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AFC is taking a leadership role in promoting strategies to improve the availability of safe and affordable housing for low-income people with HIV. AFC's work in housing includes:

  • Promoting public and private efforts to increase the stock of affordable housing for people with disabilities, including those living with HIV
  • Convening AIDS housing advocates and organizing efforts to assess and improve the housing continuum
  • Providing research on the state of Chicago-area housing environment
  • Managing a network of regional AIDS housing advocates and coordinating the delivery of AIDS rental subsidies among other housing programs for low-income people with AIDS



SAMHSA Consortium Quarterly Report 1: July 1 – September 30, 2013
Written by Marty Hansen, Associate Director, SAMHSA Consortium

October 31, 2013

The SAMHSA Chicago Community Consortium (SCCC) brought together leaders from more than 40 organizations in the City of Chicago and Cook County to develop a strategic plan, beginning spring 2012 through spring 2013. The plan’s 23 recommendations were approved on April 18, 2013. They aim to improve housing and health outcomes for people in Cook County who have experienced homelessness and who also have long term histories of mental illness and/or substance use.

Implementation of the plan’s recommendations began July 1, 2013, and will be completed by June 30, 2016.  The AIDS Foundation of Chicago (AFC), which convened the SCCC, will play three major roles in achieving and reporting on the plan’s recommendations:

• Monitoring progress of innovations already underway, such as enrollment of our target population into CountyCare and Medicaid
• Supporting collaborative efforts, such as assisting with initiatives to help individuals reconnect with entitlement programs after leaving jail
• Leading implementation of recommendations, particularly in outreach where AFC and its Center for Housing and Health (CHH) already play an important coordinating role

Recommendations fall under four strategic priorities:

1. Increase the number and variety of supportive housing units for the target population
2. Enroll the target population into coordinated care services
3. Simplify and expand eligibility for and access to benefits, services, and entitlements
4. Increase and strengthen outreach to link the target population to housing and health services

This is the first quarterly report on the plan’s implementation. The report will highlight three categories: 1) recommendations that are being met; 2) recommendations that are works-in-progress, and 3) recommendations that have not yet been initiated.

Recommendations Being Met

1.3 By June 2016, increase the number of permanent supportive housing units/subsidies for the target population by at least 400

To date, AFC has received information that 140 new units have been filled with our target population. The participating agencies reporting progress are Renaissance Social Services, Inc., Lincoln Park Shelter, Trilogy, Inspiration Corporation, Matthew House, Facing Forward, and the Center for Housing and Health (CHH Partners: Beacon Therapeutic, Chicago House, Thresholds, Northside Housing, Deborah’s Place, and Alexian Brothers Bonaventure House).  Units from the Suburban Alliance to End Homelessness in Cook County will be reported next quarter. We will also report next quarter on all the new units being filled this fall and winter. This recommendation is on target because we have made tremendous progress toward our benchmark in less than a year.

2.2 By December 2013, enroll at least 5,000 individuals of the target population into County Care

Cook County Health and Hospitals System (CCHHS) reports that 115,000 applications for CountyCare have been taken, with 47,000 people enrolled so far, according to the Illinois Department of Healthcare and Family Services (HFS). The Medical Home Network data base will be able to identify how many applicants have experienced homelessness by year’s end. Claims data, not available in the near term, are needed to determine those who have received care for mental health and substance use issues.   The sheer number of those who have already been enrolled assures that this recommendation is on target.

2.5 By June 2015, enroll all eligible individuals in the target population who are in jails into Medicaid and coordinated care services to be effective upon release

CountyCare has received 7,700 applications initiated in Cook County Jail.  HFS estimates “a couple of thousand” have been enrolled so far. Agencies within the Be Well Partners Coordinated Care Entity (CCE) are participating in a jail in-reach coordinated care pilot project to enroll inmates into coordinated care services.

3.1 By December 2013, enroll at least 1,000 members of the target population into the Chicago Referral System (CRS), and at least another 800 individuals by 2016

Since early 2013, more than 8,500 names of homeless persons have been entered into the CRS data base. Over 4,500 of the 8,500 have identified themselves as receiving care for mental health and/or substance use issues.  Nearly 2,000 are chronically homeless.

4.6 By June 2016, establish 15 short-term emergency units with specialized supports for the target population who are homeless or unstably housed

The Bridge Program, led by CHH and Heartland Health Outreach (HHO), has established 15 units for this sub-population.  Fifteen individuals currently reside in and a total of 20 have passed through these units since late June 2013. Of these 20, 18 are members of the target population (13 dually diagnosed with mental illness and substance use issues, three with mental illness, and two with substance addictions). In January, we will report on the creation of an additional five bridge units by CHH in collaboration with Thresholds.

Recommendations that are Works-in-Progress

1.1 By December 2013, survey the variety of services in permanent supportive housing (PSH) that is available and desired by participants

A survey of nine AFC-partner PSH programs was completed in June 2013.  Before year’s end, three other groups will assist in gathering responses from a larger, more diversified sample of PSH participants/providers: the PSH constituency group, the Supportive Housing Providers Association (SHPA) residents committee, and the Chicago Alliance to End Homelessness (CAEH) consumer commission. An update will be provided in the next report.

1.2 By December 2014, identify and establish at least three models of supportive housing programs that provide workforce development and assist residents with employment, entrepreneurship, volunteer, and/or other meaningful activities

Descriptions of innovative models of supportive housing program have been received from HHO and Thresholds. We will continue to identify others in the months to come.

1.6 By June 2016, make available 200 existing units by “moving on” at least 200 existing PSH or group home residents into independent living apartments

AFC’s pilot project involves reducing the level of case management services for clients who have shown long term housing stability and self-sufficiency. Clients will receive quarterly home visits and support as opposed to the standard minimum of at least one monthly home visit. AFC will then measure the success of those clients to determine what our “moving on” program will look like in the future.   Deborah’s Place also has a “moving on” program in place. Details will follow in the next report.

2.1 By December 2013, establish an informed estimate of the number of individuals in our target population

On October 30, a small task group of experts will convene to identify an informed range/estimate of the number people in Cook County who belong to the target population.  The range/estimate will be determined by early next year.  Achievement of this recommendation is important, as other recommendations are frequently measured as a number or percentage of the target population enrolled, engaged, or housed.

2.3 By December 2014, identify and evaluate at least three models which integrate medical, behavioral, and in-home health care services into coordinated care, including a strategy for share electronic health information and simplified billing for reimbursement of Medicaid services

Together for Health (T4H), a CCE led by HHO, will begin operations December 1. The next report will update its progress and developments on two other identified CCEs, CountyCare and Be Well Partners.

2.4 By December 2014, ensure that Medicaid coverage for substance use and mental health treatment is sufficient to meet the needs of the target population

HFS is working on aligning the “alternative benefit package” for the new Medicaid as fully as possible with the current Medicaid program.  Coverage should include Assertive Community Treatment (ACT) and Community Support Teams (CST), and Rule 132 (for mental health) and Rule 2090 (for substance abuse) services. It is important to note that coverage does not guarantee access due to shortages in capacity in some areas.

2.6 By June 2016, enroll at least 75 percent of individuals in the target population into coordinated care services that are well-funded through Medicaid and other sources

HFS is finalizing a document for purposes of public notice and discussion regarding what mental health (MH), substance abuse (SA), and other services will be funded under the new Medicaid. Advocates are pushing, for instance, for coverage to include case management, residential room and board services, and medication assistance services for substance abuse, as well as expanded dental, home health, optometry, and respite care services.

In January, we will report on enrollment rates of our target populations into coordinated care programs.

3.2 By December 2013, help members of the target population leaving jail reconnect with Medicaid, SSI/SSDI, and VA benefits

Providers serving jail inmates who are their clients work to reconnect them with a range of benefits. There is no system-wide effort to reconnect people with SSI/SSDI benefits. Inmates with Medicaid are no longer automatically terminated from benefits, but may lose them through inability to answer re-determination letters while incarcerated. CountyCare applications taken in jail are helping inmates who are not yet enrolled or who may lose existing benefits.

3.4 By December 2014, ensure that at least 90 percent of our target population in enrolled in Medicaid, including Medicaid expansion, and that the process for enrollment is streamlined and accessible

Illinois successfully launched a new integrated eligibility system, the Application for Benefits and Eligibility (ABE) on October 1. ABE allows people to apply for Medicaid (old and new), cash assistance, and/or Supplemental Nutrition Assistance Program (SNAP) benefits at one time.  16,000 applications for Medicaid have been received to date. Navigators or In-Person Counselors have been employed state-wide to educate and assist people with enrollment.

3.5 By December 2014, expand access to benefits and services for the target population through one-door opportunities

ABE is an example of one such one-door opportunity. In January, we will report on others.

4.1– 4.5: Outreach Recommendations

4.1 By December 2014, support the work of outreach teams by providing them with the necessary tools, resources, and worker-to-participant ratios

4.2 By December 2014, ensure that all homeless outreach workers are trained in SOAR eligibility procedures within 60 days of employment

4.3 By June 2015, ensure that at least 50 percent of the target population with serious mental illness and substance use disorders are engaged in services that match their level of need and choice

4.4 By June 2016, at least 50 percent of the target population served by outreach teams will be housed

4.5 By June 2016, ensure that all homeless outreach teams have access to adequate clinical support and include persons in recovery

An outreach implementation work group has met twice to strategize how to tackle the recommendations in this area.  Meetings have included four major funders of mobile outreach teams in Chicago and Cook County: the Chicago Department of Family and Support Services (CDFSS), PATH (Projects for Assistance in Transition from Homelessness—a SAMHSA-funded, state-wide program), the Chicago Alliance to End Homelessness (HUD funded), and the Veterans Administration. 

More than 25 mobile outreach teams operate in the Chicago and Cook County.  There is a need to understand the definitions and scope of their work, and to improve their coordination.   Major goals of the outreach work group include developing a unified vision of mobile outreach, and moving toward models of mobile outreach that are person-centered and housing-focused.

The next meeting of the outreach group will be in December.

Recommendations Not Yet Initiated

1.4 By June 2016, establish 50 bridge units with specialized supports for members of the target population leaving long term incarceration

1.5 By June 2015, develop a home sharing program that provides at least 100 units to members of the target population

3.3 By December 2013, secure Social Security presumptive eligibility for SSI/SSDI benefits for people with schizophrenia in the target population

This recommendation’s implementation has been delayed due to issues related to the government shutdown and federal staffing issues.


We wish to thank the SCCC Steering Committee members, their staff, and the countless community partners who have made the progress reported above possible—and who have assisted in producing this report.  The next quarterly update will be released on January 15.

If you have questions or feedback, please contact Marty Hansen: This e-mail address is being protected from spambots. You need JavaScript enabled to view it or (312) 334-0947.



The SAMHSA Consortium Strategic Plan

The AIDS Foundation of Chicago (AFC) recently published a report that details a cutting-edge plan to house and better coordinate health care for people who are homeless, diagnosed with at least one severe mental illness, and have a history of alcohol or substance use.

Under the Substance Abuse and Mental Health Services Administration (SAMHSA) Chicago Community Consortium (SCCC), AFC brought together leaders from more than 40 organizations in Cook County to shape this strategic plan.

Public services for one person who is homeless can cost Cook County and the City of Chicago as much as $100,000 per year. Integrating supportive housing and health services has been proven to alleviate suffering while saving taxpayers millions.

The National Coalition for the Homeless estimates that approximately 20 to 25 percent of single homeless adults suffer from some form of severe and persistent mental illness. Additionally, up to 50 percent of homeless adults have substance use issues, and one-third has co-occurring diagnoses with both mental health and substance use disorders. These rates rise among homeless veterans, with approximately 76 percent experiencing alcohol, drug, or mental health problems.

The strategic plan seeks to address these issues in Cook County.

AFC published both the full report online, as well as an abridged version. If you have any questions regarding the report or SCCC, please contact Hansen at (312) 334-0947 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .