2
Explore establishment of preference for disabled or homeless in County-owned rental units and/or Section 8 programs
Note: State owned projects already have a preference for homeless

HCDCH and City

County governments
(Maui has no inventory)

Increased availability of affordable rental units 10 per year

1 year

Action 3.1.3
Aggressively pursue funding for additional rent subsidies including but not limited to project based Section 8, assigned Section 8, Section 8 mainstream vouchers, Shelter Plus Care, HOME.

HCDCH and City

Nonprofit agencies
Public housing authorities to extent possible

Increased availability of affordable rental units

Application each year

Action 3.1.4
Amend county Consolidated Plans to make homeless a funding priority.

HCDCH

Counties

2004 Consolidated Plans

Action 3.1.5
Identify existing clean and sober housing and explore the establishment of additional clean and sober housing for clients

ADAD

Nonprofit agencies

Determine need

1 year

Action 3.1.6
Determine need for group homes for dual diagnosis clients and explore establishing more to fill the need.

Bernie Miranda

DOH AMHD and ADAD

Determine need

1 year

Action 3.1.7
Investigate alternative financing sources for development of housing, including medical healing house, clean and sober housing, and group homes.

Nonprofit agencies
HCDCH
Counties

Initially 1 year but ongoing

Action 3.1.8
Work with other advocates to reduce timeframes for HUD 811 program approvals and release of funds

Bernie Miranda

Nonprofit agencies
AMHD

Action 3.1.9
Explore the need for an Oahu medical healing house.

Millie Tanabe/Leslie Uehara

Kalihi Palama Health Center/ Queens Hospital

Strategy 3.2
Reduce barriers to securing and maintaining permanent affordable housing

Action 3.2.1
Provide training to Section 8 staff (including inspectors) and property managers on dealing with the chronically homeless.

Bernie Miranda

AMHD

Better accommodation of clients with special needs

18 months

Action 3.2.2
Explore establishment of affordable housing placement service linked with case management, providing assistance to tenants and maintaining list of potential landlords

HCDCH

HCDCH

Tenants who are ready to rent

2 years

Action 3.2.3
Institute damage guarantee or other mechanism for Section 8 program to encourage program participation
Note: AMHD has program in place already

HCDCH
Counties

Landlords willing to rent to Section 8 clients

1 year

Strategy 4.1
Develop and implement a collaborative model to secure permanent housing and supportive services for chronically homeless individuals.

Action 4.1.1
Develop new supportive housing projects, first in one county, ultimately in each county
Note: Project hoped to serve as demonstration to other counties and community. Phased development will reduce competition for limited funds

Department of Health Adult Mental Health Division

Department of Health Adult Mental Health Division and Outreach agencies on the Waianae Coast

Twenty three chronically homeless persons will retain permanent housing for eight to twelve months.

MOUs executed.
Care Coordination teams committee formed.
Private provider agencies contracted.
Housing placement begins.
Client intervention and case management continues as needed by each individual placed in housing.
Outcomes measured.

December 2004