Connecticut Integrated Health and Housing Neighborhoods

Supportive Housing for Super Utilizers of Homeless Service and Medicaid Systems - Connecticut Integrated Healthcare & Housing Neighborhoods (CIHHN)

Program Overview

In 2012, AIDS-CT (formerly the Connecticut AIDS Resource Coalition), in collaboration with the Partnership for Strong Communities, was selected as one of four sub-grantees to take part in the national Social Innovation Fund (SIF) initiative to address one of the most pressing policy problems currently facing the state and the nation as a whole: rising public health care costs associated with fragmented and uncoordinated care that result in poor health outcomes.

Through an administrative data match, Connecticut's implementation of the multi-year grant, CIHHN, is identifying and targeting 160 high-need and medically frail individuals in four different regions through collaborative partnerships between supportive housing, primary healthcare, and behavioral healthcare. The CIHHN cohort accrued on average $73,000 in Medicaid expenditures in the year before being housed.

Core Components of the Model

Four sites are implementing CIHHN:

  • Supportive Housing Works
  • Hands on Hartford
  • Columbus House
  • New London Homeless Hospitality Center

Each agency’s program is staffed by one or more patient navigators – direct service providers whose work focuses on helping clients overcome barriers to connecting with medical and behavioral healthcare – as well as a systems coordinator tasked with addressing challenges and building bridges among the housing and healthcare providers in each area. The patient navigators seek out and engage individuals in the community who are identified as eligible, building relationships that serve as the clients’ anchors while facilitating their connections with case management, housing, and multiple healthcare systems.

The State of Connecticut provided 150 Rental Assistance Program vouchers for scattered-site apartments, as well as 10 additional housing vouchers through various mainstream housing programs. Service delivery employs evidence-based practices that embed Housing First principles within intensive case management and a Harm Reduction approach to substance use.


Eligibility for CIHHN is determined through a data match between Medicaid utilization data and the CT Homeless Management Information System. This match identifies super utilizers who are experiencing homelessness. CIHHN providers coordinate with other providers in their Coordinated Access Network (CAN) and local Community Care Teams to locate, outreach, and engage potential participants.

CSH's Role

CSH provides technical assistance and support to CIHHN implementation, in collaboration with the Connecticut Department of Mental Health and Addiction Services and the Connecticut Department of Housing. CSH coordinates a network of CIHHN service providers and facilitates monthly case conferences and meetings to ensure program efficiency and support providers.


Administration and Program:

  • Department of Mental Health and Addiction Services
  • Department of Housing
  • Department of Social Services
  • Office of Policy and Management
  • Partnership for Strong Communities
  • AIDS-Connecticut
  • CT Coalition to End Homelessness


  • New York University


For additional information about CIHHN, or a request for training or technical assistance, please contact us at (860) 560-0744.



Work In the Field


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