Population: Complex Health Needs

The needs of people living in supportive housing have become increasingly complex, yet the systems, funding structures, and service models designed to support them have not always evolved at the same pace. This paper explores how changes across housing, healthcare, behavioral health, and homelessness response systems have contributed to growing challenges in serving individuals with high-acuity needs, particularly in Los Angeles County.

Developed through a partnership between CSH and Housing Works of California, the paper emerged from conversations among leaders from Los Angeles County’s housing, healthcare, behavioral health, and supportive housing sectors who recognized the need for a more coordinated and sustainable approach. Drawing on lessons from the Los Angeles Mobile Integrated Services Team (MIST) model, which closely reflects the evidence-based Pathways to Housing’s Housing First model, the authors developed a High Acuity Pilot Framework to improve outcomes for individuals with the most complex needs.

The paper examines the historical, policy, and operational factors shaping supportive housing today and offers recommendations to strengthen service delivery, workforce capacity, funding alignment, and cross-system coordination. It is intended as a resource for policymakers, funders, housing providers, healthcare partners, and community leaders working to build a more responsive and sustainable supportive housing system.

In addition to the full report (here and to download above), here is a short, executive summary.

The First Statewide Supportive Housing Forum of Its Kind in Maryland

More than a conference, the first-of-kind 2026 Maryland Supportive Housing Forum hosted by CSH served as a space for connection, problem-solving, and shared commitment to ensuring vulnerable Marylanders have access to stable housing and supportive services. The Forum comes at a critical time, with more than 17,000 people in Maryland in need of stable housing while federal cuts to affordable housing and Medicaid threaten the resources that help people secure and maintain housing.  

Over two days, leaders representing supportive housing developers, service providers, healthcare partners, government agencies, advocates, philanthropic organizations, and community-based organizations came together to explore the policies, partnerships, and investments needed to strengthen supportive housing across Maryland. By bringing decision-makers together with practitioners and people with lived expertise, the Forum created opportunities for conversations that do not often happen across systems. Throughout the event, speakers reinforced a shared message: supportive housing is most effective when housing, healthcare, behavioral health, justice, and community partners work toward common goals. 

A recurring theme throughout the Forum was partnership. When attendees were asked what ideas from the event were still resonating with them, responses repeatedly highlighted system alignment, cross-department collaboration, data sharing, healthcare and housing partnerships, coordinated funding strategies, and stronger connections among providers, developers, and government agencies. 

Attendees responded enthusiastically to the Forum experience. One participant described the event as an “absolutely incredible convening,” while another noted it was “great to see so many leaders speaking at the forum.” Others highlighted the relevance of the content and the value of bringing together stakeholders from different sectors to learn from one another and identify new opportunities for collaboration. 

The Forum concluded with a discussion about the future of the Maryland Alliance for Supportive Housing (MASH), a growing coalition CSH is leading that is focused on strengthening supportive housing throughout the state. During an interactive session, attendees identified building partnerships as the alliance’s highest priority, followed by coordinating advocacy efforts and sharing knowledge across sectors. Participants ranked connecting people and organizations as the most important first step for MASH’s work and reported a strong readiness to contribute to ongoing coalition-building efforts.  

Participants also shared concrete actions they plan to take following the Forum, including strengthening local partnerships, engaging with state policy efforts, participating in MASH, advancing housing and healthcare collaborations, and bringing new stakeholders into supportive housing conversations. Across responses, a clear message emerged: people are ready to move from conversation to action.  

As attendees looked ahead to the future of supportive housing in Maryland, Councilwoman Odette Ramos offered a reminder of what is ultimately at stake: 

“If we can’t, as a society, provide the care and support to our veterans and those who need it most, we shouldn’t be here.” 

Thank You to Our Partners and Sponsors 

The Maryland Supportive Housing Forum would not have been possible without the support of our partners and sponsors. We extend our sincere gratitude to The Harry and Jeanette Weinberg Foundation and the Maryland Department of Housing and Community Development for their generous support and partnership in helping bring this first-of-its-kind statewide convening to life. 

We also thank our sponsors for their commitment to advancing supportive housing across Maryland: Foliot Furniture, Southway Builders, Inc., Enterprise Community Partners, The Zanvyl and Isabelle Krieger Fund, Homes for America, LifeStyles, Inc., Jaydot, Blue Beacon Advisors, Amanda J. Harris Consulting, and Episcopal Housing Corporation. Their support and partnership helped create meaningful opportunities for learning, connection, and collaboration among leaders from across the state. 

As Maryland continues to expand and strengthen supportive housing opportunities, the relationships built and ideas generated during this year’s Forum provide a strong foundation for future collaboration. We are grateful to every speaker, sponsor, planning committee member, and attendee who contributed their time, expertise, and commitment to creating a Maryland where everyone has the opportunity to thrive.

Photography Credit: Rodney Brown 

This August, supportive housing providers welcomed 21 policymakers for tours, conversations with residents, ribbon cuttings, and community events The visits were part of CSH’s inaugural Supportive Housing Week and gave members of congress and other public officials a closer look at how supportive housing works in the communities they represent. Across 11 states and more than 12 supportive housing communities, local partners showed how supportive housing can help people with disabilities find and keep stable homes, improve their health and independence, and stay connected to their communities. Local leaders in two communities announced proclamations recognizing the week. 

One message remained constant and prominent throughout the week: supportive housing works.  

Supportive Housing Works 

At its core, supportive housing is a proven, cost-effective approach that helps people break cycles of homelessness and maintain stable housing. While every supportive housing community is unique, the goal is the same: helping people find and keep a home. 

During the week, providers shared how supportive housing residents who have strengthened their health, made progress through treatment, gained independence, and built more stable futures.  Communities showed how housing paired with services can help people remain housed and connected to their neighborhoods and support networks. 

The week also highlighted the broader community benefits of supportive housing. Across urban, suburban, and rural communities, supportive housing developments demonstrated how investments in housing can create safe, thriving neighborhoods. 

From newly opened developments to long-standing supportive housing communities, local organizations gave policymakers and community leaders a closer look at their work. The stories shared throughout the week reinforced a simple but important truth: when people have access to stable housing and the services they need, individuals and communities both benefit. 

Communities Across the Country Opened Their Doors 

Supportive Housing Week came to life through site visits, community celebrations, ribbon cuttings, and conversations with policymakers. The examples below represent just a few of the many events that took place during the week. 

• In Pennsylvania, partners and community leaders visited supportive housing programs and discussed the role housing plays in helping individuals and families thrive. 

• In New York, policymakers and community leaders toured supportive housing communities in Westchester County and the borough of Brooklyn and engaged with providers and residents about the impact of housing with services. 

• In Nevada, community stakeholders toured supportive housing developments and learned more about efforts to address homelessness through housing and services. 

• In Illinois, providers welcomed visitors to supportive housing communities as part of broader Supportive Housing Week celebrations. 

• In Ohio and Kentucky, ribbon-cutting events highlighted new supportive housing developments and expanded opportunities for people with disabilities and others with complex needs. 

A Bipartisan Show of Support 

Supportive Housing Week brought together Republican and Democratic leaders at the federal, state, and local levels. Participants included members of Congress, congressional staff, mayors, and county leaders. 

Their participation reflected a shared interest in how supportive housing helps people achieve stability. Local leaders in Kansas and North Carolina also issued proclamations recognizing Supportive Housing Week. 

Partners Leading the Way 

Supportive housing providers, developers, and community partners hosted events and shared stories, photos, videos, and resident successes that showed the impact of supportive housing. 

Together, these efforts helped amplify a simple message: supportive housing works. CSH is grateful to every organization that participated and helped make the inaugural Supportive Housing Week a success. 

Supportive Housing Week in the News 

Supportive Housing Week generated attention from policymakers, housing leaders, and media outlets across the country. Highlights included: 

• SunHaven opens in Las Vegas as 50-unit supportive housing community (News 3 Las Vegas) 

• New Jersey Department of Community Affairs participates in Nationwide Supportive Housing Week to highlight the impact of collaborative housing initiatives (NJ DCA) 

• Rep. Mike Lawler tours Homes for Heroes in Tappan, New York during Supportive Housing Week (YouTube)  

• Community Block Party celebrates Supportive Housing Week in Illinois, bringing residents, providers, and community members together (Illinois Partners for Human Service) 

• Minnesota Senator Grant Hauschild attends Supportive Housing Week event in Grand Rapids, including a discussion with housing providers and a tour of Aurora Heights supportive housing community (Cook County News Herald) 

• Douglas County Kansas published a series of articles during the week to highlight programs and tenants thriving in supportive housing. (Douglas County Kansas website) 

The Work Continues 

Supportive Housing Week 2026 was designed to spark ongoing engagement between providers and policymakers, not just a single week of events. CSH encourages providers and partners to continue developing the relationships built through site visits and the community conversations to keep leaders connected to the housing needs and successes in their communities. 

Save the date for Supportive Housing Week 2027 – August 23-27, 2027! 

CSH is grateful to every provider, partner, resident, and public leader who helped make this first year a success and looks forward to building on this momentum in the years ahead. Thank you. 

This Crosswalk examines how Illinois Medicaid services align with the supportive housing services needed to help people experiencing homelessness, housing instability, and complex health needs achieve long-term housing stability. The report analyzes existing Medicaid authorities, highlights promising opportunities within Illinois’ new 1115 waiver Housing Supports benefit, identifies remaining service and funding gaps, and offers recommendations to better coordinate housing, healthcare, and supportive services. Designed for housing providers, healthcare partners, policymakers, and advocates, the Crosswalk outlines practical strategies to expand supportive housing capacity and improve outcomes for Illinois residents with the greatest needs.

CSH applauds Governor Whitmer and the state legislature for their continued bipartisan support of this funding, which has delivered measurable results, helping more than 1,800 individuals secure and maintain housing while accessing supportive services. 

Michigan Governor Gretchen Whitmer signed the FY27 state budget this week, which includes a $5 million investment in supportive housing services to help individuals and families achieve long-term housing stability. Administered by the Michigan Department of Health and Human Services, the funding will enable supportive housing providers statewide to add capacity and provide intensive, person-centered services to residents. Supportive housing combines stable, affordable housing with services for people with disabilities and long histories of homelessness. It is a proven, accountable, and cost-effective approach to lasting stability.

This funding follows previous appropriations totaling $31 million for supportive housing services between FY2023 and FY2026. The impact of that investment is measurable, transparent, and already evident: 98% of residents served through this funding have remained stably housed, and 63% have maintained or increased their income. These results show that when people receive the help they need, they can break the cycle of homelessness, achieve better health outcomes, and reduce reliance on costly public systems. State lawmakers are making public investments that produce lasting stability while reducing reliance on more expensive emergency and crisis services.

CSH thanks state Senators Jeff Irwin, Sylvia Santana, and Sarah Anthony, state Representative John Roth, and House and Senate leadership for their continued bipartisan support for this impactful investment.

CSH is also grateful to all the individuals and organizations in the state who have advocated for supportive housing, in particular, Avalon Housing, Communities First, Faith in Action, Goodwill of Northern MI, ICCF Community Homes, and Room at the Inn, all of which hosted tours for legislators this year or provided committee testimony.

“Every dollar Michigan invests in supportive services goes toward something measurable: helping people obtain stable housing and build healthier, more secure futures,” said Catherine Distelrath, Michigan Director at CSH. “We look forward to continuing our partnership with state leaders, providers, and advocates to expand these measurable results across the state.

By: Aubrey Patino, Third Sector Manager and Catherine Distelrath, CSH Michigan Director 

As the nation continues to grapple with homelessness driven by severe shortages of affordable housing and coordinated services, the State of Michigan is advancing critical efforts to improve the quality of supportive housing. A proven solution to addressing homelessness for those with complex needs, supportive housing pairs safe, affordable, and stable housing with support services. 

But the success of supportive housing is fundamentally dependent on sustainable, scalable service funding. Today, Michigan providers, like many supportive housing providers across the country, are navigating a fragile patchwork of revenue streams: time-limited grants, developer fees, limited state resources, and highly competitive federal funding such as the Department of Housing & Urban Development (HUD) Continuum of Care (CoC) funds. 

While Medicaid cannot close the entire funding gap, it is a critical piece of the puzzle for building a resilient, accountable, and performance-driven supportive housing services system. Over the past year, Third Sector and Corporation for Supportive Housing (CSH) have actively collaborated to build the operational capacity of Michigan’s long-term supportive housing network. Together, they have equipped providers to deliver high-quality, Medicaid billable services (once contracted with Community Mental Health providers) that directly improve behavioral health outcomes and housing stability, while reinforcing strong standards for documentation, billing integrity, and outcomes tracking. 

Michigan is not alone in this effort. To date, thirty-one states have received approval from the Centers for Medicare & Medicaid Services (CMS) to fund supportive housing services through Medicaid. This reflects a growing national recognition that stable housing is a fundamental social determinant of health and cost-effective alternative to crisis care. 

Supportive housing offers a clear opportunity to spend smarter, not more. This approach shifts resources away from costly emergency room visits, crisis services, and jail stays toward proven solutions that stabilize individuals and reduce long-term public costs. By pairing housing with targeted services, states can improve health outcomes, reduce system strain, and deliver stronger returns on taxpayer investment. Michigan has an opportunity to lead by demonstrating how supportive housing drives measurable results—fewer people in crisis, safer communities, and more efficient use of public resources. 

RECOMMENDATIONS TO IMPROVE MEDICAID UTILIZATION FOR SUPPORTIVE HOUSING 

There is a need for targeted national and state-level analysis to evaluate how Medicaid-funded supportive housing services influence provider revenue, housing stability, and health outcomes. This means assessing each state’s supportive housing capacity, Medicaid billing requirements, reimbursement structures, referral pathways, provider readiness, and cross-agency coordination. These efforts can help states determine whether rates reflect the full cost of service delivery, whether providers have the tools to meet Medicaid requirements, and whether clear contracting pathways exist between regional payors and supportive housing providers. These analyses should distinguish between traditional healthcare providers and organizations with deep experience in housing and homelessness services that may be newer to Medicaid to ensure program design supports effective implementation while maintaining strong standards for provider qualification, oversight, and accountability. This learning can also help state Medicaid offices and supportive housing providers develop shared quality metrics that align with HUD and CMS standards. 

Technical assistance is vital for bridging the implementation gaps as they emerge. This work is complex and dynamic and requires ongoing support to help providers navigate Medicaid requirements, build operational capacity, and deliver services that meet both compliance standards and outcome expectations.  

PRIORITY ACTIONS FOR MICHIGAN 

Building on CSH’s national best practices and real-time implementation experience, Third Sector and CSH have seven recommendations for Michigan to improve Medicaid utilization to reduce homelessness and support better well-being outcomes in their communities: 

Financial Sustainability  

Establish standardized reimbursement rates (“a floor”) and develop evidence demonstrating how tenancy supports reduce high-cost crisis care (ER/inpatient stays) to make a clear business case for payors. 

Systemic Coordination 

Create dedicated cross-agency workgroups that bring together supportive housing agencies, Medicaid, housing finance, and payors to resolve barriers, share data, and promote peer learning. These groups should also play a role in oversight and continuous improvement. 

Policy & Incentives 

Implement performance metrics and incentive structures to encourage state housing finance agencies to utilize available Medicaid benefits. 

Evaluation & Learning 

Evaluate the impact of services on housing stability and health outcomes while documenting successful local operational models to streamline benefit delivery.  

Benchmarking 

Establish clear benchmarks for utilization, outcomes, and provider performance to guide decision-making and ensure consistent standards statewide. 

Advocacy & Education 

Engage in statewide advocacy to educate consumers, advocacy groups, and key stakeholders on the importance and availability of the Medicaid benefit. 

Local Examples 

Identify local examples that have successfully overcome these barriers, documenting innovative operational models, successful policy adjustments, and mechanisms for streamlining benefit delivery. 

MICHIGAN’S IMPLEMENTATION PATHWAY  

Michigan has already taken a significant step forward. On October 1, 2023, the state transitioned its Housing Assistance (HA) benefit from a limited 1115 waiver to a 1915(i) State Plan Amendment (iSPA). This transition signaled a permanent commitment to integrating housing support into the state’s healthcare system.  

Despite this progress, utilization of the HA benefit remains very limited, indicating that both supportive housing providers and the behavioral health system lack the tools and resources needed to leverage this opportunity. 

To address this gap, CSH and Third Sector implemented a targeted, multi-pronged strategy focused on three key groups:  

• Supportive housing providers 

• State leadership 

• Regional Prepaid Inpatient Health Plans and Community Mental Health Service Programs (PIHPs/CMHSPs) 

These regional entities are crucial as they serve as the primary payors and contract holders, managing enrollment, oversight, and funding for the Housing Assistance code, which reimburses supportive housing providers for their essential services. 

KEY AREAS OF PROGRESS 

Systems Coordination 

By focusing on individuals with complex housing and social needs, supportive housing directly targets individuals for whom traditional community mental health interventions alone are often insufficient. Current efforts should focus on: 

• Enable providers to successfully bill Medicaid 

• Improve operational readiness and capacity 

• Enhance the delivery and access to supportive housing 

State-Level Advocacy and Case-Making 

Partner with the critical stakeholders to advocate for the HA benefit’s utilization as a clinical necessity and facilitating direct meetings with regional entities to model financial impact and scope of need. 

Administrative Streamlining 

Establish a state leadership workgroup, including Medicaid staff from the Michigan Department of Health and Human Services (MDHHS) and state housing finance agency staff from the Michigan Department of Housing Development Authority (MSHDA), which resulted in the publication of a statewide memo and FAQ document to clarify implementation standards. 

Exploration of the Role of CCBHCs 

Analyzing the capacity of Certified Community Behavioral Health Clinics (CCBHCs) to incorporate housing supports within their integrated care models. 

LOOKING AHEAD 

By focusing on these targeted strategies, states can effectively solidify Medicaid as a reliable revenue stream, contributing to the sustainable infrastructure needed to end homelessness and improve health outcomes statewide. 

For more information, contact: 

• Aubrey Patino, Manager at [email protected] 

• Catherine Distelrath, CSH Michigan Director at [email protected] 

Third Sector is a national nonprofit technical assistance organization that advises government agencies on effective ways to reshape their policies, systems, and services toward better outcomes for all people, no matter their race, background, or circumstance.

On June 19^th, just days before the 27th anniversary of the Supreme Court’s decision in Olmstead v. L.C., the Department of Justice (DOJ) issued a memo advancing an interpretation of the Olmstead decision that breaks from decades of established precedent. The memo questions whether the Olmstead decision requires states to serve people with disabilities in the most integrated setting appropriate to their needs. As the DOJ acknowledged, the new interpretation is out of step with how federal courts have understood Olmstead since 1999.

CSH is deeply concerned about this departure. Defending and advancing Olmstead is central to our work. The core principle— that people with disabilities should be able to live, work, and thrive in the community of their choice — is the foundation of supportive housing. At its heart, Olmstead recognized that no one should be cut off from their families, friends, and people they love simply to receive the care they need.

Olmstead has shaped how states support people with disabilities for nearly three decades. Courts across the country have consistently affirmed its core principle: that unnecessary isolation is a form of discrimination. That principle has guided state investment and practice. It has moved systems toward community-based housing and services that help people achieve stability, health, and independence. 

This does not mean that treatment and housing are at odds. Some people, at some point in their lives, need intensive clinical care, including time-limited stays in hospitals or residential settings. A strong system includes that full continuum, but those settings work best as a bridge to stable community living, not a substitute for it. The choice is not between treatment and housing. Both are essential, and neither works in isolation.  

The harder truth is that legal standards are only part of what stands between a person and a life of their choosing in the community. America faces a severe shortage of affordable housing and wide gaps in access to care. Efforts to expand access to evidence-based treatment supports, particularly community-based models, would be more effective than focusing on compelling services that simply are not available. These realities do more than any legal interpretation to determine whether someone with any disability including serious mental illness stays housed or falls into homelessness. Without a stable home, too many people either languish in institutional care or leave institutional care only to cycle back through emergency rooms, shelters, and jails.

Our FUSE work had demonstrated for more than two decades that when communities prioritize intensive services with housing, even people with the most complex needs find stability and recovery while communities enjoy reduced homelessness and costs associated with institutionalization.

North Carolina shows what is possible and what it takes to ensure that people have freedom of choice and the opportunity to thrive. Before 2012, the state relied on large, segregated adult care homes to serve people with serious mental illnesses. Those conditions resemble what this memo would now treat as legally acceptable. The DOJ found that this reliance violated the ADA and Olmstead, and that the resulting agreement required the state to build supportive housing and community-based services.

Building that capacity took the state more than a decade, several extensions, and sustained public investment, and the work continues today. The work required new levels of cross-sector collaboration between the housing and health sector state and community leaders.  That investment has helped thousands of North Carolinians leave institutional settings for homes of their own.

The DOJ memo targets the very tool that drove progress. North Carolina’s problem was a shortage of housing and services. The legal expectation to integrate is what finally pushed the state to address the shortage. Removing that expectation, while the capacity gap remains, abandons people in the middle of a transition that is finally helping them.

Stepping back from community-based housing and services will push more people, and more cost, onto public systems. Institutional and crisis care is much more expensive than supportive housing, by many estimates more than three times as much per person. Without stable housing to exit to, that spending recirculates through repeated hospitalizations, law enforcement contacts, and time in jail, with little lasting stability to show for it.

The evidence of the last quarter century points in one direction. Supportive housing and community-based care improve health, strengthen communities, and reduce reliance on costly crisis systems. As policymakers and state leaders study this memo, the strongest path forward is to follow the evidence and build on community integration for people with disabilities by: expanding supportive housing, strengthening access to mental health and substance use care, and ensuring a full continuum of support that meets people where they are.

CSH remains committed to working with federal, state, and local partners so that every person has access to safe, stable housing and the support they need to thrive in the community.

The 2026 Kentucky Medicaid Crosswalk provides a comprehensive analysis of how Kentucky’s Medicaid program aligns with evidence-based supportive housing services. Developed in partnership with the Kentucky Housing Corporation, the report examines current policies—including the 1915(i) RISE program—alongside provider insights and national best practices to identify strengths, gaps, and opportunities for improvement. It explores how Medicaid-funded services can better support people experiencing homelessness or housing instability, highlights the critical role of cross-sector coordination, and offers actionable recommendations to expand access to stable housing, improve health outcomes, and strengthen system efficiency across Kentucky.

The projects will serve more than 250 residents through innovative initiatives that tackle complex health, substance use, and aging challenges.

The Challenge: Rising Acuity Among Supportive Housing Residents

Over the last five years, New York City’s supportive housing system has been stretched by a growing number of people experiencing homelessness who need more intensive, coordinated support to stay housed.

More people are experiencing prolonged homelessness due to obstacles in accessing health care, housing, and community-based services. Many individuals entering or living in supportive housing are navigating complex trauma and health conditions, often without consistent access to coordinated and person-centered care.

Supportive housing providers have seen a drastic rise in serious health challenges for their residents. At the same time, the population within supportive housing is aging. Older adults, age 50+, now represent the fastest-growing group of New Yorkers facing housing instability, with many entering homelessness and crisis systems for the first time. Providers are struggling to support aging residents who have lived with substance use disorder for decades, often experiencing cognitive decline and aging issues nearly 20 years earlier than those who have never been homeless.

The COVID-19 pandemic also led to the closure of many nonprofit service providers, and the sector continues to feel the devastating impact of a critical service infrastructure that has been reduced in scale. Further, the sector has received insufficient public and private investments to meet the needs at the required scale.

CSH’s Response: A Multi-Year Initiative

Funded by a three-year grant from The Leona M. and Harry B. Helmsley Charitable Trust, CSH launched a three-phased project to both identify service gaps and surface solutions that better address the needs of supportive housing residents with complex health challenges in New York City (NYC). CSH’s NYC metro team, led by Lauren Velez, launched this project by engaging teams of collaborators and advisors on key phases of the project: starting with establishing partnerships with network leaders at The Supportive Housing Network of New York (the Network) and The Health and Housing Consortium to bring their expertise and membership’s perspectives to the project; followed by convening an advisory committee for input and feedback that includes providers, government leaders, and people with lived expertise.

The first official phase of the project was to complete a full landscape assessment aimed at understanding the local and national challenges, and opportunities to serving this population in the supportive housing field.

Informed by and in response to these findings, Phase Two included the creation and announcement of a competitive RFP to solicit ideas with the most promise to improve the service levels in the sector to better meet these unmet needs. In November 2025, CSH selected four proposals to be the pilot projects for the “High Health Acuity in Supportive Housing Initiative”, awarding a total of $1,000,000 in grants over 2 years. The selected pilot projects will holistically address the high acuity health needs of supportive housing residents through increased capacity and innovative interventions.

Evidence Towards Innovation

Phase Three of this project involves CSH choosing and engaging an evaluation partner, L&G Research and Evaluation Consulting, Inc., to evaluate learnings from the initiative and, together with CSH’s deep expertise in the field, and the input from their expert advisory committee, coordinate the evaluation for the pilots projects with an eye towards opportunities for scaling and sustainability for those that are successful. The evaluation partner will also develop education materials to share with policy makers and other stakeholders.

“I couldn’t be more excited about this initiative as it combines grant funding with CSH’s tailored technical assistance and policy expertise to help providers better support residents living with multiple co-occurring physical and behavioral health conditions,” said CSH NYC Metro Director, Lauren Velez. “Pilot programs test innovations that include hiring additional specialized staff, implementing flexible service models, and strengthening collaboration across homelessness and health systems. We need to reimagine our investment in supportive housing services. Cost effective measures don’t mean that we can fail to provide adequate funding- it means that the return on that investment is greater and more stable than alternatives. “

Private funding is often needed to create the evidence and testing needed to advocate for public adoption. “A project like this with three important ingredients of evidence-based innovation – research, testing, and evaluation – bolstered by the deep bench of expertise from CSH and their partners to find solutions to this growing challenge for New Yorkers living with complex health issues in Supportive Housing, is one of the strongest doses of philanthropic support that we could apply to the problem,” said Tracy Perrizo, NYC Program Officer from the Leona M. and Harry B. Helmsley Charitable Trust. The project’s aim is to show why making the necessary investments to meet these needs at scale is smart and cost-effective policy. Decades of research have proven that supportive housing offsets public costs of crisis systems and creates safe, thriving communities.

“This project gives us the ability to explore the impact of interventions that are truly person-centered, responsive to need, and properly funded on the overall health and well-being of high-need supportive housing tenants,” added Velez.

Meet the Four Pilot Projects

CSH and evaluation partners selected these four organizations from an extremely competitive applicant pool of New York City supportive housing providers.

Alliance for Positive Change

Alliance for Positive Change will integrate a housing-focused social worker to provide comprehensive clinical support services to residents of their Bronx supportive housing building. Residents have complex health needs including HIV and other chronic illnesses, mental health concerns, aging issues, and other challenges. The new full-time staff member will provide frequent, one-to-one counseling to improve residents’ financial skills, apartment-care skills, self-efficacy, and independence.

Lantern

Lantern’s Adapted-Intensive Case Management (A-ICM) pilot project will adapt the most effective elements of the traditional Intensive Case Management (ICM) model to make it more sustainable and scalable for organizations with limited resources. Case managers will receive training to support residents with complex needs through intensive services. Within the A-ICM model, services will include needs assessments, referrals and warm handoffs, health navigation, and accompaniment to health appointments. The pilot also includes hiring new Tenant Peer Navigators who will leverage their lived expertise to help residents navigate complex health systems.

Project Renewal

Project Renewal’s High-Acuity Response Team (HART) project will pilot a care team consisting of a nurse care manager and occupational therapist who will support their highest-need supportive housing residents. The new full-time staff members will manage a shared caseload to serve residents with complex needs including substance use, serious mental illness, aging, generational trauma, and/or chronic health issues. This pilot project will bring coordinated in-house care that specializes in complex needs, while increasing capacity for frontline staff who are strained in supporting 100 of their highest need residents across multiple supportive housing sites.

St. Nicks Alliance

The St. Nicks Alliance project will pilot a new mobile Wellness Outreach Team to support residents of their scattered-site supportive housing program. Tenants living in scattered-site supportive housing can be more difficult to reach, as they live in units rented from private landlords throughout the city. This multidisciplinary team will conduct comprehensive in-home assessments and provide ongoing support services including medication management, behavioral health support, and health education. This new team will coordinate with existing case managers and be integrated with community providers to facilitate warm hand-offs when clients stabilize. The outreach team plans to serve around 60 tenants during the pilot period.

This resource is intended to support health centers in identifying some important components to effective programming for HIV+ individuals leaving carceral settings to ensure smooth linkage to care and housing following discharge.