Sonoma DHS Homeless Revamping Workshop, Oct 23rd

Short Summary

You participated in a feedback session on the county’s new vision for homeless services.

Long Summary

The meeting was called by the Department of Health Services feedback session where new leadership, Nolan Sullivan and Desirae

Olstrom, unveiled a revamped strategy to address homelessness. They proposed a “funnel” system using county facilities to support individuals with high-acuity behavioral health needs. The majority of the meeting was dedicated to gathering your and other partners’ feedback on this new model, identifying systemic gaps, and discussing the need for better collaboration, data transparency, and a unified system of care.

The problem

The Department of Health Services is revamping its homeless services team and seeking feedback on a new vision to improve partnerships and service delivery. The county aims to address its historically siloed approach and open up its resources and processes for better collaboration. The primary focus of the new vision is the segment of the homeless population with high-acuity behavioral health and substance use needs, which is estimated to be 5-10% of the total 1,900 homeless residents. This group is often difficult to serve in traditional programs and can destabilize properties.

Themes discussion

A new “funnel” system was proposed by the county to create a continuum of care for high-acuity individuals. The pathway would move clients through a series of facilities with increasing levels of independence: 

• Eliza’s Village: The entry point for stabilization.
• Arrowwood: Single occupancy rooms with more services. 
• Mickey Zane: Individual apartments to prepare for independent living.

The end goal is to graduate individuals back into the Coordinated Entry (CE) system for Permanent Supportive Housing (PSH).

A major concern raised was the large population that the county’s proposed funnel would not serve, leaving approximately 1,500 individuals for partner agencies to handle. This includes specific hard-to-house groups, such as arson (219) and sex offense (290) registrants, who are often screened out of existing housing options. The need for a single, unified system of care was a recurring theme, emphasizing the need to break down silos between county departments (e.g., Homelessness and Behavioral Health) and external partners. Data transparency and system functionality were highlighted as critical for building trust and enabling effective

collaboration. The current HMIS system is considered limited in its reporting capabilities. Resource constraints and funding limitations for the county, cities, and non-profit providers were an underlying issue throughout the discussion.

Specific ideas

Integrate county behavioral health staff directly with partner agencies and on-site at facilities. This “in-person handoff” is seen as extremely beneficial for navigating clients into services. 

• Develop a centralized and transparent referral system for providers. This would allow agencies to submit referrals for high-needs clients and track their status. 
• Provide a higher level of ongoing support for clients once they are in PSH. An Assertive Community Treatment (ACT) model was suggested for individuals who continue to need intensive services after being housed. 
• Address the challenge of individuals who refuse services or are too ill to engage with support systems. 
• Streamline the contracting and RFP process to reduce administrative burden. Suggestions included creating multi-year contracts and consolidating various city and county RFPs into a single cycle.

Future directions

• The county should take on a lead role as a convener to bring together all stakeholders, including shelter providers, tribal entities, and cities, to address system-wide issues. 
• One immediate project suggested was creating a coordinated emergency weather response plan. 
• The group should develop a unified advocacy message to state legislators regarding restrictive funding and unfunded mandates.
• A formal “gap analysis” is needed to inventory all existing services and providers in the county to identify where deficiencies lie.
• The county will continue to refine its “funnel” model while considering the feedback on excluded populations and operational challenges, such as the remote location of Eliza’s Village. 
• The county acknowledged the need to improve internal policies, noting they recently implemented a six-month time limit at facilities like Eliza’s Village to ensure client progression.