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	Five Ways to Help Homeless New Yorkers By supporting programs that help people leave the street, you can make a lasting difference. Find out how you can help. Read More

THE CHALLENGE
Homelessness is triggered by the loss of housing, but the loss of housing is usually precipitated by the presence of other risk factors. These include poverty; a history of childhood housing instability or incarceration; a lack of adequate education, employment readiness or opportunity; and the presence of mental health or substance abuse issues.

By the time individuals and families reach out for shelter, many have had long histories of interaction with other social service agencies and providers. Yet these agencies do not routinely or easily share information with each other to create integrated service plans, maximize resources available to clients, and decrease housing instability that may lead to homelessness.

In addition, eligibility rules and the service approaches of varying agencies sometimes come into conflict, leaving clients confused or unaware of services that can help them. These disruptions can add to the challenges at-risk or homeless New Yorkers already face.

SOLUTIONS
At-risk and homeless New Yorkers are typically eligible to receive a wide range of benefits from federal, state, and local agencies. The initiatives in this chapter aim to ensure that benefits are maximized and services streamlined in order to increase stability in their lives.

New case conferencing models will bring together caseworkers from multiple agencies to problem solve and mitigate barriers their shared clients may face. New technologies will enable caseworkers to share information about those they serve – again to troubleshoot more effectively on their client’s behalf. An emphasis on ensuring access to benefits at the community level is also included.

The ultimate goal for those serving homeless and at-risk New Yorkers is to help them move toward self-sufficiency. By ensuring the streamlined delivery of services to individuals and families during their most vulnerable moment, public agencies work to advance this important goal.

The Next Step	Current Status	Taking Action
Coordinate City’s Human Services and Benefits with a “One-City” Integrated Case Management System	Some people receive services from many public agencies, yet there are no technologies in place to systematically share information from one agency to the next. This leads to unnecessary waiting periods for clients, as well as some duplication of work for city agencies and clients.	A “one-city” case management system will improve information sharing, the delivery of resources, and the ability of clients to receive timely and responsive aid. It will include every appropriate safeguard to ensure confidentiality.
Implement Cross-Agency Case Conferencing	Clients often receive services from multiple public agencies. Yet each agency is designed to address a specific issue. This can lead to conflicting directions and a fragmented approach. Few opportunities exist for clients to interact with multiple agencies at the same time in order to create coordinated service plans.	Mechanisms will be created to enable and ensure that agency case workers collaborate with colleagues at other agencies. This will help to avoid contradictory decisions and reduce duplicated efforts. Clients will participate in creating service plans and addressing problems, stressing a client-centered and strengths-based approach to services.
Deliver and Coordinate Services and Benefits at the Community Level	Individuals seeking and receiving services are not always able to do so in their neighborhood. Community-based providers experience frustration as they attempt to access benefits from multiple agencies for their clients.	With services delivered at a community level through neighborhood groups, holistic service plans that build on clients’ strengths and minimize their frustrations will be developed. The city will pilot this effort in one community in order to develop strategies that can be taken citywide.
Implement New Tools to Improve Access to Benefits	Many people who are eligible for but do not receive benefits have difficulty keeping housing and accessing services. Technologies do exist that minimize access challenges, but they are not in widespread use.	The city will expand use of computerized technologies to help calculate the benefits at-risk and homeless New Yorkers are eligible to receive. This will enable caseworkers to help them access and learn about appropriate resources, in order to avoid homelessness or move from shelter to permanent housing and self-sufficiency.
Coordinate Services and Benefits to Chronically Homeless Individuals	Many chronically homeless people, particularly street homeless individuals, are eligible for a range of federal, state, and local benefits that could help them access services and leave the streets. Accessing benefits is difficult, often because of the mental health or substance abuse issues they experience.	New strategies to link street homeless individuals with available assistance will be pursued. Cross-agency partnerships and accountability mechanisms to track outcomes will be developed.
Pursue “Express Eligibility”	Individuals who are eligible for one public benefit are often eligible to receive others. Yet agencies have separate application processes and do not share information. This creates lost opportunities for clients and duplicative staff efforts.	New standards will be developed so that individuals who are known to be eligible for one benefit will have access to a shortened review for other benefits or an assumption of eligibility in limited instances. This may include a shared database between participating agencies.
Expand Benefits Access Supports	A unit at DHS called the Case Management Field Team has been very successful in helping homeless families who are eligible for public assistance access those benefits. Other homeless populations, however, do not receive similar assistance.	The city will expand the unit’s responsibilities and the populations served, with a particular focus on prevention assistance.
Advance Take Care New York Community Initiatives	People living in poverty experience high rates of HIV, depression, substance abuse, mental health problems, and other medical issues. The city recently released TAKE CARE NEW YORK, a health policy that prioritizes actions that help individuals, health care providers, and New York City as a whole improve its health.	As close points of contact to at-risk New Yorkers, new community-based prevention providers will provide educational materials and make referrals that support the goals of TAKE CARE NEW YORK. This will support the Department of Health and Mental Hygiene’s health-related prevention efforts and reduce reliance on acute care interventions like emergency rooms.


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