HOPWA Housing
Plans
What is a Comprehensive
Housing Plan?

It is a tool for case managers and
clients to outline and manage housing
and supportive services needs and
goals to achieve housing stability.
What is the purpose of the
Comprehensive Housing
Plan?

To help HOPWA clients achieve
housing stability without long-term
dependence on HOPWA assistance
and improve clients’ access to
medical care and supportive services
associated with HIV/AIDS.
Is a Comprehensive
Housing Plan required for all
HOPWA clients?

Yes. All clients receiving HOPWA
TRBA, STRMU, Permanent Housing
Placement and Supportive Services
must have a Comprehensive Housing
Plan at enrollment.
What should case managers
put in the Comprehensive
Housing Plan?
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Issues that led to housing instability and dates
assessed
For STRMU, the emergency situation that led to
the request for assistance and evidence of that
emergency
Action steps to be taken to address housing
issues and the dates these were completed
Referrals offered to client and document
referrals utilized by client
Key Components of Housing
Plan
Determine housing needs
 Identify eligibility for other housing
assistance
 Supportive services needs to maintain
housing stability
 Eligibility for mainstream assistance
 Client sets goals for housing and
independence.

Plan Development
Developed jointly by client/case
manager
 Client develops own goals and
commits to accomplishing them
 CM confers with other providers
 Plan is updated on regular basis or
when client’s condition/needs change

How Plan Assists HOPWA
STRMU
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Creates a framework for addressing
“conditions” that gave rise to shortterm need
Establishes time frame to achieve
stability within 21 week assistance
period
Allows time to plan for and arrange
longer term housing, if needed
Can avoid repeated 21 week cycles of
assistance
How Plan Assists HOPWA
TBRA
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Assure that supportive service needs are
met
Identify any resources, skill deficits or
service needs that could lead to lack of
housing stability
Mainstream rental assistance opportunities
for long-term support
Develop strategies to avoid perpetual
dependence on HOPWA rental assistance
Goal Setting/Housing
Planning

Housing Preferences
Unit Size
 Location
 Tenure (lease/own)

Housing Stability Related
Goals
Income
 Earned income goals
 Benefits sought
Education/Skills goals
 Degree related
 Job Training
Supportive Service Required
Access to primary health care
 Behavioral health needs

Mental Health
 Substance Abuse

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Child Care/Support Needs
Goal Setting

Client establishes goals for :
Housing to be obtained
 Income/Employment
 Independent living skills
 Mental health/substance abuse
treatment
 Family connections

Plan for Achieving Goals

Key Elements
Time Frame
 Specific outcome to achieve
 Support needed to achieve goal
 Tasks to be accomplished by client
and case manager

Role of the Case Manager

Identify assistance needed to
accomplish plan
Skills deficits
 Budgeting support
 Negotiation health care of behavioral
health

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Encourage clients to develop future
oriented goals
Evaluation and Plan
Updating

Purpose

Identify changes in circumstances that
could impact plan
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•
•
•
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Health status
Family composition
Income/employment
Behavioral health needs
Amended plan also includes time
frames and client/CM responsibilities
Intervals for Updating Plan
If receiving time limited HOPWA
services such as STRMU, whenever
client applies for assistance
 Otherwise, for clients receiving TBRA,
plan should be updated when you talk
to client.
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Stages in Developing
Housing Services Plan
Engagement
 Assessment
 Goal Setting and Housing Planning
 Evaluation and Plan Updating
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Engagement
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Establishing clear communications
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Active listening
Non-judgmental
Meeting client where they are
Capitalize on interest in housing : provide
information, encourage client to make the
choice
Will require multiple encounters to develop
working relationship
Change the client’s role from passive to
active
Assessment - 1

Housing Needs
Currently homeless
 Cannot afford current housing
 Inappropriate or sub-standard housing
 Not accessible or presenting other
health related problems

Assessment - 2
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Issues that could impact ability to
be housed

Criminal justice background
• Prior offenses
• Currently on parole/probation

Credit problems
• Poor credit history
• Bankruptcy
Assessment – 3
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Other issues related to housing
instability

Co-Occurring disorders
• Mental health issues
• Connection to care/services
• Able to manage care
• Able to manage symptoms
Assessment - 4
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Other issues (continued)
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Substance use/abuse
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Use history
Awareness of relapse patterns
Treatment history
Interest in treatment/sobriety
Assessment - 5
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Other issues

Illness/disabilities
• HIV confidentiality
• Special housing needs related to disability
• Equipment/furnishings
• Live-in personal care attendant
• Location requirements related to accessing
health care/services
Assessment - 6
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Family or Social Network

Positive contributions
• Counter loneliness
• Financial support
• Other assistance
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Negative contributions
• Drug use
• Violence
• Anti-social behavior
Assessment - 7
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Daily living skills and resources for
housing stability
Self care
 Transportation
 Maintaining an apartment
 Financial literacy
 Managing nutrition

Assessment – 8
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Income and access to benefits
Source of income
 Receiving any benefits
 Eligible for any mainstream programs
 Expect to receive benefits in the future

Assessment – 9
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Family and social supports
Connections to family
 Other significant people
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Assessment – 10
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Employment
Work history
 Currently employed?
 Skills/education for potential
employment
 Prior job training experience

Goal Setting and Housing
Planning
Use the assessment items to set
goals
 Include assessment items and goals
in housing plan
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If a client does not comply
with the Comprehensive
Housing Plan?
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Case managers should make a good faith effort
to achieve client’s compliance and all efforts
should be documented in the CHP.
The agency should have a termination policy
and procedures that establish concrete
requirements and procedure if a client is noncompliant with the CHP.
Termination of clients must comply with Section
14 of the HOPWA Manual and must be
implemented in a uniform manner.
Evaluation and Plan
Updating
Review housing plan and client’s
progress
 Review clients’ CHP at each contact
with the client, assessing the current
housing situation and update the CHP
accordingly
 Document all activities and efforts
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