TPCH Coordinated Assessment Planning

Workshop Afternoon Session

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Afternoon Session:• Coordinated Assessment Design &

Implementation Considerations• Defining Roles and Management

Expectations• Key Considerations for Next Steps

Workshop Overview

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Participants will…• understand design considerations as they

impact individual programs and systems• Understand key roles and participation

expectations that need to be defined• Learn to apply written standards for

administration of programs• Identify next steps for planning and

implementation.

Workshop Learning Objectives:

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Core Operational Components

Access

Coordinated Referral

Standardized Access and Assessment

Assess Assign

Coordinated Assessment Roles and Responsibilities

Establish roles and responsibilities for each constituent group• CoC Leadership• CoC Providers and Projects• Clients• HMIS & other information systems• Funders• Mainstream service partners• Faith community

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Roles and Responsibilities

Potential CoC Leadership Roles:• Planning, Design, Implementation• Management and coordination• Resource development strategy• Ongoing funding• Monitoring and evaluation• Communication

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Roles and ResponsibilitiesPotential Role for CoC Providers and Projects:• Planning, design, implementation feedback• Written standards for administration of programs• Document referral, eligibility, enrollment, and

case disposition protocols• Participation in Coordinated Assessment

systems• Staff training, capacity building, compliance

monitoring7

Roles and Responsibilities

Potential Client Roles:• Planning, design, and implementation

feedback• Review of processes, forms, protocols• Participation/adherence to access,

assessment, and referral design• Case conferencing

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Roles and Responsibilities

Potential roles for HMIS and other data systems:• Functionality adjustments or expansion (triage, intake,

assessment, referral, placement info)• Track client consent and data sharing decisions• Monitor Coordinated Assessment performance metrics• Manage program occupancy info• Manage program waitlist• Manage prioritization protocols, scores, indices

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Roles and Responsibilities

• Funders– $, design, strategic initiative alignment,

oversight• Mainstream service partners– Coordination, access, leverage other human

services• Faith community– Coordination, resource gaps, volunteer

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Written Standards for Administration of Programs

For each Program Type:Description – services and target populationEssential Elements – what clients receiveEligibility Criteria – who gets inProgram Standards – baseline expectations for

service type and qualityReferral Sources – define where referrals will come

fromProgram Outcomes – performance expectationsSystem Outcomes – linkage of program outcomes to

system outcomes 11

Access – Design Considerations • What is the access model?• What is the extent (reach) of the CoC’s geographic

coverage?• What is the projected demand for crisis response

throughout the CoC?• Is there demand for other permanent housing options

and resources?• What is the technical capacity of staff to manage access

services?• How will access services be integrated into HMIS?• What is the role for SocialServe.org?

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Assessment – 3 Stages• Crisis assessment – how will client’s crisis

needs be addressed?• Housing stability assessment – what criteria

for different types of housing and service combinations will help to create a referral match?

• Client assessment – what personal characteristics and considerations are necessary to understand how the client will maintain housing stability?

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Assessment Stages

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Crisis Assessment

Housing Stability Assessment

Client Assessment

Also Called Diversion, Triage, Intake

Index, Housing Barrier Assessment

Assessment

Goal Address immediate housing crisis and plan next steps

Identify barriers and interventions related to rapid housing placement and ongoing stability

Gather data sufficient for documenting a nuanced picture of client’s housing-related history.

Time When client enters access point

0 to 7 days7 to 14 days

0 to 3 days0 to 7 days

Assessment Stages

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Crisis Assessment

Housing Stability Assessment

Client Assessment

Structure Short- and low-barrier form or interview that captures sufficient information to determine immediate needs and eligibility

Often includes assessment tool but may rely on score or index and cumulative case management interpretation

Longer form, interview, or series of interviews that captures background info, co-occurring needs, funder required fields

Staff Specialist Staff trained in crisis assessment, client sensitivity, solid knowledge of community resources

Staff trained in housing stability, with solid knowledge of CoC projects

Staff trained in client assessment, client sensitivity, solid CoC knowledge, estab. trust w/ client

Assessment Stages

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Crisis Assessment

Housing Stability Assessment

Client Assessment

Key Questions Any safe, immediate housing options besides emergency shelter?

Housing barriers?Financial assistance, service intensity needed?Can HH remain stably housed w/out resources?Which project/provider is best match?

How long homeless?Housing Hx, health, finances, legal?What services must be provided to ensure safety and stability and achieve housing goals?

Outcomes End of immediate housing crisis.Diversion or entry into CoC project.

Provide “just enough” services to address client’s needs

Identify housing retention barriers.

Assign/Referral – Design Considerations

• Referral process begins when crisis assessment ends

• Guided by intentional referral protocol that follows written standards for administration of programs

• Matches threshold criteria determination from assessment to available resources within the CoC

• Tiered approach – “low” vs. “high” barrier 17

Assign/Referral Considerations:

• Project Coordination. Match provider-type determination with project(s) offered within CoC. May require triage, prioritization, or waitlist.

• System Map. Inventory all projects and document service strategy, scope, eligibility criteria, enrollment processes. Seek to prevent incompatible referrals and reduce placement time.

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Assign/Referral Considerations:

• Real-time bed vacancy and service availability. Only successful match is an available match. Real-time info can be managed manually or leveraged through HMIS.

• Relevant client history. Referral agency must have access to client’s assessment profile, history, past project placement in order to make best referral.

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Referral Collaboration

Referral agency and service provider collaboration: keep record of referral Clearly communicate expectations and timing for client transfer Determine extent of data transfer – disclosures, consents, release

authorization Can provider agency deny or defer client enrollment? Coordinate and communicate referral coordination with client Determine what resources or protocols are necessary to manage

the client transition from one program to another

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Referral Collaboration

What to do when the referral is incompatible? Process failures. Determine what broke down, when,

document issues, use practical experience to improve future processes.

Preference and circumstance-based incompatibilities. Develop mechanism for addressing client and/or provider concerns and preference differences.

Case counseling and reconciliation. Consider case conferencing to identify and mediate differences.

Provider right of refusal. What are the circumstances and protocols for providers to deny/defer enrollment?

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Assign/Referral Coordination

Creating and Managing a Waitlist:• First come first served?• Prioritization protocol – vulnerability, LOS,

subpopulation specific• Centrally managed vs. provider specific• Managing updates, changes, purges• Ensure transparency and accountability

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Performance Measurement

Coordinated Assessment performance objectives:• Quality/accuracy of assessment and

referral• Timing of linkage• Contribution to system objectives:– Reduced incidence of homelessness– Reduced homeless length of stay – Increased housing retention/decreased recidivism

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TPCH Coordinated Assessment

BREAK

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Key Considerations and Next Steps

• Decide which group is charged with leading the development of the coordinated access system. Assembling a small group to make decisions and take action will move the conversation from the backroom to the front door.

• Identify implementation steps based on an established “Go Live” date. Setting a date establishes urgency. It is important, however, to make sure that the “Go Live” date is sufficiently realistic so as not to have the reverse effect of paralyzing champions and disillusioning those less committed.

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Key Considerations and Next Steps

• Compile a detailed list of homelessness projects, referral agencies, and mainstream programs whose cooperation is required. Refer to the community analysis of stakeholders and compile your findings into an organized list of providers and their respective target populations, program dynamics, facility and bed capacities, locations, and contact information.  

• Create a report of client demographics, system inventory, and utilization patterns. Refer to the community analysis of client demographics, inventory, and utilization to create an organized report of your current client base and physical resources.

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Key Considerations and Next Steps

• Create a report of current access, assessment, and referral client flow. Refer to the analysis of the current assessment system’s client flow and draft a detailed flow chart. The flow chart will be of great use to the leadership.

 • Create a report of current access, assessment, and

referral data entry and operations work flow. Refer to the analysis of the current assessment system’s work flow and draft a detailed flow chart. The flow chart will be of great use to the governance committee.

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Key Considerations and Next Steps

• Define guiding principles and shared values. Guiding principles and shared values will be unique to each community and will emerge from one-on-one conversations between stakeholders, from small-group meetings, and from CoC-wide conversations.

 • Identify the coordinated assessment structure and

location (if applicable). Define the access and assessment structure. Agreement on the structure and location of the process will then allow the group to focus on important details that are heavily reliant on the number of locations, the type of managers at each location, and the types of co-located services.

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Key Considerations and Next Steps

• Establish clear system participation expectations for all CoC providers. Refer to the decisions made regarding access, assessment, and referral and the work flow that each partner will be required to follow. Remember – all CoC and ESG funded recipients and sub-recipients must use the coordinated assessment system.

 • Develop a community plan with mainstream

providers. The act of drafting a community plan with mainstream providers will encourage community buy-in and participation, enrich the possibilities for collaborations, and support the overall efficiency gains of a coordinated assessment system. 29

Key Considerations and Next Steps

• Determine the role of HMIS and data systems in management, monitoring, and evaluation. Create an ideal flow chart of how data will move from one step of the process to the next and then map the types of systems currently used and the systems that will need to be augmented or changed.

 • Develop a coordinated assessment–specific

financial plan. Costs should be considered with the entire CoC in mind and should be considered when discussing ESG allocations, CoC program applications, CoC reallocation processes, CoC planning dollars, CoC committee dues, CoC State and local funding, and other CoC-wide funding sources. 30

Key Considerations and Next Steps

• Develop a monitoring and evaluation plan. Developing a monitoring and evaluation plan will go a long way to meeting stakeholder demands for transparency. Make sure to plan for upfront, short-term monitoring and evaluation, which will decline in frequency with project maturity.

 • Identify a managing body for the assessment

process. Reach an agreement with the leadership regarding the agency, group, or committee charged with managing the assessment process. That body will responsible for all future referrals and referral reconciliations. 31

Key Considerations and Next Steps

• Create a resource development strategy. Develop a plan to acquire and develop resources, particularly the human resources needed to carry out access interviews and assessments, make referrals, operate new data systems, and monitor and evaluate the coordinated assessment system.

 • Develop access, assessment, and referral policies

and procedures manual as a staff resource. Develop a model for all of the steps from initial client interaction through post-referral follow-up and all of the various scenarios along the way.

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Key Considerations and Next Steps

• Identify and train access, assessment, and referral staff. Identify and train staff by using the staff policy and procedure guidebook.

 • Develop a public communication plan and

promotional material. Identify where clients currently seek services and where the community at large learns about new projects. Develop a plan that leverages existing communication networks and conveys a consistent message about system access across several channels.

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Questions and Feedback

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