Creating aUnified Person-

Centered Housing and Homelessness System

February 2015

Why Implement a Unified System?

• Most efficient use of finite resources• Improves consumer access to housing and

supports• Improves system navigation & function• Leverages the strength of individual service

providers• Proven to shorten pathway from homeless to

housed with supports• An important element in ending homelessness

Person-Centered vs. System Centered• A person-centered approach:– Tries to figure out the best way to care for the person’s

needs, holistically, and without judgment– Attempts to modify behavior through reasoning and access

to most appropriate programs

• A system-centered approach:– Tries to figure out how to determine individual system

responsibility, or co-responsibility across silos– Works to reduce costs and duplication– Attempts to modify behavior through retribution and

reciprocityWe choose person-centered!

Comprehensive Coordinated System

• System principles• Coordinated Access & Diversion• Comprehensive Assessment• Service Prioritization• Formalized Service Pathways• Accountability & Transparency

A Person Centered Service Approach

First Step: Define our Principles

Our first goal is to have agreed upon, defensible principles to inform the homeless service delivery system in our community.

• The fundamental beliefs of our system• Serve as the foundation for the behavior of our service

delivery and chain of reasoning• Inform our ethics and standards of service• Allows us to formulate opinions on “rights” and “wrongs”

in how we deliver services when made transparent.

A jumping-off point• Partners=Anyone/any agency providing “touch” to client• Need to understand system and what everyone does • Collaboration• Housing Focused• Coordinated Access structure• Person-centered Case Management• Evidence-based processes• Economically efficient system with best service delivery• Trusted communication• Treat with dignity• Follow-up with clients when exit programs/keep them housed• Clear one-step• Efficiency• Safe venue for everyone to speak

Local Work Groups: What are the NWCOC Principles?

A Person Centered Service Approach

Non-Negotiable Elements of a System Approach to Ending Homelessness

• What service providers say they do on paper is what they do in practice. No exceptions.

• Access to PSH is centralized. No secondary assessments.• As many rules/barriers/compliance requirements that can be

eliminated are eliminated.• People are people. Not a number. Not a conclusion of an

assessment.• Coordination and assessment inform choices that people can

make, not make choices for people.• Operates with transparent decision-making process. Not

dependent on case manager knowing how to skirt around the system.

Ensure the Foundation is Strong with Solid Implementation of the Basics

• Consistent tools and referral procedures• Written procedures explaining how and why

people are referred/prioritized• No side doors• Provider, funder, and consumer understanding

of the point of the process• Consistent HMIS or data tool usage…how to

share the data

Another Jumping-off point• Access

– Access points need to know the next steps/where to refer– Collaborative agency transparency– Agencies should have uniform diversion

• Assessment– To improve assessment we need consistency and follow through. We also

need improved coordination between triage and central intake. Lastly, training those that work with people experiencing homelessness on the VI SPDAT

– Community partners working with persons experiencing homelessness to complete triage

– Case managers to complete assessment– Results are shared at IST to prioritize to make sure we are Housing First and

helping most vulnerable

• Service Prioritization and Matching– Assessment (VI) is completed. Identified needs determine potential service

pathways within the community to help the referred individual/family end homelessness or achieve housing stability. VI Score of 0-4 is Information and Referral, 5-9 is Rapid Rehousing, 10+ is Housing First with supports

– Programs engage with service prioritization through IST meetings and weekly meetings between HARA staff and provider agency staff. Program stall will collaboratively identify resources, continually update and share this information. ( I&R, educate/coach, full support)

– Suggest universal Release of Information for all agencies at time of entry into homelessness services

– Unit availability share and maintained through central registry at HARA– COC should work to assure maximum utilization of existing Permanent

Supportive Housing locations– HARA to improve housing stock (available) situation with assistance of

dedicated Americorps FTE– Information from programs

• All eligibility requirements• Current caseload (capacity) and housing openings• Results of individual assessments

• Service Referrals– 211 in Manistee, Wexford, Missaukee, GT Eviction Diversion,

Faith based organizations, thrift stores, food pantries– Communication: lack of transparency in funding between

agencies making it difficult to get people sheltered. Agencies-Who answers the phone?

– Participate in Community Collaboratives and Continuum of Care. • Educate individuals to pay rent first and access mainstream

services for other things like utilities, clothing and informing tenants about their rights

– Better record keeping, especially for those not using HMIS

Local Work Groups: What is the NWCOC System Design?

A Person Centered Service Approach

Local Work Group Assignments

• What are the NWCOC Principles? Start with the first draft and build on it.

• What is the NWCOC System Design? Start with the draft and build on it.

• Continue building the Housing Resources List. • Start the discussion about the development of Policies

and Procedures for partners and community members to know exactly how to access supports when experiencing a housing crisis and/or homelessness, including a communication plan to advertise the Coordinated Access phone number to the community