Coordinated Assessment Planning Workshop

Report
TPCH Coordinated
Assessment Planning
Workshop
Afternoon Session
Workshop Overview
Afternoon Session:
• Coordinated Assessment Design &
Implementation Considerations
• Defining Roles and Management
Expectations
• Key Considerations for Next Steps
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Workshop Learning Objectives:
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.
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Core Operational Components
Standardized Access and
Assessment
Access
Assess
Coordinated
Referral
Assign
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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 Responsibilities
Potential 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
monitoring
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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
resources
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Written Standards for
Administration of Programs
For each Program Type:
 Description – services and target population
 Essential Elements – what clients receive
 Eligibility Criteria – who gets in
 Program Standards – baseline expectations for
service type and quality
 Referral Sources – define where referrals will come
from
 Program Outcomes – performance expectations
 System Outcomes – linkage of program outcomes to
system outcomes
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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
Crisis
Assessment
Housing
Stability
Assessment
Client
Assessment
Also Called
Diversion, Triage,
Intake
Index, Housing
Assessment
Barrier 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 housingrelated history.
Time
When client enters
access point
0 to 7 days
7 to 14 days
0 to 3 days
0 to 7 days
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Assessment Stages
Crisis
Assessment
Housing
Stability
Assessment
Client
Assessment
Structure
Short- and lowbarrier 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.15
trust w/ client
Assessment Stages
Crisis
Housing
Client
Assessment Stability
Assessment
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.
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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
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Assign/Referral Considerations:
• Project Coordination. Match providertype 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.
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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.
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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.
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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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