HEAPA Homelessness Advocacy and Policy Updates Sonoma County

1 source·May 23, 2026

This text highlights the transition of street outreach from providing basic survival aid to functioning as a professional, housing-focused pipeline for the unsheltered. While regions like Sonoma County and San Francisco report measurable successes in housing placement and retention, significant systemic hurdles remain, including a shortage of affordable units and fragmented data systems. Local advocates express concern over the Behavioral Health Services Act integrated plan, arguing that its medical-clinical model may exclude vulnerable populations and lacks sufficient community input. To address these gaps, the Homeless Emergency Assistance Program Association (HEAPA) is actively promoting civic engagement and leadership among those with lived experience. Their initiatives focus on providing digital tools, stipends, and advocacy training to ensure unhoused individuals have a voice in the policy decisions that shape their lives. Through these efforts, the organization seeks to bridge the divide between high-level bureaucratic planning and the practical needs of the community.

How is street outreach evolving from survival aid to housing?

Street outreach is transforming from simply providing basic survival aid, like handing out blankets or water, into a professional, housing-focused pipeline. Rather than just managing the crisis of living on the streets, modern outreach workers act as mobile case managers who meet individuals where they are to actively end their homelessness.

Today, successful programs focus on building trust over extended periods to achieve the practical milestones required for housing placement. This evolution includes several key strategies:

• Document Readiness: Outreach teams help individuals navigate complex government bureaucracies to secure necessary identification, such as lost birth certificates, social security cards, and state IDs.
• Coordinated Entry Integration: Workers use localized data systems like the Homeless Management Information System (HMIS) to assess people directly in the field, ensuring the most vulnerable are prioritized and seamlessly matched with open shelter beds, rapid rehousing, or permanent supportive housing.
• Multidisciplinary Teams: Modern outreach programs often deploy hybrid teams featuring mental health professionals, substance use counselors, and peer navigators with lived experience of homelessness, allowing them to provide immediate, trauma-informed care on the sidewalk.
• Warm Handoffs: Success is no longer defined by simply handing out a flyer with a list of resources. Instead, outreach workers personally walk with individuals, drive them to appointments, introduce them to shelter staff, and remain with them throughout the intake process to ensure continuity of care.

Real-world models reflect this shift, such as Los Angeles’s “Pathway Home” initiative, which brings entire encampments indoors while offering comprehensive care, and family reunification programs that safely reconnect individuals with their existing support networks.

However, while the mechanics of modern outreach are highly effective at preparing people for housing, the ultimate success of these programs remains completely dependent on the availability of low-barrier shelters and permanent affordable housing to fully resolve the crisis.

What are the success rates of Bay Area programs?

Recent data from the Bay Area and Northern California shows that when street outreach is well-resourced, it achieves high transition and housing retention rates. Local municipalities and Continuums of Care track these efforts closely, highlighting several notable success rates across the region:

San Francisco San Francisco’s multi-disciplinary outreach programs have achieved significant permanent housing placements and high long-term stability:

• Housing Placements: Between July 2023 and June 2025, the system successfully moved 10,300 people from homelessness into permanent housing.
• Retention Rates: The city reported an exceptional 93% retention rate, meaning 93% of those who exited homelessness did not return to the system within 12 months, exceeding their goal of 85%.
• Reduced Emergency Calls: In neighborhoods where street outreach and ambassador programs were deployed, there was a 30% to 60% reduction in 911 calls.
• Immediate Shelter: The RESTORE project successfully served over 2,500 clients by providing nighttime shelter placements and immediate substance use treatment directly from the street.

Santa Rosa and Sonoma County Targeted outreach and expanded interim housing have led to some of the lowest homelessness numbers in the county since 2007:

• Pipeline Success: In Santa Rosa, city-funded outreach programs successfully transitioned nearly 30% of all unsheltered people they engaged into formal shelters or permanent housing during the 2024–2025 fiscal year.
• Population Declines: Overall homelessness dropped by 23% countywide and 16% in Santa Rosa. Rohnert Park experienced a dramatic 60% reduction in overall homelessness (including a 78% drop in unsheltered individuals) due to targeted outreach and the opening of a new interim housing site.
• Veterans: Targeted outreach paired with housing vouchers achieved a 39% reduction in homeless veterans across the county.
• Challenges: Despite these successes, the number of chronically homeless individuals rose by 20%, emphasizing that the most vulnerable populations still lack adequate Permanent Supportive Housing (PSH).

Berkeley and the East Bay While specific percentage success rates aren’t detailed for Berkeley, the city has successfully implemented the Homeless Outreach Treatment Team (HOTT). Instead of short-term fixes, this specialized model utilizes an evidence-based Critical Time Intervention (CTI) framework to build long-term relationships with highly vulnerable, severely mentally ill individuals to navigate them into housing stability.

Ultimately, regional data demonstrates that the mechanics of modern street outreach are working, but the ceiling of their success is currently capped by a severe regional shortage of affordable housing units and state/federal budget cuts.

Tell me more about Berkeley’s HOTT model.

The Homeless Outreach Treatment Team (HOTT) is a specialized outreach pilot program operated by the City of Berkeley that aims to bridge the gap between psychiatric crises and housing.

Funded largely by the Mental Health Services Act, the HOTT model distinguishes itself through the following key characteristics:

• Evidence-Based Framework: The program is built on an evidence-based approach known as Critical Time Intervention (CTI).
• Targeted Population: It specifically focuses on highly vulnerable unhoused individuals who are experiencing severe mental health needs.
• Long-Term Relationship Building: Rather than offering short-term or temporary fixes, the team is entirely focused on cultivating long-term, trusting relationships with the people they serve.
• Active System Navigation: Outreach workers don’t just provide information; they physically help individuals navigate the highly fragmented county system to help them achieve long-term housing stability.

What is Critical Time Intervention?

Based on the provided sources, there is no comprehensive, standalone definition of Critical Time Intervention (CTI). However, the sources describe CTI as an evidence-based framework that is put into practice through programs like Berkeley’s Homeless Outreach Treatment Team (HOTT).

In the context of the HOTT model, CTI is characterized by the following approaches:

• Avoiding short-term fixes: Instead of offering temporary solutions, the framework is entirely focused on cultivating long-term, trusting relationships.
• Targeting severe mental health needs: It is designed to assist highly vulnerable unhoused individuals who are dealing with severe mental health crises.
• Active, hands-on navigation: Rather than just giving out information, workers physically help individuals navigate the fragmented county systems necessary to achieve long-term housing stability.

(Note: If you would like a broader clinical or academic definition of Critical Time Intervention, I would need to draw on outside information not included in your current sources. Let me know if you would like me to do so!)

What are the common challenges when implementing HOTT?

The provided sources do not explicitly detail the administrative or operational challenges specifically faced when implementing Berkeley’s Homeless Outreach Treatment Team (HOTT). However, they do identify the broader systemic challenges that affect the success of specialized regional outreach programs like HOTT:

• Navigating Fragmented Systems: A major hurdle for vulnerable, unhoused individuals is the bureaucracy of local government. HOTT outreach workers must physically help clients navigate a highly fragmented county system to help them achieve long-term housing stability.
• Affordable Housing Shortages: The ultimate ceiling on the success of these outreach programs is macro-economic; there is a severe regional shortage of affordable housing units.
• Budget Cuts: Furthermore, state and federal budget cuts restrict the number of permanent beds that outreach teams can actually offer to the people they engage on the street.

How does the fragmented county system affect HOTT’s success?

The fragmented county system acts as an incredibly overwhelming barrier for highly vulnerable, unhoused individuals, particularly those dealing with severe mental health needs or chronic trauma. Because individuals struggle to navigate these disjointed bureaucracies on their own, the fragmentation makes HOTT’s active, hands-on approach the critical factor for their success.

Instead of offering short-term fixes or simply handing out a list of resources, HOTT workers succeed by physically navigating clients through the fragmented county system. They build long-term, trusting relationships and rely on “warm handoffs”—such as driving individuals to appointments, introducing them to shelter staff, and remaining with them throughout the entire intake process—to ensure that clients achieve long-term housing stability without slipping through the cracks of the broken system.

What is the RESTORE project in San Francisco?

The RESTORE project is a specific street outreach initiative in San Francisco that focuses on providing “on-demand” placements and care.

The program is designed to deliver immediate substance use treatment and secure nighttime shelter placements for unhoused individuals directly from the street. As part of the city’s broader “Home by the Bay” strategy to reduce homelessness, the RESTORE project has been highly active, successfully serving more than 2,500 clients.

What is the RESTORE project’s success with substance use treatment?

Based on the provided sources, the RESTORE project in San Francisco is designed to provide immediate substance use treatment and nighttime shelter placements directly to individuals on the street.

In terms of its success, the sources note that the expanded program has successfully served more than 2,500 clients. However, the data provided does not include specific outcome metrics or success rates detailing the long-term effectiveness of the substance use treatment itself, such as sobriety or recovery statistics.

What is the 30% reduction in 911 calls attributed to?

The 30% to 60% reduction in 911 calls in San Francisco is attributed to the deployment of proactive street outreach and neighborhood-based ambassador programs in specific neighborhoods. This reduction demonstrates that engaging directly with individuals on the street helps relieve the overall pressure on emergency services.

What is the RESTORE project’s total client outreach goal?

The provided sources do not specify a total client outreach goal for the RESTORE project. They only note that the expanded program has already successfully served more than 2,500 clients by providing immediate substance use treatment and nighttime shelter placements directly from the street.

What is the RESTORE project’s role in the city’s broader strategy?

The RESTORE project operates as a key outreach initiative within San Francisco’s broader “Home by the Bay” strategy.

Within this strategic framework, San Francisco relies heavily on multidisciplinary street teams—such as the Street Crisis Response Team (SCRT) and the SF Homeless Outreach Team (HOT)—to manage non-violent, health-focused crises. The RESTORE project specifically fulfills the role of providing “on-demand” placements by delivering immediate substance use treatment and nighttime shelter directly to unhoused individuals on the street.

Working alongside neighborhood-based ambassador programs, these proactive street engagements are a vital part of the city’s overall strategy, effectively relieving pressure on emergency services and contributing to significant reductions in 911 calls.

What makes the 93% housing retention rate so successful?

The 93% housing retention rate in San Francisco is a significant marker of success because it means that 93% of individuals who exited homelessness did not return to the homelessness system within 12 months, comfortably exceeding the city’s target of 85%.

This exceptional long-term stability is largely attributed to how modern street outreach has transformed into a professional, housing-focused pipeline rather than simply providing short-term survival aid. The success of this retention rate is driven by several critical practices:

• Continuity of Care and “Warm Handoffs”: Navigating local bureaucracies can be incredibly overwhelming for individuals dealing with chronic health issues or trauma. Instead of merely handing out a flyer with a list of resources, outreach workers walk with clients, drive them to appointments, introduce them to shelter staff, and stay with them throughout the intake process. This hands-on approach is what prevents vulnerable people from slipping through the cracks.
• Long-Term Trust Building: Successful programs require workers to build trust over weeks or months to help individuals accomplish practical milestones, such as overcoming complex government bureaucracy to replace lost identification cards.
• Targeted Matching: Outreach teams integrate with localized data systems to assess people directly in the field, ensuring they are accurately prioritized and matched with the right open shelter beds, rapid rehousing, or permanent supportive housing.
• Adequate Resourcing: Regional data consistently shows that when these targeted outreach teams are deployed with adequate resources, they are highly effective at achieving these exceptional long-term housing stability rates.

How does Coordinated Entry Integration prioritize the most vulnerable?

Coordinated Entry Integration prioritizes the most vulnerable by bringing the assessment process directly to people living on the street. Rather than waiting for individuals to seek out services, outreach teams use localized data systems, such as the Homeless Management Information System (HMIS), to assess individuals in the field.

This direct, field-based assessment allows outreach workers to identify the most vulnerable people sleeping outside and ensure they are seamlessly matched and prioritized for available resources, such as open shelter beds, rapid rehousing programs, or permanent supportive housing.

The effectiveness of this system has made it a focal point for local housing advocates in the sources. For example, in Sonoma County, advocates have praised the Coordinated Entry System as a carefully built, proven, and effective tool, expressing concern when local government plans—like the draft Behavioral Health Services Act 3-Year Integrated Plan—fail to utilize it. To maximize its impact, advocates have proposed solutions such as requiring 100% of rooms for homeless individuals in county-owned facilities to be filled exclusively through the Coordinated Entry System.

What is the role of the Street Crisis Response Team?

The Street Crisis Response Team (SCRT) is a multidisciplinary outreach group utilized in San Francisco as a key component of the city’s “Home by the Bay” strategy.

Its primary role is to proactively handle non-violent, health-focused crises for individuals living on the streets. Working alongside other groups like the SF Homeless Outreach Team (HOT), the SCRT engages vulnerable individuals during these crises to offer immediate assistance and provide direct shelter placements.

By dispatching specialized teams to manage these health-related emergencies, the SCRT directly relieves pressure on traditional emergency services, contributing to the broader citywide effort that has successfully reduced 911 calls by 30% to 60% in targeted neighborhoods.

How does the Homeless Management Information System work?

The Homeless Management Information System (HMIS) is a localized data system used by county outreach teams to collect data and assess individuals directly in the field.

When used effectively, HMIS is the technical backbone for Coordinated Entry Integration. Outreach workers use the system during street engagements to evaluate an individual’s needs on the spot, ensuring that the most vulnerable people sleeping outside are prioritized and seamlessly matched with open shelter beds, rapid rehousing programs, or permanent supportive housing.

However, the system’s effectiveness relies heavily on how well it communicates with other local government databases. For example, in Sonoma County, homeless data is collected through HMIS, but the county’s Behavioral Health Department uses a completely separate data system called SmartCare (or Smart Key). Local advocates have identified this lack of integration as a major systemic weakness, noting that without integrating the two systems, data becomes disjointed, making it difficult to accurately track a person’s homeless outcomes alongside their clinical visits. This fragmentation creates a risk that vulnerable individuals will “fall through the statistic crack”.

To address these data problems, local advocacy groups like Homeless Action! have proposed the immediate, formal integration of HMIS and SmartCare, while organizations like HEAPA are actively developing projects to help case managers better communicate and collect data across these amalgamating county systems.

What is the SmartCare data system used for?

SmartCare (sometimes referred to as Smart Key) is the primary data system used by Sonoma County’s Behavioral Health Department.

It currently operates as a completely separate system from the Homeless Management Information System (HMIS), which the county uses to track homeless data. Local advocates point out that the lack of integration between these two databases is a major systemic weakness, making it difficult to accurately track a person’s clinical visits alongside their homeless outcomes.

To prevent vulnerable individuals from slipping through the cracks due to disjointed data, advocacy groups have proposed the immediate, formal coordination of SmartCare and HMIS. Meanwhile, organizations like HEAPA are working on upcoming projects to train case managers on how to better communicate and collect data across these amalgamating county systems.

What is the goal of the California Transparency Project?

While the sources do not explicitly define a single overarching “goal” or mission statement for the California Transparency Project, they outline its active initiatives, which demonstrate a focus on improving agency communication, expanding government transparency, and increasing citizen involvement in strategic planning.

Specifically, the project aims to achieve these objectives by:

• Improving Communication and Data Management: The project purchased digital personal assistant devices for several agencies to test their effectiveness and produced instructional videos showing users how to provide meeting reports with these devices.
• Increasing Public Transparency: The project requested copies of all service contracts issued by the Departments of Health Services and Human Services for the 2025–2026 fiscal year and made them publicly available online.
• Prioritizing Citizen Access: The project called for the convening of NOFA (Notice of Funding Availability) planning committees across several groups—including the Sonoma County Community Development Commission, the Santa Rosa Housing Authority, the Sonoma County Homeless Coalition, and the Behavioral Health Boards—to prioritize citizen access to strategic planning and help coordinate their work.