Connecting Fractured Lives to a Fragmented System: A Process Evaluation of the Chicago Housing for Health Partnership

1. Connecting Fractured Lives to a Fragmented System: A Process Evaluation of the Chicago Housing for Health Partnership Center for Urban Research and Learning Friday morning seminar Friday, October 6, 2006

2. Presenters Arturo Valdivia-Bendixen AIDS Foundation Chicago CHHP Director Jennifer Nargang Chernega Center for Urban Research Learning Community Research Coordinator Anne Figert, Ph.D. Department of Sociology Associate Professor Christine George, Ph.D. Center for Urban Research and Learning Senior Research Fellow Sarah Stawiski Center for Urban Research Learning Community Research Coordinator

3. Overview CHHP Project Context Project Design Outcome Research Process Evaluation Methodology Findings Discussion

4. Historical Background Experience at Interfaith House NY/NY Research Study Chicago Plan to End Homelessness

5. Interfaith House Stably Housed after IH Discharge: Returned for social visits or follow up appointments Homeless or Sheltered after Discharge: Returned after another discharge from the hospital needing housing

6. NY/NY Cost Savingsafter homeless were housed Decreased use of state psychiatric centers by 60% [68days to 10 days per year] Decreased use of acute hospital care by 80% [8.2 days to 1.6 days per year]

7. Chicago�s Plan to End Homelessness �Housing First� Approach Interim Housing Replaces Shelters Need for Demonstration Projects

8. Organizational Partners 3 Key Medical Centers / Hospitals 11 Supportive Housing Providers 3 Respite/Interim Housing Providers 7+ Health Care Foundations HUD / HOPWA

9. Client Partners Adults who are homeless In-patient at 3 area hospitals At least 1 chronic medical illness Willingness to give consent

10. 4-Year Demonstration ProjectJan. 2003 to Aug. 2007�CHHP� First of Chicago�s Plan to End Homelessness

11. Key Periods Initial Period January 2002 Pilot Period November 2002 Full Project Begins September 2003 Full Project End May 2006 Evaluation Ends November 2007 Planned Permanent Project Jan. 1, 2007

12. CHHP Project Design Hospital Respite Program Permanent Housing

13. Project Design Supportive Housing � variety of models Intensive Case Management � 10:1 ratio �Housing First� approach �Harm Reduction� models Research Component Policy Initiatives Planned

14. CHHP ParticipantsJune 30, 2006 � Final Enrollment Intervention: 216 Usual Care: 220 TOTAL: 436

15. Intervention GroupTop Multiple Diagnoses - 216 Participants

16. Not Achieved Stable Housing�Engaged Participants�After 120 days after hospital discharge 21 out of 216 = **** 10% ****

17. Preliminary OutcomesJune 2006 Nursing Home Days Intervention Group: 2,146 days Usual Care Group: 6,553 days

18. Preliminary OutcomesJune 2006 Emergency Room Visits Intervention Group 2.5 times less (mean: 1.6) Usual Care Group 2.5 times more (mean: 4.0)

19. Preliminary OutcomesJune 2006 Hospitalizations Intervention Group: Mean: 1.5 Usual Care Group: Mean: 2.3

20. Process Evaluation Definition �an evaluative study that answers questions about program operations, implementation and service delivery.� (Rossi, Freeman and Lipsey, 1999).

21. Why do a Process Evaluation? Answer basic questions: How does the CHHP program work as a system? What are the strengths as it is designed? What are the challenges? What are the outside influences that affect the system? Address policy questions: How does this program work? Could this be a model for other homeless programs? Could this be a model for other inter-agency collaborations? Today we will answer the first four basic questions. We will address the policy questions in the final report. Today we will answer the first four basic questions. We will address the policy questions in the final report.

22. Our Charge The purpose of this research is to: evaluate the implementation process of this demonstration project for the CHHP and various stakeholders and to inform policy makers as to the operations of this innovative model of addressing and preventing homelessness.

23. 3 Levels of Analysis Street level: How did the collaboration/referral system work? Look at both housing and social services From the standpoint of street level workers From standpoint of clients How did engagement process with clients work? Street level workers clients What organizational issues did individuals programs encounter in setting up and implementing model?

24. 3 Levels of Analysis 2. Organizational level How did collaboration between partners work? What issues came up as functions as a systems? Examples-- Referral vs. collaboration Joint case management How were they addressed? Were there issues related to different organizational cultures, capacities, different disciplines?

25. 3 Levels of Analysis 3. Governance/ Interagency level What were the external issues that shaped the collaboration? Advantages/Challenges to formation How decisions made Resources Policies

26. Methodology: Data Sources We elicited feedback from key stakeholders, observed interaction at regular meetings and analyzed organizational documents. *Make a comment that not all of their titles were Executive Directors. Regarding the SIT meetings, we learned about the interactions of the case managers but we also learned about clients, how the partner agencies work together and the role of the lead agency. We were able to arrange at least one interview with all but one agency. *Make a comment that not all of their titles were Executive Directors. Regarding the SIT meetings, we learned about the interactions of the case managers but we also learned about clients, how the partner agencies work together and the role of the lead agency. We were able to arrange at least one interview with all but one agency.

27. Client Quote �When I first heard about it, I heard that not only did they help you with your medical condition, but they give you a place to stay and get you off the streets�I was like, �What�s the name of this program?� She said �CHHP.��

28. Visual Representation of CHHP Model CHHP�s mission of housing the chronically medically ill homeless is accomplished through coordination of both intensive case management and resources for providers through two key structures: the systems integration team (SIT) and CHHP�s governance model which combines the lead agency with a collaborative partnership. In short, CHHP works by funneling both funds and clients into centralized structures and then redistributes them to the partnering agencies. Note, there are two centers of gravity in the model. This is important � Most collaborations only have linkages at the top rather than the bottom, requiring communication to be filtered down through the agency. Under this model, there are linkages at both the top and bottom, allowing for communication to move in both directions. Creates a much hardier and flexible system. CHHP�s mission of housing the chronically medically ill homeless is accomplished through coordination of both intensive case management and resources for providers through two key structures: the systems integration team (SIT) and CHHP�s governance model which combines the lead agency with a collaborative partnership. In short, CHHP works by funneling both funds and clients into centralized structures and then redistributes them to the partnering agencies. Note, there are two centers of gravity in the model. This is important � Most collaborations only have linkages at the top rather than the bottom, requiring communication to be filtered down through the agency. Under this model, there are linkages at both the top and bottom, allowing for communication to move in both directions. Creates a much hardier and flexible system.

29. Areas of findings 1. Harm Reduction 2. Intensive Case Management 3. Lead Agency 4. Sense of Ownership

30. 1. Harm Reduction Harm reduction is integral to housing first What is harm reduction? Agencies responded differently to the move to harm reduction. Partner agencies reported having different understandings of harm reduction For some agencies, there was total acceptance of the harm reduction model. For those who already employed harm reduction principles in their agency, it was a chance to expand their work and share their expertise with other agencies. Other agencies reported that working with CHHP�s harm reduction model was an opportunity to expand into different housing options and funding streams. Harm reduction is a set of practical strategies that reduce negative consequences of drug use, incorporating a spectrum of strategies from safer use, to managed use to abstinence. Harm reduction strategies meet drug users "where they're at," addressing conditions of use along with the use itself. Harm Reduction Coalition For some agencies, there was total acceptance of the harm reduction model. For those who already employed harm reduction principles in their agency, it was a chance to expand their work and share their expertise with other agencies. Other agencies reported that working with CHHP�s harm reduction model was an opportunity to expand into different housing options and funding streams. Harm reduction is a set of practical strategies that reduce negative consequences of drug use, incorporating a spectrum of strategies from safer use, to managed use to abstinence. Harm reduction strategies meet drug users "where they're at," addressing conditions of use along with the use itself. Harm Reduction Coalition

31. Harm Reduction Hidden slide-use only for notes Our interviews with executive directors and program managers, and program staff indicate that there were many different ways of talking about harm reduction. Some equate harm reduction with a system of care that does not pass judgment on those who are not clean and sober and does not necessarily push clients to become clean and sober. Others see harm reduction as a series of case management techniques (system of change, motivational interviewing) and the issue of substance use is secondary or not mentioned at all. In some cases, staff seemed to use the harm reduction tools to motivate clients to become clean and sober. These differences in perception of the harm reduction model become especially apparent when staff members describe success stories from their agency. The different perceptions of what success entails is indicative of what they see as the goals of the program: Some program managers defined success as clients who had been permanently housed for a long time; Sometimes success explicitly meant housing someone for a long time while they were using alcohol and drugs; Sometimes success was measured by �small changes� such as building trusting relationships; For other program managers, even under the harm reduction model, success was helping clients become clean or sober; Some organizations indicated that they had adopted a harm reduction model that allowed for alcohol and drug consumption, but they worried about the effect of this model on the clients and if it was really helping them.Our interviews with executive directors and program managers, and program staff indicate that there were many different ways of talking about harm reduction. Some equate harm reduction with a system of care that does not pass judgment on those who are not clean and sober and does not necessarily push clients to become clean and sober. Others see harm reduction as a series of case management techniques (system of change, motivational interviewing) and the issue of substance use is secondary or not mentioned at all. In some cases, staff seemed to use the harm reduction tools to motivate clients to become clean and sober. These differences in perception of the harm reduction model become especially apparent when staff members describe success stories from their agency. The different perceptions of what success entails is indicative of what they see as the goals of the program: Some program managers defined success as clients who had been permanently housed for a long time; Sometimes success explicitly meant housing someone for a long time while they were using alcohol and drugs; Sometimes success was measured by �small changes� such as building trusting relationships; For other program managers, even under the harm reduction model, success was helping clients become clean or sober; Some organizations indicated that they had adopted a harm reduction model that allowed for alcohol and drug consumption, but they worried about the effect of this model on the clients and if it was really helping them.

32. Harm Reduction Clients and case managers reported that harm reduction facilitates and enhances clients� compliance with CHHP and positive interactions with case managers Administering and maintaining a harm reduction program was �challenging� Landlord burnout Conflicts with other clients/case managers Different than previous methods of case management For the clients, questions about harm reduction elicited a very positive response. Two larger themes emerged from their responses: 1) A harm reduction philosophy alleviated their constant fear of being kicked out of the program and increased their ability to cope with life circumstances and 2) the harm reduction philosophy allowed them to be honest with their case managers about their substance use and that this made for more meaningful and directive help. Case managers reported that harm reduction allows flexibility in working with clients. For the clients, questions about harm reduction elicited a very positive response. Two larger themes emerged from their responses: 1) A harm reduction philosophy alleviated their constant fear of being kicked out of the program and increased their ability to cope with life circumstances and 2) the harm reduction philosophy allowed them to be honest with their case managers about their substance use and that this made for more meaningful and directive help. Case managers reported that harm reduction allows flexibility in working with clients.

33. Harm Reduction Hidden slide-use for notes only a) The push for harm reduction created tensions both within agencies and amongst their clients. Case managers reported tensions between their agencies� philosophy/rules and CHHP focus on harm reduction. In some of the interviews with executive directors and programs directors, there was some expression of resistance and/or rejection of the harm reduction philosophy for their agency. Also case managers reported tensions between CHHP clients and non-CHHP clients in same housing facility over drug/alcohol use. b) Harm reduction demands more skilled and experienced case managers A belief was expressed that the harm reduction model requires more training and different training of existing case managers and the hiring of more specialized case workers. c) It is challenging to find and maintain scattered site housing and harm reduction units. Some agencies reported that harm reduction presented a challenge in securing and maintaining scattered site units: Many administrators and case managers from scattered site agencies reported that harm reduction clients �burn through apartments� which can negatively impact the agency�s relationship with those landlords for any kind of housing. The shift highlighted the numerous legal issues facing landlords and agencies. (what is this) Some administrators wanted help and resources from the CHHP program or the AIDS Foundation to identify and work with landlords over harm reduction clients. d) Clients, case managers and administrators all reported difficulty in having harm reduction units in group based living situations, whether shelters or residential shared living agencies. Relapse is �contagious� and therefore can negatively impact other clients who may be trying to maintain sobriety.a) The push for harm reduction created tensions both within agencies and amongst their clients. Case managers reported tensions between their agencies� philosophy/rules and CHHP focus on harm reduction. In some of the interviews with executive directors and programs directors, there was some expression of resistance and/or rejection of the harm reduction philosophy for their agency. Also case managers reported tensions between CHHP clients and non-CHHP clients in same housing facility over drug/alcohol use. b) Harm reduction demands more skilled and experienced case managers A belief was expressed that the harm reduction model requires more training and different training of existing case managers and the hiring of more specialized case workers. c) It is challenging to find and maintain scattered site housing and harm reduction units. Some agencies reported that harm reduction presented a challenge in securing and maintaining scattered site units: Many administrators and case managers from scattered site agencies reported that harm reduction clients �burn through apartments� which can negatively impact the agency�s relationship with those landlords for any kind of housing. The shift highlighted the numerous legal issues facing landlords and agencies. (what is this) Some administrators wanted help and resources from the CHHP program or the AIDS Foundation to identify and work with landlords over harm reduction clients. d) Clients, case managers and administrators all reported difficulty in having harm reduction units in group based living situations, whether shelters or residential shared living agencies. Relapse is �contagious� and therefore can negatively impact other clients who may be trying to maintain sobriety.

34. 2. Intensive Case Management There is a great deal of complexity in and diversity of client engagement patterns Getting and keeping clients placed and engaged is a major challenge Client diversity impacts how clients get into the program, move through the stages, and their experiences once they attain �permanent� housing. For example, of the 111 clients permanently housed by CHHP, 81% did not go through the intended track (stage 1 ? stage 2 ? stage 3) and 23% were disengaged at some point during the process. Getting clients placed is very challenging-clients have to be able to make and keep appts, get paperwork together, and so forth, Sometimes they miss appts, or may not be in touch for long periods at a time which can slow the process. B/C of these challenges, this is WHY intensive case management is so important! While there are undoubtedly challenges involved in placing clients in permanent housing, what sometimes may be even more concerning are the obstacles in keeping clients housed. Again, the diversity of clients and their needs adds to the difficulty in keeping them housed. For example, the following common client conditions jeopardized their ability to keep permanent housing: History of substance abuse or active use; Ongoing mental illness ; Disruptive behavior on site; Violent behavior Allowing multiple people to stay at apartment All of these things can lead to tension arising between landlords and Stage 3 agencies. In fact several people we talked to mentioned landlord burnout as a significant concern, especially for active substance abusers. This requires negotiation and relationship building with landlords on the part of case managers. It requires that case managers are very aware of what is going on with clients to prevent problems and to troubleshoot. Some agency staff expressed a desire for the AFC to help them find landlords to work with CHHP clients. This demonstrates many of the challenges faced by clients and by the agencies that serve them in trying to house the chronically ill homeless and illustrates the need for an intensive one on one case management approach. Client diversity impacts how clients get into the program, move through the stages, and their experiences once they attain �permanent� housing. For example, of the 111 clients permanently housed by CHHP, 81% did not go through the intended track (stage 1 ? stage 2 ? stage 3) and 23% were disengaged at some point during the process. Getting clients placed is very challenging-clients have to be able to make and keep appts, get paperwork together, and so forth, Sometimes they miss appts, or may not be in touch for long periods at a time which can slow the process. B/C of these challenges, this is WHY intensive case management is so important! While there are undoubtedly challenges involved in placing clients in permanent housing, what sometimes may be even more concerning are the obstacles in keeping clients housed. Again, the diversity of clients and their needs adds to the difficulty in keeping them housed. For example, the following common client conditions jeopardized their ability to keep permanent housing: History of substance abuse or active use; Ongoing mental illness ; Disruptive behavior on site; Violent behavior Allowing multiple people to stay at apartment All of these things can lead to tension arising between landlords and Stage 3 agencies. In fact several people we talked to mentioned landlord burnout as a significant concern, especially for active substance abusers. This requires negotiation and relationship building with landlords on the part of case managers. It requires that case managers are very aware of what is going on with clients to prevent problems and to troubleshoot. Some agency staff expressed a desire for the AFC to help them find landlords to work with CHHP clients. This demonstrates many of the challenges faced by clients and by the agencies that serve them in trying to house the chronically ill homeless and illustrates the need for an intensive one on one case management approach.

35. Client Codes (condensed) The CHHP coordinator has used a coding scheme with 17 different codes to try to capture some of the complexity and diversity of client situations (Some clients are asked to leave because they cannot meet the sobriety regulations of a particular housing facility; some have to be re-hospitalized throughout the stages; and others are lost-to-contact for various reasons. This is a condensed version of all of the possible situations that Ed must keep track of for clients. But we just wanted to give you a sense of how many different situations or engagement patterns that need to be tracked. For example, he actually keeps track of whether they are housed at an ICF temp or perm but we have condensed it here to make it fit on the graph! Same with family living situation. Also, multiple situations could mean housed with family AND blacklisted or housed for one year but then incarcerated, etc. Importance of coordinators role- tracks all this complexityThe CHHP coordinator has used a coding scheme with 17 different codes to try to capture some of the complexity and diversity of client situations (Some clients are asked to leave because they cannot meet the sobriety regulations of a particular housing facility; some have to be re-hospitalized throughout the stages; and others are lost-to-contact for various reasons. This is a condensed version of all of the possible situations that Ed must keep track of for clients. But we just wanted to give you a sense of how many different situations or engagement patterns that need to be tracked. For example, he actually keeps track of whether they are housed at an ICF temp or perm but we have condensed it here to make it fit on the graph! Same with family living situation. Also, multiple situations could mean housed with family AND blacklisted or housed for one year but then incarcerated, etc. Importance of coordinators role- tracks all this complexity

36. Intensive Case Management CHHP has invested a great deal in case management Weekly Systems Integration Team (SIT) meetings Uniform pay Low client case load Extensive training Clients� reports of their interaction with CHHP reflect the effectiveness of the intensive case management approach ------------------------------------------------------------------------------------------------------------------------- Overall clients were extremely positive when they talked about their experiences with the case managers. ------------------------------------------------------------------------------------------------------------------------- Overall clients were extremely positive when they talked about their experiences with the case managers.

37. Clients� experience of intensive case management Overall positive assessment of case managers Clients viewed CHHP as a program that provides a respite �You have a chance to sit down and get your mind together�When you�re on the streets your mind is in two or three other places. With the CHHP program, you have the chance to actually sit down on a couch and think for awhile�You can relax and get well and be rested, and take care of your business at the same time.� (CHHP client) Case managers as advocates Case managers are dependable and responsive Case manager as coach Case managers are supportive and respectful Case managers as preservers Clients see case managers as advocates who are dependable and responsive. Many of the permanently housed clients' stories of success present the case manager as a �life coach� helping these clients strategize, with personal interactions being tailored to each individual. All reported that case managers were supportive and respectful. Conducting the client focus groups really gave us the opportunity to see the model from the viewpoints of the clients�as clients described their experiences with case management very positively, they also saw the CHHP program a whole very positively. One finding about the impact of CHHP on clients is that� Case managers as advocates Case managers are dependable and responsive Case manager as coach Case managers are supportive and respectful Case managers as preservers Clients see case managers as advocates who are dependable and responsive. Many of the permanently housed clients' stories of success present the case manager as a �life coach� helping these clients strategize, with personal interactions being tailored to each individual. All reported that case managers were supportive and respectful. Conducting the client focus groups really gave us the opportunity to see the model from the viewpoints of the clients�as clients described their experiences with case management very positively, they also saw the CHHP program a whole very positively. One finding about the impact of CHHP on clients is that�

38. Clients� assessment of case management Clients were positive but saw some room for improvement Drawbacks to the model Housing quality Housing location Living expenses 25. CHHP is seen as successful in providing resources Clients talked about how being in CHHP helped them to connect to the services that they needed. 24. CHHP is viewed as a program that provides a respite. In focus groups, just like the quote provided here, client have numerous examples of the value of being more able to cope, of not having to worry about things, and of the housing being a place from which to move forward and/or to find refuge and privacy. Again, clients consistently offered examples including social, emotional and economic support that they received. 28. Clients see some room for improvement. While there was enormous support and praise of the CHHP program expressed by the clients, there were some areas that were perceived to be in need of improvement including more geographic diversity in housing, assistance with providing furnishing for scattered site apartments and more second stage options. 25. CHHP is seen as successful in providing resources Clients talked about how being in CHHP helped them to connect to the services that they needed. 24. CHHP is viewed as a program that provides a respite. In focus groups, just like the quote provided here, client have numerous examples of the value of being more able to cope, of not having to worry about things, and of the housing being a place from which to move forward and/or to find refuge and privacy. Again, clients consistently offered examples including social, emotional and economic support that they received. 28. Clients see some room for improvement. While there was enormous support and praise of the CHHP program expressed by the clients, there were some areas that were perceived to be in need of improvement including more geographic diversity in housing, assistance with providing furnishing for scattered site apartments and more second stage options.

39. 3. Lead Agency/Collaboration Model Strength of dual model Benefits to participating agencies Organizational hurdles and issues

40. Strength of dual model CHHP combines the centrality of a lead agency with the diverse resources and expertise of the partnership agencies It did not add to the competition over resources Leadership Participatory governance � Often in service partnership�one of two things can happen: A lead agency gives out contracts�and the relationship is very hieratical or legalistic�it resorts to the contractual buying and selling of services Or the other extreme, each agency continues to go its own way, little monitoring or oversight, little common culture, sharing Here we can see that the goal of �system building� really guided the partnership The AIDS foundation brought enormous adminsitrative skills They had a lot of capacity and history they could easily The central agency coordinated, expediated resources, handled administration (cutting checks, vouchers), �monitored for fidelsity, pushed planning� But they were not a provider agency and therefore did not add to the competition of resources Leadership (Very active non bureacratic(passive or command approach)�its about people) provided the GLUE�Very skilled, non bureaucratic but authoritative�inclusive(art, buidling consensus, meeting with people, constantly organizting touching base) Coordinator�case managed the case managers�again on top of details, contstantly faciliating interactions, on telephone a lot; conduit of information..etc Very immerse in program and aware of fidelity of program Participatory governance -- Power rested in partners�they actually voted, very transparent�(nursed along) Same time balance �meeting very functional, practical. Real guidelines. Of course, some more buy in than others� � Often in service partnership�one of two things can happen: A lead agency gives out contracts�and the relationship is very hieratical or legalistic�it resorts to the contractual buying and selling of services Or the other extreme, each agency continues to go its own way, little monitoring or oversight, little common culture, sharing Here we can see that the goal of �system building� really guided the partnership The AIDS foundation brought enormous adminsitrative skills They had a lot of capacity and history they could easily The central agency coordinated, expediated resources, handled administration (cutting checks, vouchers), �monitored for fidelsity, pushed planning� But they were not a provider agency and therefore did not add to the competition of resources Leadership (Very active non bureacratic(passive or command approach)�its about people) provided the GLUE�Very skilled, non bureaucratic but authoritative�inclusive(art, buidling consensus, meeting with people, constantly organizting touching base) Coordinator�case managed the case managers�again on top of details, contstantly faciliating interactions, on telephone a lot; conduit of information..etc Very immerse in program and aware of fidelity of program Participatory governance -- Power rested in partners�they actually voted, very transparent�(nursed along) Same time balance �meeting very functional, practical. Real guidelines. Of course, some more buy in than others�

41. Benefits to participating agencies Fills a service gap at the hospital level Expands organizational capacity Allows engagement in leadership roles Facilitates participation in a research project For the hospitals within the partnership, the CHHP program fills a significant service gap. While hospital staff tended to see their role as stabilizing clients and getting them ready for the next stage of their care, they expressed serious concerns about where homeless patients would go after their release. CHHP helped them help their patients. Increased organizational capacity was seen as a key advantage to agency participation in the CHHP program. CHHP helps agencies increase their capacity along many variables including services, client populations, organizational knowledge, and funding. Expanded organization capacity in a number of ways a. Increased Services Organizations were able to explore new programming opportunities such as scattered site housing. Others said that they had improved their referral relationships and increased their referral and resource databases through CHHP. Additionally, partnering with diverse agencies with a variety of criteria or programming allowed organizations to continue helping clients, even if they didn�t work out in their own programs. b. Diversify Client Populations Another way to increase organizational capacity is to broaden the range of clients served. CHHP expanded client bases and encouraged agencies to work with substance abusers through the harm reduction model and other clients who they may not have otherwise included in their programs. While organizations may find the experience of serving new client populations initially challenging, an expanded client base may eventually help open up new funding streams. c. Expanding Organizational Knowledge Many cited the trainings for CHHP case managers as an important source of new information for their agency. Heads of agencies appreciated learning new techniques for serving clients. Some agencies indicated they wanted even more training for case managers. d. Expanding Funding Funding is a critical issue. Many program managers and executive directors cited funding benefits as a key reason to participate in the CHHP program and to stay engaged in CHHP. Other organizations cited the direct funding they received from CHHP for a case manager or other costs as beneficial. Other organizations cited the increased visibility for other funding opportunities as being a key motivator for participation.For the hospitals within the partnership, the CHHP program fills a significant service gap. While hospital staff tended to see their role as stabilizing clients and getting them ready for the next stage of their care, they expressed serious concerns about where homeless patients would go after their release. CHHP helped them help their patients. Increased organizational capacity was seen as a key advantage to agency participation in the CHHP program. CHHP helps agencies increase their capacity along many variables including services, client populations, organizational knowledge, and funding. Expanded organization capacity in a number of ways a. Increased Services Organizations were able to explore new programming opportunities such as scattered site housing. Others said that they had improved their referral relationships and increased their referral and resource databases through CHHP. Additionally, partnering with diverse agencies with a variety of criteria or programming allowed organizations to continue helping clients, even if they didn�t work out in their own programs. b. Diversify Client Populations Another way to increase organizational capacity is to broaden the range of clients served. CHHP expanded client bases and encouraged agencies to work with substance abusers through the harm reduction model and other clients who they may not have otherwise included in their programs. While organizations may find the experience of serving new client populations initially challenging, an expanded client base may eventually help open up new funding streams. c. Expanding Organizational Knowledge Many cited the trainings for CHHP case managers as an important source of new information for their agency. Heads of agencies appreciated learning new techniques for serving clients. Some agencies indicated they wanted even more training for case managers. d. Expanding Funding Funding is a critical issue. Many program managers and executive directors cited funding benefits as a key reason to participate in the CHHP program and to stay engaged in CHHP. Other organizations cited the direct funding they received from CHHP for a case manager or other costs as beneficial. Other organizations cited the increased visibility for other funding opportunities as being a key motivator for participation.

42. Lead Agency/Collaboration Model Hidden slide-use for notes only Engagement in Leadership Roles Some agencies saw CHHP as an opportunity to become a leader in the partnership and to inform other agencies of their work. This is an especially important benefit for small agencies in marginal communities who might otherwise not have the opportunity to network with large organizations or to take on leadership positions in collaborative partnerships. Participation in a Research Project The design of CHHP as a research project was appealing to many agencies as well. Agencies cited the ability to gather data at the same time that they were serving clients as an advantage. Many organizations were excited to see the final outcomes of the research project. Organizations said that the more information they had about programmatic outcomes, the better they could serve clients and create better programs. In addition, they cited the project as a way their work would have a voice in the national policy discussions on homeless. Engagement in Leadership Roles Some agencies saw CHHP as an opportunity to become a leader in the partnership and to inform other agencies of their work. This is an especially important benefit for small agencies in marginal communities who might otherwise not have the opportunity to network with large organizations or to take on leadership positions in collaborative partnerships. Participation in a Research Project The design of CHHP as a research project was appealing to many agencies as well. Agencies cited the ability to gather data at the same time that they were serving clients as an advantage. Many organizations were excited to see the final outcomes of the research project. Organizations said that the more information they had about programmatic outcomes, the better they could serve clients and create better programs. In addition, they cited the project as a way their work would have a voice in the national policy discussions on homeless.

43. Organizational hurdles and issues Funding concerns Organizational culture clashes Public health vs. clinical model Funding Concerns Several organizations indicated that funding for ancillary services would help them serve more CHHP clients and help them provide more complete services. CHHP clients within certain agencies felt this lack of funding and also in talks with each other, identified the inequality of resources between agencies. The additional funding needs that they cited included administrative costs (administrative staff, fees for applications, etc.) as well as costs for furniture and other living necessities (beds, sheets, appliances, etc.). Organizational Culture Clashes While most organizations reported that CHHP fit well into their existing programs, some indicated that their organizational culture clashed with the CHHP model. (Harm reduction mentioned early�mixing clients�giving certain clients priority to permanent housing, or to extra services) Also: Public Health vs. Clinical Model Under the public health (hospital) model, all clients need to be served regardless of their status, substance use. A clinical social work model is traditionally more restrictive and involves criteria that clients must meet in order to be served by an agency. This tension was highlighted in CHHP. Funding Concerns Several organizations indicated that funding for ancillary services would help them serve more CHHP clients and help them provide more complete services. CHHP clients within certain agencies felt this lack of funding and also in talks with each other, identified the inequality of resources between agencies. The additional funding needs that they cited included administrative costs (administrative staff, fees for applications, etc.) as well as costs for furniture and other living necessities (beds, sheets, appliances, etc.). Organizational Culture Clashes While most organizations reported that CHHP fit well into their existing programs, some indicated that their organizational culture clashed with the CHHP model. (Harm reduction mentioned early�mixing clients�giving certain clients priority to permanent housing, or to extra services) Also: Public Health vs. Clinical Model Under the public health (hospital) model, all clients need to be served regardless of their status, substance use. A clinical social work model is traditionally more restrictive and involves criteria that clients must meet in order to be served by an agency. This tension was highlighted in CHHP.

44. 4. Ownership of the CHHP Program There is a high level of buy-in and �ownership� at the various levels of the CHHP program Clients Case managers Agency Level �Because I was in from the very beginning and the planning, I don�t think I ever fully imagined what this could become because I hadn�t ever done anything like this before. It�s a wonderful group. I�ve never been involved with something this successful that we�ve built from the ground up.� Why important to have ownership for staff For any system to work need commitment�perhaps especially here�building among diverse agencies- trying to build a system Also an empowerment model (climate, culture of agency)�school research etc Why important to have ownership for staff For any system to work need commitment�perhaps especially here�building among diverse agencies- trying to build a system Also an empowerment model (climate, culture of agency)�school research etc

45. Ownership Clients� ownership Clients identify as �CHHP� clients CHHP provides a strong sense of belonging CHHP is transformational and empowering �You know I can go back to the old program, my friends see me, and they say what you doing, you are a totally different person, and I give them hope that they can change too. It�s a whole different world out there; I just want to be an example for my friends. CHHP program changed me, I can change them too. I want to be an example for them...� (CHHP Client) For clients�has a theurapiecti or programmatic effect�strenghtens them Clients present CHHP as a transformative experience. They talk about being valued and empowered. Again there were several examples like this one here. CHHP combines autonomy and respect to the individual with support and help. Clients become forward-looking. For example, one client talked about looking to the future, and indicating that eventually he would like to find a larger apartment because he hoped to not be alone forever. Others talked about being able to house their children, about being sober, or about controlling tempers, so they really talked about CHHP as life changing. 26. CHHP provides a strong sense of belonging Clients identify with and get identity from CHHP. They talk about being a �CHHP� person. Many expressed wanting to be its own program ( Here who question of feeling of homeless, that they have no place�don�t have or weak connections with family for identity. Etc) For clients�has a theurapiecti or programmatic effect�strenghtens them Clients present CHHP as a transformative experience. They talk about being valued and empowered. Again there were several examples like this one here. CHHP combines autonomy and respect to the individual with support and help. Clients become forward-looking. For example, one client talked about looking to the future, and indicating that eventually he would like to find a larger apartment because he hoped to not be alone forever. Others talked about being able to house their children, about being sober, or about controlling tempers, so they really talked about CHHP as life changing. 26. CHHP provides a strong sense of belonging Clients identify with and get identity from CHHP. They talk about being a �CHHP� person. Many expressed wanting to be its own program ( Here who question of feeling of homeless, that they have no place�don�t have or weak connections with family for identity. Etc)

46. Conclusions CHHP stakeholders have ownership Investment in case management is key Harm reduction is crucial to a housing first model CHHP works because it has a �flexible� learning and organizational model