Good Works, Better Practices, Great Homes
An interactive guide to operating AIDS housing

Section I: SERVICES

A. OUTREACH & REFERRAL

The goal of your outreach efforts will be to disseminate information about your program to your target population and to encourage potentially eligible people to apply. Establishing a successful outreach and referral system in the initial stages of your program's operation requires knowing your clientele and developing strong community relationships. Your target population may be defined by your agency's mission and by funders. The work you do to attract consumers may be narrowed by the expectations laid out in your program design and, most likely, in your grant contracts.

For instance, your program may be funded through a federal grant that permits beds for homeless individuals from the streets only. The outreach work your program needs to do will be distinct from that of a program that serves individuals who are homeless or at risk of homelessness. These programs can accept referrals from a variety of sources: hospitals, skilled nursing facilities, shelters, AIDS service organizations, to name a few. Your program may need to hire staff experienced in street outreach or you may need to establish strong working ties with street outreach workers in shelters or with the police department. You would also want to be hospitable to walk-in or self-referred applicants. All programs will need to consider their ability to welcome non-English speaking applicants.

Client referrals will differ dramatically in urban versus rural settings. Urban service providers may decide to narrow their referral network to a few sources such as a nearby hospital, skilled nursing facility and shelter. This will reduce a surfeit of applications. A rural program may need to broaden its service area to include a number of neighboring towns and work with a much broader network of referral sources.

If you are having a difficult time filling beds, consider expanding your referral network and public relations efforts to include: churches, Infoline, leaflets at grocery stores and fairs. Other statewide referral sources would include the Department of Corrections and state mental health agencies. If you are still in the planning stages, be sure there is a need for this service in your area!

Once established, your program will want to maintain a record of all referrals to your program. This will help you and advocacy organizations you work with better identify the level of need in your geographic area.

Useful Forms

Referral form
Referrals: A Month at a Glance

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B. THE APPLICATION PROCESS

The application process serves two purposes: first, to find out if an individual meets the specific eligibility criteria of a program, and second, to see if the program offers the kind of support and services suitable to the applicant's needs and wants. It is important to keep in mind that a person who is homeless, or nearly so, and who has few or no other housing options, may feel that he has no real choice but to accept the requirements that come with being a part of a supportive housing program. These requirements may range from meeting with a case manager periodically to submitting to random urine toxicology screening. You can make the client more comfortable by spending the first part of the interview giving information to the client, and not expect to get information from the client until later.

You will want to describe what services the program offers, as well as what liberties the client may be expected to give up. For example, does the program request urine samples? Does staff have access to client rooms? If so, explaining all of this up front before questioning the client will establish trust. The program's substance use policies also should be frankly discussed.

When you are asking questions, the client will want to know why the information is needed, how it is being recorded, and who will have access to the information. At this stage, questions should elicit only that information necessary to determine if the applicant meets your eligibility criteria. Asking detailed questions that are more appropriate to developing a case management plan may feel invasive to the client at this point, and some questions may be prohibited by anti-discrimination laws.

Finally, when applicants are denied admission to the program, they should be entitled to appeal the decision. The applicant should be informed in writing why she was denied and how she can appeal the decision. You will also need to decide how you will manage applications that are denied because of lack of space (e.g. waiting list).

Click on the list below for a sample policy in the following areas:

Sample Policies

Admission criteria
Application process
Waiting list
Appeal of denial of admission
Tuberculosis Screening

Useful Forms

Application for admission
Medical documentation form
Authorization for release of information
Reference form

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C. INTAKE

During the intake, the foundation is laid for building a relationship of mutual trust and respect. The ultimate goal of the intake is to begin the groundwork for providing comprehensive and useful services to the client. One difficult aspect of this relationship is the dual role of the program staff, usually the case manager, who serves as both advocate for the client and as a representative of the program. While a case manager serves primarily as an advocate, the case manager must explain the need to enforce the program's rules and regulations. When the client's individual interest conflicts with the rules of the program, the case manager may not be able to advocate fully for the client's interest. This conflict of interest can make building trust more difficult. However, this problem can be alleviated to some extent by making the two roles distinct and clear.

The "case management plan" (sometimes called the "service plan" or "treatment plan") should encompass client-driven goals and should not be tied to the client's right to remain housed by the program. Upon intake, if it is possible, the rules and requirements of the program might be reviewed with the client in a meeting with a staff member other than the case manager. The client will need to know what the consequences are for failing to follow the rules and the grievance procedure available if she wishes to protest them. Particular attention should be paid to explaining rules that require the client to give up some civil liberty (e.g. urine surveillance or staff access to rooms). These kinds of procedures can be particularly damaging to a client's trust unless she feels that the circumstances under which they are allowed are clear, explained ahead of time, and that the rules are consistently applied.

Of paramount importance in providing supportive housing for persons living with HIV/AIDS is the client's confidentiality. In order to feel safe about the information she is giving, it is helpful for the client to understand the organizational structure of your program. She will need to know who within the organization has access to her file and under what circumstances others would be allowed access to information. She should be informed that staff are required by law to maintain her confidentiality. For independent living programs, special attention needs to be taken in preserving client confidentiality in the program's relationship with the landlord.

Click on any item in the list below for a model policy covering that area:

Sample Policies

Intake
Confidentiality & Maintaining client files

Useful Forms

Intake & Needs assessment
Statement of Confidentiality
Authorization for Release of Information
Consent for Release of Confidential Information
Emergency Contact Sheet
Budget Sheet
Monitoring of Client Files Acknowledgement

Evaluating Admission & Intake

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D. CASE MANAGEMENT & PROGRAM SERVICES

The essential purpose of an AIDS housing program is to improve a resident's quality of life by providing needed services in a stable living environment. It is useful, then, to ask: how can we deliver services in such a way as to encourage resident stability? How can we keep residents housed for the long term? In other words, what circumstances lead to residents being discharged, voluntarily or involuntarily, and what can a program do to mitigate these?

As discussed in the Application and Intake sections, the services you provide should be suited to the clients' needs. But beyond that, keeping residents housed for the long term requires creating a certain kind of organizational culture. On one level, this culture is one in which residents' civil rights (their right to privacy, etc.) are respected. But in addition to that, the culture must be one in which staff and residents are involved in a process of engagement with each other. Engagement in this context, has been defined as "repeated and consistent interaction over time, sustained through formal and informal interactions that build trust, develop comfort, and enhance and solidify relationships." Some factors that can help promote engagement include:

1. Creating an atmosphere of openness and dialogue: It can be quite difficult for clients to openly discuss deeply personal matters, particularly ones carrying a social stigma such as substance use and mental illness. Therefore, staff must set a tone of openness. This can be done in a variety of ways. First, when discussing services with new clients, staff has an opportunity to describe substance abuse, mental health, and money management services in a general way that demonstrates an accepting non-judgmental attitude. The staff might even describe a hypothetical client who relapses, and how the situation would be resolved. Second, the program may use group meetings, such as house meetings or support groups, to begin dialogue about hypothetical and potential conflict situations that may lead to discharge.
2. Ensure that the entire organization is supportive of the engagement philosophy: most AIDS housing programs have some sort of hierarchical structure. This means that any actions taken by direct service staff are subject to review by supervisors, and ultimately, by the organization's board of directors. Therefore, there should be active involvement from the board of directors all the way through the chain of command in the development of a philosophy that promotes engagement.
3. Develop a foundation of mutual respect within the housing program that ensures that each individual is given the right to act autonomously provided no other staff member's or resident's rights are infringed upon. See Section F
4. On a practical level, each program will need to do some self-assessment regarding client retention. If your program has been in operation for more than a year, it is helpful to assess how effectively you have been able to maintain your consumer base. If you discover you have become a revolving door of intake and discharge, consider why clients are being discharged. Ask your residents what they find to be the most challenging part of participating in your program. Plan with staff and residents alternative policies and procedures that enhance retention and decrease the number of discharges.

In order to provide effective case management services, staff will need to be competent in areas including:

1. HIV/AIDS treatment issues
2. Public entitlements
3. Substance use and abuse
4. Mental health and illness
5. Advance medical directives (http://www.cslib.org/attygenl/)
6. Personal care for the physically impaired
7. Tenant's rights
8. Guardianship
9. Educational/vocational/recreational activities
10. Pastoral/spiritual care (HUD regulations re: proselytizing)

Click on any item in the list below for a sample policy covering that area.

Sample Policies

Client-Driven Case Management
Case Management Plan Update & Review
Comprehensive Case Management
End Term/Advanced Stage Care
Staff Communication Across Shifts [SLP]
Medications [SLP]
Temporary Absences [SLP]
Service in the Event of a Resident's Death [SLP]
Permanency Planning [TLP]
Home Visits [ILP]

Useful Forms

Client File Checklist
Client Service Plan
Progress Notes Form
Advance Directives
Statement Initiating Standby Guardianship
Nomination of Standby Guardian
Hourly Resident Care & Housekeeping Checklist
Burial Plan Sheet
Case File Audit Form

Evaluating Case Management & Program Services

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E. CLIENT RESPONSIBILITIES

Every program will have certain things its residents are required to do, whether it is as simple as meeting with a case manager periodically, or as onerous as providing urine samples for toxicology screening. Many of these rules are necessary to ensure that the program is providing effective services, or maintaining a safe living environment for all participants. Again, it is important to remember that many of these requirements may feel coercive to someone whose only other living option is homelessness. In the case of each requirement, you may ask:

1. Is this requirement absolutely necessary to meet a specific goal or objective of the program?
2. Is it narrowly tailored to meet that goal or objective?
3. What will the consequences be for a resident who fails to follow this requirement?
4. Can these consequences be consistently and fairly applied?
5. What infractions will lead to discharge from the program?
6. Are all requirements and their consequences clearly communicated to residents?

In order to maintain the integrity of the program, it is essential that clients feel that they and other residents are treated fairly with respect to rules and requirements. To this end, the process by which rules are applied and consequences are enforced may be more important than the substance of the rules. For example, program rules and their consequences will need to be clearly communicated before a client enters the program. If a consequence is imposed on a client who was unaware of the rule she has broken, she will feel unfairly treated. Similarly, if different consequences are applied to different people for breaking the same rule, clients will feel there is bias or injustice. Finally, the more that clients are involved in decision-making on a variety of levels in the program, the more ownership they will feel, which ultimately leads to an overall sense of fairness and democracy.

It may be useful here to say another word about the dual role of program staff. Whenever a program finds it necessary to impose some disciplinary procedure on a client, it can threaten the empowerment model of case management. Very often, probationary agreements begin to look like case management plans, with the exception that a probationary agreement has a coercive power behind it. This is because the client knows that the program has the power to discharge him. These agreements can be very useful when used as an alternative to discharging the client. They should not, however, be used to push the client to meet goals in a case management plan. Furthermore, a probationary agreement should always remain distinct from the client-driven case management plan. One possibility is to have all probationary agreements (sometimes called "program contracts") executed between the program director and the participant, rather than between the case manager and the participant. This preserves the advocacy role of the case manager.

Some areas where programs commonly find a need to create clear rules are listed below. Click on any one for sample policies and procedures covering that area. Other areas may include: required meetings, smoking policy, curfews, and financial contribution of the client.

Sample Policies

Code of Conduct
Harm Reduction
Clean and Sober Policy
Drug Testing
Progressive Discharge
Involuntary Discharge
Readmission
Reporting of Child Abuse/Neglect (http://www.cslib.org/attygenl/)
Staff Access to Resident Rooms

Useful Forms

Behavioral Improvement Action Plan
Warning Notice
Discharge in Progress Form
Client Discharge Form

Evaluating Client Responsibilities

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F. PROMOTING PARTICIPANT AUTONOMY

Every participant in a supportive housing program has the inherent human right to be self-governing and self-determining. For people living in chronic poverty, this right can often be undermined by the complex systems they must negotiate simply to get by from day to day. For people living in poverty with HIV, the number of agencies, bureaucracies and systems to be negotiated can be enormously daunting. It is one of the challenges of supportive housing programs, not only to assist clients in navigating systems, but also to ensure that the program itself does not become just another bureaucracy.

In designing a program that promotes rather than undermines client autonomy, it is helpful to ask:

1. Does the program have a variety of effective ways of communicating with participants?
2. Does the program have a variety of effective ways of receiving communication from participants?
3. Are participants involved in program decision-making on a variety of levels?
4. Are participants leaders in their own care, life plans, and goals?

Promoting client autonomy can take different forms for different kinds of programs. For both supported living and independent living programs, the case management philosophy is a fundamental place where the client's right to self-govern can be nurtured. In supported living programs, resident participation in setting and implementing the rules of community life promote a feeling of ownership among all residents which enhances the self-directed living of each individual.

Sample Policies

Client-driven case management
Resident Governance [SLP]
Communication Board [SLP]
Grievances

Useful Forms

Client Self-Report Form
Client Satisfaction Survey
Resident Satisfaction Survey
Resident Satisfaction Survey (Spanish)

Evaluating Promoting Participant Autonomy

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Section II: FACILITY

The "facility" component of a supportive housing program comprises the physical environment in which clients live. The supportive housing model presumes that people need, first and foremost, to have safe and affordable housing before other barriers to independent living can be addressed. Therefore, the quality of the facility component of your program is fundamental to all other services.

For some programs, the facility takes the form of individual apartments. For others, the housing is some kind of congregate living structure. When you contemplate the "facility" of your program, you will want to consider everything from concrete structures, to safety, to the aesthetic feeling the facility gives to its inhabitants.

On a practical level, there are several legal requirements that need to be met, such as compliance with fire, health, and building codes, and with laws governing accessibility for persons with disabilities. For supportive living programs, the selection of a building, maintenance and housekeeping are important issues. For programs that provide a housing subsidy and services, finding an appropriate apartment and landlord lays the foundation of the living environment. Once the apartment has been selected, you can be proactive about ongoing maintenance issues by knowing these basic regular maintenance facts. Further, the respective rights and responsibilities of the client, the program, and the third party landlord should be clearly communicated from the beginning.

In addition to these structural issues, programs will need to pay attention to the prevention of communicable diseases. This is particularly relevant for supportive housing environments where a variety of group interactions occur from shared housekeeping, to meals, to social interaction. Due to the susceptibility of all individuals living with HIV to other illnesses, it is essential for all programs to practice and educate participants and staff in basic hygiene and precautionary measures.

The governing regulations in the area of communicable diseases are the model Occupational Safety and Health Administration's Bloodborne Pathogen standards (Model Exposure Control Plan). These regulations require employers to protect employees and clients who may be exposed to blood or other infectious material. This includes practices aimed at preventing exposure, as well as guidelines to follow when someone has been exposed. The term "universal precautions" (also referred to as "standard precautions") refers to uniform practices used by public institutions to prevent the transmission of disease. Using universal precautions presumes that all blood and body fluid should be treated as potentially infectious, thereby preventing discriminatory treatment of only certain individuals. The use of these preventative measures should be explained to residents upon admission so that no one feels that they are being ostracized due to their HIV status. In addition to universal precautionary procedures, good hygiene practices, including hand washing, can be applied to further prevent illness.

Finally, you will want to pay attention to the atmosphere and ambiance of the physical environment of your program. AIDS housing programs strive to provide alternatives to institutionalization for people living with HIV. To this end, the décor of the facility should be as homelike and nurturing as possible, while also fostering independence and privacy.

Click on any item in the list below for a sample policy in that area.

Sample Policies

Incident Reports
Medical Emergencies
Fire Prevention [ILP]
Fire Prevention [SLP]
First Aid Kit [ILP]
First Aid Kit [SLP]
Prevention of Communicable Diseases
Universal Precautions [ILP]
Procedures for Handling Spilled Blood and Body Fluids
Housekeeping [SLP]
Telephone [SLP]
Private Parking [SLP]
Maintenance and Repair [SLP]
Regular Maintenance Facts [ILP]
Model Exposure Control Plan

Useful Forms

Incident Report Form
Incident Report Review Form
Apartment Evaluation
Apartment Inspection Checklist
Apartment Move-in/Move-out checklist
Maintenance Job Request
OSHA Supplies Checklist
Procedures for Handling Spilled Blood and Body Fluids
Report of Employee Infection or Communicable Disease

Evaluating Facility Services

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Section III: PERSONNEL

Maintaining staff longevity and building staff expertise are essential to creating an environment which is safe, stable, and enriching to residents. When developing policies designed to achieve these goals, it is helpful to consider the following areas:

1. Recruiting staff: Recruitment is an ongoing responsibility which can be assigned to one staff member and should not be viewed as a task performed only on an as needed basis. You can ensure the greatest pool of applicants by maintaining contact with a wide variety of sources. Your sources should be selected with the goal of ensuring diversity including individuals with HIV and individuals in recovery.
2. Orienting staff: Orientation is a critical period for ensuring staff comfort and competence on the job. Because of the often hectic pace of work in the supported housing field, especially at the direct service level, there may be a great deal of pressure for new staff to assume full responsibilities immediately. However, there should be some initial period when the staff person can apprentice with a "mentor" or senior staff member. This helps create a sense of teamwork as well as build relationships in which more experienced staff act as an ongoing resource for newer staff members. New staff should also be given instruction in areas such as confidentiality, OSHA, emergency procedures, organizational structure, policies and procedures, and performance review routines.
3. Training staff: While experienced staff can provide valuable on-the-job training, all staff should also be given the opportunity to enhance their expertise through formalized trainings in relevant areas. These trainings can provide substantive knowledge as well as opportunities to network with other service providers. Areas of training can include: first aid and CPR; HIV/AIDS treatment updates; AIDS dementia; universal precautions; substance abuse; personal care for the bed-bound; counseling skills; conflict resolution; working with the chronically mentally ill; financial entitlements; cultural issues; and case management skills such as using objective, non-judgmental language, discerning between observations and opinions, and relevance in note-taking.
4. Ongoing support and supervision of staff: Staff burnout can be very high in a field that requires a great deal of emotional energy. Therefore, time spent in support and supervision should be built into job descriptions just as any other essential task. In addition, individual staff isolation can be minimized by team work and shift overlap. Employee involvement in program design and decision-making can increase staff sense of ownership of and value to the program and thereby promote longevity. Some ways that staff can be supported in this work include: having a mental health clinician available to consult regarding residents with mental health issues; regular staff meetings; periodic staff retreats, particularly for long-term staff; weekly or biweekly direct individual supervision including problem solving of resident related issues, feedback on performance, staff feedback on job satisfaction, and assessment of need for emotional support.
5. Boundaries: In every social services job, the issue of boundaries between the client and the service provider is raised. Some organizations deal with these issues by creating rules against lending money to clients, sharing personal information with clients, or meeting clients outside of work, and all these can be useful practices. However, it is important to remember that the primary issue of boundaries is to ensure two things: first, that staff do not push themselves beyond their own reasonable limits in serving clients and, second, to ensure that staff are not relying on their relationships with clients to meet their own emotional needs. To this end, the following factors may be helpful to keep in mind: a) remind staff that each resident is in control of his or her own life; b) staff should be aware of their own emotional needs and ensure that those needs are met outside of their work relationships with residents; c) disciplinary proceedings and other limits on residents can be developed through a team approach so that no one staff person is responsible for an individual resident's success or failure.

In addition to the policies listed below, the employee manual should also cover: personnel record keeping, an organizational chart, position classification (including job descriptions noting title, responsibilities, experience and educational requirements); benefits (holidays, insurance, vacation, leaves of absence, worker's compensation, overtime); performance review, time and attendance reporting; terms and conditions of employment including hours; confidentiality of personnel records; reference to code of ethics and conflict of interest policies; compliance with federal and state statutes relating to equal employment opportunities, affirmative action, etc; plan to comply with the ADA; reimbursement of employee expenses; and termination and demotion.

Sample Policies

Orientation
Staff Development Plan
Problem Resolution
Grievance Policy & Procedures
OSHA Training & Compliance
Code of Ethics
Professional Boundaries
Sexual Harassment
Drug Free Workplace
Smoking
Hepatitis B Vaccines
Tuberculosis Testing

Useful Forms

New Employee Orientation Checklist
New Employee File Checklist
Hepatitis B Vaccination Record
Employee TB Summary Record

Evaluating Personnel Management

Visit the Connecticut Association of Nonprofits (http://www.ctnonprofits.org) website where you can order a copy of their comprehensive and useful Model Employee Manual.

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Section IV: VOLUNTEERS

Informing the community of particular program needs and volunteer opportunities is vital to the success of most not-for-profit organizations. For small programs or agencies, it may be one of the greatest assets in assisting your staff to deliver services. Volunteers can free up staff time for more vital duties by accomplishing tasks that require may not require skill but a willingness to be of assistance. Some volunteers can bring greatly needed talents to the program which it might not necessarily be afforded in a typical agency's operating budget. For instance, a program may utilize the creative talents of interior decorators in designing community spaces within a congregate living program. Many programs are reliant on outside groups and individuals to prepare meals for their residents. Some volunteers may desire to work individually with one or two residents and offer to act as a "buddy." All of these contributions are invaluable program assets.

Staff and residents will probably think of numerous ways volunteers can serve the program. A list of these suggestions should be kept and used in your outreach efforts. If possible, select one staff person to serve as the contact between volunteers and the program. The "volunteer coordinator" might be a volunteer job in itself. This person would be responsible for recruiting volunteers through a variety of means: mailings, public speaking, press releases, and phone calls. Typically, volunteers will be recruited most easily from local churches, senior centers, civic organizations, area colleges and high schools, and personal contacts made through your Board of Directors and other agency volunteers.

Once your volunteers have been recruited, be sure they understand the mission and philosophy of your program; the expectations that will be placed on them; the basics of HIV/AIDS and universal precautions; the importance of confidentiality; boundary setting, and who they should turn to for guidance and support. This means that education and orientation are absolutes in building healthy relationships with your volunteers. A volunteer is not dissimilar to an employee: he wants to know his job and he wants to know who to rely on for supervision. Finally, he wants to be appreciated, not with a paycheck, but with a handshake, smile and thank you.

There are two vital things to remember when working with volunteers: a) match the right volunteer with the right job; b) have a task ready when your volunteer arrives. People volunteer because they want to feel worthwhile and know they have contributed something of value. An idle volunteer quickly loses interest.

Useful Forms

Volunteer Selection Procedure
Volunteer Manual
Volunteer Application
Volunteer Orientation Checklist
Volunteer Cook Application

Evaluating Volunteer Services