Committee Co-Chairs: Brad Hume, Margot Antonetty
Chris Calandrillo (Catholic Charities CYO), Tom Swindler (Catholic Charities
CYO), Tyrone Payne (TARC), Matt Geltmaker (SFAF), Andre Robertson (Black
Coalition on AIDS), Carli King (Ark of Refuge)
Sara Malan (ALRP), Dana VanGorder (SFAF), Sherilyn Adams (LSYS), Tim Patriraria
(Maitri), Elizabeth Cromello (SFRA), Pam Sims (SFRA), Kevin Fauteux (Derek
Silva), Brian Basinger (AIDS Housing Alliance), Raymond Banks (Council Member),
Michelle Long Dixon (SFDPH), Harold Phillips (Consultant)
1. Introductions
2. Review/Approve Agenda
The group reviewed the agenda for the current meeting. One change was made
that the ending time should be 6:00 p.m. No other changes noted and the agenda
was approved by consensus.
3. Review and Approval of Minutes- May 5, 2005
The group reviewed the minutes from the May 5, 2005 Housing Work Group meeting.
Without objection the minutes were approved.
4. Announcements
No announcements.
5. Public Comment
No public comment.
6. Housing Program Presentations
Matt Geltmaker from SFAF – discussed his program with 303 subsidy clients. Mr. Geltmaker provided statistics on the clients with regard to income, insurance coverage, and substance abuse issues. More than half of subsidy clients are in the 40s and 50s age groups. He also discussed the reasons people left the program, most died, some moved out of the county, some increased income and no longer qualified, health declined and moved into hospice or supportive living facility, some moved to other subsidized wait-list housing, some became incarcerated. This highlights that there are few options for people to move to. He discussed the SRO situation with shared bathrooms and community kitchens that many people are not able to tolerate. Additionally, issues with going back to work and increasing income that disqualifies people from the programs can inhibit people from returning to work. He discussed the SFAF three-phase policy for returning to work. He discussed a 300% increase in clients discussing their anxiety and fear about budget cuts and losing housing, which has a direct impact on client quality of life. (Handout available to Mr. Phillips and on file at Council Support Offices).
Andre Robertson from Black Coalition on AIDS – Program Director. He discussed that BCA faces similar issues and that housing is at a premium in San Francisco and people look outside the county for affordable housing. He mentioned that people transition to Bernal Heights housing project. Some need intensive care and support to manage a household. When they transition out they end up in the Tenderloin, and often tend not to want to go there because of substance abuse issues. Double and triple diagnoses, with HIV, substance abuse issues, and mental health issues may be significant barriers to stable housing. He mentioned that one of the challenges is that African American MSMs are in the top priority, and most services are oriented toward gay men, suggesting that services for women are few and far between.
Chris Calandrillo from Catholic Charities -- Discussed two programs. Partial rent subsidy and Derek Silva. He discussed a range of 9 programs, including the CARE-funded programs. Housing for women, facilities for disabling HIV, a health fund that is funded by a foundation to pay for glasses and other medical needs. He explained other sources of funding. Chris reviewed the programs and qualification criteria. He presented data on how many people had been in the program over the past 24 month period. He indicated that these subsidies only pay for SROs (again with shared kitchen and bathroom) and emphasized that there are few or no options for people to move to. He discussed program caps, and how people left the program. He indicated that the program targets those with the highest level of financial need. (Supporting document with statistics and data provided to Mr. Phillips, and on file at Council Support Offices)
Kevin Fauteux from Derek Silva discussed the program that provides housing at a building located at Market and Van Ness. He discussed that the building went on the market which threatened the housing situation of the residents. The building was purchased by Mercy, and residents were transitioned to Section 8. He discussed that Catholic Charities provides support services for the 70 or so residents. He explained the transition that has taken place and the new population of residents with new problems (directly out of prison, off Section 8 waiting list, from the Tenderloin). He indicated they are trying to integrate with the current population. The previous residents who have lived there for up to ten years, and CCCYO is attempting to work with the residents to make a stable housing environment. Population is primarily a gay population, and they are now bringing in women and children and integrating them together which can be challenging.
Tyrone Payne from TARC – Unlike other programs discussed today, the program at TARC is truly an emergency program. He mentioned that most clients stay 7-21 days, and it is not designed for permanent housing. Primarily focused on getting clients hooked up with medical care. Clients have little housing history, but may have significant problems with substance abuse, mental health issues, and a history of incarceration. He mentioned a large client population of transgender, and that TARC has become a home in the Tenderloin, with the drop in center and the emergency housing program. Regarding where people can go for housing, he discussed HOPWA, SFAF, and Catholic Charities, as a bridge to connect to other services. Issues unique with San Francisco, he discussed the lack of housing available and mentioned that the landlords have difficulty accepting someone with no rental history or other problems.
Jonathan Vernick from Baker Places – Executive Director. He discussed that their program is support housing and is an outcome of treatment and not a primary task. He described how people needed a place to go after substance abuse treatment. He explained how this was developed during the time before medical interventions that are available today. Mr. Vernick discussed the history of Baker Places. He indicated that the San Francisco population has a significant percentage with mental health and substance abuse issues (in addition to the issues with regard to HIV/AIDS). He indicated that substance abuse does not have the same continuum of care and does not have as many options for supportive housing. With mental health disorders there seems to be more programs and housing options available. The program first designed for those with substance abuse issues and HIV/AIDS who needed housing. He stated that it is easier to get into the program than it is to get out. Not a question of affordability or absence of housing, but rather lack of universal agreement on a policy of which population should be served. He discussed the way housing is set up in San Francisco does not address the needs of many of the Baker Places clients. He discussed that on a provider level there is a large amount of coordination with other agencies taking place, however the same is not true for the administration. He ended by saying that the longer term coops are more stable than the short-term housing arrangements. He said this has as much to do with the demographics as with the medical interventions available for extending life. He explained that the short-term housing is less desirable and people are less likely to enroll in those programs. The client population of substance abusers is less challenging today than it was only a few more years ago. He indicated that the provider must change with the client population to avoid exiling the clients.
Sherilyn Adams from Larkin Street Youth Services – She discussed Larkin Street Youth Services that provides programs to youth age 13-24. She described the demographics and issues around substance use and mental health disorders. She indicated that many of their clients arrived in the city after fleeing their home state or country of origin who were escaping abuse. Many have lack of verifiable income, have not signed up for entitlements, have limited medical care, and come to the program through the rapid testing program. She mentioned the process for transitioning people off the program. She discussed the unique issues with the younger population that has difficulty understanding that their behavior has direct consequences on their life.
7. Questions and Answer Session
Harold Phillips, HRSA Technical Consultant will ask questions of the presenters
CM Antonetty discussed the activities from yesterday and today with site visits
with Harold Phillips. She mentioned that Harold Phillips will ask questions
of providers. He described what has happened in San Francisco and Washington
DC with regard to HRSA. He worked at HRSA on the housing policy and mentioned
that he has
left HRSA and works as a consultant. He understands HRSA in a way that few
people do.
He explained that a lot gets lost in the dialogue. Because when the housing policy was created, it emerged as part of an “unfortunate accident.” A question came about regarding amount of funds spent on housing rather than health care services. At that point it went to the attorneys at HRSA who decided that they needed a policy as there was no legislation around it. Fear that if left up to Congress they would say the money could not be spent on housing. In 1999, To avoid leaving it in the hands of Congress, HRSA put out the policy and got through reauthorization. The policy is still unclear about housing. Since then HRSA has been trying to determine how to implement the policy. With Mr. Phillips’ background in housing, he was able to create the document. He moved on to discuss the OIG audits that looked at several EMAs. One of the problems with the OIG audit is that HRSA did not define “length of stay” deliberately because it could not be mandated by Washington because the housing issues of different EMAs are so vastly different. He indicated that Washington did not have the ability to define length of stay. He discussed that HRSA needs to define length of stay. The possibility is that it will be enforced by the City and HRSA and providers and clients being put out on the street again.
Harold discussed why he believes that retroactivity is a bad idea. He also discussed that the 18-24 months is arbitrary and unsure where that came from, and people at HRSA have talked about it but he believes they never gave this specific number.
He indicated that the direction he is moving in is to have extenuating circumstances. No defined length of stay, but rather a defined length of stay for each provider that uses funds for housing. Since each provider works with different target populations and barriers and issues and unpredictability. Part of contract negotiation will include some discussion with regard to their average length of stay and barriers to cause length of stay to be extended.
He suggested monitoring the performance goal, and an opportunity to discuss extenuating circumstances. He also discussed looking at clients with extenuating circumstances to determine why someone may have been receiving housing subsidies for 8 or more years.
The majority of people are moving through the system, and providers are finding funds from different sources. However, the reality is that sometimes it is not possible with the issues. This provides the opportunity to monitor the policy and have discussions on the issues that will keep Washington content.
Regarding discussion of clients not able to move through the system it will be necessary to look at and come up with explanations for why they cannot move on and come up with solutions.
HRSA will get a definition for length of stay, but not just one definition. If trying to reach hard to reach, multi-diagnosed clients, it could take more than 36 months and identify the reasons.
HRSA watching this process in San Francisco, because whatever happens here may be implemented in all the Title I EMAs throughout all 50 states. What is done here will be duplicated elsewhere.
Harold’s major points and beliefs around this issue are:
1. Nobody has done anything wrong
2. It is not HRSA’s desire to put clients out on the street again
3. HRSA feels a little bit stuck because OIG has been pressuring HRSA to come
up with a definition for length of stay
4. The providers are working very hard to move people through the system, despite
the OIG report that gives a different impression
Jonathan Vernick expressed that he appreciates the value of Mr. Phillips’ proposal and that the appeal is the flexibility. He stated that as a recipient of one of the OIG audits that it would be useful to have some definition for length of stay, without too much specificity and some flexibility. He stated that he appreciates the suggestions that Mr. Phillips is coming up with.
CM Banks asked if Mr. Phillips could craft his proposal for an extension. As the decision is being made too fast without client input, and also the EMA has three different counties. He asked why San Francisco is being “picked out” to come up with this definition. He suggested that without the help of some of the programs represented here today he would probably be locked up again or not as healthy. He asked again if more time could be allowed before making a decision.
Mr. Phillips mentioned that he has always had the client foremost in his mind. Even if the time limit is four years, he has been concerned what will happen to those people when the clock runs out. He also indicated that it is not only San Francisco, but also nation-wide implications. Therefore, his decision to make it as flexible as possible. He is unsure why San Francisco was chosen to work on housing. He also indicated that San Francisco is not the highest on the list as far as Title I funded housing expenditures. The goal is not to put people out on the street, and will remain flexible with regard to that. Will look at other funding, other strategies, and other means to keep people in housing.
CM Banks emphasized that the outlying counties have different housing needs than San Francisco and it seems unfair to impose a number on other counties. He suggested that Mr. Phillips craft into his policy something to reflect this. He suggested that Mr. Phillips visit the other counties and understand that this is not a single-county EMA.
Tyrone of TARC mentioned the impact on continued budget cuts on his programs.
Brian Basinger of AIDS Housing Alliance discussed housing subsidies lost in
HOPWA and the attrition of subsidies. Instead of an environment where housing
is viewed as an entitlement to encourage people to see it as a short-term
arrangement.
Mr. Phillips responded by saying that HRSA looks at housing as short term and a bridge to care. He believes that will continue. The amount of dollars spent on housing in each EMA is left up to the respective Planning Councils. Ryan White funds for housing will continue in this EMA.
Pam at SFRA, discussed the shallow and deep subsidy attrition is due to their allocation from HUD decreasing.
The group echoed and agreed that everyone has received cuts, as well as the demand is going up.
Jonathan Vernick mentioned that the housing situation is worse than ever, and discussed unprecedented diminishment of Section 8 housing and reduced funding. He suggested that these are all good arguments for having some flexibility around length of stay. Every organization has less money than before.
CM Antonetty discussed how the AIDS Office hears about the budget and passes this on to the agencies can cause a delay of more than a month into the new fiscal year. She discussed the impact of ongoing budget cuts.
Mr. Robertson discussed whether anyone looked at people leaving a program
because of cuts in funds.
Several in the group agreed that it had been done on a program or agency level
but not on a city-wide level.
Mr. Vernick mentioned that even with flat funding they have managed to survive,
and discussed other funding streams. He suggested that it is bad business to
get involved in providing service based on the flat-funding and reduced funding
with the AIDS Office is a formula for going out of business.
Mr. Phillips mentioned that he will take some of the data presented today and incorporate this into his report.
8. Break for early dinner
9. CARE Housing Work Group Meeting
Group will discuss the provider presentations and other issues for developing
a length of stay policy
CM Antonetty reviewed the process with HRSA requesting that the SF Planning
Council request technical assistance with regard to developing a length of
stay policy. She mentioned that the consultant, Mr. Phillips, has helped
relieve some of the anxiety around implementation and timelines.
Mr. Phillips mentioned that another piece of the puzzle is the following. In 2001-2002 the Planning Council allocation for housing was $6.3 million, which is the number two ranked EMA using Title I dollars for housing or housing-related services. Actually, $6.3 million is not for housing, but rather much of that is for case management and other supportive services around housing. Had HRSA known that it would have changed the response to the OIG report. One of the messages that HRSA and the Planning Council needs to hear, is that when planning allocations, it is ok to think about housing in a residential setting, but needs to be reported within a service category. He described how this gets rolled up to Congress and everyone thinks that the full amount was spent on housing when in reality that has not been done. He mentioned that San Francisco may drop down on the list with this new calculation. He indicated that this caused many in Washington to breathe a sigh of relief. Once this word gets out about San Francisco everyone will feel better about this. He also explained how case management is the service that everyone loves to hate. If the Council is providing case management in a housing residential setting, then it is easier to get it funded. He suggested keeping this issue forefront when prioritizing and needs assessment data to get across to the Council. He offered various suggestions for looking at how to report this allocation to HRSA.
CM Antonetty discussed how with some programs the housing is actually not paid for, but it is case management at the housing program, and that the real housing allocation is about $3 million. She discussed the need to change some of the subcategories.
CM Calandrillo asked if categories were changed would it go to HUD and move from the AIDS Office.
CM Antonetty explained that there is no concern.
Jack Newby asked about the EMA-wide Needs Assessment and discussed the completion of the survey instrument. He asked if there should be some focus groups around housing and case management
Mr Phillips mentioned that in the short run it is probably okay. If the change is considered before June 1st, when the deadline when the EMA must fund for the 2005 Allocations Table. Pull it apart and put it into the service categories to show what is truly being spent on housing. Regarding the Needs Assessment, he stated that it is okay for now. But in three years when there is likely to be a different group of people around the table, he implied that there may be problems when people forget why this was pulled apart, with regard to the case management for housing services to help people get access to care.
CM Hume suggested that Mr. Phillips meet with Michelle Long Dixon of the AIDS Office. They discussed the short amount of time between now and June 1.
CM Thomas asked if this could be done in this time period. The budget is coming to the Council’s May meeting for approval. She suggested that the Housing Work Group request the AIDS Office to look at service categories and re-categorize them and bring a budget to the Council Meeting showing the difference. She also suggested that the Work Group recommend that the Planning Council approve this change in case management. The other piece for the Planning Council is to remember what is in the service categories and to understand that if cutting case management and other programs may have implications beyond that category if they are actually linked to a housing program.
CM Hume asked whether this means asking the AIDS Office to do this work.
CM Thomas, yes it will have to come to Steering to get on the agenda. But Council will have to vote on it. In interest of expediency, she recommended that the Working Group ask the AIDS Office do this analysis.
Sharilyn expressed concern that the CARE Council be sure of keeping clear about the changes so certain category cuts do not result in the end of housing programs.
Mr. Phillips suggested the Working Group do whatever necessary to ensure that information does not get lost with regard to the changes in case management and housing. Leave things alone, but when doing the report to HRSA take the steps to put it back into the appropriate service categories.
CM Thomas explained how that is problematic due to the service categories that do not line up with HRSA’s service categories. She indicated that the more they can be consistent the better off they are. If things are sent to HRSA that don’t match what went to the Planning Council it can be problematic.
CM Antonetty reviewed the Guidelines for Length of Stay document that was distributed to all present (and on file at Council Support Offices). Group discussed, with special emphasis on the issue with regard to applying the policy to each housing program separately in order for clients to maintain access and compliance with medical care.
Mr. Phillips asked about the 12 month extension. Group discussed. He mentioned that the exceptions and extenuating circumstances need to be documented, but he had not gotten to the extension piece and will think about it.
CM Thomas discussed the need for the flexibility of extensions to ensure that people are not getting evicted from their housing at an inconvenient medical time.
CM Calandrillo mentioned that the group is thinking about client needs from a program perspective, and in the future it will be looked at from different angles He discussed the need for a grievance procedure.
CM Antonetty reviewed the availability of the HIV Advocate and that any grievance could be handled there, if it was not resolved in-house with the particular agency grievance procedure.
Mr. Phillips mentioned that it is necessary for consumers to work together with providers to maintain their housing (and consequently their health care).
CM Antonetty mentioned that this is an implementation issue for the Council and for the agencies, and it will be decided after the change in policy they need to be willing to look at how to handle the grievance.
CM Hume mentioned that a common theme with regard to grievances is comparing what happens to an individual to what happens to their friends at a different agency. He discussed that it is somewhat subjective in deciding who needs to stay in a program, and there is a need for clear objective policies and documentation around making the decisions for whether someone stays in a program or not.
Group discussed some of these issues with deciding whether it will be individual or a standard form will be approached in future working group meetings.
CM Thomas returned to the HRSA process and Harold’s work. She asked about the process of developing the policy and the timeline. Will HRSA develop a policy for all Title I providers or something specific for San Francisco.
Mr. Phillips explained that after HRSA gets over their shock they will likely generalize their definition for length of stay and apply this to all EMAs. They must come up with a definition, but how they take what San Francisco plans to do and direct other EMAs that this is what they have to do will be very interesting.
CM Thomas asked what San Francisco could do to help move the process forward. She likes Mr. Phillips’ approach which addresses the concerns and she is vested in HRSA agreeing with Mr. Phillips recommendation. What can be offered in the way of data or anything else?
HRSA will get the report and recommendation, followed by a conversation with the grantee’s office. If they hear support for it, then the Title I office will find it difficult to have another answer. Mr. Phillips indicated that his report will indicate that it is a very good policy, and that the variable approach with agencies is the best approach, recognizing the realities, meets HRSA’s needs, gives OIG something realistic to audit, and keeps clients where they are.
CM Calandrillo mentioned that if does have to come up with a number, is there a number that is totally unacceptable?
Mr. Phillips stated that is one aspect that has not been worked out yet. He suggested dialogue to determine how this number would be arrived at.
CM Antonetty mentioned that after the OIG report and the response to the report, she expressed appreciation to the providers for supplying the important data, and suggested developing a tool for looking at the average length of stay.
CM Hume questioned the part of the comments that implied the policy will keep people where they are. CM Hume suggested that many people now do not have a place to stay where they are, and it is important to think about moving people up to more stable housing.
Mr. Phillips clarified that he does not want to see people put out on the streets due to some arbitrary number, and wants people to move through a continuum of services, including a continuum of housing and doesn’t want people stuck in emergency or transitional housing. Housing is a finite resource, especially in San Francisco.
Brian B. asked whether changes will need to made to the AIDS Housing wait list.
CM Antonetty explained that the specific resource, whether a subsidy or whatever, will have a maximum length. If no extenuating circumstances, should be working to find another way to provide housing and eventually the subsidy would not belong to the client any longer.
Brian characterized subsidized housing and is and indicated that self-sufficiency is the actual goal, with subsidized housing as a stepping stone. If a client moves from a rehab program, it would be more appropriate for them to transition into a deeper subsidy, to a shallow subsidy, to self-sufficiency. With this model, would changes in the AIDS Housing wait list help to facilitate this process.
CM Antonetty indicated that this deals with nitty-gritty local implementation issues that will be dealt with soon enough, and for Brian to keep those issues in mind.
Sharilyn emphasized being aware of the changes in staffing required for transitioning people on to the program. This all requires support staff and explained that this has policy level implications although it is an implementation piece.
Mr. Phillips mentioned that the biggest paradigm change is around the rental subsidy programs. The type of staffing for those programs will have to change, because the staffing component is to move people off or through the subsidy program. Housing placement aspect of service may have been previously missing, and will play a role in compliance and performance.
Matt indicated that the goal is for people to become self-sufficient. He suggested that this may happen for some people, but the reality is that it is rare and does not or will not happen for everyone.
CM Thomas commented on the reliance of case managers and social workers to help people with those programs. She indicated that as it works now clients rely on a case manager. Now the housing subsidy provider is not providing the housing services beyond a certain level, and is not expected to make that a part of their service provision that they are moving people on to other funding streams. Doesn’t want the service provider accountable for a service they are not providing. She suggested some way to make sure communication is happening so one agency is not held accountable for a service that another agency is providing.
Dana clarified the next step for Mr. Phillip and asked if it will return to the Planning Council or if it is approved by the AIDS Office. Mr. Phillips explained that when he returns to the Planning Council he will have the recommendation. One concern is how this is going to be rolled out to the rest of the country. If it is decided to do this to San Francisco, then he will point out in the report that it needs to be fair to everyone, which will result in a few months of delays while they figure this out. Once it starts it will still involve negotiations with HRSA and the AIDS Office. None of this applies to this fiscal year.
With regard to rolling out the new policy and implementing locally, whether this would be done in phases at each agency with regard to new clients and existing clients. Mr. Phillips reviewed with Michelle Long Dixon his recommendation with regard to changing the service categories.
CM Hume informed Michelle that the Council would like to request the AIDS Office to ensure that the allocation table sent to HRSA on June 1 reflects these changes.
Mr. Phillips mentioned that services such as case management and substance abuse in a residential setting need to be moved back to the appropriate categories.
Dana suggested moving it to a “Housing Support” category.
For HRSA purposes it would still be housing and needs to be moved out.
Michelle indicated that she would take it back to fiscal and CM Hume asked if it is doable or not by the June 1 deadline. Michelle indicated that she would get back to Jack Newby of Council Support.
CM Thomas added that in terms of what the Council puts together in the Council Meeting to go to HRSA for June 1, move what is easier to move now, and for more complicated programs they be left in housing with the goal of moving them by next year. A good faith effort to move as much as possible now, and that for the prioritization and allocation process later this year, the remainder could be worked on.
Group thanked Mr. Phillips and CM Hume and CM Antonetty.
10. Next Meeting Date & Agenda Items
Group will discuss items for the agenda at the next meeting scheduled for May
26.
The next meeting is May 26. A room has not been decided. 4:30-6:30
11. Meeting Adjourned
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