History and Program Information Rita da Cascia/ / Project Positive Match, San Francisco, CA Housing Opportunities for People with AIDS (HOPWA) Special Projects of National Significance (SPNS) Multiple Diagnosis Initiative (MDI) A nationally competitive grant process One of 26 projects selected nationwide Only project selected targeting women and children Demonstration grant 1
Population Served Homeless multiply diagnosed mothers and their children 30% of the children are living with HIV 98% of mothers have a history of domestic violence 43% are Latino, 37% African American, 12% Asian Pacific Islanders, 8% Native American Currently serving 140 Families History 1989 - Upon inception, the program was the first transitional housing program for homeless women and children with HIV in San Francisco 1995 - Transitioned to model using tenant based housing subsidies and home- based case management 1996 - Applied and received funding under a nationwide competitive grant process the HOPWA SPNS MDI initiative 1997 - Prioritized #4 of all new programs in city wide competitive grant process through HUD McKinney with funding granted in Dec. 1997 1997 - In July granted funding in competitive City-wide process through DPH Ryan White Care Act Title 1 for integrated service collaborative 1998 - In August closed escrow on seven unit building in the Western Addition of San Francisco 1998 - In November centralized operations in leases service site on Sacramento St. in San Francisco 2
History 2002- Centralized operations at 1652 Eddy St. Permanent Housing facility- intensive case management and housing. Policy and Procedure Manual Development: RDC has always met with Agencies and Clients in collaboration on for the Development of Policies and Procedures and overall programmatic changes. From our beginnings we met and continue to meet regularly with Doctors, Nurses, Social Workers, Pharmacists, Clients, Advocates, Staff and friends of Rita da Cascia.. Together we developed protocols and policies designed to support the women in our care. The Program Director met countless hours while writing out original policy and procedure manual to edit and revise the sections so that they were accurate and meaningful. Services Provided Intensive home-based case management Weekly art therapy based support groups for children living with HIV and their siblings with concurrent mothers support group Peer advocacy Treatment advocacy Educational workshops Weekly family activities program Permanency planning and legal representation Kinship support and aftercare case management for relative caretakers akers Seven unit permanent housing component 3
Program Goals: Case management services are based on harm reduction techniques and follow the family from point of entry throughout the continuum of housing and HIV services. The Case Manager travels to the participant s home to deliver case management services. Participants in the Positive Match Case Management Program are housed in scattered site housing including market rate housing, subsidized units, housing projects administered by the San Francisco Housing Authority, SRO hotels, and shelters. Following acceptance into the Eddy Street residence or case management program, the Case Manager and client jointly develop an Individual Service Plan (ISP) during the first thirty days of enrollment. The goal of the care plan is to identify and prioritize service needs and to link the participant to services that meet the identified needs. Discharge from case management services will occur in the following circumstances a) incarceration in the prison system with a sentence of more than six months b) movement out of San Francisco County; or c) death. Augmented Services: Concurrent Activities Programs include: tutoring, educational programs, art programs, and children and mothers support groups are conducted at the centralized service site. The family activities program assists in the development of linkages with other participants and reinforces positive interactions and parent/child bonds. Participants are additionally linked with network partners for psychiatric consultation, medication monitoring and mental health treatment. 4
Outreach and Collaborative Referral Services: The outreach component of this project will maximize existing outreach to identify and engage service recipients in coordinated service delivery. Case Managers, in conjunction with other service providers, will conduct basic triage to assess and identify immediate needs of potential participants, provide referral and linkage to service providers and accompany the client to secure immediate necessary services. Multi disciplinary teams consisting of HIV medical providers, and a social service staff will conduct annual educational forums. Existing referral relationships include medical, legal, housing, substance abuse, mental health, and childcare. Appropriate referral relationships with key points of access outside of the HIV care system to ensure referral into care of newly diagnosed and not in care. Key points of access include emergency rooms, substance use treatment programs (non-hiv), detox centers (non-hiv), adult probation, juvenile probation, HIV counseling and testing, mental health programs (non-hiv), and homeless shelters. Cultural Competency: Rita da Cascia seeks to employ staff that is representative of the ethnic, racial, and cultural background of the clients served by the program. Recruitment efforts target women, particularly women of color who are living with HIV. Multi-cultural and diversity training is provided to all staff and volunteers to enhance the provision of culturally sensitive services. Successful Outcomes: the effects that case management has on improving the client s quality of life. Measurement of client satisfaction, with ICM services; timeliness s of service provision; cultural competency; and the specific outcomes s from care delivered. 5
Success Stories The following stories illustrate how the Rita da Cascia Program has affected the lives of women and children living with disabling HIV/AIDS in our community. At a routine pregnancy check-up, a woman in her 20 s learned that she was HIV positive. She developed medical and psychiatric problems and soon lost her job and home. Eventually, she ended up in a hospital where staff contacted the Rita da Cascia Program. She was rapidly admitted to the program so that her treatment needs could be managed. She now has a healthy daughter and she is able to work part-time time and live independently. Rita da Cascia continues to provide her and her daughter with supportive case management. A 6 year old girl was left alone in a basement apartment when her mother died of advanced HIV disease. The child urgently needed a home and support services due to her own HIV disease and its devastating cognitive effects. She was placed with a relative caregiver and was referred to the Rita da Cascia Program for support services that would address her medical, psychological, and educational needs. Stabilized by support and care and in good health, she is now succeeding in a regular school program and continues to participate in the Rita da Cascia support group and activities programs. 6
A physically abused 45 year old mother with disabling HIV entered the Rita da Cascia Housing Program upon discharge from a substance abuse treatment program. Her three children had been placed in the home of relatives. At Rita da Cascia, medical, psychological, and substance abuse treatment was coordinated for her within a collaborative network. After four months of treatment and care, she was reunited with her three children who joined her at Rita da Cascia.. She now works and provides volunteer services for other women and children who enter the program. HOPWA SPNS Multi Site Evaluation A joint HRSA (Health Resources and Service Administration) and HUD (Housing and Urban Development) initiative- A Program of National Significance (SPNS). Designed to provide a mechanism for the evaluation and dissemination of information particular to innovative models of care Columbia University serves as the national evaluator and Harder and Co. as the local evaluator All projects collect common data elements for the purpose of cross site evaluation Data utilized to determine the most effective models of care for the target population 7
HOPWA SPNS Local Evaluation Quantitative and qualitative analysis National evaluator is Columbia University and Local evaluator Harder & Co. Mechanism for evaluation of effectiveness, replicability,, and innovation Assist in national and local advocacy for the clients Preliminary Results 100% of clients placed in permanent housing have maintained their housing placement for a minimum of one year 85% of children have demonstrated an improvement in socialization and cognitive skills 97% of participants have demonstrated improved utilization of community resources 100% of families have demonstrated improvement in social support networks and self-sufficiency sufficiency 8