Rebuilding Systems: Adapting Housing Assessments to Prioritize Health, Equity, and Belonging

Introduction

There is a significant lack of affordable housing within the U.S. The resulting process of accessing housing resources for people experiencing or at risk of homelessness is complicated, lengthy and filled with inequities. The U.S. Department of Housing and Urban Development (HUD) requires that every region create a Coordinated Entry1 (CE) system to streamline this process. The group of organizations within a region that provides and oversees homeless services and works to make this process more equitable is called the Continuum of Care (CoC) 2 In design, this system should serve as a single access point to emergency services and appropriate long-term housing. The CE system develops an order of who should receive housing first based on a series of vulnerabilities that a person or family might have. The lack of affordable housing has necessitated this ranking system.

HUD provides guidance3 on the types of risks that a community may choose to consider for prioritization. These may include specific illness or medical fragility, risk of victimization, frequency of use of emergency services, and/or continued risk of homelessness. The CoC decides which factors to include. These decisions often reflect the subjective values of the community and may not be based on risk or maximizing resources/programs. Historically, the community members experiencing homelessness are those that have experienced systemic discrimination, including Black and Indigenous communities and those with disabilities or high medical needs.4 Communities are seeking guidance on how to create equity within this housing process while balancing the pressure to focus on outcomes and cost. This process is further challenged by numerous data systems that do not interface and the reality that any intake system will serve as a barrier to many of the people it is designed to help.

By nature of “prioritization,” communities are tasked with identifying who should have housing access first, which decreases the priority of other lived experiences. There is the potential for significant inequities in the process of prioritizing individuals for scarce resources. Many studies have demonstrated that CE systems prioritize white people, which only exacerbates the inequities already in place from structural racism Our

1 Jean, M. (2020). Coordinated Entry Systems, Assessment of Vulnerability, and Housing Prioritization for People Experiencing Homelessness. Healing Hands, 24(1). https://nhchc.org/wpcontent/uploads/2020/02/HealingHands_USE_020620.pdf

2 What is a Continuum of Care? - National Alliance to End Homelessness. (2010, January 14). https://endhomelessness.org/resource/what-is-a-continuum-of-care/

3 Notice CPD-16-11: Prioritizing Persons Experiencing Chronic Homelessness and Other Vulnerable Homeless Persons in Permanent Supportive Housing. (n.d.). Retrieved May 15, 2023, from https://www.hudexchange.info/resource/5108/notice-cpd-16-11-prioritizing-persons-experiencing-chronichomelessness-and-other-vulnerable-homeless-persons-in-psh

4 Jones, M. M. (2016). Does Race Matter in Addressing Homelessness? A Review of the Literature. World Medical & Health Policy, 8(2), 139–156. https://doi.org/10.1002/wmh3.189

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The need for housing prioritization results from a lack of affordable housing. Existing tools have been applied universally and have resulted in further inequity. This toolkit is intended to help communities create a process that centers equity and community-specific needs.

country’s long history of providing housing and employment opportunities for white people while simultaneously disinvesting in housing, services, education and opportunity for minority communities, especially Black people, has created a country where people who are not white are more likely to experience homelessness. With previous tools’ focus on prioritization based on “vulnerability,” which was often defined through mortality risk and medical need, those with disabilities or significant health issues were prioritized for housing but at the expense of not acknowledging other systemic causes of homelessness, such as racism.

True equity would be everyone in a community having access to safe, affordable and accessible housing; and justice would be reflected in systems that do not cause homelessness in the first place. However, until that is achieved, communities need resources to work toward a more equitable housing prioritization process and to respond to past inequities created by existing systems while acknowledging the multiple causes and contributors to homelessness.

This toolkit is designed to help communities analyze and improve the processes they use to prioritize individuals for housing, including assessing for supportive services and adaptations to sustain housing. It provides a framework for identifying and correcting the inequities created and perpetuated by racism and bias.

To understand the background and need for this toolkit, please review the factsheet “Rebuilding Systems: Adapting Housing Assessments to Prioritize Health, Equity, and Belonging.” Engaging in the work to create a more equitable housing prioritization system means we must acknowledge the trauma caused when a person is forced to live without a house. This work must include a trauma-informed approach5 that not only acknowledges the past trauma but also the ongoing trauma of these oppressive systems and actively works to stop and reverse the tools that unintentionally perpetuate them.

How to Use This Toolkit

As identified in the factsheet “Rebuilding Systems: Adapting Housing Assessments to Prioritize Health, Equity, and Belonging, ” there is not one tool that communities can or should use alone to prioritize and enter individuals or families within the housing prioritization system. Therefore, communities will need to shift from a “tool” perspective

5 To learn more about becoming a trauma-informed organization, please visit the Trauma-informed Organizations Change Package. This manual provides concrete trauma-informed improvement strategies that can help organizations think through potential improvements that move them toward more traumainformed policies and practices.

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to re-imagining a process that is as equitable as possible. This shift can be complex and requires the buy-in and participation of multiple community entities. However, this change is necessary to respond to and replace inequitable processes that do not truly meet the needs of those who are intended to be served.

Key Considerations Before Getting Started

1. Use evidence- and inquiry-driven tools and processes that can be replicated and evaluated in your community context. We understand that this is time-consuming and arduous, but the impact cannot be over-emphasized.

2. Make sure every step of creating or adapting a process meaningfully includes people with lived experience.

There is not a “one-size fits all” approach to housing prioritization, in part because each community’s resources, population, and priorities are all unique. Instead of offering a specific “model” for each community to follow, this toolkit is intended to be a framework to both evaluate current processes and identify methods to improve the housing prioritization and CE system. As a framework, this toolkit will not be able to provide all the answers for all communities. Still, it can guide conversations, determine voices that should be in these discussions and identify best and promising practices that can be implemented. 6,7

3. When determining team responsibilities and process workflows, ensure actions are within the scope of each person's role, experience and training.

Each of the considerations and practices recommended is rooted in trauma-informed practices. As communities apply these strategies, it is important to maintain these practices, even as strategies are adapted.

Features of the Guide

This guide includes nine sections that can be used linearly or separately:

• Communities may opt to move through this resource from start to finish or identify one specific section to enhance and adjust their processes.

• Communities that are seeking to evaluate and redevelop their systems are encouraged to start in the first section and move through the toolkit in order.

• Smaller work and partner groups may be able to address each section simultaneously to collectively redesign their process.

6 Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. The Open Health Services and Policy Journal, 3(1), 80–100. https://doi.org/10.2174/1874924001003010080

7 Trauma Informed Care | The Homeless Hub. (n.d.). Retrieved May 15, 2023, from https://www.homelesshub.ca/about-homelessness/mental-health/trauma-informed-care

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Each section includes a set of questions to help communities begin to evaluate their current processes, needs and spaces for improvement based on the section’s focus and content.

The appendices, as well as resources within each section, provide examples and further deep dives of the information presented in the toolkit

Terminology across communities varies widely. The glossary section will help guide you on how terms are used in the context of this toolkit:

• When starting the re-imagining work, it may be helpful for all partners to review the terminology and define terminology that is specific to the community.

This toolkit acknowledges that not every community is in the same place or has the same resources.

• In each section of this toolkit, suggested potential practices for each topic are included using a “Good, Better, Best” framework.

• We encourage you to identify where you are and what a reasonable next step is for your community. It is possible, and likely, that you may be able to implement different strategies in different areas perhaps “good” in one area and “best” in another. Start with what makes the most sense in your context, and continue moving toward what is best for your community. Equity should be incorporated into the strategies at every topic and level. For example, if you start with partner engagement, consider who is at the table and how this can impact equity.

Finally, research and best practices in this area are constantly being developed and improved. Communities should seek out and ensure they have up-to-date and recommended practices on these topics.

Figure 1 provides an overview of the “Good, Better, Best” recommendations for the housing prioritization process.

Stage Good Better Best

Look at prioritization data and compare to the population served

Compare quantitative data and collect qualitative data

Utilize mixed-methods data and develop a community resource map

Engage CE and CoC providers and staff

Engage housing staff and people with lived experience (PLE)

Engage housing staff, PLE and cross-sector partners

Center equity in the prioritization process

Center equity and include medical needs

Center equity and medical needs and match services to needs

Research validated tools on housing prioritization

Research validated tools to meet goals

Research validated tools to meet goals and connect with other communities

Determine logistics

Assemble process components (maintaining integrity of any validated tools selected) and train staff

Assemble process components and provide ongoing training and incorporate case conferencing

Assemble process components, provide ongoing training including traumainformed care and use case conferencing to match services

Test the process with navigators to address challenges proactively

Test the process to address challenges and review outcomes

Test the process, review outcomes and allow ongoing assessment updates

Ongoing evaluation

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Track outcomes and review annually

Track and regularly review outcomes and continue to adapt process and training to reach goal

Track outcomes and adapt processes to meet goal and measure quality-oflife outcomes with individuals

Figure 1. Overview of the “Good, Better, Best” framework as applied to reworking the housing prioritization process.

Reframing With Equity

Self-Assessment Questions

To assess your community’s current status on infusing equity into your housing prioritization process, please answer the following questions:

• Have we assessed our system to identify disparities?

• Are members of our decision-making group reflective of the community we serve?

o Is this a multidisciplinary body?

o Is the group diverse considering race, ethnicity, sexual orientation, gender, health status, etc.?

o Are people with lived experience part of this group?

• Do we have training on equity, justice, diversity, and inclusion?

o Who is trained on these topics?

o How often are we holding trainings?

o Do we take trainings incrementally, seeking a higher level of understanding (i.e., 101, 202, 303, etc.)?

o Who is conducting these trainings? Do we include outside experts who can critically assess our community and help us achieve our goals?

o Who is responsible for holding people/systems accountable to these trainings?

Introduction

The evidence shows that our current housing prioritization tools and processes exacerbate inequities that exist among people experiencing homelessness. Therefore, it is essential that the development of any process that takes its place starts and ends with equity.8 The updated “All In: The Federal Strategic Plan to Prevent and End Homelessness” identifies “lead[ing] with equity” as one of the three foundational pillars to end homelessness.9 Addressing equity takes time and necessarily ties into every aspect of updating a housing prioritization process. Woven through an equitable process should be trauma-informed practices and cultural humility when responding to

8 Equitable Coordinated Entry Systems. (n.d.). C4 Innovations. Retrieved May 22, 2023, from https://c4innovates.com/our-expertise/housing-solutions/equitable-coordinated-entry-systems/

9 Lead With Equity. (2022, December 22). U.S. Interagency Council on Homelessness (USICH). Retrieved May 15, 2023, from https://www.usich.gov/fsp/lead-with-equity

the needs and experiences of the people served. A truly responsive, equity-centered system and process allows communities to adapt in ways that strengthen their entire community.

In January 2021, the White House issued an executive order10 proposing strategies for the federal government to advance equity, which it defined as:

“[T]he consistent and systematic fair, just, and impartial treatment of all individuals, including individuals who belong to underserved communities that have been denied such treatment, such as Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.”

The U.S. Department of Health and Human Services (HHS)11 and HUD12 also developed plans that include strategies/plans to:

• “[Focus] on resourcing and implementing equity assessments across the [HHS] department’s major policies and programs.” (HHS)

• Promote the Minority Health Social Vulnerability Index developed by the Centers for Disease Control and Prevention (CDC) and the HHS Office of Minority Health. (HHS)13

• “Support partners to create tailored, equitable solutions for individuals’ needs informed by their lived experiences by building on prior pilot programs that bring people with lived experience into the decision-making process both with federal funding decisions and local program design decisions.” (HUD)

• “Provide technical assistance and guidance to assist communities in implementing and improving CES involving client-focused approaches and strategies that center racial equity.” (HUD)

10 Exec. Order No. 13,895, 3 C.F.R. 7009-7013 (2021).

https://www.federalregister.gov/documents/2021/01/25/2021-01753/advancing-racial-equity-and-supportfor-underserved-communities-through-the-federal-government

11 Assistant Secretary for Public Affairs (ASPA). (2022, April 14). Advancing Equity at HHS. U.S. Department of Health And Human Services (HHS). Retrieved May 15, 2023, from https://www.hhs.gov/equity/index.html

12 HUD Equity: HUD’s Equity Action Plan. (n.d.). U.S. Department of Housing And Urban Development (HUD). Retrieved May 15, 2023, from https://www.hud.gov/equity

13 Minority Health SVI. (n.d.). HHS Office of Minority Health. Retrieved May 15, 2023, from https://www.minorityhealth.hhs.gov/minority-health-svi/

As communities work to increase equity, they should consider starting with this definition, building out what this looks like in their own context, and incorporating both health and housing equity into the conversation.

Equity requires a multidisciplinary approach. It takes partnership and agreement to both prioritize equity within a system and develop a culture of equity across roles. If there is not buy-in from the front-line staff or the leadership within an organization, there will inevitably be people and processes that fall through the cracks. If partnering organizations do not commit to equity, the revamped processes will not be implemented, and people will be left out. At the center of all this is the importance of knowing who your partners and collaborators are and ensuring that individuals with lived experience are valued partners in this work. Partners in this work can and should include community-based equity advocates and leaders from the communities that are highly impacted by the housing system

Consider Intersectionality

When communities are considering how they will build a process infused with equity, it is essential that they also acknowledge and incorporate intersectionality into the discussion. According to the Center for Intersectional Justice, “intersectionality describes the ways in which systems of inequality based on gender, race, ethnicity, sexual orientation, gender identity, disability, class and other forms of discrimination ‘intersect’ to create unique dynamics and effects.”14

In looking at our housing systems, we should consider how intersectionality is at play in our community. Does our system or prioritization process address how a trans woman of color could be at greater risk of homelessness and service disconnection than any one of those identities individually? Does it consider how systemic issues of racism or ableism cause and contribute to health disparities? How we assess and address the uniqueness of an individual within a process is just as important, if not more, than the system or process itself.

Equity is not a stand-alone piece of the puzzle. It can and should influence each of the areas of this toolkit, and each piece of the toolkit can help move a system toward equity.

Map the Current System and Process

The adage “you don’t know what you don’t know” is important to remember when a community is reframing its housing processes. Starting with an equity-based inquiry into your current system can help to identify what the housing prioritization process looks like from all sides. Use this information to create a map of the system looking at who is involved, the steps and flow of the process, who shoulders the burden of making those

14 What is Intersectionality. (n.d.). Center for Intersectional Justice. Retrieved March 30, 2023, from https://www.intersectionaljustice.org/what-is-intersectionality

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steps happen, the timeline between steps (average and/or range), and barriers that are present in this process.

An important piece of understanding the system is to bring in those who are part of it the community partners. This group should include diverse perspectives and experiences and ideally be able to speak to their experience and knowledge at the multiple levels of a system (micro, mezzo and macro). This group of partners can help inform ways in which the system is operating and identify specific pain points within the system, including gaps, unmet needs and disparities they are aware of. This is essential to understanding the actual workflow rather than the intended workflow of the current system. It will also clarify whether the process works the same regardless of who is being navigated and doing the navigating through the steps. This inquiry should also seek to understand the experience of people who have moved through the process. Knowing where individuals with lived expertise find barriers within the current process is the only way to adequately address those barriers and make a system that functions for everyone. This group should also contribute to developing solutions as ideas are created and a revised process is developed. It is important to ensure that people who work or live in Black and Brown communities are part of this conversation.

Potential Partners

Community health workers (CHWs)

Social workers

Neighborhood leaders and members

Social justice advocates and/or community advocates

Community-based nurses

Legal aid

SSI/SSDI outreach, access and recovery (SOAR) workers or case managers

Subject matter experts who have contributed to local reports on health disparities or participated in research and/or advocacy

There may be barriers to engaging members of the communities you serve, but communities can engage a trusted community leader to facilitate and lead this process in a way that preserves safety for those engaging.

Deeper dives into partner engagement and integrating people with lived experience as partners are available in other sections of this toolkit.

Community and System Goals

When communities seek to create a change, it is essential to define their goals. To inform their goals, communities could consider evaluating where disparities are exacerbated through their current process, including asking:

• Are there certain screening questions that are biasing the responses?

• Is there a difference in the completion of process requirements between the groups?

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• Are we meeting people “where they are”?

• Have we identified barriers to accessing the housing system and barriers to moving through it?

• Is there missing information that could help us connect individuals to appropriate services?

• Which groups are unable to navigate the system? Without solid, measurable goals and objectives, the process risks falling into old patterns or disorganization and continuing to perpetuate existing inequities

Some questions to consider as the community sets goals include:

What Does a Functional, Equitable System Look Like?

1

Allowing partners to think outside the box can lead to true innovation. As a community seeks to build a functional and equitable system, it may be helpful to start from the beginning stripping back to what a housing prioritization process can, should, and must include.15 Then, partners can look at barriers and identify what is not necessary to include in the process.

How Do We Define Successfully Achieving Equity?

2

What Pieces of the System Can Be Changed to Improve Equity?

Envisioning what a successful process looks like is a great way for a community to understand the overall goal and what progress will look like. This necessarily starts with knowing what the baseline is and what needs to be a priority what are the current disparities and inequities in the process? As part of this conversation, a community may want to discuss whether the goal is to mitigate inequities as people enter and move through the system, where the people accessing housing and entering the prioritization process mirror the population experiencing homelessness. Or, if the goal is to close the gap, identifying who is overrepresented in the homeless population, who is accessing housing through the system, and whether it is proportionate to the overall population of people experiencing homelessness. 3

Revisiting what a functional system looks like and what the current system looks like, identify where there are discrepancies between the two. This is one way to identify opportunities for change. This should also be crosschecked with what is required of the process and the partnering organization oversight. Processes are often assumed to be required

15 Coordinated Entry Core Elements. (2017). U.S. Department of Housing and Urban Development (HUD). Retrieved May 15, 2023, from https://files.hudexchange.info/resources/documents/Coordinated-EntryCore-Elements.pdf

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because they are ingrained, but they can actually be revised. Knowing what is and is not changeable can allow the community to prioritize equity through policy and process within their systems.

Implementation

It is not enough to focus on creating equity in the components of the system. Equity must also be infused into the operation of the system. As part of implementing a process for housing prioritization, communities should embed strategies for integrating equity into their implementation plan. This could be through staff training, data collection, partner and community working groups, and more. Staff training for all who are part of the homeless response system can help to ensure a common language and understanding of what it means to be equitable and address bias in existing systems. Many tools have been developed to support staff training. Incorporating some of these tools along with formal training and conversation is key. A sample of the available racial equity tools is included in the resources below.

Data is a valuable tool for supporting equity within a prioritization process, starting with the assessment of disparities in an existing system. Both HUD16 and the National Alliance to End Homelessness17 have created tools to help communities identify and understand disparities within their housing system. Once disparities are identified, they can be addressed.

As communities review and implement policies, practices, and tools that align with the overarching goals of the process and community, they should use their assessment to address the pieces of their system that they identify as needing improvement. Additionally, communities can reference resources and guides that help to incorporate equity into the planning process, including the recommended action steps from the Racial Equity Network18 and the Coordinated Entry Systems Racial Equity Analysis of Assessment Data report,19 included in the resources below.

More information on models of prioritization processes is available later in the toolkit.

Planning and assessing equity do not end when the community reaches the point where they have a process ready for implementation. Running a pilot of the new or updated process before using it for prioritization can allow the community to identify unexpected barriers and further refine the process before implementing it systemwide. To identify opportunities to address implicit bias, communities should also consider

16 HUD. (2022, March). CoC Analysis Tool: Race and Ethnicity. HUD Exchange. Retrieved May 15, 2023, from https://www.hudexchange.info/resource/5787/coc-analysis-tool-race-and-ethnicity/

17 The Alliance’s Racial Equity Network Toolkit. (2021, March). National Alliance to End Homelessness. https://endhomelessness.org/resource/the-alliances-racial-equity-network-toolkit/

18 The Alliance’s Racial Equity Network Action Steps: Addressing Racial and Ethnic Disparities in the Homelessness System. (n.d.). National Alliance to End Homelessness. Retrieved May 15, 2023, from https://endhomelessness.org/wp-content/uploads/2020/02/REN-Action-Steps-final.pdf

19 Wilkey, C., Donegan, R., Yampolskaya, S., & Cannon, R. (2019a). Coordinated Entry Systems: Racial Equity Analysis of Assessment Data. C4 Innovates. https://c4innovates.com/wpcontent/uploads/2019/10/CES_Racial_Equity-Analysis_Oct112019.pdf

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looking at differences in scoring based on who is assessing, as well as the location of assessments and the population assessed at that location to ensure they are accessible to everyone who needs access to housing. Incorporating continuous quality improvement practices and evaluating the process with an equity lens on an ongoing basis is important to ensure that any new barriers or disparities are addressed as they arise.

More on program evaluation is available later in this toolkit.

Recommendations

This section is divided into recommendations by “good, ” “better” and “best” practices for reframing with equity.

• Identify disparities in your system through data and review the data at regular intervals.

• Train staff and partners through a one-time, introductory training on equity and bias.

Good

• Engage an equity committee made up of partners and collaborators to inform the process and practices related to housing prioritization and supports.

• Identify disparities in your system through data, using both quantitative and qualitative methods, and review multiple times each year

• Train staff and partners on equity and bias on an ongoing basis.

Better

• Engage an equity committee made up of partners and collaborators to inform the process and practices related to housing prioritization and supports and provide continuous oversight of equity-related work.

• Identify disparities in your system through data, using both quantitative and qualitative methods, including barriers to access and navigation of the system

Best

• Train staff and partners on equity and bias on an ongoing basis, making space for regular conversation and affinity groups.

• Engage an equity committee made up of partners and collaborators to inform the process and practices related to housing prioritization and supports and provide continuous oversight of equity-related work. The chair of the committee holds a leadership role in the decision-making of the system.

• Review and adapt the system continuously to ensure changes are addressing disparities.

• Employ peer workers to build trust and community to better engage people experiencing homelessness to reduce inequity at entry and within the system. Utilize their knowledge to identify gaps in community outreach, both geographically and in the types of services needed. Build robust partner and community engagement practices as part of this effort.

Key Takeaways

Framing a housing prioritization process in equity requires understanding the system as it currently functions.

Bringing people to the table is an essential part of equity and should include people with lived experience and community leaders.

Focusing on equity cannot be a one-time thing. Communities must choose to continuously infuse equity at every step of the process, and it should be part of the ongoing evaluation.

Resources

• U.S. Interagency Council on Homelessness (USICH): All In: The Federal Strategic Plan to Prevent and End Homelessness

• C4 Innovates: Coordinated Entry Systems: Racial Equity Analysis of Assessments

• National Alliance to End Homelessness: Racial Equity Network Action Steps

• National Alliance to End Homelessness: Advancing Racial Equity: Community Highlights

• Racial Equity Tools: Strategies

• Government Alliance on Racial Equity: Racial Equity Toolkit

• Equity Assessment Tools

o HUD: CoC Analysis Tool: Race and Ethnicity

o National Alliance to End Homelessness, Racial Equity Network Toolkit

Planning Group and Partner Engagement

Self-Assessment

In order to assess your community’s current status of partner engagement, please answer the following questions:

• Do we have an established partner group that reflects the population served?

• Do we center equity and lived expertise in the engagement process?

• Do we use cross-system data to estimate monthly and annual needs and gaps to advocate for resources that will right-size the system?

o Do we continuously review the system and adaptations to ensure changes are addressing disparities?

Identifying and Engaging Partners

Partners are individuals or organizations who have an interest, personal or professional, in the topic at the center of the work.20 To identify partners, communities should identify the individuals and groups who would benefit from engagement and improvements in the system. From this, communities need to consider which of these partners should be involved in the planning process. Partners can fill a variety of roles, including providing feedback and expertise to identify problems and barriers, develop solutions, establish essential partnerships, and evaluate the changes made.

To ensure that housing prioritization systems are comprehensive and accessible, a variety of partners should be involved in all aspects of the redesign process. Having different perspectives and resources can result in a more comprehensive and equitable plan that is aligned with existing community resources.

Identifying Partners

To help identify potential partners, some questions to ask include:

• Who will benefit from this?

• Who has frequent contact with people experiencing homelessness in the community?

20 Guise, J., O’Haire, C., McPheeters, M. L., Most, C., LaBrant, L., Lee, K. L., Cottrell, E., & Graham, E. (2013). A practice-based tool for engaging stakeholders in future research: A synthesis of current practices. Journal of Clinical Epidemiology, 66(6), 666–674. https://doi.org/10.1016/j.jclinepi.2012.12.010

• Who are the people with lived experience of homelessness? Who is currently involved in the housing prioritization system?

• Who is not involved but perhaps should be?

• Who provides affordable housing in our community?

• Who refers (or should refer) people experiencing homelessness to the CoC, and who completes the housing prioritization process?

• Who provides health care to people experiencing homelessness but are not considered homeless service providers?

The work of the local CoC will likely involve and benefit from a number of community and government programs. The examples below are groups that might be interested in participating in a planning group, workgroup, or advisory board. Appendix A can be used to organize partners, contact information, and potential benefit to engagement.

Key partners and/or stakeholders to consider include:

• People experiencing homelessness and/or those with lived experience (both people housed through CE and housed outside of CE)

• HUD CoC staff

• Homelessness response system staff including (but not limited to):

o CE assessors

o Outreach and navigation team members

o Case managers

o Peer advocates

o Emergency night shelter staff

o Housing providers

o Privately funded homeless shelters/drop-in centers

• Local government representatives

• Health centers and health care for the homeless programs

• Social service agencies

• Jails/prisons/detention centers

• Substance-use treatment centers

• Police department representatives

• Emergency medical services

• Public health departments

• Veterans Affairs services

• Behavioral health and psychiatric providers (local mental health authority)

• Public housing authority

• Other homelessness service providers

Engaging Partners

Once the potential partners have been identified, communities can implement the following steps for effective stakeholder engagement:

• Define the goals, scope, and purpose of partner engagement.

• Determine the logistics for partner engagement.

• Decide who will engage and recruit partners.

• Build the structure of the planning group. Consider subcommittees/working groups that are assigned specific deliverables to move progress and increase engagement.

• Convene the stakeholder group.

• Analyze the results of the engagement.

• Conclude the process.

Table 1 provides a framework for stakeholder recruitment and engagement in the program development process.

Table 1. Steps for Partner Engagement.

Step for Partner Engagement

Define the goals, scope, and purpose of engagement

State the purpose of partner engagement and desired results or outcomes

Tasks to Complete

 Identify the overall goal

 Identify goal(s) for engaging partners.

 Identify desired outcomes after engaging partners.

 Identify time involvement for partners.

 Identify the preferred number of partners

 Identify the length of involvement for partners

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Determine logistics

Identify the resources needed to engage stakeholder groups effectively Context of engagement

 Identify which steps of the program process would be helpful to have partners’ feedback and participation.

 Identify funding to compensate people with lived experience

 Determine the location of partner planning group meetings.

 Determine the frequency and duration of partner planning group meetings.

 Identify the meeting structure (full group versus working group) and the reporting structure.

 Identify whether support or staffing is needed.

 Identify whether you will be using consulting or project management services.

 Identify the technology supports needed.

 Identify whether you will be providing refreshments.

 Identify whether you will be providing printed materials or other supplies.

 Identify costs and/or funding for materials needed.

Decide whom to engage and recruiting partners

Develop a list of relevant partner planning groups, including the number of partners for each group

Consider including a diverse group of individuals who represent different aspects of the community

 Identify specific individuals within each planning group to contact.

 Plan one or more methods of contact (e.g., write email scripts or telephone dialog to convey expectations of partners).

 Clearly communicate the goal of your initiative and anticipated time commitment.

 Plan recruitment follow-up (e.g., repeat emails or return calls for refusals or nonrespondents).

 Contact individual partners, and document the results of individual responses.

 Monitor distribution of planning groups; add individuals to recruitment as necessary to ensure target stakeholder groups are included.

 Identify leads for working groups.

Step for Partner Engagement

Build the structure of the planning group

Define the roles of various partners and the expectations of partners

Organization of partners and planning group

Tasks to Complete

 Provide an orientation to the CoC and housing prioritization process; provide related materials as needed.

 Identify expected outcomes of partner engagement.

 Identify roles, responsibilities, and expectations.

 Describe the extent of expected commitment and project schedule.

 Provide contact information for project coordinators.

 Organize partners into various work groups that align with the steps of the program development process.

Convening the planning group and disseminating products

 Identify engagement method (in-person, virtual).

 Determine priorities for each planning group.

 Identify concrete activities for each planning group.

 Identify a plan to achieve outcomes for each group.

 Hold partner and planning meetings and conduct related activities.

Analyzing the results of the engagement

Document, review, synthesize and report partner outcomes

 Conduct feedback from partners regarding process.

 Identify outcomes from each work group.

 Plan for review and validation of results by partners to ensure that their intended priorities are accurately communicated.

 Develop products to support implementation of the program.

 Share outcomes with the larger partner group and/or community members.

Conclusion

 Share outcomes with the larger partner group and/or community members.

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Dissemination  Express appreciation to partners for their participation.

Being thoughtful in the partner engagement process will help to ensure a broad representation of perspectives, which is essential in the next steps of the housing prioritization redesign process.

Recommendations

This section is divided into recommendations by “good,” “better” and “best” practices for engaging partners and the community.

• Engage CE and CoC providers and staff.

• Establish a partner planning group that reflects the population served, including people with lived experience

Good

• Identify the group’s goal; center equity and lived expertise in the process

• Engage CE and CoC providers and staff.

• Establish a partner planning group that reflects the population served, including people with lived experience

Better

• Identify the group’s goal; center equity and lived expertise in the process.

• Use cross-system data to estimate monthly and annual needs and gaps to advocate for resources that will right-size the system.

• Engage CE and CoC providers and staff

• Establish a partner planning group that reflects the population served, including people with lived experience and others engaged with homeless services and programs within the community.

Best

• Identify the group’s goal; center equity and lived expertise in the process.

• Use cross-system data to estimate monthly and annual needs and gaps to advocate for resources that will right-size the system.

• Review the system regularly and adapt to ensure changes are addressing disparities.

See the toolkit sections Integrating People With Lived Experience as Partners and Measuring Performance and Evaluating Programs for more information on including people with lived experience and setting up a process for using data.

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Key Takeaways

It is critical that equity and the voices of community members with lived expertise are centered as subject matter experts in each phase of the planning process.

Establish a partner planning group that reflects the population served, including people with lived experience and others engaged with homeless services and programs within the community.

Use cross-system data to estimate needs and gaps to advocate for resources that will right-size the system; review the system regularly and adapt as needed to ensure changes are addressing disparities.

Integrating People With Lived Experience as Partners Within the CoC and CE Process

Self-Assessment

In order to assess your community’s current status in integrating people with lived experience as partners in CE, please answer the following questions:

• Do we include individuals with lived experience in our leadership and workgroup activities?

o If yes, are we using strategies that are inclusive and supportive to ensure equitable engagement?

• Do we include more than one individual with lived experience, and do our lived-experience partners reflect the different communities of people seeking housing through our CE system?

Engaging those with lived experience of homelessness is essential to re-imagining the housing prioritization process. Those with lived experience bring valuable insights into the barriers and experience of engaging in systems that are not represented by other partners. Re-imagining a system that does not include this experience will continue to perpetuate biases, trauma, and unnecessary hurdles to housing. By including those with lived experience within the re-imagining process and ongoing work of CoCs, new strategies can be identified that will help to better engage those experiencing homelessness and contribute to a more equitable process.

It is critical that those with lived experience are equally included in the CE process, that feedback and perspectives gained are used and applied, and that the lived experience perspective is valued, respected and prioritized. Communities should seek to avoid tokenism, or only including people with lived experience as examples and not truly integrating them and their experiences into the work.

Effective and inclusive engagement includes:

Ensuring opportunity for participation

Assigning equal ranking to all other partners and offering compensation when possible

Including people currently experiencing homelessness along with formerly unhoused individuals

Respecting the voice and opinion of those with lived experience, even when it may be uncomfortable or highlights parts of the system that are not working

Offering different opportunities for involvement so a variety of skill sets can be able to contribute to the process

The following section provides specific recommendations to include people with lived experience in the re-imagining and ongoing CE process

Recommendations for Integrating People With Lived Experience in the CE Process

Recommended for All Communities

• Use a trauma-informed approach to ensure safety for all members of the housing prioritization stakeholder work and planning groups.

o Establish group-identified ground rules for participation, such as ensuring everyone has the opportunity to speak and share their perspective, respecting everyone’s contributions and maintaining confidentiality of conversations/meetings as appropriate.

• Ensure that meeting times and locations are always accessible to those with lived experience.

• Ensure that people with lived experience have access to technology to participate, and provide support for accessing this technology (e.g., Zoom meetings, email, phone, etc.)

• Examples of making participation accessible include:

o Meeting times that are flexible and accommodating of work or shelter schedules

o In-person meeting locations accessible by public transit

o Virtual meetings that do not require prohibitive technology to participate (such as a subscription to a service or only useable on a computer)

o Participants are supplied with resources to mitigate barriers (e.g., bus passes or cab vouchers, tablets for Zoom meetings)

• People with lived experience are given formal recognition for their time contributed to the workgroup and ongoing CE activities, such as certificates that indicate time spent in workgroup activities or including workgroup leaders as references.

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Good

• The housing prioritization workgroup includes at least two people with lived experience, which may include individuals employed by engaged agencies.

• People with lived experience are engaged on a volunteer basis (if other workgroup members not employed by the CoC are also volunteers).

• People with lived experience are recognized for their time and participation (via certificate, ability to put experience on a resume or recognition at public events, as preferred).

• People with lived experience receive support to attend meetings (e.g., payment for transportation, meals provided at meetings).

• People with lived experience are engaged in ongoing work of the CoC, including evaluation and revision of processes.

• The housing prioritization workgroup includes at least three or four people with lived experience who represent different subpopulations of those experiencing homelessness in the community (e.g., representing different gender identities, race, age, duration of homelessness).

Better

• Workgroup members with lived experience receive a stipend for time and participation in the workgroup.

• People with lived experience receive support to attend meetings (e.g., payment for transportation, meals provided at meetings).

• People with lived experience are given opportunities to hold leadership positions or direct some component (e.g., leading a smaller workgroup) and receive mentorship and support as needed when within these roles.

• People with lived experience are given ongoing opportunities to engage in the process, including evaluation and ongoing decisionmaking after the initial process or pilot is determined.

• More than four individuals with lived experience are part of the workgroup so that there is lived experience representation in any/all smaller workgroups.

Best

• People with lived experience are paid for their time to participate in workgroup meetings and activities (including if they are employees of participating organizations).

• People with lived experience receive support and opportunities to hold leadership positions within workgroup activities.

• People with lived experience are given different opportunities for participation that match with preferred activities and skill sets.

• People with lived experience are engaged in ongoing work of the CoC, including evaluation and revision of processes.

• People with lived experience are engaged in the housing prioritization process, including roles such as peer support and/or decision-making activities.

Key Takeaways

People with lived experience should be meaningfully involved in the CE planning group and in smaller workgroups.

Workgroups should utilize trauma-informed principles and practices to ensure the safety of people with lived experience participating in the process.

The planning groups should be accessible to people with lived experience, including meeting format, time and compensation for participation.

Resources

• NHCHC: Consumer Advisory Board Manual. Provides guidance for health centers on including consumer advisory boards.21 Applicable to CoCs.

• PubMed Central: “Engaging women with lived experience of homelessness: Using the Community of Solutions Framework.” This paper highlights a novel use of the Community of Solutions framework by Downtown Women’s Center, located in Skid Row, Los Angeles, to guide community health improvement work with women who are survivors of domestic violence and have lived experience of homelessness.

• NHCHC: Trauma-Informed Organizational Toolkit This manual provides concrete trauma-informed improvement strategies that can help organizations think through potential improvements that move them toward more trauma-informed policies and practices

21 A consumer is a term used to describe a person with the experience of homelessness who either is using/has used services at a health center or medical respite program

Centering the Preferences of Community Members Experiencing Homelessness

Self-Assessment

In order to assess your community’s current status in integrating the preference of people experiencing homelessness in the housing prioritization process, please answer the following questions:

• Do we currently include the person’s or family’s preferences for housing within the coordinated assessment?

o If yes, how do we capture this?

• Is the information gathered around the person’s or family’s preference actually utilized in the prioritization and housing selection process?

o If yes, how is this integrated into the process?

• Do we follow up and assess housing satisfaction with those who have been housed through the CE system?

Introduction

People experiencing homelessness are often told how they should engage in their daily lives, what resources they should use, and to be appreciative of what they receive. However, most people prefer autonomy in decision-making around their personal lives, including where they live. Often, the voices of unhoused community members are an afterthought when re-imagining service systems or even when determining where someone will live when exiting homelessness. Instead, the perspective of people with lived experience and who are currently unhoused should be centered in the conversation of housing prioritization. Additionally, because of the high prevalence of trauma among people experiencing homelessness, services and systems should be implemented using a trauma-informed approach. Inclusion of those with lived experience in the CE process is critical. However, it is equally important to integrate and prioritize preferences of the person seeking housing when they are engaged in the CE process.

Integrating Housing Preferences

Integrating preferences of community members and families experiencing homelessness within the housing prioritization process means providing and honoring the person’s (or family’s) choice and priorities when exploring housing options. Within the process, community members experiencing homelessness should have an opportunity to identify what is important to them and how this can be met by the housing available. This information should be gathered at the beginning and throughout the housing prioritization process, as needs may change. This information can be acquired through informal conversations or more formal checklists. These

preferences should be documented along with other key information so that it is easy to access and communicate across providers.

Examples of preferences for housing could include (see Appendix B for more examples):

Location (neighborhoods, transportation line, close to certain resources, etc.)

Safety (determined by the person, including neighborhood, number of windows/doors, controlled access to units, presence of security/staff, etc.)

Housing type (apartment, stand-alone, efficiency versus one-bedroom, etc.)

Location within building (first floor versus upper level)

Facility rules (visitors, pets, etc.)

Housing navigators should also be aware of different resources available and potential barriers to the community’s neighborhoods and housing options. This should be informed by those with lived experience who are engaged in the housing prioritization redesign process, as well as members of the community and neighborhoods.

Recommendations for Integrating Individual Preference

This section is divided into recommendations for all communities and then by “good,” “better” and “best” practices for integrating the preferences of the person engaged in the CE and housing navigation process.

Recommended for All Communities

• Use a trauma-informed approach to identify the person's or family’s preferences

o Providers should aim to decrease judgment or reaction to preferences or priorities in housing.

o Providers should aim to decrease judgment, reaction, or labeling of the community member experiencing homelessness (e.g., avoid using terms such as “difficult,” “needy,” and “high maintenance”) when they have multiple priorities or decline housing options that do not meet the identified needs or priorities.

• Give options for housing (type, location, accessibility, amenities) as available.

o This will be dependent on each community, but providing options and choices is ideal.

• Allow for ranking or prioritization by the person or family

o Community members experiencing homelessness should be able to identify top priorities, and these should be equal to or considered more highly than provider priorities.

• Give community members experiencing homelessness the opportunity to review, clarify and negotiate lease agreements and building/facility rules and restrictions prior to lease signing and, if needed, the opportunity to pursue other housing options.

o Community members experiencing homelessness should not feel coerced into signing lease agreements, especially if they feel they are unable to adhere to components of the lease (e.g., smoking within the unit).

• Develop a centralized information hub of available housing, landlords, permanent supportive housing, nonprofit housing organizations, and other community housing options (see Appendix B) that can be accessed and utilized by all case managers/housing navigators involved in the housing process.

Good

o This helps to ensure equitable access to housing locations independent of knowledge of or relationship with a housing navigator.

• Train housing navigators to use motivational interviewing to identify priorities, especially for community members experiencing homelessness who are unsure of what their priorities may be.

• Ensure that the person’s or family’s preference(s) carry equal weight to other components of coordinated assessment when identifying the best available option for housing.

• Ensure the community member experiencing homelessness has the option to visit housing at least once before lease signing, ideally with identified supports if desired.

• Complete an environmental scan of available housing including affordable, subsidized, accessible, and permanent supportive housing (see Appendix B) and the neighborhoods these options are located.

Better

o Identify if these areas represent preferred neighborhoods and options of community members experiencing homelessness

o Identify gaps in community services that would limit independence or quality of life (e.g., not on public transit lines, no grocery stores with fresh produce, lack of pharmacy access).

Best

• Use the findings from the environmental scan to develop a centralized hub of housing options, which may include descriptions or more detailed information.

• Provide descriptions and details when discussing housing options with community members experiencing homelessness (especially if they are unfamiliar with the neighborhood/area).

• Prioritize the person or family’s preference(s) when possible based on available housing.

• Train housing navigators to use motivational interviewing to identify priorities, especially for those who are unsure of what their priorities may be.

• Ensure the community member experiencing homelessness has the option to visit housing at least once before lease signing, ideally with identified supports if desired.

• Collaborate between the CoC and community organizations to broaden options for housing to accommodate individual needs, varying family structures, and natural support systems.

o Mitigate rules that are unnecessary and create barriers to housing/safe housing (e.g., a person with disabilities who would like live-in support from family/friends).

• Develop and make available a centralized and comprehensive hub of housing options and resources to all housing navigators, and routinely update this information to include feedback from people with lived experience and providers, as well as to ensure the accuracy of information.

• Prioritize the person’s preference as the first factor in determining housing options

• Provide a number of housing options, and minimize limits that result in community members experiencing homelessness losing their spot on the list if available housing does not meet their needs (e.g., when the person must select from one of three available units, and if they refuse, they will be skipped over).

• Ensure the community member experiencing homelessness has the option to visit housing at least once before lease signing, ideally with identified supports if desired.

Key Takeaways

The housing preferences of the person or family engaging with the CE process should be prioritized and valued.

Housing navigators should have awareness of different housing options within the community, which is informed by those with lived experience and those from the local communities.

Communities should work to increase housing availability to provide greater choice in housing to meet the needs of those seeking housing.

Resources

• Appendix B: Housing Preferences and Increasing Choices in Housing Options

• Ending Community Homelessness Coalition (ECHO), Austin, Texas: Example of a comprehensive resource list for a community

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Models of Prioritization

Self-Assessment

In order to assess your community’s current status in implementing an inclusive, assessable and equitable model of prioritization, please answer the following questions:

• Do we currently require individuals to complete a full assessment before being placed in the CE prioritization system?

o Is someone with severe mental illness or cognitive deficits able to navigate the process and be ranked for prioritization?

• When in our process do we require documented “proof” of homelessness, disability, income, identification, etc.?

o Do we have resources available for someone who does not currently seek health care to obtain this documentation?

• Have our questionnaires and forms been developed by people with lived experience (past and current)?

o If no, have we included this perspective in the assessment/testing phase before implementation?

Introduction

The process of ranking or putting people in a prioritization order for housing is a manufactured process that takes the focus away from the work, which should be to invest in enough adequate and affordable housing for all people. The use of the word “prioritization” suggests that not everyone is equally worthy of having a safe place to live and that it is appropriate to have people wait in homelessness for their “turn” to be housed. However, changing this requires a political and financial investment in affordable housing and services after decades of disinvestment and segregation. Until then, communities are forced to find a way to match their unhoused population with the too-few units of housing they have available.

The process of developing a model of prioritization will reflect the priorities and resources that a community has. In addition to centralizing the input, priorities, and goals of the people who will utilize the system, it is beneficial to leverage the resources and processes created by other communities. There is not one model of prioritization that will fit all communities. However, utilizing components that have been developed, tested, and reworked by others will enhance your process and help create validity.

Accessibility of the Process

Because the prioritization system was created because there are not enough affordable housing units for all the people who need them, there is an innate rush to “get on the list” to begin the waiting process. While almost all communities have moved

away from a simple “first-come, first-serve” process, the amount of time a person has been on the list typically comes into play at some point in the process. It is essential that communities develop a low threshold for someone to be able to get on the list. Requiring many data points and complete, complex assessments creates an artificial but often insurmountable barrier to housing that many people with complex medical and behavioral health needs cannot overcome.

The process must also allow for regular reevaluation and “reprioritizing” based on new information. By creating a low threshold for someone to enter the prioritization system, it will be essential to be able to add more information as the person becomes better known to service providers. There should never be a point when someone’s information cannot be updated or modified to more accurately reflect that individual.

It should be as difficult to get off a list as it is easy to get on. Far too often, communities want to define “active” participation and require a certain amount of contact from someone while they are waiting, despite the fact that the system is not offering that individual what they are seeking: housing. A person should not be removed from a prioritization list until it is confirmed that they have obtained permanent, adequate, and affordable housing or that they no longer are able to be housed (deceased, residential facility, etc.).

Utilizing Structured/Standardized Tools

The first step to building an effective and equitable tool is to assess what information you need and what information you are trying to get. It can be tempting to collect as much information as possible. However, asking for large volumes of information, especially through very personal questions, can jeopardize the integrity of the quality of the information you receive. It is important to explain why the information is being collected and how it impacts the person’s ability to get housing to help develop transparency in the process, which will, in turn, help you earn trust.

Although there is not one tool that can adequately meet the needs of all communities, there are a number of well-developed, tested, and validated tools with questions that could be utilized to help your community reach its goal of infusing equity in the prioritization process. It is important to note that individual questions from a validated tool are not considered validated unless they were tested separately. However, these questions are often highly effective ways of getting the information you are seeking. It is also important to determine whether the assessment tool was validated on the population you intend to use it with. This determination should include race, gender identity, age, and cognitive and literacy levels. Using tools that were not validated for the population creates a risk of misidentifying or underrepresenting the needs of populations.

If your community moves toward creating a new tool rather than utilizing an existing tool, it is important to validate the questions you create. If you do not validate questions, there is significant opportunity for unintended and unexpected bias in the tool and results. If your team does not have experience creating validated surveys, connect with a local university to engage someone with expertise in psychometrics to assist in this process. In any case, it is important to validate the tools you use to ensure they work as intended in your community.

How you ask something is as important as what you are asking. Questions are often suggestive as to what is the “correct” answer, or they don’t consider that there are multiple ways in which something can manifest itself. For example, it can be tempting to ask just about hospital visits to demonstrate acute episodes of a person’s conditions or instability. However, interactions with police, arrests, incarcerations, and episodes in treatment for substances can also demonstrate instability and occur before a person is ever able to seek help at a hospital.

For more information on selecting the appropriate tool(s), please see Leveraging Existing Tools in this toolkit.

Examples of Tool and Process Reviews

Charlotte-Mecklenburg County (North Carolina) Prioritization Tool Workgroup created a list of tools and policies to review alongside their supplemental tool. View their resources and presentation.

The Homeless Hub (Canada) cross-referenced various tools, uses, strengths and weaknesses. View their summary table.

Implementation of Case Review

No length of assessment and documentation review will ever be able to give the full picture of a person. To fill in some of the gaps created in this process, many communities have turned to case reviews, which allow for input directly from the individual and from people who know them (clinical care teams, homeless service providers, peer advocates, etc.). Case reviews create an opportunity for any person to speak directly about their own experiences without having to complete questionnaires or answer questions in a specific order or about pre-defined topics. The case conference process is time-consuming and is not necessary for every person. However, it can be especially important for individuals who are most often missed by complex systems because of the numerous requirements necessary to engage in them, or when providers have concerns about the person and a need for additional resources.

Some communities may be able to case conference every person who comes through their CE system, while others will have to create a system for determining who receives a case conference. Case conferencing can be used to provide a counterbalance to inequities in a prioritization tool. Utilizing data to assess scores based on race, gender identity, age, etc., as well as looking at equity across assessors, housing status (sheltered versus unsheltered), housing history, and other health conditions, should inform who is prioritized for case conferencing.

Verification of Information

Part of the requirement for receiving housing through CE is the need to prove and document eligibility. Far too often, this requires that someone have recent (less than 1year-old) documented records of their condition(s) that make them disabled, as well as documented proof that they were not housed. Proving someone is house-less is

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extremely difficult in the best of circumstances and often impossible in many communities. The focus must be on having the burden be on the system and not the individual to obtain this information. Establishing data exchanges with health care providers allows medical records to be obtained, with consent, so that the individual does not have to track down, and often pay for, their own records. These systems do not necessarily need to be complicated, although they must take into consideration HIPAA and the amount of information that is actually needed versus how much information might be desired. Allowing individuals to complete assessments and be placed on the prioritization list without “proof” is an important step in increasing access and equity. This also assures that time is not wasted obtaining documents that will only need to be reobtained once a person is ready for housing because the original documents are outdated.

Documentation of homelessness is a particular challenge when someone does not reside in a shelter where utilization is recorded daily. Outreach staff, peer advocates, and CHWs can help document homelessness by recording contacts, going to places where people are residing, and serving as a consistent contact point for some of the most vulnerable individuals. Community residents and businesses may also be able to attest to a person’s homeless status by virtue of the person staying in that area.

Partnering with and employing individuals who can provide assessments, particularly those willing to do outreach and meet a person where they are, can help provide documentation for individuals who have not sought care through traditional health care systems. Health Care for the Homeless health centers and staff have experience and expertise in engaging people experiencing homelessness and can help document a person’s health conditions to generate the proof necessary to meet the HUD/housing documentation requirements.

Form Development

The forms used to collect information, especially during self-reports, can add to the harm caused by the prioritization process. Lengthy forms with invasive questions that have not been designed to be inclusive can cause and exacerbate trauma and will not be successful in obtaining the information desired. Start by asking people with current or prior lived experience how they want to be asked about each topic area. In addition, have this group design how and where these questions should be asked. Utilize forms from various organizations that are experts in collecting different types of information. Seek suggestions from domestic violence service providers, health care providers, and behavioral health organizations to identify best practices for phrases on forms. It is important to test the forms prior to implementation to ensure they collect appropriate information and are trauma-informed, as well as to understand the length and time to complete the form. There should also be a process in place to connect individuals with additional resources to address needs identified in the assessments, in addition to being added to the housing list.

Recommendations

This section is divided into recommendations by “good,” “better” and “best” practices for considering models of prioritization.

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Good

• Utilize a validated assessment tool for CE that can be updated/edited throughout the process.

• Require only one contact, regardless of type, per year to remain “active” in CE

• Allow CE assessors to recommend people for the case review process.

• Request medical records to document disability rather than require individuals to obtain the documents themselves.

• Use outreach and homeless management information systems (HMIS) to document homelessness.

• Allow individuals to enter CE with minimal information. Allow time to build answers to an assessment made up of combined questions from various assessment tools that focus specifically on the information you want to collect.

Better

• Require only one contact, regardless of type, every three years to remain “active” in CE

• Conduct regular reviews of the prioritization list, and seek out case reviews from various referral/assessor sources.

• Seek out forms from organizations that specialize in different types of service delivery (domestic violence, behavioral health, sexual orientation and gender identity, etc.).

Best

• Allow individuals to enter CE with minimal information. Allow time to build answers to assessment tools that have been tested for equity and inclusion while only collecting information that is necessary. Allow for self-assessment contributions from providers, staff, and peers, and never limit the sources of information or frequency with which it can be modified.

• Never remove an individual from CE until it is verified that they no longer need to or can be housed through the system.

• Use data to assess for equity on scoring across race, gender identity, and referral/assessor sources. Conduct case reviews of all unsheltered individuals and everyone who has been homeless for one year or longer.

• Partner with and hire licensed individuals who are willing to conduct outreach to meet individuals who are missing necessary documentation and, ideally, bridge them to care.

• Create and test all forms with people with lived experience prior to implementation.

Key Takeaways

Using a validated tool is essential for avoiding unintentional bias. Many tools have previously been validated and can be used, or you can create your own and complete the process of validation before implementation.

Case reviews should be utilized to get the input of the individual, as well as those who have worked with them, in an effort to fill in gaps that are left by the assessment process.

Develop the infrastructure and systems necessary to build the verifying documentation needed and minimize the burden on the individual/family.

Resources

• The Homeless Hub, Canada, Table of Homelessness-Specific Tools

• Charlotte-Mecklenburg County, North Carolina, Housing Prioritization Tool Workgroup Materials

Leveraging Existing Tools

Self-Assessment

In order to assess your community’s current status assessment tool, please answer the following questions:

• Are you using a tool or combination of tools that are made up of validated questions?

o If not, who wrote the questions?

• Is your community continually engaging in evaluation and improvement of your CE assessment?

o If yes, what is the process to change questions/revise forms in the assessment tool?

o Are people with lived experience involved in the improvement process?

o Are you using data analysis to test for validity and equity?

• Does your assessment tool include assessment for non-homeless service-specific resources? Do these service providers have a homeless unit or staff trained in working with people experiencing homelessness?

Introduction

When HUD introduced CE in 2015, jurisdictions began looking for ways to meet the first quality defined by HUD: Prioritization. In explaining this characteristic, HUD wrote: “HUD has determined that an effective CE process ensures that people with the greatest needs receive priority for any type of housing and homeless assistance available in the CoC, including permanent supportive housing, rapid rehousing, and other interventions.”22 Immediately, jurisdictions across the country began to search for strategies to develop a way to assess for “greatest need” in order to develop a fair process for everyone to go through.

HUD started by defining that communities should prioritize people who meet their definition of being chronically homeless homeless for at least the past 12 months or having experienced at least four separate episodes of homelessness over the past

22 Coordinated Entry Policy Brief. (2015a, February). HUD Exchange. Retrieved May 17, 2023, from https://www.hudexchange.info/resource/4427/coordinated-entry-policy-brief/

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three years that combine to a total of at least 12 months.23 HUD then listed several characteristics that a community could choose to prioritize, including veterans, people with certain health conditions, families, and pregnant persons, but there was flexibility within the guidance for communities to choose which areas they focused on. Pressed with the need to prioritize due to an overall lack of affordable housing options, communities inevitably created a values statement in saying who they believe “deserved” to be prioritized. In addition to adding unnecessary barriers that keep people homeless longer, this process adds to the burnout, secondary trauma, and moral injury sustained by the staff who are helping them through this process.

While there are not specifically required questions that all communities must use, HUD described four core elements that every community must address in the creation of their CE system: access, assessment, prioritization and referral. Pressed with the responsibility to create a CE system quickly, communities looked for questionnaires and assessment tools that had already been created. In addition, there are specific data elements that are necessary in order to determine what resources a person is looking for (i.e., current housing status), while there are many other elements that are not necessary but often collected because of a desire to know more about who is being served by the CE system.

There were many tools24 that had been used for different purposes of data collection, most notably the Vulnerability Index (VI) and the Service Prioritization Decision Assistance Tool (SPDAT). The VI was created by Community Solutions to help determine the chronicity and medical vulnerability of homeless individuals. The SPDAT was originally developed by OrgCode Consulting as an intake case management tool designed to help service providers allocate resources in a logical, targeted way.25 They were combined to create a method to collect information on an individual or family’s health, service needs, chronicity of homelessness, and ability to navigate their own housing needs, matching that information with the most appropriate level of services and housing to avoid future episodes of homelessness. This combined tool, the VISPDAT, has since been de-validated for its use in CE because it was proven to prioritize white people over BIPOC for permanent supportive housing.26

As a result of no longer using the VI-SPDAT, many communities are faced with determining a new assessment process and identifying an alternative tool. There is not one singular tool that will be adequate for all communities. Instead, communities may

23 Homeless Emergency Assistance and Rapid Transition to Housing: Defining “Chronically Homeless,” 80 F R 75791 (proposed December 4, 2015) (to be codified at 24 C.F.R. Parts 91 and 578).

https://www.federalregister.gov/documents/2015/12/04/2015-30473/homeless-emergency-assistance-andrapid-transition-to-housing-defining-chronically-homeless

24 Table of Homelessness-Specific Tools. (2017, November). The Homeless Hub. Retrieved May 17, 2023, from https://homelesshub.ca/sites/default/files/ScreeningforHF-Table-Nov17.pdf

25 Vulnerability Index (VI) & Service Prioritization Decision Assistance Tool (SPDAT): Prescreen Assessment for Single Adults. (n.d.). Contra Costa Health. Retrieved May 17, 2023, from https://cchealth.org/h3/coc/pdf/2014-0521-packet-2.pdf

26 Wilkey, C., Donegan, R., Yampolskaya, S., & Cannon, R. (2019b). Coordinated Entry Systems: Racial Equity Analysis of Assessment Data. C4 Innovates. https://c4innovates.com/wpcontent/uploads/2019/10/CES_Racial_Equity-Analysis_Oct112019.pdf

need to identify several assessments that help to determine priority based on their redesign process.

Utilizing Validated Questions

Although it is clear that there is not one adequate assessment tool that can be used in all jurisdictions, there are benefits to utilizing questions from other tools that have gone through a validation process. These tools may or may not have been created for the purpose of service prioritization, but they can be more accurate ways to collect information about certain health conditions, past experiences, and current barriers. Questions being validated mean they actually measure what they are intended to measure.

The process of validating a question or assessment tool is time-consuming and requires academic rigor. Thus, communities should not create their own questions or tools without the support of someone experienced in measurement development. In addition, there may be topics that your community decides to assess for that have not been used for housing prioritization. When this happens, the next step would be to seek out alternative assessment tools that have been used for similar purposes and ask questions about topics you are seeking information on.

Using questions or assessment tools that have been validated may provide a false sense of confidence in the quality of the questions. Verify that the people who the questions/tool were validated on are a match for the community you plan to use it with. Surveys that do not validate their questions on a diverse group of individuals will infuse unintended bias into the CE assessment. Make sure to pilot the tool with your community before it is used for prioritization so you can identify and address disparities that arise. It is also important to be aware of what questions may be in violation of equity laws such as the Fair Housing Act 27 This law prohibits discrimination of sale, rental, and financing housing on the bases of race, national origin, religion, or sex.

Utilizing Existing CE System Assessment Tools

By 2023, every community has implemented some form of prioritization assessment. However, communities are working at different rates to evolve, adapt, and improve their systems. Implementation of a CE system is time-consuming and expensive, and it can feel daunting to make changes to improve it.

However, it is important to have your CE system evolve with the research and experiential learning of both your community and others. The CE system will include assessment tools to determine eligibility and prioritization status of those experiencing homelessness who are entered into the system.

27 Housing Discrimination Under the Fair Housing Act. (n.d.). HUD. Retrieved February 2, 2023, from https://www.hud.gov/program_offices/fair_housing_equal_opp/fair_housing_act_overview

If your community moves toward creating a new tool rather than utilizing an existing tool, connect with someone with expertise in psychometrics to assist in this process.

Benefits of Using Existing CE Tools

• Consultation and technical assistance are possible from the jurisdiction(s) using the tool.

• Existing data sets to use as a comparison for validation and equity assessment.

• Includes important core structures, such as informed consent, and has been tested for certain target populations.

• Can be operationalized quickly and often are already formatted to integrate with certain data-capturing systems.

Challenges of Using an Existing Tool

• Not specialized for your community’s specific needs and structure, and may assess for resources not currently available or exclude resources your community has.

• Risks complacency with “good enough” and may be more difficult to change.

• Does not foster community engagement and shared decision-making.

• No one tool has been determined to be the best option, and every tool has been identified as having limitations and weaknesses.

• Using individual questions from different tools decreases the validity of the question.

Utilize Alternative Assessment Tools

To develop an assessment tool that meets the needs of your CoC, you must start with identifying areas you would like to prioritize. Possibilities include prioritizing behavioral health conditions, age, and health conditions that are known to cause early mortality among people experiencing homelessness in your community. Information should not be collected for information’s sake if it is not going to inform the person’s status in the CE system or connect them to other resources. Considerations might include:

• What conditions have been leading causes of mortality in your community?28

• What team structures do or could provide supportive services once the individual is housed?

28 Homeless Mortality Data Workgroup of the National Health Care for the Homeless Council. (2021). Homeless Mortality Data Toolkit: Understanding and Tracking Deaths of People Experiencing Homelessness. NHCHC. https://nhchc.org/wp-content/uploads/2020/12/Homeless-Mortality-Toolkit-FULL-FINAL.pdf

• What prevention services are available to support people unstably housed, and how are they allocated?

When determining what categories to prioritize around, a community may start by defining risk. In addition to prioritizing people based on their length of homelessness and meeting the chronic homeless definition, HUD suggests several risk categories that a community may include in its prioritization:29

• Significant health or behavioral health challenges or functional impairments that require a significant level of support in order to maintain permanent housing

• High utilization of crisis or emergency services, including emergency rooms, jails, and psychiatric facilities, to meet basic needs

• The extent to which people, especially youth and children, are unsheltered

• Vulnerability to illness or death

• Risk of continued homelessness

• Vulnerability to victimization, including physical assault or engaging in trafficking or sex work

Experts across every area of service have developed validated assessment tools that are not specifically designed for individuals experiencing homelessness but have been validated for the community they are designed to assess. Possible tools to include are:

• Brain injury screening tool

• Activities of daily living (PROMIS, WHODAS 2.0, EQ-5D)

• Domestic violence

• Development disability/delay

Assess for Additional Service Eligibility

CE systems should not simply assess for services eligible for people experiencing homelessness, but rather for all supportive services, organizations, and resources that a person might be eligible for. Comprehensive assessments are particularly important in areas that do not have robust homeless services. These resources include:

• Veterans Affairs

• Housing Opportunity for Persons With AIDS

• Developmental disability administration

29 Coordinated Entry Policy Brief. (2015b, February). HUD Exchange. Retrieved May 17, 2023, from https://www.hudexchange.info/resource/4427/coordinated-entry-policy-brief/

www.nhchc.org

• Medicaid supportive services

• National Alliance on Mental Illness

• State-specific home and community based services

• School systems/educational services (McKinney Vento)

• Adult protective services (APS)

Assessing for Family Structure and Reasonable Accommodations

Very often, the homeless services structure forces a family to separate and live in a dynamic that they would not if they had housing. Adults are forced to live in single-bed, gender-specific facilities rather than together; older children are often forced to be separated from their opposite-gender adult(s); and children live in other houses, sometimes by choice and other times by court mandate, to prevent the child from entering homelessness.

It is important to include questions that allow exploration of different family systems. In addition, a single adult may be identified as needing or benefiting from live-in support.

Recommendations

This section is divided into recommendations by “good,” “better” and “best” practices for leveraging existing tools

• The CE assessment tool was created using validated questions but cannot be changed.

• Include questions from other assessment tools designed for people experiencing homelessness.

Good

• Those implementing the tool are trained in administering the tool at onboarding to ensure fidelity to the tool.

• The CE assessment tool was created using validated questions and is reviewed incrementally (every year) to consider additions, changes, and improvements to current questions.

Better

• Include questions from a validated tool for conditions such as brain injury, cognitive delays, and domestic violence.

• Those implementing the tool are retrained in administering the tool annually alongside the review.

• The CE assessment tool can be continually adapted and changed to meet the needs of the community. The process of doing so is transparent, involves data collection and validation, and is rooted in the involvement of people with lived experience.

Best • All questions on the assessment tool have been validated and assessed for equity.

• Those implementing the tool are retrained in administering the tool and implicit bias annually.

Key Takeaways

Consider validated assessment tools not just designed for people experiencing homelessness but also for other conditions that your community is choosing to prioritize.

Proper implementation requires piloting the assessment tool and being prepared to make changes or start over completely.

Ongoing validation and evaluation of the assessment tool will allow for adaptation to changes in the community and regular evaluation for bias.

Resources

• The Homeless Hub, Canada, Table of Homelessness-Specific Tools

• NHCHC: Homelessness Mortality Data Toolkit

Identifying Supports Needed for Successful Housing

Self-Assessment

To assess your community’s current status in identifying supports needed for successful housing in the housing prioritization process, please answer the following questions:

• Do we currently assess for individual needs or needs for support once someone is housed within our process?

o If yes, do we use a deficit- or strengths-based approach?

o How are we currently assessing? Is it a recommended/best practice?

o What aspects are we assessing?

▪ Physical needs

▪ Behavioral health needs

▪ Activities of daily living (ADL) needs

▪ Instrumental activities of daily living (IADL) needs

▪ Community/social support needs

▪ Community integration needs

• How do we balance the needs of the person with lived experience and provider needs?

• How are the person’s preferences considered? Do we have a strong knowledge base for the types of resources that could support these needs or preferences?

Introduction

Due to the scarcity of affordable housing and minimal choices within available housing options, it can be challenging to identify the appropriate match (of both housing and supports) when someone is transitioning out of homelessness. Additionally, because of the environmental and contextual restrictions that exist when someone is unhoused, community members experiencing homelessness do not have the opportunity to demonstrate, use, or develop skills that would support housing stability. Concerns about mental health stability, substance use, and medical needs also contribute to providers’ hesitation in moving some community members into housing.

This uncertainty often leads to providers being unsure whether a person can effectively stay housed, which can lead to individuals not being considered for housing placement. Providers may make an assessment as to whether they believe a person will be “successful” at being housed using a pre-defined concept of what they believe

constitutes housing success. This is an undesirable alternative, as many individuals are forced to either spend more time unhoused or are moved into more restrictive and institutional environments (such as long-term care). However, studies have found that there is not one indicator that identifies whether someone will be able to maintain stable housing, even when factors such as ongoing substance use, cognition, or psychiatric symptoms are considered.30

Importantly, studies looking at housing stability across people experiencing homelessness have found that those who are the most successful are those that receive supports to meet their needs, matching resources with their identified diagnoses or abilities or functional skills sets.31, 32, 33, 34 Loss of housing after going through the housing prioritization process may be due to a lack of resources and supports that would have assisted the person and addressed individual circumstances. Housing loss can also occur when new needs arise once housed that were not detected due to a lack of adequate ongoing assessment. One example is when someone is hospitalized, especially for a longer period of time, and returns home without additional supports or resources.

Developing resources to support those who have moved from homelessness to housing includes: identifying supports needed for housing transition, identifying available community resources to meet individual needs, and integrating these into the housing transition process from a strengths-based perspective. This process should replace the practice of only identifying deficits or perceived barriers to housing success without providing options to address them.

30 Adair, C. E., Streiner, D. L., Barnhart, R., Kopp, B., Veldhuizen, S., Patterson, M., Aubry, T., Lavoie, J., Sareen, J., LeBlanc, S. R., & Goering, P. (2017). Outcome Trajectories among Homeless Individuals with Mental Disorders in a Multisite Randomised Controlled Trial of Housing First. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 62(1), 30–39. https://doi.org/10.1177/0706743716645302

31 Gabrielian, S., Hellemann, G., Koosis, E. R., Green, M. F., & Young, A. S. (2021). Do cognition and other person-level characteristics determine housing outcomes among homeless-experienced adults with serious mental illness? Psychiatric Rehabilitation Journal, 44(2), 176–185. https://doi.org/10.1037/prj0000457

32 Gicas, K. M., Mejia-Lancheros, C., Nisenbaum, R., Wang, R., Hwang, S. W., & Stergiopoulos, V. (2021). Cognitive determinants of community functioning and quality of life in homeless adults with mental illness: 6-year follow-up from the At Home/Chez Soi Study Toronto site. Psychological Medicine, 1–9. https://doi.org/10.1017/S0033291721001550

33 Raphael-Greenfield, E. (2012). Assessing executive and community functioning among homeless persons with substance use disorders using the executive function performance test. Occupational Therapy International, 19(3), 135–143. https://doi.org/10.1002/oti.1328

34 Synovec, C. E. (2020). Evaluating Cognitive Impairment and Its Relation to Function in a Population of Individuals Who Are Homeless. Occupational Therapy in Mental Health, 36(4), 330

352. https://doi.org/10.1080/0164212X.2020.1838400

When re-imagining the housing prioritization process, communities need to consider equity within the process and identify how communities and services are structured to support people once they are housed.

Within this section, the term “supports” includes both person/social supports and environmental supports. An example of a “person” support might be a case manager serving as a rep payee. An example of an environmental support might be a unit that has a shower accessible to wheelchair users. Most of us use some form of supports to navigate our daily lives. It is important to note that needing a support does not mean the person cannot live independently. Instead, it means that modifications, often simple ones, are needed to achieve housing stability and optimal quality of life.

Areas in which an individual might need a support can include:

ADL35 (e.g., a home health aide who visits three times per week)

IADL,36 such as:

Budgeting (e.g., rep payee, case manager support to develop a monthly budget)

Home care and maintenance (e.g., support to acquire supplies, set up routines for cleaning, hiring someone to clean the home)

Meal preparation and grocery shopping (e.g., transportation to food pantries and affordable grocery stores)

Health management,37 medical, and behavioral health care (e.g., weekly registered nurse visits)

Community transportation (e.g., support to learn new public transit routes, application for mobility transportation services)

Building/facility resources (e.g., accessibility, front desk or security staff)

Community resources and safety (e.g., well-lit area, maintained sidewalks, ability to engage in leisure/social activities)

See Appendix C for additional examples and strategies to implement a variety of supports.

35 ADLs are activities oriented toward taking care of one's own body and completed on a routine basis. ADL include: bathing and showering, toileting and toilet hygiene, dressing, feeding, eating and swallowing, functional mobility, personal hygiene and grooming, and sexual activity (American Journal of Occupational Therapy, 2020).

36 Activities to support daily life within the home and community (AOTA, 2020).

37 Activities related to developing, managing and maintaining health and wellness routines, including selfmanagement, with the goal of improving or maintaining health to support participation in other occupations (AOTA, 2020).

Assessing Supports Needed

Although the housing prioritization process is often deficits-based to demonstrate need or “vulnerability,” the process for identifying supports needed doesn’t have to be. Instead, this process should be strengths-based equally identifying skills and assets of the person, in addition to potential needs. Furthermore, need for support should not be used as a reason to keep someone from housing but should be viewed as a way to determine the resources necessary to facilitate the transition into housing. Assessing supports needed can be part of the CE process, along with other assessments, or be determined on a case-by-case basis due to information gained from the coordinated assessment.

A strengths-based approach to evaluating supports needed is one that:

• Includes the priorities, requests, or concerns of the person with lived experience

• Is used for every individual being housed through CE, regardless of perceived needs/deficits

• Focuses on what can be addressed and accommodated by the housing or community resources

• Uses findings from assessments to identify resources and does not use information against the person unless significant concerns are uncovered, and the person would be unsafe unless in a more structured environment

o It is important that this process minimizes bias and is as objective as possible.

• Is not based on diagnosis alone

o Criteria to gain entry to the housing prioritization list are often diagnostic and based on quantitative data (e.g., days spent homeless).

o Diagnoses are NOT indicators of what supports someone needs, as each person will manage their diagnoses and needs differently and will have varying impacts on housing/community living skills.

• Recognizes that lack of participation in certain activities may be a result of the environment and not necessarily the skills of the person (e.g., if bathrooms are not fully accessible to someone in a wheelchair, then their participation in ADLs will be lower because it’s unsafe; difficulty with budgeting may be due to significantly low income versus inability to manage funds)

• Uses each provider’s skill set and expertise appropriately and does not require providers to make assessments or predictions that are out of their scope or knowledge (e.g., home safety assessments are completed by trained occupational therapists).

Recommendations

The next section is divided into recommendations for all communities and then by “good,” “better” and “best” practices for identifying supports needed

Recommendations for All Communities

• Use a trauma-informed approach to identify the person’s needs, strengths, and preferences.

• Include the person and their self-identified needs. Do not just rely on the report or perspective of providers.

• Evaluations and assessment of needs, skills, and diagnoses should be within the provider’s scope and skill set.

o Only providers who are licensed to diagnose and/or those where diagnosis is within their scope of practice should make official physical or mental health diagnoses.

o Non-clinical providers should seek clarification with the person’s providers when information is unclear instead of making guesses or judgments. In some cases, using the community member’s responses will be necessary if there is not access to providers or medical records.

o Case notes and case conferences should clarify terms as much as possible. Assessments of “function” look at different aspects depending on the provider. For example, a mental health provider may assess “function” by looking at symptomology and impact on day-to-day experience; medical providers may assess “function” as mobility status and ability to complete ADLs; occupational therapists may assess “function” as ability to engage in daily life roles. All of these assessments are meaningful but not interchangeable. The assessments and potential implications should be considered and applied appropriately.

o Providers and direct staff should not be tasked with making assessments that are not within the skill set of their position. It is also not likely that one individual provider can determine if the person is “appropriate” or “ready” for housing, especially when observing the person only in the context of homelessness. Observations of how a person manages their day-to-day should be combined with other assessments and feedback from the person themselves.

• Respect the person with lived experience’s choice to decline supports/services this should not be a requirement for housing unless dictated by the housing’s funding source and options for support should remain open to the person during transition and after they are housed.

• Be creative and comprehensive when identifying possible supports, and spend time learning what is available in the community.

• Be assessed on an on-going basis, as skills are developed and circumstances change. In some cases, after the period of transition, individuals may no longer need the supports initially identified, while others may have new supports based on changes in health status.

See the section on Centering Preferences of Community Members Experiencing Homelessness to integrate choice in location/type of housing.

• Self-assessment of needs/supports is conducted by the person with lived experience

• Case conference with the person’s current providers to determine any immediate or emergent concerns prior to housing

Good

o Referral to appropriate resources to address emergent needs

• Review previous experiences of housing and identify barriers encountered in that process to determine potential new supports (e.g., if a person lost housing because of smoking in unit, then the need is finding a unit that is not smoke-free).

o Review can occur with providers familiar with the person and should also include the individual in discussion

• Maintain a centralized list for providers/housing navigators of available community resources for housing supports to access and refer people experiencing homelessness as needed

• Connect community members experiencing homelessness with appropriate community-based services to address identified needs as available

• Assist community members experiencing homelessness in accessing immediate, needed supplies to support transition into housing (e.g., bed or air mattress, food, basic household goods)

o Items supplied via donations

o Support to drive to and purchase supplies

• Self-assessment of needs/supports is conducted by the person with lived experience

Better

• Case conference with person’s current providers and the person to determine any immediate or emergent concerns prior to housing, as well as support needs for transition

o Referral to appropriate resources to address emergent needs and for transition

Best

• Maintain a centralized list for providers/housing navigators of available community resources for housing supports to access and refer community members experiencing homelessness as needed.

• Engagement, collaboration, and partnerships among organizations in the community to support individuals when they move into housing using “warm hand-offs” prior to the person becoming housed

o Connection of community members experiencing homelessness to identified supports prior to or at transition to housing

• Assist community members experiencing homelessness in accessing immediate, needed supplies to support transition into housing (e.g., bed or air mattress, food, basic household goods)

o Items supplied via donations

o Support to drive to stores and purchase supplies

o Community members experiencing homelessness are able to identify priorities and make personal selection for items

• Engage with community and housing providers to identify gaps in current housing options and advocate for needs/gaps identified.

• Self-assessment of needs/supports is conducted by the person with lived experience

• Occupational therapy assessment determines existing functional skills and supports needed

• Discuss with the community member experiencing homelessness and their team to identify supports needed for health/health management (including physical and behavioral health)

o Discussions should include the individual’s current providers and support persons as available

o If the person is not currently connected to health care/behavioral health providers, assessment may be beneficial if the individual is willing

o Providers may opt to case conference and then hold discussion with all individuals involved in housing process

• Discuss with the community member experiencing homelessness and their team to identify supports needed for completing ADL and IADL and engaging in the local community. This should include discussion of results from case conferencing, occupational therapy assessment, and needs identified by the person with lived experience.

• Identify ideal environments by community member experiencing homelessness and team (see also, Centering Preferences of Community Members Experiencing Homelessness).

• Make a determination of individual plans for each person based on centralized list of resources

o Ideally, initiate connection and transition to services prior to housing, as appropriate.

• Identify of supports needed for community integration once housed, as well as referrals or transition to supports during the housing transition or immediately after housing.

• Assist community members experiencing homelessness in accessing immediate, needed supplies to support transition into housing (e.g., bed or air mattress, food, basic household goods).

o Items supplied via donations

o Support for individuals to drive to and purchase supplies

o People experiencing homelessness are able to identify priorities and make personal selection of items

• Engage with community and housing providers to identify gaps in current housing options.

• Advocate for and initiate process to develop varying types of housing based on gaps identified.

Key Takeaways

Assessment of a person’s skills for maintaining housing should be done from a strengths-based approach that focuses on the person’s existing skills and supports needed.

Determining supports needed for housing should include a range of perspectives, including the person themselves, and utilize a range of available community resources.

Providers and staff working with the person should only make assessments and recommendations that fall within their scope and expertise.

Resources

• Healing Hands: From Homelessness to Housing: Challenges and Opportunities of Housing Transitions

• The Canadian Journal of Psychiatry: Outcome Trajectories among Homeless Individuals with Mental Disorders in a Multisite Randomized Controlled Trial of Housing First

• Housing with Supports:

o Permanent supportive housing and housing first

o Home and community-based waiver programs

• Health Supports:

o Assertive community treatment (ACT) (behavioral health)

o Home health care

o Health Care for the Homeless programs

o Permanent supportive housing: Integrated health models

o CHWs

• Housing transition: Additional roles to support housing transition:

o Peer support

o Intensive case management

o Occupational therapy

• Examples of a comprehensive resource list for a community

o ECHO: Resource Guide

o Housing Benefits 101, Minnesota

Examples of tools to determine supports needed that can be administered by different individuals engaged in the housing prioritization process This table is not comprehensive, and there may be additional tools or tools that are more appropriate to a community and those engaged with the CE system.

Tool Who Can Administer the Tool?*

Self-report of needs by the person with lived experience

• Person with lived experience

• Support person (designated by the person with lived experience)

World Health Organization Disability Assessment Schedule (WHODAS 2.0)

www.nhchc.org

• Person with lived experience

• Case manager

• Social worker

• Health care provider

Table 2. Tool Examples.

Functional assessment of independent living skills

Checklist of items needed to transition into housing (see Appendix E)

• Occupational therapy

• Person with lived experience

• Case manager

• Social worker

• Case manager

Provider feedback

• Social worker

• Health care provider

*Note: The recommended providers have been identified to administer and interpret the suggested tools. Some tools may require training to be able to administer.

www.nhchc.org

Preventing Housing Loss

Self-Assessment

In order to assess your community’s current status of housing loss prevention, please answer the following questions:

• What is directly impacting housing loss and/or preventing access to housing in our community, and how are we addressing this?

• What equitable community-based, focused strategies do we have in place to reduce housing crises?

• How do we integrate community-based organizations in solutions and ensure a diverse and equitable response?

• How have we established low-barrier funds for homelessness prevention?

• What equitable physical and virtual hubs are in place for community members to access resources within their communities of origin?

o Focus on which areas/neighborhoods experience health disparities at a disproportionate rate.

• Do hospital and health care, legal, education and homelessness response systems all know how to assess for housing stability and effectively link community members to resources?

o If yes, what continuing education do you have in place to support this?

• To what extent are people experiencing housing instability due to hospitalization or medical challenges?

• What supports does your local public housing authority have in place in order to support households in preventing evictions and preserving housing rights (e.g., fair housing, the Violence Against Women Act, housing protections, reasonable accommodations)?

• What legal advocacy groups and services exist to help people maintain housing and avoid eviction and/or housing injustices?

Bathtub Model

Homelessness is a direct result of housing loss or the inability to ever afford housing, and most communities are faced with the continual cycle of housing loss and housing prioritization. The causes of homelessness are complex; however, we must acknowledge and strive to reverse and eliminate the lasting impact that systemic racism has had on perpetuating this cycle.

The homelessness response system, like other systems, often uses the bathtub model as an analogy. In a high-level overview of a bathtub as a model: The faucet feeds the water into the tub, the tub has a specific capacity to hold the inflowing water, and the drain is to remove or exit the water so the tub doesn’t overflow. Within the homelessness response system, community members enter into homelessness, experience homelessness as they work through resources needed to access temporary shelter and supportive services within the homelessness response system, and then exit homelessness through temporary or permanent housing.

The goal of the homelessness response system is to end and prevent homelessness altogether. However, communities working to end homelessness strive to reach the current gold standard, often outlined as a community member being housed within 30 days of entering into homelessness moving straight from the faucet (1), spending minimal time waiting to exit (2) and exiting to housing (3).

1) Individuals enter into homelessness

2) Homelessness response system capacity

3) Exit from homelessness

However, what if people didn’t have to enter into homelessness at all? What if we took a step back and looked at why community members are pouring into homelessness at such a fast rate? Moreover, what if we were able to take that information and turn the faucet off?

This is where housing loss prevention becomes the key.

What Is Housing Loss Prevention?

Housing loss prevention, also referred to as homelessness prevention or prevention, is defined by USICH as “strategies that represent a wide array of efforts to prevent housing crises from occurring and to prevent people who face such crises from experiencing homelessness.”38 Housing loss prevention can be a complex topic, with multiple strategies requiring a communitywide approach, but the goal is straightforward housing loss prevention is the act of preventing community members from entering into homelessness.

38 Homelessness Prevention, Diversion, and Rapid Exit. (2019, July). USICH. Retrieved May 18, 2023, from https://www.usich.gov/resources/uploads/asset_library/Prevention-Diversion-Rapid-Exit-July-2019.pdf

www.nhchc.org

Additional critical terms to become familiar with and to utilize in your community are “diversion” and “rapid exit.” You can find more information about those important interventions in the resources below.

What Are Strategies to Prevent Homelessness?

USICH outlines prevention strategies that fall into the following categories:

• Activities that reduce the prevalence of risk of housing crises within communities

• Activities that reduce the risk of homelessness while households are engaged with or are transitioning from systems

• Activities that target assistance to prevent housing crises that do occur from escalating further and resulting in homelessness

*Note: The following information is pulled from the USICH prevention strategies.

In the first category of prevention, we recognize that housing crises can be reduced systemically when multiple sectors focus on big-picture goals:

• Ensuring an adequate supply of affordable and accessible housing

• Addressing systemic racial inequities

• Improving education, meaningful and gainful employment and/or income

• Ensuring access to affordable child care, legal assistance, and physical and behavioral health care

While these multisector strategies may be less often framed as homelessness prevention, they can have the greatest impact on preventing homelessness.

www.nhchc.org

In the second category, homelessness can be prevented through enhanced cross-system collaboration, including systems such as health care, child welfare and corrections. Such collaboration includes increased awareness and

Landlord Mediation

attentiveness to housing stability, as well as effective transition and/or discharge planning. In this category, systems must ensure that individuals are linked effectively to mainstream resources, including employment, Social Security benefits, and health care, to reduce the risk of homelessness upon discharge or following the end of service provision.

In the third category of prevention, assistance helps keep housing crises that do occur from escalating further and resulting in homelessness. In most communities, this assistance is provided through mainstream systems and/or through the homelessness services system. Prevention services in this category often include a combination of financial assistance, mediation with landlords, legal services, and other supports. When multiple systems provide prevention assistance, it is critical that they be coordinated and utilize common assessment tools to identify and assist those at the greatest risk of homelessness.

Recommendations

This section is divided into recommendations by “good,” “better” and “best” practices for housing loss prevention based on USICH strategies.

Recommendations Based on USICH Strategies

Activities That Reduce the Prevalence of Risk of Housing Crises Within Communities

• Understand what causes homelessness in your community

• Understand the statistics and prevalence of the vulnerable groups in your community

Good

• Understand what causes homelessness in your community.

• Understand the statistics and prevalence of the vulnerable groups in your community

Better

• Have equitable community-based focused strategies in place to reduce housing crises (to include, but not limited to, the connection of community members to supports such as health care and SOAR).

Best

• Understand what causes homelessness in your community

• Understand the statistics and prevalence of the vulnerable groups in your community.

• Have equitable community based focused strategies in place to reduce housing crises (to include, but not limited to, the connection of community members to supports such as health care and SOAR)

• Be prepared for changes in the economy, workforce and environment.

• Continuously review the system and adapt to ensure changes are addressing disparities.

Activities That Reduce the Risk of Homelessness While Households Are Engaged With or Are Transitioning From Systems

• Know what cross-systems exist within your community and how they operate.

• Understand cross-system gaps and best avenues to advocate for equitable changes in operations, resources, and policies.

Good

• Use cross-system data to estimate monthly and annual needs and gaps to advocate for resources that will right-size the system

• Know what cross-systems exist within your community and how they operate.

• Understand cross-system gaps and best avenues to advocate for equitable changes in operations, resources, and policies.

Better

• Use cross-system data to estimate monthly and annual needs and gaps to advocate for resources that will right-size the system.

• Integrate community-based organizations to collaborate on solutions and ensure a diverse and equitable response

• Know what cross-systems exist within your community and how they operate.

• Understand cross-system gaps and best avenues to advocate for equitable changes in operations, resources, and policies.

Best

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• Use cross-system data to estimate monthly and annual needs and gaps to advocate for resources that will right-size the system.

• Integrate community-based organizations to collaborate on solutions and ensure a diverse and equitable response

Good

• Hospital and health care, legal, education, and homelessness response systems all know how to assess for housing stability and effectively link community members to resources.

• Use CE to streamline access and real-time referrals

Activities That Target Assistance to Prevent Housing Crises That Do Occur From Escalating Further and Resulting in Homelessness

• Have established accessible low-barrier funds for prevention.

• Understand how prevention funds can be used and what additional strategies can be used as prevention (i.e., connection to case management, legal aid services, or aging and disability resources).

• Have established accessible low-barrier funds for prevention.

• Understand how prevention funds can be used and what additional strategies can be used as prevention (i.e., connection to case management, legal aid services, or aging and disability resources).

Better

• Service providers and community members know how to access prevention funds and receive funds in an equitable and timely manner

• Have established accessible low-barrier funds for prevention.

• Understand how prevention funds can be used and what additional strategies can be used as prevention (i.e., connection to case management, legal aid services, or aging and disability resources).

Best

• Service providers and community members know how to access prevention funds and receive funds in an equitable and timely manner.

• Create equitable physical and virtual hubs to access resources, including hubs within their communities of origin.

Key Takeaways

Housing loss prevention can be a complex topic, with multiple strategies requiring a communitywide approach, but the goal is straightforward housing loss prevention is the act of preventing community members from entering into homelessness.

Housing crises can be reduced systemically when multiple sectors focus on big-picture goals, such as: ensuring an adequate supply of affordable and accessible housing; addressing systemic racial inequities; improving education and meaningful and gainful employment and/or income; and ensuring access

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to affordable child care, legal assistance, and physical and behavioral health care.

Homelessness can be prevented through enhanced cross-system collaboration, including systems such as health care, child welfare and corrections. Such collaboration should include increased awareness and attentiveness to housing stability, as well as effective transition and/or discharge planning.

Resources

• USICH: All in: The Federal Strategic Plan to Prevent and End Homelessness

• USICH, HUD, Veterans Affairs: Homelessness Prevention, Diversion, and Rapid Exit (from Home, Together)

• National Alliance to End Homelessness: Closing the Front Door: Creating a Successful Diversion Program for Homeless Families

• CSH: Ten Things to do Now to Prevent Family Evictions

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Measuring Performance and Evaluating Programs

Self-Assessment Questions

To assess you community’s current status regarding evaluating your housing prioritization process, please answer the following questions:

• Have we engaged partners in the process of determining goals?

o Are partners informing the needs addressed?

• Are the goals we have identified measurable?

o Have we identified evaluation questions to assess progress towards goals?

o Have we identified indicators for the evaluation measures?

• Do we have indicators that we will track as performance measures?

• Do all partners know what the indicators are?

Introduction

The key to ensuring that any intervention is effective is to have an evaluation plan in place. Creating a strong evaluation plan starts early as communities identify goals for their process and system, they are laying the foundation for how to determine their process’s efficacy toward that goal. When looking toward formalizing their evaluation plan, communities should consider what they want to achieve, what success looks like, and what is appropriate and realistic based on their capacity. Consider the goalsetting questions in the equity section as a starting place. Evaluating a program can take many forms and does not have to include high-level statistical analysis to be useful and important.

Program evaluation and performance measurement are complementary processes that can help not only determine whether a program is working (evaluation) but also how well it is working (performance measurement). Performance measurement can help to supplement data needed in an overall program evaluation and may be conducted with more frequency as a monitoring activity. A strong evaluation plan will have a complementary process for measuring performance along the way.39,40

39 Program Evaluation: Key Terms and Concepts (GAO-21-404SP). (2021). Government Accountability Office. https://www.gao.gov/assets/gao-21-404sp.pdf

40 Performance Measurement & Program Evaluation: A Suite of Evaluative Insights. (n.d.). Centers for Disease Control and Prevention (CDC). Retrieved May 18, 2023, from https://www.cdc.gov/asthma/program_eval/performance-measurement.htm

Although there are many ways a community can construct an evaluation, identifying a framework to build off is an important first step. The CDC has created the Framework for Program Evaluation in Public Health (Figure 2),41 which can serve as a helpful starting place for any program. The corresponding self-study guide42 provides an in-depth look at the steps of this framework and how to implement those steps.

Communities have access to many other useful tools to help create and conduct a program evaluation. One that can be beneficial on multiple levels is logic models. Logic models are often used in program planning and have significant value in the evaluation process. Activities and defined outcomes identified in a logic model can help determine what data can and should be collected to evaluate the efficacy and impact of a program. Logic models also allow for the determination of shorter-term and longer-term outcomes, providing opportunities for assessing progress in multiple ways. Many examples of logic models exist, and the CDC has guides and workbooks available to help with the development of a logic model.43 Additionally, the Seattle/King County Continuum of Care and End Homelessness Winnipeg have published their CE evaluation plans, which include examples of their logic models. The evaluation plans are linked in the resource section below, and the logic models are available in Appendix F.

Piloting a Process or Tool

To prevent further or new disparities in a process when new questions or steps are rolled out, communities should implement a pilot process. In their pilot stage, communities can add individual questions, tools, or steps to the existing practice before fully implementing them. New information at this stage should not be used to prioritize people for housing or services until the change has been evaluated. This gives communities a chance to identify and address any disparities before they impact someone’s ability to access needed resources. Each community should consider an appropriate sample size, based on their population, depending on the extent of

41 Framework for Program Evaluation. (n.d.). CDC. Retrieved May 18, 2023, from https://www.cdc.gov/evaluation/framework/index.htm

42 Introduction to Program Evaluation for Public Health Programs: A Self-Study Guide. (n.d.). CDC. Retrieved May 18, 2023, from https://www.cdc.gov/evaluation/guide/index.htm

43 Step 2B Logic Models. (n.d.). CDC. Retrieved May 18, 2023, from https://www.cdc.gov/oralhealth/funded_programs/pdf/logic_models.pdf

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Figure 2 CDC Framework for Program Evaluation in Public Health.

analysis they will do during the pilot phase. However, they should use the new process with a sample of the population before rolling it out to the larger community.

If a community is having difficulty determining what an appropriate sample size would be, they could consider starting with a minimum of 50 individuals — ideally, 100 individuals.

Communities should ensure that they pilot their new survey or process in a population that is diverse and representative of the individuals experiencing homelessness in their CoC area. If the population is not demographically diverse, potential inequities can fall through the cracks during the pilot process. It is also important that population groups that are “difficult to measure” are not excluded, so as to prevent missed challenges and needs these individuals may experience.

This stage should also include a process for establishing inter-assessor reliability. Having the same individual complete the assessment questions or steps with more than one assessor can help to ensure that the process and/or tools are reliable and that opportunities for bias are limited

Program and System Outcome Goals

Setting outcome goals is essential for demonstrating whether a process or intervention is doing what it is intended to do and whether there are opportunities for improvement. To make the process of creating outcomes and an evaluation feasible, communities can use SMARTIE goals to ensure that they are measurable and equitable (see Figure 3). Having measurable goals is key to a successful evaluation.

Strategic Clear and focused DETAILS describe what will be done.

Measurable Progress is assessed using DATA that is tracked over time.

Attainable The team is ABLE and AGREES to accomplish the goal as written.

Relevant The goal is MEANINGFUL and aligned with values and outcome statements.

Time-Bound Clear START and END dates exist to achieve completed work.

44 Institute on Community Integration, University of Minnesota. (n.d.). SMARTIE Goal Setting. Retrieved May 18, 2023, from https://ici-s.umn.edu/files/nGmP9MXh7Y/smartie-goal-sheet

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Figure 3. Description of SMARTIE Goals, as define by the Institute on Community Integration at the University of Minnesota44

Inclusive

INCLUDES setting the conditions for sharing power, collective policymaking, and data-informed decision-making with traditionally marginalized people.

Equitable

Elements of FAIRNESS and JUSTICE exist that address systemic inequity and oppression.

In determining the outcomes of a program, communities can start by looking at the performance measures that are important to reaching their desired goals. Types of performance measures45 include:

• Input measure: measure of resources used to implement an intervention

• Process measure: measure of program activities or steps leading to an outcome

• Output measure: measure of the immediate results of what an intervention’s activities accomplished

• Outcome measure: measure of results toward goals and impact of the intervention

Using a mix of these measures at various stages can help to assess how well the new process is working. Additional resources on performance measures are included in the resources below.

Consider reviewing the Substance Abuse and Mental Health Services Administration’s (SAMHSA) permanent supportive housing evaluation guide and the included fidelity tool to evaluate how close your permanent supportive housing programs are to the ideal model.

When creating the evaluation plan, communities should keep in mind the purpose of the evaluation, who will use the findings, and how will they be used.46 When answering these questions, communities can determine the best fit for the type of evaluation (feasibility, process, or outcome), design of the evaluation (experimental, quasiexperimental, or non-experimental), and the questions the evaluation needs to address. In determining the questions the evaluation will address, communities can start to identify indicators that would answer the question, the data sources for that measure, and the collection methods. It is important to consider how quantitative and qualitative data can each be part of the evaluation process.

More information on designing a program evaluation is available in the resources linked below. Consider reviewing the Federal Strategic Plan to End Homelessness,47 the

45 Measuring What Matters in Public Health: A Health Department’s Guide to Performance Management. (2018). National Association of County and City Health Officials

https://www.naccho.org/uploads/downloadable-resources/NACCHO-PM-System-Guide.pdf

46 Program Evaluation Framework Checklist for Step 3: Focus the Evaluation. (n.d.). CDC. Retrieved May 18, 2023, from https://www.cdc.gov/evaluation/steps/step3/index.htm

47 ALL IN: The Federal Strategic Plan to Prevent and End Homelessness. (2022). USICH

https://www.usich.gov/All_In_The_Federal_Strategic_Plan_to_Prevent_and_End_Homelessness.pdf

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SAMHSA supportive housing fidelity measure48 and other community examples to identify possible evaluation measures.

Type Question

Process Evaluation

How were individuals with living and lived experience included in the development of coordinated access?

Data Source(s)

• Elders and knowledge keepers

• Individuals with living and lived experience

• End Homelessness

Winnipeg partners

• Homelessness and housing sector partners

Implementation Evaluation

Were diverse communities (e.g., First Nations, Métis and Inuit communities, young people, older adults, 2SLGBTQ+ communities, women and gender diverse individuals, racialized individuals, immigrants and refugees, individuals with physical disabilities, etc.) accessing the coordinated access system? How did diverse communities feel accessing the coordinated access system?

• Elders and knowledge keepers

• Individuals with lived and living experience

• End Homelessness

Winnipeg partners

• Homelessness and housing sector partners

• Participants at engagement events

Collection Method

• Interviews

• Focus groups

• Surveys

• Interviews

• Focus groups

• Post-event surveys

48 HHS, SAMHSA, & Center for Mental Health Services. (2008). Evaluating Your Program: Permanent Supportive Housing (HHS Pub. No. SMA-10-4509). The Homeless Hub. Retrieved May 18, 2023, from https://homelesshub.ca/resource/evaluating-your-program-permanent-supportive-housing

49 Edel, B., Clemens, K., Nolin, C., Reinink, A., Ecker, J., Sehn, C., & Olusola Alabi B. (2022a). Sharing the Journey of Coordinated Access in Winnipeg: Logic Model and Evaluation Framework. End Homelessness Winnipeg, Canadian Observatory on Homelessness. Retrieved May 18, 2023, from https://www.homelesshub.ca/resource/sharing-journey-coordinated-access-winnipeg-logic-model-andevaluation-framework

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Table 3. Sample Evaluation Questions From End Homelessness Winnipeg.49

Outcome Evaluation

Were community members being housed in an efficient manner compared to processes used prior to the implementation of coordinated access?

• Elders and knowledge keepers

• Individuals with living and lived experience

• End Homelessness Winnipeg partners

• Homelessness and housing sector partners

• Administrative data

• Interviews

• Focus groups

• Administrative data

• Length of time to attain housing

In starting the evaluation process, a needs assessment can be conducted to create a baseline of where the community is and to help inform the development of the housing prioritization process. The assessment can also be repeated, after making changes to the process, to evaluate improvement or additional gaps. This could look like asking:

• What are the gaps or issues with our prioritization process?

o What gaps or issues still remain after initial changes?

• What are the existing inequities?

• What do we have available in our community?

• What are the gaps in resources?

• What are our priorities that need to be modified in the process?

Continuous Re-Evaluation After Implementation

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

Consider the continuous and evolving nature of the housing prioritization system and process, it is important to note that both performance measurement and program evaluation should be continuous and re-occurring, respectively. Performance measurement is naturally a continuous process, but consider how this information is shared and with whom, as well as how measures collected may be adapted over time to reflect new information and priorities. Program evaluation typically occurs over a discrete time frame but can be replicated at regular intervals to ensure the process is still effective as programs, priorities, and participant populations change. Additionally, it is important to have a process for reviewing the program evaluation and responding to the findings; program evaluation and data collection are only useful if they are utilized to create meaningful change.

Communities may consider adopting Plan-Do-StudyAct (PDSA) cycles50 (see Figure 4) as part of their system model to allow for early implementation, identification of issues and adapting processes as necessary. This model is often used to test a single step within a tool or process so as to focus on specific areas of improvement. PDSA cycles are typically brief and include a small sample to allow for quick adaptation of a practice before moving on.

Recommendations

This section is divided into recommendations by “good,” “better” and “best” practices for program evaluation and performance monitoring.

• Create measurable goals to inform outcomes.

• Engage partners and collaborators as part of qualitative data collection for evaluation.

Good

• Track performance measurement outcomes, and review at regular intervals

• Conduct evaluation at a regular interval determined by system partners

50 Health Literacy Universal Precautions Toolkit, 2nd Edition: Plan-Do-Study-Act (PDSA) Directions and Examples. (2015, February). Agency for Healthcare Research and Quality. https://www.ahrq.gov/healthliteracy/improve/precautions/tool2b.html

Plan Do Study

Act

Figure 4. PDSA Cycle Model

Better

• Create a plan to address key findings from program evaluation and performance measures.

• Create measurable goals to inform outcomes

• Engage partners and collaborators as part of qualitative data collection for evaluation.

• Track performance measurement outcomes and review quarterly.

• Conduct an evaluation annually.

• Implement PDSA cycles during initial piloting of the program

• Create a plan to address key findings from program evaluation and performance measures.

• Create measurable goals to inform outcomes, including those with lived experience in defining goals.

• Engage partners and collaborators as part of qualitative data collection for evaluation and in determining evaluation measures

Best

• Track performance measurement outcomes and review at least quarterly, with potentially automated revision. Update the measures tracked as needed and based on priorities and goals.

• Conduct evaluation annually, with updated outcomes as needed and based on priorities and goals

• Implement PDSA cycles during initial piloting of the program and as the process needs to be further adapted to meet needs.

• Measure quality-of-life outcomes as part of the evaluation

• Connect with external evaluators to support robust evaluation.

• Create a plan to address key findings from program evaluation and performance measures.

Key Takeaways

Communities should work on their evaluation plan concurrently with the implementation plan, using qualitative and quantitative measures.

An evaluation plan should be rooted in equity and allow for the prioritization process to be adapted in the face of new information. As such, the plan should include performance measurement, in addition to outcomes evaluation.

Communities must have partner engagement and buy-in when developing and conducting evaluation. Understanding what is important can help to identify outcome and process measures to include in the plan.

Resources

• CDC evaluation framework

o Framework for Program Evaluation

o Documents, Workbooks and Tools

o Program Evaluation Steps

o Self-Study Guide

• CDC: Steps Logic Models Workbook

• Agency for Healthcare Research and Quality: Plan-Do-Study-Act (PDSA) Directions and Examples

• National Association of County and City Health Officials, Measuring What Matters in Public Health

• SAMHSA: Evaluating your Program: Permanent Supportive Housing

• USICH, Federal Strategic Plan to Prevent and End Homelessness

• Seattle/King County Continuum of Care: Coordinated Entry for All, 2019 Annual Evaluation Plan

• End Homelessness Winnipeg, Sharing the Journey of Coordinated Access in Winnipeg: Logic Model and Evaluation Framework

• SMARTIE goals worksheets

o National Council for Mental Wellbeing: Creating SMARTIE Goals & Objectives Worksheet

o Institute on Community Integration, University of Minnesota, SMARTIE Goal Setting

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Glossary

Coordinated Entry System

The HUD interim rule51 defines Coordinated Entry (CE) as a centralized or coordinated process designed to coordinate program participant intake, assessment, and provision of referrals.

Housing Prioritization Process

The Coordinated Entry Core Elements52 states, "The prioritization process is the coordinated entry step before working with a person to determine the most appropriate referral(s). Using the prioritization standards and coordinated entry policies and procedures the CoC developed, the entity charged with prioritizing reviews information collected during assessment and determines the person’s priority level. Often this determination uses criteria that relate the person’s service intensity needs and vulnerability to a score, which is then used to inform a referral. The scoring and other processes used by CoCs to establish a person’s level of priority based on his or her vulnerability most often use multiple considerations such as length of time homeless, number of times homeless, number and severity of behavioral and/or medical problems, age, and other factors that vary by community."

Coordinated Assessment

The coordinated assessment is a comprehensive and standardized assessment tool utilized to assess vulnerability.

Trauma-Informed (Approach/Care)

Trauma-informed care is when “a program, organization, or system … realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization.”53

People with Lived Expertise (PLE)

This term is an abbreviated term for people with lived expertise of homelessness or housing loss. The term people with lived expertise (PLE) signifies the authoritative and superior knowledge the community member has on the subject of literal homelessness and navigating the CE and homelessness response system due to their firsthand lived

51 CoC Program Interim Rule. (2012a, July). HUD Exchange. https://www.hudexchange.info/resource/2033/hearth-coc-program-interim-rule

52 Coordinated Entry Core Elements. (n.d.-b). HUD. Retrieved May 15, 2023, from https://files.hudexchange.info/resources/documents/Coordinated-Entry-Core-Elements.pdf

53 SAMHSA’s Trauma and Justice Strategic Initiative. (2014a). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. SAMHSA. Retrieved May 18, 2023, from https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf

experience. This term is used for community members who survived being unhoused and are now currently housed.

People Experiencing Homelessness (PEH)

The term people experiencing homelessness (PEH) signifies the active presence of housing loss and literal homelessness. PEH also hold authoritative and superior knowledge on the subject of literal homelessness due to their firsthand lived experience. This term differs from PLE, as it acknowledges the community member is actively unhoused and currently experiencing a housing crisis.

Continuum of Care

A continuum of care (CoC), as defined by HUD in the interim rule,54 at the macro level, is designed to:

• Promote communitywide commitment to the goal of ending homelessness.

• Provide funding for efforts by nonprofit providers, states, and local governments to quickly rehouse individuals and families experiencing homelessness while minimizing the trauma and dislocation caused to individuals through experiencing homelessness.

• Promote access to and effective utilization of mainstream programs by individuals and families experiencing homelessness.

• Optimize self-sufficiency among those experiencing homelessness.

Equity

A January 2021 presidential executive order55 defines equity as the consistent and systematic fair, just and impartial treatment of all individuals, including individuals who belong to underserved communities that have been denied such treatment, such as Black, Latino, Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.

U.S. Interagency Council on Homelessness

The U.S. Interagency Council on Homelessness (USICH) is the only federal agency with a sole mission focused on preventing and ending homelessness in the U.S.

54 CoC Program Interim Rule. (2012b, July). HUD Exchange.

https://www.hudexchange.info/resource/2033/hearth-coc-program-interim-rule

55 Exec. Order No. 13,895, 3 C.F.R. 7009-7013 (2021).

https://www.federalregister.gov/documents/2021/01/25/2021-01753/advancing-racial-equity-and-supportfor-underserved-communities-through-the-federal-government

Housing and Urban Development (HUD)

The Department of Housing and Urban Development (HUD) is the federal agency responsible for national policy and programs that address the country’s housing needs, that improve and develop U.S. communities and enforce fair housing laws.

Health and Human Services (HHS)

The Department of Health and Human Services (HHS) is the federal agency responsible for national policy and programs that address the health of all Americans and provides essential human services by fostering advances in the sciences underlying medicine, public health, and social services.

Activities of Daily Living (ADL)

Activities of daily living (ADLs)56 are activities oriented toward taking care of one's own body and completed on a routine basis. ADLs include: bathing and showering, toileting and toilet hygiene, dressing, feeding, eating and swallowing, functional mobility, personal hygiene and grooming, and sexual activity.

Instrumental Activities of Daily Living (IADL)

Instrumental activities of daily living (IADL)57 are activities to support daily life within the home and community

56 Occupational Therapy Practice Framework: Domain and Process Fourth Edition. (2020). American Journal of Occupational Therapy, 74(Supplement_2), 7412410010p1-7412410010p87. https://doi.org/10.5014/ajot.2020.74s2001

57 SAMHSA’s Trauma and Justice Strategic Initiative. (2014b). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. SAMHSA. Retrieved May 18, 2023, from https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf

Appendix A: Organizing Partners

Appendix B: Housing Preferences and Increasing Choice in Housing Options

This resource provides examples of different types of housing and considerations for creating greater choice and options for housing. Communities can use this resource to begin organizing and categorizing their housing options to be able to match housing with the choices and preferences of community members experiencing homelessness. This process may also identify gaps in housing or resources and inform what additional types of housing need to be developed or advocated for within the community.

Types of Housing

A housing unit or building may fit into multiple categories listed here. This list provides general definitions of types of housing, eligibility and application will likely vary by community.

• Accessible unit: A unit that is designed and built to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design.

o Accessible Housing Units meet the people with disabilities requirements of the state building code. Collectively, this includes housing units that are on an accessible route, are accessible, and are located in an accessible housing development.

• Senior housing: Housing for individuals (typically 62 years of age or older; criteria may vary by setting) that is subsidized in whole or in part under any local, state, or federal program.

• Low-barrier housing: Rooted in the philosophy that providing basic needs first will allow an individual to thrive in other areas of their lives. Low-barrier housing minimizes or limits the requirements to access housing services. Low-barrier housing may:

o Have a flexible intake process and focus on quickly obtaining and moving a person into a permanent housing unit

o Not require background checks with housing applications

o Not require credit histories or references from previous landlords

o Not require documentation of citizenship

o Not require income or levels of income

o Not screen out due to debt or lack of credit or eviction history

o Not require employment or history of employment

o Not require or set low security deposits that can be paid after move in

o Not have rules specific to tobacco use, substance use, alcohol use, or intoxication on property

o Includes supports to help people navigate the intake/app process to ensure people are successful in moving into housing units.

o Include an emphasis on safety and access to services

o Work to avoid housing loss

• Sober living housing: Alcohol- and drug-free living environments for individuals attempting to abstain from alcohol and drugs. Often located within transitional housing, sober housing helps protect and honor a group of people who have decided they want to live around other people who are in recovery and maintaining sobriety. If someone does not follow the community rules, they usually have to leave the housing.

• Stand-alone housing unit: Housing that is not attached to another building.

• Shared building: The unit is located in the same building as or is attached to another unit, such as an apartment complex, duplex, or condominium.

• Transitional housing: Refers to a supportive yet temporary type of accommodation that is meant to bridge the gap from homelessness to permanent housing by offering structure, supervision, support (for addictions and mental health, for instance), life skills and, in some cases, education and training.

Potential Housing Preferences to Consider and Increase Access to

• Ability to accommodate family size

• Neighborhood or area of the community where the housing unit is located:

o Proximity to support systems

o Accessibility of public transit

o Proximity to grocery stores, pharmacies, banks, etc.

• Area where less substance use may be less visible or prevalent. Although substance and alcohol use occur in most neighborhoods, there will likely be areas of each community where use is less observable. This will also be subjective to both people with lived experience and providers and will require conversation between the community member experiencing homelessness and their housing navigators to determine preferred areas.

• Features of the unit:

o Accessibility features

o Access to outdoor space and/or natural light

o If unit entry doors are ground level, accessible from the outside or inside

o Ability to make modifications to the unit itself (e.g. paint, wall hangings)

o Unit layout/size

o Lease requirements

• Features of the building:

o Security presence within the building/community

o Requirements for access to the building/controlled access to units

o Presence of on-site staff

o On-site laundry or other amenities

o Unattached/proximity to neighbors

Considerations for Increasing Housing Choice or Developing New Housing

• Be prepared to confront NIMBY-ism. How does this impact housing choice and equitable access to community resources?

• When creating new housing, use strategies to ensure community buy-in:

o Consider how other people in the community can currently access resources at or around the housing site. This is especially important when communities add housing in areas that are already limited in resources and experience racial trauma due to historical and current discrimination.

o In what ways can the new housing increase communitywide opportunities and increase a sense of community and belonging for everyone?

▪ E.g., what resources can be added to a building that would benefit the entire neighborhood?

• Have we engaged with community leaders across neighborhoods? How can our community invest in equitable housing and neighborhood development?

• What already exists in neighborhoods and communities that we may be underutilizing?

Appendix C: Housing Supports Supports for Transition Into Housing Areas Addressed

Note: This table includes several examples, but supports/strategies are not limited to what is listed here and should be individualized based on need and preference.

Bathing/ showering

• Shower chair

• Grab bars

• Non-slip mats

• Bright lighting

• Other adaptive equipment

• Setting up auto-draft payments

Budgeting

• Using budgeting apps/systems

Home care and maintenance

• Reminders or chore lists to develop a schedule or routine for cleaning

• Home health aid

• Personal care attendant

• Occupational therapy

• Physical therapy

• Accessible unit or unit with walk-in shower or space to add equipment

• Landlord willing to make basic modifications

• Places to buy or receive low-cost or free supplies (soap, shampoo, etc.)

• Places to purchase, rent or be donated durable medical equipment

• Free rep payee services/ payee designated by the person

• Working with a provider to learn and use budgeting strategies

• Hiring someone to routinely clean the home

• Support to identify, find and purchase supplies

• Education/teaching on home management tasks

Meal preparation and grocery shopping

• Microwave, crockpots, or electric griddles for simplified cooking

• Using foldable carts or reusable bags to help transport groceries

• Support to identify grocery lists and meal plan

• Transportation to grocery stores

• Support to identify and apply to meal assistance programs

• Being able to turn in rent checks to an on-site office

• Location close to bank/ATM/ money order

• On-site tax support

• Building/landlord/ maintenance provides basic assistance (e.g., changing lightbulbs)

• Laundry facilities are within or close to building

• Kitchen areas are maintained, and appliances are working

• Building is accessible to and willing to work with mealdelivery programs

• Setting up an easy-to-use, nonpredatory, low-barrier bank account

• APS support

• Stores with low-cost home supplies

• Donation banks for home supplies

• Home-delivery meal programs

• Nearby grocery stores

• Low-cost grocery stores

• Food banks and mealassistance programs

Health management

• Pillboxes

• Timers/alarms for medications

• Storing medications in a safe but visible location

• Printout of providers’ names and contact information

• Printout of emergency health contact information

• Access to a phone

• Unit is able to support needed medical supplies

• Home health teams

• ACT teams

• Permanent supportive housing teams

• Medication assisted treatment programs

• CHWs

• Registered nurse support for health/med management

• Support to access needed medical supplies

• Transportation services to appointments

Transportation

• Use of community mobility/ transportation services

• Phone to call transit services to arrange rides

• Building is free from irritants (e.g., mold, air pollution) and has appropriate ventilation

• Located near to or accessible to health care providers

• Residents are not stigmatized for receiving in-home supports/person supports

• Building is low barrier for those who may be using substances, including tobacco

• Pharmacies that provide blister/bubble packs

• Pharmacies that offer easy-open tops, large print medication information

• Health centers

Safety

• Knowledge and awareness of emergency services (information posted easily)

• Access to a phone

• Locks and peepholes are in good working order

• Implementing strategies to reduce fall risks

• Use of only certain appliances (e.g., microwave instead of stove/oven)

• Support to learn new transit routes

• Support to apply for mobility/transit support programs

• Education and teaching on how to use various transit services

• Wellness checks or regular provider check-ins

• Home safety assessment and modifications

• Education and skill building to address potential safety concerns (e.g., cooking, cleaning)

• Identifying key and safety information to have the person easily access

• Building is nearby or accessible to public transit routes

• Building has space for individual transit drop off/pickup

• Public transportation

• Mobility transit for those unable to use general public transit

• Nonprofit transit services (may be specific to population or diagnosis)

• Building/home/units are wellmarked for emergency services to easily find

• Security/front desk staff that monitors activity or admits individuals to the building

• Visitor policies

• Buildings are up to code for safety/local regulations

• Individual preference on location of housing where they feel safe

• Sidewalks/roads/transit stops are well-lit

• Sidewalks are maintained

Leisure, social, and community engagement

• Supplies for leisure engagement at home, such as TVs, books

• Access to a phone to connect with others and needed resources

• Support to identify spaces to participate in desired leisure or social activities (e.g. volunteer groups, senior centers)

• Education and skill building for social skill development from providers

• Support to identify funds or low-cost leisure/social activities

• Building that offers community activities routinely

• Building that offers community day area for informal social gatherings

• Located near spaces to engage with communities of choice (e.g., church, community centers)

• Transportation to and from community activities

• Opportunity for community engagement: Libraries, community centers, churches, support groups, schools/education facilities, parks, etc.

Appendix D. Self-Assessment and Checklist of Supports Needed or Desired for Housing Transition

Note: Providers can use Appendix C Housing Supports to identify options or prompts for individuals or families to consider.

Self-Care

I Would Like Support With: What Kind of Help? How Often (If Applicable)?

 Bathing

 Dressing

 Grooming/hygiene

 Toileting

Other:

Health

I Would Like Support With: What Kind of Help? How Often (If Applicable)?

 Managing medications

 Getting medicine from the pharmacy

 Keeping track of doctor’s appointments

 Going to doctor’s appointments

Other:

www.nhchc.org

Home Management

I Would Like Support With: What Kind of Help? How Often (If Applicable)?

 Keeping up with chores

 Checking, organizing and responding to mail

 Maintenance, such as changing lightbulbs, fixing things that are broken

 Communicating with my landlord or maintenance person

Other:

Budgeting

I Would Like Support With: What Kind of Help? How Often (If Applicable)?

 Making sure my bills are paid on time

 Setting up a budget

 Following a budget

 Finding a place to keep my money safe

Other:

Meal Preparation and Grocery Shopping

www.nhchc.org

I Would Like Support With: What Kind of Help? How Often (If Applicable)?

 Planning meals for myself

 Grocery shopping

 Cooking meals and/or learning how to cook

 Finding low-cost places to buy foods

Other:

Transportation

I Would Like Support With: What Kind of Help? How Often (If Applicable)?

 Finding affordable transportation

 Learning public transit routes near my home

 Getting a driver’s license

 Getting access to accessible transit

Other:

Safety

www.nhchc.org

I Would Like Support With: What Kind of Help? How Often (If Applicable)?

 Figuring out what I need to make my home safe

 Finding donated or purchasing supplies to make my home safe

 Learning how to use the lock/fob/code system to access my building or home

 Learning strategies to keep myself safe at home

Other:

Social, Fun, Relaxation

I Would Like Support With: What Kind of Help? How Often (If Applicable)?

 Communicating with my neighbors and people in my neighborhood

 Getting a phone

 Learning to use a phone

 Getting things for my home that I enjoy doing

 Finding places that I can spend my time

Other:

Other Supports Needed

www.nhchc.org

I Would Like Support With: What Kind of Help? How Often (If Applicable)?

www.nhchc.org

Appendix E. Home Starter Kit List

Note: This is an example that can be used for community members experiencing homelessness to identify tangible resources needed when transitioning into housing. This can be adapted, and costs should be adjusted by location.

Person’s Name: Case Manager: Move-In Date: Prices listed are average prices of basic name brands. *Donation refers to services other than a housing provider

Self-Care/Toiletries

Shampoo $3.50

Soap $1.50 (bar)

Toothbrush $1.25

Toothpaste $3.50

Deodorant $3.50

Total:

Bathroom

Shower curtain and rings $15

Toilet paper (1 roll) $2

Toilet bowl plunger $10

Bath towel $6

Bath mat $7

Washcloth $1

Total:

Bedroom

Air mattress with pump $35 (twin)

Pillow $10

Sheets, full size (based on St. Vincent’s beds) $25 for set

Blanket $25 (full size)

Self-inflating mattress (less cushion) $25 (twin)

Total:

Kitchen

Utensils (disposable set spoons, forks, knives) $3.50

Plates (disposable) $3

Bowls (disposable) $3

Cups (disposable or plastic) $3

Pots/Pans (starter set) $25

Kitchen utensil set (including a can opener) $15

Can opener $10

Paper towels (1 roll) $2

Total:

Living Space

TV (minimum $85)

Radio Microwave (minimum $65)

Cleaning Supplies

Broom with dustpan $15

Mop $10

Mop bucket $10

Swiffer dry/wet mop $15

Swiffer refills (dry) $10

Swiffer refills (wet) $10

Garbage can $15

Garbage bags $10

Sponges $3 for 3-count

Liquid cleaners:

Brand preference: $3 per bottle

Dish soap $3 per bottle

Rags $2 for 3-pack Total:

Other

Laundry bag $8

Detergent

Brand preference: $8 per bottle

Plastic bin to store items $10, 66-quart, Vacuum (Minimum $40)

Person receiving bed from another source

Total # of items for starter kit: ______

Total cost of items for starter kit: $______ (not to exceed $ )

Recipient Signature Date

• This is a family order

# of Adults: ____ (2 twin or 1 queen)

Children:

Age: _______

Age: _______

Age: _______

Age: _______

Age: ______

Case Manager Signature Date

Date ordered:

Date received:

www.nhchc.org

Appendix F. Logic Model Examples

Seattle/King County Continuum of Care’s Simplified Logic Model of CEA. Available as Part of the 2019 Evaluation Plan58

Inputs Activities Outputs Outcomes

Attempt diversion Households diverted

Assessors and front-door staff

Assess households with a housing triage tool Assessments completed

Highest-need, most vulnerable households are prioritized and placed in housing

Housing navigators and providers

Referral specialists and CEA staff

Locate and communicate with households Case conferences attended

Learn and share household housing preferences

Organize and facilitate case conferencing

Clients nominated for resources

Housing referrals Manage referrals

Manage priority pool

Housing resources

Data systems

Resource availability and eligibility requirements communicated

Program enrollments

Housing move-ins

Routine data entry Households prioritized

Supportive services are utilized as efficiently and effectively as possible

Disparities and inequities in the experience of homelessness are eliminated

58 Coordinated Entry for All: Seattle/King County Continuum of Care: 2019 Annual Evaluation Plan. (2019). King County Department of Community and Human Services. https://kingcounty.gov/~/media/depts/community-human-services/housing-homelessness-communitydevelopment/documents/CEA/Coordinated_Entry_for_All_-_2019_Evaluation_Plan_FINAL.ashx

Coordinated Access in Winnipeg: Logic Model59

Inputs Activities Outcomes

A coordinated body to organize, operate and adapt coordinated access processes

• Includes dedicated staff

• Includes direction from individuals with lived and living experience of homelessness

Local organizations to participate in the coordinated access system

Educational and community engagement materials on the coordinated access system

An assessment process

An inventory of housing and support providers for matching and referrals

A data management system (i.e., homeless individuals and families information system)

Awareness: Education, outreach and community engagement activities to ensure the whole community understands the processes.

Collaboration: Collaborate with other systems (e.g., child welfare, justice, employment and income assistance, violence against women) and prevention and diversion (e.g., eviction prevention, shelter diversion) organizations.

Training: Ensure that all staff participating in the coordinated access process are sufficiently trained, particularly related to trauma-informed care, harm reduction and anti-racism/antioppression.

Access points: Physical and virtual spaces where people experiencing homelessness can access the system. This includes centralized (i.e., one primary location for in-person access) and decentralized (i.e., multiple secondary locations for in-person access and phone/internet/apps) options to reduce the number of organizations a person may need to access.

Assessment: A process to understand the person accessing the coordinated access system and to reduce the number of times a person must share their story. The process should be simple, contextualized to the community and may include an assessment tool.

Prioritization: A community-based consultative process to identify community members with housing and support needs that fit best to what the coordinated access system can offer.

Matching and referral: A fair and transparent process to match people to housing and supports based on their needs and choices. Ensure there are several comprehensive services available and safe housing options.

Follow-up supports: Offer follow-up supports to people once they are housed.

Peer supports: Offer peer supports throughout the system.

Data management: A system to manage the data that is collected from people who participate in the coordinated access system. Recognizes privacy, confidentiality and data sovereignty.

Evaluation: Processes to conduct quality checks to ensure the same quality of service Is being offered to all people who access the system.

Short-term

• Enhanced awareness of the coordinated access system among community members and service providers

• Improved access to housing and support options for community members

• Increased engagement of community members in developing housing and support plans

Mid-term

• More appropriate matching to housing and support based on the unique identities of community members

• More equitable access to housing and supports for community members

Long-term

• Decreases in returns to homelessness

• Achieving housing stability more quickly

• Improved spiritual, physical, mental and emotional health of community members

59 Edel, B., Clemens, K., Nolin, C., Reinink, A., Ecker, J., Sehn, C., & Olusola Alabi B. (2022b). Sharing the Journey of Coordinated Access in Winnipeg: Logic Model and Evaluation Framework. End Homelessness Winnipeg, Canadian Observatory on Homelessness. Retrieved May 18, 2023, from https://www.homelesshub.ca/resource/sharing-journey-coordinated-access-winnipeg-logic-model-and-evaluation-framework