*U.S. Department of Health and Human Services*

*U.S. Department of Housing and Urban Development*

*U.S. Department of Veterans Affairs*

*U.S. Department of Labor*

**Preventing Chronic Homelessness Through Effective Transitions and
Discharge Planning: A Learning Community Workgroup**

*September 28--29, 2007*

*Philadelphia, PA*

**Meeting Summary**

**OVERVIEW**

**Purpose:** Within the Policy Academy framework, the Learning Community
Workgroup (LCW) provided an opportunity for Policy Academy States to
focus on a particular topic (e.g., youth, employment, data and outcome
measures, discharge planning) in order to:

-   Maximize peer-to-peer learning

-   Address what helps and hinders implementation of State action plans

-   Highlight innovative approaches that States have implemented, with a
    focus on how they may be adapted in other States

-   Stimulate communication within the Learning Community that will
    prompt States to use and leverage different resources around them
    and across systems

**Participants:** In September 2006, 41 attendees were convened for 2
days in Philadelphia, including:

-   28 State participants representing 17 States

-   Seven Federal resources persons and presenters

-   Six additional attendees, including an additional State presenter, a
    national resource person, and four facilitators and staff members

**Workgroup Learning Objectives:** A planning group comprising Federal
Agency and State representatives, and a Technical Assistance Continuity
Team (TACT) representative (who had been working closing to provide
technical assistance (TA) to States) held ongoing meetings to identify
key topic areas and create learning objectives in support of the general
LCW objectives that would enable participants to learn at their
appropriate level and would result in participants bringing home
practical ideas and strategies. Objectives designed for the Transition
LCW were to:

-   Understand how policy and regulatory issues impact discharge
    planning from various systems -- including criminal justice, health,
    behavioral health, and foster care -- and identify policies that
    have been adopted to ensure that people are not discharged into
    homelessness

-   Identify common barriers and challenges within and across systems to
    implementing discharge policies effectively and linking people to
    needed housing, health care, mental health and substance abuse
    treatment, income support and entitlement assistance, employment,
    and other needed services or supports

-   Learn about promising practices that have been implemented to
    support discharge policies and key success strategies

-   Identify the partnerships, funding, and resources that are needed to
    implement effective policies and practices to prevent homelessness
    across systems in your State

**AGENDA**

The 2-day agenda included plenary sessions, full-group discussion,
breakout groups, and topical roundtables. Following plenary sessions,
breakout group discussions enabled participants to brainstorm about
coordination, funding, and systems change issues around key topics, such
as:

-   Housing

-   Services and Treatment

-   Incomes and Employment

-   Cross-Cutting Issues

Based on hot topics and requests for more indepth discussion, the
roundtable discussions that were held toward the end of the 2-day
session were customized to address participant-identified topics.

**Plenary Sessions:** Plenary sessions were designed to provide an
overview of and frame key issues, featuring State individuals in order
to maximize peer-learning opportunities, as well as providing an
opportunity for sharing insights and remarks from national and Federal
representatives.

> ***Plenary #1:** Overview of Policy and Regulatory Issues in
> Transition and Discharge Planning*

-   Overview: Marty Fleetwood, HomeBase/The Center for Common Concerns

-   State Presentations

```{=html}
<!-- -->
```
-   Utah: Lloyd Pendleton

-   Washington: Blake Chard

> ***Plenary #2:*** *Incarceration Initiative and Keynote*

-   Incarceration Initiative: James McGuire, U.S. Veterans Association

```{=html}
<!-- -->
```
-   Keynote: Mary Ellen Hombs, U.S. Interagency Council on Homelessness

***Plenary #3:** Promising Practices to Promote Successful Transitions*

-   State Presentations

    -   Kansas: Cathy Hausheer

    -   Alaska: Colleen Patrick-Riley

    -   Illinois: Ed Bird (AIDS Foundation of Chicago)

**TOPICAL DISCUSSIONS**

> The tables below summarize breakout group discussions of housing,
> services and treatment, incomes and employment, and cross-cutting
> issues. Strategies for each topic were brainstormed in the following
> areas:

-   Coordination and Collaboration

-   Funding

-   Systems Change

> In general, strategies identified were based on actual examples
> provided by State participants (to the extent possible, the State was
> identified in parenthesis following the strategy). Additional
> strategies not based on actual examples or evidence were suggested and
> noted as "dream strategies."

+-----------------------+-----------------------+-----------------------+
| **Housing             |                       |                       |
| Strategies**          |                       |                       |
+=======================+=======================+=======================+
| **Coordination and    | **Funding**           | **Systems Change**    |
| Collaboration**       |                       |                       |
+-----------------------+-----------------------+-----------------------+
| -   Collaborate with  | -   Maximize existing | -   Expand and        |
|     specific systems  |     housing resources |     develop housing   |
|                       |                       |     options           |
| ```{=html}            | ```{=html}            |                       |
| <!-- -->              | <!-- -->              | ```{=html}            |
| ```                   | ```                   | <!-- -->              |
| -   Engage landlords  | -   Use HOME funds to | ```                   |
|     in creating new   |     community mental  | -   Broaden public    |
|     housing options   |     health centers to |     perspective       |
|                       |     serve mentally    |     housing needs     |
| ```{=html}            |     ill (OK)          |                       |
| <!-- -->              |                       | -   Facilitate        |
| ```                   | -   Use Recovery Home |     conversations in  |
| -   Conduct outreach  |     Initiative to     |     neighborhoods     |
|     to jails (OK)     |     enhance housing   |     about housing     |
|                       |     capacity          |                       |
| -   Collaborate with  |                       | -   Identify vacancy  |
|     agencies          | -   Create multiple   |     (e.g., look at    |
|     addressing sex    |     options for       |     utility hookups   |
|     offenders,        |     bridge subsidies: |     where no one is   |
|     domestic          |     home TBR, State   |     paying a bill)    |
|     violence,         |     appropriations,   |     and avenues for   |
|     substance abuse,  |     shelter plus care |     rehabilitation    |
|     and mental health |     (OK)              |     and new housing   |
|                       |                       |     (UT)              |
| -   Collaborate with  | ```{=html}            |                       |
|     faith-based       | <!-- -->              | -   Convert vacant    |
|     groups            | ```                   |     hotels for people |
|                       | -   Explore options   |     on probation and  |
| -   Develop Circles   |     for expanding     |     parole            |
|     of Support with   |     housing           |                       |
|     faith-based       |                       | -   Consider          |
|     groups (e.g., for | ```{=html}            |     inclusionary      |
|     paying first      | <!-- -->              |     housing to expand |
|     month's rent)     | ```                   |     affordable        |
|     (OR)              | -   Conduct Capital   |     housing as part   |
|                       |     campaigns (e.g.,  |     of new            |
| ```{=html}            |     Mental Health     |     development       |
| <!-- -->              |     Association in    |                       |
| ```                   |     Tulsa, OK)        | -   Add job trainers  |
| -   Build public and  |                       |     and developers to |
|     political will    | -   Strategize with   |     Housing First     |
|                       |     tax credit,       |     program (MD)      |
| ```{=html}            |     homeless trust,   |                       |
| <!-- -->              |     landlords about   | -   Continuum of      |
| ```                   |     funds for new     |     housing           |
| -   Conduct regular   |     housing (UT)      |     opportunity for   |
|     meetings with     |                       |     all: small        |
|     politicians and   | -   Get State to add  |     facilities,       |
|     communities to    |     points for these  |     scattered site,   |
|     address community |     populations in    |     tolerant          |
|     resistance and    |     competitive       |     communities,      |
|     build buy-in (WI) |     funding proposals |     services          |
|                       |                       |     attached, housing |
| -   Invite public     | -   Create locally    |     management, and   |
|     involvement in    |     driven            |     service providers |
|     solving problems  |     initiatives       |     coordinate for    |
|                       |     matching landlord |     the benefit of    |
| ```{=html}            |     needs (UT)        |     the tenant        |
| <!-- -->              |                       |     *(Dream           |
| ```                   | -   Expand definition |     Strategy)*        |
| -   Help scattered    |     of assisted       |                       |
|     site and mixed    |     living facility   | ```{=html}            |
|     use sites to be   |     linked to grants  | <!-- -->              |
|     good neighbors    |     for mental health | ```                   |
|                       |     to include        | -   Build public and  |
| -   Have a plan,      |     permanent         |     political will    |
|     engage housing    |     supportive        |                       |
|     developer and     |     housing and       | ```{=html}            |
|     providers, hold   |     single room       | <!-- -->              |
|     elected officials |     occupancy (SROs)  | ```                   |
|     accountable,      |     units             | -   Regular meetings  |
|     promote public    |                       |     with politicians  |
|     information on    | ```{=html}            |     and communities   |
|     effort, foster    | <!-- -->              |     to address        |
|     community         | ```                   |     community         |
|     tolerance, have   | -   Reinvest money    |     resistance and    |
|     large, flexile    |     into supportive   |     build buy-in;     |
|     pot of funds,     |     housing           |     requires          |
|     easy to           |                       |     persistence and   |
|     administer,       | -   Consider          |     patience (WI)     |
|     perceive housing  |     adjusting         |                       |
|     as treatment      |     quarterly         | -   Invite public to  |
|     *(Dream           |     estimated         |     become engaged in |
|     strategy)*        |     payments for tax  |     solving the       |
|                       |     credits and using |     problem (UT)      |
|                       |     a lower funding   |                       |
|                       |     ration            | ```{=html}            |
|                       |                       | <!-- -->              |
|                       | -   Allow master      | ```                   |
|                       |     leasing in        | -   Send legislators  |
|                       |     tax-credit funded |     to see where      |
|                       |     projects          |     clients live      |
|                       |                       |                       |
|                       | -   Offer small       | ```{=html}            |
|                       |     copayment for     | <!-- -->              |
|                       |     residents to help | ```                   |
|                       |     fund future       | -   Reduce the        |
|                       |     housing costs     |     complexity of the |
|                       |     (WI)              |     emergency shelter |
|                       |                       |     grants            |
+-----------------------+-----------------------+-----------------------+

+-----------------------+-----------------------+-----------------------+
| **Services and        |                       |                       |
| Treatment**           |                       |                       |
+=======================+=======================+=======================+
| **Coordination and    | **Funding**           | **Systems Change**    |
| Collaboration**       |                       |                       |
+-----------------------+-----------------------+-----------------------+
| -   Use community     | -   Maximize Federal, | -   Help case         |
|     volunteers to do  |     State, and local  |     managers develop  |
|     inreach in        |     funding           |     natural supports  |
|     prisons/build     |                       |     instead of        |
|     community         | ```{=html}            |     relying on        |
|     networks (OR)     | <!-- -->              |     professional      |
|                       | ```                   |     supports; help    |
| -   Conduct outreach  | -   Use social        |     people use        |
|     to faith-based    |     security "Bounty  |     mainstream        |
|     communities (MD)  |     Dollars" to get   |     providers and     |
|                       |     people back onto  |     natural supports  |
| -   Give landlords    |     social security   |     in the community  |
|     24-hour phone     |     upon release (see |     (OK)              |
|     access to case    |     1999 Government   |                       |
|     managers          |     Accounting Office | -   Create            |
|                       |     report "SSI:      |     administrative    |
| -   Discharge people  |     Incentive Payment |     rule to require   |
|     (especially       |     Has Reduced       |     transition        |
|     mentally ill)     |     Benefit           |     planning from     |
|     during day;       |     Overpayments to   |     corrections (OR)  |
|     provide           |     Prisoners")       |                       |
|     transportation to |                       | -   Make probation    |
|     day labor         | -   Utilize State     |     officers          |
|     directly from     |     appropriations    |     caseloads lighter |
|     release (NYC)     |     for Intensive     |     and more flexible |
|                       |     Care Coordination |     to be able to     |
| -   Increase          |     Teams (ICCT)      |     provide more      |
|     collaboration     |     (corrections and  |     supports (WI)     |
|     with public       |     discharge         |                       |
|     health system     |     managers) (OK)    | -   Create easier     |
|     *(Dream           |                       |     access to         |
|     strategy)*        | -   Utilize private   |     prescription      |
|                       |     foundations to    |     refills (MD, NY,  |
|                       |     support hospital  |     OR)               |
|                       |     linkages to       |                       |
|                       |     housing (Chicago, | -   Implement         |
|                       |     IL)               |     critical time     |
|                       |                       |     intervention      |
|                       | -   Use funding       |     model (e.g., U.S. |
|                       |     differently;      |     Department of     |
|                       |     e.g., convert     |     Veteran Affairs;  |
|                       |     psychiatric day   |     OK's ICCT)        |
|                       |     treatment         |     *(Dream           |
|                       |     programs *(Dream  |     strategy)*        |
|                       |     strategy)*        |                       |
|                       |                       | -   Offer universal   |
|                       | ```{=html}            |     health care       |
|                       | <!-- -->              |     *(Dream           |
|                       | ```                   |     strategy)*        |
|                       | -   Reimburse for     |                       |
|                       |     services          |                       |
|                       |                       |                       |
|                       | ```{=html}            |                       |
|                       | <!-- -->              |                       |
|                       | ```                   |                       |
|                       | -   Create a Parity   |                       |
|                       |     Law to pay for    |                       |
|                       |     substance abuse   |                       |
|                       |     and mental health |                       |
|                       |     treatment like    |                       |
|                       |     any other chronic |                       |
|                       |     disease *(Dream   |                       |
|                       |     strategy)*        |                       |
|                       |                       |                       |
|                       | -   Make outreach     |                       |
|                       |     etc. reimbursable |                       |
|                       |     *(Dream           |                       |
|                       |     strategy)*        |                       |
|                       |                       |                       |
|                       | ```{=html}            |                       |
|                       | <!-- -->              |                       |
|                       | ```                   |                       |
|                       | -   Create more case  |                       |
|                       |     management for,   |                       |
|                       |     e.g., Housing     |                       |
|                       |     First *(Dream     |                       |
|                       |     strategy)*        |                       |
+-----------------------+-----------------------+-----------------------+

+-----------------------+-----------------------+-----------------------+
| **Incomes and         |                       |                       |
| Employment**          |                       |                       |
+=======================+=======================+=======================+
| **Coordination and    | **Funding**           | **Systems Change**    |
| Collaboration**       |                       |                       |
+-----------------------+-----------------------+-----------------------+
| -   Add job trainers  | -   None identified   | -   Offer a living    |
|     and developers to |                       |     wage *(Dream      |
|     Housing First     |                       |     strategy)*        |
|     program           |                       |                       |
+-----------------------+-----------------------+-----------------------+

+-----------------------+-----------------------+-----------------------+
| **Cross-Cutting       |                       |                       |
| Issues**              |                       |                       |
+=======================+=======================+=======================+
| **Coordination and    | **Funding**           | **Systems Change**    |
| Collaboration**       |                       |                       |
+-----------------------+-----------------------+-----------------------+
| -   Succeed by        | -   Support           | -   Focus on dealing  |
|     reducing stigma,  |     client-level      |     with individuals  |
|     helping leaders   |     efforts           |     who say "no" (OR) |
|     made this a       |                       |                       |
|     priority, making  | ```{=html}            | -   Shift             |
|     the issue visible | <!-- -->              |     philosophical     |
|                       | ```                   |     perspective       |
| -   Enhance           | -   Conduct outreach  |     (victimization,   |
|     Infrastructure    |     to access         |     rescue mentality) |
|                       |     benefits          |                       |
| ```{=html}            |                       | -   Move on to self   |
| <!-- -->              | -   Create debit      |     sufficiency (FL)  |
| ```                   |     cards for food    |                       |
| -   "Shared space" -- |     stamps upon       | -   Reimburse case    |
|     colocate various  |     release           |     managers to help  |
|     agencies          |     (Multnomah,       |     natural supports, |
|     (One-Stop model)  |     Oregon)           |     not professional  |
|     *(Dream           |                       |     supports (OK)     |
|     strategy)*        | -   Utilize           |                       |
|                       |     volunteers (OR)   | -   Offer in-prison   |
| -   Create            |                       |     certification for |
|     administrative    | -   Collaborate with  |     highway flagging  |
|     rule to require   |     thrift stores,    |     jobs (OR)         |
|     transitional      |     plant nurseries,  |                       |
|     planning from     |     corrections       | -   Implement         |
|     corrections       |     industries, etc.  |     critical time     |
|     (e.g., telephone  |                       |     intervention (FL) |
|     conference calls  | ```{=html}            |                       |
|     including family  | <!-- -->              | -   Hold individuals  |
|     and parole        | ```                   |     and the systems   |
|     officers (OR))    | -   Support           |     they serve        |
|                       |     system-level      |     accountable (FL)  |
| -   Start planning 6  |     efforts           |                       |
|     months prior to   |                       |                       |
|     release (OR)      | ```{=html}            |                       |
|                       | <!-- -->              |                       |
| -   Use cross-systems | ```                   |                       |
|     data collection   | -   Develop           |                       |
|     to show cost to   |     for-profit        |                       |
|     community (OR)    |     businesses to     |                       |
|                       |     fund nonprofit    |                       |
| ```{=html}            |     activities (FL)   |                       |
| <!-- -->              |                       |                       |
| ```                   | -   Pursue large      |                       |
| -   Community         |     private donors    |                       |
|     outreach and      |     (FL)              |                       |
|     involvement       |                       |                       |
|                       | -   Utilize           |                       |
| ```{=html}            |     cross-system data |                       |
| <!-- -->              |     collection and    |                       |
| ```                   |     analysis of how   |                       |
| -   Create            |     community pays    |                       |
|     broad-based       |     for services      |                       |
|     efforts, similar  |     (e.g., emergency  |                       |
|     to what some      |     room cost) to     |                       |
|     communities did   |     inform how to     |                       |
|     for Katrina       |     shift resources   |                       |
|     relocates (FL)    |     *(Dream           |                       |
|                       |     strategy)*        |                       |
| ```{=html}            |                       |                       |
| <!-- -->              | -   Need better       |                       |
| ```                   |     prioritization at |                       |
| -   Promote mentoring |     Federal level to  |                       |
|     by successful     |     mirror what is    |                       |
|     community members |     needed at ground  |                       |
|     (OR)              |     level for serving |                       |
|                       |     people most at    |                       |
| -   Reentry chaplains |     need *(Dream      |                       |
|     in community (OR) |     strategy)*        |                       |
|                       |                       |                       |
| ```{=html}            |                       |                       |
| <!-- -->              |                       |                       |
| ```                   |                       |                       |
| -   Increase access   |                       |                       |
|     to services       |                       |                       |
|                       |                       |                       |
| ```{=html}            |                       |                       |
| <!-- -->              |                       |                       |
| ```                   |                       |                       |
| -   Help individuals  |                       |                       |
|     take advantage of |                       |                       |
|     mainstream        |                       |                       |
|     resources (e.g.,  |                       |                       |
|     workforce         |                       |                       |
|     centers) (OK)     |                       |                       |
|                       |                       |                       |
| ```{=html}            |                       |                       |
| <!-- -->              |                       |                       |
| ```                   |                       |                       |
| -   Conduct benefits  |                       |                       |
|     access outreach   |                       |                       |
|     (OR)              |                       |                       |
|                       |                       |                       |
| -   Provide easy      |                       |                       |
|     access to IDs     |                       |                       |
|     (State agencies   |                       |                       |
|     and local         |                       |                       |
|     financial         |                       |                       |
|     institutions)     |                       |                       |
|                       |                       |                       |
| -   Create            |                       |                       |
|     arrangements with |                       |                       |
|     local pharmacies  |                       |                       |
|     (330b program)    |                       |                       |
|                       |                       |                       |
| -   Create aftercare  |                       |                       |
|     medication        |                       |                       |
|     programs (NY)     |                       |                       |
|                       |                       |                       |
| -   Request court     |                       |                       |
|     dates for         |                       |                       |
|     misdemeanors to   |                       |                       |
|     allow for 30 days |                       |                       |
|     of medication     |                       |                       |
|     (OR)              |                       |                       |
|                       |                       |                       |
| -   Create day        |                       |                       |
|     shelters with     |                       |                       |
|     storage, medical  |                       |                       |
|     services, and     |                       |                       |
|     employment        |                       |                       |
|     assistance (OK)   |                       |                       |
+-----------------------+-----------------------+-----------------------+

Participants also identified cross-cutting strategies, strategies that
are the same for collaboration, funding, and systems change. They
considered these to be additional keys to success:

-   Universal zip code (unique identifier for homeless population)

-   Mobile One-Stop van

-   SOAR project

-   Identify Federally Qualified Health Centers (FQHCs)

-   Plan discharge planning workshop at Sheriff's Association annual
    meeting

-   Hold Discharge Summit and develop statewide discharge planning
    process (with, e.g., FQHCs, Corrections, Kids Department, CMHC,
    substance abuse and mental health housing providers)

-   Electronic Birth Certificates

**ROUNDTABLE DISCUSSIONS**

After the plenary presentations and the breakout discussions, attendees
participated in roundtable discussions around topics they had identified
for further discussion or ideas that State participants had shared about
which other participants wanted more indepth information. In the round
table context, participants addressed strategies, keys to success,
stakeholders, and resources related to the selected topics. Roundtable
discussions were held on:

-   Identification

-   Continuity of Care

-   Pilot Programs

The tables below summarize key issues discussed in the roundtables. Not
all roundtables addressed each component (strategies, keys to success,
stakeholders, and resources).

+-----------------------------------+-----------------------------------+
| **Identification**                |                                   |
+-----------------------------------+-----------------------------------+
| **Strategies and Keys to          | **Resources**                     |
| Success**                         |                                   |
+-----------------------------------+-----------------------------------+
| -   Get Governor to recognize     | -   Staff                         |
|     that this issue is important  |                                   |
|                                   | -   Budget                        |
| -   Get Social Security           |                                   |
|     Administration, Department of |                                   |
|     Motor Vehicles, and budget    |                                   |
|     people involved               |                                   |
|                                   |                                   |
| -   Start developing process at   |                                   |
|     ground level (how much will   |                                   |
|     happen inside and outside     |                                   |
|     institution -- often need     |                                   |
|     residence to get              |                                   |
|     identification)               |                                   |
|                                   |                                   |
| -   Ensure all agencies agree and |                                   |
|     have bought into the process  |                                   |
|                                   |                                   |
| -   Create sample Memoranda of    |                                   |
|     Understanding (MOUs) for      |                                   |
|     identification (MD)           |                                   |
+-----------------------------------+-----------------------------------+

+-----------------+-----------------+-----------------+-----------------+
| **Continuity of |                 |                 |                 |
| Care**          |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| **Strategies**  | **Keys to       | *               | **Resources**   |
|                 | Success**       | *Stakeholders** |                 |
+-----------------+-----------------+-----------------+-----------------+
| -   Provide     | -   Explore     | -   Everyone    | -   Money       |
|     targeted,   |                 |     (including  |                 |
|     intensive   |   reimbursement |     the media)  | -   Legislative |
|     case        |                 |                 |     support     |
|     management  |   methodologies | -   If you do   |                 |
|     with        |                 |     it well:    | -   Faith-based |
|     wraparound  | ```{=html}      |                 |     communities |
|     services    | <!-- -->        | ```{=html}      |                 |
|                 | ```             | <!-- -->        | -   Rotary      |
| ```{=html}      | -   Can make    | ```             |                 |
| <!-- -->        |     programs    | -   Builds      | -   Kiwanis     |
| ```             |     look        |     better      |                 |
| -   Utilize     |     different   |     community   | -   Other       |
|     medical     |                 |                 |     States (for |
|     home        | -   Find out    | -   Provides    |     peer-TA)    |
|     concept:    |     best        |     better      |                 |
|     create      |     methodology |     services    | (Note: Some are |
|     mu          |     for what    |                 | also            |
| ltidisciplinary |     you want    | -   Costs less  | stakeholders)   |
|     teams and   |                 |     or the same |                 |
|     utilize a   | ```{=html}      |     (but with   |                 |
|     system of   | <!-- -->        |     better      |                 |
|     care        | ```             |     patient     |                 |
|     approach    | -   Promote     |     outcomes)   |                 |
|     that        |     ongoing     |                 |                 |
|     focuses on  |                 |                 |                 |
|     clients,    |   collaboration |                 |                 |
|     not systems |     of all      |                 |                 |
|     (WI)        |     parties     |                 |                 |
|                 |     (e.g.,      |                 |                 |
| -   Utilize     |     every time  |                 |                 |
|     model that  |     a person    |                 |                 |
|     starts at   |     sees        |                 |                 |
|     corrections |     another     |                 |                 |
|     and is run  |     doctor,     |                 |                 |
|     by mental   |     they get    |                 |                 |
|     health,     |     different   |                 |                 |
|     which       |     medication  |                 |                 |
|     results in  |     -- so have  |                 |                 |
|     fewer       |     psychiatry  |                 |                 |
|     problems    |     program     |                 |                 |
|     getting     |     doctor talk |                 |                 |
|     access to   |     with        |                 |                 |
|     services at |     doctors     |                 |                 |
|     discharge   |     from        |                 |                 |
|     (OK)        |     community   |                 |                 |
|                 |     program)    |                 |                 |
| -   Identify a  |                 |                 |                 |
|     group of    | -   Collect     |                 |                 |
|     responsible |     meaningful  |                 |                 |
|     people to   |     data to     |                 |                 |
|     provide     |     show what   |                 |                 |
|     services    |     you are     |                 |                 |
|     with        |     doing and   |                 |                 |
|     continuity  |     be able to  |                 |                 |
|                 |     make case   |                 |                 |
|                 |     (show cost  |                 |                 |
|                 |     savings)    |                 |                 |
|                 |                 |                 |                 |
|                 | -   Fund crisis |                 |                 |
|                 |     response    |                 |                 |
|                 |                 |                 |                 |
|                 |   interventions |                 |                 |
|                 |     because     |                 |                 |
|                 |     people land |                 |                 |
|                 |     in          |                 |                 |
|                 |     emergency   |                 |                 |
|                 |     rooms (ER), |                 |                 |
|                 |     but ER does |                 |                 |
|                 |     not know    |                 |                 |
|                 |     what to do  |                 |                 |
|                 |     with those  |                 |                 |
|                 |     patients in |                 |                 |
|                 |     crisis      |                 |                 |
|                 |                 |                 |                 |
|                 | -   Offer       |                 |                 |
|                 |     respite     |                 |                 |
|                 |     care as key |                 |                 |
|                 |     to success  |                 |                 |
|                 |                 |                 |                 |
|                 |    (alternative |                 |                 |
|                 |     to more     |                 |                 |
|                 |     expensive,  |                 |                 |
|                 |     more        |                 |                 |
|                 |     intensive   |                 |                 |
|                 |     programs)   |                 |                 |
+-----------------+-----------------+-----------------+-----------------+

The following roundtable discussion used Oregon's Pilot Reentry Program
as an example and focused on how to take a pilot program statewide.

+-----------------+-----------------+-----------------+-----------------+
| **Pilot         |                 |                 |                 |
| Programs**      |                 |                 |                 |
+=================+=================+=================+=================+
| **Strategies**  | **Keys to       | *               | **Resources**   |
|                 | Success**       | *Stakeholders** |                 |
+-----------------+-----------------+-----------------+-----------------+
| -   Look for    | -   Engage      | -   Public      | -   Money       |
|     what or who |                 |     (jail,      |                 |
|     is out      |    stakeholders |     etc.)       | -   Bill Gates, |
|     there and   |                 |                 |     Sam Walton, |
|     find a      | ```{=html}      | -   Nonprofits  |     and other   |
|     champion    | <!-- -->        |     and         |                 |
|     who can     | ```             |     providers   | philanthropists |
|     give voice  | -   Develop     |                 |                 |
|     to the      |     support of  | -   Native      | -   People on   |
|     vision      |                 |     tribes      |     and off     |
|                 |    policymakers |                 |     staff       |
| -   Make sure   |     and         | -   Elected and |                 |
|     you have    |     decision    |     appointed   | -   Champions   |
|     data        |     makers      |     officials   |                 |
|                 |                 |     (local and  | -   Media,      |
| -   Build       | -   Balance     |     State)      |     marketing,  |
|     consensus   |     influence   |                 |     and public  |
|                 |     (e.g.,      |                 |     relations   |
| -   Be          |     equal       |                 |                 |
|     inclusive   |                 |                 | -   Volunteers  |
|                 |  representation |                 |                 |
| -   Focus on    |     of voices)  |                 | -   Housing     |
|     results     |                 |                 |                 |
|                 | -   Involve     |                 | -   Research    |
| -   Start with  |     consumers   |                 |                 |
|     end in mind |     in process  |                 | -   Community   |
|                 |                 |                 |                 |
| -   Be          | -   Involve all |                 |                 |
|     expansive   |                 |                 |                 |
|                 |    stakeholders |                 |                 |
| -   Think       |     and         |                 |                 |
|     globally    |     partners at |                 |                 |
|                 |     high level  |                 |                 |
| -   Think "womb |     of          |                 |                 |
|     to tomb"    |                 |                 |                 |
|                 |  decisionmaking |                 |                 |
| -   Involve     |                 |                 |                 |
|                 | -   Partner     |                 |                 |
|    stakeholders |     with        |                 |                 |
|     from the    |                 |                 |                 |
|     onset --    |   organizations |                 |                 |
|     some may    |     that can    |                 |                 |
|     only be     |     bring their |                 |                 |
|     interested  |     staff who   |                 |                 |
|     in bottom   |     are experts |                 |                 |
|     line;       |     in their    |                 |                 |
|     others may  |     disciplines |                 |                 |
|     want        |                 |                 |                 |
|     anecdotal   | -   Identify    |                 |                 |
|     evidence    |     champions   |                 |                 |
|                 |                 |                 |                 |
|                 | -   Use data    |                 |                 |
|                 |     and show    |                 |                 |
|                 |     partners    |                 |                 |
|                 |     cost, and   |                 |                 |
|                 |     convince    |                 |                 |
|                 |     them that   |                 |                 |
|                 |     it is in    |                 |                 |
|                 |     their best  |                 |                 |
|                 |     interest    |                 |                 |
|                 |                 |                 |                 |
|                 | ```{=html}      |                 |                 |
|                 | <!-- -->        |                 |                 |
|                 | ```             |                 |                 |
|                 | -   Coordinate  |                 |                 |
|                 |     efforts     |                 |                 |
|                 |                 |                 |                 |
|                 | ```{=html}      |                 |                 |
|                 | <!-- -->        |                 |                 |
|                 | ```             |                 |                 |
|                 | -   Timing is   |                 |                 |
|                 |     important   |                 |                 |
|                 |     -- strike   |                 |                 |
|                 |     while it is |                 |                 |
|                 |     a hot       |                 |                 |
|                 |     button      |                 |                 |
|                 |     issue       |                 |                 |
|                 |                 |                 |                 |
|                 | ```{=html}      |                 |                 |
|                 | <!-- -->        |                 |                 |
|                 | ```             |                 |                 |
|                 | -   Develop     |                 |                 |
|                 |     MOUs        |                 |                 |
|                 |     quickly     |                 |                 |
|                 |                 |                 |                 |
|                 | -   Constant    |                 |                 |
|                 |                 |                 |                 |
|                 |   communication |                 |                 |
|                 |     and         |                 |                 |
|                 |     feedback    |                 |                 |
|                 |                 |                 |                 |
|                 | -   Use known   |                 |                 |
|                 |     information |                 |                 |
|                 |     outlets     |                 |                 |
|                 |     effectively |                 |                 |
|                 |                 |                 |                 |
|                 | ```{=html}      |                 |                 |
|                 | <!-- -->        |                 |                 |
|                 | ```             |                 |                 |
|                 | -   Evaluate    |                 |                 |
|                 |     progress    |                 |                 |
|                 |     and         |                 |                 |
|                 |     outcomes    |                 |                 |
|                 |                 |                 |                 |
|                 | ```{=html}      |                 |                 |
|                 | <!-- -->        |                 |                 |
|                 | ```             |                 |                 |
|                 | -   Use private |                 |                 |
|                 |     money for   |                 |                 |
|                 |     evaluation  |                 |                 |
|                 |                 |                 |                 |
|                 | -   Implement   |                 |                 |
|                 |     objective   |                 |                 |
|                 |     evaluation  |                 |                 |
|                 |     immediately |                 |                 |
|                 |                 |                 |                 |
|                 | -   Tell naked  |                 |                 |
|                 |     truth about |                 |                 |
|                 |     how it is   |                 |                 |
|                 |     happening   |                 |                 |
|                 |                 |                 |                 |
|                 | -   Build on    |                 |                 |
|                 |     successes   |                 |                 |
|                 |                 |                 |                 |
|                 | -   Learn from  |                 |                 |
|                 |     what did    |                 |                 |
|                 |     not go well |                 |                 |
+-----------------+-----------------+-----------------+-----------------+

**NEXT STEPS AND RESOURCES**

**Next Steps to Incorporate upon Return Home:** As part of the closing
session, participants outlined who they plan to talk with and resources
needed before they can make those contacts. They identified plans to
talk with:

-   Legislators

-   Department and cabinet heads

-   Interagency Council

-   Continuum of Care

-   Providers

-   National Institute of Corrections

-   Local community development corporations

-   County prosecutors (e.g., who think ex-offenders should not be able
    to return to their communities)

-   Judiciary representatives

In order to approach the above list of stakeholders, participants
identified the need to have the following resources available:

-   Data (for legislators, etc.)

-   Fast facts (one-pagers)

-   Timing

**Desired Actions and Changes:** Participants discussed actions, events,
and changes that they would like to see in the future in order to
support effective transitions and discharge planning, including:

-   Define someone who is in an institution as homeless

-   Establish a common definition across agencies for homeless

-   Create a listserv to share ideas (will be added to the Policy
    Academy listserv)

-   Work with Housing and Urban Development (HUD) to change laws about
    sex offenders (e.g., aging out of foster homes)

-   Work with Department of Agriculture (USDA) about TA on grant writing
    and completing their application

-   Bring the "atypical" to a brainstorm like this (i.e. the "nay-sayer"
    potential partners: prosecutors, the media, etc.)

-   Use CHOTO (State housing experts) as a resource more effectively
    (the National Council of State Housing Agencies (NCSHA) Web site has
    more information)

**Resources:** Participants requested that the following resources and
information be shared post-Workgroup:

-   Critical time intervention

-   Adult foster care

-   Articles on cost or estimating the cost

-   SSI/SSDI Outreach, Access, and Recovery (SOAR) training information
    (e.g., State participation)

-   More information on FQHCs at [www.bphc.gov](http://www.bphc.gov/)

-   Bounty dollars (related to SSI)

-   Presenters' Microsoft PowerPoint slides

-   Workgroup notes

-   Table regarding Thursday's discussion

-   Maryland's sample MOU

-   Oregon's materials

-   NCSHA's Web site

These resources and pieces of information are available at
[www.hrsa.gov/homeless](http://www.hrsa.gov/homeless) as part of the
materials for the Transition and Discharge Planning LCW.