Transcript Centralized Assessment & Referral

Coordinated
Assessment
Federal Definition
“… a centralized or coordinated process
designed to coordinate program participant
intake, assessment, and provision of referrals.
A centralized or coordinated assessment
system covers the geographic area, is easily
accessed by individuals and families seeking
housing or services, is well advertised, and
includes a comprehensive and standardized
assessment tool.”
- CoC Interim Rule, Section 578.3
Components
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Access
Assessment
Assignment
Evaluation
Components
1. Access: Coordinated and simplified entry
point into the homeless response system.
Components
1. Access: Coordinated and simplified entry
point into the homeless response system.
• Well-advertised, collaborative process with
no side doors and no wrong doors.
Components
1. Access: Coordinated and simplified entry
point into the homeless response system.
• Well-advertised, collaborative process with
no side doors and no wrong doors.
• Access to initial assessment no matter
where first point of contact may be.
Components
2. Assessment: Uniform, progressive assessment
and documentation of clients’ housing needs and
barriers by well-trained and clearly identified
assessors.
Components
2. Assessment: Uniform, progressive assessment
and documentation of clients’ housing needs and
barriers by well-trained and clearly identified
assessors.
• Initial Assessment : Screen to divert or prevent
homelessness.
Components
2. Assessment: Uniform, progressive assessment
and documentation of clients’ housing needs and
barriers by well-trained and clearly identified
assessors.
• Initial Assessment : Screen to divert or prevent
homelessness.
• Full Assessment: Comprehensive assessment to
identify:
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history of homelessness,
barriers to housing, and
personal goals, skills and assets of household.
Components
2. Assessment: Uniform, progressive assessment
and documentation of clients’ housing needs and
barriers by well-trained and clearly identified
assessors.
• Initial Assessment : Screen to divert or prevent
homelessness.
• Full Assessment: Comprehensive assessment to
identify:
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history of homelessness,
barriers to housing, and
personal goals, skills and assets of household.
Priority scoring based on assessment and
community prioritization.
Components
3. Assignment: Linkage to appropriate services
based on assessment, system mapping and
written programs standards.
Components
3. Assignment: Linkage to appropriate services
based on assessment, system mapping and
written programs standards.
• Utilization of uniform system tools and process
based on system mapping.
Components
3. Assignment: Linkage to appropriate services
based on assessment, system mapping and
written programs standards.
• Utilization of uniform system tools and process
based on system mapping.
• Waitlist and prioritization based on
assessment score and community priorities.
Components
3. Assignment: Linkage to appropriate services
based on assessment, system mapping and
written programs standards.
• Utilization of uniform system tools and process
based on system mapping.
• Waitlist and prioritization based on
assessment score and community priorities.
• Assistance with linkage to services for
individuals with high barriers.
Components
4. Evaluation: Comprehensive evaluation of
consumer outcome and performance (program,
agency and system) to increase; effective use of
resources (both staff and fiscal), quality of service
to consumers, and the ability to proactively
identify and plan services.
Components
4. Evaluation: Comprehensive evaluation of
consumer outcome and performance (program,
agency and system) to increase; effective use of
resources (both staff and fiscal), quality of service
to consumers, and the ability to proactively
identify and plan services.
• Establishment, promotion and review of
system-wide performance standards.
Components
4. Evaluation: Comprehensive evaluation of
consumer outcome and performance (program,
agency and system) to increase; effective use of
resources (both staff and fiscal), quality of service
to consumers, and the ability to proactively
identify and plan services.
• Establishment, promotion and review of
system-wide performance standards.
• Annual review of system tools and process with
multi-level feedback.
Why Coordinated
Assessment?
1. Opportunities for improved client outcomes.
2. Better utilize resources.
3. Opportunities for improved data:
4. Principals of effective crisis response
5. Experience with the Rapid Re-Housing Demonstration
6. CoC and ESG requirement
System Change
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CURRENT
Uncoordinated
Forms & Assessment are
unique to system
(prevention, ES, PH)
Forms & Assessments
are different for each
provider.
Referrals inconsistent
and sometimes
incomplete.
“Should we accept this
client into this program?”
COORDINATED
o Coordinated
o Standardized
assessment/forms.
o Uniform process
o Referral is
comprehensive and
done with
understanding of
entire system.
o
“What housing and
service strategy is
best for this household
based on the services
available?”
The Fargo-Moorhead Pilot
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Start Date: July 2, 2012
Goal: Soft Pilot of Coordinated Assessment
Involved 4 Pilot Agencies
Tested:
- Triage tool,
- timing,
- access,
- targeted referrals
- opening up HMIS
Included evaluations of:
- consumers,
- agencies
- community partners
What we learned!
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Triage Tool
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simplified process for consumers & Case
Managers
Training is essential.
Multi-levels assessment process is necessary
for those with higher barriers to and to
prioritize waiting lists and to help assure
accuracy of referrals.
Took about 20 minutes longer post CA, but
they felt they had a better assessment
overall.
What we learned!
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HMIS
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Open system can provide benefits to
consumers & agencies.
Need access to HMIS for non-HMIS referral
agencies.
What we learned!
Other
o Education & training is essential!
o Process in writing.
o Tool not enough,
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Case Management is needed to help
individuals prepare for housing once on the
list (obtain ID’s, gather rental history, etc.)
Few individuals follow-up on their own.
Moving Away From…
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Having to call the same programs every day for
weeks or months
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Being sent from program to program
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Finding out about more helpful programs too late
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Being asked the same questions over and over
again
CARES is a collaborative initiative between
North Dakota & West Central Minnesota
Continuums of Care (CoC) designed to
create a more effective and efficient
homeless response system.
CARES Partners
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Churches United for the Homeless
City of Fargo
City of Moorhead
Clay County Housing & Redevelopment Authority
Creative Care For Reaching Independence
Dorothy Day House of Hospitality
Fargo Housing & Redevelopment Authority
Fargo Public Library
First Link
Gladys Ray Shelter and Veterans Drop-in Center
Lakes & Prairies Community Action Partnership
Legal Services of NW MN
Moorhead Public Housing Authority
New Life Center
SouthEastern North Dakota Community Action Agency
The Salvation Army of Fargo, North Dakota
Fargo VA
Welcome House
YWCA Cass-Clay
CARES Overview
The joint CoC initiative is based upon;
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A desire to ease access to services for clients who
migrate across the ND/MN border. (26.8%
A long history of cross-boarder collaboration
FM Coalition for the Homeless
 Tri-annual Wilder Study
 Annual Homeless Point-in-time count
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A desire to have improved data.
Better understand duplication of client data & services
 Identify gaps & needs for improved system planning.
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Guiding Principles
1. Reorient service provision
2. Identify which strategies are best for each household
3. Link households to the most appropriate intervention
4. Provide timely access and appropriate referrals
5. Shorten the number of days homeless
6. Provide immediate access to information
7. Create an advanced system Collaborate
8. Provide for ongoing participation
Anticipated Benefits
1. Client focused
2. Increased efficiency
3. Improved Communication
4. Planned service strategies
5. Better-quality data
6. Greater Consistency
Anticipated Benefits
Client focused:
• Easier access. Don’t have to navigate what can
sometimes be a complex system.
• More effective outcomes for clients when linked
to right intervention.
Anticipated Benefits
Increased efficiency:
• Case managers will have quick access to online
service directory and key client data.
• Clients do not have to repeatedly fill out intake
forms and repeat their story.
• Progressive assessment and online directory
simplify eligibility and referral process.
Anticipated Benefits
Improved Communication:
• Easier for agencies to identify discrepancies,
missing data and issues.
• Agencies utilizing system have reported better
collaboration in helping client achieve goals.
Anticipated Benefits
Planned service strategies:
• Communities can prioritize service specific
populations/subpopulations based on current
trends and needs of clients.
• Service delivery system is clear and intentional.
• Written standards for administration of programs.
Anticipated Benefits
Better-quality data:
• Increased understanding of system
gaps/duplication (unduplicated & system-wide).
• Easier to review performance (agency, program
and system).
Anticipated Benefits
Greater Consistency:
• Equal access to services for anyone entering the
system eliminating inequality based on personality
conflicts, discrimination or agency/client history.
• Process (access, assessment, and referral) is the
same for everyone and based on assessment
score not where or when a client enters the
system.
Managing Expectations
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Coordinated Assessment won’t create more
housing.
An assessment tool and open system won’t deliver
perfect information.
A system mapping survey and assessment tool
alone won’t change your system.
Planning: Next Steps
1. System Mapping
2. Continue with HUD Technical Assistance
3. Establish a Governance Structure
4. Launch an open data management system.
Planning: System Mapping
1. Understand existing system interventions:
• Identify stakeholders and services in each CoC system.
• Identify the system gaps and duplications
• Identify the flow of persons through the system.
2. Help to establish link between CARES assessment and
intervention:
• Determine assessment score linkage to intervention type.
• Help individuals be placed in right intervention as soon as
possible to assure best outcome and utilization of services.
3. Help set written standards for CARES:
• List eligibility criteria for intervention and programs.
• Identify intervention components and definitions.
• Help determine processes and protocols.
4. Determine system intervention improvements:
• Evaluate inventory for potential development.
• Determine if there are needed changes to the flow.
• Analyze inventory for potential reassignment or program
specialization to better meet needs of the system.
Planning: TA
1. Coordinators participate in monthly progress calls.
2. Review TA timeline and make assignments to
respective committees.
3. Review example documents provided by TA
providers.
4. Host TA calls and webinars as needed to provide
education, support and information to identified
groups (committees, subpopulations, governance,
etc.)
5. Send proposed forms, policies and protocols to TA
providers for review.
Planning: Structure
1. Elect a Governance Board
• CoC’s vote on representatives.
• FMCHP votes on representative.
2. Participate in a Committee
• Protocol
• Implementation
• Performance & Evaluation
• Data
3. Hire Staff
• Continue to fundraise for key positions
• Evaluate reassignment of existing resources
Planning: Data
1. Participate in State of MN HMIS Technical
Assistance
2. Obtain estimate from Bowman for Data Bridge
3. Review and pilot potential assessment tools
4. Develop a fundraising plan for Data needs.
THANK YOU!
Questions?
Comments?