Health and Housing Strategy for Virginians with Serious Mental Illness (January 2023)
Summary
Health and Housing Strategy for Virginians with Serious Mental Illness, a report to the General Assembly submitted by the Department of Housing and Community Development (DHCD) in January 2023. The executive summary states that in 2017 the General Assembly requested that DHCD work with state agencies and other stakeholders on strategies to expand Permanent Supportive Housing (PSH) for individuals with serious mental illness (SMI). It describes the report as the fifth to the General Assembly and states a long-term 5,000-unit need for PSH. It states that as of Fiscal Year 2022 the state has developed 1,746 of the approximately 5,000 PSH units.
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“Health and Housing Strategy for Virginians with Serious Mental Illness (January 2023).”
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Health and Housing Strategy for Virginians
with Serious Mental Illness:
A Report to the General Assembly
Submitted by Department of Housing and
Community Development – January 2023
Table of Contents
Executive Summary 3
Annual Report on Housing Strategies for the Seriously Mentally Ill 6
Background 7
General Assembly Request 7
Permanent Supportive Housing 8
What is PSH? 8
An Evidence-Based Practice 9
Why is a PSH Housing and Services Strategy Important for Virginia? 10
Assessing Cost Avoidance 12
Estimates of PSH Need for Virginians with SMI 14
Progress and Accomplishments 14
PSH Services and Supports - Accomplishments 15
Capital Investment in PSH - Accomplishments 21
Rental Assistance for PSH - Accomplishments 23
Enhancing System Capacity - Accomplishments 27
Strategies for Continued Progress 31
Strategies to Continue to Expand PSH Housing Supports 31
Strategies to Expand Capital and Rental Assistance for PSH 34
Strategies to Increase Capital Investment in PSH 34
Strategies to Increase Rental Assistance for PSH 37
Strategies to Increase PSH through Existing Affordable Housing Programs 38
Strategies to Increase PSH through Enhancing System Capacity 39
Leadership Key to PSH Strategy 39
Appendices 41
Appendix A Action Plan 42
Appendix B PSH Steering Committee Agencies 60
Appendix C Governor’s Coordinating Council on Homelessness and Housing Vulnerable
Populations - Committee Relationship Graphic 61
2
Executive Summary
In 2017, the General Assembly requested that the Department of Housing and Community
Development (DHCD) work with state agencies and other stakeholders to develop and
implement strategies to expand opportunities for Permanent Supportive Housing (PSH)for
individuals with serious mental illness (SMI). PSH is an evidence-based practice where housing
is provided in conjunction with wraparound support and health services including rental
assistance, and it demonstrates positive outcomes such as reduced hospitalizations and
homelessness, increased housing stability, and improved behavioral and physical health. PSH
still allows for individual choice and preferences around where housing is located and which
service providers are utilized.
This fifth report to the General Assembly provides the state’s 2022 accomplishments as well as
recommendations to continue to expand PSH to meet the long-term 5,000-unit need for PSH.
The PSH Steering Committee1, which is composed of representatives from multiple state
agencies, continues to meet regularly to guide this cross-agency collaborative work within the
following five goals:
● Goal #1 - Increase Services and Supports to Assist Individuals with SMI to Gain Access to
and Maintain Supportive Housing
● Goal #2 - Provide Capital Subsidies to Expand PSH
● Goal #3 - Increase Rental Assistance to make Units Affordable
● Goal #4 - Increase PSH through Preferential Access to Existing Affordable Housing
Programs
● Goal #5 - Strategies to Increase PSH through Enhancing System Capacity
The Committee developed a three-year Action Plan with 57 specific strategies and action items
to reach these goals. The Lead state agencies designated for the strategies provide regular
updates that will be shared with the Housing Virginians with SMI Strategy Group.
Working collaboratively, the state agencies that comprise the PSH Steering Committee made
significant progress towards meeting each of these goals. Highlights of the FY 22
accomplishments include:
Success Towards Overall Goal of 5,000 PSH Units: As of Fiscal Year 2022, the state has
developed 1,746 or 31 percent of the approximately 5,000 PSH units needed. This includes
● 1,648 PSH SMI units funded by state general funds appropriated to DBHDS,
● 128 Auxiliary Grant in Supportive Housing (AGSH) units, and
● 69 leveraged HUD Mainstream vouchers.
1 For a full list of the steering committee agencies, please see Appendix B.
3
DBHDS PSH SMI Program Outcomes: FY22 DBHDS PSH outcomes for the 1,578 individuals who
were housed between February 6, 2016 and June 30, 2022 include:
● Ninety-one (91) percent of individuals served in PSH remained stably housed for at least
one year.
● Nearly half (49.1 percent) of PSH participants were hospitalized in a state psychiatric
facility at some point in their lifetimes.
● Two hundred seventy-two (272) individuals were discharged from a state psychiatric
hospital into DBHDS PSH, and 359 individuals in PSH for at least twelve months had a
state hospital admission in the year before move-in.
● Only nine percent of those served have been discharged to an institutional setting or
higher level of care.
● State hospital utilization decreased 76 percent the year after PSH move-in, resulting in
avoided costs of $27.6 million.
VH Leasing Preference: In order to have a more significant impact, VH modified its CY22
Qualified Allocation Plan to require that every development awarded 9% LIHTC as well as 4%
tax credit funding provide a PSH leasing preference for 10 percent of its units. In 2022, 30
deals/1,803 total units/191 target population units with 9% Low Income Housing Tax Credit
(LIHTC) and 31 deals/4,260 total units/436 target population units using 4% LIHTC. A total of
3,058 total target population units have been funded with approximately 1,000 target
population units placed in service to-date.
Virginia Housing Trust Fund (VHTF): In FY22, the DHCD-administered Virginia Housing Trust
Fund (VHTF) was funded at $55m. DHCD allocated $44m towards the Competitive Loan Pool
funding new construction or substantial renovations of affordable housing. The $44m was
awarded to a total of 76 projects which created or preserved 313 units of PSH and 4,626 units
overall. Some of these projects received tax credit awards referenced above during or previous
to CY22, and not all PSH units funded are specifically held for those with SMI.
The remaining $11m was allocated to projects which aim to reduce homelessness, funding 100
targeted community efforts to reduce homelessness, including 14 rapid re-housing (RRH)
projects, 18 permanent supportive housing (PSH) projects, and 14 underserved population
innovation projects.
While not all of the homelessness reduction projects specifically target the creation of PSH for
individuals with an SMI diagnosis, the homelessness data collected through Point In Time
counts and other demographic surveys demonstrate some overlap between individuals
experiencing chronic homelessness and individuals with SMI.
4
Mainstream Voucher Program: With the support of the state agencies, local Virginia Public
Housing Agencies leveraged 1,071 federally-funded vouchers to serve non-elderly people with
disabilities who are homeless, institutionalized, at risk of either condition, or who will move on
from a PSH/Rapid Rehousing program
Building and Transforming Coverage, Services, and Supports for a Healthier Virginia Waiver:
CMS approved Virginia’s High Needs Support benefit, which DMAS now expects to implement
on July 1, 2024, will provide critical housing and employment support services to the
Commonwealth’s high need Medicaid members, to address the social and environmental needs
that impact health, wellbeing, and medical expenditures.
It is important to note that the state agencies that comprise the PSH Steering Committee were
able to not only safely operate but continued to expand PSH programs for people with SMI and
other vulnerable populations during the COVID-19 pandemic. This is a testament to the
agencies’ collaborative relationships as well as the deep commitment of the staff.
Meeting the long-term need for PSH will require the continued support of leadership and the
commitment of state and local public and private entities to make rental units available and
affordable, to target those units to individuals in the state’s priority populations, and to provide
readily accessible supportive services through the ongoing development of systems capacity
and sustainable funding strategies.
5
Annual Report on Housing Strategies for the Seriously Mentally Ill
The following report complies with 2022 Budget Bill (Special Session I) language Item 114 H
Commerce and Trade – Department of Housing and Community Development
"H. The Department of Housing and Community Development (DHCD) shall develop and
implement strategies, that may include potential Medicaid financing, for housing individuals
with serious mental illness. DHCD shall include other agencies in the development of such
strategies including the Virginia Housing Development Authority, Department of Behavioral
Health and Developmental Services, Department for Aging and Rehabilitative Services,
Department of Medical Assistance Services, and Department of Social Services. The Department
shall also include stakeholders whose constituents have an interest in expanding supportive
housing for people with serious mental illness, including the National Alliance on Mental Illness
Virginia, the Virginia Housing Alliance and the Virginia Sheriff's Association. An annual report on
such strategies and the progress on implementation shall be provided to the Chairmen of the
House Appropriations and Senate Finance Committees by the first day of each General Assembly
Regular Session."
6
Background
Directive
Item 108 (H) of Chapter 836 of the 2017 Acts of Assembly (also known as the budget bill)
charged the Department of Housing and Community Development (DHCD) with developing and
implementing strategies to increase permanent supportive housing (PSH) for individuals with
serious mental illness (SMI). The General Assembly budget language indicated that strategies
could potentially include Medicaid financing and directed DHCD to include other agencies in the
development of strategies, naming Virginia Housing (VH), Department of Behavioral Health and
Developmental Services (DBHDS), Department for Aging and Rehabilitative Services (DARS),
Department of Medical Assistance Services (DMAS), and Department of Social Services (DSS)
(Item 108 H). Direction for this effort has been provided on two levels – through the
Interagency Leadership Team (ILT), comprised of heads of the agencies described above and
through the Permanent Supportive Housing (PSH) Steering Committee comprised of program
directors and managers of the same agencies.
Further, the General Assembly required DHCD to include stakeholders whose constituents have
an interest in expanding supportive housing for individuals with SMI, naming the National
Alliance on Mental Illness Virginia, the Virginia Housing Alliance and the Virginia Sheriff's
Association. Finally, the budget language required DHCD to provide an annual report on such
strategies and the progress on implementation to the Chairmen of the House Appropriations
and Senate Finance Committees. This report is the fourth DHCD report to the General Assembly
in response to its charge to develop PSH strategies. The 2018-2022 reports can be found here:
● https://rga.lis.virginia.gov/Published/2018/RD12
● https://rga.lis.virginia.gov/Published/2019/RD100
● https://rga.lis.virginia.gov/Published/2020/RD10
● https://rga.lis.virginia.gov/Published/2021/RD50/PDF
● https://rga.lis.virginia.gov/Published/2022/RD22/PDF
7
Permanent Supportive Housing (PSH)
What is PSH?
The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) describes PSH
as “decent, safe, and affordable community-based housing that provides tenants with the rights
of tenancy under state and local landlord tenant laws and is linked to voluntary and flexible
supports and services designed to meet tenants’ needs and preferences.2” PSH is affordable
rental housing that may be scattered site or single site. Support services are available to tenants
but not required and PSH is not a treatment setting. PSH is a cross-system approach that
requires tactical use of resources.
Housing must be safe, decent and affordable. Housing affordability is a critical issue for states
working to comply with Americans with Disabilities Act of 1990, as amended (ADA)
requirements because most individuals with significant disabilities rely primarily on federal
Supplemental Security Income (SSI) payments that average only 20 percent of median income
nationally. Nowhere in the U.S. can a person with a disability on SSI afford housing at the Fair
Market Rate3. Affordability is created with capital to write down the cost of acquisition,
development or rehabilitation of housing and rental or operating assistance to ensure tenants
pay only what they can afford for rent. The tenant’s limited income also means it is difficult to
save for payment of a security deposit, utility hook-ups or furnishings and tenants often need
assistance with these one-time costs as well.
Services are essential to assist individuals with SMI in gaining access to and transitioning to
housing, and for successfully sustaining PSH. PSH programs generally provide tenancy supports
to help individuals maintain successful tenancies and connect tenants with community-based
organizations for health care, mental health, substance abuse (mental health and substance
abuse hereafter collectively referred to as behavioral health) and other services. States have
options for how to deliver and fund PSH services. It is critical to ensure services are readily
available when needed and available for as long as the individual wants and needs them.
System Supports are essential, to serve as the “glue” that makes PSH work. The delivery of
housing and services requires the collaboration of systems that use different language, rely on
different funding sources and have different measures of accountability. Collaboration and
strategic planning at multiple levels including the state, regional, and local are critical to the
development and management of system supports. Each system’s roles and responsibilities
2 SAMHSA (2010). Permanent Supportive Housing Evidence-Based Practices (EBP) Kit. PowerPoint Presentation. Retrieved from
https://store.samhsa.gov/sites/default/files/d7/priv/howtouseebpkits-psh.pdf
3 Technical Assistance Collaborative. (nd) Priced Out. Retrieved from http://www.tacinc.org/knowledge-resources/priced-out-
v2/
8
need to be clear and accountable at the planning stage to ensure the needed collaboration and
communication is functional when programs are ready for implementation.
An Evidence-Based Practice
SAMHSA has identified PSH as an evidence-based practice (EBP) for individuals with SMI.
Research has shown the cost-effectiveness of the PSH model, particularly for people with
extensive or complex needs such as those with co-occurring mental health and substance use
disorder conditions who often experience homelessness, or who are frequent users of costly
institutional and emergency care4. Research has also demonstrated positive impacts of PSH on
housing stability, health, and behavioral health5. In one review of existing research studies, a
consistent finding emerged that the “provision of housing had a strong, positive effect in
promoting housing stability and reducing homelessness.”6
Other federal agencies, including the Department of Housing and Urban Development (HUD),
the Center for Medicare and Medicaid Services (CMS), the Department of Justice (DOJ), and the
US Interagency Council on Homelessness (USICH) recognize PSH as a best practice. HUD and
CMS for example, have programs or projects in place to promote PSH. HUD has provided funds
annually to Continuums of Care serving chronically homeless individuals – the vast majority of
whom have SMI - to expand PSH. As costs for institutional settings have grown, and alternative
service approaches emerged, CMS recognized and promoted options for states to shift, when
appropriate, the care of individuals in nursing facilities and intermediate care facilities for
individuals with intellectual disabilities (ICF-IIDs) to more inclusive and less costly community-
based alternatives. Initiatives such as Money Follows the Person and the Balancing Incentive
Program, as well as Home and Community-Based Services (HCBS) Waivers became popular
tools to assist states in reducing reliance on institutional settings. In January 2014, CMS put in
place the HCBS Waiver “Settings Rule” that provided strong incentives for state Medicaid
agencies and their Mental Health and Intellectual/Developmental Disabilities counterparts to
develop and promote integrated community-based housing for individuals with disabilities. In
June 2015, CMS issued an Informational Bulletin clarifying that while Medicaid cannot pay for
4 Culhane, D. P. et al. (2002). Public service reductions associated with placement of homeless persons with severe mental
illness in supportive housing. Housing Policy Debate, 13(1):107–163
Larimer, M. E. (2009). Health care and public service use and costs before and after provision of housing for chronically
homeless persons with severe alcohol problems. The Journal of the American Medical Association 301(13):1349
Chalmers McLaughlin, T. (2010). Using common themes: Cost-effectiveness of permanent supported housing for people with
mental illness. Research on Social Work Practice, 21(4):404–411.
5 Rog, D. et al. (2014). Permanent supportive housing: Assessing the evidence. Psychiatric Services 65(3):287-294
Padgett, et al. (2011). Substance use outcomes among homeless clients with serious mental illness: Comparing Housing First
with Treatment First programs. Community Mental Health Journal 47(2):227–232.
Wolitski et al. (2009). Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and
unstably housed people living with HIV. AIDS and Behavior 14(3):493–503.
6 Rog, D. et al. (2013). Permanent supportive housing: Assessing the evidence. Psychiatric Services 65(3):290.
9
room and board, the program can assist states with coverage of certain housing-related
activities and services.7 The bulletin was intended to assist states in designing Medicaid
benefits, and to clarify the circumstances under which Medicaid reimburses for certain housing-
related activities, with the goal of promoting community integration for individuals with
disabilities, older adults needing long-term services and supports (LTSS), and those experiencing
chronic homelessness.
Prioritizing the housing needs of individuals with disabilities who are institutionalized or
homeless is not only the most cost-effective strategy for states and the federal government, it
is also a requirement of the ADA. States are increasingly moving toward expansion of PSH
within their housing and services continuums because of its alignment with the ADA’s
integration mandate, as well as with housing preferences and choices for many individuals with
SMI in particular. This is especially true where lack of availability or lack of access to such
options, due in part to a history of reliance on congregate or institutional settings, seriously
limits the housing choices of individuals with disabilities.
Why is a PSH Housing and Services Strategy Important for Virginia?
PSH can be a valuable tool to help the Commonwealth of Virginia address a number of public
policy challenges. First, Virginia has implemented Medicaid expansion, affording access to
health care for up to 400,000 low-income qualifying Virginia residents. Based on other states’
experiences, it is estimated that as many as 35 percent of these individuals will have significant
chronic physical and behavioral health conditions that have previously been untreated or
under-treated due to their lack of coverage. Many of these individuals are likely to be unstably
housed, adding to the myriad of needs to be addressed to improve their health. In addition to
the array of support services now available to them through Medicaid, PSH can help by
improving housing stability, leading to more effective use of healthcare services for this newly
covered population.
Development of a housing and services strategy for individuals with SMI is also important to the
Commonwealth because it will facilitate the timely discharge of individuals from state
psychiatric beds and prevent returns to inpatient care. Virginia is experiencing a census crisis in
its state hospitals due to “bed of last resort” legislation, which has left those hospitals
shouldering a disproportionate share of temporary detention order admissions. Lack of
affordable housing with robust supportive services is a commonly cited barrier to discharge.
PSH is widely recognized as a critical resource to assist states with ensuring individuals are
supported in the least restrictive setting, as required by the Olmstead decision, and with
reducing the use of costly inpatient care.
7 Center for Medicaid and Chip Services. (June 2015). Coverage of Housing-Related Activities and Services for Individuals with
Disabilities. Retrieved from https://www.medicaid.gov/federal-policy-guidance/downloads/cib-06-26-2015.pdf
10
PSH can help the subpopulation of people with SMI exit homelessness more quickly and
successfully. As illustrated in Figure 1 below, between CY2010 and CY2021 overall
homelessness in Virginia has decreased 28 percent. As illustrated in Figure 2 below, in the 2022
PIT count, there were 5,111 adults experiencing homelessness. Of these adults, 22% were
chronically homeless, eight percent were veterans, 13% were survivors of domestic violence,
14% had a substance use disorder, and 26% has a serious mental illness.
Figure 1
Figure 2
11
Virginia’s criminal justice system would also benefit considerably from additional PSH capacity.
For justice system-involved individuals with SMI, and co-occurring substance use disorders
(SUD), housing is critical for successful re-entry into the community and sustained recovery
over time. Without safe, affordable housing and appropriate community supports, individuals
with behavioral health disorders are less likely to remain in recovery and more likely to come
back into contact with the criminal justice system, become re-incarcerated, or even
hospitalized.
Item 394 (J), Chapter 854 of the 2019 Acts of Assembly continued funding for the Jail Mental
Health Pilot Program. The Act required the pilot sites to report quarterly performance data, to
include the provision of appropriate services to jail mental health pilot participants after
release, and the number of inmates re-arrested or re-incarcerated within 90 days after release.
Initial recidivism findings were provided from five of the six participating jails in the FY20
report. The data, while significantly limited, revealed that 18% of the program inmates returned
to jail within 90 days after release, and 82% did not return within that time frame. Some
projects shared examples of successful re-entry by program participants, attributing these
successes to individuals rebuilding support systems, obtaining housing and employment,
getting needed medication and restoring benefits. Overall, provision of aftercare services
improved. Notably, in contrast to FY2019, the number of inmates who were provided housing
post release reportedly increased from the first quarter of FY2020 to the fourth quarter of
FY2020. However, the FY20 Report indicated that “finding safe and affordable housing for
program participants….was a major difficulty in FY2019, and continued to challenge staff
throughout FY2020.”8 The report emphasized that obtaining housing, among other supports, is
essential to successful re-entry and reducing recidivism.
Assessing Cost Avoidance
A housing and services strategy is also important because national and state data suggest that
PSH results in some public cost avoidance.
Opportunities for Cost Avoidance for Virginia as a Result of Increased PSH Data Reflecting the
National Experience
Studies demonstrate that providing PSH can help achieve significant savings by reducing
avoidable emergency department (ED) visits, hospitalizations, readmissions, and other health
care costs – particularly when the assistance is targeted to the most high-cost and highly
vulnerable Medicaid beneficiaries experiencing homelessness.9 Combining affordable housing
8 Virginia Department of Criminal Justice Services. (January 2021). https://rga.lis.virginia.gov/Published/2021/RD68/PDF
9 See The Commonwealth Fund (2014) In Focus: Using Housing to Improve Health and Reduce the Cost of Caring for the
Homeless. Retrieved from http://www.commonwealthfund.org/publications/newsletters/quality-matters/2014/october-
november/in-focus and
12
with intensive services, including help finding housing, working with a landlord, accessing
physical and behavioral health care, and finding employment, for a high-needs group saved an
average of $6,000 a year per person in health care: 23 percent fewer days in hospitals, 33
percent fewer ED visits, and 42 percent fewer days in nursing homes. 10
Data Reflecting Virginia Experiences
Virginia has also conducted evaluations of its own PSH programs and generated findings
consistent with national research. DBHDS has been operating PSH for adults with serious
mental illness with targeted state general funds since 2016.
Before moving into DBHDS PSH, individuals have had long histories of homelessness as well as
crisis contacts and institutional care resulting in multi-system involvement, poor outcomes, and
failed interventions. After move-in into DBHDS PSH, individuals experienced dramatically
improved housing stability and reduced utilization of inpatient care.
As noted earlier, outcomes for the 1,578 individuals who were housed between February 6,
2016 and June 30, 2022 include:
● Ninety-one (91) percent of individuals served in PSH remained stably housed for at
least one year.
● Nearly half (49.1 percent) of PSH participants were hospitalized in a state psychiatric
facility at some point in their lifetimes.
● Two hundred seventy-two (272) individuals were discharged from a state psychiatric
hospital into DBHDS PSH, and 359 individuals in PSH for at least twelve months had a
state hospital admission in the year before move-in.
● Only nine percent of those served have been discharged to an institutional setting or
higher level of care.
● State hospital utilization decreased 76 percent the year after PSH move-in, resulting
in avoided costs of $27.6 million.
The 2018 Mental Illness in Jails Report analyzed data on the 27,044 individuals incarcerated in
Virginia’s jails in June 2018. Nearly twenty percent were known or suspected to have a mental
illness. Further, 10.42 percent of inmates had an SMI. The reported percentage of inmates with
SMI has increased nearly 74 percent since 2011. Jails also identified 875 inmates who were
homeless, 377 of whom had a mental illness and 277 of whom had a mental illness and co-
occurring substance use disorder. Fiscal Year 2018 jail behavioral health costs were reported at
$23.2 million for the jails that responded to the Compensation Board’s survey.
http://aspe.hhs.gov/daltcp/reports/2011/ChrHomlr.pdf
10 Parekh, A & Krustick, C. (November 2017) Building the Case: Low-Income Housing Tax Credits and Health, Bipartisan Policy
Center.
13
Estimates of PSH Need for Virginians with SMI
In November 2018, Executive Order 25 was issued recognizing Virginia’s unmet housing needs
and highlighting the need for PSH as one of his three top priorities. At the request of the Deeds
Commission, DBHDS assessed the number of adults with serious mental illness who need PSH
to address extreme crises such as long-term homelessness, institutionalization, and frequent
use of emergency services and criminal justice interventions. DBHDS’s assessment established a
need for 5,000 PSH units. This is consistent with Executive Order 25 and is supported by the
Administration’s Housing and Supportive Services Interagency Leadership Team (ILT).
Table 1 illustrates how DBHDS arrived at the need for an estimated 5,000 additional PSH units
for Virginians with SMI. It is important to note that while many individuals with SMI would
benefit from PSH, DBHDS’ estimate of need below includes only those who need PSH to address
extreme crises such as long-term homelessness, institutionalization, and frequent use of
emergency services and criminal justice interventions.
Table 1: DBHDS Estimates of Need for PSH for Persons with SMI
Current Status of Individual Number of Persons with SMI Data Source
11
Homeless 516 The State of PSH in Virginia, 2015
(Virginia Housing Alliance)
Jail 1,056 Mental Illness in Jails Report
(Virginia Compensation Board,
2015)
Assisted Living Facility 824 Auxiliary Grant payments to
localities (2016 Estimate of SMI
based on AG recipients in one
month as provided by DARS)
Unstably Housed - Top 20 percent 2,684 Community Services Board (CSB)
highest utilizers of crisis and (including 464 individuals with a CCS_3 data submissions (DBHDS,
emergency services state psychiatric facility stay) 2016)
Progress and Accomplishments
As described above, since the submission of the 2021 report to the General Assembly, DHCD
has been working with its state partners and the Housing People with SMI Strategy Group
comprised of stakeholders to implement the report recommendations. PSH expansion requires
the identification of new or redirected resources for supports and housing as well as systemic
11 The 2017 PIT for the State of Virginia (combined data from all Virginia Continua of Care) is 611 persons in shelters and 251
unsheltered persons for a total of 862 homeless individuals with SMI.
14
infrastructure such as staffing, policies and procedures. Together, these all must align for
successful expansion.
PSH Services and Supports - Accomplishments
Services are essential to assist individuals with SMI in gaining access to and transitioning to
housing, and for successfully sustaining PSH. PSH programs generally provide tenancy supports
to help individuals maintain successful tenancies and connect tenants with community-based
organizations for health care, mental health, substance abuse (mental health and substance
abuse hereafter collectively referred to as behavioral health) and other services. Like many
other states, Virginia has historically covered housing acquisition and tenancy supports for
individuals with behavioral health disorders using state funds, more specifically through
continued investment of state general funds in DBHDS’ PSH program.
While most of the DBHDS PSH program funds are directed to long-term rental assistance, more
than thirty percent of these funds have been used for housing stabilization services, one-time
client assistance, or staff time to administer the rental assistance. Following CMS Guidance to
explore the use of Medicaid Authority to cover certain housing related-services and supports,
Virginia determined it was in the state’s interest to seek Medicaid coverage for many of these
state-funded services, freeing up state dollars to fund additional rental assistance.
On June 7, 2018, Governor Northam signed Chapter 2 of the 2018 Acts of Assembly (2018
Appropriations Act) directing DMAS to submit a Medicaid Section 1115 Demonstration Waiver
seeking federal approval for new Medicaid program features “designed to empower individuals
to improve their health and well-being…,” including a housing supports benefit.
Housing Support Benefit in the Medicaid 1115 Demonstration Waiver
On July 9, 2019, CMS approved Virginia’s High Needs Support benefit. The High Needs Supports
(HNS) program, which DMAS now expects to implement on July 1, 2024, will provide critical
housing and employment support services to the Commonwealth’s high need Medicaid
members, to address the social and environmental needs that impact health, wellbeing, and
medical expenditures.
DMAS has continued to work with CMS to finalize the standard terms and conditions and
continues to engage Managed Care Organizations (MCOs), sister agencies and other
stakeholders to operationalize aspects of the benefit. DMAS utilized input from a Town Hall
meeting to inform the initial implementation and operational planning, stakeholder
workgroups, and provider trainings for the year.
In January 2021, CMS issued guidance to state health officials on addressing social
determinants of health including housing. The guidance acknowledged that an understanding
of the social, economic, and environmental factors that affect the health outcomes of Medicaid
populations can be an integral component of states’ efforts to realign incentives, reduce costs,
15
and advance value-based care in their health systems. Several of the principles outlined in the
letter were incorporated by DMAS in to this year’s activities to advance the HNS program’s
design:
1. Services must be provided to Medicaid beneficiaries based on individual assessments of
need, rather than take a one size-fits-all approach
2. Medicaid is the payer of last resort that aligns with other programs and fills gaps where
appropriate. Accordingly, states must assess all available public and private funding
streams, including Medicaid, to cover assistance with unmet social needs.
3. States should ensure that services provided to address SDOH are limited to those
expected to meet the beneficiary’s needs in the most economic and efficient manner
possible and are of high-quality.
DMAS held several state-to-state meetings to learn more about Medicaid-funded supportive
housing programs. Washington State’s Health Care Authority launched the Foundational
Community Supports program, which is also funded through a Medicaid 1115 Demonstration
program. Their initial evaluation report found that the program’s supportive housing services
helped people transition or begin to transition out of homelessness or housing instability. In
addition, the program showed promising reductions in emergency room visits and
hospitalizations for people enrolled in supportive housing. Finally, the people who enrolled in
their supportive employment services, which is also part of Virginia’s program, found
employment at a higher rate, earned more money, and worked more hours. 12 To continue the
state-to-state engagement, Virginia applied and was awarded two technical assistance grants
that included state-to-state peer learning opportunities.
State Medicaid Learning Collaborative
In November 2020, CMS selected Virginia to participate in the State Medicaid Learning
Collaborative Advancing housing-related supports for individuals with a Substance Use Disorder
(SUD). This project included several selected Medicaid agencies interested in advancing
housing-related supports for individuals with a Substance Use Disorder (SUD) to advance the
goals of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment
for Patients and Communities Act (SUPPORT Act). The program goals included developing and
expanding the knowledge base and capacity of state Medicaid agencies to implement and
strengthen strategies for providing housing-related supports and care coordination under
Medicaid for individuals with substance use disorders (SUD), facilitating peer-to-peer learning
across states, and strengthening critical partnerships between state Medicaid, behavioral
12 Washington State Health Care Authority. (February 2020). Primary Evaluation Report Findings
Are In: Foundational Community Supports Program Work. Retrieved from
https://www.hca.wa.gov/assets/program/fcs-preliminary-report-one-pager.pdf.
16
health, and housing agencies through shared learning and the opportunity for action planning
and/or strategy implementation.
Virginia’s interagency team developed and implemented several project goals, which continue
to enhance both housing services and the partnership needed to coordinate across state
agencies to advance SDOH in accordance with the CMS-issued guidance:
● Determine opportunities to add diverse and inclusive perspectives and imbed racial
equity into governance structures.
● Begin an analysis of housing programs, both housing-related services and affordable
housing, to identify the array of housing programs available in Virginia
● Create a draft plan to increase housing options for individuals with a SUD
The Collaborative team included individuals with lived experience to help further the state’s
efforts to address the housing needs of individuals with substance use disorders. Training for
and outreach to providers of SUD was identified as two opportunities and led to the
development of a housing training. DMAS in partnership with DHCD held two training sessions
with SUD providers on accessing housing resources and how to work with Continuums of Care
to address the needs of individuals at risk of or experiencing homelessness.
The team also held a listening session with stakeholders from the various stakeholders working
with individuals with SUD including two local hospitals, the CSB, the Greater Richmond CoC,
private behavioral health providers, and representatives from the state agencies on the team
and the Department of Corrections. The session identified points of intersection that require
further stakeholder listening sessions including hospital discharges, coordination between
behavioral health providers and the CoCs, and crisis intervention teams at the CSBs. The
housing training has been provided to the crisis intervention teams at the CSBs and further
engagement is anticipated. In addition, a webinar was held in July to enhance the connection
between the MCOs and CoCs to partner
By the end of the project in August 2021, the Collaborative team determined that Virginia’s
ability to increase housing options for individuals with a SUD is largely driven by two factors:
funding available in Virginia and understanding how individuals access programs through the
service delivery system that will administer the funding. With the infusion of the American
Rescue Plan’s (ARA) investment in housing for individuals experiencing homelessness, Virginia
can plan longer term to ensure the service delivery system is able to make best use of available
funds that are administered with a common goal and consistent strategy across our agencies.
Given the complexity of the funding and service delivery system, the team recommended that
the Governor’s Coordinating Council on Housing and Homelessness expand to include
vulnerable populations, which would allow for more holistic focus on health outcomes. In
addition, the team provided a roadmap for a housing and health strategy that barriers and
opportunities braided funding at the state level in order to streamline operations and reduce
the time individuals and providers spend searching for available housing resources and ensuring
services are available.
17
Interim Strategies Using Existing Medicaid Services and Authorities
In FY21, DBHDS increased the number of individuals served by existing providers and
established additional PSH providers in Horizon Behavioral Health, Highlands, and New River
Valley CSB catchments. In addition, DBHDS Office of Community Housing partnered with Region
Ten CSB to contract with national experts on PSH fidelity to provide training and technical
assistance (TA) to DBHDS PSH providers across the state to ensure implementation of high
fidelity PSH that demonstrates positive outcomes and maximizes the use of resources. Focus
areas for TA will include an examination of best practices in ensuring racial equity, state
hospital care transition planning, ending homelessness and reducing incarcerations.
Continued Work on Behavioral Health Enhancement
Behavioral Health Enhancement (also known as Project BRAVO: Behavioral Health Redesign for
Access, Value and Outcomes) is an interagency implementation between the Department of
Medical Assistance Services (DMAS) and DBHDS that strives for systems alignment in
developing an evidence-based, trauma-informed, person-centered and prevention-oriented
array of services for the Medicaid-funded behavioral health system. Project BRAVO’s
preliminary goal is to address the Commonwealth’s psychiatric bed crisis by implementing new,
enhanced services that provide effective diversion and step-down options for emergency room
visits and admission into inpatient psychiatric hospitals and offers both diversion and step-
down resources.. The services selected for implementation have demonstrated success towards
these goals in other states and include partial hospitalization programs (PHP), intensive
outpatient services(IOP), Assertive Community Treatment (ACT), Multisystemic Therapy (MST),
Functional Family Therapy (FFT) and a set of crisis services consistent with the Crisis NOW
model (mobile crisis response, community based stabilization, 23 hour observation, residential
crisis stabilization units). While the funding for Project BRAVO was initially on hold due to the
Coronavirus pandemic, funding in the amount of $24,343,875 was re-allotted in the 2021
special session of the General Assembly. The above referenced services have been in effect
since 2021.
Non-Medicaid Supportive Housing Services
Medicaid Expansion has afforded many more individuals with behavioral health disorders
access to healthcare coverage, however there will continue to be some Virginians who may not
qualify for the Building and Transforming Coverage, Services, and Supports for a Healthier
Virginia (previously referred to as “COMPASS ”) Waiver Housing Support benefit. The PSH
Steering Committee continued to identify and focus on increasing other key resources that can
be used to support individuals with SMI in accessing and sustaining successful independent
living.
Expansion of PSH Supports through DBHDS PSH Program
Almost all of the growth in individuals with SMI served in PSH has been made possible through
continued investment of state general funds in DBHDS’ PSH program.
18
Almost all of the growth in individuals with SMI served in PSH has been made possible through
continued investment of state general funds in DBHDS’ PSH program. To date, individuals use
state-funded rental assistance to secure rental housing available on the private market.
While most DBHDS PSH funds are directed to long-term rental assistance, more than thirty
percent of these funds continue to be used for housing stabilization services, one-time client
assistance, or staff time to administer the rental assistance. Given that the 1115 demonstration
waiver has been approved, as the Medicaid High Needs Support benefits are phased in, many of
these currently state-funded supports may be reimbursable under the waiver. According to
Table 2, 1, 557 slots are available for individuals with SMI.
Table 2: PSH SMI Slots by Region FY21
PROVIDER DBHDS AGSH Leveraged Total Units
PSH Vouchers
ARLINGTON 70 70
BLUE RIDGE 115 40 155
CHESAPEAKE 15 10 25
DANVILLE 42 42
HAMPTON 134 134
HENRICO 45 45
HORIZON 30 30
HARRISONBURG -ROCKINGHAM 45 25 70
HIGHLANDS 15 15 30
MT ROGERS 60 45 4 109
NEW RIVER 25 5 30
NORFOLK 161 10 171
NORTHWESTERN 67 67
PATHWAY HOMES 138 138
PIEDMONT* 3 8 11
DISTRICT 19 60 60
RAPP AREA 50 50
RAPP-RAP 40 20 60
REGION TEN 95 95
RICHMOND 152 152
SOUTHSIDE* 13 7 20
VA BEACH 122 122
VALLEY 60 60
TOTAL 1,557 120 69 1,746
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DBHDS PSH Funds Ensure Safety of People with SMI Who Are Homeless or in State Hospitals
During COVID-19
DBHDS provided guidance to community service boards (CSBs) about the use of PSH funds to
implement short-term housing interventions for individuals with SMI who were homeless or in
state hospitals during COVID-19. Between March 2020 and October 2021, ten CSBs assisted 455
individuals with SMI with securing non-congregate shelter while they worked on a permanent
housing plan. By October 2021, 216 individuals had moved from shelter into homes of their
own. These CSBs were required to coordinate with their local CoC and state hospitals to ensure
that COVID-19 housing activities were coordinated and responsive to these vulnerable
community members.
Expansion of PSH Supports through State Housing Trust Fund
The code of Virginia indicates that up to 20 percent of the Virginia Housing Trust Fund (VHTF)
may be used for competitive grants to help reduce homelessness through Homeless Reduction
Grants. For FY21 this percent was increased to up to 40 percent to allow for flexibility in
responding to the COVID-19 pandemic. These grants were used to provide temporary rental
assistance not to exceed one year, housing stabilization services in supportive housing for
chronically homeless households, and predevelopment assistance to support long-term housing
opportunities for individuals experiencing homelessness and those populations
overrepresented in homelessness including individuals with serious mental illness and
individuals with intellectual or developmental disabilities. Because these grants rely on annual
state appropriations, there is some concern that providers are reluctant to request funding for
on-going services.
With increased VHTF funding in the FY20 and FY21 budgets, DHCD was able to expand the
number of PSH projects awarded funds in 2020 and 2021. DHCD received over $6.4 million in
requests for the Homeless Reduction grants which was nearly twice the amount requested in
the year prior. DHCD awarded $6.4 million through 37 projects for Homeless Reduction grants.
The selected projects resulted in 102 targeted community efforts to reduce homelessness,
including 15 rapid re-housing (RRH) projects, 12 permanent supportive housing (PSH) projects,
nine innovative and pilot projects to serve older adults and unaccompanied youth ages 18-24
and two projects for the pre-development of permanent supportive housing. These projects are
currently being implemented. DHCD developed and issued an FY22 Request for Proposals in
August 2021, and selected grantees with the goal of at least 50 persons to be served, with a
percentage of the households presenting with SMI. In CY 21, DHCD’s homeless reduction grants
served 644 households in the rapid rehousing programs, 288 households in permanent
supportive housing programs and 266 households through youth and older adults innovation
projects.
Virginia Department of Veterans Services
Virginia has long made it a priority to reduce the number of Veterans’ experiencing
homelessness, targeting resources to reduce chronic homelessness since 2013. These efforts
20
have proven successful, reducing Veterans’ homelessness by 63 percent from 2010 to 202113,
with a similar reduction in chronic homelessness; there was a 12 percent reduction from 2020
to 2021.
The Virginia Department of Veterans Services (DVS) attributes its success to aligning services
and housing resources, both internal to the department as well as external partners:
● DVS, through the Virginia Veteran and Family Support (VVFS) Program, employs
approximately 43 Resources Specialists statewide that serve as navigators to assist
Veterans in need of services. These include those with SMI in connecting to Continua
of Care (CoCs), PSH programs, and BH services in addition to connecting to Support
Services for Veterans and their Families (SSVF) program and HUD-VA Supportive
Housing (SH) programs. Some Resource Specialists coordinate regularly with
Community Service Boards, strengthening their ability to connect veterans with
needed services and supports.
● DVS also administers the DVS Homeless Veterans Fund through donations provided
by the Veteran Service Foundation. These funds assist in covering “gap” expenses
such as security deposits for homeless veterans and prevention resources (rent
arrears, utility assistance, etc.) for previously chronically homeless veterans.
● Fifteen PHAs and the VH have a total of 1,600 Veterans Affairs Supportive Housing
(VASH) vouchers.
Capital Investment in PSH - Accomplishments
Given low vacancy rates and strong demand for rental housing across much of the state, it will
be difficult to scale up PSH without new production of PSH units. At the state level, there are
two capital programs that are primarily responsible for new affordable rental production that
benefit people with SMI - the Affordable and Special Needs Housing (ASNH) and the Low
Income Housing Tax Credit (LIHTC) programs.
Expansion of PSH through DHCD’s Affordable and Special Needs Housing Program
With the Affordable and Special Needs Housing (ASNH) program, developers can apply to
access any of the five funding sources through a single competitive application process: the
federal HOME Investment Partnerships Program (HOME), the federal National Housing Trust
Fust (NHTF), the Virginia Housing Trust Fund (VHTF), Housing Innovations in Energy Efficiency
(HIEE), and the state funded PSH program. Combining the funds into one proposal process
makes requesting funds significantly easier for developers, especially smaller, nonprofit
developers who are more likely to be seeking these sources.
13 Unofficial HUD data as of November 2021 and some CoCs did not collect veteran status in the 2021 Point in
Time count.
21
The Biennium Budget for 2020-2022 allocated $70,000,000 in the first year and $55,000,000 in
the second year to fund activities through the Virginia Housing Trust Fund (VHTF). This is an
increase from the 2018-2020 Biennium Budget, which allocated $11,000,000 for the first year
and $14,000,000 for the second year to support the activities of the VHTF. Of note,
approximately $28.2 million of the 2020-2021 allocation was appropriated to the Virginia Rent
and Mortgage Relief Program, now known as the Virginia Rent Relief Program (RRP).
During FY 21, at least 60 percent of the VHTF was used for short, medium, and long-term loans
to reduce the cost of homeownership and rental housing; and up to 40 percent of the VHTF
may be used to provide grants for targeted efforts to reduce homelessness. Historic
investments to the trust fund resulted in over a 60% increase in the number of PSH units that
will be created in 2020-2021 compared to 2019-2020.
Table 3: PSH Funded by Virginia Housing Trust Fund 2013-2022
Year Number PSH Projects Number PSH Units
2013-2014 6 203
2015-2016 8 373
2016-2017 6 346
2017-2018 4 75
2018-2019 10 347
2019-2020 9 140
2020-2021 25 383
2021-2022 8 313
Total 76 2180
Expansion of PSH through VH’s Low Income Housing Tax Credit Program
The LIHTC program is considered the driver of affordable rental housing production (as well as
rehabilitation) across the country. This is also the case in Virginia. Since VH’s inception in 1972,
the organization has financed nearly 160,000 rental units.
Since 2015, VH has committed to assisting DBHDS in meeting its housing goals for people with
intellectual and/or developmental disabilities under the state’s settlement agreement with the
U.S. Department of Justice (DOJ). This commitment has resulted in LIHTC allocations to projects
in which owners committed a marketing preference for the Settlement Agreement population.
22
As discussed in previous reports to the General Assembly, VH reviewed the need for PSH for
people with SMI and other populations. In order to have a more significant impact, VH modified
its CY19 Qualified Allocation Plan to require that every development awarded 9% LIHTC as well
as 4% tax credit funding provide a PSH leasing preference for 10 percent of its units. In 2021,
this resulted in tax credit awards for 173 preference units; 1,730 total units through the 9% and
251 preference units; 2,501 total units through the 4% program.
The 29 properties funded in the 2021 competitive tax credit round will produce approximately
173 units required to provide the leasing preference.[[2] The 29 funded properties include
forward funded deals from innovation, new construction and ASNH. 2]; this is close to the
estimated annual 200 units anticipated in the last report to the General Assembly. Another 18
properties receiving 4 percent credits will be producing an additional 251 anticipated units.
In CY22, VH estimates 200 units with a leasing preference will be created through the 9% tax
credit program, and estimate another 250 will be created through the 4 percent tax credit
program.
Rental Assistance for PSH - Accomplishments
Rental assistance is critical to ensure PSH can serve people with disabilities who are extremely
low-income (ELI), including people with disabilities whose sole source of income might be SSI.
Beginning in January 2022, an individual whose sole income is SSI will receive $841 per month.
The FY22 HUD Fair Market Rents for an efficiency unit range from $530 per month in
Martinsville and other rural areas to $1,539 in Arlington and Alexandria. Whether the individual
lives in rural Virginia or in the metropolitan area, these rents are unaffordable without state or
federal rental assistance.
Expansion of PSH through DBHDS PSH Program
As described above, almost all of the new PSH units for individuals with SMI have been created
through continued investment of state general funds in DBHDS’ PSH through its rental
assistance component. The $20 million invested in FY20 is expected to serve approximately
1,400 individuals in PSH. An additional $5 million in State and Local Fiscal Recovery Funds from
the American Rescue Plan Act was appropriated to DBHDS in the recent Special Session. As
directed from Chapter 1 of the 2021 Acts of Assembly, Special Session II Appropriations Act
language, these funds will be used for a range of strategies to expand PSH to address the state
hospital census crisis in Northern Virginia.
Expansion of PSH Supports through the Auxiliary Grant Program
Virginia’s Auxiliary Grant (AG) Program is an income supplement for recipients of Supplemental
Security Income (SSI) and certain other aged, blind, or disabled individuals residing in an
assisted living facility (ALF), in an adult foster care (AFC) home, or in a supportive housing (SH)
setting through a licensed service provider that is approved by DBHDS and certified by DARS.
23
Supportive housing was added as an approved setting to the AG Program in 2016 and
emergency regulations for the new setting were issued in 2017, followed by final regulations in
2019. In the AG Program, SH is defined as “a residential setting with access to supportive
services for an AG recipient in which tenancy … is provided or facilitated by a provider licensed
to provide mental health community support services, intensive community treatment,
programs of assertive community treatment, supportive in-home services, or supervised living
residential services...” In July 201914, the General Assembly made modifications to the AG
program intended to enhance use of the AG Program for PSH. As a result of the legislative
change, eligibility for AGSH no longer requires the individual to first be an ALF resident. The
legislation also increased the number of allowable PSH participants from 60 to 90 effective July
1, 2019, and since there were 30 persons on the AGSH waiting list as of October 1, 2020, the
AGSH program cap increased again, from 90 to 120 persons.
DBHDS is identified in Virginia Code as the agency responsible for monitoring AGSH providers.
DBHDS has entered into AGSH provider agreements with Mt. Rogers CSB, Blue Ridge Behavioral
Healthcare, Southside CSB, Piedmont CSB, Highlands CSB, and New River Valley CSB. Seventy-
four (74) individuals were housed through AGSH during this reporting period.
Table 4: AGSH Program and PSH SMI Program Providers
Provider AGSH PSH Date Est. Provider AGSH PSH Date Est.
Arlington ✔ FY 2016 Norfolk ✔ FY 2016
Blue Ridge FY 2018 Northwestern FY 2020
✔ ✔ ✔
Chesapeake FY 2020 Pathway Homes FY 2016
✔ (Alexandria, Fairfax, ✔
Prince William)
Danville- FY 2018 Piedmont FY 2020
✔ ✔ ✔ ✔
Pittsylvania
District 19 FY 2018 Rappahannock - FY 2018
✔ ✔
Rapidan
Hampton-Newport FY 2016 Rappahannock Area FY 2020
✔ ✔
News
Harrisonburg- Region Ten FY 2018
✔ ✔
Rockingham
Henrico ✔ FY 2018 Richmond BHA ✔ FY 2017
Highlands ✔ ✔ FY 2021 Southside FY 2020
✔ ✔
Horizon ✔ FY 2021 Valley FY 2019
✔
Mt. Rogers ✔ FY 2018 Virginia Beach FY 2017
✔ ✔
New River Valley ✔ ✔ FY 2021
14 C.657 and C.658 of the 2019 Acts of the Assembly.
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Expansion of PSH through the Mainstream Program and Building Relationships with PHAs
The Steering Committee has used the Mainstream Voucher program as an opportunity to both
bring new rental assistance resources into the Commonwealth and also build relationships with
Public Housing Agencies (PHAs) to expand PSH and access to affordable housing resources in
other ways.
The Mainstream Voucher program is a subset of the federal Housing Choice Voucher (HCV)
program in which eligible participants must be very low-income households that include as
least one person with a disability ages 18-62. On the last few Consolidated Appropriations Bills,
Congress provided a total of $500 million for Mainstream Vouchers. When HUD issued the first
NOFA, not only were these vouchers specifically for non-elderly people with disabilities, but
they were targeted to some of the specific populations the state agencies were targeting for
PSH, people with disabilities living in institutional settings, at risk of institutionalization,
homeless or at risk of homelessness. The second HUD Mainstream NOFA added a fifth target
population: people with disabilities ready to “move-on” from rapid rehousing or permanent
supportive housing (thus freeing up those units for people with more intensive support needs).
In order to encourage Virginia PHAs to respond to HUD NOFAs for these funds, the PSH Steering
Committee held a number of outreach and engagement events over the last two years,
including an in-person event pre-COVID. This event was attended by over 70 PHAs, cities,
nonprofit housing and CSBs. The ILT offered a support letter to those PHAs that would commit
to serving the state’s target populations; nine PHAs requested and were provided with such a
letter.
These outreach efforts were successful. As indicated in Table 5 below, 14 housing agencies
were awarded 1,071 Mainstream Vouchers in the first two NOFAs.
In September, HUD issued a Notice providing an opportunity for PHAs to apply
noncompetitively for additional funds. Awards were made on a rolling basis; as of this report,
four VA PHAs had been awarded an additional $1.8 million for this program including Virginia
Housing.
In December 2019, the PSH Steering Committee held an in-person meeting to support PHAs as
they begin to implement their programs. The feedback on the program was positive, but this
activity was interrupted by the rise of COVID-19. In June, the PSH Steering Committee formed a
PHA Outreach Subcommittee to continue to build relationships with the local PHAs and to
encourage these vouchers to be targeted to the Commonwealth’s priority populations. The
Subcommittee invited all PHAs with Mainstream vouchers to a focus group meeting to identify
ways the state agencies could support the PHAs. Based on those results, the Subcommittee
have formed a collaboration with several PHAs. One of the items identified for this
collaboration post-COVID is landlord engagement.
25
Table 5 Mainstream Awards
2017/2018 2019 Combined
PHA Name Awards Awards Total Awards 30 % Boost Total
Danville Redevelopment &
41 100 141 42 183
Housing Authority
Roanoke Redevelopment &
40 30 70 21 91
Housing Authority
Chesapeake Redevelopment
40 0 40 12 52
& Housing Authority
Lynchburg Redevelopment &
0 30 30 9 39
Housing Authority
Harrisonburg
Redevelopment & Housing 25 50 75 23 98
Authority
Hampton Redevelopment &
Housing Authority 0 50 50 15 65
Fairfax County
Redevelopment & Hsg 55 41 96 29 125
Authority
Arlington County Dept of
Human Services 40 0 40 12 52
County of Albemarle/Office
0 15 15 5 20
of Housing
Va. Beach Dept. of Hsg &
Neighborhood Pres. 0 60 60 18 78
James City County Office of
Hsg & Comm Dev 0 20 20 6 26
People Inc. of Southwest
Virginia 24 24 48 14 62
Prince William County Office
of HCD 0 60 60 18 78
Virginia Housing
Development Authority 79 0 79 24 103
Total
344 480 824 247 1071
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Enhancing System Capacity - Accomplishments
While affordable housing, tenancy supports and community-based services are critical to
expanding PSH for individuals with SMI, even these resources are not sufficient to ensure an
expanded PSH system will be successful. State and local/regional structural systems supports
are key to ensuring an effective PSH system, one that provides a fidelity-based service, targets
the state’s priority populations, fills units in a timely manner and maintains owner confidence
by addressing tenant issues that arise.
PSH Tracking and Metrics
During 2021, the PSH Steering Committee put into place several frameworks to track activities
and outcomes related to the steering committee work.
Action Plan
In 2019, the PSH Steering Committee developed a detailed, 19-page Action Plan with goals,
strategies and action steps to achieve the goals, agency responsibilities and timeframes. The
Action Plan is provided in Appendix A. In 2020 and 2021, the PSH Steering Committee
continued to focus on the following five goals identified in the plan:
● Goal #1 - Increase Services and Supports to Assist Individuals with SMI to Gain Access to
and Maintain Supportive Housing
● Goal #2 - Provide Capital Subsidies to Expand PSH
● Goal #3 - Increase Rental Assistance to make Units Affordable
● Goal #4 - Increase PSH through Preferential Access to Existing Affordable Housing
Programs
● Goal #5 - Strategies to Increase PSH through Enhancing System Capacity
The PSH Steering Committee is actively developing an action plan for CY22-CY24.
Executive Order 25 Metrics
As described above, in November 2018, Executive Order 25 was issued, identifying the need for
PSH as one of three top housing priorities. DBHDS’s conducted an assessment of need for PSH;
the assessment established a need for 5,000 PSH units. The PSH Steering Committee developed
a comprehensive plan to put as many PSH units in place as efficiently as possible. This
thoughtful, realistic plan relies on a combination of new federal and state funding for both
capital and rental assistance as well as strategies to redirect or prioritize existing resources for
the target population. The ILT voted its support for the plan, and state agency budget requests
have aligned with plan goals.
State Level Systems
DHCD continued to work with its partners made a number of enhancements to strengthen PSH
systems at the state level.
27
The state agencies and VH continued to revise an existing MOU to reflect new activities of the
PSH Steering Committee including the leasing preference in tax credit units. DBHDS and VH also
designed and began to implement a referral protocol for the units with leasing preferences that
became available in 2020.
To further the shared vision, Virginia applied and was accepted for the 2021-2023 Housing &
Health Institute led by the National Academy for State Health Policy, which supports a cohort of
states to break down silos and strengthen services and supports to help low-income and
vulnerable populations become and remain successfully housed. Virginia launched an
interagency team and project to address three core areas: financial modeling for supportive
housing, data sharing, and capacity building.
The two-year project will ensure the interagency state efforts maximize Medicaid funding and
create sustainable financial models for supportive housing. Financial modeling will ensure the
agencies can maximize the use of federal funding available at the state and local level. Financial
modeling across several programs and agencies will allow for long-term planning to ensure the
housing needs of vulnerable Virginians can be addressed.
The team is leveraging the Homeless Data Integration Project (HDIP) to match Medicaid and
CSB data with HMIS to identify individuals accessing multiple systems and support operations
that will reduce the cost of accessing support services and housing resources. The data will
support an analysis to measure the return on investment to further incentivize investments in
housing from managed care organizations and philanthropic entities.
Virginia HHI’s capacity building goal aims to align outcomes across the partnering state agencies
to ensure consistency for providers and allow for training initiatives to support the needs of
homeless service providers, CSBs and private behavioral health providers. The team will work
with local and regional stakeholders throughout the project to identify and support targeted
capacity building needs.
Local/Regional Level Systems
The PSH Steering Committee conducted a housing system crosswalk analysis to identify the
federal, state and local funding streams and operations that are critical to supportive housing.
The team identified 18 housing -related programs, seven rental assistance programs, seven
rental unit production programs, nine critical behavioral health services, and four points of
entry that make up the housing and service delivery systems in Virginia. This analysis was
critical to identifying opportunities to partner with local and regional systems and align with the
funding made available through ARPA. The committee is actively working to support
partnerships between CoCs, PHAs, CSBs, and MCOs.
Notably, the Emergency Housing Voucher (EHV) program has been made available through the
American Rescue Plan Act (ARPA). Through EHV, HUD is providing over 1000 housing choice
vouchers to local Public Housing Authorities (PHAs) in Virginia, in order to assist individuals and
28
families who are homeless, at-risk of homelessness, fleeing, or attempting to flee, domestic
violence, dating violence, sexual assault, stalking, or human trafficking, or were recently
homeless or have a high risk of housing instability. While the EHV are not specifically targeted
to individuals with SMI, a great percentage of persons experiencing homelessness experience a
co-occurring SMI.
National best practice webinars for the Emergency Housing Vouchers (EHVs) identified the role
of MCOs as a critical component for ensuring individuals who are in Medicaid are supported in
their own homes. To further this in Virginia, DMAS hosted a webinar for the CoCs and their PHA
partners to meet the six MCOs and learn more about the model of care and robust network of
behavioral health providers available to support the application for EHVs as well as the
utilization of the vouchers that are targeted to vulnerable individuals. Several MCOs have
developed and maintained partnerships with both the CoCs and PHAs to support Members’
path to housing stability.
DBHDS’s PSH program has demonstrated the importance of local/regional housing specialists in
developing and maintaining tenant-landlord relationships and ensuring their region has as an
effective system in place to identify interested, eligible applicants and to assist these individuals
to locate and apply for housing, including making requests as needed for reasonable
accommodations. Currently, all regions have some housing specialist capacity – however
limited. DBHDS has continued to expand local PSH Program Housing Specialists to ensure all
consumers in DBHDS PSH-funded programs have access to this service.
In March of 2021, DHCD held four virtual input sessions to secure community input into the
VHTF as well as HUD’s Consolidated Plan’s Annual Action Plan, which covers the Community
Development Block Grant, HOME and the National Housing Trust Fund.
Alignment with other State Activity
During CY19, the PSH Steering Committee continued working to align PSH funding, policies and
systems across partner agencies.
Evictions
While the issue of evictions is not included in the scope of this effort, some of those individuals
who get evicted are people with serious mental illness. During the 2020 Special Session, $3.3
million was allocated for DHCD to design and implement the Virginia Eviction Reduction Pilot
(VERP) which began implementation in the spring of 2021. DHCD conducted a competitive
application process in winter 2021 and awarded more than $2.6 million in grants to four
grantees serving the counties of Lee, Scott, Wise, Gloucester, James City, Matthews, and York,
as well as the cities of Norton, Richmond, Norfolk, Hampton, Newport News, Poquoson, and
Williamsburg. Notably, a portion of the 2021 allocations were set aside for planning grants for
priority localities not selected as an awardee of the pilot. The planning grants were designed to
29
aid localities and nonprofits to better understand eviction preventions needs and to build local
capacity to mitigate evictions. In spring 2021, DHCD conducted another competitive process for
the planning grants and ultimately awarded six grantees who serve 17 localities across Virginia.
A second year of funding for the pilot was awarded the following year. At the time of this.
Governor’s Coordinating Council on Homelessness
The Governor’s Coordinating Council on Homelessness (GCCH), co-chaired by the Secretary of
Commerce and Trade and the Secretary of Health and Human Resources, is focused on ending
homelessness in the Commonwealth of Virginia. Due to COVID-19, the GCCH delayed meeting
during the 2020 calendar year. In October of 2021, the GCCH held its first meeting since the
pandemic during which the council agreed to expand the scope of the council to include
housing for vulnerable populations. The expansion of the scope, which involves the
restructuring of the existing committee structure, will allow the council to further identify
housing solutions for those individuals at risk of or experiencing homelessness. Appendix D
includes additional information regarding these committees and their coordination. As
previously noted, individuals with serious mental illness are at higher risks of housing instability
and homelessness. Recent Point-in-Time count data revealed that individuals with SMI
comprise Virginia’s largest homeless subpopulation. According to Point-in-Time count data, the
number of adults experiencing homelessness with a serious mental illness in 2021 increased by
~15% between 2020 and 2021. The Governor’s Coordinating Council on Homelessness and
Housing Vulnerable Populations will coordinate with the PSH Steering Committee to improve
access to housing solutions, including permanent supportive housing, for vulnerable
populations.
Olmstead Strategic Plan
The Olmstead Strategic Plan has been updated to support partner requests to HUD for
preferences in HCV or public housing (PH) for persons with SMI as part of voluntary affirmative
Olmstead planning and implementation efforts. In 2020, one Executive Order (E.O.) and one
Executive Directive (E.D.) -- E.O. 47 and E.D. 6 -- were signed, re-committing the
Commonwealth to community integration as envisioned by the Olmstead v. L.C. decision.
Discharge Planning for Successful Reentry
The General Assembly continues to fund a number of different initiatives whose goals are to
facilitate reentry of people with psychiatric disabilities from jail including the Department of
Criminal Justice Service’s Jail Mental Health pilot program and the DBHDS grant funded
Forensic Discharge Planning (FDP) programs. FDP programs focus on the early identification of
individuals with SMI, and provide a range of case management services to individuals
being released to the community - FDPs provide services during an individual's period of
incarceration, and for a minimum of 30 days post-release. Currently, there are nine programs in
local and regional jails across the state. These programs are providing FDP services in fourteen
facilities by fifteen CSBs. Since program inception in FY19, FDP programs have enrolled a total
of 1,666 individuals for services. DBHDS funded five additional FDP programs in FY22 in
30
Richmond, Virginia Beach, Prince William, Staunton, and Henrico. Annual Reports with
additional information regarding program services and outcomes are available for FY19 and
FY20, and FY21 is expected to be completed in January 2022.
CARES Act Energy Assistance
In 2020, the Virginia Department of Social Services (VDSS) received CARES Act funds to
supplement the Low-Income Home Energy Assistance Program (LIHEAP) to ensure households
impacted by COVID-19 could address their immediate energy costs include energy debt
accumulated during the pandemic. VDSS issued a one-time supplemental payment of $100 to
households who received assistance during the FY20 r heating season . The VDSS also
established a new standalone program, Virginia COVID19 Energy Assistance Program, to
provide heating/cooling utility payment assistance to households who did not qualify for Energy
Assistance in 2020 and have a heating or cooling expense.
Strategies for Continued Progress
Even with the significant accomplishments in recent years, people with SMI continue to live on
the streets, in shelters and in jails and other institutions for lack of PSH. In order to scale up the
housing component of PSH, the following three elements are key:
● Effective, reliable housing supports: When dependable services are made available to
aid in ensuring lease compliance, many providers of affordable housing are eager to
consider the potential for PSH preferences or initiatives. Although it was already
mentioned above, it is crucial to stress the significance of support services as the state's
top incentive to attract housing agencies.
● Increased capital funding: Both rural areas of Virginia and high cost cities like Northern
Virginia have experienced difficulties utilizing vouchers due to a lack of rental housing
stock and/or competitive marketplaces. Significant capital investment in the supply of
affordable housing generally and PSH especially is just as important as rental assistance,
if not more so.
● Increased rental assistance: Project-based rental assistance is important to ensure new
place-based PSH is affordable to people with SMI who are extremely low-income (ELI)
and that there are available units to go with the vouchers.
Outlined below are the strategies the PSH Steering Committee members will utilize in the
coming year to continue to secure the necessary capital and rental assistance from a variety of
existing and new state and local resources.
Strategies to Continue to Expand PSH Housing Supports
Strengthen Provider Capacity to Deliver the Housing Supports Benefit
With implementation of the HNS benefit MCOs will be required to contract with a network of
housing and employment supports provider entities, and will need to leverage existing
31
providers in the community that are experienced and qualified to address the health-related
needs of the population. Many of these providers may be new to the Medicaid program. In
preparation for implementation, DMAS will focus on engagement with potential providers and
training efforts to strengthen their ability to not only provide high quality supportive housing
services but also to successfully enroll and bill as Medicaid providers. The HNS benefit also
includes employment supports, which can be leveraged along with the supportive housing
services to ensure individuals in need of housing also have employment opportunities.
DMAS will continue to provide training and engagement with current and potential providers to
strengthen the provider network’s capacity to deliver housing services. DMAS developed a tool
to identify interested providers along with specific training needs. A provider input session on
the HNS benefit identified additional interested providers as well training needs. Additional
trainings will occur in collaboration with the state agency partners through the development of
a supportive housing training curriculum and certification program that the agencies will all
utilize to align outcome measures for housing related programs.
Realizing the optimal impact of the HNS housing benefit
The agency members of the PSH Steering Committee have spent the past several years working
together to increase availability of affordable housing options with support services for
individuals with disabilities in Virginia. However, a number of challenges exist and will need to
be overcome to realize the optimal impact of the HNS supportive housing benefit.
Differences in Priority Populations
DBHDS, DMAS, DVS and DHCD share common goals across similar target populations, including
individuals with SMI and/or SUD who are homeless or unstably housed. Yet, there are
differences within each agency for who truly “rises to the top” of the priority list and is matched
with housing-related and other supports. DMAS and the MCOs may be more likely to prioritize
individuals for the HNS benefit who are high utilizers of costly Medicaid services such as
emergency Department visits or community inpatient bed days, while DBHDS and the local
CSBs may prioritize individuals who are leaving state hospitals or are highly visible in their
communities but who do not use costly Medicaid services for rental assistance.
Multiple pathways to accessing housing
Each system has designated staff/points of responsibility to assist their target populations with
identifying the need for and accessing housing and support services. MCOs conduct Health Risk
Assessments, CSBs conduct discharge planning and housing assessments and CoCs apply a
vulnerability assessment and use Coordinated Entry for federal and state homeless resources.
Each of these processes may result in identification of individuals in need of the HNS benefit
and RA, yet they may be disconnected and can result in inefficient use of resources and
duplication of efforts across agencies. The agencies should review program administration
functions to determine opportunities to further align and share costs in order to serve more
individuals.
32
Roles of local housing and services agencies
While the state agencies have provided considerable leadership in creating a vision for
affordable housing for individuals with disabilities in Virginia, that vision must be shared in
every region to achieve intended outcomes. Individuals with disabilities may have difficulty
accessing rental housing through Public Housing Authorities, local developers and private
landlords, regardless of the HNS benefit. Continued outreach and partnership with these key
local and regional actors is critical to success.
Lack of sufficient affordable housing
In many areas of Virginia, especially in areas with the greatest concentration of Medicaid
members, there is an inadequate supply of affordable housing units or rental assistance. The
HNS benefit will only be helpful to individuals who are able to access affordable housing
resources in communities where they choose to live.
Limitations of Rental Assistance
Availability of the HNS benefit must align with affordable housing resources to be most
impactful. Currently, most long-term rental assistance is targeted to individuals with SMI and/or
SUD through the DBHDS PSH program’s network of local administrators. Individuals who do not
meet the eligibility criteria or prioritization for that program have little access to long-term
rental assistance other than the Housing Choice Voucher Program. Individuals in most
communities in Virginia experience lengthy wait times for access to Housing Choice vouchers,
which limits this funding source as a solution.
While it’s important to recognize these challenges, it is also important to acknowledge that
there are opportunities to address them.
Develop a strategy for “braiding” various housing support and housing resources
DMAS, DBHDS, DVS and DHCD as well as other agencies and system partners, will need to
establish agreed-upon strategies to intentionally align the HNS supportive housing benefit with
non-Medicaid housing resources and vice versa. As discussed previously, the agencies share
target populations, but may have different priorities for their program’s limited resources.
Braiding the HNS benefit with rental assistance and other needed services and supports will
help even the most vulnerable populations to be more stably housed and ensure a cost
effective approach that makes the best use of public funding.
Encourage and Incent MCOs to Invest in Housing
Virginia has a number of Managed Care Organizations (MCOs) that are known nationally for
their interest and investment in supporting high risk/high need individuals in stable housing
including United Healthcare, Magellan and Anthem. The MCOs will likely want to prioritize the
HNS benefit to high risk/hi cost members and may be more willing to invest in affordable
housing that will meet the needs of this population. DMAS regularly engages with the MCOs
who are already contractually required to “develop programs and establish partnerships to
33
address social factors that affect health outcomes, also called social determinants of health
(SDOH), which contribute significantly to the cost of care and the Member’s health care
experience.” DMAS provides technical assistance to encourage the MCOs to build or enhance
partnerships with the regional homeless systems as well as the CSBs. DMAS will continue to
continue the HNS training series as well as identify pilot projects to house high-cost members
by partnering with the regional homeless systems across the state.
Tie Resources to Outcomes
Identifying agreed upon outcome measures across the agencies will help to assure that both
the HNS benefit and housing resources are being utilized most efficiently and effectively. While
the agencies may have different measures used to assess the desired outcomes for their
programs and populations served, the following measures could serve as a beginning point and
be expanded to include others as well:
● Reduced Homelessness
● Cost savings
● Increased Efficiencies across state agencies
The agencies will need to continue efforts to resolve issues related to data sharing in order to
assess these outcomes. DMAS is working with DHCD on a data matching project to connect
Medicaid data with HMIS data, which will allow the state to better understand the individuals
that are prioritized and eligible for the HNS supportive housing benefit.
Behavioral Health Enhancements
Since Behavioral Health Enhancement funding was realloted, DMAS continues to convene
stakeholder workgroups to continue the planning and implementation of behavioral health
services. Ongoing planning focuses on Systems changes; a state plan amendment, revised
regulations and Medicaid manual updates; and providing education and training opportunities
for stakeholders. Once a plan to move forward is established, DMAS will engage with CMS to
pave the way for an 1115 SMI demonstration waiver application.
Strategies to Expand Capital and Rental Assistance for PSH
Outlined below are the strategies the PSH Steering Committee members will utilize in the
coming year to continue to secure the necessary capital and rental assistance from a variety of
existing and new state and local resources.
Strategies to Increase Capital Investment in PSH
VH Low Income Housing Tax Credit Program
As discussed earlier in this report, low vacancy rates and strong demand for rental housing
across much of the state make it challenging to scale up PSH and reach the 5,000 goal without
34
production of new PSH units. VH’s 9 percent and 4 percent tax credit programs are some of the
primary tools developers rely on for the production of new affordable rental housing.
As described above, beginning with the FY19 Qualified Allocation Plan (QAP), VH has committed
that all 9 percent and 4 percent tax credit projects will be required to provide a leasing
preference for PSH in 10 percent of units. No specific target population is named. Rather, VH
has linked the leasing preference to populations covered by the Memorandum of
Understanding (MOU) entered into by the state agencies represented on the PSH Steering
Committee. Such an arrangement will allow the state to modify its target populations as needs
may change over the project’s compliance period. This also means the state agencies and
departments serving each target population must collaborate to develop a protocol for referral
to these housing units; the development of a referral protocol is discussed further below.
In CY22, VH estimates 200 units with a leasing preference will be created through the 9% tax
credit program.
Virginia Housing Trust Fund
The VHTF impacts PSH growth in two ways. First, services and pre-development costs for PSH
targeted to persons at risk of or experiencing chronic homelessness are funded through a
competition for no more than 20 percent of the VHTF allocation. Second, the majority of the
remaining funds are combined with federal HOME, National Housing Trust Fund, and Housing
Innovations in Energy Efficiency funds to make up the Affordable and Special Needs Housing
(ASNH) program competition. The limited allocation of funds is shared between homebuyer and
rental projects, with rental projects making up approximately 90 percent of the allocated funds.
Of the 40 projects awarded VHTF in FY 2020-21, twenty-five projects set aside an estimated 383
permanent supportive housing units. The PSH units are specifically targeted for individuals with
disabilities, serious mental illness, and/or chronically homeless. Notably, a growing amount of
research has revealed the bi-directional relationship between the prevalence of severe mental
illness and homelessness. According to a recent study published in 2020, studies have shown
that between 25-30% of persons experiencing homelessness have a severe mental illness such
as schizophrenia.15
Historical investment in the VHTF has allowed for increased development in both affordable
and permanent supportive housing units. However, there remains great need for additional
PSH and affordable housing units.
Behavioral Health and Developmental Services (BHDS) Trust Fund
Virginia has a special non-reverting fund called the Behavioral Health and Developmental
Services Trust Fund. This Trust Fund consists of the net proceeds from the sale of vacant
15 Padgett, D. (October 2020). “Homelessness, Housing Instability and Mental Health: Making the Connections.”
BJPsych Bulletin 44(5), 197-201.
35
buildings and land held by DBHDS and any General Assembly appropriations to the fund. The
DBHDS Commissioner administers this Trust Fund. Among other approved uses, current Virginia
code allows for these funds to be used for financing of "appropriate community housing, for
the purpose of transitioning individuals with intellectual disability from state training centers to
community-based care." Trust Fund monies have been used for a range of community-based
services, primarily for individuals in the DOJ Settlement Agreement population. DBHDS is
pursuing a code change to expand the populations eligible to be served in community housing
financed by the Trust Fund.
Enhance Housing Development Capacity
Increased resources alone may not be sufficient, however, to scale up PSH. DHCD staff
indicated that competition for affordable housing resources is highly competitive and that some
of the mission-driven developers who might consider PSH development do not have the
capacity to produce projects that are always competitive.
Developed by VH, the “Fundamentals of Affordable Housing Development” class is a two-day
workshop designed to walk housing and community development professionals through the
development process and best practices. These best practices include but are not limited to
organizational and developer capacity, asset mapping, intervention strategies, plan
development, key partnerships, homeownership financing and qualifications, rental financing
and compliance, and evaluation. The class includes hands-on activities including community
design activities and development pro-forma work. This course is intended for beginner and
mid-level professionals in the field of housing planning and/or development.
Strategies to Secure Local Capital for PSH
Thirty localities in Virginia receive an allocation of CDBG and/or HOME funds directly from HUD;
some of these communities also provide local general funds for affordable housing
development. Many PSH projects require multiple sources of grants or deferred payment loans
to make a project affordable. Local HOME or CDBG funding is often one of these sources.
Piecing together funding for projects can be challenging. If DBHDS is able to make additional
capital, rental assistance and/or supports available16 for projects under consideration, the
developer and local funders are likely to be much more receptive to creating projects.
DBHDS is working with a statewide CSB PSH Capacity Development Team to increase CSB
activity on the Action Plan items involving local partners. Rappahannock Area CSB has
contracted with Technical Assistance Collaborative (TAC) to support CSBs to pursue local
strategies to increase PSH. DBHDS will also continue to work with individual communities
where there is the possibility of leveraging local funding for PSH for individuals with SMI.
16 Either directly or through CSBs or another local entity.
36
DBHDS also continues to participate in DHCD’s statewide input sessions to provide education to
local governments on the need for PSH and the PSH resources available through the state for
communities interested in PSH development.
Strategies to Increase Rental Assistance for PSH
DBHDS PSH SMI Program
Continuing to grow this demonstrated successful program will be an essential component to
meeting the need for 5,000 PSH units and receiving all the benefits that accrue to PSH programs
including moving people from institutionalization and homelessness into housing and avoiding
associated costs. TA continued increase in the PSH SMI program will be especially important as
the VH LIHTC units come on-line every year; the majority of these units will not have project-
based funding and will need rental assistance to be affordable to clients.
DBHDS will also continue to explore project-basing some portion of the PSH program. Project-
basing has a number of advantages including long term access to high cost area such as
Northern Virginia and better access to housing for persons with criminal backgrounds or poor
tenancy histories.
Mainstream Housing Choice Voucher (HCV) Program
As described above, in the first round, the state was successful in securing over 1,000
Mainstream vouchers for people with any disability including people with SMI. In September,
HUD issued PIH Notice 2020-22 providing PHAs with an opportunity to apply for the remaining
Mainstream Voucher funds through a non-competitive process provided by the CARES Act.
PHAs can apply for funds through the end of the calendar year. In November, a first round of
awards was announced and included $1.8 million for four PHAs in Virginia including VH. These
are likely results of the extensive outreach and engagement by the PSH Steering Committee. It
is hoped additional awards will be announced for VA PHAs.
Auxiliary Grant Supportive Housing (AGSH) Program
As described above, the state has expanded the number of AGSH providers. Seventy-four
individuals were served through AGSH in FY21.
At the beginning of SFY 2022, a 10% rate increase took effect. This increase should provide
much needed financial support to AG providers, and is offset by balances in the AG program. An
increase to the AG rate benefits individuals in the AGSH program by improving housing
affordability and potentially increasing the number of communities that can use the AGSH.
Continuums of Care Rental Assistance
There are 16 Continuums of Care (CoCs) across the state, including 15 independent CoCs and 12
local planning groups (LPGs) of the Balance of State CoC. CoCs and LPGs are tasked with
creating effective community-wide emergency crisis response systems that will ensure
37
homelessness is rare, brief, and one time. This requires the coordination of federal, state, local,
and private funding. CoCs will be encouraged to apply for specialized resources for PSH when
available from HUD. Many CoCs in Virginia have developed PSH programs available to people
who are experiencing homelessness – generally chronic homelessness – through their CoC
Coordinated Entry System.
Strategies to Increase PSH through Existing Affordable Housing Programs
The production of new units and bringing new rental assistance resources into the state are the
preferred strategies for expanding PSH for Virginians with SMI. However, given limitations on
state and federal budgets, and the length of time for new production, increasing access to
existing affordable housing resources is also an important strategy to meet the state’s need for
5,000 PSH units for individuals with SMI.
Public Housing Agency Resources
There are 41 PHAs in Virginia. Of these, two administer only public housing units, 13 administer
only vouchers, and 26 administer both the HCV and public housing programs. The PHAs in
Virginia administer over 52,200 HCVs17 and own and operate a total of 17,897 units of federally
funded public housing18. PHA resources are generally made available to eligible applicants on a
first-come, first-served basis but are allowed to use preferences or priorities to serve local
needs or public policy priorities, as long as these are nondiscriminatory. For example, PHAs are
allowed to offer preferences for people who are homeless, people with disabilities (broadly
defined) and people who are institutionalized. According to the Center for Budget and Policy
Priorities, 17 percent of federal rental assistance (largely housing choice vouchers but also
public housing and HUD-Assisted developments) goes to single adults in Virginia who have
disabilities, compared to the national average of 19 percent.
Per federal regulation (24 CFR Part 982), PHAs may not direct their resources towards people
with specific disabilities, such as ID/DD and SMI, except in accordance with HUD guidance and
as a HUD approved remedial preference.19 However, with sufficient marketing and outreach by
CSBs, people with SMI can be well represented in any applicant pool that targets people who
are homeless or who are coming from institutions, both general preferences acceptable to
HUD.
Project-basing HCV offers DBHDS a unique opportunity to target federal funding for PSH for
people with SMI. The regulations covering the project-based component of the HCV program
17 This estimate does not include the newly awarded Mainstream Vouchers.
18 Data from the state’s IAP Housing Assessment (March 2018).
19 HUD currently limits disability-specific preferences to HUD-approved remedial actions. According to HUD, such remedial
actions must be provided in response to” Olmstead-related litigation or enforcement, including a settlement agreement, court
order or consent decree, or in response to a public entity’s documented, voluntary affirmative Olmstead planning and
implementation efforts.” https://www.hud.gov/sites/documents/PIH2012-31.PDF
38
(24 CFR Part 983), allow PHAs to target resources to persons needing certain services including
disability-specific services. DBHDS should consider identifying PHAs already project-basing or
interested in project-basing this resource and reach out to these agencies to determine
whether there are opportunities to develop PSH for people with SMI. For PHAs with low leasing
rates, project-basing vouchers can offer a way to improve leasing rates.
Strategies to Increase PSH through Enhancing System Capacity
As described above, state and local/regional structural systems supports are key to ensuring an
effective PSH system, one that provides a fidelity-based service, targets the state’s priority
populations, fills units in a timely manner and maintains owner confidence by addressing
tenant issues that arise.
PSH Inventory
The PSH Steering Committee has identified a strategy for developing a comprehensive PSH
inventory. An inventory would list existing properties that operate as supportive housing, their
owners, number of units, special populations served, and other key features. Such an inventory
would better permit the state to assess provider capacity and to identify existing PSH resources
that might assist with meeting the state's priorities.
Finalize Shared Referral Protocol
Under the DOJ Settlement Agreement, referrals of persons with Intellectual/Developmental
Disabilities (I/DD) to PSH resources are made through the DBHDS Central Office, but referrals of
people with SMI are made at the local level through CSBs. The expanded target population for
units developed through DHCD or VH’s tax credit programs will require additional coordination
on referrals. The PSH Steering Committee continues to work on finalizing a referral protocol.
Continue PSH Alignment with Related Activities
The state has a number of initiatives that have some overlapping goals and strategies. The PSH
Steering Committee will continue to align efforts to house people with SMI with efforts to
house people with I/DD and people who are experiencing chronic homelessness. Each of these
populations has an advisory or coordinating body overseeing or guiding the work. The PSH
Steering Committee will also seek to coordinate with eviction prevention efforts and general
affordable housing development activities.
Leadership Key to PSH Strategy
As described above, there are many opportunities to leverage supports, capital, and rental
assistance resources to expand PSH for Virginians with SMI. No single state or federal resource
will help Virginia meet the need for 5,000 PSH units. Scaling up PSH will require coordinating
multiple housing and service funding mechanisms at both the state and local levels. Continued
leadership is necessary to ensure state agencies collaborate effectively. Leadership will be
39
necessary at key points such as calling for owners to step up to serve the state’s most
vulnerable populations while guaranteeing that the state will provide supports to tenants and
be available to owners when issues arise. Since the start of this process, the ILT as well as the
PSH Steering Committee have provided such leadership.
40
Appendices
41
Appendix A Action Plan
Goal #1 - Increase Services and Supports to Assist Individuals with SMI to Gain Access to and Maintain Supportive Housing
Strategy 1.1: Obtain CMS approval of a supportive housing benefit as part of the renewal of Virginia’s 1115 Demonstration
Waiver
Action Lead Agency(s) Others Involved CY22 Goal CY23 Goal
1.1.2 Engage DMAS DMAS Begin to identify key Continue stakeholder
stakeholders in the stakeholders sessions to gain input on
DBHDS
design and development benefits implementation
VH Convene stakeholder
of the Supportive
meetings to gain input on
Housing (SH) benefit
VDH benefit implementation
DSS
DVS
DARS
Providers
1.1.3 Issue service DMAS DMAS/MCOs MCOs, providers receive
definitions, Member necessary guidance for
eligibility criteria, service
provider eligibility provision/payment
criteria, rates
42
1.1.4 Align housing DMAS DBHDS Begin identification of
outcome measures outcome measures
DVS
across agencies funding possibly including:
supportive housing DHCD
State hospital bed days
Local inpatient bed days
Returns to homelessness
# days incarcerated
Medicaid costs
CSB data: community
services, PSH-SMI service
costs
CoC data
1.1.5 DMAS works with DMAS DBHDS Review alignment of If applicable, region(s)
partners to establish housing and services identified for initial
VH
implementation resources phase-in where SH
schedule. DHCD expansion is anticipated
and/or there are strong
MCOs service providers
43
1.1.6 Develop DMAS MCOs Determine credentialing Credentialing process
credentialing process for requirements established
HNS providers
1.1.7 Enhance provider DMAS MCOs Develop and Deliver Continue training
capacity to deliver SH training
benefit services
Provide training to MCO
staff, existing BH
providers, and non-
Medicaid providers
Strategy 1.2: Ensure Managed Care Organizations maximize housing options for Medicaid members in CCC Plus
Action Lead Agency(s) Others Involved CY 22 CY 23
1.2.1 Provide training to DMAS MCOs Develop universal Training provided
providers in MCO supportive housing/PSH
DBHDS
network to deliver training curriculum
housing support services DVS
DHCD
44
1.2.2 Engage housing DMAS MCO Identify organizations Training provided
providers to become and training needs
Medicaid providers with
experience delivering
housing support services
1.2.3 MCOs provide Care DMAS MCOs Care Coordination Care Coordination
Coordination to support provided to individuals in provided to individuals in
individuals with CCC Plus CCC Plus
behavioral health needs
in CCC Plus program
Strategy 1.3: Explore non-Medicaid options for funding housing transition and housing sustaining services
Action Lead Agency(s) Others Involved CY22 Goal CY23 Goal
1.3.1 Continue to include DHCD Develop and issue a Develop and issue FY22
support services in PSH Request for Proposal Request for Proposal
as an eligible activity for
Select grantees. At least Select grantees
the Homeless Reduction
50 persons served, some
Grants portion of the At least 50 persons
of whom will have SMI.
Housing Trust Fund (HTF) served, some whom will
(up to 20%). Explore SMI data have SMI.
collection as part of
Projects implemented
required reporting
45
1.3.2 Explore a statewide DBHDS Develop ad hoc pilot Continue pilot
pilot that would secure design committee with a
DMAS
funding for housing potential of including in
supportive services DARS Fall 2022 ASNH or HRG
NOFA
DVS
Implement pilot
DHCD
Goal #2 - Provide Capital Subsidies to Expand PSH
Strategy 2.1: Expand PSH through the VH Low Income Housing Tax Credit Program
Estimated 200 units with leasing preferences annually beginning in FY20; leasing preference for SMI and other populations
targeted under state partner MOU
Action Lead Agency(s) Others Involved CY22 Goal CY23 Goal
2.1.1 Develop MOU on VH DBHDS MOU executed Annual MOU review
PSH collaboration with
DHCD Annual MOU review
appendix related to SMI
population DMAS
46
2.1.2 Finalize referral VH DBHDS Develop guidance; Review and update
process for individuals existing process as
DHCD Release final referral
referred to new or needed
process
existing LIHTC units DVS
Pilot referral process in
DMAS
one community
2.1.3 Determine roles DBHDS Stakeholders Roles and outreach
and outreach needs for activities identified in
VH
stakeholders MOU
DHCD
DMAS
DVS
2.1.4 Establish referral DBHDS Stakeholders Launch Coordinated Manage CRN
system process and Referral Network
VH Monitor and report
outcome measures and
Monitor and report utilization of LIHTC units
develop infrastructure DHCD
utilization of LIHTC units
for implementation Conduct outreach as
DMAS
Conduct outreach when needed
DVS utilization falls below
60%
47
Strategy 2.2: Expand PSH through the Affordable and Special Needs Housing Program
Estimated 56 total PSH projects produced in FY19 and FY20; number of units per project provided after projects are selected.
Action Lead Agency(s) Others Involved CY22 Goal CY23 Goal
2.2.1 Host input sessions DHCD DBHDS Host five regional input Host five regional input
to secure local input into sessions - Stakeholder sessions -
VH
Consolidated Plan and education and input re:
Stakeholder education
Annual Action Plan. PSH
and input re: PSH
Request input related to
PSH development and
possible new state
resources
48
2.2.2 Secure additional DHCD Issue Request for To be determined once
PSH through Affordable Applications Spring and projects selected in CY22
and Special Needs Fall 2022.
Housing (ASNH) Program
Estimated 52 affordable
housing construction
projects selected for
CY22 and 52 projects for
CY23; over 60% of the
projects estimated to
contribute between 5 to
80 affordable units for
supportive housing with
various target
populations
Projects constructed/
rehabilitated
2.2.3 Identify targeted DHCD DBHDS Identify developers and Development support
capacity development determine interest in
that may assist in capacity development
increased PSH through
ASNH program and/or
identify developers well
positioned to create PSH
49
2.2.4 Explore developing DHCD Internal DHCD ASNH and If determined feasible,
a system to track non- HSNH teams will work begin tracking non-LHITC
LIHTC developments with with policy team to developments
a special populations determine feasibility of
leasing preference creating a process
Strategy 2.3: Expand PSH through Investment of DBHDS funds in capital subsidies
Action Lead Agency(s) Others Involved CY22 Goal CY23 Goal
2.3.1 Examine the use of DBHDS If legislation is approved If approved, implement
the DBHDS Trust Fund for in the 2022 GA, develop selected strategies
investment in PSH should strategies for housing
funds become available investment should funds
become available.
2.3.2 Invest DBHDS funds DBHDS Fund at least one project Continue to make
in housing development through DHCD’s pre- investments, if possible
DHCD
activities development
Assess the outcomes and
competition
modify strategies
Identify at least one
community where
DBHDS funding can be
leveraged with other
funds to develop PSH
50
Strategy 2.4: Strategies to Collaborate with Local Communities to expand PSH
Action Lead Agency(s) Others Involved CY20 Goal CY21 Goal
2.4.1 Collaborate with DBHDS VH Plan and conduct the 2-4 projects secure
Northern Virginia Institute development funding
DHCD
stakeholders to
Identify development Based on outcomes,
implement ARPA funding DMAS
and services activities to modify approach and
to launch a Supportive
DVS be supported by ARPA consider replicating in
Housing Institute in
funds other communities
Northern VA
At least 4 teams
(developer, property
management, and
services) will complete
the Spring 2022 Institute.
Evaluate outcomes
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Goal #3 - Increase Rental Assistance to make Units Affordable
Strategy 3.1: Expand PSH through the DBHDS PSH SMI Program
FY23 – 150 household expansion (funds dependent on final budget)
Action Lead Agency(s) Others Involved CY22 Goal CY23 Goal
3.1.1 Expand the PSH- DBHDS Request additional funds Request additional funds
SMI program and through budget through budget
improve fidelity and development. development.
outcomes
Allocate and administer Allocate and administer
funds
Complete PSH training
Complete PSH training and technical assistance
and technical assistance initiative. Use results to
initiative. Use results to improve racial equity in
improve racial equity in access, outcomes, and
access, outcomes, and services.
services.
Increase PSH referrals
Increase PSH referrals from state hospitals and
from state hospitals local/regional jails
52
Strategy 3.2 Identify available rental assistance option and gaps to meet need statewide
3.2.1 Document rental DHCD DBHDS Document existing
assistance resources resources and known
VH DMAS
available in Virginia and barriers
barriers to accessing DVS
resource
3.2.2 Review best DHCD DBHDS Review best practices
practices and federal and develop primer
VH DMAS
policy goals to determine
Determine opportunities
opportunities to leverage DVS
to align state priority
federally funded
Stakeholders populations with existing
vouchers
federally funded
vouchers
3.2.3 Develop outreach DHCD DBHDS Build outreach plan Determine ongoing
plan to leverage federally around best practices outreach needs
VH VH
funded vouchers and identified
Conduct ongoing
DMAS opportunities
outreach
DVS Conduct outreach
53
Goal #4 - Increase PSH through Preferential Access to Existing Affordable Housing Programs
Strategy 4.1: Expand PSH through access to public housing agency resources
Action Lead Agency(s) Others Involved CY22 Goal CY23 Goal
4.1.1 Work with VAHCDO DHCD DBHDS Create a plan with Implement plan
to develop a plan for how implementation time
VH DMAS
public housing frames
authorities can assist in DVS
meeting state goals of
expanding PSH DARS
DSS
Goal #5 - Strategies to Enhancing System Capacity to deliver PSH
Strategy 5.1: Utilize data to inform implementation plans
Action Lead Agency(s) Others Involved CY22 Goal CY23 Goal
5.1.1 Identify data needs DBHDS DARS Finalize data plan.
(including but not limited to
program evaluation and DMAS
documentation of program
success and cost avoidance), DHCD
how information will be
collected, shared, reported
VH
54
5.1.2 Examine trends in DHCD VH Create data sharing ILT release data in GA
homelessness for agreement linking HDIP, annual report
DBHDS DVS Medicaid and DBHDS data
individuals with SMI to
measure use of multiple DMAS to examine inflow, housing
outcomes, and returns to
systems and develop
homelessness for
data-driven strategies to
individuals with SMI in
reduce the number of
HMIS.
individuals with SMI
identified in the Data sharing agreement
Homeless Point in Time executed including
(PIT) Count DHCD/HDIP, DMAS, DBHDS
Utilize HDIP data on
addressing the needs of
individuals experiencing
homelessness with SMI
DBHDS will secure technical
assistance to support PATH
providers.
Develop a scope and
methodology to examine
inflow, housing outcomes,
and returns to
homelessness for
individuals with SMI in
HMIS. (Consider piloting in
a couple of communities)
55
Strategy 5.2: Enhance PSH housing development capacity
Action Lead Agency(s) Others Involved CY22 Goal CY23 Goal
5.2.1 Assess the need for DBHDS DMAS Determine scope of Implement capacity
additional capacity within capacity building effort building strategy
CSBs, nonprofit mission- and funding to support
driven developers and
other organizations to
develop PSH
5.2.1a Explore strategies DHCD DVS Support CSBs to
to address the need participate in the PSH
VH
identified in 5.4.1 Capacity- building
Initiative with TAC.
5.2.2 Identify funds for DBHDS DMAS Identify funding source(s)
needs assessment and
DHCD DVS
strategy development
and implement as soon VH
as possible.
56
Strategy 5.3: PSH Steering Committee continues PSH alignment with related activities
Action Lead Agency(s) Others Involved CY22 Goal CY23 Goal
5.3.1 PSH Steering DHCD VH Monthly meetings Monthly meetings
Committee continue to
DBHDS
meet regularly to ensure
plan is implemented on DMAS
schedule
DARS
VDH
5.3.2 PSH Steering DHCD VH Analyze group
Committee reviews how composition and
DBHDS
plans and projects approaches to decision-
address racial equity as DMAS making
well as other historically
DARS Determine opportunities
marginalized populations
to advance racial equity
in decision-making,
VDH as well as other
process development,
historically marginalized
and action planning
populations and begin
implementing
57
5.3.3 PSH Steering DHCD VH Document activities Document activities
Committee obtains input occurring across groups occurring across groups
DBHDS
on related activities that
Obtain input on priorities
align with needs DMAS
identified by stakeholder Begin Coordination
groups including DARS
between committees
Governor's Coordinating
VDH
Council, SMI Strategy
Group, Integrated
Housing Advisory Council
(IHAC), Inter-agency
Leadership Team (ILT),
Heath and Housing
Initiative (HHI), and other
relevant groups
5.3.4 PSH Steering DHCD VH PSH Steering Committee PSH Steering Committee
Committee to continue expanded as appropriate expanded as appropriate
DBHDS
to include state agencies
as appropriate DMAS
DARS
VDH
58
Acronyms
SH = DMAS Supportive Housing benefit
PSH = permanent supportive housing
LIHTC = Low Income Housing Tax Credit program
SE = DMAS Supported Employment benefit
MH = mental health
VBH = behavioral health
TCM = target case management
MHSS = mental health skill building
CC = care coordinators (DMAS)
HH = Health Homes
59
Appendix B PSH Steering Committee
State Agency
Virginia Department of Housing and Community Development (DHCD)
Virginia Housing (VH)
Virginia Department of Behavioral Health and Developmental Services (DBHDS)
Virginia Department of Medical Assistance Services (DMAS)
Virginia Department for Aging and Rehabilitative Services (DARS)
Virginia Department of Health (VDH)
Virginia Department of Social Services (DSS)
Virginia Department of Veterans Services (DVS)
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Appendix C Governor’s Coordinating Council on Homelessness and Housing Vulnerable
Populations - Committee Relationship Graphic
61
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