Provide care coordination and housing services to individuals at early intercepts

Lead agency: Health and Human Services Agency, Office of Homeless Solutions (OHS)

Population of focus: Individuals with repeated encounters with the justice system who are at risk of or experiencing homelessness and other unmet needs.

SIM intercept: 0-1, 2-3, 4-5

Summary of planned action:

Contract with community-based providers for care coordination and housing services to create additional capacity for individuals identified by Sheriff’s correctional counselors or through community-based partners or health and justice partners who contact individuals at risk of arrest or after short jail stays.

Actions taken:

  • Signed a contract for new Care Coordination and Housing services and began serving clients in October 2024. The focus population includes individuals who are at risk of or experiencing homelessness with additional unmet needs, such as behavioral health treatment and employment. These individuals have repeated encounters with the justice system on low-level matters. The service population also includes high-need individuals experiencing homelessness who touch jail briefly on felony cases and are at risk of failures to appear or other adverse outcomes. Clients are referred to the ATI program’s contractor UPAC, by OHS direct service workers and partners from law enforcement, City Attorney, Sheriff, Public Defender, and Probation. 

  • The ATI program provides intensive care coordination, individualized case management, and housing services for up to 12 months, with a goal of reducing justice involvement, increasing permanent housing placements, and increasing other positive outcomes such as improved health and increased self-sufficiency. The program can serve up to 90 individuals at any given time and about 125 people a year, County wide.

  • In December 2025, a peer staff member completed the clearance process to pilot engaging individuals released from custody as they walk out of jail. Future meetings will be held to finalize the location, schedule, and Sheriff’s support for the outreach efforts, during which the peer staff member can distribute flyers to people as they exit. The flyers were designed with the input of County consultants with lived justice system experience.  

  • The program received 312 referrals and enrolled 138 individuals as of September 2025. OHS has developed equity dashboards to ensure that the population served closely mirrors the ATI population of focus. Other outcomes tracked include number of participants:
    • Immediately housed
    • Permanently housed
    • Connected to self-sufficiency benefits
    • Linked to mental health treatment, substance use disorder treatment and healthcare
    • Connected to employment, education/training, and other supportive services
    • With justice involvement after enrollment (number of bookings and days in custody)

Next Steps:

  • Housing models, including the strategy in the ATI care coordination program, will be evaluated for effectiveness to better understand the clients being served and assess whether the model is implemented equitably. The ATI program is being carefully monitored and adjusted as the County and referring partners identify effective ways to engage individuals when there is insufficient time in custody for traditional re-entry planning and coordinated releases to community providers.

  • Public Safety Executive Office, the Sheriff’s Office, and HHSA will review the peer connector’s methods and results to understand whether peers can effectively connect people leaving jail to transportation and reentry programs, and if so, whether the strategy can be expanded within the ATI program and to other facilities and programs.