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TO: BOARD OF SUPERVISORS � �:�. CosaCou�/
FROM: Harvey E. Bragdon ' "�
Director of Community Development
DATE: April 22, 1997
SUBJECT: Contra Costa County HIV/AIDS Housing Plan
SPECIFIC REQUEST(S) OR RECOMMENDATIONS(S) & BACKGROUND AND JUSTIFICATION
RECOMMENDATIONS
RECEIVE the Contra Costa County HIV/AIDS Housing Plan, which identifies priorities and strategies
to address the affordable housing needs of low-income persons living with HIV/AIDS in the County. (A
copy of this plan is on file with the Clerk of the Board.)
FISCAL IMPACT
No General Fund impact. No allocation of funds involved.
CONTINUED ON ATTACHMENT: X YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR_RECOMM ATION OF BOARD COMM�T EE
APPROVE OTHER
SIGNATURE(S):
ACTION OF BOARD O -W IffZ APPROVED AS RECOMMENDED_OTHER_
VOTE OF SUPERVISORS
I HEREBY CERTIFY THAT THIS IS A
X UNANIMOUS (ABSENT ) TRUE AND CORRECT COPY OF AN
AYES: NOES: ACTION TAKEN AND ENTERED ON THE
ABSENT: ABSTAIN: MINUTES OF THE BOARD OF
SUPERVISORS ON THE DATE SHOWN.
Contact: Kathleen Hamm (335-1257) ATTESTED
cc: County Administrator PHIL BATCHELOR, CLERK OF
County Counsel THE BOARD OF SUPERVISORS
Community Development Dept. AND COUNTY ADMINISTRATOR
Rusty Keilch, AIDS Program/Dept.'of Health Services
(via CDD) Cities: Antioch, Concord, Pittsburg, Richmond, B*, ,DEPUTY
Walnut Creek, Oakland
BACKGROUND/REASONS FOR RECOMMENDATIONS
The U.S. Department of Housing and Urban Development (HUD) allocates federal Housing
Opportunities for Persons with AIDS (HOPWA) funds to the largest city within an Eligible
Metropolitan Area (EMA). Within the Alameda-Contra Costa County EMA, HOPWA funds are
allocated to the City of Oakland to provide affordable housing and related services to low-income
individuals with HIV/AIDS throughout the two counties. Oakland, and the Counties of Alameda and
Contra Costa recently completed work to prepare an HIV/AIDS Housing Plan for each county which
identifies priorities and develops strategies to meet the affordable housing needs of low-income
persons with HIV/AIDS. Efforts to prepare the Contra Costa County plan (the Plan), which consists
of a comprehensive needs assessment, five-year strategy, and prioritized annual goals, included review
and analysis of existing housing and epidemiological data as well as direct solicitation of input from
individuals with HIV/AIDS, case managers, service providers, and affordable housing developers
through task force meetings, focus groups, and surveys.
Contra Costa County has the ninth highest incidence of AIDS in the state of California. Through
October 31, 1996, a cumulative total of 1,807 cases of AIDS had been reported to the Health
Services Department, including 626 individuals with AIDS currently living in the County. It is
estimated that an additional 1,600 Contra Costa residents are currently HIV-infected. During the six-
month period from January 1, 1996 to June 30, 1996, a survey of 520 clients receiving services
through the County AIDS Program indicated that 94 percent had incomes at or below $1,200 per
month (extremely-low and very-low income households).
Major Plan findings include:
• finding and keeping safe, affordable housing is a constant challenge for low-income people
living with HIV/AIDS across Contra Costa, many of whom are also struggling with substance
abuse and mental illness;
• low-income women and families with children affected by HIV/AIDS have unique social and
support service needs which negatively impact their ability to maintain housing; and
• poor rental and previous criminal histories make it hard for many low-income people living
with HIV/AIDS to find housing.
The Plan therefore identifies the priority target population as low-income people disabled with
HIV/AIDS who are either homeless or have unstable housing. Within this target population, the Plan
further prioritizes housing and services to low-income persons disabled with HIV/AIDS who have
families and/or young children, and/or are dually or triply diagnosed with one or more disabilities.
Major Plan recommendations include:
• requirement that people in HIV/AIDS affordable housing programs must have a case manager
and where appropriate, money management services;
• creation of a short-term housing assistance program which combines rent subsidies with case
management services and links to permanent housing;
• increasing target population access to mainstream affordable housing, Section 8 certificates
and vouchers, and Shelter Plus Care; and
• development of a permanent supportive housing program for low-income people living with
HIV/AIDS who are also mentally ill and/or have been discharged from drug treatment and/or
correctional facilities.
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Contra Costa County
HIV/AIDS Housing Plan
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December 1996
Funded in Part by the City of Oakland
Table of Contents
1
1
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
' Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
HIV/AIDS in Contra Costa County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Housing in Contra Costa County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
1 HIV/AIDS Housing Survey Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
' Housing Provider Survey Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
HIV/AIDS Housing in Contra Costa County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
1 The Context of HIV/AIDS Housing in Contra Costa County . . . . . . . . . . . . . . . . . . . . . . . . . . 91
' Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
HIV/AIDS Housing Plan Proposed Implementation Timeline and Budget . . . . . . . . . . . . . . . 145
Appendices
' I: Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
II: Program Recommendations for HIV/AIDS Housing Programs . . . . . . . . . . . 157
III: Resources For HIV/AIDS Housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
IV: Long Term Care Reimbursement Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
' V: Contra Costa County HIV/AIDS Housing Survey Instruments . . . . . . . . . . . . 195
VI: Assisted Housing Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Community Planning Participants
Carol Austin Pittsburg Preschool Coordinating Council
Melissa Ayres City of Walnut Creek
Barbara Bacon City of Martinez
Ron Bendorff City of Antioch
James Bonner Pittsburg Preschool Coordinating Council
Lori Bowley Shelter,Inc.
Kim Brownlow Community Housing Development Corporation of North Richmond
Elaine Burres Shelter Plus Care
Maria Camacho AIDS Project of Contra Costa County
Deborah Dias City of Richmond
Barbara Hall Rubicon Programs
Elizabeth Gearin Contra Costa County Community Development Department
Marge Gladman Housing Authority of Contra Costa County
Janis Glover City of Pittsburg
Lisa Grady Resources for Community Development
Frances Greene Pittsburg Preschool Coordinating Council
Barbara Hall Rubicon Programs
Kathleen Hamm Contra Costa County Community Development Department
Melanie Hobden City of San Ramon
Bob Hopkins Contra Costa County AIDS Program
Rusty Keilch Contra Costa County AIDS Program
Janet Kennedy City of Concord
�. Christine Leivermann Contra Costa County AIDS Program
Marilyn Lovelace Catholic Charities of the East Bay
Louie Martirez Contra Costa County AIDS Program
Frank Motta Shelter Plus Care
Craig Munroe City of San Pablo
Mario Navarro Catholic Charities of the East Bay
Lynn Nesselbush Contra Costa County Health Services Department Homeless Program
Kristine Pettersson Bay Area Addiction Research and Treatment,Inc.
Pat Pinkston Contra Costa County Health Services Department Homeless Program
Gerry Raycraft City of El Cerrito
Mark Reilly Resources for Community Development
Louis Sands Contra Costa County AIDS Program
Susan Shelton City of Oakland
Richard Sherwin Hospice of Contra Costa and Co-Chair of HIV/AIDS Consortium
James Smith Genard AIDS Foundation
Jerry Snyder AIDS Alliance
John Sturr Contra Costa County AIDS Program
Theresa Talley-Wilkerson City of Richmond
Norma Thompson Corporation for Supportive Housing
Bea Tracy Bay Area Addiction Research and Treatment,Inc.
Margaret Walker Co-Chair HIV/AIDS Consortium
Merlin Wedepohl Shelter,Inc.
Doris Willis Tranquillium Center
Approximately 100 people living with HIV/AIDS in Contra Costa
1 •
Contra Costa County HIV/AIDS Housing Plan
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"It's horrible enough to have full-blown AIDS, but being homeless on top of it is
horrible. "
-- focus group participant
This section provides a summary of the multi-year plan for HIV/AIDS housing in
Contra Costa County. It summarizes:
0 why finding and maintaining housing is such a crisis for people living with
HIV/AIDS;
., 0 why Contra Costa County need an HIV/AIDS Housing Plan
• how the plan was created and its goals;
• primary findings of the HIV/AIDS Housing Survey; and
• recommendations to improve the HIV/AIDS housing continuum in Contra
Costa County.
Finding and keeping a safe and affordable place to live is a constant challenge for many people
living with HIV/AIDS across Contra Costa County. The research conducted for this plan
indicates:
• Homelessness and the underlying potential for homelessness is the number one
housing Issue for low income people living with HIV/AIDS in Contra Costa
County.
I
Contra Costa County HIV/AIDS Housing Plan
• Many people living with HIV/AIDS in the County are also struggling with
poverty, substance abuse, mental illness, physical disability and other
stresses. These complex issues make succeeding in the general housing
market difficult for many people, and addressing the specific health care
challenges associated with BMAIDS, therefore, only one of the many
components of providing appropriate FMAIDS housing.
• There is not enough safe, affordable and appropriate housing for the 2,600
men, women and children living with AIDS or HIV infection in Contra
Costa County.
Why is housing so vital for people living with HIV/AIDS?
Without secure housing, persons living with-HIV/AIDS are often unable to get the basic
health care, social service and financial resources they need to live safe and healthy lives.
• Homeless people are more likely to use emergency rooms for basic medical
services—the most expensive treatment setting.
• Most people living with HN/AIDS have a hard time living on their own
when they get sicker. Accessing the supportive services than can help ease
the pain of dying—services like home care, counseling, and home delivered
meals—is nearly impossible without a stable place to live.
• Providing safe and secure housing for people living with HIV/AIDS is also
a public health intervention. People without a regular place to live may be
more likely to engage in behavior that can transmit the virus, and housing
increases health stability.
How many people with HIV infection and AIDS live in Contra Costa County.
i
This plan uses the language `people living with HIV/AIDS' to describe the population
targeted by the HIV/AIDS housing continuum and this plan. It is important, however, to
understand the difference to acuity, or severity of illness, between HIV infection and `full-
blown' AIDS. People infected with the Human Immunodeficiency Virus, sometimes
called `HIV positive' can maintain a good health status for years, particularly if they have
no preexisting medical conditions. This is called `asymptomatic HIV infection'. Children,
people with histories of substance abuse and people who cannot receive regular
medical care, however, can become `symptomatic', or have increasingly complicated
health issues, earlier in their disease process. Some of these symptoms, including weight
2
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Contra Costa County HIV/AIDS Housing Plan
and muscle mass loss, fatigue, fevers and neurological impairments, can be so severe that
people become disabled and have trouble living independently even before receiving a
formal diagnosis of AIDS.
Individuals are diagnosed with AIDS when they have one of many opportunistic
infections, including types of pneumonia and cancers, fungal infection, `wastings' and
dementia. Some people with AIDS are able to recover from these specific diseases and
return to work. Others become progressively ill, and many people die two to five years
after a diagnosis of AIDS. New treatments may increase the average life span of a person
living with AIDS, but these therapies--the medications alone average$15,000 a year--
' create great financial hardship.
Contra Costa County has the ninth highest incidence of AIDS in the state of
California. As of January 19, 1996:
• 1,684 cumulative adult cases of AIDS have been reported
throughout the County;
• 8 pediatric cases have been reported;
• 599 individuals were presumed to be currently living with AIDS;
• 200 new HIV infections are reported each.year - 16 new cases each month;
• Over 4,000 people are estimated to have become HIV-infected in Contra
Costa County.
A total of 2,600 people are assumed to be living with either AIDS or HIV-infection in
Contra Costa County.
Why is finding housing so hard for people living with HIV/AIDS in Contra Costa
County?
"I used to make $30,000 a ear selling cars. I of neumonia one and I ound out it
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was AIDS. Since then it has all fallen apart. And I ask myself Vow did this happen? 'All
I want is a roof over my head I'm clean. I have no record I am just an average guy. And
I just want someplace to stay the night, but I can't get the first and last and security
together. I just will never have that kind of money. "
-- focus group participant
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Contra Costa Count HIV/AIDS Housing Plan
Poverty, illness, the need to be cared for, discrimination, isolation, and the high cost of
housing all make it hard for people living with HIV/AIDS to find housing that meets their
needs. Using'the HIV/AIDS Housing Survey conducted for this plan and the 1994
Oakland EMA Needs Assessment, we estimate:
• At least 1,634 persons with HIV/AIDS living in the Oakland EMA are in
need of housing assistance;
• At least 130 people(five percent of the total)with HIV/AIDS in Contra
Costa County live in shelters or on the streets.
The AIDS epidemic has become increasingly concentrated in the most economically
disadvantaged areas of cities. People with HIV/AIDS who are employed often have to
stop working as their health declines, and eventually most people with HIV/AIDS live on
Social Security and Social Security Disability. The health care costs associated with this
disease are well documented, and the addition of new therapies, especially protease
inhibitors, will only increase the financial burden. The poverty of people with HIV/AIDS is
perhaps best illustrated by the fact that 50 percent of people living with HIV/AIDS in
California receive Medicaid. Across the United States including Contra Costa County,
the limited resources of the poor who have HIV/AIDS make dealing with this illness even
more devastating.
The HIV/AIDS Housing Survey and focus groups conducted for this plan were
particularly successful in reaching low income, high need people living with HIV infection.
• The average rent paid by survey respondents in Contra Costa County is
$439 a month and 65 percent pay between $400 and $900 a month in rent.
• People with HIV/AIDS on SSI disability as their sole income source
receive $624 a month.
The fluctuating nature of the health of people living with HIV/AIDS presents an additional
challenge. Even people whose health is relatively stable often have severe fatigue, high
fevers and need help to continue to live on their own.
• It is common for people with HIV/AIDS to have difficulty absorbing
nutrients, causing the extreme loss of weight and muscle mass known as
`wasting'. Home delivered meals become vital in order to avoid
institutionalization.
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Contra Costa County HIV/AIDS Housing Plan
1
• One third of all HIV/AIDS Housing Survey respondents said they were
chemically dependent making finding and keeping housing even more
difficult.
• As the disease progresses AIDS-related dementia, blindness, and a range of
other terminal illnesses mean that people often require 24-hour care.
Family members and friends caring for people in later-stage AIDS also
need a break('respite care') so that they can continue to support their
loved one. For some individuals with end-stage AIDS in need of 24-hour
care, a Skilled Nursing Facility is the best or only option.
Why does Contra Costa County need an HIV/AIDS housing plan?
Making sure that there is enough appropriate housing for persons with HIV infection and
AIDS has been a major concern for years. In Contra Costa County, that need has largely
been addressed by a small collection of dedicated providers, including public agencies.
The need for HIV/AIDS housing far exceeds the units provided by these projects. How to
best meet that need, however, has been the subject of some debate in Contra Costa
County.
• What do people with HIV/AIDS need and want?
• Which people living with HIV/AIDS are most in need of housing
assistance?
• How will decreasing resources impact HIV/AIDS housing
development?
• What is the best balance between short-term assistance, like rent
subsidies, and long-term capital intensive projects?
• Where should resources and new HIV/AIDS-dedicated housing units be
located?
• How can developers who have not been involved to date be
encouraged to develop HIV/AIDS housing?
• How can we increase community support for HIV/AIDS housing?
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Contra Costa County HIV/AIDS Housing Plan
• How can we address the needs of the hard-to-serve and
hard-to-reach, including the homeless, and people living with
HIV/AIDS and other disabling conditions, like mental illness and
substance abuse?
• How can we create a system which people with HN/AIDS will find fair
and easy to use, and which will help them find housing which is appropriate
to their needs?
• How can we increase the chances that people will be successful in the
housing that is provided?
These tough questions could only be answered by an objective community-driven process '
involving housing and HIV/AIDS service providers, government and people living with
HIV/AIDS. This plan provides a way to create a broad community understanding of what
is needed and how the need can be met.
The arrival of federal housing dollars dedicated to persons with HN/AIDS, called the
Housing Opportunities for Persons with AIDS (HOPWA) program, provided an important
opportunity to address the County's efforts in this more comprehensive manner.
What is the
oal of the plan?
g
One of the strengths of a community planning process is the rich and varied experiences
which people contribute when joining together for a common purpose. The first—and
sometimes most difficult—step is for the group to decide on a common vision for what the
plan should accomplish. This is the primary goal for the Contra Costa County Multi-Year
HIV/AIDS Housing Plan as articulated by the participants of the planning process:
To develop a pragmatic and specific multi-year strategy to create a continuum
of housing to meet the needs of people living with HIV/AIDS in all regions of
Contra Costa County.
Who worked on the plan and how was it developed?
The plan was initiated by the Contra Costa County Community Development Department
in early 1995. The principal consultants for the plan were the staff of AIDS Housing of '
Washington, a Seattle-based nonprofit organization which both develops HIV/AIDS
housing in Seattle and provides technical assistance to communities nationwide.
6
Contra Costa County HIV/AIDS Housing Plan
The plan is the final product of a community-based process which included site visits to
HIV/AIDS housing providers, focus groups, a housing survey of persons living with
HIV/AIDS, and a series of meetings with a community planning group made up of people
and agencies with the greatest stake in HIV/AIDS housing in Contra Costa County. The
information gathering strategies included:
• 90 HIV/AIDS Housing Surveys completed by persons living with
HIV/AIDS, who currently access public services (those persons who are
most likely to be in need of housing assistance);
• 15 HIV/AIDS Housing Surveys completed by affordable housing
developers active in the Bay Area;
• 16 case managers and service providers surveys completed by service
provider agencies;
• 3 focus groups and site visits held for this plan;
• Review of current HIV/AIDS epidemiology reports for the County
provided by the HIV/AIDS Epidemiology and Surveillance Office of the
Contra Costa County Public Health Department;
• Review of 13 focus groups conducted in 1994 for the Oakland Eligible
Metropolitan Statistical Area(EMA)HIV Planning Council (referred to as
the 1994 Oakland EMA focus groups);
• Review of the 1994 Oakland EMA HIV Services Needs Assessment
Report (referred to as the 1994 Oakland EMA Needs Assessment) and
Title I Ryan White CARE Act application; and
• Review of additional key information, including the Contra Costa County
Consolidated Plans for Housing and Community Development.
Thelan was created with consistent and broad community input, including participation
P Y P � gP P
from HIV/AIDS housing and service providers, local health and community development
agencies, and, through the focus groups, persons living with HIV/AIDS. This planning
group met on a regular basis to develop and review this plan. The plan was reviewed
throughout its development by the planning committee.
7
Contra Costa Count HIV/AIDS Housing Plan
What are the main findings of the HIV/AIDS Housing Survey?
The HN/AIDS Housing Survey reached low income people living with HIV/AIDS, many
of whom had histories of homelessness and chemical dependency. For these individuals:
•
Finding and keeping housing is a crisis for many people with HIV/AIDS.
• Homelessness and HIV/AIDS are an overwhelming—and
common—combination.
• Many more people living with HIV/AIDS in Contra Costa County could
lose their housing at any time because of poverty. -
• People with HIV/AIDS have complex health care needs and can't always
get the health and supportive,services they need to stay independent.
• Many people are struggling with substance abuse and mental illness in
addition to HIV/AIDS.
• Women and families with children affected by HIV/AIDS have unique
social and support service needs which negatively impact their ability to
maintain housing.
• Poor rental and previous criminal histories make it hard for many people
living with HIV/AIDS to find housing.
• Some people living with HIV/AIDS feel they face discrimination when
looking for and trying to keep housing in Contra Costa County.
• People want to remain in their homes and live as independently as possible
for as long as possible.
What would improve HIV/AIDS housing in Contra Costa County?
This plan outlines steps that will help meet the immediate needs of people and improve the
system for the families and individuals who will face HIV/AIDS for years to come. The
plan sets out recommendations that, if funded and implemented, will:
• Target the limited resources available to those most in need: the homeless,
the very ill and those whose life histories make it very difficult to succeed
in independent, permanent housing.
I
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Contra Costa Count HIV/AIDS Housing Plan
• Streamline access to housing and create an easy and reliable source of help
to find safe and appropriate housing.
• Develop programs and services so that people with HIV/AIDS who are
homeless and sick, including people who right now are being released from
the hospital to the streets, can become healthier and get help finding
permanent housing.
• Create housing for people who need help to reestablish their ability to live
in independent, permanent housing.
• Develop a safe and supportive environment for people with HIV/AIDS
who are dying or have intense health care needs which make 24-hour care. .
and services vital.
• Provide help so that people can remain independently in their own homes
for as long as possible.
j What does the plan recommend?
The plan makes recommendations in,five areas:
• Populations which should be targeted for assistance;
• Programs and services which impact the way people living with HIV/AIDS
and professionals working with them access housing;
• Programs and services to increase the number of units dedicated to persons
with living with HIV/AIDS over five years;
• Ways to improve the services people with HIV/AIDS need in order to
remain independent; and
How the plan should be implemented and resources allocated over the next
five years.
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Contra Costa County HIV/AIDS Housing Plan
Priority population recommendations
Many people living with HIV/AIDS have a hard time finding and keeping safe affordable
and appropriate housing. Although the community based planning committee would
prefer that all persons infected and affected by HIV/AIDS would be targeted for the
programs and services recommended by the plan, limited resources require that assistance
be targeted to those most in need.
HIV/AIDS housing resources should be targeted to individuals who meet these`threshold'
characteristics:
1. Be disabled with HN/AIDS;
2. Be low income; and
3. Be either homeless or have unstable housing, including those being released
from prisons or treatment programs and those at risk of homelessness by
paying greater than 50 percent of their income for rent. (People paying
greater than 30 percent of their income for housing costs are considered
cost-burdened. People paying greater than 50 percent of their income for
housing costs are considered to be severely cost-burdened).
Within these `threshold' characteristics, the following populations of people receive.
priority for HIV/AIDS housing and services:
1. Low-income people disabled with HIV/AIDS who have families and/or
young children; and
2. Low-income people disabled with HIV/AIDS who are dually and
triply-diagnosed with another disability(i.e. mental illness or chemical
dependency).
HIV/AIDS housing system recommendations
The limited amount of resources available to create and maintain HIV/AIDS housing
means that services need to be focused on those most in need: the homeless and people
disabled with HIV/AIDS. The plan recommends four ways to improve the HIV/AIDS
housing system for all people living with HIV/AIDS in Contra Costa County, and for the
agencies and individuals that provide support:
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Contra Costa County IW/AIDS Housing Plan
1. Build on the existing system to centralize affordable housing information
and referral; and facilitate access to the HIV/AIDS housing continuum.
2. Require people in HIV/AIDS housing programs to have a case manager
and, when appropriate, money management services; and increase the
number of money management slots and HIV/AIDS housing advocates in
the County to the extent possible.
3. Create standards to help ensure the quality of all HIV/AIDS housing.
4. Encourage new housing developed for people disabled with HIV/AIDS to
have the ability to become licensed.
HIV/AIDS housing development recommendations
There are two pressures on the HIV/AIDS housing system: to meet the immediate needs
of homeless people disabled with HIV/AIDS and to develop a system of housing and
services which will last for the duration of the epidemic. The pian recommends that
resources be used to both meet the immediate needs of people who are homeless or at
very high risk of homelessness through emergency assistance, to increase access of
existing affordable and special needs housing, and to create housing programs through
new construction, and/or acquisition and renovation of existing homes and apartments:
1. Continue funding for emergency housing but relocate program
administration to the Centralized Housing Information and Referral and
Intake System and re-configure the program as a limited Emergency
Housing Fund.
2. Create a new short-term Intensive Housing Intervention program which
provides rent subsidies with case management services and links to
permanent housing.
3. Explore developing a new permanent supportive housing program for
people who are living with HIV/AIDS, substance abuse and/or mental
illness, are on the street, or are being discharged from drug treatment
and/or correctional facilities.
4. Increase access to mainstream disabled and supportive housing, Section 8
certificates and vouchers, and permanent affordable housing stock, which
contain many units which could be accessed by people living with
HIV/AIDS. Continue efforts to increase usage of Shelter Plus Care.
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Contra Costa County HIV AIDS Housing Plan
5. Encourage the use of set-asides for persons with disabilities, including
HIV/AIDS, in all.appropriate low income housing in development. Work
specifically to create units in low income housing that are set aside for
families in which a member of the family has HIV/AIDS. Ensure that these
are at affordable rent levels and connected to appropriate supportive
services.
6. Encourage the County to create new service-enriched emergency housing
for medically-frail, low-income people being discharged from hospitals who
are homeless but still need medical attention and provide funding for set
aside-beds for people living with HN/AIDS in this program.
7. Participate with Alameda County in developing a plan to establish licensed
long-term care facility to serve individuals in the final stages of HIV/AIDS
in both Counties. ,
Support service recommendations
Independent housing is preferred by the person living with HIV/AIDS, can help reduce
community concerns, and can be cost efficient; however, maintaining independence is not
simply a question of paying the rent. Many people with HIV/AIDS need supportive
services in order to avoid a more institutional setting. The plan recommends:
1. Work within existing priority-setting systems to ensure that support
services linked to housing for people with HIV/AIDS are funded
adequately.
2. Maintain, and increase as needed, levels of support services which are most
critical to success in housing for people living with HIV/AIDS, such as:
case management; money management; transportation; attendant and home
health care; and nutrition.
Plan implementation and allocation recommendations
There are not enough resources to meet the housing needs of all people living with
HIV/AIDS in Contra Costa County. The key to meeting the need is to coordinate planning
and fund allocation, maximize existing resources and leverage other funds and programs.
Homelessness, substance abuse, mental illness and poverty all intersect with HIV/AIDS,
and each of the systems which provide support and housing to individuals affected by
these issues share an obligation to meeting the needs of people with HIV/AIDS.
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Contra Costa County HIV/AIDS Housing Plan
1. Coordinate planning and fund allocation for HIV/AIDS housing and
services and set criteria to encourage and maximize the efficient use of
limited resources.
2. Increase community acceptance of the need for and benefits of HIV/AIDS
housing and conduct an educational audit to determine the extent of
HIV/AIDS-related housing discrimination in Contra Costa County.
3. Update the community on implementation of the HIV/AIDS Housing Plan
1 and update the plan as needed to reflect community needs and
achievements.
Who can help?
P
It is true people are suffering because of the critical lack of HIV/AIDS housing, but due to
the effort of housing and service providers and local public agencies, the situation in
Contra Costa County is beginning to improve.
• During the time this report was being written, 25 new units of HIV/AIDS
housing were either opening their doors or in the planning stages.
• Thislan was undertaken by Contra Costa Count Comunit
P Y Y
Development Department in large part to increase cooperation and
understanding between County jurisdictions, housing developers,
providers and HN/AIDS service organizations. The plan is a strong
statement of the cities', County's, and broader community's commitment
to respond to the housing needs of its citizens living with HIV/AIDS.
• These goals will give both established and emerging housing and
HIV/AIDS service providers a shared foundation on which to make tough
decisions about the types of programs to develop.
LThe plan illustrates clearly the crucial need for HIV/AIDS housing in Contra Costa
County and the clear community benefits of HIV/AIDS supportive housing. Providing a
safe, appropriate and affordable home for people with HIV/AIDS—and all under-served
populations—saves money, saves fives, affirms a sense of community and is supportive of
community values. The entire community shares a responsibility to ensure that safe,
affordable and appropriate housing exists for people with HIV/AIDS in Contra Costa
County. The uncertainty of HIV/AIDS-specific housing funds (called HOPWA) from the
federal government makes other resources, especially Ryan White funds, even more
important. The plan makes specific recommendations for how HOPWA and other
housing funds should to be allocated to programs and services.
13
Contra Costa County HIV/AIDS Housing Plan
Creating a system of housing for people with HIV/AIDS in Contra Costa will take time,
resources and cooperation. Real improvements will be made by people living with
HIV/AIDS, housing providers, community-based and HIV/AIDS service organization&
working toward common goals.
Several individuals and agencies have already begun this work by coming together to
create this plan. The plan was undertaken by Contra Costa County Community
Development Department, with assistance from AIDS Housing of Washington. Special
appreciation goes to the more than 40 people who participated in community meetings to j
develop these recommendations, and to the 90 people living with HIV/AIDS who took the
time to complete surveys and participate in focus groups.
The next five years
Creating a system of housing in Contra Costa County will take time, resources and
cooperation. Real improvements will be made when people living with HN/AIDS,
housing providers, community based organizations, HIV/AIDS service providers, federal,
state and local government join forces to implement the strategies outlined in this plan.
Accomplishment of plan objectives will be facilitated by:
• Acceptance of this report as an important planning document by
governmental jurisdictions within the County;
• Advocacy and monitoring of progress by local jurisdictions and the broader
HIV/AIDS community.
This plan outlines a year-by-year strategy to increase housing options over the next five
years. In light of the major changes anticipated in federal funding for housing, health and
support services, the plan should be revisited approximately every six months. At that
time the community should share progress on the specific recommendations of the plan,
and troubleshoot any barriers to implementing the plan. The semiannual evaluation can
also provide a time to reexamine the changing needs of people with HIV/AIDS.
Meeting the goals of this plan-- creating a continuum of housing resources able to meet
the needs of people living with HIV/AIDS in Contra Costa County now and into the
future--will take leadership and commitment on the part of government agencies, housing
providers, HIV/AIDS services providers and people with HIV/AIDS. The recent progress
in HIV/AIDS housing and the voices contained in this plan speak to the challenges and
opportunities.
14
Contra Costa County HIV/AIDS Housing Plan
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This section provides an introduction to the multi-year plan for HIV/AIDS housing
in Contra Costa County. It summarizes:
• the planning process;
• the region and funding sources discussed in the plan, including the
Oakland Eligible Metropolitan Area and the Housing Opportunities
for Persons with AIDS (HOPWA) funds;
• how the plan will be used;
• critical issues raised in the planning process and addressed by.the
plan; and
• community and governmental roles in implementing the plan.
jIt also provides a brief description of a similar planning effort in neighboring
Alameda County and how these two HIV/AIDS housing plans are similar.
How was the Contra Costa County Multi-Year HIV/AIDS Housing Plan created?
' The plan was initiated by the Contra Costa County Community Development Department
and the City of Oakland in 1995. The community-wide planning process took place in the
context of a larger HIV/AIDS housing planning effort taking place in the East Bay area.
15
Contra Costa County]W/AIDS Housing Plan
The principal consultants for the plan were the staff of AIDS Housing of Washington, a
Seattle-based nonprofit organization which both develops HIV/AIDS housing in Seattle
and provides technical assistance to communities nationwide.
The plan is the final product of a community-based process which sought to gather and
summarize the needs and opinions of people and agencies with the greatest stake in
HIV/AIDS housing in Contra Costa County. The information gathering strategies
included:
• 90 HIV/AIDS Housing Surveys completed by persons living with HIV and
AIDS in Contra Costa County;
• 15 HIV/AIDS Housing Surveys completed by housing developers;
• 16 case managers and service providers surveys completed by service
providers/agencies;
• 3 focus groups and site visits held at HIV/AIDS housing facilities and
health and supportive service centers in the County;
• Review of current HIV/AIDS epidemiology reports for the County
provided by the HIV/AIDS Epidemiology and Surveillance Office of the
Contra Costa County Public Health Department;
• Review of 13 focus groups conducted in 1994 for the Oakland (EMA) �.
Ryan White CARE Act Title I Needs Assessment (referred to as the'1994
Oakland EMA Focus Groups');
• Review of the survey data collected for the 1994 Oakland EMA HIV
Services Needs Assessment Report (referred to as the `1994 Oakland EMA
Needs Assessment') and Oakland EMA Ryan White CARE Act Title I
Supplemental Application;
• Review of additional key information, including the Contra Costa County
Consortium Consolidated Plans for Housing and Community Development;
and
• Meetings with housing, HIV/AIDS service, community development, and
human service staff at several cities and towns in the County.
16
Contra Costa County HIV/AIDS Housing Plan
From June of 1995 through May of 1996, over forty dedicated citizens came together at
five community meetings to review this information and deliberate on how the Contra
Costa County HIV/AIDS housing continuum could be improved. At the initial meeting
participants identified the goals and critical issues which would guide the development of
the plan. The second meeting identified existing services and gaps in the HIV/AIDS
housing continuum and reviewed the data collection instruments designed for the
HIV/AIDS Housing Surveys. The third meeting looked at preliminary results of the
HIV/AIDS Housing Surveys and generated ideas for how the gaps could be filled and
priority needs established. The fourth meeting focused on the results of the HIV/AIDS
Housing Surveys and the preliminary recommendations. The final meeting reviewed the
plan and approved priority recommendations.
Acknowledgments
The plan was created with participation from HIV/AIDS housing and service providers,
local health and community development agencies, and people living with HIV/AIDS.
Special appreciation goes to the forty individuals who attended community meetings
which developed these recommendations, to Christine Leivermann of the County
Department of Health who oversaw the data collection and analysis, and Elizabeth Gearin
of the Community Development Department, who documented the community meetings
and oversaw the housing developer survey and provider data-collection and analysis.
!� Special thanks go to the 90 individuals living with HIV and AIDS who took the time to
complete yet another survey. The names of the planning participants precede the
Executive Summary of the plan.
The plan was funded with the support of the Office of Housing and Neighborhood
Development of the City of Oakland.
What area, funds and programs does the plan cover?
In 1990, Congress authorized the Ryan White CARE Act. This Act provides emergency
,j funding to states and cities to provide health care and supportive services to people living
with HIV/AIDS. Contra Costa and Alameda Counties together make up the `Oakland
Eligible Metropolitan Area', the region of this part of California designated to receive
CARE Act Title I funds. This area is referred to as the`Ryan White Title I EMA' or the
Oakland EMA. A second Care Act allocation, Title H, goes to the state and is allocated
on a regional level through Title H consortia, based on cumulative number of reported
AIDS cases.
17
Contra Costa County HIV/AIDS Housing Plan
The main source of HIV/AIDS-specific housing funds in Contra Costa County is the U.S.
Department of Housing and Urban Development's Housing Opportunities for Persons
with AIDS program(HOPWA). HOPWA funds follow the CARE Act EMA designation
and are allocated under the same formula to the largest municipality within the EMA. In
Contra Costa County, HOPWA funds first go to the City of Oakland, which then gives
funds to Alameda and Contra Costa counties based on the cumulative number of AIDS
cases reported in each County. In Contra Costa County, HOPWA funds are administered
by the Community Development Department at the County level.
Why is this important?
First, different federal grants have different requirements for how the local communities
decide which services are most needed and how funds will be distributed to the
community. CARE Act funding priority decisions are made by the Ryan White Title I
Planning Council. This is a body of individuals selected from the community to represent
diverse experiences and opinions during the funding priority and allocation process.
Members include health care providers, social service agencies, and people living with
HIV/AIDS. Each year, the Planning Council conducts an HIV/AIDS services needs
assessment for the Oakland EMA, which sets priorities for services which should receive
Ryan White CARE Act funds for Contra Costa and Alameda. For this reason, some of the
information about the needs and preferences of people living with HIV/AIDS included in
this report covers both Counties.
The HOPWA program does not require a standing body of community members to
oversee the priority setting process for these funds. Instead, agencies which administer
HOPWA are required to consult with all local HIV/AIDS planning bodies and funders.
Decisions about the use of HOPWA funds have been coordinated by the Contra Costa
County Community Development and Health Services Departments, using competitive
Requests for Proposals(RFP) process. Funding to date has been based on annual
community input and consultation with the various community HN/AIDS priority-setting
bodies, including the Title I Planning Council and the HIV/AIDS Consortium and the
other entitlement cities.
How will the plan be used? '
The Contra Costa County Multi-Year HIV/AIDS Housing Plan describes the existing
housing continuum, identifies existing needs, and makes recommendations to improve the
continuum. The plan will be used to:
18
Contra Costa County HIV/AIDS Housing Plan
1) Set priorities for how HOPWA funds will be used in Contra Costa County;
and
2) Provide guidance and direction to the Ryan White Title I Planning Council,
Contra Costa County and local city and town governments as they seek to
share in the creation of housing programs and services to meet the needs of
people with HIV/AIDS.
The creation of a multi-year plan:
• Allows anonymous participation in decision making through the HIV/AIDS
Housing Survey, making it possible for more people to be involved in the
priority setting process.
• Provides a long-term proces$that builds each year so that providers of
HIV/AIDS housing can design or enhance programs based on a set of
priorities.
• Serves to increase cooperation and understanding between housing
i developers, providers and HIV/AIDS service organizations.
• Provides a strong statement of the cities', County's, and broader
communities' commitment to respond to the housing needs of their citizens
living with HIV/AIDS.
• Establishes common mission and goals for HIV/AIDS housing outlined by
the plan and sets clear priorities for the most efficient and cost effective use
of the region's limited resources for HIV/AIDS housing.
These elements of the plan will give both established and emerging housing and
HIV/AIDS service providers a shared foundation on which to make tough decisions about
the types of programs to develop.
What is the
oal of the plan?
g
The plan illustrates the crucial need for HIV/AIDS housing in Contra Costa County and
the clear community benefits of HIV/AIDS supportive housing. Providing safe,
appropriate and affordable homes for people with HIV/AIDS—and all under-served
populations—saves money, saves lives, affirms a sense of community and is supportive of
community values.
19
Contra Costa County HIV/AIDS Hdusink Plan
One of the strengths of a community planning process is the rich and varied experiences
people contribute when joining together for a common purpose. The first(and sometimes
most difficult) step is for the group to decide on a common vision of what the plan should
accomplish.
In addition to the three goals identified by the community planning group, the committee
described and debated several critical issues. These goals and issues became the guiding
tools for the development of the plan.
Goals
To develop a pragmatic and specific multi-year strategy to create a continuum of housing
to meet the needs of people living with HIV/AIDS in all regions of Contra Costa County
by: '
• Identifying the housing needs of people with HIV/AIDS in Contra Costa
County;
• Developing strategies to meet those needs with limited resources, including
both housing and supportive services; and
• Developing prioritized annual goals to address strategies and gaps in the
system, including targeted populations to be served and integrating services
and housing.
Critical Issues and Criteria
Several critical issues which will influence the success of the plan were also identified early
in the planning process:
• The funds available for housing and services will not be able to meet the
needs of all people living with HIV/AIDS; therefore both mainstream
affordable housing providers and special needs housing providers are
essential.
20
Contra Costa County HIV/AIDS Housing Plan
• Most people living with HIV/AIDS have a need for housing assistance of
some type, including help finding a place they can afford as their income
declines, assistance paying rent, and help to stay independent, like
homemaking and home health care. There are not enough funds available
to meet the needs of all people living with HIV/AIDS, therefore prioritizing
both the populations to be served by HIV/AIDS-specific housing programs
and the programs which should be funded with HIV/AIDS-specific funds is
crucial.
• There is little information about the housing needs or preferences of people
living with HIV or AIDS, or how those needs and preferences differ by
race, gender, life experience or area of the County.
Who can help implement the plan?
When this planning process began in the Spring of 1995, fewer than 10 units of housing
were set aside for people living with HIV/AIDS in Contra Costa County. Since that time,
the six group home beds in Amara House have been joined by a program by Shelter, Inc.
(4 1-bedroom units)Resources for Community Development's 11 unit Aspen Court, (in
planning stage), and Rubicon Programs, Idaho Motel (10 Single Room occupancy units)
in planning stage. This plan outlines a year-by-year strategy to increase the number of
available units and resources over the next five years. Making sure that a continuum of
HIV/AIDS housing exists in Contra Costa County is a shared and critical responsibility:
• The governmental agencies which oversee and administer funding for
HIV/AIDS housing and the supportive services which can help people
maintain their homes, including the Contra Costa Department of Public
Health, and the Contra Costa Community Development Department must
continue to work together in order to ensure that existing housing
programs, those coming on line and those envisioned in this plan, are
supported in an efficient, effective and cooperative manner;
• It is critical that all governmental jurisdictions within the County, including
cities with the greatest numbers of people living with HIV/AIDS like
Richmond, Antioch and Pittsburg, continue to increase their commitment
and support to HIV/AIDS housing-,
•
Non-profit housing developers must continue to strengthen their capacity
Y
and commitment to serving people living with HIV/AIDS;
21
Contra Costa County HIV/AIDS Housing Plan .
• HIV/AIDS service organizations must integrate their programs with those
of housing providers to ensure that people receive safe and appropriate
housing; and
People living with HIV/AIDS and HIV/AIDS service agencies must
continue to advocate for the needs of people with HN/AIDS and actively
monitor the progress made in implementing this plan and improving the
continuum of HIV/AIDS housing in Contra Costa County.
The Alameda Housing Plan
Alameda and Contra Costa Counties together comprise the"Oakland EMA" for the
purposes of allocating funding and implemeliting programs for the HIV/AIDS housing and
care services under the federal Ryan White CARE and Housing Opportunities for Persons
With AIDS (HOPWA)Programs. Although the two counties differ in many ways; there
are strong similarities, and, more importantly, residents in the two counties cross County
lines in their search for appropriate housing and services to meet their needs. In
recognition of this phenomenon, and in hopes of better coordinating services to East Bay
residents, the City of Oakland—the recipient jurisdiction for Ryan White and HOPWA
funds—has taken the lead to coordinate bi-County needs assessment and planning.
Recommendations in the two plans parallel each other, and fall within five common areas:
priority populations, systems, housing development, support services and implementation.
The attached summary of recommendations will enable the reader to quickly perceive the
similarities and differences between the two plans. Of note, is one recommendation that
occurs in both plans and requires bi-County coordination to implement. This
recommendation calls for a planning process which will result in the development of a
licensed long term care facility. The costs of such a facility, for both capital development
and ongoing operations, and the necessity of achieving some economies of scale to
provide operating efficiency preclude either county's ability to complete such a facility
independently. Rather, the permeability of the County boundary, easy transportation links,
and need to assure an adequate referral base dictate collaboration as the key to success.
Further, both plans include a recommendation to develop standards to help ensure the
quality of all HIV/AIDS housing To the extent possible, developing and implementing
these standards should be undertaken jointly.
22
Contra Costa County HIV/AIDS Housing Plan
+!i!{:�:{;}:aiSSf iri�:}7JTT.'NJ}.%•Nr>S.`rn`iF 7»:jir};
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{ in Contra Costa County
NM
"These are some of the factors potentially contributing to the setting and the
continuation of the HIV epidemic: The lack of full acceptance of gay life-styles in
the communities of the East Bay.... The economic disempowerment of residents of
1 the inner cities[makes]concerns about HIV infection likely to be secondary to
the financial challenges of daily subsistence. The reality of sexism and women's
oppression adds another layer to the contextual medium where HIV disease
continues to propagate. "
—'IV/AIDS Epidemiology of the East Bay', 1994.
This section of the plan provides an overview of the HIV/AIDS epidemic in Contra
Costa County and how it differs by region. It includes:
• an overview of Contra Costa County and the regions of the County;
• the number of people estimated to be living with HIV/AIDS in the
entire County and by region; and
• projections for how the epidemic is changing.
An epidemic is defined as a sudden and unexpected appearance of disease. In 1996,
however, high rates of HIV and AIDS—particularly among certain ethnic populations—is
the norm for many parts of Contra Costa County. Public health officials have begun to
redefine the HIV/AIDS crisis, saying that rather than a single epidemic, there are many
`mini' epidemics affecting some neighborhoods and communities more than others.
23
Contra Costa County HIV/AIDS Housing Plan
This is the case in Contra Costa County. The County is one of California's most
geographically and culturally diverse regions and includes five large cities, the"urban
County" of Contra Costa, which includes thirteen additional cities, and ten unincorporated
communities. While people living with HIV/AIDS live in each region of
the County, depending on where one lives, the risk of becoming infected, the communities
most affected, and the services available can be very different. Nevertheless all people,
including people living with HIV/AIDS share a similar basic need—housing.
Contra Costa County is geographically, ethnically and economically diverse. The County
spans over 800 square miles and 28 towns and cities. Contra Costa County is often
thought of as a collection of middle class suburban bedroom communities of the San
Francisco and East Bay area; however, the County is far more diverse. This diversity and
natural geographic boundaries have led residents to describe their County by regions:
• East County is the fastest growing region of the County and includes large
areas of agricultural land as well as the cities of Antioch, Brentwood and
Pittsburg and the communities of Byron, Oakley, and Bay Point. The area
has a large Hispanic population(20 percent).
• Central and South County includes the cities and towns of Moraga,
Clayton, San Ramon, Lafayette, Danville, Orinda, Pleasant Hill, Martinez,
Walnut Creek and Concord. This area is predominately Caucasian (88.3
percent).
• West County, includes the shoreline area of the San Francisco and San
Pablo Bays. This area is somewhat cut off from the rest of the County by
the East.Bay Hills and includes Crockett, Kensington, Rodeo, El Sobrante,
Hercules,North Richmond, Pinole, El Cerrito, San Pablo and Richmond.
This area has the highest proportion of African American (25.6 percent)
and Asian(6.2 percent) residents.
The HIV/AIDS epidemic in Contra Costa County
In Contra Costa County, cases of AIDS and AIDS deaths are required to be reported to
the department of health. Cases of HIV infection are not required to be reported, and
thus, most epidemiological information is about AIDS and not both AIDS and HIV
infection. The County operates a number of HIV testing sites, and information about
people who choose to seek testing can also be analyzed. Because cases of AIDS and
death from AIDS, as well as HIV testing data are available, this information can help
discern the number of people assumed to be living with HIV/AIDS.
24
Contra Costa County HN/AIDS Housing Plan
Contra Costa has the ninth highest incidence of AIDS in the state of California. As of
January 19, 1996:`
• 1,684 cumulative adult cases of AIDS have been reported throughout the
County;
.� 8 pediatric cases.have been reported;
• 599 individuals were presumed to be currently living with AIDS.
In addition to these reported cases of AIDS:'
• 200 new HIV infections are reported each year•, 16 new cases each month;
• Over 4,000 people are estimated to have become HIV-infected in Contra
Costa County; and
• 2,600 persons are currently estimated to be living with HIV-infection
and/or AIDS.
The Contra Costa County Health Services Department AIDS Program issues regular reports
which measure the epidemic in the Contra Costa County and the East'Bay"'. These reports
and others draw the following conclusions about the region's epidemic:
• Contra Costa County has the state's ninth highest rate of HIV infection.
1,546 individuals have been diagnosed with AIDS in Contra Costa County;
over 2,600 are estimated to be currently alive with HIV and AIDS. .
• At least .5 percent of the entire County's population is estimated to be HIV
infected, including 10 percent of all injection drug users (IDUs) and 11
percent of gay and bisexual men..
• Although white gay men continue to be the largest group (63 percent) of
people living with HIV and AIDS, the epidemic is growing among
heterosexual injection drug users (IDUs), women, African Americans and
Latinos. In 1989, IDUs accounted for 14 percent of reported cases; in
1995, they accounted for 39 percent—a nearly three fold increase. Over 6
' percent of IDUs entering treatment programs in Contra Costa County in
1994 were found to be HIV-infected; the rate for African Americans was
four times as high-25 percent.
25
Contra Costa County MWAIDS Housing Plan
• Injection drug users in Richmond have the highest HIV prevalence rate in
the East Bay. In 1992, the rate was 27 percent compared to 17 percent in
Northwest Oakland.'
• Heterosexual drug use accounts for nearly 20 percent of all cases. The
infection rate of HIV among African American drug users is 30.5 percent.
• The number of people reported with AIDS in the 1990's will be twice that
of the 1980's. An estimated 200 new HIV infections will be reported
annually in Contra Costa County.
• The incidence of HIV is highest among African Americans. While African
Americans represent only 9 percent of the population they make up 27
percent of the cumulative cases of AIDS.
• Women are increasingly affected by HIV/AIDS in the East Bay and in
Contra Costa County. A study by the Centers for Disease Control and
Prevention(CDC) found that 1 out of 60 African American women in the
East Bay is HIV-infected, the highest incidence in the state.of California."
Women now represent 17 percent of all cases in Contra Costa County.
More than half(53 percent) of these women have histories of injection
drug use and over 30 percent are African American.
• As more women are diagnosed with HIV and AIDS, more children will be
affected. Nearly 50 HIV-infected babies have been born in Contra Costa; 8
children have been diagnosed with AIDS. One woman delivering a child in
every thousand in the County is estimated to be living with HIV. HIV
prevalence among childbearing women is higher in the East Bay than in
any other area of California. To illustrate, in 1992, less than 6 percent of all
California babies were born in the East Bay, but almost 20 percent of the
state's HIV-infected babies were born in the East Bay.
• Most cases are being reported in West and Central County. The cities with
the largest numbers of cases of AIDS are Richmond (371), Concord (221)
and Pittsburg (141). However, there are cases of AIDS reported in each
community in Contra Costa County.
26
Contra Costa County HIV/AIDS Housing Plan
How does the epidemic differ by region of the County?
While people living with HIV/AIDS live in each area of the County, the housing'and
supportive services (such as transportation, in-home care and substance abuse treatment)
available to individuals and families in need differ widely. Depending on where one lives, the
risk of being infected(as measured by the`case rate') and the communities most affected can
be very different.
East County
• A total of 314 cases of AIDS have been reported in the East County since
• 1982;
• 121 persons are estimated to be currently living with AIDS; 20 percent of
the County's total;
• The majority of AIDS population cases have been reported in Pittsburg
(141) and Antioch (89); and
• East County has the highest proportion of cases associated with
heterosexual contact (7 percent), a high proportion associated with
injection drug use(49 percent) and the highest proportion of cases among
women(18 percent) and Hispanics(18 percent).
Central County
• A total of 722 cases of AIDS have been reported in Central County;
• 247 persons are estimated to be currently living with AIDS (41 percent of
the County's total)
• The largest number of cases have been reported in Concord (221), Walnut
Creek(153), and Martinez(74); and
• Central County has the highest proportion of cases associated with male to
male sex(77 percent) and among Caucasians (83 percent).
27
Contra Costa County HIV/AIDS Housing Plan
West County
A total of 648 cases of AIDS have been reported in West County;
Y;
• 231 persons are estimated to be currently living with AIDS (39 percent of
the County's total)
• The largest number of cases in a Contra Costa city have been reported
from the City of Richmond(371); San Pablo has reported 93 cases; and
• West County has the highest proportion of cases among Afiican Americans
(51 percent) and the highest proportion associated with injection drug use
(31 percent). The proportion of cases among women is also high(15
percent).
Conclusion
The HIV/AIDS epidemic in each area-of the County may differ, but the
information gathered in the creation of this plan reveals that the housing needs of
people with HIV/AIDS are similar no matter where they reside in Contra Costa
County. The`quantitative' data(like the HIV/AIDS Housing Survey and other
studies) and the`qualitative' data gathered at focus groups and site visits point to
several shared issues. The recommendations in this plan address both these similar
issues and needs and the specific HIV/AIDS housing issues faced in each area of
the County. Chief among these is people's need for a home that is safe, that meets
their physical needs, and that they can afford.
`Data for this section are taken from AIDS surveillance reports generated by the Contra Costa County Department of Public Health.
2TheHIVIAIASEpidemiologyRepor4 Contra Costa County,April 1995,which includes cases reported through March 31,1995,and
the Oakland EMA Needs Assessment Report,1994.
'The HIV/AIDS Epidemiology Report,Contra Costa County,April 1995,and MAIDS Epidemiology Profile of the East Bay,Juan
Reardon,MD,MPH,October 1994.
'
HIVIAIDS Epidemiology Repor4 Contra Costa County,April 1995.
University of California,San Francisco,Institute of Health Policy studies,Urban Health Study,John Waters,Ph.D.
6 HIV/AIDS Epidemiology Profile of the East Bay, 1994.
28
Contra Costa County HIV/AIDS Housing Plan
X Nix:
n Contra Costa County:
4:.•}j{iii n..i?:1....}?{?;}{:v v;
S'?:;.:;.::i::i ii}:.S.::ii:.,>.•?'•;}:;ir4?:Cjni?::vfv.v] .
;.}}}}};.v{i:.i?;}iii%S•:L-:JCS}}:i�:;}3JY?:_ii
There's way more people in Contra Costa than there 's room for—and I can see
the changes since I went into San Quentin. The city has gone down hill. There is
no work and there is no decent cheap housing.
Pittsburg focus group participant
This section of the plan provides an overview of housing in Contra Costa Count
p g Y
and places housing for people with HIV/AIDS in the broader context of
' homelessness, low income and special needs housing in the region. It discusses:
• the characteristics of the housing market in Contra Costa County;
• the average rents in each area of the County;
• the number of HIV/AIDS housing units available in each region; and
• the degree to which homelessness is an issue for all residents of Contra
Costa County, including people living with HIV/AIDS.
What is affordable housing?
According to the federal government, housing is considered `affordable' if the amount a
family or individual pays for housing, including utilities, is equal to or less than 30 percent
of the adjusted household income. In other words, to be considered affordable, housing
should cost no more than 30 percent of a person or family's total combined income,
adjusted for certain allowances like unreimbursed medical costs, household size and
reasonable child care expenses. Lack of affordability is measured in terms of`cost burden'.
If a family or individual pays more than 30 percent of their total income for housing they
are considered to have a`cost burden'; if they pay more than 50 percent the burden is
considered`severe'.
29
Contra Costa County HIV/AIDS Housing Plan
If a single person disabled with HIV/AIDS received as their only source of income the
average Social Security Insurance(SSI) income of$626, for example, their monthly rent
and utility payments would have to be no more than $187 to be considered `affordable'.
What Is the housing market In Contra Costa County?
Affordable housing is elusive for many individuals and families in Contra Costa County. r
Housing construction has not kept pace with the area's growth, and as a result affordable
housing has diminished. Rents are higher here than in many parts of the nation, and the
vacancy rates are lower. Like many areas of California, some parts of Contra Costa
County, particularly the more urban regions, have recently faced economic hardships.
Other regions of the County, however, have seen a growth in the economy, and,
consequently, in the value of their homes and the cost of housing.
• The median value of homes was over$250,000 in 1990, not within reach
of many working families.'
• The Contra Costa Consolidated Plan for 1995-1999 estimates that 5,700
new units of housing are needed every year to meet the need of people
moving into the area.
Contra Costa County has the third highest average annual income in the State of
California. For many individuals and families, the rising prosperity has not reached their
homes and neighborhoods:
• Richmond, the area with the highest number of reported AIDS cases (353)
also has one of the lowest median annual household income,
( $38,429) (1990). By contrast, unincorporated Alamo had the lowest
number of reported AIDS cases (9) and one of the highest median annual
incomes($117,595).
The rising economy and subsequent growth in housing has not, however, always resulted
in the development of new affordable housing. The Contra Costa County HOME
Consortium found that the greatest housing problems facing residents were overpayment,
or`cost burden'.
• Nearly% of all extremely low income households pay more than 30 percent
of their income on rent—more than 16,700 families in all.
30
Contra Costa County HIV/AIDS Housing Plan
- r
• . 59 percent of these families pay more than 50 percent of their income on
rent— 13,100 households.
• The Association of Bay Area Governments estimated that an additional
8,600 units of housing are needed or families with incomes under$19,075
a year.
• Less than 20 percent of the entire stock of rental housing is affordable to
households which earn less than 50 percent of the area median income, or
$22,425. Many people with HIV/AIDS who receive disability, however,
have annual incomes of$7,512.
• There are a total of 11,183 households on Section 8 and public housing
unit waiting lists in Contra Costa County, excluding the city of Richmond.'
How does housing differ in the regions of Contra Costa County?
The cost and availability of affordable housing differ widely across the regions of Contra
Costa County. In 1990, median rents in the area ranged from a low of$257 per month in
North Richmond to a high of$1,046 in Clayton. The number of units dedicated to people
living with HIV and AIDS does not differ as widely: less than 20 units of housing are
dedicated to persons with HIV/AIDS in all of Contra Costa County. The following
outlines the general housing market and the HIV/AIDS dedicated units by region:
• The median rent for Contra Costa County in 1990 was $615.
• In East County the 1990 median rent in Pittsburg was $506; in Antioch it
was $564. There are 4 assisted/affordable 1 bedroom units reserved for
low-income people with HIV and AIDS in East County.
• Central and South County had some of the highest average rents in 1990 in
the region and the highest percentage of home owners. The median rent in
Concord was $618; in Walnut Creek it was $675. Although there are
currently no HIV/AIDS-dedicated units in Central County, 11 units are in
development.
• West County 1990 median rents were $504 in Richmond and $503 in San
Pablo. This area has the lowest percentage of owner-occupied housing in
the County. A total of 6 HIV/AIDS-dedicated beds in a group setting are
available in West County and an additional 10 units are in development.
31
Contra Costa County HN/AIDS Housing Plan
Homelessness in Contra Costa County
Given the scarcity and expense of market-rate housing it is not surprising that:
• Between 2,722 and 4,000 individuals and families are homeless in any
given month in Contra Costa County; and
• 15,000 individuals and 4,000 families are estimated to experience an
episode of homelessness during any one year.
The areas with the greatest degrees of homelessness are North Richmond, Bay Point,
Pittsburg, San Pablo and the Pacheco area near Concord. These areas also have among the
highest numbers of residents living with HIV and AIDS.
For people with HIV/AIDS, very low incomes and the expense of the market combine to
make the risk of homelessness even more acute:
• The average Social Security Income payment to a persons with HIV/AIDS
is $626;
• The median gross rent in Contra Costa County is $615; and
• HIVIAIDS Housing Survey respondents spent an average of$20 a month
on medical care.
This scenario leaves a typical low income person with HIV/AIDS in Contra Costa County
a deficit of$9 a month! The stress of not having a place to live or enough money for
food is overwhelming to many. As one homeless focus group participant said, "You can't
go find a job when you're hungry and don't have food. I have never experienced this kind
of hunger. "
This situation is even more acute for people with non-disabling HIV infection who do not
qualify for SSI and may receive only $300 in General Assistance. One study of General
Assistance recipients found that the average amount a single, low income person needs to
spend on expenses each month is $161 for food and $106 for nonfood items; since people
with AIDS need a high caloric and high protein diet to help keep healthy their costs may
be even higher.'
32
Contra Costa County HIV/AIDS Housing:Plan
The HIV/AIDS Housing Survey, which reached people most likely to be in need of
housing assistance, provides the details of the crisis implied by this scenario:
• 31 percent of respondents had experienced homelessness since learning of
their HIV status; and
• 35 percent of respondents had experienced at least 1 episode of
homelessness in the past 5 years
• 4 percent were currently homeless, living on the streets, in cars, in
abandoned building or in shelters.
The results of the HIV/AIDS Housing Survey are described in the following section of the
plan and illustrate the realities of finding and keeping affordable housing in Contra Costa
County for people living with HIV and AIDS.
1 Information for this section is taken from the HOME Consortium Consolidated Plan,Contra Costa County,February,
1995.The Consortium does not include the City of Richmond.
'Consolidated Plan,Contra Costa County HOME Consortium,June,1995.
'Homelessness in Alameda County,The Housing and Community Development Program of the Alameda County
Planning Department,1995.
I
33
Contra Costa County HIV/AIDS Housing Plan
l
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r}:?:ii: iiY::i:;'iiii:.t;_.:.'>{:.<?{:ii'4::i
F". '14 n'tii•:J:\�,�j3.V
W{ :r;:' ,. ..: A: Housing Survey Results
[i}....;..iii:::>.;:}y,'�::•:+Y'::Y,n4: i::0:;::'i.i.:.,y.
M::.:
Man, I wish I had control of these funds. My top priority would be mothers with
kids who are homeless. I would provide shelter to these kids. "
- focus group participant
This section of the plan presents the results of 90 HIV/AIDS Housing Surveys and
the three focus groups conducted for the HIV/AIDS Housing Plan. It also
describes the methodology and limitations of the survey research, the
demographics of respondents, and major conclusions which can be drawn from the
research.
The HIV/AIDS Housing Study Methodology
The quantitative and qualitative data collection process for the Contra Costa County
Multi-Year HIV/AIDS Housing Plan had several components: a sur:ey of 90 people living
with HIV/AIDS in Contra Costa County, three focused discussion groups of individuals
living with HIV/AIDS held at a variety of HIV/AIDS service providers in the County; and
a review of additional data collection efforts conducted for previous or concurrent
planning processes. This section of the plan presents the data from these efforts.
' The information from these activities was presented and reviewed by a community-based
planning committee, whose members provided input and information to the process. The
following provides a brief overview of the methods associated with the HIV/AIDS
Housing Survey data collection activity and the limitations of the process.
1 35
Contra Costa County HIV/AIDS Housing Plan ._
The HIV/AIDS Housing Survey
Originally, it was hoped that the HIV/AIDS Housing Survey could be completed by 10
percent of people living with HIV/AIDS in the County, or about 200 people. This
`sample' (or group of people who filled out the survey) would be large enough to be
`representational' (or be like) all the people living with HIV/AIDS in the County.
It became apparent that the ideal sample size of 10 percent.was beyond the resources of
the County Health Services Department AIDS Program. There are several reasons why
the Department felt that the original number was not achievable, including:
• People with living with HIV/AIDS in Contra Costa County, particularly
West County, have been asked to complete many surveys about their needs
and experiences over the past few years. As a result, many people living
with HIV/AIDS are tired of participating in surveys, and did not agree to
participate;
• People living with HIV/AIDS in Contra Costa County, particularly people
who receive their health care from private doctors and people staying at
public emergency shelters, are leery of losing their confidentiality; and
• The budget for this plan did not allow for substantial payment for -
completing the survey, while other surveyors are offering significant
compensation for participation in current and upcoming surveys.
These reasons led to the decision to strive for a sample of 100 individuals, approximately 5
percent of the estimated HIV-infected community, to use as a baseline assessment of
housing needs in the County. In all, 90 people completed the survey, about 4 percent of
people estimated to be alive with HIV and AIDS in Contra Costa County.
The survey was based on similar surveys used for HIV/AIDS Housing Plans in other
jurisdictions. Separate surveys were developed for people living with HIV/AIDS, for case
managers and for housing providers in the County. A small group, consisting of three
HIV/AIDS case managers, an HIV/AIDS Housing Advocate, a planner from the Contra
Costa County Community Development Department, and a planner from the County
AIDS Program modified the consumer survey tool to solicit the additional information
required by this County.
The HIV/AIDS Housing Survey contained over 40 questions designed to help the
planning group better understand the barriers people living with HIV/AIDS face when
trying to find and keep housing which meets their financial and physical needs and to
36
Contra Costa County HN/AIDS Housing Plan
access which types of housing program and services people in Contra Costa County
prefer. The broad interest was for information on stage of disease, household size,
monthly household income, amount of income spent on housing, barriers which might
influence the type of housing available to individuals with HIV/AIDS, and use of existing
resources. In several questions, respondents were asked to rank choices. Many
individuals did not rank but simply marked the number 1 or the letter"x" next to many of
the variables. All those who marked at least one response were included in the tally. The
numbers (one through five) were assigned opposite values and then summed across
respondents. In the instance where an"x" was placed, the response was interpreted as a
number 1 (one).
This survey was conducted as a`convenience sampling', meaning that participation was
not based on a random or scientific process but on individuals agreeing to participate
when asked. More than 700 surveys were distributed to service agencies, providers,
related County programs, hospitals, and to Kelevant members of the HIV Interagency
Service Providers' Network. Five outreach workers facilitated the distribution of surveys
to individuals not currently accessing public services. Case managers, agency volunteers
and other providers distributed surveys to their clients. The County AIDS Program
offered"housing clinics" at several sites to provide additional assistance to consumers in
completing the forms.
An attempt was also made to encourage responses from individuals currently within the
private-sector health care system. None of the completed surveys are coded with the
private sector code, indicating that all those who returned the surveys are receiving
publicly funded services, know where to access publicly funded services, or have been
contacted by publicly funded outreach workers. The fact that no surveys were completed
by people in the private pay sector, who may be of higher income or currently employed,
also influences the high need indicated among most housing survey respondents.
Therefore, some of the conclusions drawn are the direct result of the population
surveyed - very-low income individuals with unstable housing who require a
multiplicity of services. The characteristics of this population guided subsequent
development of priority population recommendations.
Additional studies consulted
iThis plan also draws on additional sources of information regarding the housing and
service needs of people living with HIV and AIDS in Contra Costa County, including:
iThe 1994 Oakland EMA Needs Assessment, which surveyed 316
individuals receiving HIV/AIDS care and services—one quarter of whom
were Contra Costa County residents;
37
Contra Costa County HIV/AIDS Housing Plan
• The Contra Costa County.Consolidated Plan, 1995-1999; and
The 1995 Title I EMA Application for CARE Act funding.
' PP .g
Limitations of the data gathering strategies
Any survey data based on a convenience sample its by nature not statistically
representative, and the conclusions cannot, thereiFore, be generalized to the entire
population being studied. To know if a survey is representational, one needs to know the
total number of people who could be surveyed and what those people are like in terms of
their demographics(race, age, sex, etc.). The total number of individuals living with HIV
and/or AIDS in Contra Costa County, however, its unknown. Estimates are also hard to
create, since the decision to seek testing or health care treatment is influenced by many.
factors.
First, not all people who have HIV are aware that they may be infected and thus do not
seek testing. Second, continued concerns about breach of confidentiality lead some
people to seek anonymous testing outside the County, and these tests are not included in
estimates. Third, people who have little or no access to health care may not know how or
where to access HIV testing. Finally, despite Health Department policy to provide services
to all individuals regardless of their residency status, undocumented people fear they will
be deported if found to be HIV-infected, and Proposition 187 has only increased this fear.
Because the total number of people living with HIV infection, or the total number of
people alive with HIV/AIDS, cannot be determined,.it is not possible to state with
complete certainty to what degree this survey research effort is representative of all people
living with HIV/AIDS in Contra Costa County. Therefore, the results can not be
generalized to the entire HIV/AIDS population in Contra Costa County. ,
Some HN/AIDS housing advocates, case mangers and people living with HIV/AIDS
expressed concerns that the reading level of the survey was very high and that the
complexity of the survey instrument reduced the number of people who were willing to
take part.
The other primary limitation of the study has to do with the small sample size and the fact
that, like with most surveys, not all respondents answered all questions. Questions asking
respondents to rank choices and preferences were poorly completed by those who
self-administered the survey. Because participants were offered a small stipend for
participation and were largely recruited through HIV/AIDS service providers, the degree
to which the survey is representative of the population is further diminished. Additionally,
analysis of some questions identified areas where not enough information was requested,
such as the amount illegal drugs used or concurrent use of different substances.
38
Contra Costa County HIV/AIDS Housing Plan
Finally, because the questions did not focus on cultural issues, little data is available about
the housing needs or preferences of specific ethnic or language groups.
Nonetheless, demographic comparisons between the HIV/AIDS population at large and
the survey respondents indicate that the results of this survey are a reasonable baseline
from which to develop a plan for housing services within the County. Both nationally and
locally the epidemic is moving from the predominantly gay white male population to the
' heterosexual injection drug using population. The number of new cases among
heterosexual women of color who either have used drugs or who are partners of injection
drug use(IDU) has sky rocketed. In the 1980's women constituted 4.7 percent of the
total East Bay women diagnosed with AIDS. Currently, women in Contra Costa comprise
17 percent of the population living with AIDS. Nearly 70 percent are women of color and
more than half have a history of IDU. This data is particularly helpful in designing a
continuum of HIV/AIDS housing to meet the needs of people with low incomes and more
complex health and social service needs. ,
Focus Groups
The HIV/AIDS Housing Survey provided the planning process with a great deal of
quantitative data about the needs and experiences of people living with HIV and AIDS in
Contra Costa County. This information is objective and measurable—but it is only part of
the picture. To fully understand the HIV/AIDS housing continuum in the County and the
needs and hopes of people trying to find their way through the housing system, it was
important to spend time at the actual housing sites and with individuals. These
conversations took the form of focused group discussions with seventeen people who
were willing to share their experiences. The three focus groups were held at the Pittsburg
Pre-school, the Tranquillium Center and the Antioch office of AIDS Alliance. The results
from these more `qualitative' aspects of the data collection are included throughout the
plan in the form of quotations which illustrate the main findings of the HIV/AIDS Housing
Survey and the gaps in the housing continuum.
How do people who completed the HIV/AIDS Housing Survey and participated
in the focus groups compare to people living with HIV/AIDS in Contra Costa
' County?
The HIV/AIDS Housing Survey participants are broadly representative of all people living
with HIV and AIDS in Contra Costa County, but is particularly representative of people
who are most likely to be in need of housing and housing related services. Respondents
indicated high levels of poverty and complex health and social support needs. While not all
people living with HIV/AIDS in Contra Costa County have extremely low incomes, the
1 39
Contra Costa County HIV/AIDS Housing Plan
recommendations of the HIV/AIDS Housing Plan are designed to assist those in greatest
need: the homeless and extremely low income people disabled with HIVWDS. Therefore,
while the survey sample is small and not representative of the diversity of individuals
whose lives are affected by HIV and AIDS, it does provide information which is of
particular use to the purposes of this plan. The survey data and the information gathered r
from the focus groups are also useful because it is more reflective of trends in the
epidemic, particularly the rise in cases among people of color, injection drug users, and
women.
Participants in the focus groups were also representative of higher-need people living with
HIV/AIDS. The majority had experienced homelessness since their HIV infection, and
most had a history of substance abuse or were currently using drugs, primarily heroin. All
were low income, and all had current housing needs.
Table 1 illustrates the survey sample as coMpared to people living with AIDS (not HIV) in
the County.
How do these respondents compare to people who receive HIV and AIDS
services?
In a review of housing advocacy data.of 151 clients served by HOPWA- and
CARE-funded housing advocates during the period between April 1, 1994 and March 31,
1995, several similar themes emerged which complement and validate the survey findings:
• 59 percent of service recipients are African American, 7 percent
Latino/Hispanic, and 34 percent Caucasian.
Half the population served during this period had a diagnosis of AIDS, and
the majority of those served received their diagno-sis some time in the last
five years.
• 16 percent are homeless, 93 percent have incomes under$900 per month
and 59 percent live alone and/or do not have others contributing to their
household income.
• 87 percent received some form of public insurance/entitlement program ,
assistance.
These percentages closely mirror the survey results presented above and offer further ,
validation of its use as baseline information on which to support a housing plan for low-
income people living with HIV/AIDS in Contra Costa County.
40
Contra Costa County HIV/AIDS Housing Plan
Table 1:Comparison of HIV/AIDS Epidemiology and Survey Respondents
I
Demographic Variable Persons living with AIDS only as Survey respondents of October 1,1995 (includes both AIDS and
(n=608) HIV)n--90
Age at diagnosis Age when surveyed
<5 6 (<1 percent) 0 (<1 percent)
5-12 2 (<1 percent) 0 (<1 percent)
13-19 4 (<1 percent) 0 (<1 percent)
20-29 197 (12.1 percent) 1 (1 percent)
30-39 689 (42.4 percent) 25 (27.8 percent)
40-49 492 (30.3 percent) 37 (41 percent)
50 and above unknown 235 (14.5 percent) 12 (13.3 percent)
n/a 15 (16.6 percent)
Note:reflects cumulative
AIDS cases(n=1625)
Sea of Adults
Male 503 (83 percent) 40 (46.6 percent)
Female 105 (17 percent) 42 . (44.4 percent)
Transgender unknown 1 (1.1 percent)
unknown n/a 7 (7.7 percent)
Race
Caucasian 327 (54 percent) 27 (30 percent)
African American 200 (33 percent) 45 (50 percent)
Hispanic 63 (10 percent) 4 (4.4 percent)
Asian/P.I. 13 (2 percent) 1 (1.1 percent)
Native American 4 (<1 percent) 1 (1.1 percent)
Other/Unknown 1 (<1 percent) 12 (13.3 percent)
Residence
West county 619 (38.1 percent) 51 (56.6 percent)
East county 300 (18.5 percent) 12 (13.3 percent)
Central county 694 (42.7 percent) 9 (10.1 percent)
Unknown/other 12 (0.74 percent) 18 (20 percent)
Note:reflect cumulative
AIDS cases(n=1625)
41
Contra Costa County HIV/AIDS Housing Plan
What did the survey reveal about people living with HIV and.AIDS?
l with Sin
The survey and focus groups reveal the difficulty of living wit HIV/AIDS Contra
Costa County and the impact that poverty and health status have on people's ability to '
find and keep safe, secure and affordable housing.
• Finding and keeping housing is a crisis for many people living with
HIV/AIDS.
• Homelessness and HIV/AIDS are an overwhelming—and
common—combination.
• Many more people living with HIV/AIDS in Contra Costa County could ,
lose their housing at any time because of poverty.
• People living with HIV/AIDS have complex health care needs and can't
always get the health and supportive services they need to stay
independent.
• Many people are struggling with substance abuse and mental illness in
addition to HIV/AIDS.
• Women and families with children affected by HIV/AIDS have unique
social and support service needs which negatively impact their ability to
maintain housing.
• Poor rental and previous criminal histories make it hard for many people
living with HIV/AIDS to find housing; ,
• Some people living with HIV/AIDS feel they face discrimination when
looking for and trying to keep housing in Contra Costa County. ,
• People want to remain in their own homes and live as independently as
possible for as long as possible.
Finding and keeping housing is a crisis for many people living with HIV/AIDS
`I need someone to help me find housing can afford. I've been homeless ten
times in the past three years. "
-- survey respondent
42
Contra Costa Count HIV/AIDS Housing Plan
The HIV/AIDS Housing Survey asked people to identify their current housing situation
and found that significant numbers of people living with HIV/AIDS in the County face
barriers and difficulties locating and keeping their housing, are currently homeless, or are
at risk of losing their housing:
• More than half of all survey respondents felt they needed housing
assistance;
• 25 percent indicated that they were on a waiting list for government
assistance; and
• 27 percent of those currently on the waiting list indicated that they have
been waiting for more than 5 years for government housing assistance.
Many people also did not feel that the services available to them would be much help, and
felt largely unaware of the services which do exist:
• 44 percent said that a lack of client and/or provider knowledge prevented
them from receiving assistance.
' The individuals surveyed also had a high degree.of instability in their housing:
• 35 percent indicated that they had been homeless at least once in the last 5
years; and
• 26 percent had moved 3 or more times in the last 3 years.
• The primary reason for moving was to get away from the old
neighborhood, but other reasons included a decline in income/no money for
rent and to move closer to family.
The consequences of instability in housing among people living with HIV/AIDS have both
individual and public health consequences. Since learning of their HIV/AIDS diagnosis,
• 30 percent of people who experienced difficulties locating a place to sleep
had spent the night in a car; and
• 9 percent had traded sex for a place to spend the night.
43
Contra Costa CountyMV/AIDS-Housing Plan- -
The Oakland EMA Needs Assessment gives us other information about the need for
HIV/AIDS housing services in the East bay as a whole:
• More than 40 percent of the people who said they needed housing services
were not receiving help;
• 27 percent of the people who got help were unsatisfied with the help they
received;
• 23 percent received financial assistance to help pay for utilities;
• 28 percent reported needing ongoing rental assistance(Section 8); and
• 18 percent reported needing free or subsidized housing for 6 months or
more (transitional housing).,
Homelessness and HIV/AIDS are an overwhelming—and
common—combination
"I am homeless right now. I should have a place to live. It has been damn
rough. " I
-- focus group participant
The HIV/AIDS Housing Survey performed for this study found:
• 31 percent of all respondents had experienced homelessness since they
learned of their HIV infection;
• Half had been homeless at least once in their lives; and ,
• 35 percent homeless in the last 5 years; and
• 4 percent were currently without a place to live.
In addition, 13 percent of CARE Act clients in Alameda and Contra Costa counties stated
they were homeless. 1
. - r
44
Contra Costa County HIV/AIDS Housing Plan
1 Current Housing Status
Transitional Housing
SRO
Rented Room
Rental Unit
Public Housing
Own Home
Homeless
Group Home
Friends Home
Emergency Shefter
' 0 5 10 15 20 25 30 35 40 45
The impression given by this data was confirmed in the focus groups and in the community
planning meetings, Time and again, individuals voiced their concerns about homelessness
or the threat of be coming`homeless.
A 1992 report by the National Commission on AIDS estimated the rate of HIV infection
-among homeless persons to be between 15 and 20 percent. Using this estimate rate,
between 390 and 520 people living with HIV or AIDS in Contra Costa County are
without shelter, and many more are at risk of becoming homeless.
' The reasonsP eople became homeless are numerous and interrelated, including:
' 0 97 percent were unable to afford their rent (30 of 31);
• 90 percent because of alcohol or drug use (28 of 31);
• 39 percent became homeless because of eviction due to non-payment of
rent, drug use, and/or discrimination, fire, etc. (12 of 31); and
• 35 percent were`forced out' by family or partners (11 of 31).
People living with HIV/AIDS who participated in the focus groups had even higher
' degrees of homelessness. Of the seventeen focus group participants,
80 percent were currently homeless. Drug use was identified as the primary reason for
homelessness, with high costs of rents as the second reason.
45
Contra Costa County HIV/AIDS Housing Plan:: '
Many in the focus groups were frustrated by the lack of opportunity for stable lives and
stable housing. Concerns include: limited job opportunities; limited housing; the '
widespread availability of drugs; decreased income; frustration generated at providers and
local government; issues of the cost of telephone calls to access programs, services and
the voice mail systems used by housing program providers; perceived and discrimination
based on HIV/AIDS status and drug addiction.
Some of the focus group participants had recently been released from San Quentin federal
penitentiary. For these individuals, the chances of finding work and a place to live seemed
even more remote: ,
Many more people living with HIV/AIDS in Contra Costa County could lose
their homes at any time because of poverty
`I want something stable, but you have to have three times your income to move
into an apartment, and I can It save that. "
--focus group participant
Like other Americans, many low-income people living with HIV/AIDS are only one
unexpected financial emergency away from homelessness. The highest rates of AIDS in
the East Bay are in those neighborhoods with the lowest median annual incomes.' The
HIV/AIDS Housing Survey found that people live on very low fixed incomes and spend
most of their income on housing.
Theoverty of many people living with HIV/AIDS in Contra Costa Count was well
P Y
documented by the survey:
The majority of families and individuals surveyed exist on monthly incomes I
J Y Y Y
of$650 or less;
• 60 percent of the respondents indicated that their income was the only
source of income in the family;
• 37 percent indicated that they supported at least one other individual; and
• Of those with one or more dependents, 42 percent claimed 2-5 dependents.
46
1
Contra Costa County MMAIDS Housing Plan
Table 2: Incomes
Individual Monthly Income n=77 Household Monthly Income n=50
Income Number Percent Income Number Percent
<$650 51 66.2 <$650 21 42
$651-1,000 19 24.7 $651-1,000 11 22
$1,001-1,500 4 5.2 $1,001-1,500 12 24
>$1,500 3 3.9 >$1,500 6 12
Table 2 indicates the degree of poverty faced by these families and individuals. Only 3 out
of 77 individuals had incomes of over $18,000; only 6 of 50 households had incomes in
that range.
The majority of low income people living with HIV/AIDS in Contra Costa County, as in
other parts of the country, rely on public assistance to survive:
• 14 percent of respondents receive government assistance in order to keep
the housing that they have; and
• 89 percent of respondents receive at least one form of public assistance.
' The poverty experienced by these families is further exacerbated by the fact that most of
what little money they have is spent on rent:
• 33 percent of respondents spent between $400 and $590 per month on
rental payments; and
• 32 percent paid between $600 and $900 on their monthly rent.
The largest percentage of respondents (50 percent) lived in a rented room or apartment.
While these individuals have a place to stay currently, many are in unstable housing
because of high housing cost. To be considered `affordable', housing should cost no
more than 30 percent of a family's adjusted income. Households which spend more than
30 percent of their gross monthly income on housing are considered to be `cost burdened'.
The HIV/AIDS Housing Survey measured the incidence of cost burden by comparing
income, expenses, and rent, and found that:
47
Contra Costa County HIV/AIDS Housing Plan
Benefits Received
Waiver
Veterans
Prioete Insurance
SSI
SSA
SDI
Pd%ete Disability
Medicare
Medi-Cal
General Assistance
AFDC '
0 5 10 15 20 25 30 35 40 45 50
• 60 percent of HIV/AIDS Housing Survey respondents renting or owning
housing spent more than 50 percent of their income on their rent or
mortgage; and
• An additional 23 percent spent more than 30 percent.
48
Contra Costa County HIV/AIDS Housing Pian
This means that only 17 percent of those individuals who completed the survey were in
`affordable 'housing!
Percentage of Income Spent on Housing
1 17%
❑<30%
23% :>50%
60%
Y
In addition to the 4 percent of survey respondents who were currently without a place to live, an
additional 18 percent are in danger of losing their housing because they are in transitional housing,
are staying with friends, or are staying in a shelter. Table 3 summarizes all the information from
the HIV/AIDS Housing Survey which illustrates the degree to which homelessness and unstable
' housing is a factor in the lives of low-income people living with HIV/AIDS in Contra Costa
County:
49
Contra Costa County HIV/AIDS Housinnflan -
Table 3: Housing Instability
Risk Percentage
Currently homeless 4
Staying in temporary-housing 18
Spend 50 percent or more of income on 60
P
housing
Spend 30 percent or more of income on 23
housing
Previous eviction 39 '
People living with HIV/AIDS have complex health care needs and can't always get
the health care or supportive services they need to stay independent
"Now I got to go to the doctor because I am real sick, but I don It have an address so I
don't know how I am going to work that. The doctor's got his house—let me get one too
and then I'll see about a doctor!"
-- focus group participant
Both people living with symptomatic HIV infection and those disabled with HIV/AIDS
face an array of painful, complex health issues ranging from severe weight loss and fatigue
in the earliest stages, to mental impairment, pneumonia, cancers, blindness, and loss of
major organ functions in the later stages. The housing needs of people living with
HIV/AIDS can change as the disease progresses; often in-home and.ancillary supportive
services are needed in order to avoid costly institutionalization. These services are not
always available.
Most of those surveyed have a diagnosis of AIDS or disabling HIV. While slightly more
women than men have a diagnosis of AIDS, the HIV status by gender is relatively
consistent between men and women. More than 63 percent of the respondents have
received their current diagnosis since 1991. Fully one third of this number(21 percent of
the total respondents) received their current diagnosis in 1995.
50
Contra Costa Count HN/AIDS HousingPlan
Respondents' HN Status
19SG
❑HN Disabled
a HN Positive
51 SG xAIDS
- 3oX
Respondents were also likely to have more than one health condition that could impact
their ability to maintain independent housing. One third indicated that they had a physical-
disability, including hearing or vision loss.
The HIV/AIDS Housing Survey, the 1994 Oakland EMA Needs Assessment, and other
information about the health care status of people living with HIV/AIDS in the region
reveals:
' 23 percent of HIV/AIDS Housing Survey respondents had an AIDS
diagnosis and were potentially in need of a higher degree of support
services to maintain housing.
• Tuberculosis(TB) continues to be a concern. (It is estimated that by the
year 2000, 10 percent of all people living with HIV/AIDS will be
co-infected with this highly contagious airborne infection and
' life-threatening disease). Contra Costa County reported 103 new cases of
TB in 1995. Of these, 8 were resistant to one drug therapy and need more
intensive health care services.
When questioned as to the most important housing-related supportive services necessary
to retain housing, transportation was ranked the most important, followed by benefits
counseling, emotional support, practical support and access to meals/nutritional
counseling. Not surprisingly, the same five issues were also identified as the top unmet
needs. Transportation is particularly important since the survey found that 18 percent of
respondents received their health care at hospitals outside of Contra Costa County.
51
I,.ontra-Costa County HIVUEDS.Housing Plan
Many people are struggling with substance abuse and mental illness in.
addition to HIV infection and AIDS
`7f you say no to drugs in this Countyyou are really in the minority. It's a sad
reality. There is nothing here but drugs.
-- focus group participant
In Contra Costa County, substance abuse, homelessness and HIV/AIDS go hand in hand.
Both focus group and survey participants indicated that substance abuse both placed them
at risk for acquiring HIV/AIDS and continues to place them at risk for losing their
housing:
• More than half the survey respondents indicated that using needles placed ,
them at risk for HIV/AIDS;
• 31 percent indicated that they had a chemical dependency; '
• 32 percent are in a methadone program currently;
• 44 percent report using drugs and/or alcohol;
• 44 percent report having used heroin;
• 22 percent report having used crack;
• 38 percent report having used cocaine; and
• 31 percent of all respondents say they had become homeless because of ,
substance abuse.
People are also struggling to maintain or reattain a degree of recovery and sobriety, but
substance abuse treatment slots are hard to come by and illness and poverty add to the
difficulty of this goal:
• 45 percent of the respondents indicated that they are currently in some type
of substance abuse program; and '
• Another 43 percent indicated that they felt they needed some form of
treatment. ,
52 '
r
Contra Costa County HIV/AIDS Housing Plan
1
Drugs Ever Used
No Drugs
Other
Prescription Drugs
Non-prescription Pills
Marijuana
Heroin
Crack
Cocaine
Alcohol
0 10 20 30 40 50 60 70
1
This means that only 12 percent of respondents had no current or previous
1 chemical dependency or did not want drug treatment.
' Substance abuse services are also hard to receive in the East Bay:
• 17 percent of the 1994 Oakland EMA Needs Assessment participants were
Iunable to receive the substance abuse services they said they needed in that
survey; and
' 14 percent of people in the HIV/AIDS Housing Survey who wanted help
to quit using drugs were unable to get the help they needed.
The HIV/AIDS Housing Survey found that the most common reasons for not entering
therapy/treatment included lack of transportation, location of site and cost of program.
Mental illnessresents an additional challenge to man people living with HIV/AIDS.
p g YP P g
National studies indicate that 10-20 percent of homeless individuals suffer from severe
mental illness.4 Forty percent of all people living with HIV/AIDS eventually develop
significant neurological problems; as many as 90 percent have central nervous system
damage by the end of life.' Of the survey respondents:
• 21 percent indicated a history of depression.
1
53
r
Contra Costa County HN/AIDS Housing Plan
Mental health care is also difficult for people with HIV/AIDS in Contra Costa County to
obtain:
• 23 percent of those persons using mental health services were not satisfied ,
with their care.
Women, and families with children affected by HIV/AIDS, have unique social
and support service needs which negatively impact their ability to maintain
housing
"Seems that services are too sparse. I have four children and have been homeless three
times in the last three years. I'm in active recovery now, and sharing a living situation. I '
desperately need my privacy. I want to live in as safe a neighborhood as possible, where
smoking weed as medicine is tolerated--hopefully, not where people who openly use
drugs and/or sell them live. I'm skeptical of living where it's been advertised housing'
because of the many fears surrounding contracting HIV I'd personally be afraid
someone would bomb the place."
--survey respondent '
As has been noted, women—and subsequently children and families—are a growing
component of the epidemic. The HIV/AIDS Housing Survey found that for women living '
with HIV and AIDS, particularly those with children, finding safe and affordable housing s
a primary concern. Women were well represented in the HIV/AIDS Housing Survey
which revealed significant differences between women and men in the area of housing.
A third of the respondents live alone, and 34 percent live with children. While half of the '
respondents with children indicated that they had only one child, 27 percent indicated that
they had 3 children. Of those respondents living with children of all ages, 35 percent of the
children are less than 5 years of age. More than half of all children living with the
respondents are teenagers between the ages of 12 and 18.
The data revealed other important differences between men and women: '
• Women were much more likely to say they were depressed than men (40
percent compared to 8 percent);
• Women were more likely than men to be living with other people (75
percent as compared to 57 percent);
• 45 percent of all women respondents were living with their children or step
children. ,
54 '
Contra Costa County HIV/AIDS Housing Plan
Although 53 percent of the women living with HIV/AIDS in the County reported injection
drug use as a risk factor 6 women were somewhat less likely than men to have a history of
using drugs, but were more likely to be in recovery and as likely to say they were
' chemically dependent.
Several focus group participants were women who shared their concerns about their
children's health and safety. Each woman stressed the importance of having a safe, drug
free neighborhood in which to raise their children. Several women had lost custody of
their children and were struggling to become sober. One child, who attended the
Tranquillium Center focus group with his mother, and spent the time enjoying a bowl of
stew and a coke, said"I like this place."
Families also present special needs:
• 29 percent of all respondents lived in at least three-person households; and
• 21 percent of all HIV/AIDS Housing Survey respondents lived in
households where at least one other person was also living with HIV or
AIDS.
' Child care and mental health services for women were particularly seen as lacking in the
EMA. Female participants in the 1994 Oakland EMA focus groups reported insensitivity
among service providers and the need for on-site child care if women are to take
1 advantage of existing services and feel welcome.
Poor rental and criminal histories make it harder for some people living with
HIV/AIDS to find housing
"I figure if I am dying who cares?I didn't care about moving the right way out. I didn't
notify people even though I left the apartment clean. In order to be able to move it costs
1 $1,300 dollars so you burn them for the last month rent. That is the real reason—to get
money for next month. So you don't realize what you are doing to yourself when you get
an eviction. It is not easy to move with all this credit stuff. It isn't even easy now with
' Section 8. Those places don't usually do credit checks—but now a lot of them want
credit checks. "
--focus group participant
rThe HIV/AIDS Housing Survey found that many individuals had poor rental histories.
Thirty five percent of the surveyed population indicated they had been homeless at some
point in the past five years:
55
Contra Costa County HIV/AIDS Housing Plan;
•_ 65 percent of all respondents had moved since learning.of their HIV .
infection or AIDS;
• 25 percent of all homeless respondents had been evicted;
• 62ercent of these had been asked to move because of drug or alcohol '
P g
use; and
not cover i
• 62 percent moved because they could o co a their rent
Recent incarceration also creates problems finding housing because landlords are often
unwilling to rent to people with felony convictions.
Some people living with HIV/AIDS feel they face discrimination when looking
for and trying to keep housing in Contra Costa County
`7 was evicted because of my HIV status. She said it was because I was 3 days late with
the rent. "
-- written survey response
For some people living with HIV/AIDS in Contra Costa County, particularly those who ,
participated in the focus groups, housing discrimination is a concern. This discrimination
could be based on HIV status, on race, or on perceived drug use. It is not possible to state
to what extent discrimination based on HIV status is a factor in the difficulty people have
finding and maintaining housing. What is clear, however, is that some individuals feel
discriminated against and that there is a considerable perception that discrimination against
people living with HIV/AIDS exists in the County.
The majority of the people living with HIV/AIDS who participated in the focus groups
were people of color, particularly African Americans. Many of these individuals voiced
their general dissatisfaction with the housing system and their concern that people of color
were not afforded the same access to health and housing services as whites, particularly r
when compared to the services available to people living with HIV/AIDS across the Bay
in San Francisco. ,
In addition, a number of focus group participants spoke of recent acts of discrimination in
the areas of housing and employment. ,
56
Contra Costa County.HIV/AIDS Housin .Plan
• "I was working with food and I thought I should tell him. Well, as soon as
I did, I was fired You have to keep it a close secret in this town."
• "Some of my family don't understand, they don't want me no more. They
' are watching me like I am a germ. They almost make me hate them, which
I don It want to do. "
'
People want to remain in their homes and live as independently possible for
P P Y as
' as long as possible
The most important qualities I would seek in a new home are the same as those that you
would like. "
-- survey respondent
' Respondents were asked to rank(from 1 to 9, best to worst)thoughts on what type of
housing best serves their needs given current health status as well as if health changes as a
' result of HIV/AIDS. They were also asked to identify all support services that best served
their needs given their current health and should their health change as a result of
HIV/AIDS. Most survey respondents feel their needs are best served now, and in the
future, in their own homes. Emotional support and case management were identified as
the most desirable support services to maintain this option.
' Preferences by type and location
' The overwhelming top choice for where people would like to live now was independently.
The preferences are ranked (most favored to least) in Table 4.
' In terms of location, should they be forced to move, high value was placed on:
• living close to doctors;
g
livin in safe neighborhoods;
' g
' easy access to transportation and shopping; and
' living near friends and family.
57
Contra Costa County HIV/AIDS Housing Plan '
Preferences by quality
People were asked to rank several housing qualities that were important to them. The
most important qualities they would be looking for in a different home were:
• living in clean and sober housing; '
• living with people of the same ethnic or cultural background; and '
• living in a wheelchair-accessible building.
Half of the respondents indicated that they preferred not to live with other HIV-
positive individuals, citing their need for privacy as the primary reason.
Table 4: Housing and Service Preference Over Time
Listed in Priority Order
Which Best Suits Your Needs ... Which Best Suits Your Needs ... ,
given your current health? should you become more ill?
Housin Service Housing Service '
Rental Unit Case Management Rental Unit Emotional Support
Owned Home Emotional Support Owned Home Case Management ,
Single Room Practical Support Skilled Nursing Medical Care
Occupancy Facility
Transitional Medical Care Residential Assist with Daily
Housing Hospice Activities
Shared/Group Money Shared/Group Money
Home Management Home Management '
Emergency Shelter Mental Health Single Room Home Delivered
Counseling Occupancy Meals '
Skilled Nursing Home Delivered Transitional Practical Support
Meals Housing
Residential Hospice Assist with Daily Emergency Mental Health '
Activities Shelter Counseling
58 '
Contra Costa County HMAIDS Housing Plan
Case Manager Survey Results
' As of December 23, 1995, the Contra Costa County Health Services Department AIDS
Program had received 16 `Case Managers and Services Providers" surveys completed by
service provider and case management agencies. (This figure is believed to be very
representative of the existing network of service providers serving people with HIV/AIDS
in Contra Costa.) The majority of survey respondents, or 75 percent (n=12) offer case
management services. Additionally, 50 percent (n=8) of respondents provide emotional
support services and 44 percent(n=7) provide practical support services.
' Respondents were asked to estimate the percentage of their agencies', non-housing
services to people living with HIV/AIDS. The average of the percentages given was 65.5
percent with nine, or 56 percent of respondents indicating that 100 percent of their
' agencies' services are provided to people living with HIV/AIDS.
Findings of the survey
1 When asked to rank the types of housing assistance most needed by their clients,
respondents gave higher rankings to `emergency/ short term financial assistance for rent
and utilities', `shared houses/apartments with little or no on-site support services', and
' `subsidized independent living in an apartment with no on-site support services'.
According to these responses, it appears as though service providers support the desires of
most clients (as per the HIV/AIDS Housing Survey results) for independent living
situations and minimal on-site support service.
It is also interesting to note that although as many as 53 percent of HIV/AIDS Housing
' Survey respondents indicated past and/or present drug use, Case Managers and Services
Provider Survey respondents gave relatively low rankings to the `housing program that
tolerates drug/alcohol use off premises', and `clean and sober housing program' options.
' In terms of barriers to access housing assistance, respondents ranked inadequate rental
assistance as the greatest barrier.
When asked to rank, in order of importance, the services required for their clients to
1 maintain an independent housing situation for the longest feasible period, respondents
scored `protective payee/money management' as the most important service. `Alcohol and
drug treatment/counseling' received the second highest ranking. These responses
' underscore a reality for many people living with HIV/AIDS in this County: as the
proportion of income to housing costs approaches one and as alcoholldrug use continues
59
Contra Costa Count HIV/AIDS Housing Plan '
to be a competing priority for personal funds, the combination of money management and
drug treatment/counseling services has become a significant need. It appears that while
service providers want to support their.clients' desires for independent living, they
recognize that it is not a feasible option for this population without appropriate
supportive services. '
Conclusion '
The HIV/AIDS Housing Survey found that low income people living with HIV and AIDS
in Contra Costa County face substantial barriers when seeking and keeping housing that is '
safe, meets their needs, and is within their budget. Poverty, the challenge of substance
abuse, perceived or actual discrimination, limited options for families, and the physical
devastation of HIV/AIDS combine to create homelessness and unstable housing among '
people living with HIV and AIDS in Contra Costa County.
1 1995 Title I EMA Supplemental Application,CARE Act clients,first quarter Fiscal Year 1994. ,
2 HIV/AIDS Epidemiology Profile of the East Bay, 1994.
3 Oakland Ryan White Title I EMA Needs Assessment, 1994.
' Tessler,RC and Dennis,DL A Synthesis of Research Concerning Persons who are Homeless and Mentally Ill.National
Institutes of Mental Health,Rockville,NO;(1989) ,
5 Elders,GA&Sever,JL,AIDS&Neurological Disorders:an overview.Annals of Neurology 23(Suppl):54-5-6.Nov.
1988.
6 Contra Costa County AIDS Epidemiology Report. '
1
60 '
Contra Costa Count HIV/AIDS Housin .Plan
?:><
t>
ijj;:tits\;.ii<CLC{J.jjyGj�jO}•.}}y.}}±}}:.}:.±u'
ry 'rovider Survey Results
This section of the plan presents the results of surveys of housing providers from
across Contra Costa County.
Methodology and limitations
The survey was sent to 28 nonprofit and other developers of affordable housing active in
the East Bay Area on September 22, 1995. A follow-up survey was sent to 19
non-respondents on December 20, 1995. Fifteen(15) developers had responded to the
survey, representing a 54 percent response rate.
' Limitations to the survey application include a discrepancy in responses. For example,
some respondents placed senior/disabled housing in an"other" category, rather than by
unit size. In addition, rather than responding in the negative, some agencies simply
skipped questions on the survey which they felt did not apply to them.
The following summarizes the main findings of the survey.
' Experience with development of affordable housing
Contra Costa County surveyed nonprofit developers with experience creating affordable
housing. Of those agencies responding to the survey, only one indicated they have no
development experience in Contra Costa County. Four agencies currently have projects in
development; four have completed one acquisition, rehabilitation, or new construction
project; three have completed 2-3 projects and five have completed 4 or more projects.
61
,
Contra Coat&County 111WAIDS Houainx Plan.
All responding agencies had development experience in other counties, ranging from .
projects currently in development to completion of 4 or more projects. ,
The projects these developers have completed or in development in both Contra Costa
County and other jurisdictions cover a range of options, as illustrated in Table 1. Other
housing owned or developed includes farm worker housing, housing for seniors/disabled,
and single-room occupancy(SRO) housing.
Table 1 '
Type of Housing Project Number developed Number Owned '
Group homes 6 4
Single family rental 3 16
2 - 4 Unit multifamily rental 1 4
5 - 20 Unit multifamily rental 10 17
20 - 50 Unit multifamily 15 79
housing '
Transitional.housing 7 26
The survey identified the following HIV/AIDS-specific housing experience, although not '
all of this experience is specific to Contra Costa County.
• 1 agency provides 14 group home beds for people living with HIV/AIDS;
• 2 agencies provide a total of 17 units in 5-20 unit complexes dedicated for ,
people living with HIV/AIDS;
• 1 agency provides 20 SRO units for people living with HIV/AIDS and '
• 1 agency provides 24 units for persons with functional limitations due to a
physical disability. These units are not limited to people living with
HIV/AIDS, although at the time of survey completion all residents I
currently did have HIV/AIDS.
62
Contra Costa County HIV/AIDS Housing Plan
Although not all these programs are in Contra Costa County, the information illustrates
the capacity which exists in the County.
Provision of supportive services
Only four housing development agencies report providing any support services directly to
residents of assisted rental housing.
• The most common services are practical support, emotional support and
service coordination, which are each provided by 3 agencies.
' Case management services, money management, mental health and
substance abuse counseling, and assistance in daily living are all provided
by 2 agencies
• The majority of agencies provide only one service, including transportation
services, pre-vocational activities and activities for children.
Only three agencies provide services specifically for people living with HIV/AIDS: one
provides emotional support; one provides mental health counseling; one provides service
coordination; and one provides transportation services.
Seven agencies report providing support services to residents through formal agreements
with service providers to people living in permanent or transitional affordable housing,
including case management, money management, practical support, emotional support,
medical care, mental health counseling, substance abuse counseling, and assistance in daily
' living. In addition, one agency provides nutritional support and job training; one provides
food; one provides transportation; two provide service coordination/referrals; and one
provides SSI advocacy and legal services.
Four agencies report providing support services through formal agreements with service
' providers, to people living with HIV/AIDS living in permanent or transitional affordable
housing, including two which provide case management, money management, practical
support, medical care, substance abuse counseling, and assistance with daily living. Three
1 agencies provide both emotional support and mental health counseling; one provides
transportation and service coordination; one provides nutritional support and job training.
63
Contra Costa County HIV/AIDS Housing Plan ,
Agency,plans to develop affordable housing for people living with HIV/AIDS .
Five agencies report they would consider or are considering providing supportive services
as part of the development of supportive housing for people living with HIV/AIDS; seven
report they would consider or are considering developing/owning/managing such
housing, including two agencies which are considering participating in both aspects. Only
one agency explicitly indicated they are not interested in this aspect of affordable housing,
although seven respondents left this section blank.
• One agency indicated they currently do not have a project identified.
• Another agency is working to develop five units in the South Lake Tahoe
area. '
• A third agency is developing 50 units, affordable to households with low,
very-low, and extremely-low incomes, within a large multifamily rental
complex in San Francisco.
• A fourth agency is working to develop 29 units in a large multifamily rental
property, affordable to very-low and extremely-low income households,
including 10 units reserved for people with HIV/AIDS in West Contra
Costa County.
• A fifth agency is developing 10 hospice units for extremely-low, very-low,
and low income households in Berkeley. ,
• A sixth agency is working to develop: 20 units of rental housing affordable
to very-low income households; and 20 units of transitional housing '
affordable to very-low and low-income households,both in East County.
• A seventh agency is in pre-development on the following three projects: 12 1
units of multifamily rental housing for very-low and extremely-low income
households in Central Contra Costa County including 11 units reserved for
people with HIV/AIDS; 8-12 units of either group home housing or '
multifamily rental units affordable to very-low and extremely-low income
households, in Central or West Contra Costa County; and 6-8 units of
group home housing or multifamily rental housing affordable to very-low
and extremely-low income households in Berkeley.
Note that not all of these projects are in Contra Costa County. ,
64
Contra.Costa County HIMEDS.Housing Plan_.
Perceived barriers to development of affordable housing for people
living with HIV/AIDS
Meeting the housing needs of people living with HIV/AIDS however, is seen by some
providers as challenging. Many of the issues identified by providers are outlined in the
`Context of HIV/AIDS Housing in Contra Costa County" section of this plan, and include,
1 in order of the number of respondents identifying the barrier:
#1 Long-term funding of services;
#2 Lack of politically feasible sites;
#3 Lack of financially feasible sites;
44 Unfamiliarity with [other] housing developers or service providers that
' could be partners in the development and management of affordable
housing for people living with HN/AIDS; and
I #5 Unfamiliarity with the needs of persons with HIV/AIDS.
LAdditional barriers included inadequate fiscal and/or administrative systems, inadequate
staffing, the limited amount of available development funding, community concerns, and
need for community outreach and approval in selected jurisdictions.
' One agency with significant experience in the provision of housing forspecial needs
populations, including people living with HIV/AIDS, is concerned with the need for a
housing continuum-group homes, independent living, hospice services, transitional
housing-within the community. They identified the legally-required community process
' as an enormous hindrance in the development of such housing, due to community
concerns, and related homophobia; as well as the issue that the community process results
in labeling future residents as having HIV/AIDS.
An agency which has been researching the possibilities of developing housing for people
living with HIV/AIDS has found two issues to be especially problematic: ensuring ongoing
' support service funds to serve future residents; and coordinating the worlds of service
provision and development funding into single projects.
65
Contra Costa County HIV/AIDS-Housing-Plan,
Agencies,which have had experience developing and operating housing for people living
with HIV/AIDS, cite the following project operations issues:
• Attracting and retaining appropriate tenants, especially people who are
clean and sober, was a concern for the community and the agency both;
• Unit retention in the event of disease progression/tenant hospitalization;
• Unit vacancyand tenant transition to facilities designed to provide
g
comprehensive medical care;
• Legal or other issues of providing hospice care in existing units; and t
• Death of tenants in their units. r
Addressing perceived barriers to development of affordable housing for people '
living with HIV/AIDS
Housing developers were asked to rank possible strategies to address barriers to the
development of housing for people living with HIV/AIDS. These strategies are listed
below, again in rank order: ,
#1 Technical assistance in the areas of funding applications, licensure
requirements, and program design;
#2 Training in the needs of people living with HIV/AIDS;
#3 Assistance in identifying housing/services partners or consultants and
assistance in identifying politically and/or financially feasible sites; and
#4 Training in affordable housing development.
66
' Contra Costa County HIV/AIDS Housing Plan
Conclusion
' A number of additional pieces of information were received from survey P P participants,
which indicate a willingness to be part of the solution to the need_ for a continuum of
' HIV/AIDS housing in Contra Costa County. For example:
' An agency with experience managing a 24-unit building where the majority
of residents have a functional disability due to HIV/AIDS indicated they
would be happy to discuss their knowledge/experience.
• Two agencies indicated they would consider collaborative efforts with
other agencies in any aspect of supportive housing.
• Although a third agency has not identified special needs housing as part of
their mission, they have designed units in all new projects to be in
compliance with ADA.
Providing people living with HIV/AIDS in Contra Costa County a safe, appropriate and
affordable place to live will require the considerable experience and efforts of the County's
' nonprofit developers. In order to benefit from their expertise, however, the HIV/AIDS
community and local public agencies government must work together to address the
specific barriers they identify to facilitate the creation of more affordable HIV/AIDS
' housing.
67
Contra Costa County HIV/AIDS Housing Plan
The HIV/AIDS Housing Survey, which reached people most likely to be in need of
housing assistance, provides the details of the crisis implied by this scenario:
• 31 percent of respondents had experienced homelessness since learning of
their HIV status; and
• 35 percent of respondents had experienced at least 1 episode of
homelessness in the past 5 years
• 4 percent were currently homeless, living on the streets, in cars, in
abandoned building or in shelters.
The results of the HIV/AIDS Housing Survey are described in the following section of the
plan and illustrate the realities of finding and keeping affordable housing in Contra Costa
County for people living with HIV and AIDS.
1 Information for this section is taken from the HOME Consortium Consolidated Plan,Contra Costa County,February,
1995.The Consortium does not include the City of Richmond.
'Consolidated Plan,Contra Costa County HOME Consortium,June,1995.
'Homelessness in Alameda.County,The Housing and Community Development Program of the Alameda County
Planning Department,1995.
33
Contra Costa County HIV/AIDS Housing Pian
34
Contra Coat&County HIV/AIDS Housing Plan
3 Housing Survey Results
Man, I wish I had control of these funds My top priority would be mothers with
kids who are homeless. I would provide shelter to these kids."
- focus group participant
' This section of the plan presents the results of 90 HIV/AIDS Housing Surveys and
the three focus groups conducted for the HIV/AIDS Housing Plan. It also
describes the methodology and limitations of the survey research, the
demographics of respondents, and major conclusions which can be drawn from the
research.
1
The HIV/AIDS Housing Study Methodology
The quantitative and qualitative data collection process for the Contra Costa Count
4 4 P Y
Multi-Year HIV/AIDS Housing Plan had several components: a survey of 90 people living
with HIV/AIDS in Contra Costa County, three focused discussion groups of individuals
living with HIV/AIDS held at a variety of HIV/AIDS service providers in the County; and
a review of additional data collection efforts conducted for previous or concurrent
planning processes. This section of the plan presents the data from these efforts.
The information from these activities was presented and reviewed by a community-based
planning committee, whose members provided input and information to the process. The
following provides a brief overview of the methods associated with the HIV/AIDS
Housing Survey data collection activity and the limitations of the process.
35
Contra Costa County HIV/AIDS Housing Plan
The HIV/AIDS Housing Survey
Originally, it was hoped that the HIV/AIDS Housing Survey could be completed by 10
percent of people living with HIV/AIDS in the County, or about 200 people. This
`sample' (or group of people who filled out the survey) would be large enough to be
`representational' (or be like) all the people living with HIV/AIDS.in the County.
It became apparent that the ideal sample size of 10 percent.was beyond the resources of
the County Health Services Department AIDS Program. There are several reasons why
the Department felt that the original number was not achievable, including:
• People with living with HIV/AIDS in Contra Costa County, particularly
West County, have been asked to complete many surveys about their needs
and experiences over the past few years. As a result, many people living ,
with HIV/AIDS are tired of participating in surveys, and did not agree to
participate-,
• People living with HIV/AIDS in Contra Costa County, particularly people
who receive their health care from private doctors and people staying at
public emergency shelters, are leery of losing their confidentiality; and
• The budget for this plan did not allow for substantial payment for
completing the survey, while other surveyors are offering significant
compensation for participation in current and upcoming surveys.
These reasons led to the decision to strive for a sample of 100 individuals, approximately 5
percent of the estimated HIV-infected community, to use as a baseline assessment of
housing needs in the County. In all, 90 people completed the survey, about 4 percent of
people estimated to be alive with HIV and AIDS in Contra Costa County.
The survey was based on similar surveys used for HIV/AIDS Housing Plans in other
jurisdictions. Separate surveys were developed for people living with HIV/AIDS, for case
managers and for housing providers in the County. A small group, consisting of three
HIV/AIDS case managers, an HIV/AIDS Housing Advocate, a planner from the Contra
Costa County Community Development Department, and a planner from the County
AIDS Program modified the consumer survey tool to solicit the additional information
required by this County.
The HIV/AIDS Housing Survey contained over 40 questions designed to help the ,
planning group better understand the barriers people living with HIV/AIDS face when
trying to find and keep housing which meets their financial and physical needs and to
36
Contra Costa County HIV/AIDS Housing Plan
access which types of housing program and services people in Contra Costa County
prefer. The broad interest was for information on stage of disease, household size,
monthly household income, amount of income spent on housing, barriers which might
influence the type of housing available to individuals with HIV/AIDS, and use of existing
resources. In several questions, respondents were asked to rank choices. Many
individuals did not rank but simply marked the number 1 or the letter"x" next to many of
the variables. All those who marked at least one response were included in the tally. The
numbers (one through five) were assigned opposite values and then summed across
respondents. In the instance where an"x" was placed, the response was interpreted as a
number 1 (one).
This survey was conducted as a`convenience sampling', meaning that participation was
not based on a random or scientific process but on individuals agreeing to participate
when asked. More than 700 surveys were distributed to service agencies, providers,
related County programs, hospitals, and to Kelevant members of the HIV Interagency
Service Providers' Network. Five outreach workers facilitated the distribution of surveys
to individuals not currently accessing public services. Case managers, agency volunteers
and other providers distributed surveys to their clients. The County AIDS Program
offered"housing clinics" at several sites to provide additional assistance to consumers in
completing the forms.
An attempt was also made to encourage responses from individuals currently within the
private-sector health care system. None of the completed surveys are coded with the
private sector code, indicating that all those who returned the surveys are receiving
publicly funded services, know where to access publicly funded services, or have been
contacted by publicly funded outreach workers. The fact that no surveys were completed
by people in the private pay sector, who may be of higher income or currently employed,
also influences the high need indicated among most housing survey respondents.
Therefore, some of the conclusions drawn are the direct result of the population
surveyed - very-low income individuals with unstable housing who require a
multiplicity of services. The characteristics of this population guided subsequent
development of priority population recommendations.
i n
Additional studies consulted
rThis plan also draws on additional sources of information regarding the housing and
service needs of people living with HIV and AIDS in Contra Costa County, including:
jThe 1994 Oakland EMA Needs Assessment, which surveyed 316
individuals receiving HIV/AIDS care and services—one quarter of whom
were Contra Costa County residents;
37
Contra Costa County HIV/AIDS Housing Plan
• The Contra Costa County.Consolidated Plan, 1995-1999; and
The 1995 Title I EMA Application for CARE Act fundin
• PP .g
Limitations of the data gathering strategies
Any survey data based on a convenience sample is by nature not statistically
representative, and the conclusions cannot, therefore, be generalized to the entire .
population being studied. To know if a survey is representational, one needs to know the
total number of people who could be surveyed and what those people are like in terms of
their demographics(race, age, sex, etc.). The total number of individuals living with HIV
and/or AIDS in Contra Costa County, however, is unknown. Estimates are also hard to
create, since the decision to seek testing or health care treatment is influenced by many
factors.
First, not all people who have HIV are aware that they may be infected and thus do not
seek testing. Second, continued concerns about breach of confidentiality lead some
people to seek anonymous testing outside the County, and these tests are not included in
estimates. Third, people who have little or no access to health care may not know how or
where to access HIV testing: Finally, despite Health Department policy to provide services
to all individuals regardless of their residency status, undocumented people fear they will
be deported if found to be HIV-infected, and Proposition 187 has only increased this fear.
Because the total number of people living with HIV infection, or the total number of
people alive with HIV/AIDS, cannot be determined,.it is not possible to state with
complete certainty to what degree this survey research effort is representative of all people
living with HIV/AIDS in Contra Costa County. Therefore, the results can not be
generalized to the entire HIV/AIDS population in Contra Costa County. ,
Some HIV/AIDS housing advocates, case mangers and people living with HIV/AIDS
expressed concerns that the reading level of the survey was very high and that the
complexity of the survey instrument reduced the number of people who were willing to
take part.
The other primary limitation of the study has to do with the small sample size and the fact
that, like with most surveys, not all respondents answered all questions. Questions asking
respondents to rank choices and preferences were poorly completed by those who
self-administered the survey. Because participants were offered a small stipend for
participation and were largely recruited through HIV/AIDS service providers, the degree ,
to which the survey is representative of the population is further diminished. Additionally,
analysis of some questions identified areas where not enough information was requested,
such as the amount illegal drugs used or concurrent use of different substances.
38
Contra Costa County HMAIDS Housing Pian
Finally, because the questions did not focus on cultural issues, little data is available about
the housing needs or preferences of specific ethnic or language groups.
Nonetheless, demographic comparisons between the HIV/AIDS population at large and
the survey respondents indicate that the results of this survey are a reasonable baseline
from which to develop a plan for housing services within the County. Both nationally and
locally the epidemic is moving from the predominantly gay white male population to the
heterosexual injection drug using population. The number of new cases among
heterosexual women of color who either have used drugs or who are partners of injection
drug use (IDU) has sky rocketed. In the 1980's women constituted 4.7 percent of the
total East Bay women diagnosed with AIDS. Currently, women in Contra Costa comprise
17 percent of the population living with AIDS. Nearly 70 percent are women of color and
more than half have a history of IDU. This data is particularly helpful in designing a
continuum of HIV/AIDS housing to meet the needs of people with low incomes and more
complex health and social service needs. ,
Focus Groups
The HIV/AIDS Housing Survey provided the planning process with a great deal of
quantitative data about the needs and experiences of people living with HIV and AIDS in
Contra Costa County. This information is objective and measurable—but it is only part of
the picture. To fully understand the HIV/AIDS housing continuum in the County and the
needs and hopes of people trying to find their way through the housing system, it was
important to spend time at the actual housing sites and with individuals. These
conversations took the form of focused group discussions with seventeen people who
were willing to share their experiences. The three focus groups were held at the Pittsburg
Pre-school, the Tranquillium Center and the Antioch office of AIDS Alliance. The results
from these more `qualitative' aspects of the data collection are included throughout the
plan in the form of quotations which illustrate the main findings of the HIV/AIDS Housing
Survey and the gaps in the housing continuum.
How do people who completed the HIV/AIDS Housing Survey and participated
in the focus groups compare to people living with HIV/AIDS in Contra Costa
County?
The HIV/AIDS Housing Survey participants are broadly representative of all people living
' with HIV and AIDS in Contra Costa County, but is particularly representative of people
who are most likely to be in need of housing and housing related services. Respondents
indicated high levels of poverty and complex health and social support needs. While not all
people living with HIV/AIDS in Contra Costa County have extremely low incomes, the
39
Contra Costa County HIV/AIDS Housing Plan
recommendations of the HIV/AIDS Housing Plan are designed to assist those in greatest
need: the homeless and extremely low income people disabled with HIV/AIDS. Therefore,
while the survey sample is small and not representative of the diversity of individuals
whose lives are affected by HIV and AIDS, it does provide information which is of
particular use to the purposes of this plan. The survey data and the information gathered
from the focus groups are also useful because it is more reflective of trends in the
epidemic, particularly the rise in cases among people of color, injection drug users, and
women.
Participants in the focus groups were also representative of higher-need people living with
HIV/AIDS. The majority had experienced homelessness since their HIV infection, and
most had a history of substance abuse or were currently using drugs, primarily heroin. All
were low income, and all had current housing needs.
Table 1 illustrates the survey sample as coippared to people living with AIDS (not HIV) in
the County.
How do these respondents compare to people who receive HIV and AIDS
services?
In a review of housing advocacy data.of 151 clients served by HOPWA- and
CARE-funded housing advocates during the period between April 1, 1994 and March 31,
1995, several similar themes emerged which complement and validate the survey findings:
• 59 percent of service recipients are African American, 7 percent
Latino/Hispanic, and 34 percent Caucasian.
Half the population served during this period had a diagnosis of AIDS
' g , and
the majority of those served received their diagno_is some time in the last
five years.
• 16 percent are homeless, 93 percent have incomes under $900 per month
and 59 percent live alone and/or do not have others contributing to their
household income.
• 87 percent received some form of public insurance/entitlement program ,
assistance.
These percentages closely mirror the survey results presented above and offer further '
validation of its use as baseline information on which to support a housing plan for low-
income people living with HIV/AIDS in Contra Costa County.
40
Contra Costa County HIV/AIDS Housing Plan
1
Table 1: Comparison of HIV/AIDS Epidemiology and Survey Respondents
Demographic Variable Persons living with AIDS only as Survey respondents
of October 1,1995 (includes both AIDS and
(n=608) HIV)n=90
Age at diagnosis Age when surveyed
<5 6 (<1 percent) 0 (<1 percent)
5-12 2 (<1 percent) 0 (<1 percent)
13-19 4 (<1 percent) 0 (<1 percent)
20-29 197 (12.1 percent) I (1 percent)
30-39 689 (42.4 percent) 25 (27.8 percent)
40-49 492 (30.3 percent) 37 (41 percent)
50 and above unknown 235 (14.5 percent) 12 (13.3 percent)
n/a 15 (16.6 percent)
Note:reflects cumulative
AIDS cases(n=1625)
Sea of Adults
Male 503 (83 percent) 40 (46.6 percent)
Female 105 (17 percent) 42 . (44.4 percent)
Transgender unknown I. (1.1 percent)
unknown n/a 7 (7.7 percent)
Race
Caucasian 327 (54 percent) 27 (30 percent)
African American 200 (33 percent) 45 (50 percent)
Hispanic 63 (10 percent) 4 (4.4 percent)
Asian/P.I. 13 (2 percent) 1 (I.I percent)
Native American 4 (<1 percent) I (1.1 percent)
1 Other/Unknown I (<I percent) 12 (13.3 percent)
Residence
West county 619 (38.1 percent) 51 (56.6 percent)
East county 300 (18.5 percent) 12 (13.3 percent)
Central county 694 (42.7 percent) 9 (10.1 percent)
Unknown/other 12 (0.74 percent) 18 (20 percent)
Note:reflect cumulative
AIDS cases(n=1625)
41
Contra Costa County HIV/AIDS Housing Plan
What did the survey reveal about people living with HIV and AIDS?
r reveal the difficult of livin with HIV/AIDS in Contra
The survey and focus groups e y g Cot a
Costa County and the impact that poverty and health status have on people's ability to
find and keep safe, secure and affordable housing.
• Finding and keeping housing is a crisis for many people living with ,
HIV/AIDS.
• Homelessness and HIV/AIDS are an overwhelming—and
common—combination.
• Many more people living with HN/AIDS in Contra Costa County could
lose their housing at any time because of poverty.
• People living with HIV/AIDS have complex health care needs and can't '
always get the health and supportive services they need to stay
independent.
• Many people are struggling with substance abuse and mental illness in
addition to HIV/AIDS.
• Women and families with children affected by HIV/AIDS have unique
social and support service needs which negatively impact their ability to
maintain housing.
• Poor rental and previous criminal histories make it hard for many people
living with HIV/AIDS to find housing; ,
• Some people living with HIV/AIDS feel they face discrimination when
looking for and trying to keep housing in Contra Costa County. ,
• People want to remain in their own homes and live as independently as
possible for as long as possible.
Finding and keeping housing is a crisis for many people living with HIV/AIDS r
`I need someone to help me find housing can afford. I've been homeless ten
times in the past three years.
-- survey respondent
42
Contra Costa Count HIV/AIDS Housing Plan
The HIV/AIDS Housing Survey asked people to identify their current housing situation
and found that significant numbers of people livingwith HIV/AIDS in the County face
barriers and difficulties locating and keeping their housing, are currently homeless, or are
at risk of losing their housing:
• More than half of all survey respondents felt they needed housing
assistance;
• 25 percent indicated that they were on a waiting list for government
assistance; and
• 27 percent of those currently on the waiting list indicated that they have
been waiting for more than 5 years for government housing assistance.
Many people also did not feel that the services available to them would be much help, and
felt largely unaware of the services which do exist:
• 44 percent said that a lack of client and/or provider knowledge prevented
them from receiving assistance.
' The individuals surveyed also had a high degree.of instability in their housing:
• 35 percent indicated that they had been homeless at least once in the last 5
years; and
• 26 percent had moved 3 or more times in the last 3 years.
• The primary reason for moving was to get away from the old
neighborhood, but other reasons included a decline in income/no money for
rent and to move closer to family.
The consequences of instability in housing among people living with HIV/AIDS have both
individual and public health consequences. Since learning of their HIV/AIDS diagnosis,
• 30 percent of people who experienced difficulties locating a place to sleep
had spent the night in a car; and
• 9 percent had traded sex for a place to spend the night.
43
Contra Costa County 11lV/AIDSHousing Plan
The Oakland EMA Needs Assessment gives us other information about the need for
HIV/AIDS housing services in the East bay as a whole:
• More than 40 percent of the people who said they needed housing services
were not receiving help;
• 27 percent of the people who got help were unsatisfied. with the help they
received;
• 23 percent received financial assistance to help pay for utilities;
• 28 percent reported needing ongoing rental assistance(Section 8); and
• 18 percent reported needing free or subsidized housing for 6 months or
more (transitional housing).,
Homelessness and HIV/AIDS are an overwhelming—and
common—combination
"I am homeless right now. I should have a place to live. It has been damn
rough. " I
-- focus group participant
The HN/AIDS Housing Survey performed for this study found:
• 31 percent of all respondents had experienced homelessness since they
learned of their HIV infection;
• Half had been homeless at least once in their lives; and
• 35 percent homeless in the last 5 years; and
• 4 percent were currently without a place to live.
In addition, 13 percent of CARE Act clients in .Alameda and Contra Costa counties stated
they were homeless. `
44
Contra Costa County HIV/AIDS Housing Plan
Current Housing Status
Transitional Housing
SRO
Rented Room
Rental Unit
Public Housing
Own Home
Homeless
Group Home
Friends Home
Emergency Shelter
' 0 5 10 15 20 25 30 35 40 45
The impression given by this data was confirmed in the focus groups and in the community
planning meetings. Time and again, individuals voiced their concerns about homelessness
or the threat of becoming homeless.
A 1992 report by the National Commission on AIDS estimated the rate of HIV infection
among homeless persons to be between 15 and 20 percent. Using this estimate rate,
between 390 and 520 people living with HIV or AIDS in Contra Costa County are
without shelter, and many more are at risk of becoming homeless.
The reasonseo le became homeless are numerous and interrelated, including:
P P
• 97 percent were unable to afford their rent (30 of 31);
• 90 percent because of alcohol or drug use (28 of 31),-
39
1);39 percent became homeless because of eviction due to non-payment of
rent, drug use, and/or discrimination, fire, etc. (12 of 31); and
• 35 percent were`forced out' by family or partners (11 of 31).
People living with HIV/AIDS who participated in the focus groups had even higher
' degrees of homelessness. Of the seventeen focus group participants,
80 percent were currently homeless. Drug use was identified as the primary reason for
homelessness, with high costs of rents as the second reason.
45
Contra Costa County HW/AIDS Housing Plan
Many in.the focus groups were frustrated by the lack of opportunity for stable lives and
stable housing. Concerns include: limited job opportunities; limited housing; the
widespread availability of drugs; decreased income; fiustration generated at providers and
local government; issues of the cost of telephone calls to access programs, services and ,
the voice mail systems used by housing program providers; perceived and discrimination
based on HIV/AIDS status and drug addiction.
Some of the focus group participants had recently been released from San Quentin federal
penitentiary. For these individuals, the chances of finding work and a place to live seemed
even more remote: '
Many more people living with HIV/AIDS in Contra Costa County could lose
their homes at any time because of poverty
`I want something stable, but you have to have three times your income to move
into an apartment, and I can't save that."
--focus group participant
Like other Americans, many low-income people living with HIV/AIDS are only one
unexpected financial emergency away from homelessness. The highest rates of AIDS in
the East Bay are in those neighborhoods with the lowest median annual incomes.' The
HIV/AIDS Housing Survey found that people live on very low fixed incomes and spend
most of their income on housing.
The poverty of many people living with HIV/AIDS in Contra Costa County was well
documented by the survey:
' The majority of families and individuals surveyed exist on monthly incomes ,
of$650 or less;
• 60 percent of the respondents indicated that their income was the only
source of income in the family;
• 37 percent indicated that they supported at least one other individual; and
• Of those with one or more dependents, 42 percent claimed 2-5 dependents.
46
Contra Costa County HIV/AIDS Housing Plan
Table 2: Incomes T
Individual Monthly Income n=77 Household Monthly Income n=50
Income Number Percent Income Number Percent
<$650 51 66.2 <$650 21 42
$651-1,000 19 24.7 $651-1,000 11 22
$1,001-1,500 4 5.2 $1,001-1,500 12 24
>$1,500 3 3.9 >$1,500 6 12
Table 2 indicates the degree of poverty faced'by these families and individuals. Only 3 out
of 77 individuals had incomes of over $18,000; only 6 of 50 households had incomes in
that range.
The majority of low income people living with HIV/AIDS in Contra Costa County, as in
other parts of the country, rely on public assistance to survive:
• 14 percent of respondents receive government assistance in order to keep
the housing that they have; and
• 89 percent of respondents receive at least one form of public assistance.
' The poverty experienced by these families is further exacerbated by the fact that most of
what little money they have is spent on rent:
• 33 percent of respondents spent between $400 and $590 per month on
rental payments; and
• 32 percent paid between $600 and $900 on their monthly rent.
The largest percentage of respondents (50 percent) lived in a rented room or apartment.
While these individuals have a place to stay currently, many are in unstable housing
because of high housing cost. To be considered `affordable', housing should cost no
' more than 30 percent of a family's adjusted income. Households which spend more than
30 percent of their gross monthly income on housing are considered to be`cost burdened'.
The HIV/AIDS Housing Survey measured the incidence of cost burden by comparing
income, expenses, and rent, and found that:
47
Contra Costa County HIV/AIDS Housins Plan
Benefits Received
Waiver
Veterans
Private Insurance
SSI
SSA
SDI
Private Disability
Medicare
Medi-Cal
General Assistance
AFDC
0 5 10 15 20 25 30 35 40 45 50
• 60 percent of HIV/AIDS Housing Survey respondents renting or owning
housing spent more than 50 percent of their income on their rent or
mortgage; and
• An additional 23 percent spent more than 30 percent.
i
. 1
• 1
1
1
• f48
Contra Costa County HIV/AIDS Housing Plan
This means that only 17 percent of those individuals who completed the survey were in
`affordable 'housing!
Percentage of Income Spent on Housing
r3<30%
®>30%
j023% M>50%
60%
In addition to the 4 percent of survey respondents who were currently without a place to live, an
additional 18 percent are in danger of losing their housing because they are in transitional housing,
are staying with friends, or are staying in a shelter. Table 3 summarizes all the information from
the HIV/AIDS Housing Survey which illustrates the degree to which homelessness and unstable
' housing is a factor in the lives of low-income people living with HIV/AIDS in Contra Costa
County:
49
Contra Costa County HIV/AIDS Housing Plan
Table 3: Housing Instability
Risk Percentage
Currently homeless 4
Staying in temporary housing 18
Spend 50 percent or more of income on 60
housing
Spend 30 percent or more of income on 23
housing
Previous eviction 39 ,
People living with HIV/AIDS have complex health care needs and can't always get
the health care or supportive services they need to stay independent '
"Now I got to go to the doctor because I am real sick, but I don It have an address so I
don't know how I am going to work that. The doctor's got his house—let me get one too
and then I'll see about a doctor!"
-- focus group participant
Both people living with symptomatic HIV infection and those disabled with HIV/AIDS
face an array of painful, complex health issues ranging from severe weight loss and fatigue ,
in the earliest stages, to mental impairment, pneumonia, cancers, blindness, and loss of
major organ functions in the later stages. The housing needs of people living with
HIV/AIDS can change as the disease progresses; often in-home and.ancillary supportive
services are needed in order to avoid costly institutionalization. These services are not
always available.
Most of those surveyed have a diagnosis of AIDS or disabling HIV. While slightly more
women than men have a diagnosis of AIDS, the HIV status by gender is relatively
consistent between men and women. More than 63 percent of the respondents have '
received their current diagnosis since 1991. Fully one third of this number(21 percent of
the total respondents) received their current diagnosis in 1995.
50
Contra Costa County HN/AIDS Housing Plan
Respondents' HN Status
191A
❑HN Disabled
a HN Positive
51 SG xAIDS
'
0030%
Respondents were also likely to have more than one health condition that could impact
their ability to maintain independent housing. One third indicated that they had a physical-
disability, including hearing or vision loss.
The HIV/AIDS Housing Survey, the 1994 Oakland ENa Needs Assessment, and other
information about the health care status of people living with HIV/AIDS in the region
reveals:
• 23 percent of HVAIDS Housing Survey respondents had an AIDS
diagnosis and were potentially in need of a higher degree of support
services to maintain housing.
• Tuberculosis (TB) continues to be a concern. (It is estimated that by the
year 2000, 10 percent of all people living with HIV/AIDS will be
co-infected with this highly contagious airborne infection and
' life-threatening disease). Contra Costa County reported 103 new cases of
TB in 1995. Of these, 8 were resistant to one drug therapy and need more
intensive health care services.
When questioned as to the most important housing-related supportive services necessary
to retain housing, transportation was ranked the most important, followed by benefits
counseling, emotional support, practical support and access to meals/nutritional
counseling. Not surprisingly, the same five issues were also identified as the top unmet
' needs. Transportation is particularly important since the survey found that 18 percent of
respondents received their health care at hospitals outside of Contra Costa County.
51
Contra Costa County HMAIDS.Housing Plan
Many people are struggling with substance abuse and mental illness in
addition to HIV infection and AIDS
`7f you say no to drugs in this County you are really in the minority. It's a sad
reality. There is nothing here but drugs.
-- focus group participant
In Contra Costa County, substance abuse, homelessness and HIV/AIDS go hand in hand.
Both focus group and survey participants indicated that substance abuse both placed them
at risk for acquiring HIV/AIDS and continues to place them at risk for losing their
housing:
• More than half the survey respondents indicated that using needles placed ,
them at risk for HIV/AIDS;
• 31 percent indicated that they had a chemical dependency; ,
• 32 percent are in a methadone program currently;
• 44 percent report using drugs and/or alcohol-, ,
• 44 percent report having used heroin; ,
• 22 percent report having used crack;
• 38 percent report having used cocaine; and
• 31 percent of all respondents say they had become homeless because of '
substance abuse.
People are also struggling to maintain or reattain a degree of recovery and sobriety, but
substance abuse treatment slots are hard to come by and illness and poverty add to the
difficulty of this goal:
• 45 percent of the respondents indicated that they are currently in some type
of substance abuse program; and ,
• Another 43 percent indicated that they felt they needed some form of
treatment.
52 '
Contra Costa County HIV/AIDS Housing Plan
' Drugs Ever Used
No Drugs
Other
Prescription Drugs
Non-prescription Pills
Marijuana
Heroin
Crack
Cocaine
Alcohol
0 10 20 30 40 50 60 70
This means that only 12 percent of respondents had no current or previous
1 chemical dependency or did not want drug treatment.
' Substance abuse services are also hard to receive in the East Bay:
• 17 percent of the 1994 Oakland EMA Needs Assessment participants were
I unable to receive the substance abuse services they said they needed in that
survey; and
' 14 percent of people in the HIV/AIDS Housing Survey who wanted help
to quit using drugs were unable to get the help they needed.
Th HIV/AIDS Housing Survey found that the most common reasons for not entering
The g y e g
therapy/treatment included lack of transportation, location of site and cost of program.
fMental illness presents an additional challenge to many people living with HIV/AIDS.
National studies indicate that 10-20 percent of homeless individuals suffer from severe
mental illness." Forty percent of all people living with HIV/AIDS eventually develop
significant neurological problems; as many as 90 percent have central nervous system
damage by the end of life.' Of the survey respondents:
• 21 percent indicated a history of depression.
53
Contra Costa County HIV/AIDS Housing Plan
Mental health care is also difficult for people with HIV/AIDS in Contra Costa County to
obtain:
• 23 percent of those persons using mental health services were not satisfied '
with their care.
Women, and families with children affected by HIV/AIDS, have unique social ,
and support service needs which negatively impact their ability to maintain
housing
"Seems that services are too sparse. I have four children and have been homeless three
times in the last three years. I'm in active recovery now, and sharing a living situation. I '
desperately need my privacy. I want to live in as safe a neighborhood as possible, where
smoking weed as medicine is tolerated--hopefully, not where people who openly use
drugs and/or sell them live. I)"skeptical of living where it's been advertised housing' '
because of the many fears surrounding contracting HIV I'd personally be afraid
someone would bomb the place."
--survey respondent '
As has been noted, women—and subsequently children and families—are a growing
component of the epidemic. The HIV/AIDS Housing Survey found that for women living ,
with HIV and AIDS, particularly those with children, finding safe and affordable housing s
a primary concern. Women were well represented in the HIV/AIDS Housing Survey
which revealed significant differences between women and men in the area of housing.
A third of the respondents live alone, and 34 percent live with children. While half of the '
respondents with children indicated that they had only one child, 27 percent indicated that
they had 3 children. Of those respondents living with children of all ages, 35 percent of the
children are less than 5 years of age. More than half of all children living with the
respondents are teenagers between the ages of 12 and 18.
The data revealed other important differences between men and women:
• Women were much more likely to say they were depressed than men (40
percent compared to 8 percent); ,
• Women were more likely than men to be living with other people (75
percent as compared to 57 percent); '
• 45 percent of all women respondents were living with their children or step
children.
54 '
Contra Costa County HIV/AIDS Housing Plan
Although 53 percent of the women living with HIV/AIDS in the County reported injection
drug use as a risk factor 6 women were somewhat less likely than men to have a history of
using drugs, but were more likely to be in recovery and as likely to say they were
chemically dependent.
Several focusPP participants artici ants were women who shared their concerns about their
g
children's health and safety. Each woman stressed the importance of having a safe, drug
free neighborhood in which to raise their children. Several women had lost custody of
their children and were struggling to become sober. One child, who attended the
Tranquillium Center focus group with his mother, and spent the time enjoying a bowl of
stew and a coke, said "I like this place."
' Families also present special needs:
• 29 percent of all respondents lived in at least three-person households; and
r21 percent of all MWAIDS Housing Survey respondents lived in
households where at least one other person was also living with HIV or
AIDS.
' Child care and mental health services for women were particularly seen as lacking in the
EMA. Female participants in the 1994 Oakland EMA focus groups reported insensitivity
among service providers and the need for on-site child care if women are to take
advantage of existing services and feel welcome.
Poor rental and criminal histories make it harder for some people living with
HIV/AIDS to find housing
r "I figure if I am dying who cares?I didn't care about moving the right way out. I didn't
notify people even though I left the apartment clean. In order to be able to move it costs
$1,300 dollars so you burn them for the last month rent. That is the real reason—to get
money for next month. So you don't realize what you are doing to yourself when you get
an eviction. It is not easy to move with all this credit stuff. It isn't even easy now with
' Section 8. Those places don't usually do credit checks—but now a lot of them want
credit checks. "
--focus group participant
rThe HIV/AIDS Housing Survey found that many individuals had poor rental histories.
Thirty five percent of the surveyed population indicated they had been homeless at some
point in the past five years:
55
r
Contra Costa County HIV/AIDS Housing Plan
r
•. 65 percent of all respondents had moved since learning.of their HIV
infection or AIDS;
• 25 percent of all homeless respondents had been evicted;
• 62ercent of these had been asked to move because of drug or alcohol ,
P g
use; and '
• 62 percent moved because they could not cover their rent.
r
Recent incarceration also creates problems finding housing because landlords are often
unwilling to rent to people with felony convictions. r
Some people living with HIV/AIDS feel they face discrimination when looking
for and trying to keep housing in Contra Costa County
"I was evicted because of my HIV status. She said it was because I was 3 days late with
the rent. "
-- written survey response
For some people living with HIV/AIDS in Contra Costa County, particularly those who ,
participated in the focus groups, housing discrimination is a concern. This discrimination
could be based on HIV status, on race, or on perceived drug use. It is not possible to state
to what extent discrimination based on HIV status is a factor in the difficulty people have
finding and maintaining housing. What is clear, however, is that some individuals feel
discriminated against and that there is a considerable perception that discrimination against
people living with HIV/AIDS exists in the County.
The majority of the people living with HIV/AIDS who participated in the focus groups
were people of color, particularly African Americans. Many of these individuals voiced
their general dissatisfaction with the housing system and their concern that people of color r
were not afforded the same access to health and housing services as whites, particularly
when compared to the services available to people living with HIV/AIDS across the Bay
in San Francisco. r
In addition, a number of focus group participants spoke of recent acts of discrimination in
the areas of housing and employment. ,
1
56
1
' Contra Costa Count .HIV/AIDS Housin .Plan
• `I was working with food and I thought I should tell him. Well, as soon as
' I did, I was fired You have to keep it a close secret in this town."
• "Some of my family don't understand, they don't want me no more. They
are watching me like I am a germ. They almost make me hate them, which
I don It want to do."
'
People want to remain in their homes and live as independently possible for
P P Y as
' as long as possible
"The most important qualities I would seek in a new home are the same as those that you
would like. "
-- survey respondent
Respondents were asked to rank(from 1 to 9, best to worst) thoughts on what type of
housing best serves their needs given current health status as well as if health changes as a
' result of HIV/AIDS. They were also asked to identify all support services that best served
their needs given their current health and should their health change as a result of
HIV/AIDS. Most survey respondents feel their needs are best served now, and in the
' future, in their own homes. Emotional support and case management were identified as
the most desirable support services to maintain this option.
Preferences by type and location
The overwhelming top choice for where people would like to live now was independently.
The preferences are ranked (most favored to least) in Table 4.
' In terms of location, should they be forced to move, high value was placed on:
• living close to doctors;
living g in safe neighborhoods;
' easy access to transportation and shopping; and
• living near friends and family.
' 57
Contra Costa County HN/AIDS Housing Plan '
Preferences by quality
People were asked to rank several housing qualities that were important to them. The '
most important qualities they would be looking for in a different home were:
• living in clean and sober housing; '
• living with people of the same ethnic or cultural background; and '
• living in a wheelchair-accessible building.
Half of the respondents indicated that they prefbrred not to live with other HIV-
positive individuals, citing their need for privacy as the primary reason.
Table 4: Housing and Service Preference Over Time
Listed in Priority Order
Which Best Suits Your Needs ... Which Best Suits Your Needs ... t
given your current health? should you become more ill?
Housing_ —T—ServiceHousin Service '
Rental Unit Case Management Rental Unit Emotional Support
Owned Home Emotional Support Owned Home Case Management ,
Single Room Practical Support Skilled Nursing Medical Care
Occupancy Facility
Transitional Medical Care Residential Assist with Daily
Housing Hospice Activities ,
Shared/Group Money Shared/Group Money
Home Management Home Management
Emergency Shelter Mental Health Single Room Home Delivered
Counseling Occupancy Meals ,
Skilled Nursing Home Delivered Transitional Practical Support
Meals Housing
Residential Hospice Assist with Daily Emergency Mental Health ,
Activities Shelter Counseling
58 '
Contra Costa County HN/AIDS Housing Plan
Case Manager Survey Results
' As of December 23, 1995, the Contra Costa County Health Services Department AIDS
Program had received 16 `Case Managers and Services Providers" surveys completed by
' service provider and case management agencies. (This figure is believed to be very
representative of the existing network of service providers serving people with HIV/AIDS
in Contra Costa.) The majority of survey respondents, or 75 percent(n=12) offer case
' management services. Additionally, 50 percent (n=8) of respondents provide emotional
support services and 44 percent (n=7) provide practical support services.
' Respondents were asked to estimate the percentage of their agencies', non-housing
services to people living with HIV/AIDS. The average of the percentages given was 65.5
percent with nine, or 56 percent of respondents indicating that 100 percent of their
' agencies' services are provided to people living with HIV/AIDS.
Findings of the survey
When asked to rank the types of housing assistance most needed by their clients,
respondents gave higher rankings to `emergency/ short term financial assistance for rent
and utilities', `shared houses/apartments with little or no on-site support services', and
' `subsidized independent living in an apartment with no on-site support services'.
According to these responses, it appears as though service providers support the desires of
most clients(as per the HIV/AIDS Housing Survey results) for independent living
' situations and minimal on-site support service.
It is also interesting to note that although as many as 53 percent of HIV/AIDS Housing
' Survey respondents indicated past and/or present drug use, Case Managers and Services
Provider Survey respondents gave relatively low rankings to the `housing program that
tolerates drug/alcohol use off premises', and `clean and sober housing program' options.
' In terms of barriers to access housing assistance, respondents ranked inadequate rental
assistance as the greatest barrier.
When asked to rank, in order of importance, the services required for their clients to
1 maintain an independent housing situation for the longest feasible period, respondents
scored `protective payee/money management' as the most important service. `Alcohol and
drug treatment/counseling' received the second highest ranking. These responses
' underscore a reality for many people living with HIV/AIDS in this County: as the
proportion of income to housing costs approaches one and as alcohol/drug use continues
59
Contra Costa Count HIV/AIDS Housing Plan ,
to be a competing priority for personal funds, the combination of money management and
drug treatment/counseling services has become a significant need. It appears that while ,
service providers want to support their.clients' desires for independent living, they
recognize that it is not a feasible option for this population without appropriate
supportive services. '
Conclusion '
The HIV/AIDS Housing Survey found that low income people living with HIV and AIDS
in Contra Costa County face substantial barriers when seeking and keeping housing that is ,
safe, meets their needs, and is within their budget. Poverty, the challenge of substance
abuse, perceived or actual discrimination, limited options for families, and the physical
devastation of HIV/AIDS combine to create homelessness and unstable housing among '
people living with HIV and AIDS in Contra Costa County.
1
1995 Title IFMA Supplemental Application,CARE Act clients,first quarter Fiscal Year 1994. ,
4 HIV/AIDS Epidemiology Profile of the East Bay, 1994.
l Oakland Ryan White Title I EMA Needs Assessment, 1994.
4 Tessler,RC and Dennis,DL A Synthesis of Research Concerning Persons who are Homeless and Mentally 111.National
Institutes of Mental Health,Rockville,MD;(1989) ,
3 Elders,GA&Sever,JL,AIDS&Neurological Disorders.an overview.Annals of Neurology 23(Suppl):S4-5-6.Nov.
1988.
6 Contra Costa County AIDS Epidemiology Report. '
1
60 '
' Contra Costa County HIV/AIDS Housing-Plan
)v:•.'•7+%rhr y:>yt?;ryfi);:;:'•.••,•i{�ikn�%:%h rf•
viSiiii>:f??:::i:???:X=??i::•i:;'{ii:i?`\j;`-:rL??ii;:i
h ' a► rovider Survey Results
`i
This section of the plan presents the results of surveys of housing providers from
across Contra Costa County.
Methodology and limitations
The survey was sent to 28 nonprofit and other developers of affordable housing active in
the East Bay Area on September 22, 1995. A follow-up survey was sent to 19
non-respondents on December 20, 1995. Fifteen (15) developers had responded to the
survey, representing a 54 percent response rate.
Limitations to the survey application include a discrepancy in responses. For example,
some respondents placed senior/disabled housing in an"other" category, rather than by
unit size. In addition, rather than responding in the negative, some agencies simply
skipped questions on the survey which they felt did not apply to them.
The following summarizes the main findings of the survey.
Experience with development of affordable housing
Contra Costa County surveyed nonprofit developers with experience creating affordable
housing. Of those agencies responding to the survey, only one indicated they have no
development experience in Contra Costa County. Four agencies currently have projects in
development; four have completed one acquisition, rehabilitation, or new construction
project; three have completed 2-3 projects and five have completed 4 or more projects.
61
Contra Coat&County HIV/AIDS Housing Plan
All responding agencies had development experience in other counties, ranging from
projects currently in development to completion of 4 or more projects. ,
The projects these developers have completed or in development in both Contra Costa
County and other jurisdictions cover a range of options, as illustrated in Table 1. Other
housing owned or developed includes farm worker housing, housing for seniors/disabled,
and single-room occupancy(SRO) housing.
Table 1 '
Type of Housing Project Number developed Number Owned '
Group homes 6 4
Single family rental 3 16
2 -4 Unit multifamily rental 1 4
5 - 20 Unit multifamily rental 10 17
20 - 50 Unit multifamily 15 79
housing
Transitional.housing 7 126
The survey identified the following HIV/AIDS-specific housing experience, although not '
all of this experience is specific to Contra Costa County.
• 1 agency provides 14 group home beds for people living with HIV/AIDS; '
• 2 agencies provide a total of 17 units in 5-20 unit complexes dedicated for '
people living with HIV/AIDS;
• 1 agency provides 20 SRO units fbr people living with HIV/AIDS and '
• 1 agency provides 24 units for persons with functional limitations due to a
physical disability. These units are not limited to people living with
HIV/AIDS, although at the time of survey completion all residents
currently did have HIV/AIDS.
62
Contra Costa County HIV/AIDS Housing Plan -
Although not all these programs are in Contra Costa County, the information illustrates
1 the capacity which exists in the County.
Provision of supportive services
Only four housing development agencies report providing any support services directly to
residents of assisted rental housing.
• The most common services are practical support, emotional support and
service coordination, which are each provided by 3 agencies.
' Case management services, money management, mental health and
substance abuse counseling, and assistance in daily living are all provided
by 2 agencies '
• The majority of agencies provide only one service, including transportation
services, pre-vocational activities and activities for children.
1 Only three agencies provide services specifically for people living with HIV/AIDS: one
provides emotional support; one provides mental health counseling; one provides service
coordination; and one provides transportation services.
Seven agencies report providing support services to residents through formal agreements
' with service providers to people living in permanent or transitional affordable housing,
including case management, money management, practical support, emotional support,
medical care, mental health counseling, substance abuse counseling, and assistance in daily
' living. In addition, one agency provides nutritional support and job training; one provides
food; one provides transportation; two provide service coordination/referrals; and one
' provides SSI advocacy and legal services.
Four agencies report providing support services through formal agreements with service
providers, to people living with HIV/AIDS living in permanent or transitional affordable
housing, including two which provide case management, money management, practical
support, medical care, substance abuse counseling, and assistance with daily living. Three
' agencies provide both emotional support and mental health counseling- one provides
transportation and service coordination; one provides nutritional support and job training.
63
Contra Costa County HIV/AIDS Housing Plan '
Agency plans to develop affordable housing for people living with HIV/AIDS
Five agencies report they would consider or are considering providing supportive services
as part of the development of supportive housing for people living with HIV/AIDS; seven
report they would consider or are considering developing/owning/managing such
housing, including two agencies which are considering participating in both aspects. Only
one agency explicitly indicated they are not interested in this aspect of affordable housing,
although seven respondents left this section blank.
• One agency indicated they currently do not have a project identified.
• Another agency is working to develop five units in the South Lake Tahoe
area. '
• A third agency is developing 50 units, affordable to households with low,
very-low, and extremely-low incomes, within a large multifamily rental
complex in San Francisco.
• A fourth agency is working to develop 29 units in a large multifamily rental
property, affordable to very-low and extremely-low income households,
including 10 units reserved for people with HIV/AIDS in West Contra
Costa County.
• A fifth agency is developing 10 hospice units for extremely-low, very-low,
and low income households in Berkeley. '
• A sixth agency is working to develop: 20 units of rental housing affordable
to very-low income households; and 20 units of transitional housing '
affordable to very-low and low-income households,both in East County.
• A seventh agency is in pre-development on the following three projects: 12 '
units of multifamily rental housing for very-low and extremely-low income
households in Central Contra Costa County including 11 units reserved for
people with HIV/AIDS; 8-12 units of either group home housing or '
multifamily rental units affordable to very-low and extremely-low income
households, in Central or West Contra Costa County; and 6-8 units of
group home housing or multifamily rental housing affordable to very-low
and extremely-low income households in Berkeley.
Note that not all of these projects are in Contra Costa County.
64
Contra Costa County HIV/AIDS Housing Plan
Perceived barriers to development of affordable housing for people
living with HIV/AIDS
' Meeting the housing needs of people living with HIV/AIDS however, is seen by some
providers as challenging. Many of the issues identified by providers are outlined in the
`Context of HIV/AIDS Housing in Contra Costa County" section of this plan, and include,
1 in order of the number of respondents identifying the barrier:
#1 Long-term funding of services;
1 #2 Lack of politically feasible sites;
#3 Lack of financially feasible sites;
#4 Unfamiliarity with [other] housing developers or service providers that
' could be partners in the development and management of affordable
housing for people living with HIV/AIDS; and
1 #5 Unfamiliarity with the needs of persons with HIV/AIDS.
' Additional barriers included inadequate fiscal and/or administrative systems, inadequate
staffing, the limited amount of available development funding, community concerns, and
need for community outreach and approval in selected jurisdictions.
' One agency with significant experience in the provision of housing forspecial needs
populations, including people living with HIV/AIDS, is concerned with the need for a
housing continuum -group homes, independent living, hospice services, transitional
housing-within the community. They identified the legally-required community process
' as an enormous hindrance in the development of such housing, due to community
concerns, and related homophobia; as well as the issue that the community process results
in labeling future residents as having HIV/AIDS.
An agency which has been researching the possibilities of developing housing for people
living with HIV/AIDS has found two issues to be especially problematic: ensuring ongoing
' support service funds to serve future residents; and coordinating the worlds of service
provision and development funding into single projects.
65
1
Contra Costa County HIV/AIDS Housing.Pian .
1
Agencies which have had experience developing and operating housing for people living
with HIV/AIDS, cite the following project operations issues:
• Attracting and retaining appropriate tenants, especially people who are
clean and sober, was a concern for the community and the agency both;
• Unit retention in the event of disease progression/tenant hospitalization;
• Unit vacancyand tenant transition to facilities designed to provide
g
comprehensive medical care; ,
• Legal or other issues of providing hospice care in existing units; and
• Death of tenants in their units.
Addressing perceived barriers to development of affordable housing for people ,
living with HIV/AIDS
Housing developers were asked to rank possible strategies to address barriers to the
development of housing for people living with HIV/AIDS. These strategies are listed
below, again in rank order: 1
#1 Technical assistance in the areas of funding applications, licensure
requirements, and program design; 1
#2 Training in the needs of people living with HIV/AIDS;
#3 Assistance in identifying housing/services partners or consultants and
assistance in identifying politically and/or financially feasible sites; and
#4 Training in affordable housing development. ,
1
1
1
66
1
' Contra Costa County HIV/AIDS Housing Plan
}"4:S<t:ii{p.in;:i•';':{}ii'.is\.F^.±'i•.{�++t(�ij:YY
Housing in Contra Costa County
S1v:'rH S,S',. v riii?t`! ^:i:Y• •`M1.-:
...................
"I have a sleeping bag and you just wake up and hope it will be warm. You go to bed
hoping that it will get better, but eventually you want to die. You get grubby, a little
stinky, and nobody wants you around I miss being warm. Going to the bathroom is
a hassle. My T cells are down to 4, and I just may not wake up one morning in the
cold Maybe I'll be blessed. "
—East County Consumer Focus Group participant
This section of the plan provides an inventory of the current `continuum of HIV/AIDS
housing and resources in Contra Costa County. It includes:
• definitions of the types of housing covered in the continuum;
• issues specific to HIV/AIDS for each type of housing;
• an inventory of current and planned units; and
• a summary of gaps for each type of housing.
Information to create this inventory of HIV/AIDS housing in Contra Costa County was
gathered in a number of ways: through input from the community-based planning group,
from the focus groups and site visits, and from resource directories and other information
sources. The gaps listed in this section of the plan were developed through a consensus
process during the planning group meetings.
i
69
Contra Costa.Count HIV/AIDS Housing Plan
The continuum of HIV/AIDS housing in Contra Costa County
The following provides an overview of the total number and type of housing beds/units ,
reserved for individuals with HIV infection or AIDS in Contra Costa County.
HIV/AIDS Specific Housing Resources in Contra Costa County '
Type of Resource Total Number of Units Available
Emergency shelter beds None
Emergency vouchers and assistance 2 Emergency voucher and assistance
programs '
Transitional housing 6 Group home beds
4 Current
21 In development
Permanent housing 180 Tenant-based Shelter Plus Care
certificates for homeless people with
HIV/AIDS, mental illness and/or
substance abuse
Skilled nursing and hospice beds 2 - 7 Beds
HIV/AIDS-specific services are extremely limited. In addition to these HIV/AIDS-specific
sites and resources, there are the following non-AIDS specific programs and services
available for people with disabilities: 280 emergency shelter beds for men, women and
families, 4 non-HIV/AIDS specific emergency housing voucher programs, 17 transitional
housing programs, and over 1,650 permanent assisted rental housing units. Although these
resources are not specifically designed for people with HIV/AIDS, they may be used by
them.
Please note that the information in this section of the plan is not representative of all
housing programs which have been used by people living with HIV/AIDS over the course
of the epidemic. It is likely that nearly every low income or special needs housing
program in the County -- from battered women's shelters to public housing units
apartments -- has provided homes to people living with HIV/AIDS and their families, '
whether or not units were reserved for this specific population.
70
Contra Costa County Housing IMAMS sin Plan
The Appendix of this plan includes inventories of Assisted Rental Units and Emergency
and Transitional Housing as well as street sheets. These documents provide information
about housing programs and services which may be accessed by people living with
HIV/AIDS although their programs are designed for low-income and/or homeless
' populations, not specifically people with HIV/AIDS.
The following is a description of the HIV/AIDS-specific housing resources and the
' non-HIV/AIDS specific resources which were mentioned by people living with HIV/AIDS
and service providers as regularly accessed by people with HIV/AIDS. Included is a brief
' exploration of the HIV/AIDS issues particular to that type of housing, gaps in the current
continuum, and comments from participants in the focus groups illustrating their concerns
and desires.
Emergency Housing Resources ,
Definition:
Emergency resources include both shelters and vouchers for a very temporary place to
spend the night. Emergency housing is designed to keep people off the streets when they
are confronted with an immediate loss of housing due to eviction, release from an
institution, or the dissolution of a household. For people who are already homeless,
emergency housing provides immediate housing and a potential first step away from living
on the streets. The core of emergency housing is homeless shelters; additional resources
include hotel/motel vouchers for short stays in single room occupancy(SRO) hotels.
Emergency resources also include vouchers to help individuals meet emergency rent and
1 utility payments on a short-term basis. These programs typically have an annual cap, and
demand always exceeds supply by a wide margin.
HIV/AIDS issues:
' While there are no shelter beds specifically dedicated to people with HIV/AIDS,people
can obtain emergency housing in existing shelters—if they are not full. However, shelters
which are not designed to meet the needs of medically fragile individuals are largely
inappropriate for people with HIV/AIDS because these settings can pose a health risk to
persons with compromised immune systems,particularly TB. In addition, shelters often
require individuals to leave the premises during the day, which can be very difficult for
those who are ill.
71
Contra Costa County HIV/AIDS Housing Plan
1
HIV/AIDS-Specific Emergency Housing ,
Zero emergency shelter beds set
Total Resources aside for persons with HIV/AIDS
Two sources for emergency
assistance and hotel/motel vouchers '
.Location County wide
Low income persons with
Target Population HIV/AIDS who are homeless or
about to become homeless
Resources: '
There are approximately 280 additional emergency shelter beds for homeless single men,
women and'families; 20 beds targeted for the mentally disabled; 24 beds targeted for i
battered women; and 95 beds for people recovering from substance abuse. None of these
emergency beds are specifically reserved for people with HIV/AIDS, although they are ,
accessible to them.
In spite of their relative inappropriateness, emergency shelters provide an important ,
resource for homeless persons living with HIV/AIDS. Unfortunately, accessing emergency
shelter is very difficult for all persons in Contra Costa County. Currently, an answering
machine takes names for the waiting list, which is limited to 20 names. Individuals must
call back each week to keep their name on the list. One individual who answers the
emergency housing request line characterized the current system this way: "The bottom
line is that there is not service you can imagine how frustrating it is for the homeless ,
person. "
Emergency voucher resources for individuals with HIV/AIDS are available but are limited ,
in the length and amount of assistance and are in high demand. These emergency resources
each have different requirements about length of stay or the number of times people can
use a voucher, but each is a short-term, stop gap measure. '
72
Contra Costa County HIV/AIDS Housing Plan
• PittsburgPre School Coordinating Council in Pittsburghousing
advocacy services in East and Central County using Ryan White CARE
Act funds. Emergency housing vouchers can be used for a
one-to-seven-night stay in a hotel or motel. An additional $18,000 in
emergency assistance is available for eviction prevention, initial housing
costs, rent and utilities: Case managers also work with clients to assist
them in securing and maintaining affordable housing. Funds are available
County-wide to people living with HIV infection and AIDS who also meet
income eligibility requirements.
• Catholic Charities of the East Bay provides housing advocacy services in
i West Contra Costa County to the homeless, marginally housed, or those at
risk of becoming homeless. Emergency vouchers are provided for up to
I seven nights stay. Rental assistance is provided to assist with deposits, first
month's rent and rental arrears.
• Contra Costa Health Services Department, which administers the
County's emergency shelter program, is developing a toll-free line for the
homeless which will facilitate access to the emergency beds which are
1 available. In addition, the AIDS Program provides direct case management
services and coordination of housing referrals for people living with
HIV/AIDS.
Although not HIV/AIDS-specific, these voucher programs are regularly accessed by
people living with HIV/AIDS: .
• St. Vincent de Paul and the Pittsburg Alliance of Technology and
1 Homeless Services (PATTY) provide emergency vouchers for up to 3
nights of motel stay and up to $300 in short term rental assistance to
homeless families and individuals and those at high risk of homelessness in
' East County.
• SHARE provides vouchers for 2 nights in a motel for homeless persons in
Central County.
• Shelter Inc. can provide motel vouchers for up to 5 nights for individuals
and families, County-wide.
' 73
Contra Costa County HN/AIDS Housing Placa
• Crisis and Suicide Intervention also provides County-wide motel ,
vouchers to individuals and families, with no set limit to the number of
nights.
The County Health Care for the Homeless program schedules regular visits to area ,
shelters, including the Concord_Shelter and the Richmond Rescue Mission. ,
Emergency Shelter Gaps ,
There are not enough shelter beds in the County for people without a place to stay the
night, regardless of their HIV status. Even though some people who attended the
community planning meetings felt that shelters were inappropriate for people living with
IMAMS, these resources are vital to people who would otherwise be on the streets.
Gaps in the emergency housing continuum exist. For people with special medical needs, ,
the gap in emergency shelter is even more acute.
• There are no emergency shelter beds set aside for people living with
HIV/AIDS.
"Emergency means.today. You are already dying and then you get a death ,
wish!"
• There is no emergency shelter in East County, and no transportation
services to allow individuals in need to access an emergency bed.
"It's sag but I tell my clients to call the hotline for the homeless. I try to ,
get them in Phoenix Rescue Mission in Richmond—but if they don't have
a way to get there I can It help. I do whatever I can, but it is really hard ,
because there are no options. "
•
People living with HIVAIDS who are well enough to leave the hospital '
but not well enough to be alone at home have no `step down' or
intermediate care options.
`I was released from the hospital without a place to go. I had no one. It
would have been nice to have a little assistance then."
74 ,
Contra Costa County HIV/AIDS Housing Plan
• There is a shortage of hotel and motel vouchers for those in need and a
lack of transitional and permanent housing options for those able to leave
the emergency housing system. People with HIV/AIDS state that the
emergency voucher system is not quick to respond to their needs.
"There is too much red tape, especially since they are going to give you
nothing anyway."
' There are not enough daytime privileges for people with chronic illness at
local shelters.
"It would be nice to have a place to be where you can have a cup of
coffee,put[your issues]on the table and relieve your stress".
• Emergency shelter effectiveness may also be hampered by a decrease in the
1 amount of time a person is able to use the program, from 6 months to 90
days.
' `I know that if I don It do well I will get arrested again and get back in
prison. I want to go forward I want to have my private life without ten
people hanging out. I came home and there were four people shooting
dope in my bedroom. I said `this ain It no shooting gallery—I got a nine
year old girl coming home from school!I am going to call the shelter
every day at 4:00 to try and get a bed The shelter lets you stay 90 days
and I have already used 20. "
Transitional Housing Resources
Definition:
Transitional supportive housing provides an interim home for people who are leaving
emergency shelters but are unable to move into permanent housing, or for people trying to
gain access to, or exiting from, mental health or substance abuse treatment programs.
Transitional programs can provide housing for a period of several weeks or months, up to
two years. These programs are often targeted to a specific subpopulation, and residents
can be required to participate in counseling and other programs to assist them in
1 overcoming a specific problem, such as substance abuse, or to receive more general life
' 75
Contra Costa Count HIV/AIDS Housing Plan '
skills training to prepare for a move into more independent permanent housing such as
Section 8 or a rental apartment. Many people entering transitional housing programs have
complex histories, including substance abuse, prison records, and little previous success
maintaining stable housing. These individuals need a great deal of assistance as they
transition to permanent housing. As in other areas of the continuum, the families have
special needs. Larger and multi-bed room units are needed to house families with
children, and many transitional housing programs have been developed with single adults
in mind. For women with HN/AIDS whose children are not infected, additional child ,
care support can be needed. For children who are themselves infected or diagnosed with
HIV/AIDS, the medical and developmental issues can be even more complex, and may
require onsite child care, family counseling, and medical care. ,
HIV/AIDS issues: '
As the HIV/AIDS Housing Survey illustrated, people living with HIV/AIDS in Contra
Costa County face a constellation of complex social, health and personal crises. Poverty, ,
substance abuse, family size and declining health impact an individual's ability to remain
independent. Housing designed to assist people with HIV/AIDS to transition to ,
permanent, independent housing must include an array of supportive services. Many
transitional housing programs for people with HIV/AIDS offer case management,
emotional and/or practical support, drug and alcohol counseling or treatment, mental ,
health counseling and rehabilitation and vocational training programs, both on-and off-site.
Resources: '
There is one 6-bed group home which provides long-term transitional housing for people ,
living with HIV/AIDS in Contra Costa County:
HIWAIDS-S ecific Transitional Housing
g
Total Resources 6 Group home beds
Location West County
People who need assistance to move
Target Population from homelessness to permanent
housing ,
76 ,
Contra Costa Count HIV/AIDS Housing Plan
r
_ •' Amara House(Catholic Charities of the East Bay)provides six transitional
beds for very low income homeless persons with HIV/AIDS in
unincorporated West County. This is.a group home setting and services are
' provided off-site. The program requires residents to be clean and sober.
rAlthough not MV/AIDS-specific, according to the Contra Costa Consortium
Consolidated Plan, the following programs offer services which may be accessed by
people living with HIV/AIDS. Additional programs are available in the City of Richmond.
5 transitional housing units for adults who are both substance abusers and
• g
mentally ill.
r
• There are 10 transitional programs with 168 beds, including those housed
in Detox programs, for men and women in recovery from substance abuse.
• 10 transitional housing beds for the mentally disabled;
• Phoenix Housing provides a two-year transitional housing program for
people with mental illness.
' There are 6 transitional housing programs for homeless individuals and
families.
rThere are no residential drug treatment slots set aside for people with HIV/AIDS in
Contra Costa County, although people living with HIV/AIDS who disclose their HIV
status receive preference.
Transitional Housing Gaps
• There are limited transitional housing programs for people living with
' HIV/AIDS in Contra Costa County.
J's homelessness is very hard on his daughter who fears for her father's
safety and health. `I can't put him up where I live and I want to help take
care of him, but I can't tell my roommate. I can't jeopardize where I live.
r It is so frustrating that I can't help my father the way I want to. I love him,
and it hurts to see him living like this. The thing I would like to see for him
is to get him his own place. " The situation is made more frustrating to M
because she works for a local social service agency and is well connected
r 77
1
Contra Costa County HVtAIDS Housin Plan : .
r
to HIV/AIDS services in Contra Costa County. Even with her knowledge
and connection there is little she,can do for her father. Her father's
homelessness has made M see things differently, "You look at the
homeless and you're kind of scared But now it is my dad "
• There is no transitional housing option for people living with HIV/AIDS
who are currently using drugs or alcohol, or for people living with
HIV/AIDS who have mental health issues(sometimes called`dually or
triply diagnosed'). This type of housing requires 24-hour supervision and
on-site supportive social services. ,
"We need something for people who are still using, because they are; and-
they can It all stop. "
• There is no transitional housing for people living with HIV/AIDS who are
leaving incarceration or have a criminal history—which makes locating and
succeeding in permanent housing more difficult. ,
`I could have dealt with being homeless after I got out of prison if I didn't
have AIDS I have done it before. But AIDS gets in your mind Being ,
homeless and not being able to sleep is the worst. You wake up with
miserable thoughts. You try to be normal and you say you don't want to
hurt anyone and you don't want to—but it is hard Homelessness is a '
disease that the government has created"
• There are no HIV/AIDS set-aside slots for substance abuse treatment and
no housing designed to meet the needs of people with HIV/AIDS coming
out of residential substance abuse treatment. ,
"We don't have to be users. Let's be real. I say I'm not going to shoot no
more dope—but excuse me, the urge is still going on. You try to put your e
life back together, but some of us are strong and some of us ain't. And if
you don't have a house it's even harder. "
78
Contra Costa Count HN/AIDS Housing Plan
Permanent Housing Resources
i -
Definition:
Simply put, permanent housing means a home orapartment. In housing planning terms,
permanent housing is defined as housing which has no limit on the length of residency and
can be part of a broad array of independent and supportive living arrangements. These
include independent living in homes and apartment units, small group homes, single room
occupancy(SRO) residential hotels, and sites for which the Residential Care Facilities for
tthe Chronically Ill (RCF-CI) licensure category is appropriate. Some programs provide a
minimum amount of support services while others provide a full range, including 24-hour
on-site residential management. Permanent housing programs may require residents to
participate in at least a minimum level of support services, such as weekly house meetings;
others provide support services such as money management, case management, mental
health counseling, and drug and alcohol counseling and treatment.
HIV/AIDS issues:
Many of the issues outlined in transitional housing exist in the area of permanent housing;
' chief among them are lengthy waiting lists, a lack of available units, and the tenants'
declining health and income. While people living with HIV/AIDS, like most of us, would
prefer to live independently for as long as possible, their unique health challenges may
' require transition to more supportive care settings. Allowing people to remain safely in
their own homes as long as possible and then transition to more acute settings is one of the
primary challenges of the HIV/AIDS housing system.
i
Resources:
1 There are currently 4 permanent housing units dedicated to people living with HIV/AIDS
in Contra Costa County.
79
Contra Costa County HIV/AIDS Housing Plan
HIV/AIDS-Specific Permanent Housing Resources
4 Current units
21 Units in development
Total resources 180 Tenant-based Shelter Plus Care r
certificates for homelessness
individuals with disabilities, including
HIV/AIDS.
Current units: East County(Pittsburg)
Location of resources Units in development: Central County
(Pacheco)West County(El Cerrito)
Clean and sober men and women, ,
Target population homeless people with HIV/AIDS, and
low income people with disabling
HIV/AIDS.
• Shelter, Inc. provides four units of independent permanent housing in East
County for very low income people living with HIV/AIDS who are
ambulatory.
• The HousingAuthority of Contra Costa County provides tenant based
ty ty
rental assistance through the Shelter Plus Care program for up to 180 units
County-wide. Shelter Plus Care is designed to assist homeless people with ,
disabilities, including HIV/AIDS, mental illness, and/or substance abuse.
An additional 21 units of permanent housing are currently in development, including the
first housing dedicated for people living with RMAIDS in Central Contra Costa County. ,
• Aspen House sponsored by Resources for Community Development,
(RCD) will provide 11 one-bedroom units for people living with ,
HN/AIDS in the community of Pacheco (Central County). RCD will
provide on-site management, while supportive service coordination will be
provided by Catholic Charities of the East Bay. '
• Rubicon Inc. is planning to acquire and rehabilitate an existing, primarily
vacant motel in El Cerrito (West County) in order to develop 28 units of
single room occupant (SRO) housing affordable to very low income
homeless adults. Ten of the units will be reserved for people living with
HIV/AIDS. Committed development funding resources include HOPWA,
80 ,
Contra Costa Count HIV/AIDS Housing Plan
County CDBG, and Low Income Housing Funds. In addition, Rubicon has
_ received allocations of HUD McKinney Act Supportive Housing Program
funds and SRO Moderate Rehabilitation Program Section 8 Certificates. If
funding applications are successful, site acquisition is estimated for
September, 1996.
1 Although not HIV/AIDS-specific, these programs offer services which may be accessed by
people living with HIV/AIDS:
' Riverhouse in downtown Martinez, which was originally developed as
affordable housing for the elderly and/or disabled, provides housing for
persons with disabilities, including HIV or AIDS. There are no support
services provided on site.
• There are an additional 1,650 County-assisted rental housing units
available to seniors and disabled adults through the Contra Costa
Consortium. It should be noted that units are designed for seniors and/or
the disabled and do not include any set-asides specifically for people
disabled with AIDS.
• Phoenix Apartments in Concord has 11 project-based Section 8
certificates for people who are mentally ill. The Phoenix Clean and Sober
House in San Pablo has 5 units for people who are dually diagnosed with
' mental illness and substance abuse.
Permanent Housing Gaps
There are clearly insufficient numbers of permanent, affordable HIV/AIDS housing units
in Contra Costa County.
• There is too little affordable permanent independent housing available to or
' designed to meet the needs of low-income individuals and households in
Contra Costa, including people living with HIV/AIDS.
' `I used to make $30,000 a year selling cars. I got pneumonia one day and
I found out it was AIDS. Since then it has all fallen apart. And I ask
myself How did this happen?'All I want is a roof over my head I'm
clean. I have no record I am just an average guy. And I just want
someplace to stay the night, but I can't get the first and last[month's
rent]and security[deposit]together. I just will never have that kind of
money. "
81
Contra Costa County HIV/AIDS Housing Plan
• Landlords are reluctant to provide housing to low income people and even
more reluctant to rent to people living with HIV/AIDS. ,
"I meet with landlords regularly to try and find places for my clients—but
they don't want low income people living in their apartments and they ,
don't want people with AIDS even more."
• Zero drug tolerance policies make it even more difficult for people who
continue to use drugs to find permanent housing. There is no `harm
reduction' model housing project. This model of housing allows people to ,
live in a safe environment while striving to achieve sobriety or to reduce
their drug use, provided they do not place others at harm or use illegal
drugs on the premises.
One man gets his health care through the Haight Ashbury Free Clinic. He ,
says that substance abuse services are better in San Francisco: "They
would put you in one of their houses and then supervise you to come off
drugs. They help you through it."
• There are no permanent supportive housing options for people who are
triply diagnosed with HIV/AIDS, mental illness, and substance abuse.
One focus group member said the best way for him to deal with AIDS and
addiction is having his own place far away from the drug scene in
Richmond "The remedy for the whole thing is that 1 have to be alone. I
have to be far away. But it don't cost me nothing but,$1.25 to come back
in on the bus and run through the jungle."
• Focus group respondents were unanimous in feeling that housing and
support services are better in San Francisco, which receives a great deal
more federal funding for HIV/AIDS services and has a stronger network of '
community-based service organizations. The proximity of this city to
'Contra Costa County makes the sense of neglect even stronger.
"We need to be more like San Francisco. Aey take care of their people
there. They don't care about us here because it is a poor city. Period "
r
82
Contra Costa Count HIV/AIDS Housing Plan
• There is a need for more,rental subsidies, both shallow and full so that
people can live independently. There are no permanent rental assistance
grants.
"We need studio apartments and what not. Individuals. Where they don't
have to necessarily share with somebody, because in some cases you are
also taking on that person's burden. And that can exacerbate the illness."
v
• The typical waiting list for Section 8 certificates and vouchers is longer
1 than the average life expectancy of many people disabled with HIV/AIDS.
There is no Terminally III Section 8 Program.
' "We need an expedited program where you can jump ahead on the list to
get Section 8, which we don't even have here at all. We can't get on
1 Section 8, there is like a two or three year waiting list."
• For people who do have a Section 8 certificate or voucher, locating an
apartment or home is extremely difficult.
"This is an ongoing situation. The issue isn't just AIDS. They are labeling
people as drug addicts. "
• There is anecdotal evidence of ongoing discrimination against people living
with HIV/AIDS who seek housing
' `It is AIDS discrimination. I was living in a hotel in Point Richmond and
one of the residents said I had messed up the bathroom because I had
1 AIDS. I was thrown out. I was never late on my rent, but they ended up
using the AIDS against me. I took them to court for five months. They
turned off my heat to force me out, but by the grace of God I found a
' place in EI Cerrito. It is$500 a month and I only get$614—but it is clean
and I don't have to deal with anyone hassling me because I have AIDS."
' Cities in the County cite a shortage of affordable supportive and
independent housing for people with all disabilities. In addition, few units
' are available on the ground level, and the cost of rehabbing older, existing
units to make them handicapped accessible may be prohibitive.
83
Contra Costa County.HIV/AIDS Housina Man
Skilled Nursing Care and Hospice Resources
Definition:
Skilled nursing facilities which are sometimes called nursing homes provide 24-hour
5 g g ,
nursing and attendant care services. Residents are placed there because they are too sick
to stay at home, but don't need immediate access to the sophisticated diagnostic and
life-support services of a hospital. Skilled nursing care is defined as nursing care to
patients who are not in need of acute(hospital) care, but who require frequent medical ,
intervention, and around-the-clock licensed nursing services. Each patient is under the
care of an attending physician. Care at skilled nursing facilities may also include
occupational, physical, and respiratory therapies; meals and nutrition counseling; hospice
care; and activities programs.
Hospice can be either a place or a type of care delivered in the home. Hospice is based on ,
a philosophy of terminal care that.emphasizes quality of life, limits invasive procedures,
and offers only palliative(pain relief) measures. "Hospice care focuses on alleviating
physical pain and symptoms while providing psychosocial, practical, spiritual, and
bereavement support. It provides an interdisciplinary team approach: physicians, nurses,
social workers, nurse's aides, pastoral care, therapists, and volunteers are all involved with
the patient.
HIV/AIDS Issues:
Providing long term care for people living with HIV/AIDS is a very complex issue, in part
because reimbursement for this service varies depending on the setting and degree of care
provided. The cost of this level of care is very high and because reimbursement does not
fully cover the cost, a stand-alone hospice is virtually infeasible in California. Rather than
provide a full discussion of this topic here, Appendix IV includes an overview of the long
term care reimbursement structure in California and recommendations for how to obtain
blended reimbursement streams to increase the feasibility of such a program.
In addition to the reimbursement issues which make many facilities reluctant to serve
people living with HIV/AIDS, placing this population in traditional nursing homes geared
for the elderly also presents problems. The recreational activities designed for these r
populations are different, and the cultural difference between people affected by
HIV/AIDS(primarily gay men and people with a history of substance abuse) and the frail
elderly can also present problems. Staff of homes geared for the elderly may not have
received sufficient training to be sensitive to the needs of people living with HIV/AIDS or
to deal with the resulting tension between types of residents.
84 r
Contra Costa County HIV/AIDS Housing.Plan
L�
• There are not enough in-home health care and support services available
(' for very ill people with HIV/AIDS and AIDS-related dementia who would
L . be able to stay in their homes with support from care givers and volunteers.
• There is a general lack of information about what steps are needed to
i_.. create a licensable long-term care facility in the East Bay, particularly
among HIV/AIDS housing providers, HIV/AIDS service providers and
' those with expertise in skilled nursing facilities.
L
Housing Information, Referral and Advocacy Resources
' Definition: \
These services are designed to prevent homelessness by helping people locate housing
which meets their financial and physical needs or by advocating on their behalf. Services of
this type are available to individuals regardless of their disability status or affiliation
L with an agency or case management program. Typical services include eviction
prevention, housing rights advocacy and tenant counseling, and information and referral
services.
�j
HIV/AIDS issues:
I, For people living with HIV/AIDS, health and income and thus housing needs can change
rapidly. Most people with HIV/AIDS must access an array of complex and piecemeal
systems, including housing, health care, mental health, drug treatment and social services.
The simplicity of centralized information, referral and advocacy services is even more
important to those who are physically or mentally impaired. The typical length of waiting
lists for most public housing programs may be longer than the average life expectancy of
a person diagnosed with HIV/AIDS. This underlines the importance of proactive tenant
counseling and quick, efficient information, referral and assistance to get them into an
appropriate home.
r,
L✓
L;
87
Contra Costa Count HN/AIDS Housing Plan
Conclusion _
The continuum of HIV/AIDS housing in Contra Costa County has gaps in each area. '
Some gaps, such as centralized access to information about HIV/AIDS housing, or
transitional and supportive housing for people multiply diagnosed with HIV/AIDS and '
substance abuse or mental health issues, are specific to the needs of people living with
HIV/AIDS. Other gaps in the housing continuum affect all low- income people living in
Contra Costa County, such as the need for more permanent, affordable units of housing in '
safe neighborhoods, and supportive services that can help people with difficult pasts
succeed in housing. Additional units dedicated to people living with HIV/AIDS are needed
across the spectrum of the housing continuum and in each part of the County. Not all of '
these units need to be provided though programs specifically targeted to people living with
HIV/AIDS. The challenges are to target services to those most in need, to create
HIV/AIDS-specific housing programs with limited resources and to use existing,
mainstream, affordable and supportive housing more effectively.
i'Building or renovating a few apartments or helping people pay their rent will not be
enough. To truly make a difference in the lives of people living with HIV/AIDS in Contra
Costa County, housing and services must be seen as interdependent and, to maximize their
effectiveness, must be targeted to those most in need.
The Contra Costa County Multi-Year HIV/AIDS Housing Plan is based on these
principles. '
i'
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90
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Contra Costa County HIV/AIDS Housing Plan
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This section of the plan presents an overview of the major issues which will
influence the ability of the community to create the changes in the Contra Costa
' County HIV/AIDS housing continuum recommended by this plan. These issues are
complex and interrelated and include:
• funding for the development and continued operation of HIV/AIDS
housing;
' the importance of cost effectiveness to insuring the future of
current and planned HIV/AIDS housing; and
' the role of community acceptance and jurisdictional leadership in
the successful implementation of the plan.
'
Providing safe, affordable and appropriate housing for people living with HIV
infection and AIDS has been a major concern of the HIV/AIDS community for
years. In Contra Costa County, the housing needs of people living with
HIV/AIDS have been met, for the most part, by a relatively small group of
dedicated community-based organizations, nonprofit housing developers and
public agencies. Their foresight and commitment created the area's
BMAIDS-dedicated beds, and the community is indebted to them.
91
Contra Costa Count HIV/AIDS Housin .Plan 1
The final section of this plan makes specific recommendations to build on the work of
community-based organizations`and expand housing opportunities for people living with
HIV/AIDS in the County. Clearly, many complex issues and constraints—such as funding,
cost effectiveness and community acceptance—must be addressed for implementation to
occur. These issues are interrelated and must be considered together when making
recommendations.
For example, the size of a project to serve people with high needs (such as the disabled
people living with HIV/AIDS who are chemically dependent) may have ramifications both
in the area of initial costs and ongoing cost effectiveness and in the area of community
acceptance. Providing scattered-site housing through rental subsidies to meet the needs of '
this population may decrease initial capital development costs and increase community
acceptance, but it may be programmatically far less cost-effective in the long nun. Building
a larger facility may have high initial costs and may create a degree of community concern, ,
but it may allow the project to provide a higher level of service at a lower cost per resident
over a much longer period of time.
This section of theP lan discusses those critical issues and trade-offs. '
Funds are limited and decreasing, but local decision-making authority is
increasing and needs to continue becoming better coordinated
One of the most pressing challenges in the implementation of this HIV/AIDS housing plan
is how to fund the programs and projects that are called for and needed to expand and '
improve the HN/AIDS housing continuum in Contra Costa County.
Funds are limited '
The main sources of HIV/AIDS-specific housing funds in Contra Costa County have been
federal Housing and Urban Development agency grants, especially the Housing
Opportunities for Persons with AIDS (HOPWA) program. In Contra Costa County, '
HOPWA has been leveraged with Community Development Block Grant (CDBG) funds
for services, Emergency Shelter Grant (ESG) resources for operating funds, and HOME
funds for acquisition and rehabilitation. HOPWA funds follow the CARE Act Eligible '
Metropolitan Area(which includes both Alameda and Contra Costa Counties) designation
and are allocated under that formula to the City of Oakland. The City provides Alameda
and Contra Costa Counties HOPWA funds on a pass-through basis to help provide
housing and housing-related services to low income people living with HIV/AIDS. In
1995, Contra Costa County received $384,377 in HOPWA funds to support these
activities. Several trends are working to limit funding for HIV/AIDS housing:
92 '
Contra Co§ta County 11MAIDS Housing Plan
• While Congress and the Clinton Administration are proposing overall
funding cuts for all housing and entitlement programs, Ryan White CARE
Act and HOPWA programs are maintaining stable levels of funding for
1996. As the epidemic continues to grow, however, the number of cities
which become eligible for these funds is growing, but because funding is
flat, the amount of funds allocated to each community is smaller. As a
result, the demand on the CARE Act and HOPWA funds will continue to
iincrease.
• The division of EMA-wide funds is based on the proportionate ratio of
cases in each county to the EMU as a whole. As the number of HIV
infections escalates in Alameda County, the proportionate percentage of
EMA funds available for Contra Costa diminishes. This trend will continue
until such time as Alameda County gains control of the HIV/AIDS
epidemic.
iDiscussions at the federal level indicate that the HOPWA program may be
combined in`Block Grants' with other`special needs' housing programs at
HUD. Block granting will increase the level of competition for these scarce
resources because HIV/AIDS could be eliminated as a specific grant
program and be grouped together with other special needs populations,
such as the mentally ill. This could have the effect of making funding of
housing for people living with HIV/AIDS even more competitive.
• Other HUD grants which assist disabled and low income people are also in
jeopardy. MediCal, which pays for the majority of health care services for
people living with HN/AIDS, has been cut on both the state and federal
' levels and the benefit plan may be revised in this session of Congress.
In addition to these government resources, private foundations, churches and synagogues,
and community-based organizations play a fundamental role, particularly in funding
projects in the planning stage and providing a volunteer base. The burden on these
organizations and their memberships will continue to grow as community needs become
more intense and federal and state safety nets provide less. A more complete listing of
resources which can be used to address the County's commitment to HIV/AIDS housing
is included in Appendix III.
Successful implementation of this plan requires community groups, local politicians and
individuals to advocate for:
'
Maximizing the level of funds provided to local government under the
• g P
block grants;
93
Contra Costa County HIV/AIDS Housing Plan
• The input of community-based agencies that serve and advocate for people
living with HIV/AIDS.to influence decisions about how funds are spent;
and
• As much funding as possible to be made available specifically to provide
housing and services to people living with HIV/AIDS.
Coordination �s p
'n n ' important .
Funding for HIV/AIDS housing and services is complicated not only by the funding
shortage, but also by the number of federal, state, County and city government agencies
which are involved in administration and allocation decisions. The federal government
provides the vast majority of HIV/AIDS service funds through programs such as CARE
Act, HOPWA, MediCal and others. These programs are administered by different federal
and state agencies and each of these funding streams has its own set of regulations and
restrictions. Some of the federal funds are awarded competitively, meaning that the
County or city has to apply and compete with other jurisdictions for funds; while others,
including the CARE Act and HOPWA funds, are awarded to local government units based '
on the cumulative number of reported HN/AIDS cases.
The government agencies which administer these programs and funds also vary: on the
local level County governments generally coordinate and pay for health care and welfare
entitlements; both County and city governments generally pay for housing. CARE Act
funding decisions are made by the community-based Title I Planning Council. Each year,
the Council conducts an HIV/AIDS services needs assessment which sets priorities for
funding for Alameda and Contra Costa Counties.
Decisions about the use of HOPWA funds have been coordinated by the Contra Costa
County Conununity Development Department, using a competitive Requests for Proposals
(RFP) process. Funding to date has been based on annual community input and
consultation with the various community HIV/AIDS priority-setting bodies, including the
Title I Planning Council and the HIV/AIDS Consortium, and the entitlement cities.
This plan is intended to set HIV/AIDS housing funding priorities for five years for Contra
Costa County. It is important to note that similar plans have been completed in Alameda
County and the City of Berkeley. Once long range priorities are set, it is hoped that:
• Community-based providers can begin to develop housing programs that
meet those funding priorities and be assured that priorities for ,
funding—regardless of the actual level of funds available—remain
relatively stable over the planning period.
94
Contra Costa County HN/AIDS Housing Plan
• Additionally, community-based service providers can use the.plan to design
' housing-related supportive services which can help people with HIV
remain independent, meet the needs identified in the HIV/AIDS Housing
Survey and help ensure that quality housing and related services are made
available.
Trade-offs among different approaches to providing HIV/AIDS
housing—development costs, cost effectiveness and community acceptance
There are essentially two ways to provide more housing to people who need it: capital
development or rental assistance. Capital development means building new buildings or
rehabilitating existing ones. Rental assistance means providing subsidies to individuals that
enable them to rent housing that is available in the private market but is too costly for
them without subsidy. The divergent implications of these two choices follow:
Capital Development
• Requires both an up-front subsidy to buy and build or rehabilitate a
residence, and often requires ongoing subsidies for property management
and supportive services.
• Costs to develop an ap artment in Contra Costa County range from about
$80,000 to $140,000 per unit (new construction).
• Annual per-unit management costs(what it costs to keep the building
open) range from about$3,000-$3,600 for regular affordable housing to
$10,000 for licensed facilities,_and $18,000 for hospice and other
service-intensive residences.
' Costs will also vary depending upon the location of the building, whether it is being
brought up to licensing standards(see below), the cost of the property, and the extent of
rehabilitation required, if any. Rehabilitating an existing building may be as expensive as
new construction, depending on the condition of the building and the level of service to be
provided.
It is possible, however, to achieve economies(or savings) in service costs by
concentrating people in a single site or cluster in adjacent properties instead of scattered
throughout a community. A home health nurse, for example, can see all of his/her clients
in one location, thereby saving tirae and related salary and transportation costs, instead of
traveling from place to place to place.
95
Contra Costa County HIV/AIDS Housing Pian
In general, it takes a minimum of two years, and often three,for a capital development ,
project to get from planning to actually housing tenants. Sometimes, if a building can be
found that requires very little rehabilitation, the time can be substantially reduced; and
projects can open more quickly.
The primary advantage of capital development is that the units created will be permanently
available and'affordable for people living with HIV/AIDS. With respect to projects serving
extremely low-income individuals and families., monthly rental payments may not be �.
sufficient to cover even basic operating and property management costs without some
ongoing subsidy.
Rental Subsidies
• The initial cost associated with rental subsidy programs is generally less
.than that associated with housing development because rental assistance
programs do not typically involve any major up-front costs.
• In general, rental subsidy programs can be started quickly, with the primary
timing issue related to how fast those receiving subsidies are able to locate
suitable apartments.
There are likely to be some additional costs required to bring available r
• Y q g
apartments up to code, or make them accessible to disabled people.
• Providing rental subsidies requires long-term, ongoing payments for both
rental costs and supportive services; rental payments reimburse owners for
the costs of operating and managing the apartments and typically include
some owner's profit.
Costs may vary depending upon the type of rental subsidy established and the cost to rent
apartments. HUD programs, such as Section 8, set limits on the amount of rent that can be
charged for an apartment and also specify that tenants can pay only 30 percent of their
income for rent. Thus, under the Section 8 program, someone with an income of$600 per
month might pay$200 for an apartment that rents for$650, and HUD would pay$450.
This is considered a`deep' subsidy. Deep subsidies often cost as much as $6,000 to �.
$8,000 per family per year, making it expensive to.assist very many individuals or families.
In an effort to increase the number of people assisted, some communities have chosen to
serve more people with lower, or`shallow' subsidy levels. Thus a community might offer
shallow subsidies of a fixed amount of$200 for example. Tenants with a $600 monthly
96
Contra Costa County HIV/AIDS Housing;Plan
income might pay$450 for the apartment, while the subsidy program pays $200. Under .
' the federal HOPWA program, assisted tenants must pay 30 percent of their income for
rent (no more and no less). In order to use HOPWA funds for a shallow subsidy program
(where households may pay more than 30 percent of their income for rent)the City of
' Oakland (as the HOPWA grantee)would be required to obtain a waiver from HUD.
' Although future funding remains uncertain, both deep.and shallow rental subsidies are
used to create stable housing;the hope is that people would not have to move again unless
their health declined to a point where more intensive services were needed than could be
delivered in the home. That means that someone could potentially require a rent subsidy
for 10 or more years. If 100 individuals or families were assisted with deep subsidies
averaging$7,000 a year for five years, the total cost would be $3,500,000—the cost of a
new building! While the cost goes down with shallow subsidies, if 100 people were to use
a shallow rent subsidy program each year for ten years in Contra Costa, the cost is over
2.4 million dollars, and no long-term housing solution has been created. In contrast,
capital investment provides a very long-term or permanent source of affordable housing.
Barriers and feasibility of rental subsidies and capital development
Rental subsidy programs assume that affordable units will be available to people living
with HIV/AIDS once a subsidy is provided. In a tight and costly rental market, affordable
apartments, including those subsidized through Section 8, may be in high-crime
neighborhoods. Further, private landlords may be'reluctant to rent to the very people
targeted by the rental subsidy program—especially if they are homeless, have a
problematic credit or criminal history, or have other issues such as mental illness(although
discrimination based on disability is illegal). Nationally, racial discrimination continues to
make it very difficult, even with a subsidy, for many minorities to find rental units.
• According to the Corporation for Supportive Housing, a recent study of
mentally ill homeless adults participating in the Section 8 housing subsidy
program found that the issue that most affected their ability to find
1 apartments using the subsidy was not their mental illness, but their race.
Although the study is not specific to Contra Costa County, this is an issue
across communities in the United States.
Some of these issues can be addressed simply by educating landlords, having people share
apartments to bring down costs, and targeting a portion of a rental subsidy program to
.� prevent homelessness for those who may be evicted from their current apartment due to a
decrease in income.
I
97
Contra Costa County HIV/AIDS Housing Plan
Capital development requires that either suitable land, or buildings in need of rehabilitation
be found and purchased at a reasonable price. '
Capacity is a key issue ,
There must be agencies that have the capacity and skills to develop and operate affordable
housing, as well as provide or ensure the provision of needed support services. The
process of developing housing is complex and requires an array of skills from financial
analysis to construction oversight. Housing management is also difficult, especially for
housing that includes people who may have special needs and in projects that integrate
supportive services programs. Providing services in long-term housing is different from
providing services to homeless people who are transient or in other settings. Supportive
services linked to permanent housing must be designed to ensure maximum tenure of
residents. ,
HIV/AIDS housing itself is a new field, combining the fields of housing, supportive
services, health care and, often, HIV/AIDS prevention and education. At site visits and
focus groups, providers spoke of the need for emotional support and financial assistance if
they are to meet the growing need and the increasing complexity of their resident's
concerns. Providers are asked not only to house people living with HIV/AIDS, but also to
encourage recovery from drug addiction, provide highly nutritious meals to people whose
ability to eat is diminishing and give emotional support to people who are facing a terminal
illness. These same providers are required to write grants, submit reports, manage and
support both boards of directors and volunteers, file paperwork on clients and to operate
and maintain properties which are sometimes in dangerous neighborhoods and, like most
homes, in need of constant upkeep. And they are asked to do all this on very limited
budgets and with very limited staffs. '
It is rare to find a single agency that can perform all of these activities. Generally,
successful supportive housing requires partnerships between service and housing
agencies—often involving more than two agencies. There are relatively few agencies in
Contra Costa County that have begun to develop service-enriched housing for people
living with HIV/AIDS, although Catholic Charities of the East Bay, Resources for . r
Community Development, Rubicon Programs and Shelter, Inc. are notable in their efforts
to develop housing specifically for people living with HIV/AIDS.
Increasing and supporting organizational capacity among those agencies which are serving
the communities most affected by HIV/AIDS is critical to the success of this plan.
1
98 l
1
1
Contra Costa County HIV/AIDS Housing Plan
1 If funding is cut, property lasts; subsidies might not
One last important trade-off between rental subsidies and capital development is that if
ongoing rental and service subsidies are no longer available, due to government funding
reductions or other issues, the entire rental subsidy program might shut down, and those
housed right end up homeless immediately or in the near future.
' On the other hand, once a building has been developed, tenants can continue to live there
as long as the operator can cover operating and property management costs through rent
supplemented by private fund-raising as needed. Over time, people living with HIV/AIDS
could still be housed, although the population might shift to those better able to maintain
independent living without rental subsidies or service support.
Licensure of P P g buildings servingpeople living with HIV/AIDS
' An issue related to the potential cost of developing housing for people with HIV/AIDS,
especially those disabled with HIV/AIDS, is state requirements for licensure of the
housing. The new Residential Care Facilities for the Chronically Ill (RCF-CI) licensing
1 category applies to both proposed and existing projects. These requirements establish
physical plant standards, including compliance with certain fire safety and seismic
requirements, and mandated staffing levels; based on the number of occupants.
The key issues determining whether or not a building must be licensed are: (1) whether the
people in the building have a need for"care and supervision' which includes a range of
services from money management to medication management and assistance with
arranging for health care; and (2) whether individuals in the building access services
independently, or if the building owner arranges for tenant services and has a financial or
organizational relationship with the agency, or agencies, that provide tenant services.
In general, licensure is not required for independent housing that offers assistance with
organizing recreational activities or even some case management, or in which tenants
access services on their own from outside agencies. A building begins to cross the line to
one that might have to be licensed when it serves a high percentage of people who are
disabled with AIDS, requires tenants to participate in a service program arranged by the
building owner(for example money management), or arranges for an array of services to
Itenants that might, for example, include home health care.
This plan suggests that all housing that will or might provide a high level of services to
people disabled with FUWAIDS be licensable under the new regulations. It is possible that
the RCF-CI license will eventually carry with it some additional reimbursement for
supportive services. It is also especially important that fire safety and staffing standards be
met in buildings that serve large numbers of highly disabled people.
1 99
Contra Costa County IMAIDS Housing Plan
l
A key issue related to licensure is that while a building might open,without a license and
function successfully, if it is operating in a way that would require licensure under the law
the costs to renovate a structure to comply with licensing standards would be much
greater if done after the fact and the disruption of residents could be significant.
While licensed buildings are often more costly to develop and operate than other buildings,
they can appropriately serve people who are more highly disabled and in need of a wider
range of in-depth services than other buildings.
Costs and cost effectiveness of supportive services
Several studies have found that offering service-enriched housing to people with
HIV/AIDS and other disabilities can save money. Two studies in 1990 and 1992 in
Massachusetts found that at any given time,approximately 30 percent of all people with
HIV disease in acute care hospitals were there because no community-based residential
program was available(Hunter-Young et al., 1990; Massachusetts Rate Setting
Commission 1992).
• The cost of an acute care bed is more than$500 per day and the cost of
community-based, service-enriched housing with a high level of service is
less than $100 per day.
• In Seattle, a University of Washington study in 1994 found that providing
health care in supportive housing to people living with HIV/AIDS resulted
in a reduction in tenants' use of emergency health care services from
$62,710 a year to $15,639 a year per person.
Other savings can be found for those with substance abuse problems and HIV/AIDS. For '
g
example, a study of 201 graduates of Eden Programs, a Minneapolis treatment program,
found that participants who live in supportive housing have stayed clean at a rate of 90
percent, compared to 55 percent of those who moved into other types of housing.
The cost of providing services to people with FIIV/AIDS in housing varies, with costs
being higher for those more severely disabled with HIV/AIDS, and for those with other
disabilities such as substance abuse or mental illness.
Some people can live in buildings or apartments with none or a very low level of on-site
services other than property management, because they are able to access services in the
community. Others need a high level of on-site service and support either because of ,
serious disabilities due to HIV/AIDS, or other issues including mental illness and
substance abuse.
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1
Contra Costa County HN/AIDS Housing Plan
The Corporation for Supportive Housing estimates that annual per=client support service
- costs range from about $3,600 for buildings that house individuals with relatively low
levels of service needs to $13,000 annually for licensed facilities and $33,000 for hospice
and other long term care facilities. These cost estimates depend on the size of the housing
facilities and the intensity/frequency of service needs of the population. The higher end of
the range is more common for buildings serving people already disabled with HIV/AIDS,
or who have disabilities in addition to HIV/AIDS such as mental illness or substance
abuse.
RCF=CI licensing requires threshold-level staffing linked to the number of clients served.
It is more cost effective to house 12-15 people, or 22-25 people at a single site, than to
house fewer than 12, or between 16 and 21 people at a single licensed site.
The cost of services may also vary depending upon the type of housing offered. For
example, if a single building houses many people living with HIV/AIDS at one site, then
some economies may be achieved by locating support services staff there. If people living
with HIV/AIDS are living scattered throughout the community, the cost of travel for
service staff, and the time involved in getting from one place to another may increase
costs. In some cases people may not live in widely scattered sites, but in apartments that
are geographically clustered, reducing travel and related costs.
While these observations about increased costs for travel and travel time have been made
by many service providers, there is not yet very much empirical evidence about the costs
of providing services to people in scattered site versus single or clustered sites.
1
Community acceptance and jurisdictional leadership
The forces which work against the creation of housing for people living with HIV/AIDS
are essentially twofold: community concerns, and jurisdictional resistance to siting
housing. This resistance may be based on fears of becoming a magnet for homeless and
other"undesirable" populations.
While jurisdictions may not deny funding or permits to a project based on factors deemed
discriminatory under federal law, communities may find issues that can be used to legally
1 oppose a particular development related to the size or density of a proposed project, its
costs, or other factors. In addition,just the existence of opposition and accompanying
lawsuits can delay projects so much that their cost rises beyond what is feasible for a
sponsoring agency or funders to tolerate.
1
101
t
Contra Costa County HN/AIDS Housing Plan
i
Some governments argue that if housing for a.population, such as people living with
HIV/AIDS, is located in their communities, the community will in essence become a
`magnet' for that population. They argue-that housing should be spread out in
communities, that each community should accept:its`fair share' of special needs housing.
Often these arguments are based on a lack of awareness of what other areas are currently ,
doing and a false sense that'we are the only ones doing anything.' The role of this plan in
laying out the need across the County is to promote a sharing of information and joint
planning so that each area of the County can take:responsibility and do its share in meeting ,
the needs of its citizens. This plan sets forth recommendations which will spread the
burden and are reflective of the actual relative need in each area of the County.
As the HIV/AIDS Housing Survey illustrated, the needs of people living with HIV/AIDS
in Contra Costa County are complex. The more complex the needs of the population, the
more likely that opposition may occur. Neighboring Alameda County has already lost a
number of much-needed projects because of misplaced community fears, a continued gap
in understanding of both the need for H1V/AIDS housing and the public health and social
benefits of providing a home to people living with HIV/AIDS. The loss of these units of
housing has directly resulted in more people living with HIV/AIDS being homeless and
more men, women, children and entire families suffering without the common decency of a
home. The recommendations created by this community-based process stand little chance
of being implemented if the forces which resist Hl[V/AIDS housing are not countered by
community acceptance and community leadership in every region of the County.
Conclusion ,
These critical issues—availability and coordination of funding choices about how to best
provide housing, addressing community acceptance issues and making programs cost
effective--can either be barriers or opportunities to carrying out the goals of this
H1V/AIDS housing plan. Public officials, advocates,people living with HIV/AIDS, service
and housing providers will be more successful in implementing this plan if they confront
and address these issues by moving forward together. The recommendations in the next
section include suggestions for how best to do so.
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102
1
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Contra Costa County HIV/AIDS Housing Plan
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"Give me a call when everything is fixed "-- focus group participant
This section details recommendations in five areas which are designed to improve the
HIV/AIDS housing continuum in Contra Costa County.
Prioritypoopulation recommendations which address populations to be targeted
for assistance:
HIV/AIDS housing resources should be targeted but not limited to individuals who
meet all three of these`threshold' characteristics:
I 1. Be disabled with HIV/AIDS;
2. Be low income; and
3. Be either homeless or have unstable housing, including those
individuals recently released from prisons or treatment programs and
those at risk of homelessness by paying greater than 30 percent of
their income for rent.
Within these`threshold' characteristics, the following populations of people receive
priori tX for HIV/AIDS housing and services:
1. Low-income people disabled with HIV/AIDS who have families
and/or young children; and
1 2. Low-income people disabled with HIV/AIDS who are dually and
triply-diagnosed with another disability (such as mental illness or
chemical dependency).
103
Contra Coat&County HIV/AIDS Housing Plan'
Systems recommendations, designed to improve access to HIV/AIDS housing
resources:-
1. Build on the existing system to centralize affordable housing
information and referral and facilitate access to the HIV/AIDS
housing continuum.
2. Require ,people in HN/AIDS housing programs to have a case
manager and, when appropriate, money management services; and
increase the number of money management slots and HIV/AIDS
housing advocates in the County to the extent possible. ,
3. Create standards to help ensure the quality of all HN/AIDS housing.
4. Encourage new housing developed for people disabled with
HIV/AIDS to have the ability to become licensed.
Housing development recommendations to increase the number of units available or
dedicated to people living with HIV/AIDS over the next five years.
1. Continue funding for emergency housing but relocate program
administration to the Centralized Housing Information and Referral
and Intake System and re-configure the program as a limited
Emergency Housing Fund.
2. Create a new short-term Intensive Housing Intervention program
which provides rent subsidies with case management services and links
to permanent housing.
3. Explore developing a new permanent supportive housing program for
people who are living with HIV/AIDS, substance abuse and/or mental
illness, are on the street, or are being discharged from drug treatment
and/or correctional facilities.
4. Increase access to mainstream disabled and supportive housing,
Section 8 certificates and vouchers, and permanent affordable housing
stock,which contains many,units which could be accessed by people
living with HIV/AIDS, continue efforts to increase usage of Shelter
Plus Care.
5. Encourage the use of unit set-asides for persons with disabilities,
including HIV/AIDS, in appropriate low-income housing in
development. Work specifically to create units in affordable housing
that are set aside for families in which a member of the family has
HIV/AIDS. Assure that these are at affordable rent levels and
cormected to appropriate supportive services.
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Contra Costa County HIV/AIDS Housing Plan
6. Encourage the County to create new service-enriched emergency
housing for medically-frail people being discharged from hospitals
who are homeless but still need medical attention and provide funding
for set aside-beds for people living with HIV/AIDS in this program.
7. Create a plan which will result in the development of a licensed
long-term care facility.
Service recommendations to improve access to the services people with HIV/AIDS need
in order to remain in housing.
1. Work within existing priority-setting systems to ensure that support
I services linked to housing for people with HIV/AIDS are funded
adequately.
2. Maintain, and increase as needed, levels of support services which are
most critical to success in housing for people living with HIV/AIDS:
case management, money management, transportation, attendant and
home health care and nutrition.
Plan Implementation recommendations which outline how the plan .should be
implemented and resources allocated over the next five years.
1. Coordinate planning and fund allocation for HIV/AIDS housing and
services and set criteria to encourage and maximize the efficient use
of limited resources.
2. Increase community acceptance of the need for and benefits of
HIV/AIDS housing and conduct an educational audit to determine the
extent of HIV/AIDS-related housing discrimination in Contra Costa
County.
3. Update the community on implementation of the HIV/AIDS housing
plan and update the plan as needed to reflect community needs and
1 achievements.
This section also provides a detailed implementation strategy, including target
' dates and funding amounts for priority programs and services.
The unmet housing needs of lower-income people living with HIV/AIDS in Contra
Costa County present this community with a serious social and public health crisis.
The results from the qualitative and quantitative data collected and analyzed for
this plan indicate that there are hundreds of people living with HIV/AIDS who may
be in immediate need of housing, or who may lose their housing in the near future.
105
i
Contra Costa County MMAIDS Housing Plan
The recommendations of this plan are designed to address the main findings of the.
HIV/AIDS Housing Survey, including:
• Finding and keeping housing is a crisis for many people with HN/AIDS.
• Homelessness and HIV/AIDS are:an overwhelming—and
common—combination.
• Many more people with HIV/AIDS in Contra Costa County could lose
their housing at any time because of poverty.
• People with HIV/AIDS have complex health care needs and can't always
get the health and supportive services they need to stay independent.
• Many people are struggling with substance abuse and mental illness in
addition to HIV/AIDS.
• Women and families with children affected by HIV/AIDS have unique
social and support service needs which negatively impact their ability to
maintain housing.
• Poor rental and previous criminal histories make it hard for many people
living with HIV/AIDS to find housing;
• Some people living with HIV/AIDS feel they face discrimination when
looking for and trying to keep housing in Contra Costa County.
• People want to remain in their homes and live as independently as possible '
for as long as possible.
Existing resources earmarked for people living with HIV/AIDS are extremely limited.
Fiscal year`95 HOPWA funds and FY '96 CARE Act funds were allocated prior to plan
preparation. Therefore the implementation of this plan should begin in this year with
lobbying by the Planning Council and Consortium to leverage available resources in the
coming years.
Priority Populations Recommendation
`7 don't see why we have to be dying in order to get help! We have a lot of people in
Contra Costa County and Richmond especially who won It come to get help."
-- focus group participant
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Contra Costa Count HIV/AIDS Housing Plan
Need
The HIV/AIDS Housing Suryey found that many low-income people living with HIV
infection and AIDS in Contra Costa County had housing needs. This need is created
because the County as a whole has limited affordable housing, because people living with
HIV/AIDS have complex and multiple health and social support needs, and because units
of housing dedicated to individuals and families living with HIV and AIDS are insufficient
to meet demand. The data from the HIV/AIDS Housing Survey, which reached lower
income people with very high health care and social support needs, the voices heard in
focus groups, and the information gathered through the community planning process each
indicate that the need for HIV/AIDS housing outweighs the resources available.
Because resources are limited, the community planning group was faced with difficult
decisions. If there are not sufficient resources to serve everyone in need, who should be
targeted for assistance? This was a particul4rly hard discussion because many members of
the planning body struggle every day to help clients meet their basic needs with limited
staffing and resources.
First, the community planning group identified those individuals which faced greater
obstacles finding and keeping housing. The HIV/AIDS Housing Survey confirmed the
committee's feeling that some groups were greater in need than others:
• People with extremely low incomes.
Sixty-Six(66) percent of individuals and 42 percent of families surveyed
had monthly incomes below$650, or less than $7,800 a year.
• People who were currently homeless or had a history of chronic
homelessness.
Thirty-One (3 1) percent have been homeless at some time since learning of
their HIV infection and 36 percent of people with HN/AIDS have
experienced a bout of homelessness within the past five years.
' Families, including single women with children and larger families with
adults and children.
Twenty-Seven(27) percent of survey respondents lived with three or more
children. Women were more likely to be living with family and friends, and
they were more likely to be staying in shelters than men.
107
Contra Costa County HIV/AIDS Housing Plan
• People living with both HIV/AIDS and another disability, especially mental
illness or chronic substance abuse.
Only 12 percent of respondents had no current or previous drug use
history; 31 percent indicated they were chemically dependent, and 21 j
percent had a history of depression.
People, who because of current or past behavioral issues like substance
abuse or felony convictions, cannot access existing programs.
Three of the homeless respondents had been evicted. (The sample size was
n=12.)
When discussing which among these needy populations should receive priority for
assistance, the committee also stressed the goal of helping people with HIV infection and
AIDS achieve a degree of health and social stability that would enable them to succeed in
long term independent housing. This need to help clients achieve stability and independent
housing was supported by the client survey responses. Note that client survey responses
are considered to be representative of the people living with HIV/AIDS in Contra Costa
who have the greatest level of need.
The recommendations about priority populations were very difficult to make. Committee
members were concerned that targeting housing programs based on degree of illness as
opposed to people who might benefit most from the stabilizing affects of housing suggest
short-term solutions, as opposed to long-term investment. Others felt uncomfortable
distinguishing between people in need and felt that the system should be on a first-come,
first-served basis. Some people felt that people who are marginally housed, such as those
living for free with family and friends, should be targeted for assistance. All participants in
the community planning process felt uncomfortable having to distinguish among people in
need.
The planning group did agree, however, that individuals who are disabled with HIV/AIDS
need the highest levels of physical support and that people facing a life-threatening illness
should have a safe and secure home, and the fact that there are very ill people living on
the streets in Contra Costa County is not acceptable. ,
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' Contra Costa County HN/AIDS Housing Plan
r
HIV/AIDS-Specific Skilled Nursing Care and Hospice Resources
Total resources 2 - 7 skilled nursing beds
Residential care in Central and East County
' Location In home hospice available in limited areas
throughout Contra Costa County
Target population People in need of 24 hour care
Access to hospice care delivered in the home is also dependent on a number of factors.
First, the person in need must have a stable home. Second, services are not available in all
areas of the County. The neighborhoods where some people living with HIV/AIDS reside
' are quite dangerous, and a number of focus group participants spoke about the difficulty
of getting in-home care because of providers' fear for safety. In addition, the hospice
concept of care is not as historically accepted or seen as desirable by some cultural
groups, particularly among African Americans.
Resources:
There are currently 2 to 7 beds specifically set aside for people living with HIV/AIDS in
' Contra Costa County long-term care facilities; most hospice care is provided in the home.
• Facility-based short-term respite or end-of-life hospice care is provided
through the combined efforts of Oak Park Convalescent Hospital in
Pleasant Hill, Guardian of Concord Skilled Nursing Facility, St. Luke's
subacute care facility in San Pablo, Hospice of Contra Costa, and the
Genard AIDS.Foundation. These organizations work together to provide
' an average of 2-7 long-term care beds in these three facilities, allowing care
to be available in Central, East and West County. Eligible clients are
low-income people living with HIV/AIDS who have a medical need and
' who receive MediCal benefits. Hospice and the Genard Foundation provide
funds to cover the cost of room and board and MediCal funds the cost of
medication. St. Luke's provides respite care only.
r
85
Contra Costa.County HIMIDS Housing Plan,,
• The Circle of Care program of the Hospice of Contra Costa provides„a
`pre-hospice' model that bridges between acute and hospice care. Unlike
hospice, Participants can continue to receive treatment, including IV
therapy. Hospice of Contra Costa County serves about 15 individuals per
month.
• Pathways Hospice and Home Health provides in-home hospice and
home care services throughout Alameda and Contra Costa Counties. The ,
hospice team provides direct and respite services to terminally ill patients;
home health services include skilled nursing care. Individuals must have an
in-home care provider.
• Visiting Nurse Association & Hospice of Northern California serves
Alameda, Contra Costa, San Mateo, San Francisco and Solano Counties. It
provides a full range of in-hgme, professional and paraprofessional services
to people with HIV/AIDS, including hospice services. ,
In addition to these resources, the Genard AIDS Foundation and Hospice of Contra Costa
are working cooperatively to develop a long term care option for the County.
Skilled Nursing Care/Hospice Gaps '
The complexity of providing this level of care and licensing requirements may account for
the gaps in skilled nursing care, and the complexity of people's lives are such that not all '
people living with HIV/AIDS can access the services which are available.
• Too few people living with HIV/AIDS in Contra Costa County have the
intact personal support system needed to supplement in-home hospice care,
which is the service most available in the County.
"I knew someone, and they were too sick to be alone; but there they were.
I kept on checking in on them, and I'ire pretty sick too. They are dead now.
I felt I had to help people because all we have is each other.
• While in-home hospice and end-stage beds are available in Contra Costa '
County, the MediCal reimbursement is.too low for most skilled nursing
facilities to accept high-need people living with HIV/AIDS.
86
Contra Costa County BMAIDS Housing Plan
Recommendation
It was within this context—the underlying instability of manyP eople's lives brought on by
poverty, the high rates of current and chronic homelessness and substance abuse, the
difference that providing a home can make in the lives of people for whom HIV/AIDS is
one of several challenges, and very limited resources for HIV/AIDS housing—that the
committee makes this recommendation:
HIV/AIDS housing resources should be targeted to individuals rv�duals who meet these
characteristics:
1. Be disabled with HIV/AIDS;
2. Be low income; and
3. Be either homeless or have unstable housing, including those being released
from prisons or treatment programs and those at risk of homelessness by
paying greater than 30 percent of their income for rent.
Within these `threshold' characteristics, the following populations of people receive
priority for HIV/AIDS housing and services:
1. Low-income people disabled with HIV/AIDS who have families and/or
young children; and
2. Low-income people disabled with HIV/AIDS who are dually and
triply-diagnosed with another disability but who receive SSI for a diagnosis
other than substance abuse(i.e. mental illness or chemical dependency),
and who are working with a case manager to develop and implement an
individualized plan for self-sufficiency (Care-Plan-compliant).
Implementation
1 This decision impacts the rest of the plan. Pnoritizing who among people with this disease
should be served first by HIV/AIDS-specific housing impacts how local resources will be
allocated and the development of Requests for Proposals for housing programs Targeting
I the limited resources available to these populations--the most needy of people living with
HIV/AIDS--also under scores the role other low income and disabled housing providers
must play in order to meet the needs of persons living with HIV/AIDS whose primary
need is affordable housing. Most of the recommendations about new programs and
109
Contra Costa County 11MAIDS Housing Plan
services are designed to get and keep people who are disabled with HIV/AIDS into safe
permanent housing. Targeting means developing a centralized intake and assessment
system which measures need, confirms eligibility status, and helps people get into housing
that will meet their needs.
While not all programs will be designed for people who are disabled with HIV/AIDS, the
plan recommends that the majority of the money available for HIV/AIDS housing be
.targeted to people who are disabled and homeless. The remaining resources should be
used for strategies that target both the entire HIV/AIDS housing system and people with
MWAIDS who have very low incomes and may have other disabilities such as mental
illness or substance abuse history.
HIV/AIDS Housing System and Programmatic Recommendations ,
The limited amount of resources available to create and maintain MWAIDS housing
resources in Contra Costa County means focusing on those most in need: people disabled
with HIV/AIDS who are.homeless or at high risk of losing their housing. There are,
however, ways to improve the HIV/AIDS housing; system both for all people living with
HIV/AIDS in Contra Costa County and for the agencies and individuals that provide
support. These four linked recommendations are designed to improve the HIV/AIDS
housing system for all people affected by HIV and AIDS, regardless of their income,
disability status or residence.
System Recommendation #1
Build on the existing system to centralize affordable housing information and referral and
facilitate access to the HIV/AIDS housing continuum. (See HIV/AIDS Housing
Development Recommendation #5.)
"They move like they are in mud. You want to go on with this thing, and they want
another piece of paper, another interview. I need a place to live!"
—focus group participant
Need
Currently, access to HIV/AIDS housing-related information and services i
g es n Contra Costa
County is largely dependent on establishing a relationship with a housing advocate or case
manager, and the individual's initiative, persistence—and luck. The lack of housing
110
Contra Costa County HN/AIDS Housing Plan
'i
resources, too few housing advocates, and the County's confusing and generally
inaccessible housing crisis hotline system were seen by both planning committee and focus
group participants as contributing to a widespread general frustration with accessing
HIV/AIDS housing resources.
• More than half of the people surveyed said they needed housing assistance;
r44 percent felt that lack of information was preventing them from receiving
the assistance they needed.
' The relative lack of HIV/AIDS specific housing resources in Contra Costa County means
that more mainstream affordable and special needs housing providers need to provide
housing and services available to people living with HIV/AIDS. Housing programs for the
disabled and elderly are available in the County, and could serve large elements of this
population. People living with HIV/AIDS, however, have had little experience in the
larger disabled and low income housing system. Likewise the efforts of HIV/AIDS
service organizations to locate landlords willing to rent to people living with HIV/AIDS
have met with only limited success. The need for a more focused and concerted effort
persists.
Recommendation
This recommendation is to enhance mechanisms to improve and better coordinate access
to the HIV/AIDS housing continuum in Contra Costa County. There are several
components to the improved system:
1. A centralized information, referral and intake system;
2. A Housing Coordinator position whose job is to advocate for increased
access to existing affordable housing and increase the availability of low
income and disabled housing options for people living with HIV/AIDS; and
3. An increase in the number of housing advocates.
The need for a centralized intake system heightened by the recommendation to target
services to those most in need, including people who have had little past success in
1 maintaining permanent independent housing. Also impacting this recommendation are the
planning committee's recognition of the role of housing in stabilizing people's '_ives and
the hope that with sufficient support, people with histories of chemical dependency,
incarceration and evictions can find and keep a home.
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Contra Costa County HN/AIDS Housing Plan
In order to give people their best chance at succeeding, however, they must be referred to
the program that is best able to meet their needs, and agree to receive the services that can
help them maintain independence. The plan recommends employment of a single,
Centralized HIV/AIDS Housing Information, Referral and Intake system for Contra Costa ,
County. This system, which can be built on existing resources, will be charged with:
• Compiling and maintaining comprehensive information on all disabled,
supportive and low income housing available to people targeted by the
plan, including eligibility requirements, supportive services, targeted
population, rents and fees and application processes;
• Compiling and maintaining comprehensive information on all emergency
resources, including emergency funds and shelter beds, permanent and I
transitional housing resources which are available to people with
HIV/AIDS; ,
Disseminatin this resource inventory to housing advocates and case
' g rY g
managers on a regular basis;
• Educating landlords about the specific needs of people living with
HIV/AIDS so that they are more able to rent to people living with
HIV/A.IDS.
• Establishing a centralized intake system for all HIV/AIDS specific housing
including single application, screening process and centralized waiting lists
and coordinating the development of this system with all relevant parties;
and
• Assisting people living with HIV/AIDS to identify which housing options,
including market rate housing, Section 8, disabled housing and HIV/AIDS
- specific housing, are available and which best meet their needs.
Implementation
The Contra Costa County Community Development Department should draft a
competitive Request for Proposals using HOPWA.funds that will result in a centralized
system of information, referral and intake. The agency selected should demonstrate
cultural competency with under served or hard to reach populations and should have
materials available that are culturally appropriate, understandable to persons with low
levels of literacy and available in languages other than English. A new service could be
established or this work could build on existing services.
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Contra Costa County HN/AIDS Housing Plan
The following outlines the various elements of the system and staff roles.
Centralized Information, Referral and Intake System
Position Role Location
Compile and maintain data on all
housing programs people with
HIV/AIDS could use. Conduct
central intake, create housing Centralized Information,
Housing Coordinator plan for individuals (in Referral and Intake System
conjunction with case managers).
Advocate with mainstream
housing providers, including
landlords, to increase access.
Work directly with clients to Centralized Information,
Housing Advocate implement their housing plan and Referral and Intake System
access housing.
Benefits advocacy, social service
Case Manager support coordination, medical Various agencies
' case management.
Money Management Manage funds to help people with Rubicon Programs
budgeting.
Cost
The estimated cost is $50,000 annually to HOPWA to develop and manage the new
centralized system and $45,000 for the first year to fund a full-time Housing Coordinator.
If non-HOPWA sources (such as CARE Act funds) can be found to support this effort,
the amount from HOPWA can be reduced.
Timeline
' Should be implemented in Year 1 and, if successful, continue throughout the following
five years. The Housing Coordinator's job will be refocused to housing advocacy in years
2-5.
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Contra Costa County HIV/AIDS Housing Plan
System Recommendation #2
Require people in HIV/AIDS housing programs to have a case manager and, when
appropriate, money management services; and increase the number of money
management slots and HIV/AIDS housing advocates in the County to the extent
possible. (See Systems Recommendation #1.)
"I just recently got into an apartment. I'm in Shelter Plus Care. My case manager got
me in, and got me to all the meetings it takes to;get you there. I just lost everything after
I found out I had AIDS. " ,
--focus group participant
Need
People with HIV/AIDS who attended focus groups spoke with a great deal of admiration
and appreciation for the work of the area's MWAIDS case managers, housing advocates,
and the government and housing program professionals who work hard to help them
access housing and support services.
Housing advocates should work with the individual in the area of housing specifically '
helping the client to understand the housing system and identify housing options will best
suit their current needs and future plans. As the work of the current housing advocates
demonstrates, it requires a specialized knowledge;which is different than that of social or
medical case management. Given the plan's recommendation to target services to people
with complex physical and support service needs;, especially those with poor rental
histories and histories of substance abuse, intensive case management is crucial to both the
individual and a potential landlord. Money management services, which manages funds
on behalf and in cooperation with clients, were seen by case managers as equally crucial to
their ability to help some people:
• Money management was ranked highest by case managers among services
that were most important to keeping their current home; ,
• 63 percent of people who had been homeless lost their housing because
they could not afford their rent; and
• 59 percent became homeless because of drug and/or alcohol use.
There are currently insufficient money management services and not enough positions
dedicated to housing advocacy to meet the needs of people living with HIV/AIDS or to
improve the HIV/AIDS housing continuum.
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Contra Costa County H MAIDS Housing Plan
1
' Recommendation
The plan recommends that people in HIV/AIDS housing programs be required to have a
primary case manager and, when appropriate, money management services. In addition,
the number of HIV/AIDS housing advocates and money management slots reserved for
people with HIV/AIDS in the County should be increased. The function of housing
advocacy should be distinct from that of case management. Housing advocates should
focus on locating housing and administering emergency housing assistance for people who
go through intake at the Centralized Housing System. Case managers should work
cooperatively with these individuals, but will not be required to keep up-to-date on all
housing options, waiting lists, etc.
Implementation
This recommendation has several implementation components. First, people who enter
the Centralized HIV/AIDS Housing Information and Referral and Intake System and are
I accepted for placement into a housing program, including Section 8, HIV/AIDS-specific
housing or other supportive housing programs, should be required to have a relationship
with a case manager. If those individuals have histories of eviction or are currently
chemically dependent, they should also be required to participate in a money management
program. Ten additional money management slots should be purchased from Rubicon or
other qualified providers using Ryan White CARE Act funds. Case managers should have
' a significant role in identifying the individuals who would benefit from money management
services.
Second, the number of housing advocate positions in the County should be increased by 1
FTE so that there is coverage for each area of the County. In the second through fifth
years of the plan, the function of the Housing Coordinator position described in the
Centralized Housing Information, Referral and Intake System recommendation can be
changed to housing advocacy.
Third, all current and new housing advocate positions and all HIV/AIDS-specific
emergency housing funds should be administered out of the proposed Centralized
HIV/AIDS Housing Information. Referral and Intake System, and funds to cover all of
these services should be included in that RFP. (See budget sheet for more detail). The
database of housing resources and funds should include all resources available.
It should be acknowledged that these two recommendations mark a departure from the
current system, where housing advocate positions are split between two agencies. The
goal of this recommendation—and of the entire plan—is to make the HIV/AIDS housing
system as efficient, effective and simple as possible.
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Contra Costa County HTWAIDS Housing Plan
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COSI ,
Should begin Year 1. Money management slots purchased through Rubicon are $100 a
month per client. The addition of 10 money management slots provided by this agency is
therefore $12,000 annually. Funds could be allocated through Ryan White or HOPWA, or
matching funds could be requested of a private foundation, particularly if an existing non-
HIV/AIDS specific organization adds this service to its programs.
System Recommendation#3
Create standards to help ensure the quality of all HIV/AIDS housing.
`I moved out of an apartment building that was drug-infested even though it was right
across from the Police Department! I never thought it would be like this. I remember
thinking I couldn't go outside. I was clean for ten years. I felt I had to move because the
setting was too rough for my kids and it was hard for me to stay clean and sober with all
the drug trafficking and drinking going on. "
-focus group participant
Need
As more housing for people with HIV/AIDS has been created in the County, consumers, '
providers, public officials and others have all staked the importance of ensuring the quality
of the housing developed. Both the County's Community Development and Health
Departments have recognized the importance of measuring not only units of service
provided, but the outcomes, or quality, of that service. Additional quality assurance and
evaluation efforts are taking place at the EMA level through the Ryan White Planning
Council. As funds become more competitive, efforts to measure the benefits of providing
support services in conjunction with housing to people with HIV/AIDS become even
more important. This work to measure the relationship between increased support
services and increased life span, reductions in unnecessary emergency room visits and
reductions in drug-related incidents or violence in supportive housing projects can help
make the case for HIV/AIDS housing. Providers note the parallel need for good,
consistent responses from police to increase residents' confidence in the ability to police to
assist.
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Contra Costa County RMAIDS Housing Plan
1
' Recommendation
The plan recommends that all sectors of community build on current efforts of the County
Health and Community Development Departments and the Title 1 Planning Council by
working together to develop common quality standards for non-licensed HIV/AIDS
housing and other tools which can be used to evaluate HIV/AIDS-specific housing
programs. These standards can: 1) help ensure people get the same minimum set of
services at similar programs; 2) evaluate the quality of housing and services; and 3) help
ensure that the programs funded will be viable for the long term. Appendix II, Standards
for HIV/AIDS Housing Programs, includes an outline of information gathered for this
plan which may inform the development of these standards. Work on this issue will
continue throughout the implementation of the plan.
r .
Implementation
As has been noted, the Title 1 Planning Council is creating a series of standards as part of
its efforts to evaluate service delivery options. The specific standards for HIV/AIDS
housing proposed by this plan, as outlined more fully in Appendix II would focus on
residents' safety, health, and quality of life and could be integrated into those being
developed by the Council. Outcome measures currently used in contracts for services by
the Contra Costa Health Department and Community Development which might be used
in developing system-wide standard include:
• Consumer satisfaction;
• Physical accessibility;
• Residents' ability to move into and succeed in permanent, independent
housing; and
• Degree of safety and appropriateness of physical environment;
r
As the Title 1 Planning Council is planning to do, these standards should be created with
broad community input and review, including residents of HIV/AIDS housing programs,
housing providers and HIV/AIDS service providers.
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Contra Costa County HIV/AIDS Housing Plan
Cost r
While there are no direct programmatic costs to this recommendation it should be noted
that there are personal costs to agencies, including HIV/AIDS services organizations,
housing providers and governmental agencies in creating and implementing these
standards. Funds to cover these activities should, therefore, be built into program and
staff budgets.
Timeline
To begin in Year I and be complete in Year 2 to the extent that the community, including
the Title I Planning Council, provide the additional staff resources needed. ,
System Recommendation #4
Encourage new housing developed for people disabled with HIV/AIDS to have the
ability to become licensed.
Need
As discussed in the previous section, the new Residential Care Facilities for the
Chronically Ill (RCF-CI) licensure requirements of the State Department of Social
Services apply to both proposed and existing projects and establish standards for both the
physical plant (health, fire and seismic safety) and staffing levels. According to regulation
implementing the new RCF-CI licensure standards, the State is likely to require any
housing people living with HIV/AIDS with a significant service component to meet
licensure guidelines. Furthermore although RCF-CI licensure does not currently provide
any reimbursement for services, there is a serious statewide effort in include such
provisions in future state budgets.
Recommendation
This plan suggests that new housing programs which plan to provide a high level of
services to people who are, or eventually will become, disabled with HIV/AIDS be
licensable under the new regulations. In other words, the building(s) should be able to
meet licensure standards, even if a license is not initially sought, or staffing levels do not
initially meet RCF-CI requirements. There are two reasons for this: 1) it is possible that
the RCF-CI license will eventually carry with it some additional reimbursement for
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Contra Costa County HIV/AIDS Housing Plan
supportive services; and 2) most housing specifically focused on people disabled with
HIV/AIDS (the targeted population of this plan) must either provide a high level of
service to them as they become disabled, or transfer them to more suitable long-term care
facilities.
If the buildings are not licensable and licensing becomes a requirement in the future, it is
possible that the housing will have to be closed down or the target population changed to
individuals who are not disabled or who are less physically needy. If the building cannot
be made licensable, it will still be important to make sure that fire safety standards can be
met and that the service program is structured so that licensure would not be
required—for example, by ensuring that residents obtain services independent of the
building owner.
Implementation
' In evaluating proposals to develop housing for people with HIV/AIDS under this plan
Contra Costa County Community Development and other funders of HIV/AIDS housing
should include whether or not the proposal has considered licensing, especially if the
proposed population is likely to need services requiring RCF-CI licensure.
1 Cost
' Costs will vary depending upon the building(s) developed and the extent of modifications
needed to meet particular fire seismic and safety requirements. Annual per unit operating
costs are about $10,000 for licensed facilities. The annual per client support service costs
will be about $13,000 depending on the size of the housing facilities and the service needs
of the population.
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Timeline
Add as criteria in Year 1 and continue throughout the five years of implementation of this
plan.
HIV/AIDS Housing Development Recommendations
There are two sometimes-competing pressures on the HIV/AIDS housing system: to meet
the immediate needs of homeless people disabled with HIV/AIDS and to develop a system
of housing and services which will last for the duration of the epidemic. The most
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Contra Costa County HIV/AIDS Housing Plan
common way to immediately make some housing available is to provide rental assistance.
The development of housing through purchasing ;and rehabilitating existing buildings, or ,
building new structures, which typically takes two to three years, nonetheless results in
long-term housing solutions. The preceding section("the Context of HIV/AIDS Housing
in Contra Costa County") discusses the trade-offs between these two approaches in detail.
Keeping the priority populations in mind, the plan recommends that resources be used
both to: 1) meet the immediate needs of people disabled by HIV/AIDS, who are homeless
or at very high risk of homelessness through a,program of rental and emergency housing
assistance and 2) create housing through new construction and/or acquisition and
rehabilitation of existing houses and apartments. Funding both rental assistance and
capital development will meet people's immediate: needs and help ensure that units are
here for people living with HIV/AIDS in the future.
The majority of these recommendations are,for programs which will allow people to gain
the skills needed to succeed in permanent housing, rather than for building a great deal of
new HIV/AIDS-specific facilities. The reason for this is simple: Contra Costa County has
very limited funds to develop HIV/AIDS Housing and a great deal of need for housing and
services that people can access quickly. The link between housing and support services is
key.
Need
There is a real need in Contra Costa County for safe, secure and low-cost housing for
people with HIV/AIDS who can live on their own without on-site help (`independent
housing'). Many people with HIV/AIDS in the County, however, have little history of
being able to
maintain truly independent housing. Factors such as poverty, family size, chronic chemical ,
dependency and homelessness—the very issues facing the population targeted by this plan
mean that whatever independent housing is developed must be strongly linked with
supportive services. These services must be seen as integral to the housing provided.
This means that funding for independent housing:must take into account the potential for
funding services needed by residents.
• Rents in Contra Costa County are generally too high for people living on
very low incomes, but most people; with HIV/AIDS would prefer to stay in
their current housing for as long as possible;
• According to the H1V/AIDS Housing Survey, 60 percent of respondents
who rented apartments or owned their own homes spent more than 50
percent of their income on housing; and
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Contra Costa County HIV/AIDS Housing Plan
• Rental or owned housing linked with case management and emotional
support was the overwhelming preference of people surveyed, both with
their current level of health and if they were to become more ill.
The plan outlines a variety of ways that the number of affordable independent housing
units can be increased.
There are seven recommendations in this area which are outlined in a continuum, from
emergency through permanent housing. Each will maintain or increase the number of
independent HIV/AIDS housing units.
HIV/AIDS Housing Development Recommendation #1
Continue current funding for housing assistance, but relocate program administration to
the Centralized Housing Information, Referral and Intake System and re-configure the
program as a limited Emergency Housing Fund
' `I need more money, and not just emergency assistance. Forget the phone bill—I would
rather eat! You have to run from place to place. They get mad if you go to more than
one place for help, but we need all the help we can get. They will suspend you for three
months if they catch you getting services from more than one place! But I have to go to
more than one place because I need more BART vouchers than you are allowed and I
have to go to the doctor's all the time. "
--focus group participant
Need
Currently, the County lacks adequate access to dependable and appropriate emergency
assistance for all those in need. In 1995, funding for emergency assistance ran out five
months before the end of the fiscal year, with the result that people living with HIV/AIDS
in need of a one-time or short-term cash assistance grant or a hotel voucher were left
without. There are no consistent standards defining the appropriate or maximum level of
assistance people can receive. In addition, because of the lack of emergency set-aside
' beds for people with HIV/AIDS, more expensive hotel vouchers are frequently used.
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Contra Costa County BMAIDS Housing Plan
Recommendation
The plan recommends that the current system of emergency funding for hotel/motel
vouchers and other needs be reconfigured as an Emergency Housing Fund. The Fund
could provide small grants, and sometimes loans, to individuals from the targeted
populations who are homeless and need immediate assistance, or to the individuals
`graduating' from transitional housing or working with a Housing Advocate who need '
help paying first and last months' rent or a security deposit. Through flexibility is
important, the current system's lack of guidelines, has created misunderstanding among
people with HIV/AIDS. The fund should have clear guidelines about the amount of
funding available on an annual basis and the limit on the number of times or nights an
individual or family is to be provided assistance. It is important that this Fund be seen as
equally accessible by all people who meet the eligibility criteria.
Implementation
The plan recommends that this fund be administered through the County Health Services
Department and transitioned to the Centralized Housing Information, Referral and Intake
System in order to ensure that people living with HIV/AIDS who access the system are
linked to a housing advocate.
Cost
About $80,000 annually to create approximately 300 emergency grants averaging $200 to
$300 per year. Funds should come from either Ryan White, HOPWA, or a combination of
the two.
Timeline
In Year 1 continue program administration at County Health Services Department and
transfer to Centralized System in Year 2.
HIVIAIDS Housing Development ment Recommendation #2 ,
Create a new short-term Intensive Housing Intervention program which provides
rent subsidies with case management services and links to permanent housing.
1
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Contra Costa County HN/AIDS Housing Plan
"Your life is like a cigarette butt someone flipped out the window, and you're looking for
a mud puddle to land in, looking for a place to be put out, and if you don't get put out
you'll end up causing a big fire. "
--focus group participant
Need
Having to move because you can no longer afford the rent, being evicted because of
behavioral issues like substance abuse, needing to `crash' for free from place to place,
felony records and chronic homelessness all make it more difficult for people with
HIV/AIDS in Contra Costa County to succeed in independent housing. Landlords are
ioften unwilling to rent to people with these histories, yet, these are the very populations
most in need and targeted by this plan.
The HIV/AIDS Housing Survey found that in addition to the 4 percent of survey
respondents who were homeless, more than half were in imminent danger of losing their
housing, many because of poverty. The HIV/AIDS Housing Survey found:
• Only 17 percent of people surveyed had housing that met HUD standards
of affordability;
• The majority of families and individuals subsist on incomes of less than
' $8,000 a year;
• 36 percent indicated they had moved because they could no longer afford
' the rent; and
• Of the 155 people receiving assistance through the Pittsburg Pre-School
housing advocacy program in 1995, 23 percent had no permanent home.
Planning group participants also stressed the role housing can play in providing stability to
' people's lives. People with HIV/AIDS in the focus groups, however, agreed with case
managers that there is a gap between wanting independent housing and the ability to
successfully maintain a leased unit.
People disabled with HIV/AIDS who have no history of eviction or chemical dependency
could also benefit from this program if they need some short-term assistance to learn how
to live within their very limited incomes. Life skills, help getting to medical appointments,
child care, intensive case management and housing advocacy are needed to help people
break out of, or avoid, the too-common cycle of eviction and homelessness. This
recommendation seeks to address these realities.
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Contra Costa County HIV/AIDS Housing Plan
Recommendation '
The plan recommends the development of an intensive Housing Intervention Program
which will provide one-on-one housing counseling and subsidized rent to people with
disabling HIV/AIDS who have not previously been able to succeed in independent
housing. The program will function as a `Shelter Plus Care look-alike' program. The
program subsidy will make up the difference between 30 percent of the residents' income '
and the actual rental amount. It can be administered using either a voucher or project-
based model. As a recommended for all HIV/AIDS housing programs, the client will be
required to have a case manager and a housing advocate. The individual will work with ,
the housing advocate to meet goals set in their housing plan, and the case manager will
assist in coordinating supportive services, such as transportation, to ensure that the
individual can remain safely in their apartment. When the individual has established a
track record, they may be `graduated' to permanent, independent housing, perhaps at one
of the mainstream disabled housing programs, Section 8 (if available) or to an HIV/AIDS-
specific housing program.
Implementation
The plan recommends that rent subsidies be used to help reduce the cost burden of rents
so that people are able to maintain their current homes or find fair market housing on
limited incomes. These subsidies should reduce the amount people are paying for housing
to a maximum of 30 percent of their income, with the result that more people will be able ,
to stay in their housing, thereby reducing homelessness. The program could be
administered as a Shelter Plus Care 8 look-alike and could be project- or tenant-based.
One additional benefit of this recommendations is that it provides immediate assistance to '
those most in need and, in essence, creates a serviceable scattered-site independent
housing program which can provide anonymity and mitigate community concerns that can
arise when group housing is created.
The Contra Costa County Community Development or Health Services Department
should issue an RFP using CARE or other funds to select an agency or agencies able to
provide intensive case management to individuals receiving the transitional housing
subsidies. The housing advocates assigned to the Centralized Housing Information,
Referral and Intake System will assist in setting the housing aspect of the care plan and
provide intervention in the housing area.
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Contra Costa County HN/AIDS Housing Plan
Cost
The costs of providing this intensive Housing Intervention Program is primarily in the area
Q of rent subsidies, since the case managers and housing advocates positions are included in
other recommendations. Assuming 40 people will.receive a maximum subsidy of$250 per
month for a maximum of 5 months, the average cost per person is $1,250 and total annual
8 program cost is $50,000. The program is designed to minimize client duplication from
one year to the next.
Timeline
The program could be started in Year 1 and continue throughout the duration of the plan.
HIV/AIDS Housing Development Recommendation #3
Explore developing a new permanent supportive housing program for people who are
living with RIV/AIDS, substance abuse and/or mental illness, are on the street, or
are being discharged from drug treatment and/or correctional facilities.
"The said I wasn't homeless because I was in a hotel. The said anytime I wasn't
y y y
outside I wasn't homeless. Well, I needed a shower and a night's sleep! Besides the fact
1 that I have very little money, I think I'm having a hard time finding housing because I've
spent a lot of time in San Quentin. I made parole last March. "
--focus group participant
Need
The planning committee was committed to seeking to serve those with very highest needs,
' including people whose life circumstances make it more difficult for them to succeed in
independent housing. The stress of living with HIV/AIDS makes supportive, sober
housing even more important for people coming out of treatment programs or trying to
maintain recovery. Landlords are often reluctant to rent apartments to people who have
recent criminal convictions, and people coming out of prison generally do not have the
money to make the security, and first and last months' rent deposits, often required in this
' housing market. These individuals need even more direct assistance than is available
through the Intensive Housing Intervention model.
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Contra Costa County HN/AIDS Housing Plan
S
Recommendation
This plan recommends that Contra Costa County explore the feasibility of developing
permanent housing for people who are either disabled with HIV/AIDS or multiply '
diagnosed with non-disabling HIV/AIDS, mental illness, and/or substance abuse. Limited
HIV/AIDS-specific funds require that this recommendation use other sources, such as a
competitive HOPWA Special Projects of National Significance grant, or other sources. ,
In order to keep people housed who are disabled with HIV/AIDS and have multiple
disabilities, it will be critical to provide adequate supportive services tied to the permanent
housing. These programs must link people to mental health, drug counseling and aftercare
programs as needed and, for those disabled with HIV/AIDS, to appropriate medical care.
This kind of housing program can be developed in several different ways, depending upon '
the specific issues presented by those served and their level of disability with HIV/AIDS. ,
It may be possible, to cost-effectively serve individuals with a need for a very high level of
service in a serviceable scattered-site program. This alternative would place people in
privately-owned apartments with rental subsidies in a variety of buildings and locations,
although it will be important to carefully design the program so as to not trigger licensure
requirements. It is difficult to cost-effectively serve people with a very high level of
service needs in small buildings housing 5-10 people, especially if those needs are for"care '
and supervision" or other services that may require the building to meet licensure
requirements for physical plant and staffing levels. Conversely, potential neighborhood
opposition may make it difficult to site a larger building that serves this particular ,
population. This issue bears further examination.
Implementation
The Contra Costa County Community Development should bring together those service ,
agencies, housing development corporations and housing owners interested in housing
persons with multiple disabilities to discuss both potential partnership and the different
approaches to providing this type of needed housing. It should provide housing models '
from other cities that have worked effectively so that groups can understand their options
clearly. Following the meeting, the County should provide technical assistance a-d
leadership to agencies interested in providing this type of housing either as a single site or
in set asides in existing or new projects. Funds may be allocated in a competitive RFP for
the assistance creating this type of housing. Once it has selected an agency, or agencies,
the County should provide both technical assistance and support to the groups to develop
the most realistic and cost-effective model and secure the necessary capital, operating and
service support to move forward with development. If capital development is selected,
the County should work with the city in which the project is to be sited to expedite the
development process to the extent possible.
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Contra Costa County HIV/AIDS Housing Plan
Cost
If a development for 30 persons is undertaken, the total costs might be $2 to $3 million or
more in capital and, once operating, about $120,000, or more, annually for operating and
management excluding any service costs.
8 Two projects in Contra Costa County recently received allocations of HUD Section 811
Program Funds to develop housing for persons with physical disabilities. A 12-unit new
construction multifamily rental project in Central County has a total estimated
development cost of$1.5 million, or $125,000 per unit. Total annual operating costs,
excluding supportive service, are about $4,200 per unit.
A second project, a 24-unit new construction multifamily rental facility in East County for
physically disabled persons will cost approximately $2.5 million to develop, including
HUD Section 811 funds. The per unit development cost is $105,000. Total annual
operating expenses, excluding any supportive services are about $3,800 per unit.
HOPWA funds are budgeted at well under one third of the total development cost, or
about $230,000 in each of Years 2 and 3. Additional funding would have to come from a
mix of other funds, which might include the HOPWA Special Projects of National
' Significance grants, HUD Supportive Housing Program, HOME and low income housing
tax credits.
Services costs are dependent on the total number of hours staff must be on site (24 hours
in licensed facilities) and the amount of assistance an individual requires in the home, in
the case of scattered-site housing. In addition to the level of services required by an
' individual, the costs associated with scattered sites may also be dependent on the distance
between sites and the ability of programs to coordinate services and maximize resources.
' Funds for support services must be sought from a variety of different sources, especially
the Ryan White CARE Act, CDBG, Medi-Cal and managed care programs. In addition,
given the limited amount of funding, funds to develop this housing cannot be dependent
' solely on HOPWA.
' Timeline
An initial meeting should be convened by the County in late Year 1 and technical
' assistance provided throughout the plan if interest develops. If the model is to provide
scattered-site rental subsidies, a project could be started by the end of Year 2.
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Contra Costa County HN/AIDS Housing Plan
HIVIAIDS Housing Development Recommendation #4
Increase access to mainstream disabled and supportive housing, Section 8 certificates
and vouchers and permanent affordable housing stock, which contain many units '
which could be accessed by people living with HIV/AIDS. Continue efforts to
increase usage of Shelter Plus Care.
`I desperately need more advocacy. I have seizures and I take a risk every time Igo up
the stairs. I live on the third floor. I feel weak all the time. I have been on the Section 8 '
waiting list for 6 years. I am on a list to move downstairs in my apartment but nothing is
happening. I need to move. "
--survey respondent '
Need
The waiting lists for Section 8 certificates and vouchers is extremely long in all areas of
the County-longer than the average life expectancy for many people with HIV/AIDS. For
many people with HIV/AIDS Section 8 means nothing but a waiting list:
• 25 percent of all survey respondents were on a waiting list for housing '
assistance and more than a quarter of them had been waiting more than 5
years; and
the average life expectancy for person diagnosed with HIV/AIDS is two ,
' g P Y P g
years.
In addition the information from the focusgroups indicates that many landlords are '
reluctant to rent to people with Section 8. The Section 8 program itself is going through ,
changes at the federal level which may mean that people will be given vouchers to use on
the rental market, and that no additional Section 8 certificates will be available. These
changes make it even more important to maintain. and increase access for people with
HIV/AIDS to Section 8 certificates and vouchers by working with and educating landlords
and Public Housing Authorities.
The Shelter Plus Care program provides subsidy similar to the Section 8 program but it is
targeted to chronically homeless persons with disabilities. To be eligible for the County's
Shelter Plus Care Program a person must have one of three targeted disabilities: mental
illness, substance abuse or HIV/AIDS. In addition, the individual must have been
homeless for 12 of the last 36 months and, in most cases, on the streets for the last 30 '
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Contra Costa County HIV/AIDS Housing Plan
e days prior to applying to the program. This program is designed to serve the hardest-to-
serve homeless people who would not succeed in housing without this program. Some
people have felt that these requirements are prohibitive for people living with HIV/AIDS,
who may be doubling up with friends or family or staying in shelters to avoid the streets
and are therefore deemed ineligible. Shelter Plus Care and HIV/AIDS service providers
have been working together to identify ways in which the program can reach more people
living with HIV/AIDS and the County has agreed to seek out more Shelter Plus Care
resources that can be specifically targeted to people with HIV/AIDS who have not been
chronically homeless.
Recommendation -
DTheP lan recommends that a short-term effort be undertaken to increase access to Section
8 vouchers across the County and the housing information and referral system. These
efforts should be spearheaded by the HIV/AIDS Housing Coordinator described in the
Centralized Housing Information, Referral and Intake System recommendation. The
' County should continue working with HIV/AIDS service providers and people living with
HIV/AIDS to identify ways in which Shelter Plus Care can reach more eligible people with
HIV/AIDS and to secure new Shelter Plus Care resources.
Implementation
The County should work closely with advocacy organizations in the community to identify
a strategy for obtaining some dedicated Section 8 assistance, including local preferences
for Terminally ill persons. Because the use of Section 8 and the perception among
landlords varies throughout the County, it is important to take several approaches to
increasing their use. To increase access in one area might mean educating landlords about
' the program and developing a referral process. For other areas this may mean asking the
local housing authorities to prioritize terminally ill people on the Section 8 and other
waiting lists and to increase their outreach to persons with HIV and AIDS.
' Cost
No direct costs. This responsibility can be incorporated into the job description of the
' housing coordinator and housing advocates (positions currently jointly funded with
HOPWA and Ryan White program funds).
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Contra Costa County HIV/AIDS Housing Plan
Timeline '
Beginning in Year 1.
HIVJAIDS Housing Development Recommendation #5
Encourage the use of set-asides for persons with disabilities, including MWAIDS, for '
all appropriate low-income housing in development, work specifically to create units ,
in low income housing that are set aside for families in which a member of the family
has HIV/AIDS, ensure that these are at affordable rent levels and connected to
appropriate supportive service. Ensure that Housing Advocates are aware of
existing and new affordable housing opportunities in Contra Costa. (See System
Recommendation 1.)
Need
A few communities across the country have done a great job of working with low income '
and `special needs' housing developers to get them to reserve, or `set aside' units in their
buildings for people with disabilities, including HIV/AIDS. This encourages innovative '
partnerships with housing providers who may not be currently involved in HIV/AIDS
housing. It also mainstreams people living with HIV/AIDS into affordable housing
developments, reducing community acceptance concerns and allowing for anonymity. '
The need for HIV/AIDS housing is particularly acute for women and families with
children, a growing part of the epidemic in Contra Costa County. There are as many ,
women with HIV/AIDS living in the East Bay as in San Francisco despite a much lower
overall rate of HIV/AIDS in this area. Most of these women have a history of substance
abuse and are low-income. In the HIV/ADDS Housing Survey and focus groups, women '
said they were frightened for their safety, and that of their children, and tired of living in
high-crime neighborhoods that make it harder to stay off drugs. They prefer scattered site
housing in apartments not dedicated solely to people living with HIV/AIDS. Although the '
plan does not recommend the development of an HIV/AIDS housing program specific to
women, this recommendation can meet their needs.
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Contra Costa County HIV/AIDS Housing Plan
Recommendation
The plan recommends that set-asides for disabled populations including those with
HIV/AIDS be encouraged in all appropriate new housing—including new housing for
families—in development in the County. The housing could be developed for disabled
people or low income people living with HIV/AIDS, especially those in need of family-
sized units. This recommendation is directed to all areas of the County and can be
instrumental in meeting the needs of people living with HIV/AIDS in lower incidence
areas. Ensure that Housing Advocates are aware of available and new affordable housing
opportunities as they develop.
Implementation
To implement this recommendation, the County and other entitlement jurisdictions in
8 Contra Costa should include as funding criteria for affordable housing the reservation of
units for and/or accessible to disabled populations, including people with HIV/AIDS. If
HOPWA funds are reserved for this purpose, other housing applications should note that
HOPWA funds are specifically available for developing affordable units for people with
HIV/AIDS. The effort should begin in Year 1, with construction likely in Years 2-5.
Cost
' Costs will comprise either development assistance to permanently reduce debt burden
and/or operating subsidies that would allow owners to bring rents down to affordable
' levels. HOPWA funds should be used to commit units. Depending on the gap in the
budget for financing construction and/or operations the additional subsidy required could
amount of hundreds of thousands of dollars.
' This budget allows for HOPWA to commit a maximum of$40,000 per unit. Eight units
are targeted for Year 1 and 24 units are targeted in Years 2-5.
Timeline
' Implement reservation of funds for set asides in Year 1.
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Contra Costa County HIV/AIDS Housing Plan
r
HIV/AIDS Housing Development Recommendation #6
Encourage the County to create new service-enriched emergency housing for
medically-frail low-income people being discharged from hospitals who are homeless
but still need medical attention and provide funding for set aside-beds for people
living with HIV/AIDS in this program. '
"I've been sleeping in a park and empty car I can find I make a little fire, or I eat out of
the can. But you have to hide your food from other people, and you have to keep moving '
because the police get after you. I feel sick all the time and I'm not doing too good Now
I got to go to the doctor because I am real sick, but I don't have an address so I don't
know how I am going to work that. "
--focus group participant
Need '
The homeless and emergency shelter system in Contra Costa County currently has no beds 1
set aside for people with more intensive medical needs. Getting into the shelter system is
very difficult for most people, and focus group participants felt that emergency shelter was
by and large simply not available to them. People living with HIV/AIDS are not the only
individuals in need of a more medically-oriented emergency shelter, and there is no need to
create a facility specifically for people living with HIV/AIDS. '
Recommendation '
The plan recommends the creation of a `service-enriched' emergency housing program
which provides on-site medical services for people with a variety of illnesses, including '
HIV/AIDS. People could stay until in-home services, such as visiting nurses and personal
care attendants, are arranged, or, in the case of a homeless individual, until a permanent
housing solution is available. This important addition to the existing housing continuum '
could be accomplished by increasing on-site services in an existing shelter or housing
program. Alternatively, these services could be purchased through existing `board and
care' facilities.
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Contra Costa County HIV/AIDS Housing Pian
Implementation
Contra Costa County Community Development Department and Health Departments
e should meet with housing providers and hospitals to determine whether an existing site
could offer this kind of service if adequate funding, technical assistance and support is
made available. If an existing site is to be used, it would be important to ensure access for
people throughout the County either at that site, or through purchase of this service at
board and care homes. If no existing site can be identified, the County should work with
the State Department of Social Services to convene a meeting of board and care operators
1 to discuss the potential for using that resource to provide for this need.
Cost
Costs to provide the 5 to 7 licensed beds needed will depend on the facility and number of
staff, although 24-hour staffing is required for licensing. HOPWA funds could be used to
set aside beds, but the majority of funding should come from other sources. Purchasing
beds at board and care facilities may be less expensive. Funding should be sought from
HOPWA and other sources, including Medi-Cal, managed care and CARE Act funds.
Timeline
Efforts should be targeted for Year 1. If an existing facility can be modified to provide
limited medical services then the program may be made available as early as 1997.
Housing Development Recommendation #7
Participate with Alameda County to develop a plan to establish a licensed long-term
care facility or other feasible alternatives to serve individuals in the final stages of
' HIV/AIDS in both Counties.
`7 can't live with my sister because her husband does not want someone with AIDS in the
house. My wife and mother won't let me live with them because of AIDSphobia. Some of
my family don't understand, they don't want me no more. They are watching me like I
am a germ. They almost make me hate them, which I don't want to do. "
--focus group participant
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Contra Costa County HIV/AIDS Housing Plan
Need
One issue which was raise consistently in the community meetings was the lack of a safe
place for people with HIV/AIDS facing death or in need of 24-hour intensive medical
care. The costs associated with this level of care are tremendous; and since
reimbursement does not cover the costs of the service, a new stand-alone hospice is
virtually not feasible in California. It is therefore vital that any effort to create a long-term
care facility use alternative reimbursement strategies and be linked to those settings and
systems, particularly hospitals, that will create the highest and most flexible sources for
reimbursement. Hospice services provided are able to meet the needs of some people; but ,
others, largely African Americans, are not accessing hospice and a different model of care
is needed.
Recommendation
1
The plan recommends funding a plan to create a licensed long-term care facility designed
specifically to be sensitive to, and meet the needs of, homeless and very-low income
people disabled with HIV/AIDS in both Contra Costa and Alameda Counties and which
will be financially viable for the long-term. The plan does not recommend using CARE or
HOPWA funds to create a long-term care option until all the issues surrounding
reimbursement are well thought out.
Implementation
There are a number of options for reimbursement which can be used to create a long-term t
care option for people disabled with HIV/AIDS in the region, but many of these are
specifically designed for a single type of facility. Designing a program that will take
advantage of these funding streams is crucial because the costs of this kind of housing and
the required medial services and licensing are so high. The plan recognizes that many
participants in the planning process identified this as a very high need, but the complexity '
of the licensing and reimbursement issues requires a deliberative planning process. The
plan recommends that a planning grant be issued with Alameda County HOPWA funds for
a third party to convene a series of meetings with hospitals, long term cac proviuers,
nonprofit housing developers, HIV/AIDS service providers and people with HIV/AIDS to
develop and fine-tune a strategy for developing this important resource. This planning
process should take full advantage of the materials presented in Appendix IV: Long Term
Care Reimbursement Structure in California and of models which have been successfully
created in California and other states. By the end of the planning period, a plan including
financing requirements and timeline should be created by the grantee and funds sought to ,
carry out the development of this much-needed service.
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Contra Costa County HIV/AIDS Housing Plan
COSI
None - Funds were allocated in the Alameda County plan.
Timeline
Plan to be created in Year 1, and implementation to commence in Year 2. A facility could
be open by Year 3 if a commitment of sufficient resources and a long-term funding stream
are identified.
Support Service Recommendations
As the HIV/AIDS Housing Survey found, most people living with HIV/AIDS want to
remain in their own homes with as much independence as possible for as long as possible.
Independent housing, preferred by people living with HIV/AIDS, both reduces community
acceptance issues and is most cost efficient when intensive services are not needed.
Maintaining independence, however, is not simply a question of paying the rent. Many
people living with HIV/AIDS need some supportive services in order to avoid a more
institutional setting. These services can range from case management and money
management, home-delivered meals and transportation assistance to home health care
service and primary medical care. This recommendation focuses on how to maximize
people's ability to access and use those services that can help them stay in their own
homes.
Support Service Recommendation #1
Work within existing priority-setting systems to ensure that support services linked
to housing for people living with HIV/AIDS are funded adequately.
Support Service Recommendation #2
Maintain, and increase as needed, levels of support services which are most critical to
success in housing for people living with HIV/AIDS: case management, money
management, substance abuse programs, transportation, attendant and home health
care, and nutrition.
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Contra Costa County HIV/AIDS Housing Plan
"My kids had to change schools five times and they don't live with me anymore. They
need grief counseling, and I need a place where I can get support groups and help with
my mental illness and chemical dependency issues. I need help to remember to take my
AZT. " .
--focus group participant
Need
Funding for services linked to HIV/AIDS housing must be adequate and sustainable.
Funds must be sufficient to support the costs of services which are required and received
by people living with HIV/AIDS in transitional, rental assistance and permanent housing
settings. As demands on CARE ACT and HOPWA funds increase, creating
interdepartment agreements which outline the integration of these and other funding
sources becomes more important.
A number of thelan's housing recommendations involve service-enriched setting. These
P g
services are what make the programs both viable for people living with HIV/AIDS and
acceptable to the broader community.
Recommendation
The plan recommends that the CARE ACT and other funding stream priority-setting
groups continue to cover the costs of at least a portion of the housing related services.
The plan also recommends that Contra Costa County continue to maximize its use of the
AIDS Medicaid waiver, managed-care systems and other third-party payers to relieve
pressure on CARE Act and HOPWA funds. The plan further encourages the involvement
of HIV/AIDS housing providers in HIV/AIDS service-planning and priority-setting
processes so that the vital role of services in maintaining health and housing in
underscored and understood.
Implementation
The Contra Costa County Community Development and Health Departments should work ,
with the Title 1 Planning Council and HIV/AIDS Consortium to better integrate funding
priorities for HIV/AIDS programs throughout the County.
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Contra Costa County HIV/AIDS Housing Plan
Cost
While there are no direct costs associated with this recommendation, staff at both
HIV/AIDS service providers and HIV/AIDS housing organizations, as well as
governmental agencies, will be required to implement this effort.
Timeline
Beginning in 1996 and then ongoing to the extent that the agencies are able to dedicate
staff resources.
Housing Plan Implementation Recommendations
As has been stated throughout this housing plan, there are not enough resources to meet
the housing needs of all people living with HIV/AIDS in Contra Costa County. Key to
meeting the need are coordinated planning and fund allocation, maximization of existing
resources and leveraging of other funds and programs. Homelessness, substance abuse,
mental illness and poverty all intersect with HIV/AIDS, and each of the systems which
provides support and housing to individuals affected by these shares an obligation to
meeting the needs of people living with HIV/AIDS.
The increased pressure on HIV/AIDS funding, the overwhelming need for HIV/AIDS
housing and the pressing demands on staff of HN/AIDS service providers mean that
every effort must be made to reduce duplication of services. These four recommendations
outline ways in which HIV/AIDS housing can be improved by increasing the effectiveness
of HIV/AIDS housing programs and funds through coordination of planning and fund
allocation, increasing efficiency of programs and increasing the capacity of providers.
Implementation Recommendation #1
Coordinate planning and fund allocation for HIV/AIDS housing and services
P g g
and set criteria to encourage and maximize the efficient use of limited
resources.
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1
Contra Costa County HN/AIDS Housing Plan
Need
Although this plan focuses on Contra Costa County, many of the issues are similar in
Alameda County. These two counties make up the Oakland CARE Act Title 1 EMA,
which oversees many HIV/AIDS services in both counties. Alameda County has
developed a similar HIV/AIDS housing plan, as has the City of Berkeley. The high need i
and limited resources for HIV/AIDS housing programs in all regions of the County mean
that all programs should demonstrate program effectiveness and efficiency. The standard
for efficiency applies to both administrative agencies and HIV/AIDS housing providers.
There are improvements that can be made in efficiencies in both these areas. (Note that
the funding cycles for the various resources are on various fiscal years.)
In the administrative arena, fiscal years are different for the CARE Act and HOPWA
programs, resulting in duplication of reporting by both providers and the grantee. As a
result, the County must negotiate and monitor separate contracts for Title 1 and Title 11,
and HOPWA services.
Recommendation
First, the plan recommends that on specific issues where coordination would lead to good
programs and increase cost-effectiveness, Contra Costa County and Alameda County
should work together in the implementation of their HIV/AIDS housing plans. HOWPA
administrators for Alameda and Contra Costa counties should meet annually to share
strategies and resources in order to avoid duplication. It also recommended that planning
for HIV/AIDS services at the Title 1 Planning Council and other forums include persons
with an interest in HIV/AIDS housing.
Second, the plan recommends that to the extent possible, the CARE Act Titles 1 and 11,
HOPWA, the County funding bodies develop similar reporting and contract requirements
so that the paper work is cut down for both providers and people living with HIV/AIDS.
This recommendation has the added benefit of reducing administrative time and cost,
recognizing that much of this paperwork is controlled by federal requirements and cannot
be streamlined at the local level.
Third, the plan recommends that Contra Costa Community Development use the
following set of unranked criteria to gauge the effectiveness and efficiency of proposed
projects, and hereby, maximize resources:
• Long-term agency and program viability;
i
138
1 .
Contra Costa County HN/AIDS Housing Plan
• Current licensure or ability to become licensed (if applicable);
• Ability to leverage other resources;
• Geographic area served;
• Capacity to develop or operate programs and projects effectively;
• Utilization rate and cost effectiveness; and
• Relevance of project/program to identified gaps in the HIV/AIDS housing
system.
The County already uses many of these elements in evaluating whether or not new
programs should be funded. The challenge in this recommendation comes if programs
which are in existence are not meeting these standards. The community then faces a
difficult decision: should projects which cannot or do not meet standards for quality or
efficiency be closed? What is the benefit of this action compared to the immediate loss of
units or housing? The critical aspect of this recommendation, therefore, comes not so
much through the fund allocation process, but across funding years. The plan
recommends assistance and capacity building efforts; but, given concerns about safety,
licensing and efficience, programs which still do not meet the needs of their residents or of
. the housing continuum as a whole should be considered for closure, merger with other
programs, or transition to a more appropriate level of housing and services.
Finally, the plan suggests that the County continue to foster collaboration among existing
small projects in areas such as food/supply purchases, volunteers and administrative
functions. This cooperation offers one way in which projects can begin to meet some of
the criteria in this recommendation without jeopardizing their programs. The Centralized
HIV/AIDS Housing System is a continuation of this recommendation.
!� Implementation
Contra Costa County Community Development and Health Departments should identify
funding and contract coordination as key issues for interagency coordination. The County
should use these criteria as part of the RFP process. These criteria should be considered
supplemental to the proposed HIV/AIDS housing standards to be developed by the Title 1
Planning Council and are meant to evaluate the feasibility of both existing and planned
programs.
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Contra Costa County HIV/AIDS Housing Plan
Cost
While there are no direct programmatic costs to this recommendation, it should be noted
that there are personnel costs to agencies, including HIV/AIDS services organizations,
housing providers and governmental bodies to take these actions. Funds to cover these
activities should, therefore, be built into program and staff budgets.
Timeline
To be begun in Year 1 and completed by Year 2.
Implementation Recommendation #2
Increase community acceptance of the need for and benefits of HIV/AIDS housing
and conduct an educational audit to determine the extent of HIV/AIDS-related
housing discrimination in Contra Costa County.
`I was not so shocked when I ound out I was HIV and I was praying that m son would
.f � P a1' g y
not be infected, and he isn't thank God. I have been through some problems because of
my HIV. A person in the building told everyone, and some people had a problem with it. r
They hassled me all the time and wanted me gone. I have to learn to deal with it myself,
and people need to deal with it too. There was nothing either of us can do about it. "
--focus group participant
Need
To the extent that the County moves forward with capital development projects
recommended by this plan—for example permanent housing for people disabled with
HIV/AIDS, or with multiple disabilities, or transitional housing for graduates of substance
abuse treatment programs—it is likely that opposition from the communities in which
those projects are to be suited may emerge. Community opposition and jurisdictional
reluctance to siting HIV/AIDS housing in neighborhoods because of fears of their
becoming `magnets' for high-need populations may threaten needed HIV/AIDS housing
projects in Contra Costa County. People living with HIV/AIDS, particularly those who
participated in the focus groups, mentioned the extent to which they felt their HIV status
caused them to either lose or be denied housing.
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Contra Costa County HIV/AIDS Housing Plan
Recommendation
Strong leadership from elected officials, government agencies, community-based
organizations and the religious community are needed to proactively address community
concerns and counter misinformation that leads to community and jurisdictional opposition
to HIV/AIDS housing. The plan recommends that these public forces, which are
entrusted with providing for their most needy citizens, work to educate the greater public
about the need for HIV/AIDS housing and the consequences of denying housing to people
living with HIV/AIDS. Endorsement of this plan and acting towards its swift
implementation are crucial steps in creating a community which is accepting of HIV/AIDS
housing. Completion of an HIV/AIDS fair housing audit will both measure the extent of
discrimination and provide a needed response to the concerns of people living with
HIV/AIDS.
Additionally, the County should work closely with existing efforts underway by the Non-
Profit Housing Association of Northern California(NPH) and its local coordinator, East
Bay Housing Organizations (EBHO) to address community acceptance of supportive
housing.
Implementation
Contra Costa County, including the 18 city jurisdictions, should work in conjunction to
encourage each city and planning body to formally endorse this plan. Elements of the plan
should be incorporated into the HOME Consortium, and local Consolidated Plans and
housing elements. The recommendations of the plan should be incorporated into the
EMA's AIDS Response Plan.
Additionally, they should make sure that all Contra Costa County HIV/AIDS housing
providers are aware of the materials and assistance offered by NPH and EBHO related to
community acceptance. The County should also work with cities in which projects will be
located to make sure that appropriate public officials from, for example, the police or
planning departments, ^re available at comm ty forums that take place during the effort
to site specific projects, to address issues related to crime or property values and to
indicate the success of this kind of housing elsewhere.
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Contra Costa County HIWAIDS Housing Plan
Cost
There are minimal costs associated with this recommendation, primarily for materials
purchased and reproduction. As with other similar recommendations, however, there are
costs associated with staffing this effort.
Timeline
Throughout the five years of implementation.
Implementation Recommendation #3
Update the community on implementation of the ]EIIWAIDS housing plan and update
the plan as needed to reflect community needs and achievements.
Need
It will be important to ensure that ongoing, annual progress is made on implementation of
the plan, and that the plan is updated to reflect new developments related to community
needs, and gaps in the continuum of services and housing.
Recommendation
The plan recommends that Community Development Department convene the group that
developed the HIV/AIDS Housing Plan on an as-needed basis to assess progress on
implementation, and recommend updates to the Plan to reflect community needs, and
changes in gaps in the continuum of services and housing. Community and County groups
that have worked on specific implementation issues, such as the development of a strategy
for providing hospice or skilled nursing level care to people disabled with HIV/AIDS,
would be expected to report to the group on their progress.
Allocation
recommendations
If funds are found to fully implement the plan, it will identify or create additional resources
and units of HIV/AIDS housing over the next five years. The budget following illustrates
full funding for all recommendations over the next 5 years and can be used to set further
priorities for which recommendations should be implemented.
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_ Contra Costa County HIV/AIDS Housing Plan
Evaluation Recommendations
Many individuals participated in the development of this plan, and many will watching to
see that the recommendations they helped create are implemented. For some people who
attended the community planning meetings or who participated in a focus group, this plan
represents the hope that something will be done—and the fear that their needs will again
be overlooked.
This plan outlines very specific steps that can reduce homelessness and improve the quality
1 of life for people living with HIV/AIDS. These recommendations are not impossible
goals, but they will not solve the housing need of every person living with HIV/AIDS in
Contra Costa County. They do not address the root causes of homelessness, drug
addiction and HIV infection that are so harmful to residents of Contra Costa County.
They cannot, by themselves, end the prejudice that continues to stand in the way of
humane services for people living with IRWAIDS. But if fully implemented, which will
require both hard work and collaborative funding, more than 25 additional housing units
and resources will be available for people with HIV/AIDS over the next five years.
This plan will not be successful simply by virtue of its having been published. The true
achievement will be through Contra Costa Cities and the County working with non-profit
and for-profit housing developers and service providers to achieve the goal of creating a
comprehensive continuum of safe, affordable and appropriate housing for people living
with HIV/AIDS.
Who can help implement the plan?
1 This plan has stressed that the entire community shares the responsibility to ensure that
safe, affordable and appropriate housing exists for people with HIV/AIDS in the County.
The uncertainty of HIV/AIDS funding, changes in the health care and social welfare
systems of this nation, and the changes in the epidemic itself will all impact the ability of
people living with HIV/AIDS to find and keep housing—and the community's ability to
help. Creating a system of housing for people with HIV/AIDS in Contra Costa County
will take the time, unique resources and abilities of each facet of our community and the
continuation of the cooreration that developed this plan.
How can the community measure the success of this plan?
First, the community planning group which created the plan should reconvene during the
first year following its adoption to publicly evaluate the process made to date in each area
of recommendation.
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Contra Costa County HIV/AIDS Housing Plan
Second, the plan can be used in funding documents, such as the Consolidated Plans
submitted to HUD by eligible jurisdictions. These plans measure the degree of homeless
and housing problems in communities and in specific populations, including people with
HIV/AIDS. A lack of specific information has hampered the ability of some areas to
create programs for people with HIV/AIDS. With the advantage of the new information
provided in this document, these Consolidated Plans should be much more specific in their
attempts to address the needs of people with HIV/AIDS and in their continued monitoring
of the needs of this population.
Third, the success of the plan can be reviewed and documented by the Oakland EMA's
annual CARE Act Title 1 application—and an increased attention to housing in the needs
assessments undertaken as a part of the application. A measure of the plan's success will
be, for example, a reduction the number of people who report that they are homeless or
have housing problems in the annual assessments conducted by the Planning Council and
the number of main stream housing options available to people living with HIV/AIDS.
The most effective evaluation of the success of this plan will come from the experience of
people living with HIV/AIDS in all parts of Contra Costa County. If asked, they will tell
us how far we have come, and how far we have to go.
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Contra Costa County HMAIDS Housing Plan
HIV/AIDS Housing Plan Proposed
Implementation Timeline and Budget
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Contra Costa County HN/AIDS Housing Plan
Appendix I: Glossary of Terms
Affordable. This plan considers housing to be affordable when households pay no more than 30
percent of their income for housing costs.
AIDS Dementia Complex. A neuropsychiatric (brain) dysfunction that impairs thinking and/or
motor skills. This illness is believed to occur in anywhere from 30 percent to 70 percent of
individuals living with HIV/AIDS.
Assisted Living. A level of care that is less than skilled nursing (like a nursing home) but higher
than congregate care. Assisted living facilities include some degree of support for activities of
daily living (ADLs) and some medical monitoring. All assisted living programs provide assistance
with activities of daily living such as toileting, dressing, bathing, and getting in and out of bed. An
I assisted living project may have services that are provided contractually or by a combination of
paid and volunteer staff.
Case Management. The central component of HIV/AIDS care is case management.
P g
Essentially, case managers coordinate all the care that a client receives from all providers in the
community. Typically, case management services are provided by agencies separate from the
housing providers. When a case management client resides in a residence, however, the
residential staff members have the most frequent contact with the resident and end up taking on
1 more of the care coordination.
Congregate or group housing. Housing that does not provide private baths or private
cooking facilities.
Contingency reserves. A small amOLnt of funds held in reserve for use in addressing special or
emergency needs.
Disabled. For the purposes of this plan, any person who is HIV-symptomatic and has a letter
from a physician indicating that they are disabled.
Disability Insurance. Provides income for up to 52 weeks based upon inability to work due to
illness or injury (not work related). Eligibility is tied to work history and earnings. (See also Social
Security Disability Insurance).
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Contra Costa County HIV/AIDS Housing Plan
Emergency Housing. Emergency housing is intended to keep people with HIV/AIDS off the
street when they are confronted with an immediate loss of housing, or in the case of a person who
is already homeless, to provide them with housing as soon as possible. The core of emergency
housing in most communities consists of homeless shelters. Additional emergency resources can
include hotel or motel vouchers, short-stay apartments, or group living situations. Agencies may
obtain long-term leases on these units, to use them as emergency shelter for homeless individuals
or families.
Enhanced access. People with terminal illnesses, including all people disabled due to HIV
infection, should be considered for priority access to publicly-subsidized housing programs.
Extremely-low income. Extremely-low-income households are households which have income
at or below 50 percent of the Area Median Income for the Oakland PMSA as defined by the U.S.
Department of Housing and Urban Development and adjusted for household size.
Family. Fort'he purpose of this plan, family is defined as single adults, partners, single and two
parent familieswith children, other relatives living together and adults living together as a family
unit.
Homelessness. Accordingto the U.S. Department of and Urban Development, a
g P ,
homeless person is an individual or family who:
Lacks a fixed regular, and adequate nighttime residence; or
• Has a primary nighttime residence that its : I
• A supervised publicly or privately operated shelter designed to provide temporary
living accommodations (including welfare hotels, congregate shelters, and
transitional housing for the mentally ill);
• An institution that provides a temporary residence for individuals intended to be �.
institutionalized; or
• A public or private place not designed for, or ordinarily used as, a regular sleeping
accommodation for human beings. The term"Homeless Individual" does not
include any individual imprisoned or otherwise detained under an Act of the
Congress or a State law.
• Individuals paying more than 50 percent of their income for housing are also
considered at such high risk for homelessness that they are included in the federal
definition of homeless.
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Contra Costa County HN/AIDS Housing Plan
High Risk for Homelessness. This plan categorizes some people as being at `high risk'
for homelessness. For the purposes of this plan, this category includes people who pay
more than 30 percent of their incomes on housing.
Hospice. A level of care based on the philosophy of palliative care meaning easing pain
and suffering for terminal illness. The services provided in a hospice facility often include
nursing care, treatments, dietary services, and pain medication. Typically, hospices do not
attempt to cure the diseases; they attempt to ease suffering.
Housing unit or `bed'. A single unit of residence for a household of one or more
persons.
Independent Living. Independent living is a situation in which each resident can
maintain full functioning and activities of daily living (ADLs) —toileting, dressing, bathing,
I transfers—without assistance. However, the fluctuating care needs of persons with -
symptomatic HIV infection can stretch the meaning of the term "independent"; if their
care needs are not met, residents may have to move, even though the housing might be
appropriate again after the current episode is past. For this reason, monitoring residents'
status and helping them manage their health crises are critical components of keeping
people independent, and in their own homes, as long as possible. The use of
volunteer-based services can make a huge difference in keeping people in their own
homes. The services that are most useful to residents in independent living situations
typically include: emotional support, home-delivered meals, transportation assistance, and
chore services. Whether or not a person living with HIV/AIDS can remain at home, and
for how long, is determined in part by the extent to which that person has family or
care-givers in the home, by his or her ability to pay for services not available on a
volunteer basis, and by the range and accessibility of volunteer services available.
Low-income. Low-income households are households with incomes which do not
exceed 80 percent of the Area Median Indome for the Oakland PMSA as defined by the
U.S. Department of Housing and Urban Development, and adjusted for household size.
Mainstreaming. The process by which individuals in need of services are integrated
into existing systems. Integrating people living with HIV/AIDS into existing low income
and supportive housing projects is an example of mainstreaming. Attempting to combine
populations requires thorough evaluation of each group's needs.
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Contra Costa County MWAIDS Housing Plan
MediCal/Medicaid. A medical assistance program providing health insurance to
persons with low or no income, and real and personal property within the limits
established by the program. Program is available to certain families or individuals meeting
eligibility linkages such as: Aid to Families with Dependent Children(AFDC); aged 65 or
older; disabled/blind; pregnant women; refugee in the country 18 months or less; or
children under 21 years of age where no AFDC deprivation exists.
Medicare. A federal health insurance program for people aged 65 years old or older,
people who have been disabled more than 24 months, and people of any age who have
permanent kidney failure. It provides basic protection against the costs of health care, but
does not cover all medical expenses. To be eligible one must have worked long enough
and recently enough to get Social Security benefits or railroad retirement, or are entitled
to benefits based on spouse's work record, or have worked long enough for federal, state,
or local government to be insured for Medicare.
Primary Benefits for Disabled Persons. 'The Social Security Administration offers
two programs for people with disabilities: Supplemental Security Income (SSI) and Social
Security Disability Insurance (SSDI, also called SSA). Both programs assess one's
medical condition to determine disability. Disability is defined (for SSI and SSDI) as"any
medical condition (either physical or mental) that prevents or is expected to prevent you
from working for at least 12 months."
Residential settings. A residential setting is defined as a single family home, group
home, single room occupancy hotel room(SRO), an apartment, or bed in a residential
facility.
Section 8 Certificates. The U.S. Department of Housing and Urban Development
operates a rental subsidy program known as Section 8. Section 8 certificates allow
tenants who meet the income guidelines to pay only 30 percent of their income in rent for
privately owned apartments that meet Section 8 criteria. Section 8 pays the difference
between that amount and the amount of rent based on the fair market rents of each area.
There are two kinds of Section 8 certificates—those that are tied to specific project-based
or tenant based units, as in Section 811 housing, and those that are transportable
throughout the city, County, or elsewhere. Unfortunately, in most jurisdictions the wait
for Section 8 housing can be five years. As a result, few communities can access this
important source of subsidized housing effectively. In addition, a number of housing
authorities have designated Section 8 certificates providing rent subsidy in units approved
by HUD. This particular option often allows people living with HIV/AIDS to remain in
their own homes if their home or apartment passes HUD inspection, and if rent payment is
within HUD guidelines.
1
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Contra Costa County HIV/AIDS Housing Plan
Shared Living. One way to cut housing costs is to share living quarters. Although the
majority of people living with HIV/AIDS would rather have their own apartment or
house, shared living becomes an attractive option for some as their income and ability to
do everything for themselves is affected by illness. This is particularly true where houses
are organized around shared cultural values—African-American, Latino, youth, or
families. An agency's involvement in shared living can run the gamut—from maintaining a
roommate matching bulletin board to owning and managing shared-living apartments or
houses.
Skilled Nursing. A level of care consisting of continuous skilled nursing observations,
restorative nursing, and other services under professional direction with frequent medical
. supervision. Facilities with this level of care are used for patients who need care and more
intense treatment after they have been very ill or during recurrences of symptoms in
long-term illness.
Social Security Disability Insurance (SSDI). SSDI is a federal insurance program
for people who have a recent work history and whose employers paid Social Security
taxes (FICA). SSDI assesses one's employment history. SSDI provides monthly payments
to persons who become disabled and have worked long enough and recently enough under
Social Security. Benefits are available starting at any age. (If receiving SSDI when age 65
is attained, those benefits become retirement benefits, although the amount remains the
same). Certain family members can also draw disability benefits based upon the program
contributions of a parent or spouse. Eligibility requirements are:
• Disabled.
• You must have paid into the Social Security system for 5 out of the last 10
years. ("Paying into the system" means that one worked in a job(s) where
Social Security taxes (FICA)were withheld from one's paycheck, or one
paid own taxes if self-employed).
SSDI Benefits include:
• No fixed amount - benefits depend on how much and how long you paid
into the Social Security system.
• Average range: $550 - $750 per month.
• Current maximum benefit is approximately $1,100 per month.
1
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Contra Costa County RMAIDS Housing Plan
Supplemental Security Income (SSI). SSI is a federal pubiic assistance program that
provides monthly income to people who are aged 65 or older, blind, or have a disability
and who have a monthly income, real and personal property within limits established by
the program. SSI assesses one's current financial (income and assets) and living situation.
In most states when you get SSI you also get Medicaid. In 1994 eligibility requirements
include:
• Disabled.
• Assets must be less than $2,000.
• Monthly income must be less than$620.
• If you own a house, you must live in it.
• If you own a car, it must be worth less than $4,500.
• There are several resources which are not included in determining one's
assets: Plot or burial funds set aside not exceeding $1,500; and Insurance
policies valued at $1,500 or less.
• SSI Benefits include: SSI supplements income from other sources up to
the benefit amount of$614.; If you have no other income SSI pays $454
per month.
Supportive services. An array of services provided to clients with HIV/AIDS to enable
them to remain in the most independent setting as long as possible. Services may include:
representative payee; money management and 'benefits counseling; substance
abuse/mental health counseling; emotional and practical support; attendant care; home
health care; case management; and advocacy for services they may need to meet other
needs.
Transitional Housing. Transitional housing provides an interim placement for people
coming from emergency housing, the correctional system, or from mental health or drug
treatment programs. Usually, the tenants are waiting for a permanent placement and may
remain in transitional housing for several weeks, months, or up to 2 years (by HUD
definition). Some transitional housing programs typically offer a support service package
tailored specifically to the target population with the goal of helping them transition to
permanent housing.
Treatment. An intensive rigorous service program administered by trained professionals
that addresses mental health and/or substance addiction.
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Contra Costa County HIV/AIDS Housing Plan
Tuberculosis (TB). A potentially fatal communicable disease caused by a bacterium
that produces lesions primarily on the lungs, but that can also attack other organs. The
symptoms of active TB are weight loss, coughing, and fatigue. People with HIV/AIDS
can catch TB more easily than others because their immune systems are compromised.
Transmission is most likely to occur from patients with unrecognized pulmonary TB who
are not on an effective anti-TB therapy and have not been placed in TB isolation. Some
people need directly Observed therapy to make sure that they are taking their medications
and decreasing the risk to others.
Very low-income. Very low-income households are households with incomes between
50 and 80 percent of the Area Median Income for the Oakland PMSA as defined by the
U.S. Department of Housing and Urban Development and adjusted for household size.
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Contra Costa County HIV/AIDS Housing Pian
Appendix II: Program Recommendations for
HIV/AIDS Housing Programs
Both the HIV/AIDS Housing Survey conducted for this plan and the experience of HIV/AIDS
housing providers in Contra Costa County and across the nation have identified issues which lead
to recommendation about the programs and services which should be components of HIV/AIDS
housing. These programmatic suggestions could be incorporated into the standards of care
recommended by the plan, or used by agencies to evaluate their services.
i
A. Recommendations For Program Components of HIV/AIDS Housing
I 1. Programs for people who are homeless or at high risk for
homelessness:
HIV/AIDS housing services and programs designed to meet the needs of people who do
not have a place to live or are at immediate risk for homelessness should include the
following:
• Immediate access to emergency vouchers or eviction prevention funds to
help get and/or keep individuals who meet criteria for assistance off the
streets.
• A 24-hour shelter which provides nursing or medical services on a very
limited basis.
• Immediate and direct links-to transitional housing programs specifically
designed for people who have been homeless, who have poor rental
histories, and who have complex health and/or psycho-social issues.
• Shallow rental subsidies to assist people who pay more than 30 percent of
their income but who do not qu^'.ify for Section 8 or other permanent
housing programs.
• Immediate access to eviction prevention funds and short-term rental
assistance subsidies to help keep people from becoming homeless.
• Assignment of a case manager to help individuals cut through red tape and
access financial programs, benefits and medical care.
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Contra Costa County HIV/AIDS Housing Plan
2. Housing programs for people with complex health care needs:
HIV/AIDS housing programs and services to meeting the needs of people with complex
health care needs—outside of those that can only be met by end stage care through a
residential skilled nursing facility—should include the following:
• Adequate ventilation and isolation facilities to serve people living with
HIV/AIDS and tuberculosis in a manner consistent with OSHA
regulations: People with active TB should be kept in an acute hospital
isolation room until no longer contagious and then followed in
directly-observed therapy for one calendar year.
• Memoranda of Understanding or contracts for home health care
homemaker, personal care attendant and in-home hospice services.
• Memoranda of Understanding or contracts for case management services
and transportation to ongoing primary care.
3. Housing programs for dually and triply diagnosed persons:
Housing programs and services to meet the needs of the people dually and triply
diagnosed with HIV/AIDS, mental illness, dementia and/or substance abuse, should
include the following:
• Intensive on-site services, including case management, residential
management, money management, and at least one daily congregate meal.
• On-site counseling, including one-on-one and group mental health services,
substance abuse counseling, and HIV prevention education.
• Limited on-site medical services, primarily visiting nursing services and
personal care attendant services, and transportation to off-site primary
medical care appointments.
• Assignment of a case manager and/or benefits advocate to help individuals '
cut through red tape and access financial programs, benefits and medical
care. '
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Contra Costa County HIV/AIDS Housing Plan
4. Housing programs for women and families with children:
HIV/AIDS housing programs and services to meet the needs of women and families
should include the following:
• The high degree of drug use history and active drug use of women living
with HIV/AIDS mean that housing programs must be linked to drug
treatment services and recovery programs.
1 On-site child care and memoranda of understanding or contracts with home
makers and respite care providers.
• Housing should be in safe, drug-free neighborhoods, near schools and bus
lines.
1 Apartments and homes should provide separate bedrooms for children and
adults, and providers should anticipate the effect of mixing adults who are
sick and dying with those who are relatively healthy.
• Formal contracts or memoranda of understanding with hospitals and clinics
P
that serve pediatric patients.
' Additionally, housing should be located in safe, drug free neighborhoods
and housing programs and services should include the following where
appropriate:
• Formal contracts or memoranda of understanding with substance abuse
programs.
• Formal contracts or memoranda of understanding, or where possible,
on-site staff services, including resident management, money management,
counseling, mental health services, and HIV prevention education.
• Assignment of a case manager and/or benefits advocate to help individuals
access financial programs, benefits and medical care.
• Cultural and language diversity and cultural competency awareness
training.
• Linkages with community-based organizations.
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Contra Costa County HIV/AIDS Housing Plan
B. Social Services/Building Management Plan Evaluation Checklist
This document has been developed by the Corporation for Supportive Housing to assist
supportive housing providers in evaluating the supportive service and building
management issues inherent in supportive housing. These can be used as a component of
program evaluation and in the development of the recommended standards.
1. Sponsor/Development Team:
Philosophy, Mission& Objectives
• How does the proposed project fit within the philosophy, mission and
objectives of the sponsor/development team?
Experience of the Sponsor/Development Team
• What is each organization's experience with this type ofproject?
• What is each organization's experience in the specific role which it will
.play in the project (e.g. landlord, service provider, consultant)?
Staff/Board of Directors of the Sponsor/Development Team
• What are the background and experience of key staff/board members?
• How many years have they been with the organization? Turnover rates?
• Is there an adequate number of staff with necessary skills assigned to
develop the project?
• Are the Boards of Directors involved and supportive of the
sponsor/development team's activities?
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Contra Costa County HIVIAIDS Housing Plan
Financial Condition of the Sponsor/Development Team
• Size& diversity of funding
• Size and solidity of asset base (e.g. fixed assets, endowments)
• Status of current indebtedness (e.g. timeliness of payments)
• Do fees earned from services support projects?
1 Adequacy of assets and income to support/sustain growth
• Operate with a surplus/break-even/deficit? Why? Plan to correct?
Current with all taxes?
jIs the auditors opinion unqualified (i.e. indicating that financial statements
are not prepared in full accordance with generally accepted accounting
principles)?
2. Proposed Project
' Philosophy/Objective of the Proposed Project
• What will the approach to residents be (empowering, paternalistic, etc.)?
• What level of independence of the tenants will the program be designed to
encourage?
Size of Project
IAre the number of housing units being developed appropriate for the
population being served? (i.e. projects for people with HIV/AIDS typically
' include less that 50 units)
• Is the project large enough to be financially feasible (i.e. includes some
economies of scale to cover fixed costs)?
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Contra Costa County 11MAIDS Housing Plan
Type of Housing
• Will the housing be permanent, transitional or emergency? (Support of
transitional and emergency housing projects not currently in CSH's
mandate)
• Will the residence be licensed?
• Does the sponsor understand the licensing approval process?
• Does the structure and design of the project fit with the expected fund
source and licensing?
Profile of Targeted Tenancy
• Described proposed tenants. Why was this target population chosen?
• What is the target population mix(e.g. special needs, homeless, low
income, etc.)? Why was this mix chosen?
• What is the expected functional capacity of the tenants at initial occupancy?
In three years? How will the program respond to changes in the population
over time?
• Does the sponsor/development team have a good understanding of the ,
target populations' needs?
Do the sponsor, funding source(s) and community agree on the proposed
tenant mix?
Tenant Referral/Selection Criteria/Process
• Where will be population come from (e.g. shelters, streets, hospitals, other
housing)?
• Do the funding source(s) and/or community require that a specific referral
protocol be followed? If so, what is the protocol?
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Contra Costa County HMAIDS Housing Plan
Organizational Structure
• Will the owner of the project be a separate entity or part of the sponsor?
• Are memoranda of understanding in place?
• Does the structure involve a partnership between separate organizations?
• What is the structure of the partnership? What is the track record for each
organization in working in partnerships?
• Are the roles of landlord and service provider separated? (can be a
successful strategy; allows landlord to set and enforce rules; service
provider to act as advocate for tenants)
• What will the flow of the capital, operating and social services funds be?
(e.g. paid to sponsor, then to program, etc.)
Administrative Staffing
1 Number of individuals, title, experience/expertise
• Adequacy of number and experience of staff
1
Building Layout/Design
• Does the building's proposed layout/design fit with hc!-,sing& services
1 concept?
3. Social Service Plan for Proposed Project:
Philosophy (e.g. tenant/community involvement)
• Will the services provided be mandatory or voluntary?
• Will the project include Peer Support Groups, a Tenant Advisory
Committee or Council (i.e. empowerment programs) and/or a Community
Advisory Committee (community programs)?
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Contra Costa County MWAMS Housing Plan
Social Services
• Which of the followingservices are to be provided? B whom?
P Y
Case Management (i.e. service coordination, including linkages to off-site services)
Crisis Intervention
Psychiatric Services
Bereavement Counseling/Pastoral Services
Recovery Readiness Services (for individuals who have active addictions)
Substance Abuse Counseling
Methadone Maintenance(must be done through off-site linkage)
Harm Reduction Services
Daily Living Skills Assistance
Medication Management
Physical Therapy
Occupational Therapy
Pain Management (esp. for PWAs)
Medical/NursingNisiting Nurse Care
Dental & Ophthalmology Services
Counseling (Individual/Group)
Recreational/Socialization
Job/Educational Training
Personal Financial Management
Entitlement Programs Assistance
Legal Assistance ,
Transportation
Food/Nutritional Services
Services Coordination (i.e. off-site linkages)
• Will the service(s) be provided on-site or off-site? If off-site, where? How 1
will the tenants get there?
• How many hours of each service will be available to the tenants? ,
• If service are available on a 24 hour basis, for what reason and what ,
mechanism?
• How many and which individuals do you expect will utilize each service?
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Contra Costa County HIV/AIDS Housing Plan
• What are the target goals for on-site and off-site service usage? (After
project is in operation, should compare to how many people actually
anticipate?) What monitoring and evaluation mechanisms are proposed?
' What, if anything, will be done to stimulate the involvement of those who
don't participate?
• Are the type& level of social services to be provided adequate for
population served?
• What is the staff/client ratio? How does ratio company to similar projects?
• Are memoranda of understanding in place for all key services to be
provided by outside entities, both on-and off-site?
Staffing Pattern
' Days, shifts, hours, full-time/part-time?
• What is the professional vs. nonprofessional makeup of the staff on the
different shifts? Does this make sense?
• Do the salary levels of the staff make sense?
• Does the staffingplan fit with anticipated level of social services provided?
P P
Management
• What is the record keeping plan? What information will be kept? How
long will information be kept?
• What is the crisis management plan & incident review process?
' What is the plan to assure quality control (particularly important for
projects which serve people suffering from mental illness)?
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Contra Costa County HIV/AIDS Housing Plan
Funding
• What is the likelihood of thero'ect securing government contract
(s)?
J gg (s ?)
Likelihood of renewal?
•
Amount, term and adequacy of social service contract(s) for population
served? '
• Are the funding requests within a reasonable range for anticipated funding
sources?
• What is the percent breakdown of direct vs. administration costs?
(Administrative costs should not exceed 20 percent - 30 percent of total
budget)?
4. Building Management Plan for Proposed Project:
Management/Philosophy
• Lease/Occupancy Agreement (leases for permanent housing required if
using HUD funds)
• What will the House Rules be? Are they reasonable?
• Will the tenants be involved in the management of the residence (e.g.
Tenant Security Patrol)? Payments or stipends for the work performed by
the residents may jeopardize tenant entitlements.
Building Services
• What are the services to be provided in the following areas? By whom?
• Property Management (in-house/contracted, experience (current vacancy
rates, turnover rates, collection losses, 3rd party payment experience)
• Security (in-house/contracted, 24-hour or evening/weekend, trained in
crisis management)
•
Janitor/Building Manager (residing on-site?)
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Contra Costa County HN/AIDS Housing Plan
1
• Housekeeping/Maintenance
• Are the types and levels of building services provided adequate for
populations served?
• What is the staff/client ratio? How does ratio compare to similar projects?
Staffing Pattern
• Days, shifts, hours, full-time/part-time
• Fit with anticipated level of building services provided?
• Do the salary levels of the staff make sense?
Operating Funding
• Tenant rent paying ability (i.e. probable income levels & sources)
• Likelihood of securing operating subsidies (e.g. Project-Based or
competitive Section 8, McKinney, Shelter Plus Care, Mod/Rehab, SRO,
HOPWA, etc.)
• Likelihood of renewal of operating contracts
• Amount, term and adequacy of operating subsidies
• What is the agency's ability to satisfy funders' reporting requirements (e.g.
for HOPWA, Section 8 funding, tax credits, etc.)?
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Contra Costa County HMAMS Housinit Plan
Appendix III: Resources For HIV/AIDS
Housing
• Independent living: Housing Opportunities for Persons with AIDS program
(HOPWA), Section 8, Public and Indian Housing, Home Investment Partnership
Act Community Development Block Grant Program(CDBG), Low Income
Housing&Historic Tax Credits, bond financing, Federal Home Loan Bank
Affordable Housing Program (AHP), and the Resolution Trust Corporation
Affordable Housing Disposition Program(AHDP).
• Assisted or supported housing: Supportive Housing for Persons with Disabilities
(section 811), Shelter Plus Care, Supportive Housing Program (SHP), HOPWA,
Section 8, HOME, CDBG, Surplus Federal Property to Use to Assist the
Homeless, HUD-Owned Single Family Disposition, Low Income Housing and
Historic Tax Credits, bond financing, AHP, and AHDP.
• Transitional housing: SHP, Transitional Living Program, Surplus Federal
HOME Property, Shelter Plus Care, HOPWA, HOME, HUD-Owned Single
Family Disposition, bond financing, Mental Health and Chemical Dependency
facility housing, Federal Emergency Shelter Grants.
• Emergency housing: FEMA Emergency Shelter Grants, Surplus Federal
' Property, HOPWA, CDBG, and Bond financing.
• Skilled nursing care: Section 232 Program, and bond financing. HOPWA,
CDBG
• Housing referral services: HOPWA, Ryan White CARE Act (Title II), Projects
for Assistance in Transition from Homelessness (PATH), Community Mental
Health Research Demonstration Projects for the Homeless Chronically Mentally
Ill, and Community Services Block Grant Program.
• Supportive services linked to HIV/AIDS housing: HOPWA, Ryan White
I CARE Act Titles I, II and III b (which provides early intervention and primary
health care and case management), private insurance, managed care insurance
programs, MediCal, Medicare and other third party payors.
169
Contra Costa County HN/AIDS Housing Plan
Appendix IV: Long Term Care
Reimbursement Structure in
California
i
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1
Long Term Care
Reimbursement Structure
in California
Prepared by:
Bill Haskell
175 Belvedere Street
San Francisco, CA 94117
For:
AIDS Housing of Washington
2025 First Avenue, Suite 420
Seattle, WA 98121
December 4, 1995
Table of Contents
Critical Issues
Topic Area I. Existing reimbursement mechanisms for
long term care in licensed health care facilities............................................ 1
A. Congregate Living Health Facilities (CLHF)........................................................................................ 1
B. Nursing Facilities (NF)......................................................................................................................... 1
1) Nursing Facilities Providing Level A Services (previously ICFs).................................................... 1
2) Nursing Facilities providing Level B Services (previously SNFs)................................................... 2
3) A New Option in Licensed Health Care: Transitional Inpatient Care in Nursing Facilities............ 4
Topic Area II. Federal/state service reimbursement programs
which cover components of long term care..................................................5
A. Medi-Cal Hospice Benefit.................................................................................................................... 5
1) Reimbursement Rates................................................................................................................... 5
B. Medicare Hospice Benefit................................................................................................................... 6
C. Medi-Cal Long Term Care Coverage.................................................................................................. 7
D. Medicare Long Term Care Coverage .................................................................................................7
E.AIDS Medi-Cal Waiver Program ......................................................................................................... 7
F.AIDS Case Management Program...................................................................................................... 9
Topic Area III. Strategies to maximize reimbursements in
licensed health care facilities and residential programs............................. 11
A. Maximizing Reimbursement for Hospice Care by Combining Medi-Cal/Medicare
Hospice Benefits with Nursing Facility Rates.................................................................................. 11
1) Collaborations between hospice programs and nursing homes to provide hospice
care for AIDS patients in nursing homes..................................................................................... 11
2)The use of Medicare and Medi-Cal programs to provide long term care, including
hospice care, for AIDS patients in nursing facilities.................................................................... 12
B. Maximizing Reimbursement for Care in Residential Settings by Using State-Funded
Home- & Community-Based Programs for Services........................................................................ 13
1) Use of the AIDS Medi-Cal Waiver and AIDS Case Management Programs to provide
long term care in licensed and unlicensed residential settings................................................... 13
Topic Area IV. Health care facilities using reimbursement from
Medi-Cal, Medicare and other sources for long term care. ........................ 14
A. Coming Home Hospice, San Francisco, CA: A Residential Hospice Facility................................... 14
B. St. Mary's Hospital, San Francisco, CA: A Hospital-Based AIDS Dementia Care Unit.................... 15
C. Laguna Honda Hospital, San Francisco, CA: A Hospital-Based AIDS Skilled Nursing Unit............ 16
x � ,
y Ir y17" ,•J• r„ ,,
xong�'T"ermGare Reimbursement Structure In.GalI.M.IT
-
C�>tt��rait lay ssuAs' s
❑ None of the case studies presented fully cover their operating costs through
reimbursement sources. Actually, all had to raise between 22% and 40%, which
came from fundraising, Ryan White CARE grants, and contributions from the
hospitals with which the program is affiliated.
❑ Should CARE funds be reduced or eliminated in the future, programs will
have to replace these grants in their budgets by increasing fundraising
activities, and/or relying more heavily:on institutional contributions. There will
probably be increasing competition for CARE dollars. This doesn't mean
programs should not plan to use CARE funds; it does mean the program planners
should be careful and diversify the program's risk by obtaining a variety of funding
sources to support the ongoing annual operating budget.
❑ It is important to be aware that the Medi-Cal Hospice Benefit program is
designed to be all inclusive. When an individual is under the care of a hospice
program supported by the Medi-Cal Hospice Benefit, no separate payments can
be obtained from Medi-Cal for hospital care, nursing facility care, home health
agency care, medical supplies and appliances, drugs durable medical equipment,
medical transportation, and any other service related the individual's terminal ,
diagnosis. It is either the Medi-Cal Hospice Benefit or other Medi-Cal
reimbursement programs. Not both.
❑ The Medi-Cal reimbursement rate for a hospital-based nursing facility is higher
than that available for a freestanding nursing facility, but there are often costs to
cover hospital administrative expenses which must be incurred. However, if ,
necessary, a hospital institution can usually underwrite some of the cost of care in
such a nursing facility.
❑ The Medi-Cal reimbursement rate for the new transitional inpatient care ,
licensure category, which will become available in January 1996, is being set
at between $300 to $320 per patient per day. Given that the reimbursement '
rate for a distinct-part nursing facility is $214.90 per patient per day and that for a
freestanding nursing facility the rate is approximately $85 to $92 per patient per
day, this is a dramatic increase to cover the cost of patients who require
institutional care but do not need acute hospital care.
Long Term Care Reimbursement Stricture in California page[
r . ,
l�eimbursemiM mechanisms for long term care I
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' A. Congregate Living Health Facilities (CLHF)
This licensure category is specific to California, and is not recognized by the federal
government. Because CLHF is not considered a health care facility under federal law,
there is no federal or state reimbursement. One AIDS housing program in California is
' under this licensure category: Chris Brownlee Hospice, in Los Angeles. Although there
is no reimbursement for this category, the AIDS Health Care Foundation, which
operates the program, obtained a unique reimbursement through the state legislature
for this facility.
B. Nursing Facilities (NF)
Prior to 1987, California had a reimbursement structure which included two typesof
subacute health care facilities: skilled nursing facilities (SNFs) and intermediate care
facilities (ICFs). Under the federal Omnibus Reconciliation Act (OBRA) of 1987, SNFs
and ICFs were consolidated under nursing facilities (NFs). However, even though this
consolidation has taken place for purposes of federal reimbursement, California
continues to have licensed skilled nursing facilities and intermediate care facilities. The
California Code of Regulations (Title 22, Division 3, Health Care Services), defines
nursing facility as a licensed a skilled nursing facility or intermediate care facility.
Service definitions also continue to be based on the level of care provided in SNFs and
ICFs. Nursing facilities providing Level A services are the old ICFs, and nursing
' facilities providing Level B services are the old SNFs. Medi-Cal reimbursement rates
presented below are defined in terms of nursing facilities, and will correspond to these
different levels of services.
1) Nursing Facilities Providing Level A Services (previously ICFs)
Level A services refer to intermediate care services which are for persons who
require protective and supportive care, because of mental or physical conditions
or both, above the level of board and care. Except for brief spells of illness,
these patients do not require continuous supervision of care by an RN or LVN,
and do not have an illness, injury, or disability for which hospital or skilled
nursing facility services are required. The primary purpose of this institution (or
distinct part thereof) is to provide a program of health or rehabilitative services
' for developmentally disabled persons.
For nursing facilities, hospitals, or public institutions providing Level A services,
' the per diem reimbursement rate depends on licensed bed capacity and county,
as follows:
Bed Size Los Angeles County San Francisco,Alameda, All Other Counties
Contra Costa,San Mateo,
Santa Clara Counties
1-99 1 $67.59 1 $67.59 $57.14
100+ $56.38 1 $56.38 $56.38
Long Term Care Reimbursement Structure in Calitbrnia page 2
a
2) Nursing Facilities providing Level B Services (previously
SNFs)
Level B services refer to skilled nursing services which are for persons who
require the continuous availability of skilled nursing care provided by RNs or
LVNs for the treatment of illness or injury, but do not require the full range of
services provided in an acute care hospital. These patients need a level of
service which includes the continuous availability of procedures such as the
administration of injections, infusions, tube feedings, nasopharygeal aspiration,
insertion or replacement of catheters, application of dressings, treatment of skin
disorders, and restorative nursing procedures.
When used, the term "skilled nursing facility" includes the terms "skilled nursing ,
home", "convalescent hospital", "nursing home", or"nursing facility".
Reimbursement rates are separately established for hospital-based distinct part
NFs and freestanding NFs.
a. Hospital-Based Distinct Part Nursing Facilities -
For nursing facilities, hospitals, or public institutions providing Level B
services that are distinct parts of acute care hospitals, if such facilities
are not state operated, the per diem reimbursement rate is based on
projected costs up to the median of $214.90.
11p2 of Ucensure Tye of Facility Rate of Reimbursement
Hospital-Based, Level B Nursing Services $214.90
Distinct Part Nursing Facility
The Medi-Cal reimbursement rate for a hospital-based nursing facility is
higher than that available for a freestanding nursing facility, but there are
often costs to cover hospital administrative expenses which must be
incurred. However, if necessary, a hospital institution can usually
underwrite some of the cost of care in such a nursing facility.
One half of NFs get less than this amount. The weighted State per diem
reimbursement rate is $186.60, which is the average payment a Level B
hospital-based, distinct part NF receives.
b. Freestanding Nursing Facilities
For nursing facilities that are freestanding (i.e., not part of acute care
hospitals) providing Level B services, the per diem reimbursement rate
depends on licensed bed capacity and county, as follows:
Bed Size Los Angeles County San Francisco,Alameda,Contra Costa, All Other Counties
San Mateo,Santa Clara Counties
1-59 1 $76.14 $85.11 $79.25
60+ 1 $73.26 $92.31 1 $80.88
Note: These rates are lower than hospital-based NFs, because freestanding NFs are typically '
designed for geriatric patients who require custodial care.)
1
' Long Term Care Reimbursement Structure in California Page 3
C. Subacute Care in Nursing Facilities
' Subacute care services refer to a level of care which is needed by
persons who do not require hospital acute care, but who require more
intensive licensed skilled nursing care than is provided to the majority of
patients in a skilled nursing facility. Subacute care is intended for
medically fragile persons including quadriplegics, paraplegics, and
persons with tracheotomies. A subacute care unit is an identifiable unit
of a skilled nursing facility accommodating beds including contiguous
rooms, a wing, a floor, or a building approved for such purpose. This
category is not designed for chronically ill persons, including persons
with AIDS.
' For subacute care services in either. (1) a hospital-based distinct part
nursing facility, or (2) a freestanding nursing facility, the all inclusive per
' diem rates are as follows:
Typt of Licensure I Type of Patient Rate of Reimbursement*
'
Hospital-based Ventilator Dependent $423.67
Freestanding Ventilator Dependent $267.84
Hospital-based Not Ventilator Dependent $401.08
F nding Not Ventilator De dent $245.26
' ('Rates effective as ofAugust 1.1995.)
d. Ancillary Services and Items
' Nursing facilities are able to bill Medi-Cal separately for additional
ancillary services and items required for patient care, not included in NF
reimbursement rates. Not included in the payment rate, and to be billed
' separately by the nursing facility service provider, are the following:
1. Allied health services ordered by the attending physician.
2. Altemating pressure mattresses/pads with motor.
' 3. Atmospheric oxygen concentrators and enrichers and accessories.
4. Blood, plasma and substitutes.
5. Dental services.
6. Durable medical equipment(DME).
7. Insulin. '
8. Intermittent breathing equipment.
9. IV trays, tubing &blood infusion sets.
10. Laboratory services.
11. Legend drugs.
12. Liquid oxygen system.
13. MacLaren or Pogon Buggy.
14. Medical supplies
15. Nasal cannula.
16. Osteogenesis stimulator device.
17. Oxygen.
18. Parts and labor for repairs of DME.
19. Physician services.
20. Portable aspirator.
21. Portable gas oxygen system.
22. Precontoured structures.
23. Prosthetic&orthotic devices.
24. Reagent testing sets.
25. Therapeutic air/fluid support systems/beds.
' 26. Traction equipment&accessories.
27. Variable height beds.
28. X-rays.
Long Term Care Reimbursement Structure m California Page 4 ,
3) Inpatient
A New Option in Licensed Health Care: Transitional In ,
P P
Care in Nursing Facilities ,
A new category of care is being developed called transitional inpatient care,
which will soon be incorporated into a portion of the health care facilities in
California. Transitional inpatient care is intended to make institutional care more
accessible to persons who require short term care outside of an acute care
hospital. It is designed for individuals who need IV therapy, rehabilitative
services, wound care, respiratory therapy, or traction. This level of care results '
from AB 911, which provides the statutory authority for its creation. Regulations
are currently being established by the State Department of Health Services.
The Medi-Cal reimbursement rate for the new transitional inpatient care ,
licensure category, which will become available in January 1996, is being set at
between $300 to $320 per patient per day. Given that the reimbursement rate ,
for a distinct-part nursing facility is $214.90 per patient per day and that for a '
freestanding nursing facility the rate is approximately $85 to $92 per patient per
day, this is a dramatic increase to cover the cost of patients who require
institutional care but do not need acute hospital care. ,
Transitional inpatient care refers to the level of care which is needed by persons
who have suffered an illness, injury, or exacerbation of a disease, and whose ,
medical condition has clinically stabilized so that daily physician services and
procedures immediately available in an acute care hospital are not medically
necessary. Transitional inpatient care services will be available for Medi-Cal '
beneficiaries who do not meet the criteria for subacute care but who need more
medically complex and intensive services than are generally available in a
skilled nursing facility. For the first two years of this program, transitional ,
inpatient services will only be available to Medi-Cal beneficiaries 18 years of age
and older.
This new category may provide an additional option for the care of persons with '
AIDS who do not require an acute care hospital or a long stay in a nursing
facility but who need an institutional setting for medically complex or intensive
rehabilitative services of short-term duration. While this new category is not
intended for terminal care, those who are terminally ill are not excluded.
Although it can be provided in a variety of settings, transitional inpatient care will ,
probably be provided in the higher acuity areas of existing freestanding nursing
facilities and in hospital-based distinct part nursing facilities.
Long Tenn Care Reimbursement Structure in California Page S
oprcrAroa hllL p ' Federal/state senrlce reimbursement programs which cover
M
„w, uau��w'”tiF ^,xr components ofi long term care ..... .........
•in•••...•••.•.• • •.M..••• .......« ......•.. ......... .......•. ......... ••....... .....�.... ...........................................
' A. Medi-Cal Hospice Benefit
The Medi-Cal Hospice Benefit is designed for the care at home of terminally ill persons
in hospice programs. However, it is also available to support the care of terminally ill
persons in inpatient hospice facilities and nursing facilities, when their homes are no
longer appropriate or available. Any Med-Cal eligible recipient certified by a physician
as having a life expectancy of six months or less may elect to receive hospice care in
lieu of normal Medi-Cal coverage, for services related to the terminal condition.
' Hospice providers may include hospitals, skilled nursing facilities, intermediate care
facilities, home health agencies, and any licensed health provider certified by Medicare
to provide hospice services and enrolled as a Medi-Cal hospice care provider.
1 1) Reimbursement Rates
' Reimbursement rates for the Medi-Cal Hospice Benefit are initially set by HCFA
for the Medicare Hospice Benefit. These rates are then reviewed by the State
Department of Health Services, which calculates the reimbursement rates for
California. The Medi-Cal Hospice Benefit is designed to be more all inclusive
than the reimbursement rates for nursing facilities. Accordingly, in addition to
the reimbursement rates for the four different levels of care, a hospice program
can only bill Medi-Cal for room and board, and for physician care.
' When an individual is under the care of a hospice program supported by the
Medi-Cal Hospice Benefit, separate payment will not be made for the following:
hospital care; nursing facility care (Level A and B); home health agency care;
medical supplies and appliances; drugs; durable medical equipment; medical
transportation; and any other services related to the individual's terminal
' diagnosis. No ancillary services or items can be billed by nursing facilities for
patients on the Medi-Cal Hospice Benefit. In addition, in accordance with
federal requirements, no Medi-Cal copayments may be collected from Medi-cal
' recipients who are receiving hospice services for any Medi-Cal services,
including services that are not related to the terminal illness.
' Medi-Cal will make payments to a hospice provider for services rendered to an
individual living at home, or who is a resident of a Level A or Level B nursing
facility. Reimbursement will be provided for four levels of care, for room and
board, and for physician services provided by the hospice not included in one of
the levels of care.
' The four levels of care are: (1) Routine Care, which is care received in the
patient's home or in a facility in which hospice care is provided; it is not
continuous care. Payment is made on an all inclusive per diem basis without
regard to the volume or intensity of services provided on any given day; (2)
Continuous Care, which is predominantly skilled nursing care provided on an
Long Term Care Reimbursement Structure in California Page 6
hourly basis, for a minimum of eight hours during brief crisis periods. Home
health aide and/or homemaker services may also be provided; (3) Inpatient ,
Respite Care, which occurs when a patient being cared for in the home
receives care in an approved inpatient facility, on a short-term basis, to provide
respite for family members or others caring for the individual. Each episode is ,
limited to five days. This rate is not available for the care of an individual who is
already a resident of a nursing facility; and (4) General Inpatient Cale, which
occurs when the patient receives general care in an inpatient facility for pain '
control or acute/chronic symptom management that cannot be managed in other
settings. Below are Medi-Cal Hospice Benefit reimbursement rates for specific
counties:
Location by County` Routine Continuous Inpatient General ,
Care Care Respite Inpatient
(hourly) Care Care ,
Los Angeles $109.54 $26.62 $114.76 $480.95
San Francisco,Marin, 115.38 28.03 119.76 505.10
San Mateo
Alameda, 106.91 25.98 112.51 470.07
Contra Costa
Santa Clara 109.02 26.49 116.32 478.81
Santa Cruz 1 99.27 1 24.12 1 105.96 438.42
Rural Areas 1 91.30 1 22.18 99.14 405.45 ,
National Rates 1 90.65 1 22.02 1 98.56 402.67
('Rates effective as of October 1.1994.)
a. Room and Board
In addition, Medi-Cal will make payments to a hospice provider for room
and board, for an individual who is a resident of a Level A or Level B
Nursing Facility for each day an individual resides in the Facility, not to ,
exceed the following:
Type of Facil' Services Reimbursement Rate '
Level A Nursing Facil' Section 27112 $56.75
Level 8 Nursing Facility Section 27110 $75.75
b. Physician Services ,
Reimbursement for physician services is by report (which means no
reimbursement rates are established). There are no limitations on '
physician services. This provides the physician and the hospice program
with the flexibility needed for the care of the patient's condition and
provide what the patient requires. ,
B. Medicare Hospice Benefit ,
This program has the same requirements, regulations, and essentially the same
payment structure as the Medi-Cal Hospice Benefit. However, there are two important
differences: (1) a patient can only participate in one Medicare program at a time, either '
the Medicare Hospice Benefit or the limited Medicare coverage for nursing home care;
and (2) Medicare requires a 20% copayment for medications. The reimbursement rates
for the Medicare Hospice Benefit are established by HCFA, with wage components
subject to indexes. Below are Medicare Hospice Benefit reimbursement rates for
specific Metropolitan Statistical Areas (MSAs):
Long Term Care Reimbursement Structure in California page 7
' Location by MSA' Routine Continuous Inpatient General
Care Care Respite Inpatient
hour) Care Care
San Francisco,Mann, $115.22 $28.03 $113.77 $505.10
San Mateo
' Alameda Contra Costa 106.77 25.96 106.88 470.07
Santa Jose 108.88 26.48 108.60 478.81
Santa Rosa Petaluma 101.90 24.78 102.91 449.89
Vallejo Fairfield Napa 110.99 26.99 110.32 487.55
National Rates 90.63 1 22.02 98.56 402.67
('Rates effective as of October 1,1994)
C. Medi-Cal Lon Term Care Coverage
9 9
Long term care in health care facilities is covered by Medi-Cal only in terms of the per
diem nursing facility reimbursement rates. Once qualified, there is no restriction on the
number of days an individual will be covered by for long term nursing facility care.
Other types of long term care services, including home health care, personal care,and
' adult day health care are separately covered under Medi-Cal.
D. Medicare Long Term Care Coverage
Medicare is not designed to support long term nursing facility care. There is a benefit
for nursing facility care under Medicare Part A (hospital care), limited to 100 days per
' individual for a lifetime. To qualify, an individual must be very sick, meet the strict
definition for skilled care, and have been hospitalized for 72 hours in the prior 30 days.
Once an individual qualifies, Medicare pays for all or some of 100 nursing home days
of skilled care. The first 20 days are at 100% of the Medicare skilled level rate, which is
approximately $400 per day. The next 80 days are at a fixed rate, approximately $310
per day. The family or commercial insurance must cover the remaining $90 per day.
This benefit requires that rehabilitative activity will be undertaken as a goal of
treatment.
E. AIDS Medi-Cal Waiver Program
The AIDS Medi-Cal Waiver Program (MCWP) provides comprehensive nurse case
management and home and community-based care to Medi-Cal recipients with mid- to
late-stage HIV/AIDS. Services are provided in lieu of placement in a nursing facility or
hospital. The purpose of this program is to maintain clients safely in their homes and,
' thereby, avoid more costly institutional care. Clients remain at home as long as
possible. Without these services, clients would be in a nursing facility or hospital for an
extended period.
This program is approximately 50% federally funded and 50% state funded; total paid
program expenditures for 1994 were $5.3 million. The Office of AIDS contracts with 32
' county health departments, licensed home health agencies, and community-based
organizations to administer this program at the local level. These agencies subcontract
with licensed providers for direct care. MCWP services are available in 42 counties in
California.
Long Term Care Reimbursement Structure in California Page 8 '
1) Who Is Served
MCWP clients tend to be more frail than those on the AIDS Case Management ,
Plan. The average length of enrollment is approximately four months. Most
disenrollment is due to death. The remaining clients are disenrolled from the
program because their cost of care reached the cost cap, the clients leave the
service area, and/or they opt to disenroll. Clients temporarily hospitalized or
placed in a nursing facility remain enrolled and, upon discharge, will resume
MCWP services.
2) Eligibility
The MCWP serves adults and children with HIV/AIDS who meet the following
requirements: (1) are medically eligible and enrolled in fee-for-service Medi-Cal
(not managed care); (2) are at a nursing facility level of care or above, (3) have
an acuity level rating of 60 or below on the acuity level scale; (4) have a safe
home setting; (5) have exhausted coverage for health care benefits similar to
those available under the MCWP; (6) children must be mildly, moderately, or
severely symptomatic on the CDC�Classification System for HIV Infection in
Children under 13 Years of Age. '
3) Program Services
A case management team consisting of the nurse case manager, social worker,
client, and attending physician oversees the delivery of services. The nurse
case manager and social worker conduct ongoing client assessments, develop
and maintain a service plan to meet the client's needs, and coordinate the ,
provision of cost effective, quality services for the client. Services such as
attendant care are provided in the client's home, while psycho-social counseling
and emotional support can be provided in a community-based setting.
All services include: attendant care; homemaker services; benefits counseling;
psycho-social counseling; in-home skilled nursing (including infusion therapy);
non-emergency medical transportation; durable medical equipment and
supplies; minor physical adaptations to the home; nutritional supplements and
home delivered meals; nutritiongil counseling; and supplements for infants and '
children in foster care.
4) Cost of Care
Each client has an annual cost cap of $13,209 (excluding administrative fees).
The average per client cost of care for MCWP services for 1994 is estimated at
$3,189. Most clients expire before they reach the annual cost cap. If the cap is ,
reached, the nurse case manager disenrolls the client from this program and
coordinates the appropriate transfer to the AIDS Case Management Program or
an institutional setting.
5) Linkages with Other State and/or Federal Programs
Most MCWP contractors also have contracts for the AIDS Case Management '
Program. Typically, when AIDS Case Management Program clients become
Medi-Cal eligible, they are transferred to the MCWP. The co-existence of these
programs in the same agency allows clients a seamless continuum of care ,
without interruption of services or change of care providers. Likewise, as clients
Long Term Care Reimbursement Structure in California Page 9
become ineligible for the MCWP, they cavi be disenrolled and transferred to the
AIDS Case Management Program. The MCWP is formally linked with the Medi-
Cal Program which provides primary care services for MCWP clients. MCWP
contractors are required to maximize services available through Medi-Cal before
using MCWP services.
Since the MCWP does not provide for all client needs, the nurse case manager
or social worker will access other available resources (e.g., AIDS Drug
Assistance Program, Medi-Cal Health Insurance Premium Payment Program,
HOPWA for subsidies and/or other housing resources, Shelter Plus Care, or
Section 8 housing to address housing needs. For children, the MCWP
1 contractor may connect with California's Children's Services, Early and Periodic
Screening, Diagnosis and Treatment Program, and the Foster Care Program.
F. AIDS Case Management Program
The AIDS Case Management Program (CMP) provides comprehensive nurse case
management, and home-and community-based care to persons with AIDS or
symptomatic HIV. Services are provided in lieu of placement in a nursing facility or
hospital. The purpose of the program is to maintain clients safely in their homes and,
�j thereby, avoid more costly institutional care. Clients remain in their homes as long as
possible. Without these services, clients would be in a nursing facility or hospital for an
extended period.
' This program is funded by the State General Fund ($6.42 million) and supplemented by
CARE Title II funds ($1.32 million for 1995-96). Total funding for FY 1995-96 is $7.74
million. The Office of AIDS currently contracts with 36 county health departments,
licensed home health agencies, and community based organizations to administer the
program at the local level. These agencies contract with licensed providers for direct
care. AIDS CMP services are available in 42 counties in California.
1) Who Is Served .
AIDS CMP clients tend to be healthier than those on the AIDS Medi-Cal Waiver
Program. Their average length of survival from enrollment is approximately 12.8
months. In FY 93-94, close to 50% of these clients were disenrolled due to
death. Other reasons for disenrollment included transfer to the Medi-Cal Waiver
Program, transfer from the service area, improved health, and/or voluntary
disenrollment from the program. Clients temporarily hospitalized or placed in a
nursing facility remain enrolled and, upon discharge, will resume AIDS CMP
services.
2) Eligibility
The AIDS CMP serves adults with AIDS or symptomatic HIV who are unable to
function independently in some area (an acuity of 70 or less on the Karnofsky
scale) and HIV positive children at all stages.
�1
Long Term Care Reimbursement Structure m California Page 10 '
3) Program Services
The services provided under the AIDS Case Management Program are the
same as those provided under the AIDS Medi-Cal Waiver Program.
4) Cost of Care
Funding is allocated at $536 per client per month which covers case
management, data collection and reporting, and purchased direct care services.
Because the AIDS CMP was not intended to fully fund all client services and is
the payor of last resort, projects must augment reimbursement for direct care
services with other funding sources and community resources (e.g., local
govemment grants, Ryan White CARE funds, In-Home Supportive Services,
private insurance, and third-party payors).
5) Linkages with Other State and/or Federal Programs
Linkages under the AIDS CMP are the same as those established under the
AIDS Medi-Cal Waiver Program.
i�
Lo Term Care Reimbursement Structure in California
Long Pagel!
IG'Are111. Strategies to rrraxlmlze relmbcresemnts Ind llcense+ healh care
� ,.:.w �i
facill�es and residential prolgrarns t 7
A. Maximizing Reimbursement for Hospice Care by Combining Medi-
Cal/Medicare Hospice Benefits with Nursing Facility Rates
Some California hospice programs, such as the UC Davis Hospice, have established
relationships with nursing homes (freestanding nursing facilities) to provide hospice
care for terminally ill AIDS patients.
1) Collaborations between hospice programs and nursing homes
to provide hospice care for AIDS patients in nursing homes
The initial expectation was that nursing homes, through collaboration with
hospice programs, could care for a mix of AIDS patients. Some would require
routine care (reimbursed at a lower rate), while other, more medically complex
patients would require acute inpatient care (reimbursed at a much higher rate).
It was anticipated that with this higher rate of reimbursement from the Medi-Cal
Hospice Benefit, both the nursing homes and hospice programs could both
cover their costs for care.
While regulations for the Medi-Cal Hospice Benefit specify that general inpatient
care for hospice patients can be provided in an inpatient facility, in practice
Medi-Cal has denied every request made by UC Davis Hospice for this
reimbursement rate to cover the cost of such care in nursing homes. The only
time a general inpatient care rate was approved was when this level of care was
provided in an acute care hospital.
Due to this finding by Medi-Cal, nursing homes caring for AIDS patients through
collaboration with hospice programs have only received the regular per diem
Medi-Cal reimbursement rate (Level B) of approximately $80 (for freestanding
nursing facilities). This rate is intended to cover room, board and services.
Under this model, the hospice programs bill Medi-Cal for this reimbursement
and tum it over to the nursing homes to cover their room and board costs. The
hospice programs also bill Medic-Cal for their own reimbursement which has
' usually been only the per diem routine care Hospice Benefit of approximately
$100. Continuous care and inpatient respite care rates have rarely, if ever,
been approved.
Note:
1. It has been suggested that the general inpatient care rate allowable under the Medi-Cal Hospice
Benefit may be more easily approved by Medi-Cal if the nursing facility is hospital-based and
provides a level of care that falls between a hospital and a nursing home.
2. As a result of the collaboration with hospice programs, the actual room, board, and services rate is
S%less than the regular Medi-Cal reimbursement rate for freestanding nursing facilities; this is
because the hospice programs provide a significant portion of the services for hospice patients.
3. It is important to be aware that the Medi-Cal Hospice Benefit program is designed to be all inclusive.
When an individual is under the care of a hospice program supported by the Medi-Cal Hospice
Long Term Care Reimbursement Structure in California page 12
Benefit, no separate payments can be obtained from Afedi-Cal for hospital care,nursing jaciliry care,
home health agency care, medical supplies and appliances, drugs durable medical equipment, medical
transportation, and any other service related the individual's terminal diagnosis. It is either the
Medi-Cal hospice Benefit or other Afedi-Cal reirnbursanent programs Not both _
It is important to be aware that once a nursing home is in collaboration with a
hospice program, billing Medi-Cal for all services related to the care of hospice
patients must go through the hospice program. Nursing facilities can no longer
bill Medi-Cal directly. This is intended to ensure coordination of care for the
terminally ill patients. However, some nursing homes have experienced this as
losing control of their reimbursement stream.
Accordingly, because of lower Medi-Cal Hospice Benefit reimbursement rates
than anticipated and because of what some nursing homes consider to be a
loss of control over their reimbursement streams, collaborating with hospice
programs to provide terminal care to AIDS patients has generally not been
found to be financially beneficial for nursing homes—at least for those affiliated
with the UC Davis Hospice.
2) The use of Medicare and Nledi-Cal programs to provide long
tern care, including hospice care, for AIDS patients in nursing
facilities
The UC Davis Hospice employs several different options in the effective use of
Medicare and Medi-Cal to provide long-term care, including hospice care, in
nursing facilities. Each one is based on whether the AIDS patient is eligible for
Medicare (qualifies as disabled for more than two years) or Medi-Cal (qualifies
as indigent), or both (qualifies as disabled and indigent), as follows:
If an AIDS patient has Medicare coverage only: Medicare can cover most of the
cost of up to 100 days of skilled nursing care in a nursing facility, or until the patient
no longer qualifies for skilled care days. (NOTE: the maximum of 100 days of
skilled nursing care is not always authorized by Medicare.) Then, once these skilled
care days are used, the Medicare Hospice Benefit can begin to pay for hospice care.
However,the patient or family must pay for the room and board in the nursing
facility, which is not covered by Medicare. The nursing facility can charge either the
established Medi-Cal rate for room and board or, if it is private, the facility can
charge a higher rate.
• If an AIDS patient has Medi-Cal coverage only: Medi-Cal can pay for all of the
required skilled nursing care days in the nursing facility, the Medi-Cal Hospice
Benefit to cover the cost of hospice care, and also the room and board costs of the
nursing facility.
• If an AIDS patient has both Medicare and Medi-Cal coverage: Medicare can cover
most of the cost of up to 100 days of skilled nursing care in the nursing facility, or
until the patient no longer qualifies for skilled care days. Then, once these skilled
care days are used, the Medicare Hospice Benefit can pay for the hospice care. In
this instance, Medi-Cal can pay for the room and board in the nursing facility.
Long Term Care Reimbursement Structure in California Page 13
B. Maximizing Reimbursement for Care in Residential Settings by Using
State-Funded Home- & Community-Based Programs for Services
While long term care for persons with AIDS is often provided in licensed health care
settings, the AIDS Medi-Cal Waiver Program and the AIDS Case Management Program
have been developed specifically to provide case management and home and
community-based care, which allow clients to remain in their own homes, or in
residential settings, as long as possible.
1) Use of the AIDS Medi-Cal Waiver and AIDS Case Management
Programs to provide long term care in licensed and unlicensed
_ residential settings
In San Francisco, Westside Community Mental Health Services is the local
contractor with the State Office of AIDS that operates these two home-and
community-based care programs. Westside has used these programs in
combination to care for persons with AIDS in a variety of different residential
settings, including: (1) homes, (2) SRO hotels, (3) residential settings offering
primarily independent living which do not require a license to operate, and'(4)
residential care facilities licensed by the State Department of Social Services to
provide board and care.
Both licensed and unlicensed residential programs can take advantage of these
State-funded long term care services for their residents with HIV/AIDS, and case
managers can arrange for any of the wide range of home-and community-based
services covered by the AIDS Medi-Cal Waiver and AIDS Case Management
Programs. The residential programs do not have to cover the cost of this care.
However, it is important to be aware that, in each setting where these services
are provided, reimbursement goes from the State, directly to the contracted
service provider to cover the costs of this care.
Clients on the AIDS Case Management Program are often moved onto the AIDS
Medi-Cal Waiver Program when they become more frail and/or terminally ill.
Conversely, clients on the AIDS Medi-Cal Waiver Program who must be
hospitalized are often moved onto the AIDS Case Management Program.
These clients continue to receive case management services during
hospitalization, but they care be billed to the AIDS Case Management Program.
Once a person is placed on the Medi-Cal Hospice Benefit, however no services
can be provided under the AIDS Medi-Cal Waiver Program or the AIDS Case
Management Program.
Long Team Care Reimbursement Structure in California Page 14
�oplc��re�lll� r Heap"care�faclli#les�using l relm6ursemew���rom�Med>~-G"al,
}n ' s�ryjl 16 fi�q I�i dill� x' I Medlca�e andl!oterso�rces fao~.ran� term�care
««...«.. ......«««.
A. Coming Home Hospice, San Francisco, California: A Residential
Hospice Facility
None of the case studies presented fully cover their operating costs through
reimbursement sources. Actually, all had to raise between 22% and 40%, which came
from fundraising, Ryan White CARE grants, and contributions from the hospitals with
which the program is affiliated.
Should CARE funds be reduced or eliminated in the future, programs will have to
replace these grants in their budgets by increasing fundraising activities, and/or relying
more heavily on institutional contributions. There will probably be increasing
competition for CARE dollars. This doesn't mean programs should not plan to use -
CARE funds; it does mean the program planners should be careful and diversify the
program's risk by obtaining a variety of funding sources to support the ongoing annual
operating budget.
Coming Home Hospice is a residential hospice facility operated by Visiting Nurses and
Hospice (VNH) of San Francisco, a program of California Pacific Medical Center. This
residential hospice facility is licensed as an RCFCI under the State Department of
Social Services. It has 15 beds, approximately 10 are for persons with AIDS and 5 of
which are for persons with other terminal illnesses. Hospice care in Coming Home
Hospice is provided by VNH, which is a licensed Medicare hospice provider.
(Note: Coming Home,a separate non-profit organization,provides money management and conservatorship
services for persons with AIDS and the elderly in San Francisco. Coming Home Hospice was named in honor of this
organization's inspiration for the development of a residential hospice facility and its initial financial commitment in
1985. There is no present relationship between these two programs.)
In Calendar Year 1994, the total expenses incurred to operate Coming Home Hospice
amounted to $1,576,892. Given 4,817 patient days of care that year, the total daily
cost per AIDS patient was $327. This included all labor, materials, services, and some
cost allocations for VNH overhead for support functions like patient registration, billing,
management and administration. Step-down costs from California Pacific Medical
Center are only partially included in the total expenses. (NOTE: The 1994 total
expenses reflect a relatively low staffing pattern for Coming Home He pice; in 1595, to
improve quality of care, staffing will be increased at an annual cost of approximately
$50,000, which will increase the total daily cost for each patient approximately $10.)
Total revenues to operate Coming Home Hospice in 1994 amounted to $1,218,170.
This included revenue from residents who pay a percentage of income based on a
sliding scale, commercial insurance, private pay, reimbursement from both the Medi-Cal
and Medicare Hospice Benefit (hospice care was reimbursed primarily at a routine care
rate), and a portion of Ryan White CARE contract amounting to $449,400.
Long Term Care Reimbursement Structure in California Page 15
VNH has special negotiated s
g p I rates with private insurance companies which are often
higher than what insurance companies allow for hospice care, because room and board
is included. In some instances, insurance reimbursement for hospice care amounts to
$350 per patient per day. Because total revenues did not equal total expenses, the
shortfall was made up by fundraising in the amount of$358,722. Below is a budget for
the residential hospice program at Coming Home Hospice:
Coming Home Hospice: Budget for Calendar Year 1994
Operating Revenue
Gross Patient Revenue: $331,884
Medicare Hospice Benefit 316,448
_ Medi-Cal Hospice Benefit 57,888
Kaiser Hospice Benefit 23,155
Private Insurance/Hospice 11,577
Medicare(regular) 15,436
Medi-Cal(regular) 15,436
Private Insurance 771,824
Total Gross Patient Revenue (43.056)
Deductions from Revenue
Total Net Patient Revenue 728,768
Other Operating Revenue:
Other 38,576
Fees 1,426
Government Grants(CARE) 449,400
United Way 0
Fund Raising 358,722
Total Other Operating Revenue 848,124
Total Operating Revenue $1,576,892
Operating Expenses
Total Labor 1,066,842
Total Materials and Services 330,472
VNH Overhead Allocation 95,230
Corporate Allocation 14,510
r, Fund Raising Charge 69,838
�( Total Operating Expenses $1,576,892
B. St. Marys Hospital, San Francisco, California: A Hospital-Based
AIDS Dementia Care Unit
St. Mary's Hospital and Medical Center operates an AIDS dementia care unit for
patients with "moderate to severe" and end stage AIDS-related dementia. This 20-bed
unit provides care to those who have skilled nursing needs and require a secure facility
to accommodate dementia-related behavioral problems. The average daily census is
13.4 persons.
This unit is licensed as a hospital-based distinct part nursing facility and provides care
for patients recovering from acute medical illnesses where the diagnosis of AIDS-
related dementia has been established. Both ambulatory and non-ambulatory patients
are cared for; and staff provide IV therapies, ongoing medical evaluations and
Long Term Care Reimbursement Structure in California Page 16
behavioral interventions and assure corn liance with chronic drug regimens.
P 9
Emergency medical care, specialized diagnostic and therapeutic services, and case
management services are also provided.
In FY 94-95, total expenses for the dementia care unit amounted to $2,692,008. Given
4,893 days of care, the total daily cost per AIDS patient was $550. This included
labor, materials, services, and some cost allocations for St. Mary's Hospital overhead
expenses. Most care is subacute and includes a high level of occupational, physical
and speech therapy. Costs were high for pharmacy, radiology and laboratory services.
Total revenues to operate the dementia care unit amounted to $2,449,214. This
included reimbursement from: (1) Medicare in the amount of$711,870 for skilled care
days, at a daily rate of$441, which included $196 for labor, $213 for ancillary services
and items, and $32 for capital expenses; (2) Medi-Cal in the amount of$781,769 for
skilled care, at a daily rate of$278.40, which included $214.90 for hospital-based
distinct part nursing facilities, $15.00 for ancillary services and items, $7.50 for
pharmaceuticals, and $41.00 for other costs beyond insurance coverage; (3)
commercial insurance, amounting to $351,696; and (4) a Ryan White CARE contract
amounting to $603,879. Because total revenues did not equal total expenses, the
shortfall was made up by contributions from St. Mary's Hospital in the amount of
$242,794. Below is a budget for the dementia care unit:
SL Mary's Hospital AIDS Dementia Care Unit. Budget for Fiscal Year 9994-95
Operating Revenue
Net Patient Revenue:
Medicare(Skilled Nursing) $711,870
Medi-Cal(Skilled Nursing) 781,769
Government Grants(CARE) 603,879
Commercial Insurance 351.696
Total Net Patient Revenue 2,449,214
Contributions from St. Mary's 242.794
Total Operating Revenue $2,692,008
Operating Expenses
Total Labor 1,252,500
Total Materials and Services 388,910
Building g Equipment Depreciation 69,188
Hospital Support and Overhead (for 981,410
Dementia Unit g Ancillary Services)
Total Operating Expenses $2,692,008
C. Laguna Honda Hospital, San Francisco, California: A Hospital-
Based AIDS Skilled Nursing Unit
Laguna Honda Hospital (LHH) is the largest municipally owned long term care facility in
the country. It is licensed as a hospital-based distinct part nursing facility, with a total
licensed capacity of 1,457 beds. A total of 1,202 beds are being operated at the
current time. This facility is owned and operated by the City and County of San '
Francisco; if provides long term care and limited acute care services to city residents.
' Long Term Care Reimbursement Structure in California Page 17
During FY 94-95, over 400,000 days of inpatient care were provided at LHH, primarily
nursing facility level care, but also rehabilitation, acute, hospice, AIDS, and respite care
services.
An AIDS skilled nursing unit provides comprehensive and coordinated care to persons
with AIDS who cannot be cared for at home and who do not require the services of an
acute care hospital. This unit, which has 23 beds, provides a variety of treatment
options for AIDS patients, including long term skilled nursing care, rehabilitation
services, completion of acute therapy and comfort care in dying. An interdisciplinary
team provides medicine, nursing, social work, bereavement, pharmacy, dietary,
volunteer and activity therapy services. Ancillary services include occupational,
physical and speech therapy. (NOTE: no other volunteer or bereavement services are
l provided on this unit by any outside nonprofit organization.)
The AIDS skilled nursing unit is not a separate or distinct part of the hospital.
Therefore, it is not possible to break out expenses and revenues unique to this
program. However, it is possible to look at all of the expenses and revenues for the
institution and to consider the additional services and expenses required for the nursing
care of the AIDS patients. This determines the total daily cost of care for these
patients. For FY 94-95, given that the total operating expenses for LHH amounted to
$101,864,000, the total daily cost per patient was $244.11. For AIDS patients on the
AIDS skilled nursing unit, the cost of pharmaceuticals and ancillary services was an
additional $50 per day, so LHH's total daily cost per AIDS patient was approximately
$294.11. This included all salaries and benefits, materials, services and supplies.
Total revenues for LHH amounted to $99,826,645. This included reimbursement from:
(1) Medicare in the amount of$4,186,182 for skilled care; (2) Medi-Cal in the amount of
$92,993,043 at a daily rate of$214.90 for hospital-based distinct part nursing facilities;
(3) medically indigent adult(MIA) charity care (from the tobacco tax fund for indigent
care) in the amount of$654,000; and (4) commercial insurance and private pay, in the
amount of $1,993,420. Because total revenues did not equal total expenses, the
shortfall was made up by an allocation from the City General Fund in the amount of
$2,037,355. Again, because the AIDS skilled nursing unit is not a distinct part of the
facility, it is not possible to provide a separate budget. However, a budget for the entire
Laguna Honda Hospital is provided in order to demonstrate the reimbursement sources
which cover the majority of expenses incurred by this large long term care facility:
Long Term Care Reimbursement Structure m California Page 18
Laguna Honda Hospital: Budget for Fiscal Year 199495
Operating Revenue
Patient Revenue:
Medicare(Skilled Nursing) $4,186,182
Medi-Cal(Skilled Nursing) 92,993,043
MIA/charity care 654,000
Commercial Insurance/Private Pay 1.993.420
Total Patient Revenue 99,826,645
Contributions from General Fund 2.037.355
Total Operating Revenue $101,864,000
Operating Expenses
Total Salaries and Benefits $89,110,000
Total Materials and Services 6,390,777
Services from other City departments 6,393,223 ,
(including contracted services)
Total Operating Expenses $101,864,000
r
Contra Costa County HIV/AIDS Housing Plan
Appendix V: Contra Costa County HIV/AIDS
Housing Survey Instruments
.1
T
195
CONTRA COSTA COUNTY HIV/AIDS HOUSING SURVEY - CONSUMERS
This is a housing needs survey for people who have HIV/AIDS. Your participation is very important and
we would like to have your input. The information gathered ir this needs assessment will be used to
develop a five-year plan for HIV/AIDS housing in Contra Costa County, and to help our community meet
the needs of people with HIV/AIDS. If you should have any questions about this survey or the HIV/AIDS
planning process, please contact Christine Leivermann at the County AIDS Program at (510/313-6786).
Thank you for your participation.
1. Have you completed this survey before?
[ ] Yes (If yes, please do not fill out this form again.)
No.
The first part of the survey is all about you. Remember, all answers are anonymous. Your answers to
these questions will help make sure that we are reaching all kinds of people and that this survey reflects the
community of people who are living with HIV and AIDS:
2. What is your current HIV status?
[ ] HIV-positive, no physical problems
What year did you learn of your HIV status?
[ ] HIV-positive with physical problems (specify)
What year did you learn of your HIV status?
[ ] AIDS diagnosis - have been told I have AIDS
What year did you get your AIDS diagnosis?
' [ ] HIV-negative (If you are HIV-negative,please do not continue)
3. What is your gender?
[ ] Female
[ ] Male
[ ] Transgender (M-F)
[ ] Transgender(F-M)
4. What is your sexual orientation?
[ ] Lesbian - Woman who has sex only with other women
[ ] Gay - Man who has sex only with other men
[ ] Bisexual - Woman or man who has sex with people of both same and opposite gender
[ ] Heterosexual - Woman or man who has sex only with people of opposite gender
5. What is your racial/ethnic group?
Hispanic
[ ] African American
[ ] Native American
[ ] White
[ ] Asian/ Pacific Islander
`� [ ] Other racial/ethnic group:
:ontra Costa County HIVlAIDS Housing Plan-Con'sumer Survey Page 2
6. What is your primary language? ,
[ ] Spanish
[ ] English
[ ] Other:
7. What year were you born?
8. Do you have any disability other than HIV/AIDS? (Check all that apply.)
[ ] Physical handicap
[ ] Chemical dependency
[ ] Blind/sight impaired
[ ] Deaf/hearing impaired
[ ] History of depression, anxiety, or other mental health condition
[ J Other:
9. Where do you get your primary healthcare?
(i.e., clinic name, hospital name, emergency room,private doctor, other)
10. What do you believe put you at risk for HIV infection? (Check all that apply.)
[ ] Unprotected sexual activity
[ ] Sharing needles/equipment
[ ] Tainted blood products/hemophilia
[ ] Other:
The following questions have to do with your living situation. Household means you and the pggle you
live with.
11. Who do you live with. (Check only one answer.)
[ ] No one - live alone
[ ] Spouse/partner
[ ] Spouse/partner and children
[ ] Your children
[ ] Other adults and children
[ ] Parent(s)/family
[ ]
Friend(s)
[ J Shared living/roommate(s)
How many people are in your household? Total:
How many children?
What are their ages?
12. Is there another person in your household who is HIV-positive?
[ ] Yes How many?
Specify relationship(s):
No
stra Costa County HIV/AIDS Housing Plan-Consumcr Survey Page 3
13. How long have you lived where you are now?
[ ] Less than 6 months
[ ] 6 months to 1 year
[ J 1 to 2 years
[ ] 3 to 5 years
[ ] More than 5 years
[ ] All your life
14. What is your zip code?
15. Please check the kind of place you live in now (check only one), and then check all those places
you have lived in the past five years (check all that apply).
Live Ever
Now Lived
[ ) [ ] Homeless, on the streets
[ ] [ ] Emergency shelter
[ J [ ] Car, vacant building or commercial building
[ ] [ ] Halfway house
Public housing building
[ ] [ ] Transitional housing
[ ] [ ] Rented room in a house
[ ] [ ] Individual (rented) home or apartment
[ ] [ ] Drug or alcohol treatment center
[ ] [ ] Single-room occupancy (SRO) facility
[ ] [ ] Shared living/group home
[ ] [ ] Residential hospice
[ ] [ ] Skilled nursing facility
[ ] [ ] Friend's or relative's home
[ ] [ ] Owned house or condo
[ ] [ ] Other
16. Are you in your current housing as a result of having HIV/AIDS?
[ ] Yes
No
17. Do you need housing assistance?
[ ] Yes
[ ] No (If no, skip to question 21)
r. 18. Do you get any kind of assistance from the government to help with rent?
[ ] Yes (If yes, specify type(s) of assistance.)
[ ] Section 8 housing voucher
[ ] Shelter Plus Care
[ ] Other:
What is approximate monthly amount of assistance? $
No
:ontra Costa County HIV/AIDS Housing Plan-Consumer Survey Page 4
19. Are you on any waiting lists for housing or rental assistance? ,
[ ] Yes (If yes, specify type(s) of assistance)
[ ] Shelter Plus Care - how long?
[ ] Section 8 - how long?
[ ] Other waiting list - specif dhow long?
No
20. If you need housing assistance and aren't currently receiving it, what do you think prevents you
from receivin g housing assistance? (Check all that apply.)
[ ] Language barrier
[ ] Providers don't know what is available or how to access
[ ] Clients don't know what is available or how to access
[ ] Application process is too difficult
[ J Location of services
[ ] Lack of transportation
[ ] Lack of client motivation
[ ] Not enough appropriate housing options
[ ] Rental assistance isn't enough to get a decent place
[ ] Not enough clean and sober housing programs
[ ] Not enough drug/alcohol tolerant programs
[ ] Not enough options for families with children
[ J Other:
21. For respondents who rent or own housing, please: (1) rank the five most important for
maintaining independent housing for the longest feasible period (I=most important, 5=1east
important); and (2) mark the ones you need but are not getting. (Check all that apply.)
Rank Check
Importance Unmet Need
a. [ ] Practical/chore service support
b. [ ] Meals/nutrition counseling
C. [ ] Protective payee/money management
d. [ ] Personal care/personal hygiene assistant
e. [ ] Alcohol/drug treatment/counseling
Day mental health program
g. [ ] Emotional support/buddy
h. [ ] Transportation assistance
i. [ ] Benefits counseling
j. [ ] Home health care
i. [ ] Other support service:
Stra Costa County HN/AIDS Housing Plan-Consumer Survey Page 5
The following questions have to do with household income. Individual refers to your income Household
means you and the people you live with.
22. Not counting yourself, how many people do you support?
Does anyone else in your household contribute financial support? [ ] Yes [ ] No
23. What is your individual monthly income? What is your total monthly household income?
[ ] Under$300 [ ] Under $300
[ ] $300 - $500 [ ] $300 - $500
j ] $501 - $650 [ ] $501 - $650
[ ] $651 - $750 [ ] $651 - $750
[ ] $751 - $1,000 [ ] $751 - $1,000
[ ] $1,001 - $1,500 [ ] $1,001 - $1,500
[ ] $1,501 - $2,000 [ ] $1,501 - $2,000
[ ] $2,001 - $2,500 [ ] $2,001 - $2,500
[ ] Over $2,500 [ ] Over $2,500
24. Do you receive any of the following benefits? (Check all that apply.)
[ ] GA (General Assistance Unemployable)
[ ] SSI (Supplemental Security Income)
[ ] SDI (State Disability Income)
[ ] SSA/ SSDI (Social Security Disability Insurance)
[ ] AFDC (Aid to Families with Dependent Children)
[ ] Medi-Cal
[ ] Medicare
Veterans' benefits
1 [ ] Waiver services (I-HWAIDS Home and Community Services)
[ ] Private health insurance(Kaiser, Blue Cross, FHP, QualMed, etc.)
[ ] Private disability insurance (specify): [
] Other:
25. What approximate percentage of your total household income do you spend each month on
your housing, including rent/mortgage and utilities?
[ ] Less than 30 percent
[ ] More than 30 percent
[ ] More than 50 percent
26. What is the total monthly housing expense for your household, including rent/mortgage and
utilities?$
27. What are your monthly cash (out of pocket) costs for health care and prescriptions for you and
the people you support? $
28. How much do you spend each month on childcare? $
ontra Costa County HN/AIDS Housing Plan-Consumer Survey Page 6.
The following questions have to do with changes you may have had in your housing.
29. Have you moved since you learned you have HIV/AIDS? r
Y Y
[ ] Yes If Yes, What were the reasons for your move? (Check all that apply.)
[ ] I was asked to move because I am HIV-positive
[ ] I was asked to move because of my drug/alcohol use
[ ] I moved because I no longer had enough money to pay my rent
[ ] I moved for support from a caregiver or friends
[ ] I moved to live with/near family
[ J I moved to be in a safer neighborhood
[ ] I moved to get away from my old neighborhood
[ ] I moved to so that I could remain clean and sober in a new neighborhood
[ ] I moved to get better HIV/AIDS-related services
[ ] I moved to be closer to my doctor
[ ] I was released from a correctional facility/jail :
[ ] I moved due to a decline in income
[ ] Other:
No
30. How many times have you moved in the past 3 years?
31. Have you had to do any of these things to have a place to sleep since you found out about your
HIV status? (Check all that apply.)
[ ] Slept in a car
[ J Traded sex for a place to spend the night
[ ] Slept in a shelter -
[ ] Slept at a friend's house
[ ] None of these j
32. Have you ever been homeless? Homeless means: lacking a regular nighttime residence; or living in a
temporary shelter; or living in a place not ordinarily used as regular sleeping accommodations.
[ ] Yes (If yes,please answer the following questions.)
How many times in the last 3 years?
How long was your most recent period of homelessness?
Since your first homelessness, what was the longest time you lived in one place?
No
33. Why did you become homeless? (Check all that apply.)
[ ] Couldn't afford rent
[ ] Alcohol or drug use issues
[ J Health status, i.e., hospitalization
[ ] Family/partner/roommate made me move
[ ] Mental health issues
[ ] Evicted (if so, why?)
[ ] Other:
ontra Costa County HIV/AIDS Housing Plan-Consumer Survey Page 7
1
The following questions have to do with drug and alcohol use.
34. Have you in the past or do you now use any of the following? (Check all that apply.)
[ ] Prescription medications
[ ] Alcohol
[ ] Marijuana
[ ] Crack
[ ] Cocaine
[ ] Heroin
[ ] Non-prescription pills
( ] Other:
- [ ] None
35. Are you currently participating in a substance abuse treatment/recovery program?
[ ] Yes (If yes, what kind? Check all that apply.)
[ ] Methadone maintenance program
[ ] Drug-free counseling program
[ ] 12-step program(AA, NA, CA)
[ ) Residential rehabilitation program
[ ) Inpatient detox program
[ ] Other:
� No
36. Have you ever thought you might need substance abuse treatment?
[ ] Yes (If yes, and you are not currently receiving treatment, why not? Check all that apply.)
[ J Don't know where or who to call for help
[ ] Currently on a waiting list for a methadone program
[ ] Currently on a waiting list for a treatment program (not methadone)
L ] Was in a program but was asked to leave
[ ] Don't want treatment right now
[ ] Cost of treatment is too high
L ] Location of treatment program
[ J Lack of transportation
[ ) Lack of child care
[ ] Language barrier
[ J No referral
[ ] Other:
No
;ontra Costa County HIV/AIDS Housing Plan-Consumer Survey Page 8
The following questions have to do with housing preferences.
37. Based on your current health status,what kind of housing situation would best serve your
needs? (Rank in order of choice: I =first choice, 9 = last choice.)
a. Emergency shelter
b. Transitional housing
C. Individual (rented) home or apartment
d. Owned house or condominium
e. Single-room occupancy(SRO) facility
f. Shared living/group home
g. Skilled nursing facility
h. Residential hospice
i. Other:
38. What kinds of support services would best serve your needs? (Check all that apply.)
[ ] Case management
[ ] Money management
[ ] Practical support
[ J Emotional support
[ ] Meal delivery/preparation
[ ] Medical care
[ ] Mental health counseling
[ ] Substance abuse counseling
[ ] Assistance in daily living
[ ] Other(describe):
[ ] Other(describe):
39. If your health changes as a result of HIV/AIDS and you require more assistance, what kind of
housing situation would best serve your needs! (Rank in order of choice: I =first choice, 9 =
last choice.)
a. Emergency shelter
b. Transitional housing
C. Individual (rented) home or apartment
d. Owned house or condominium
e. Single-room occupancy (SRO) facility
f Shared living/group home
g. Skilled nursing facility
h. Residential hospice
i. Other:
tra Costa County HN/AIDS Housing Plan-Consumer Survey Page 9
40. What kinds of support services would best serve your needs? (Check all that apply.)
[ ] Case management
[ ] Money management
[ ] Practical support
[ ] Emotional support
[ ] Meal delivery/preparation
[ ] Medical care
[ ] Mental health counseling
[ ] Substance abuse counseling
[ ] Assistance in daily living
[ ] Other(describe):
[ ] Other (describe):
41. How would you feel about living with other people with HIV/AIDS?
[ ] Like - why?
[ ] Don't care - why?
[ ] Dislike - why?
42. If you had to move, what is most important about the location where you might live?
(Rank in order of choice: 1 =first choice, 8 = last choice.)
a. Close to shopping areas
b. Close to doctor, clinic, or hospital
C. Close to friends or family
d. Close to public transportation
e. Close to a child care or day care center
f. Close to employment
g. Living in a safe neighborhood
h. Other:
43. If you had to move,what are the most important qualities you would seek in your new home?
(Rank in order of choice: I =first choice, S = last choice.)
a. Living with people of same cultural group/language. (specify)
b. Living in a building where drug and alcohol use is tolerated
c. Living in a wheelchair accessible building
d. Living in clean and sober housing
e. Other:
ontra Costa County HIV/AIDS Housing Plan-Consumer Survey Page 10
44. Additional comments.
Thank you!
Please return completed Housing Consumer Surveys to:
Christine Leivermann
Contra Costa County Health Services Department
597 Center Avenue, Suite 200
Martinez CA 94553
313-6786
CONTRA COSTA COUNTY HIV/AIDS HOUSING QUESTIONNAIRE
HOUSING PROVIDERS
This questionnaire is part of a comprehensive county-wide needs assessment and planning process to
address the housing needs of persons living with HIV/AIDS in Contra Costa County. The information
gathered in this survey will be used to develop a five-year plan for HIV/AIDS housing in Contra Costa
County. As developers of affordable housing, your participation is very important. If you should have any
questions about this survey or the HIV/AIDS planning process, please contact Kathleen Hamm, Principal
Planner, Housing, or Elizabeth Gearin, Planner II at (510/646-4208). Thank you for your participation.
The first part of the survey is about your agency's ex erience in the development, ownership and
management of affordable housing.
1. What is your agency's experience in the DEVELOPMENT (acquisition, rehabilitation, or new
construction) of permanent or transitional affordable housing?
Contra Other
Costa Jurisdictions
[ ] [ ] No development experience
[ ) [ ] Project(s) currently in development
[ ] [ ) Completed one acquisition, rehabilitation, or new construction project
[ ] [ ) Completed 2-3 acquisition, rehabilitation, or new construction projects
[ ] [ ] Completed 4 or more acquisition, rehabilitation, or new construction projects
Projects completed or in development (in all locations) include:
Completed In Development
[ ] [ ] Group homes
[ ) [ ] Single family rental properties
[ ] [ ] Homeownership properties
[ ] [ ] 2-4 unit multifamily rental properties
[ ] [ ] 5-20 unit multifamily rental properties
( ] [ ] Multifamily rental properties with more than 20 units
[ ] [ ] Transitional housing - any number of units
[ ) [ ] Other:
2. Does your agency OWN any permanent or transitional affordable housing projects (all
locations)?
[ ] Group homes How many properties?
[ ] Single family rental properties How many properties?
[ ] Homeownership properties How many properties?
[ ] 2-4 unit multifamily rental properties How many properties?
[ ] 5-20 unit multifamily rental properties How many properties?
[ ] Multifamily rental properties with more than 20 units How many properties?
[ ] Transitional housing - any number of units How many properties?
[ ] Other: How many properties?
Contra Costa County HIV/AIDS Housing Survey-Housing Providers Page 2
3. Does your agency MANAGE any permanent or transitional affordable housing projects (all
locations)?
[ ] Group homes How many properties?
[ ] Single family rental properties How many properties?
[ ] Homeownership properties How many properties?
[ ] 24 unit multifamily rental properties How many properties?
[ ] 5-20 unit multifamily rental properties How many properties?
[ ] Multifamily rental properties with more than 20 units How many properties?
[ ] Transitional housing - any number of units How many properties?
[ ] Other: How many properties?
4. How many and what type of permanent or transitional affordable housing units provided by
your agency (OWNED or MANAGED) are dedicated for persons living with HIV/AIDS (all
locations)?
[ ] Group homes How many beds?
[ ] Single family rental properties How many units?
[ ] Homeownership projects How many units?
[ ] 2-4 unit multifamily rental properties How many units?
[ ] 5-20 unit multifamily rental properties How many units?
[ ] Multifamily rental properties with more than 20 units How many units?
[ ] Transitional housing - any number of units How many units?
[ ] Other: How many units?
The following questions are about support services your agency provides, directly or indirectly, to people
with HIV/AIDS.
5. Please indicate what types of support services, if any, your agency provides to people living in
permanent or transitional affordable housing, and which, if any, are provided only to persons
living with HIV/AIDS (dedicated services)? ('heck all that apply.)
Support Dedicated
Services to PWAS
[ ] [ ] Case management
[ ] [ ] Money management
[ ] [ ] Practical support
[ ] [ ] Emotional support
[ ] [ ] Medical care
( ] [ ] Mental health counseling
[ ] [ ] Substance abuse counseling
[ ] [ ] Assistance in daily living
[ ] [ ] Other(describe):
[ ] [ ] Other (describe):
r
Contra Costa County H1V/AIDS Housing Survey-Housing Providers Page 3
6. Please indicate what types of support services, if any, are provided through agreements with
service providers to people living in permanent or transitional affordable housing which is
developed or managed by your agency, and which, if any, are provided only to persons living
with HIV/AIDS (dedicated services)? (Check all that apply.)
Support Dedicated
Services to PWAS
[ ] [ ] Case management
[ ] [ ] Money management
[ ] [ ] Practical support
[ ] [ ] Emotional support
[ ] [ ] Medical care
[ ] [ ] Mental health counseling
[ J [ ] Substance abuse counseling
[ ] [ ] Assistance in daily living
[ ] [ ] Other (describe):
[ ] [ ] Other (describe):
7. Is your agency considering participating in any of the following aspects of supportive housing
for people with HIV/AIDS? (Check all that apply.)
[ ] Providing supportive services (specify: )
[ ] Development/Ownership/Property Management (Please complete chart below.)
Type Household Income (%
a=group home Area Median Income-
D=Develop b=single family rental Size/ AMI)
Project O=Own
c=2-4 unit rental # Estimated Cost of General
u
d=5-20 unit rental - L=50-80%AMI Development Location
M=Manage a=20+unit rentals
Units AMI
f---transitional EXE-35%AMI
g--other:
' 1
2
3
[ ] Not interested in any of the above.
Contra Costa County HIV/AIDS Housing Survey-Housing Providers Page 4
8. What are the barriers you face in moving forward with the activities you identified in question 7?
(Check all that apply.)
[ ] Concern about liability issues(specify: )
[ ] Concern about limited long-term funding for services.
[ ] Inadequate internal fiscal and administrative systems.
[ ] Inadequate staffing/limited staff capacity.
[ ] Unfamiliarity with needs of people with HIV/AIDS.
[ ] Unfamiliarity with housing developers (or service providers) that could be partners in
developing, owning, or managing housing.
[ ] Lack of politically feasible sites.
[ ] Lack of financially feasible sites.
[ ] Other. Please describe:
9. How could the barriers you identified in question 8 be addressed?
[ ] Technical assistance regarding liability issues.
[ ] Fiscal system upgrade.
[ J Agency/staff training in affordable housing development.
[ J Training in addressing the needs of people with HIV/AIDS.
[ ] Assistance in identifying housing or services partners or consultants.
[ J Assistance in identifying politically/financially feasible sites.
[ ] Technical assistance on how to apply for funds, licensure requirements, program design, or other
issues.
[ J Other. Please describe:
10. Do you have anything else you'd like to tell us about how your agency could provide housing
for people with HIV/AIDS?
Contra Costa County HIV/AIDS Housing Survey-Housing Providers Page 5
11. What else would you like to share with us regarding the housing needs of the housing system
for persons living with HIV/AIDS in Contra Costa County? (Attach additional sheets as
necessary.)
Name ofer n completing hi ry
p so t s survey:
Agency:
Address:
Telephone: Fax:
Thank you!
Please return completed Housing Provider Surveys by October 27 to:
1Elizabeth Gearin
Contra Costa County Community Development Department
651 Pine Street, 4th Floor, North Wing
Martinez CA 94553
(510)646-4208
CONTRA COSTA COUNTY HIV/AIDS HOUSING QUESTIONNAIRE
CASE MANAGERS AND SERVICE PROVIDERS
This questionnaire is part of a comprehensive county-wide needs assessment and planning process to
address the housing needs of persons living with HIV/AIDS in Contra Costa County. The information
gathered in this survey will be used to develop a five-year plan for HIV/AIDS housing in Contra Costa
County. As case managers and service providers for this populations, your participation is very important.
If you should have any questions about this survey or the HIV/AIDS planning process, please contact
Christine Leivermann at the County AIDS Program at (510/313-6786). Thank you for your participation.
The first questions are about services your agency provides to people living with HIV/AIDS.
1. Please indicate the types of services your agency provides to people living with HIV/AIDS.
' (Check all that apply.)
[ ] Case management
[ ] Money management
[ ] Practical support
[ ] Emotional support
[ ] Meal delivery/preparation
[ ] Medical care
[ ] Mental health counseling
[ ] Substance abuse counseling
[ ] Assistance in daily living
[ ] Other(describe):
[ ] Other (describe):
2. What percentage of your agency's non-housing services are for persons living with
HIV/AIDS? %
3. What percentage of your agency's housing-related services (e.g., housing advocacy, benefits
assurance) are for persons living with HIV/A1LDS? %
4. What percentage of your agency's housing assistance services (e.g., subsidized housing, rental
assistance) are for persons living with HIV/AIDS? %
5. What is the point-in-time capacity of your agency to serve clients with HIV/AIDS?
non-housing services
housing-related services
housing assistance
6. As of the date of this survey, how many HIV/AIDS clients are being served by your
agency?
non-housing services
housing-related services
housing assistance
r
7. How many HTV/AIDS clients received housing and other non-housing services through your
agency in the past twelve months (ending July 31, 1995)?
non-housing services
housing-related services
housing assistance
1
The following questions are about your client population's housing needs.
8. What is the estimated percentage of your agency's client population who need some type of
housing assistance? %
h
9. Of that portion needing housing assistance, what are the most needed types of assistance? ,
(Please rank the following as to which are most needed by your clients: I = most needed 11 = least
needed)
a. Homeless shelter
b. Emergency/short-term financial assistance for rent and utilities
C. Transitional housing(6-24 months with life skills/job skills training)
d. Shared houses/apartments with little or no on-site support services
e. Subsidized independent living in an apartment with no on-site services
f. Long-term rental/mortgage assistance to keep people in their own home
g. Shared houses/apartments with some on-site support services
h. Housing program that tolerates druglalcohol use off-premises
i. Clean and sober housing program
j. Residential hospice
k. Skilled nursing facility
10. Please rank the following barriers your clients face in receiving housing assistance. (1 =greatest
barrier, 14 = least barrier)
a. Language
b. Providers don't know what is available or how to access
C. Clients don't know what is available or how to access
d. Application process is too difficult
e. Location of services
f. Lack of transportation
g. Lack of client motivation
h. Not enough appropriate housing options
i. Rental assistance isn't enough to get a decent place
j. Not enough clean and sober housing programs
k. Not enough drug/alcohol tolerant programs
1. Not enough options for families with children
M. Client capacity to access may be impaired
n. Other:
r
r
Contra Costa County FHWAIDS Housing Plan-Case Managers and Service Providers Survey Page 3
11. For the clients that you see who rent or own their own housing, please (1) rank the following in
order of importance for maintaining independent housing for the longest feasible period
(I=most important, 11=least important); and (2) mark the ones they need but are not getting.
(Check all that apply.)
Rank Check
Importance Unmet Need
a. [ ] Practical/chore service support
b. [ ] Meals
C. [ ] Protective payee/money management
d. [ ] Personal care/personal hygiene assistant
e. [ ] Alcohol/drug treatment/counseling
f. [ ] Mental health counseling
g. [ ] Emotional support/buddy
h. [ ] Transportation assistance
i. [ ] Benefits counseling
j. [ ] Home health care/skilled nursing
i. [ J Other support service:
r
12. Please answer the following two-part question regarding housing services and assistance. First,
please indicate which services your clients access. (Check all that apply.) Then, please rank
them in order of utilization. (1 = most used, 10 = least used.)
Check Rank
Access Utilization
[ ] a. Housing information or referral
[ ] b. Housing advocacy
[ ] c. Emergency financial assistance(deposits, utilities, rent, etc.)
[ ] d. Short-term rent or mortgage assistance
[ ] e. Long-term rent or mortgage assistance
[ ] f. Section 8 housing
[ ] g. Residential drug/alcohol treatment
[ ] h. Residential mental health or developmental disability programs
[ ] i. HIV/AIDS specific housing program (specify which): [
] j. Other housing describe):
Contra Costa County HIV/AIDS Housing Plan-Case Managers and Service Providers Survey Page 4
The following questions are about your agency's experience in the development, ownership, and
management of affordable housing.
13. What is your agency's experience in the DEVELOPMENT (acquisition, rehabilitation, or new
construction) of permanent or transitional affordable housing?
Contra Other
Costa Jurisdictions
[ ] [ ] No development experience
[ ] [ ] Project(s) currently in development
[ ] [ ] Completed one acquisition, rehabilitation, or new construction project
[ ] [ ] Completed 2-3 acquisition, rehabilitation, or new construction projects
[ ] [ ] Completed 4 or more acquisition, rehabilitation, or new construction projects
Projects completed or in development(in all locations) include:
Completed In Development
[ ] [ J Group homes
[ ] [ ] Single family rental properties
[ ] [ ] Homeownership properties
[ ] [ ] 2-4 unit multifamily rental properties
[ ] [ ] 5-20 unit multifamily rental properties
[ ] [ ] Multifamily rental properties with more than 20 units
[ ] [ ] Transitional housing- any number of units
[ ] [ ] Other:
14. Does your agency OWN any permanent or transitional affordable housing projects (all
locations)?
[ ] Group homes How many properties?
[ ] Single family rental properties How many properties?
[ ] Homeownership properties How many properties?
[ ] 2-4 unit multifamily rental properties How many properties?
[ J 5-20 unit multifamily rental properties How many properties?
[ ] Multifamily rental properties with more than 20 units How many properties?
[ ] Transitional housing - any number of units How many properties?
[ ] Other: _ How many properties?
15. Does your agency MANAGE any permanent or transitional affordable housing projects (all
locations)?
[ ] Group homes How many properties?
[ ] Single family rental properties How many properties?
[ ] Homeownership properties How many properties?
[ ] 2-4 unit multifamily rental properties How many properties?
[ ] 5-20 unit multifamily rental properties How many properties?
[ ] Multifamily rental properties with more than 20 units How many properties?
[ J Transitional housing - any number of units How many properties?
[ ] Other: How many properties?
Contra Costa County HIV/AIDS Housing Plan-Case Managers and Service Providers Survey Page 5
16. How many and what type of permanent or transitional affordable housing units provided by
your agency (OWNED or MANAGED) are dedicated for persons living with HIV/AIDS (all
locations)?
[ ) Group homes How many beds?
[ ] Single family rental properties How many units?
[ ] Homeownership properties How many units?
[ ] 2-4 unit multifamily rental properties How many units?
[ ] 5-20 unit multifamily rental properties How many units?
[ ] Multifamily rental properties with more than 20 units How many units?
[ ] Transitional housing - any number of units How many units?
[ ] Other: How many units?
17. Is your agency considering participating in any of the following aspects of supportive housing
for people with HIV/AIDS? (Check all that apply.)
[ ] Providing supportive services (specify: )
[ ] Development/Ownership/Property Management (Please complete chart below)
Type Household Income (%
1 a=group home Area Median Income-
b=single family rental AMI)
D=Develop c=2-4 unit rental Size/
Estimated Cost of General
Project O=Own d=5-20 unit rental # Low--50-80%AMI
M=Manage a=20+unit rentals Units Very Low--35-50% Development Location
f--transitional AMI
g--other: Extremely Lowes-35%
i AMI
i
2
3
4
[ ] Not interested in any of the above.
Contra Costa County HIV/AIDS Housing Plan-Case Managers and Service Providers Survey Page 6
18. What are the barriers your agency faces in moving forward with the activities you identified in
question 17? (Check all that apply.)
[ ] Concern about liability issues (specify: )
[ ] Concern about limited long-term funding for services.
[ ] Inadequate internal fiscal and administrative systems.
[ ] Inadequate staffing/limited staff capacity.
[ ] Unfamiliarity with needs of people with HIV/AIDS.
[ ] Unfamiliarity with housing developers(or service providers)that could be partners in
developing, owning, or managing housing.
[ ] Lack of politically feasible sites.
[ ] Lack of financially feasible sites.
[ ] Other. Please describe:
19. How could the barriers identified in question 18 be addressed?
[ ] Technical assistance regarding liability issues.
[ ] Fiscal system upgrade.
[ ] Agency/staff training in affordable housing development.
[ ] Training in addressing the needs of people with HIV/AIDS.
[ ] Assistance in identifying housing or services partners or consultants. t
[ ] Assistance in identifying politically/financially feasible sites.
[ ] Technical assistance on how to apply for funds, licensure requirements, program design, or other
issues.
[ ] Other. Please describe:
20. Do you have anything else you'd like to tell us about how your agency could provide housing
for people with HN/AIDS?
Contra Costa County HIV/AIDS Housing Plan-Case Managers and Service Providers Survey Page 7
21. What else would you like to share with us regarding the housing needs of the housing system
for persons living with HIV/AIDS in Contra Costa County? (Attach additional sheets as
necessary.)
1
1
1
1
Name of person completing this survey:
Agency:
Address:
Telephone: Fax:
Thank you!
Please return both this questionnaire and completed Housing Consumer Surveys by October 27 to:
Christine Leivermann
Contra Costa County Health Services Department
' 597 Center Avenue, Suite 200
Martinez CA 94553
313-6786
Contra Costa County HN/AIDS Housing Plan
1
' Appendix VI: Assisted Housing Inventories
j
t
1
1
221
1
Contra Costa County Assisted Rental Units Inventory
COMPLEX CITY PHONE CONTACT TOTAL ASSISTS TYPE
UNITS D UNITS
Antioch River Town I seniors
Senior Housing Antioch 510-706-0874 Betty Johnson 50 50 62+
Brid emont Antioch 510-757-2925 Gwen Miller 36 36 family
seniors
Casa del Rio Antioch 510-777-9294 Sandora Becks 81 81 62+
Baywood Antioch 510-757-5565 Julie Clark 128 26 family
family/sr/
Delta View A is Antioch 510-757-9212 Nancy Thurm 204 51 disabled
Elder Winds Antioch 510-757-2925 Gwen Miller 100 100 sr/disabled
1 Hudson Manor Susanne
Townhouses Antioch 510-757-0110 Tumlinson 119 119 family
family/3
Lakeshore A is Antioch 510-779-0601 Wendy Martin 268 54 Handicap
Meadow Wood Antioch 510-754-4488 Sherry Hendrix 136 27 family
Runaway Bay Antioch 510-779-9999 Helen Spencer 280 68 family
Somerset Senior seniors
Apartments Antioch 510-778-7299 Veronica Bulfair 156 41 55+
Denise
Twin Creeks A is Antioch 510-778-5300 Watchem ino 240 48 family
2 for
Elaine Null Court Bay Point 510-841-4410 Kate Emanual 14 14 disabled
Hidden Cove A is Bay Point 510-458-4844 Cheri Valencia 88 88 family
Rivershore A is Bay Point 510-458-1666 Joseph LaFleur 245 49 family
Handicap
/srs 62+/
mentally
disabled/
Willow Brook A is Bay Point 510-458-6107 Toni Bergman 72 72 family
Green Valley A is Brentwood 510-634-8558 Anita Delao 28 28 family
Los Nogales Brentwood 510-625-2245 Gwen Miller 44 44 family
Kirker Court (Peace mentally
Grove) Clayton 510-673-9557 Candy Kelly 20 19 disabled
Arcadian A is Concord 510-825-1739 Karen Dunlap 192 39 family
family+ 6
Bel Air A is Concord 510-680-7744 Veronica Valdez 86 18 Handicap
Broadway Towers Concord 510-671-9701 Joanne Spry 72 14 family
Ed & Gloria
California Hill Concord 510-686-1700 Raymond 153 31 lindep living
1 family/ 1
mental/3
Clayton Creek Concord 510-676-3003 Cathy Golden 208 5 handicap
1sr
62+/disabl
Clayton Gardens Concord 510-686-4220 Carolyn Crim 131 130 ed
mobility
impaired/sr
Clayton Villa Concord 510-671-2433 Betty Mc Dermitt 80 79 /disabled
Concord Green Concord 510-687-8460 Judy Krummen 130 57 family
1/10/97 aAE93-2lasstdinv.x1s
Contra Costa County Assisted Rental Units Inventory
COMPLEX CITY PHONE CONTACT TOTAL ASSISTS TYPE
UNITS D UNITS
Concord Residential dev
Club Concord 510-689-4939 Sister Mary Ann 20 19 disabled
Concord Royale Seniors
Retirement Center Concord 510-676-3410 Man Phifer 126 41 60+
Coral Court Concord 510-686-1761 Lynn Bradford 47 11 family ,
Crossroad Concord 510-676-7827 Judy Curtis 130 26 family
Rhonda
La Vista Apts Conccrd 510-676-1724 Rodriguez 75 75 family
dev
disabled
Las Tram as Concord 510-284-1462 Mary Thomas 6 6 adults
Lime Ride Concord 510-686-2232 Karen Billecci 70 14 family
sr/
Paris Terrace Concord 510-674-8941 Helena Gonzalez 45 9 individuals
Phoenix A is Concord 510-827-3683 Royal Myers 11 11 mentally ill '
76
Market
20
Plaza Towers Concord 510-687-1200 Barbara Smith 96 Assist. sr/disabled
The Heritage Concord 510-687-1200 Barbara Smith 196 121 sr/disabled
Valley Terrace Concord 510-674-0924 Virginia Clark 312 63 family ,
Mead Property
Mgmt, 6680-B
Alhambra Ave,
#182, Martinez
Grillo Gardens Danville 510-944-6356 CA 94553 10 3 seniors
sr 62+/
Del Norte Place EI Cerrito 510-237-8300 Shawna Snyder 135 27 family
sr/congreg
EI Cerrito Royale EI Cerrito 510-234-5200 Mary K. Mones 102 51 ate
seniors
Eskaton/Hazel Shirley EI Cerrito 510-232-3430 Janet James 63 63 62+
EI
Creekside Terrace Sobrante 510-223-8373 Lauretta Russell 56 56 family
EI Captain seniors
Silvercrest Sobrante 510-758-1518 Willdonna Prack 50 49 62+
sr
62+/disabl
Chateau Lafayette Lafayette 510-283-2727 Tom Thomas 66 65 ed
dev
disabled
Las Tram as Lafayette 510-284-1462 Gina Jennings 12 12 adults
mentally
Las Tram as Lafayette
510-284-1462 Gina Jennin s 35 35 disabled
1110787 aAE83.2\asstdinv.xls 2
Contra Costa County Assisted Rental Units Inventory
COMPLEX CITY PHONE CONTACT TOTAL ASSISTS TYPE
UNITS D UNITS
abused
youthyouth aged
Youth Homes Lafayette 510-933-2627 Stuart McCllou h 6 1 12-18
Alhambra Terrace Martinez 510-687-8791 Sharon Jackson 52 52 family
Emerson Arms Martinez 510-228-5205 Rebecca Dowling 32 32 famil
Hacienda Martinez 510-687-8791 Sharon Jackson 50 50 seniors
Martinez Senior
Citizens A is Martinez 510-370-7218 Bonnie Smith 100 100 sr/disabled
Muirwood Gardens Martinez 510-372-6940 Ann Murray210 42 family
Plaka A is Martinez 510-372-0725 -Meling Desan les 168 10 family
Rid ecrest A is Martinez 510-372-9422 Hank Narasaki 72 15 family
Riverhouse Martinez 510-229-9093 Candy Kelly 75 75 sr/disabled
Valley Ridge A is Martinez 510-228-1990 Lois Mc Bride 120 6 family
sr/
Mora a Royale Mora a 510-376-8900 Laura Re nier 95 19 congregate
North
Las Deltas Richmond 510-232-8492 Beth Campbell 76 71 family
North
Las Deltas Annex#1 Richmond 510-232-8492 Beth Campbell 90 75 family
North
Las Deltas Annex#2 Richmond 510-232-8492 Beth Campbell 60 51 family
Casa de Manana Oakley 510-625-2245 Gwen Miller 40 40 sr/disabled
Los Arboles Oakley 510-625-2245 Gwen Miller 30 30 family
Orinda Sr Village Orinda 510-254-8895 Irene Thomas 150 150 sr/disabled
2101 San Pablo
Avenue Pinole 510-724-9038 Jim Schutz 1 1 family
Bayside Willows, Inc. Pinole 510-724-4844 Glen Wilson 148 22 family
Pinole Grove Pinole 510-741-1900 Barbara Hawkins 70 70 seniors
East Sante Fe A is Pittsburg510-439-9106 Yvette Amtt 20 19 sr/disabled
EI Pueblo Pittsburg510-432-3523 Terri Lockett 176 172 family
Fountain Plaza Pittsburg510-439-5655 Jennifer Pitts 224 40 family
family,
Lori Bowley, X people with
The Landings Pittsburg510-827-3598 116 8 8 HIV/AIDS
Lido Square
Townhouse 18t II Pittsburg510-432-6000 Kay Andrus 171 171 family
Lovedd a Terrace Pittsburg510-427-2202 Ellen Johnson 148 30 family
PittsburgPlaza Pittsburg510-432-0333 ShirleyBarton 126 125 family
Stoneman Village Pittsburg510-427-1870 Karen Bodiford 145 145 sr/disabled
Woodland Hills Pittsburg510-427-1225 Doris Lee 220 44 family
Woods Manor Pittsburg510-432-6161 Diana Wino 80 45 family
Pleasant
Brookside A is Hill 510-682-2424 Kay Flippo 144 29 family
Pleasant
Chil ancin o Vista Hill 510-685-2385 Lenora Doyle 25 25 disabled
Pleasant Urban Pacific
Ellinwood A is Hill 510-827-2044 Properties 154 56 sr/disabled
1/10/87 aAE83-2\asstdinv.x1s 3
i
Contra Costa County Assisted Rental Units Inventory ,
COMPLEX CITY PHONE CONTACT TOTAL ASSISTS TYPE
UNITS D UNITS
dev ,Pleasant disabled
Las Tram as Hill 510-2841462 Carol Conrad 6 1 6 adults
dev
Pleasant disabled
Las Tram as Hill 510-284-1462 Carol Conrad 6 6 adults
Pleasant seniors
Pleasant Hill Village Hill 510-937-7370 Betty Musser 100 100 62+
Kenneth people with
Amara House Richmond 510-8345656 Richardson 5 5 AIDS
The Arbors Richmond 510-236-4935, Fanny Lee 36 23 family
Barrett Plaza
Townhouses Richmond 510-237-3467 ShirleyStewart 58 58 family
Barrett Terrace A is Richmond 510-237-3467 Shidey Stewart 115 114 family ,
seniors
The Carquinez Richmond 510-215-2850 Charlote Nelson 36 35 62+
City Center ,
Apartments Richmond 510-236-4350 Patricia Wilkins 62 19 family
Crescent Park Richmond 510-237-5377 Ray Hall 378 331 family
Deliverance Temple Richmond 510-2332626 Ruby Haynes 50 48 sr/disabled
Deliverance Temple II Richmond 510-233-2626 Ruby Haynes 32 32 sr/disabled
Easter Hill Village Richmond 510-237-3271 Donnie Bell 300 237 family
homeless
women
and
Family Support families-
Center Richmond 510-235-1516 Michelle Pinckney 77 transitional
Friendship Manor Richmond 510-237-3271 Sylvia Gray 58 58 seniors
Hacienda Richmond 510-237-6917 Sylvia Gray 50 150 seniors
John F. Kennedy
Manor I Richmond 510-529-0722 Adrainne Gray 156 19 famil
John F. Kennedy
Manor II Richmond 510-5290722 Adrainne Gray 168 26 family
Nevin Plaza Richmond 510-237-3271 Sylvia Gray 142 142 seniors
Nystrom Village Richmond 510-237-3271 Ronald Keeton 102 98 family
homeless-
Ohio Ave A is Richmond 510-235-1516 Michelle Pinckney 6 6 transitional
Richmond Center Richmond voicemail sr/family
Richmond
T6wnhouses Richmond 510-235-5689 Dorthalia Hill 199 146 family
sr/mentally
Rubicon Homes Richmond 510-235-1516 Michele Pinckney 10 10 disabled
disabled/
homeless-
transitional
San Joaquin I Richmond 510-235-1516 Michelle Pinckney 9 9 (men)
'
homeless,
SanJoaquin II - job training
Supported Living -transition
Trai ning Program Richmond 510-235-1516 Michelle Pinckney 10 10 al '
1!1(ll87 aAE832tasstdinv.xis 4
' Contra Costa County Assisted Rental Units Inventory
TOTAL ASSISTE
COMPLEX CITY PHONE CONTACT UNITS D UNITS TYPE
1 St. John's A is Richmond 510-237-6426 Zelia An ele 158 157 family
The Summit at Hilltop Richmond 510-223-7001 Sam Vasquez 240 96 family
homeless-
21 st A is Richmond 510-235-1516 Michelle Pinckney 7 1 7 transitional
Virginia St. A is Richmond 510-235-1516 Michelle Pinckney 12 12 disabled
disabled/
' homeless-
West Richmond A is Richmond 510-235-1516 Michelle Pinckney 4 4 permanent
Triangle Court Richmond 510-237-3271 Sylvia Gray 98 98 family
Bayo Vista Rodeo 510-799-0400 Gwen Miller 250 250 family
Casa Adobe San Pablo 510-236-3153 ShirleyMartin 54 53 seniors
family,
Church Lane mentally
'
Apartments San Pablo 510-235-1516 Michele Pinckney 22 22 disabled
EI Portal Gardens San Pablo 510-235-3900 Chanes Dulcan 80 80 sr/disabled
Judson Homes San Pablo 510-215-2989 Anna Smith 56 56 sr/disabled
1 Kidd Manor San Pablo 510-215-3081 Julia Abdala 41 41 seniors
mentally ill
substance
I Phoenix Clean & abusers
Sober House San Pablo 510-825-4700 5 5 DD
Rumrill Gardens San Pablo 510-232-6651 Darlene Walker 61 60 family
Vista del Camino San Pablo 510-215-3081 Julia Abdala 100 100 family
San
Cedar Pointe Ramon 510-833-1813 Michelle Fraser 248 50 family
San
Villa San Ramon Ramon 510-803-9100 Durwin She son 120 24 sr/disabled
Walnut
Byron Park Creek 510-937-1700 Judy Deibler 187 19 seniors
Walnut sr 55+/
Carmel Pines Creek 510-938-2375 ShirleyPutnam 50 21 disabled
Walnut
Casa Montego Creek 510-451-8622 Carol Severin 80 79 sr/disabled
Walnut
Four Seasons A is Creek 510-947-0844 Came Kirkpatrick 176 36 family
Walnut
Heritage Pointe A is Creek 510-943-7427 Sharon Spizey 147 38 sr/disabled
Walnut seniors
Kensington Place Creek 510-943-1121 Barbara Williams 178 36 60+
dev
Walnut disabled
Las Tram as Creek 510-284-1462 Heather Amaral 12 12 adults
' Walnut
Paris Place Creek 510-256-0506 Gail Taylor 148 2 family
Pleasant
Paris Regency Hill BART 510-937-7275 Judy Baker 892 134 family
Walnut dev
Phoenix Creek 510-825-4700 1 1 disabled
Walnut
Sierra Gardens Creek 510-649-850011 Mary Dorst 28 24 famil
1/10197 aAE93.21asstdinv.x1s 5
Contra Costa County Assisted Rental Units Inventory
COMPLEX CITY PHONE CONTACT TOTAL ASSISTE TYPE
UNITS D UNITS
Walnut
The Oaks Creek 510-937-5559 Sandra McCall 36 36 family
Walnut
Tice Oaks Creek 510-943-1670 Aloha Baker 91 91 sr/disabled
abused
Walnut Stuart youth aged
Youth Homes Creek 510-933-2627 McCollou h 6 1 12-18
1/10197 aAE93-2lasstdinv.x1s 6
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