Shaping a more Holistic and Humane Approach to Care in Oregon
Q&A with Cara Caudill-Howe, Manager of HRSN Benefits at CAP
When housing becomes unstable, everything else can quickly fall out of focus—health, safety, employment, and even the ability to plan beyond tomorrow. Through a new Medicaid-funded initiative launching across Oregon, Cascade AIDS Project is stepping into that space with a powerful new tool: the CAP HRSN Assistance Program, or CHAP. Designed to address urgent health-related social needs like housing stability, CHAP reflects a growing recognition that safe, stable housing is not just a social issue—it is a health intervention.
Today, we got the chance to talk with with Cara Caudill-Howe, Manager of HRSN Benefits at CAP, about what the HRSN model is, how our HRSN program (CHAP) is already supporting clients, and why this work represents both a major opportunity for the people we serve and a pivotal moment for the future of integrated health and social care in Oregon.
Q: What is an HRSN program?
A: The Health-Related Social Needs (HRSN) benefit was created through Oregon’s 1115 Medicaid Waiver in 2022. Regulated by the Oregon Health Authority (OHA), it allows certain OHP members—particularly those navigating major life transitions alongside clinical risk factors—to access supports that address social needs like housing, safety, and stability.
Because this is a demonstration waiver, the model is still evolving. Oregon is one of the first states in the country implementing HRSN at this scale, and agencies like CAP have the opportunity to help shape what the long-term benefit will look like.
Community-Based Organizations (CBOs) contract with Coordinated Care Organizations (CCOs) to deliver HRSN services. The CCO sends referrals, the CBO provides the support, and the CCO reimburses the work.
At CAP, our program is called the CAP HRSN Assistance Program (CHAP). Through our contract with CareOregon, we currently provide:
Up to six months of rent and utility assistance
Home remediations that support safe and healthy living environments
Short-term case management to improve housing stability
We also support existing CAP clients in applying for the benefit. As we grow our capacity, we hope to expand to serving Open Card and Trillium members as well.
Q: What does CHAP do for clients?
A: CHAP provides short-term but high-impact support for people facing a housing crisis. Clients can receive:
Up to six months of rent and utility assistance
Home remediation services such as pest control and deep cleaning to help make their housing safe
Case management that focuses on restoring stability and connecting clients to longer-term resources
Although the support window is limited, the design of HRSN is to interrupt crises, reduce health risks, and give clients enough stability to prioritize their wellbeing. Housing is treated as a health intervention—a recognition CAP has long understood through our work.
Q: How does the program benefit CAP more broadly?
A: CHAP provides a wide range of benefits to our organization and community.
CAP can bill for case management at an hourly rate, creating a new and sustainable way to support the administration of these services.
This revenue can also help backfill budget gaps at a time when other housing resources are increasingly uncertain.
HRSN is encouraging deeper and more creative internal collaboration—bringing together case management, the Service Center, Benefits Navigation, ERA, and finance to explore how we can jointly support clients and streamline access to these types of benefits.
It expands our external partnerships with other CBOs and with CCOs like CareOregon.
Using the Unite Us platform, we can help existing CAP clients apply for HRSN benefits more easily and track referrals in real time.
Because HRSN referrals are not limited to people living with HIV, the program broadens CAP’s community impact and diversifies who we serve.
Participating early in this work also positions CAP for the future, as many states are watching Oregon’s HRSN model as a potential blueprint for Medicaid-funded social needs interventions.
4. Are there any recent program milestones or accomplishments that you would like to share?
Yes—several. We finalized our contract with CareOregon in October, onboarded in November, and took our first client that same month. That client is now receiving six months of assistance, enabling them to focus on their health rather than a housing crisis.
Launching quickly and successfully is a major achievement, especially given that HRSN documentation and processes are more detailed and healthcare-oriented than traditional housing programs. CAP is already demonstrating strong capacity in this new system.
5. How do people access the program?
There are a few ways to access CHAP:
CareOregon sends referrals directly to CHAP for clients needing rent or utility assistance.
To apply for the HRSN benefit itself, people can apply online, call their CCO, or work with a CAP staff member who can submit the application through Unite Us.
Because eligibility is based on a combination of life transitions and clinical risk factors, many people benefit from having support in navigating the application process.
6. Are there ways people can support the program?
HRSN is a demonstration waiver running through September 2027, so awareness and impact are the best ways to ensure its longevity. Here are ways we can all help:
As a community, staying informed, advocating for its continuation, and uplifting its successes helps support the long-term sustainability of this benefit.
Internally, staff can support the program by referring eligible clients, helping clients understand the benefit, and collaborating with us as we continue to refine our processes.
Sharing success stories helps highlight the connection between housing stability and health outcomes – an important message for funders and community partners.
7. Is there anything else folks should know about CHAP and the HRSN model?
This is an exciting opportunity for CAP and for the communities we serve. At a time when other housing funding streams are shrinking, HRSN fills critical gaps and allows us to provide meaningful, health-focused support.
HRSN also deepens the integration between health care and social services—something CAP has been advocating for years. By participating early, CAP is helping shape a more holistic and humane approach to care in Oregon.
For more information or to learn more about CHAP or the HRSN benefit, please contact:
Cara Caudill-Howe
Manager of HRSN Benefits at CAP
e: ccaudill-howe@capnw.org
p: 503-278-3898
