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NORTHWEST CONTINUUM OF CARE COORDINATED ENTRY PROCEDURE MANUAL
Version 1.0
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NWCOC Coordinated Entry System Procedure Manual Version 1.0
Adopted 01/19/2023
Click Link to access NWCOC Coordinated Entry System Web Homepage
User Notes:
• This document has many hyperlinks to quickly direct you to information and policies. You may be able to just click on documents to open them, or you may have to hit (CTRL + Click).
• This is meant to be a living document and will be updated as changes to the system are made. The most up–to-date copy will always be on the website linked above.
• This document is a companion the NWCoC CES Policy Manual
• Common terms and definitions can be found at this link: https://www.hmismn.org/definitions
1.
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NWCOC Coordinated Entry System Procedure Manual Version 1.0
Adopted 01/19/2023
2. Coordinated Entry Procedure Manual Purpose
The purpose of this guide is to create a Procedure Manual for users of the Northwest Continuum of Care (NWCOC) Coordinated Entry System (CES). The Procedure Manual is meant to create a how-to or step-by-step guide, rather than policy language.
This manual is developed and informed by approved policy of the NWCoC Governance Charter, ESG and CoC Administration Policies, and the NWCoC Coordinated Entry System Policy Manual. These documents are approved and amended with the approval of the NWCoC Board of Directors. This procedure manual must be updated to reflect changes in policy. This procedure manual is administered by the NWCoC Coordinated Entry Committee. This manual will outline the different roles for users for the system. These roles include assessors, case managers, housing navigators and the priority list manager. We know that in NWCoC the same person often has the role of both assessor and case manager. This manual will help define the roles to help staff be effective at performing key responsibilities throughout the system. The following section is helpful for a review of key terms and definitions you may see throughout the document.
Why use a Coordinated Entry? See Figure 1 Coordinated Entry Implementation.
A. Terms and Definitions Chronically
Homeless HUD’s definition:
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Chronically homeless means: (1) A “homeless individual with a disability,” as defined in Section 401(9) of the McKinney-Vento Homeless Assistance Act, who: i. Lives in a place not meant for human habitation, a Safe Haven, or an emergency shelter; AND
NWCOC Coordinated Entry System Procedure Manual Version 1.0
Adopted 01/19/2023 ii. Has been homeless continuously for at least 12 months or on at least four separate occasions in the last 3 years, as long as the combined occasions equal at least 12 months and each break in homelessness separating the occasions included at least 7 consecutive nights of not living as described in (i) above.
MN Homelessness
Case Conferencing
Dynamic Planning
Continuum of Care (COC)
The State of Minnesota defines as homeless “any individual, unaccompanied youth or family that is without a permanent place to live that is fit for human habitation.” Doubling-up is considered homeless if that arrangement has persisted less than 1 year.
Local process for CES staff to coordinate and discuss ongoing work with persons experiencing homelessness in the community, including the prioritization or active list. The goal of case conferencing is to provide holistic, coordinated, and integrated services across providers, and to reduce duplication.
A dynamic process that uses prioritization criteria (i.e., assessment result, unsheltered status, length of time homeless) to identify the most vulnerable (preferably through a case conferencing process) based on the number of anticipated housing placements across all resources that will occur in the next XX days
Group responsible for the implementation of the requirements of HUD’s CoC Program interim rule. The CoC is composed of representatives of organizations, including nonprofit homeless providers, victim service providers, faith-based organizations, governments, businesses, advocates, public housing agencies, school districts, social service providers, mental health agencies, hospitals, universities, affordable housing developers, law enforcement, organizations that serve homeless and formerly homeless veterans, and homeless and formerly homeless persons.
Continuum of Care (CoC) Program
HUD funding source to (1) promote communitywide commitment to the goal of ending homelessness; (2) provide funding for efforts by nonprofit providers, and state and local governments to quickly rehouse homeless individuals and families while minimizing the trauma and dislocation caused to homeless individuals, families, and communities by homelessness; (3) promote access to and effect utilization of mainstream programs by homeless individuals and families; and (4) optimize self-sufficiency among individuals and families experiencing homelessness.
Emergency Shelter
Emergency Solutions Grant (ESG)
Short-term emergency housing available to persons experiencing homelessness.
HUD funding source to (1) engage homeless individuals and families living on the street; (2) improve the quantity and quality of emergency shelters for homeless individuals and families; (3) help operate these shelters; (4) provide essential services to shelter residents; (5) rapidly rehouse homeless individuals and families; and (6) prevent families and individuals from becoming homeless.
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Emergency Services Program (ESP)
Family Homeless Prevention and Assistance Program (FHPAP)
Homeless Management Information System (HMIS)
Project for Assistance in Transition from Homelessness (PATH)
Public Housing Authority (PHA) or Housing Redevelopment Authority (HRA)
Permanent Supportive Housing (PSH)
Rapid Re-Housing (RRH)
Release of Information (ROI)
Transitional Housing (TH)
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MN Department of Human Service (DHS) Office of Economic Opportunity (OEO) program provides emergency shelter, motel vouchers, day shelter and essential services for children, unaccompanied youth, single adults and families who are experiencing homelessness. The department awards funds biannually to local providers through a competitive application process.
The Family Homeless Prevention and Assistance Program (FHPAP) is designed to provide supportive services and/or financial assistance to families, youth and singles that are homeless or at imminent risk of becoming homeless.
Local information technology system used by a CoC to collect participant-level data and data on the provision of housing and services to homeless individuals and families and to persons at risk of homelessness. Each CoC is responsible for selecting an HMIS software solution that complies with HUD’s data collection, management, and reporting standards.
Substance Abuse and Mental Health Services Administration (SAMHSA)–funded program to provide outreach and services to people with serious mental illness (SMI) who are homeless, in shelter or on the street, or at imminent risk of homelessness.
Local entity that administers Public Housing and Housing Choice Vouchers (HCV) (aka Section 8 vouchers).
Permanent housing with indefinite leasing or rental assistance paired with supportive services to assist homeless persons with a disability or families with an adult or child member with a disability achieve housing stability.
Program emphasizing housing search and relocation services and short- and medium-term rental assistance to move homeless persons and families (with or without a disability) as rapidly as possible into permanent housing.
Written documentation signed by a participant to release his/her personal information to authorized partners.
Program providing homeless individuals and families with the interim stability and support to successfully move to and maintain permanent housing. Transitional housing funds may be used to cover the costs of up to 24 months of housing with accompanying supportive services. Program participants must have a lease (or sublease) or occupancy agreement in place when residing in transitional housing.
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Progressive Engagement
Housing First
Progressive Engagement is the practice of helping households end their homelessness as rapidly as possible, despite barriers, with minimal financial and support resources. More supports are applied to those households who struggle to stabilize.
Housing First is a homeless assistance approach that prioritizes providing permanent housing to people experiencing homelessness, thus ending their homelessness and serving as a platform from which they can pursue personal goals and improve their quality of life. This approach is guided by the belief that people need basic necessities like food and a place to live before attending to anything less critical, such as getting a job, budgeting properly, or attending to substance use issues. Additionally, Housing First is based on the theory that client choice is valuable in housing selection and supportive service participation, and that exercising that choice is likely to make a client more successful in remaining housed and improving their life.
Access Access points are the places–either virtual or physical–where an individual or family in need of assistance accesses the coordinated entry process.
Assessment The standardized assessment process, including assessment information, factors, and documentation of the criteria used for uniform decision-making across access points and staff.
Prioritization
Placement (referral)
The factors and assessment information with which prioritization decisions will be made for all homeless assistance.
Persons are referred to available CoC housing resources and services in accordance with the CoC’s documented prioritization guidelines.
B. Coordinated Entry System Roles Overview
CoC Board Responsible for the general oversight of the CES, including the approval of the CES Policies & Procedures document.
Coordinated Entry Committee
Primary governing body for coordinated entry. Meets at least monthly to oversee the implementation and evaluation of the CES system.
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CoC Coordinator
Priority List Manager
The CoC Coordinator is responsible for assisting the NWCoC Board of Directors, Coordinated Entry Committee, and General Membership to design and implement a CES.
Staff position responsible for supporting or managing day-to-day functions of CES, which may include any combination of the following: maintaining a prioritization list, assisting with matching participants to available housing resources, communicating referrals, facilitating case conferencing meetings, assisting with grievance and appeal processes, monitoring CES activity, and preparing CES monitoring and evaluation reports.
Assessor Coordinated Entry Assessors should think of the assessment interview as a time when they should encourage clients to consider all available housing options, rather than presenting CES as the mechanism through which all clients should attempt to access housing resources. NWCOC \Coordinated Entry System Assessors are located at access points across the NWCOC region. The assessor has arguably the most important job in the entire system. It is recognized that most assessors also serve as housing case managers, it is extremely important to distinguish the roles from one another to have an effective system.
Case Manager
The case manager will be working with clients referred by the NWCOC Priority List Manager. The case manager will work with clients to find housing, and while looking for housing find any available resource that may support them. The case manager is responsible for implementing a client centered approach. This includes informing clients of all available housing options and helping them determine what type of program may be best to support them. The case manager is responsible for notifying the Priority List Manager (PLM) of any openings. This is done through an online form. You will need to e-mail the PLM to get access to this form if you do not have it.
The Housing Navigator will work through Coordinated Entry to identify and assist clients in rapidly securing housing, accessing desired services, and supporting stabilization once housed. The Navigator will utilize the CES Prioritization lists to identify persons who need formal navigation services the most. Collaborative Applicant Entity that must (at the request of the CoC Board) apply for HUD funding for coordinated entry, including planning grants.
Housing Navigator
HMIS Lead Agency Operates the Homeless Management Information System on the CoC’s behalf. Ensures the CES has access to HMIS software and functionality for the collection, management, and analysis of data on persons served by coordinated entry. Entity designated by the CoC in accordance with HUD’s CoC Program interim rule to operate the HMIS on the CoC’s behalf. The HMIS Lead designated by the CoC may apply for CoC Program funds to establish and operate its HMIS.
Participating Project Agency or organization that has agreed to provide homelessness supports/services on behalf of the CoC. A participating project must execute a CES Participation Agreement with the CoC. The Participation Agreement outlines the standards and expectations for the project’s participation in and compliance with
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NWCOC Coordinated Entry System Procedure Manual Version 1.0
Adopted 01/19/2023 the policies and procedures governing CES operations. For a project to receive CoC or ESG Program funding from HUD, it is required to participate in coordinated entry.
Referral Partner A type of participating project. Referral partner will receive and consider referrals to its project from the CES. It will sign a Referral Partner Agreement with the CES management entity affirming it is aware of and will adhere to all expectations for coordinated entry.
Mainstream Resource Provider Agency or entity that can provide necessary services or assistance to persons served by coordinated entry. Examples of mainstream system providers include hospitals, mental health agencies, employment assistance programs, and schools.
U.S. Department of Housing and Urban Development
Federal agency responsible for administering housing and homelessness programs including the CoC and ESG Programs.
U.S. Department of Veteran Affairs Federal agency responsible for providing health care and other services, including assistance to end homelessness, to veterans and their families.
3. NWCoC CES Introduction
Northwest Coordinated Entry System (CES) is not a program, but a way of providing service. Utilizing progressive engagement, CES provides multiple points for access and assessment, while maintaining standardized processes and tools to improve linkage to mainstream and homeless services.
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In HUD’s vision, the coordinated entry process is an approach to coordination and management of a crisis response system’s resources that allows users to make consistent decisions from available information to efficiently and effectively connect people to interventions that will rapidly end their homelessness. 1
CES will help our CoC better identify, document and evaluate system needs, as well as prioritize limited resources, assuring those who are most in need of services are prioritized for services.
The CES in the NWCoC serves at the Homelessness Response System to accomplish the goals of the NWCoC to end homelessness.
A. NWCoC Housing Provider Participation Expectations
As part of the annual CoC application process, each project must indicate an intent to participate in the coordinated entry process.
B. NWCoC Geographic Coverage Area
The Northwest Continuum of Care covers an expansive geographic area including three (3) Native Nations and twelve (12) counties. The Native Nations include the Leech Lake Band of Ojibwe, the Red Lake Band of Ojibwe, and the White Earth Nation. The counites include Beltrami, Clearwater, Hubbard, Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Pennington, Polk, Red Lake and Roseau. The geographic region is visualized in Figure 2 NWCoC Geographic Region.
C. Marketing and Outreach
Each project participating in CES is required to post or otherwise make publicly available a notice (provided by the CoC) that describes coordinated entry. This notice should be posted in the agency waiting areas, as well as any areas where participants may congregate or receive services (e.g., drop-in center). All staff at each agency are required to know which personnel within their agency can discuss and explain CES to a participant who seeks more information. This notice can be found on the NWCoC Coordinated Entry Website.
1 HUD Coordinated Entry Core Elements
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D. Safety Planning and Risk Assessment
The Coordinated Entry System will include access to local domestic violence shelters to ensure that all persons who are fleeing or attempting to flee domestic violence or sexual assault have immediate access to crisis response services. This will include the number to the MN Day One Crisis Line. All persons will have access to this hotline regardless of which access point they initially contact for services and assistance through the NWCoC coordinated entry.
The NWCoC assessment conducted at all NWCoC access points includes questions to screen for risk or potential harm perpetrated on participating as a result of domestic violence, sexual assault, stalking, or dating violence. In the event defined risk is deemed to be present, the participant shall be referred or linked to available specialized services and housing assistance, using a trauma-informed approach designed to address the particular service needs of survivors of abuse, neglect, and violence.
E. Nondiscrimination
The CoC has designated the NWCoC Performance and Evaluation Committee as the entity responsible for monitoring agencies on compliance with all CES requirements, including adherence to civil rights and fair housing laws and regulations. Failure to comply with these laws and regulations may affect its position in the local CoC rating and ranking process.
• Fair Housing Act – prohibits discriminatory housing practices based on race, color, religion, sex, national origin, disability, or familial status.
• Section 504 of the Rehabilitation Act – prohibits discrimination on the basis of disability under any program or activity receiving federal financial assistance.
• Title VI of the Civil Rights Act – prohibits discrimination on the basis of race, color, or national origin under any program or activity receiving federal financial assistance.
• Title II of the Americans with Disabilities Act – prohibits public entities, which include state and local governments and special purpose districts, from discriminating against individuals with disabilities in all their services, programs, and activities, which include housing and housing-related services such as housing search and referral assistance.
• Title III of the Americans with Disabilities Act – prohibits private entities that own, lease, and operate places of public accommodation, which include shelters, social service establishments, and other public accommodations providing housing, from discriminating on the basis of disability.
F. Lack of Appropriate Housing or Services
In many areas of the CoC, the CoC has insufficient resources to meet the level of need for a particular type of housing or supportive service; in some cases, no resource or housing opening may be available. The Coordinated Entry process will still focus on and prioritize the people with the highest needs, for whatever resources may be available until new resources can be
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People in a housing crisis who are not likely to be rapidly housed by a project should not be put on a priority list leaving them with the expectation that this will end their homelessness. Case managers at shelters and in the community need to work with people on alternative housing plans, including applying for affordable housing in the community, increasing income from employment and benefits, and exploring other housing opportunities available through the person’s personal support network. Alternatively, if a person is prioritized for PSH but only RRH resources are available, coordinated entry should have that person access RRH as a bridge or temporary placement, without it negatively affecting their PSH eligibility.
4. NWCoC Coordinated Entry System Overview
The Coordinated Entry System is encompassing of all partners who are part of providing services to people in communities experiencing a housing crisis. Coordinated Entry is the homelessness response system. Figure 3 NWCoC System Map provides a visual of the homelessness response system. A larger version of this graphic is included as Appendix A System Map. The goal of the response system is to get people into permanent housing as soon as possible, with the appropriate level of service.
The NWCoC will continue to strive towards streamlining the system for people who are experiencing homelessness or are at-risk of experiencing homelessness. Systems are designed to learn and adapt to ever changing needs. We can do this through standardizing our processes across the region.
An important note regarding coordinated entry is that housing is not guaranteed for clients who are added to the Priority List. The fact is there is both a limited supply of homeless-dedicated housing and a great need for that limited resource. This, unfortunately means that many people will never receive a housing referral through CES.
The system is designed to provide the most intensive resources available to the people who are most vulnerable and at-risk in the region. Using a progressive engagement approach to serving people as rapidly as possible with the minimal amount of resources to solve the housing crisis creates more opportunity for people to access the system. Whenever possible a client should be referred to mainstream resources to solve their housing crisis. Mainstream resources can be defined as “…publicly funded programs that provide services, housing and income supports to poor persons whether they are homeless or not. They include programs providing welfare, health care, mental health care, substance abuse treatment programs and veteran’s assistance.”
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Before determining that a client should be referred to an assessment for supportive housing services the Diversion process will help determine if the client could be more appropriately assisted through prevention resources. The best example of prevention resources is the Minnesota Family Homeless Prevention and Assistance Program (FHPAP). This program typically offers utility payments, deposits, one-time rent payments, and short-term rapid re-housing. The Northwest Minnesota Community Action Programs and Tribal Housing Programs typically have FHPAP funds to assist families. Other prevention resources also exist and agencies and assessors should collaborate and educate themselves on how to best work together to serve clients. In some cases, a client may have resources available and only require short term assistance or one-time assistance to access stable housing. In this case the NWCoC utilizes a Rapid Resolution pathway to divert the client from remaining homeless or having to wait on the prioritization list.
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A. Key Roles of The System
Figure 4 System Roles outlines the basic roles provides a basic breakdown of the four job roles required to operate the Coordinated Entry System (CES). It is noted that at many agencies within the NWCOC the same person may assess a client as
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Priority List Manager
Staff position responsible for supporting or managing day-to-day functions of CES, which may include any combination of the following: maintaining a prioritization list, assisting with matching participants to available housing resources, communicating referrals, facilitating case conferencing meetings, assisting with grievance and appeal processes, monitoring CE activity, and preparing CE monitoring and evaluation reports. The PLM also works to provides technical training to agencies utilizing the CES. Assessor Coordinated Entry Assessors should think of the assessment interview as a time when they should encourage clients to consider all available housing options, rather than presenting CES as the mechanism through which all clients should attempt to access housing resources. NWCOC Coordinated Entry System Assessors are located at access points across the NWCOC region. The assessor has arguably the most important job in the entire system. It is recognized that most assessors also serve as housing case managers, it is extremely important to distinguish the roles from one another to have an effective system.
Housing Provider
The Housing Provider will be working with clients referred by the NWCOC Priority List Manager. Typically, the Housing Provider will assign a case manager or other client support staff in this role. The Housing Provider will work with clients to find housing, and while looking for housing find any available resource that may support them. The Housing Provider is responsible for implementing a client centered approach. This includes informing clients of all available housing options and helping them determine what type of program may be best to support them. The Housing Provider is responsible for notifying the Priority List Manager (PLM) of any openings. This is done through an online form. You will need to email the PLM to get access to this form if you do not have it.
Housing Navigator
The Housing Navigator will work through Coordinated Entry to identify and assist clients in rapidly securing housing, accessing desired services, and supporting stabilization once housed. The Navigator will utilize the CES Prioritization lists to identify persons who need formal navigation services the most.
F IGURE 4 S YSTEM R OLES
5. Stages Coordinated Entry System
The four stages of coordinated entry required by HUD are Access, Assessment, Prioritization, and Placement (Referral). Figure 3 NWCoC System Map provides a visual overview of all stages of the Coordinated Entry System. Figure 5 NWCoC Phases of Coordinated Entry below provides a detail of each the phases.
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Access
Access points are the places–either virtual or physical–where an individual or family in need of assistance accesses the coordinated entry process.
Assessment
The standardized assessment process, including assessment information, factors, and documentation of the criteria used for uniform decision-making across access points and staff.
Prioritization
The factors and assessment information with which prioritization decisions will be made for all homeless assistance.
Placement (referral)
Persons are referred to available CoC housing resources and services in accordance with the CoC’s documented prioritization guidelines.
A. Access
Homeless assistance providers that are designated access site across the Continuum of Care (CoC) will provide access to crisis response services for persons experiencing homelessness or at imminent risk of literal homelessness. All access points are approved by the NWCoC Coordinated Entry Committee. A list of current access sites is available on the NWCoC Coordinated Entry Website at the following link. In the NWCoC a “no wrong door” approach has been adopted in which an individual or family can present at any homeless housing and service provider in the geographic area and completes the same assessment process so referral can be consistently made across the CoC. An access site can be an existing agency or point-of-contact where households facing a housing crisis can go or call as a first step to obtaining resources. It is the responsibility of the entire NWCoC community to understand these access sites and how to direct clients to them. It is the responsibility of the NW CoC access sites to market and ensure the communities and partners understand they are a first step to housing resources.
Access, Assessment & Housing Sites in Northwest Minnesota
The following outline procedures for providing Access:
• To ensure that there is sufficient coordination and attention given to certain populations, the CoC may identify specialized access sites, to ensure the appropriate services are offered.
• Each project participating in CES is required to post or otherwise make publicly available a notice (provided by the CoC) that describes coordinated entry. This notice should be posted in the agency waiting areas, as well as any areas where participants may congregate or receive services (e.g., dining hall). All staff at each agency are required to know which
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• The access sites across the NWCoC provide coverage across the entire geographic region.
• The use of virtual meetings, or phone assessments can reduce barriers to access. All CoC access sites have the ability to use translation services. If a need arises to provide access to a client that cannot be met for translation services, or visual or audible impairment the assessor should contact the Priority List Manager and CoC Coordinator for assistance.
• The NWCoC does not require a coordinated entry assessment to access emergency shelter, including shelter for fleeing domestic violence. Upon entry into shelter, shelter clients should be connected to coordinated entry within seven days.
• Access points will use the NWCoC Assessment process to determine any immediate needs that could be addressed to resolve the housing crisis. Clients that access coordinated entry who are in housing, but at imminent risk of homelessness, will be offered access to homeless prevention services.
• Street outreach staff in the NWCoC will be trained on coordinated entry and the assessment process to offer access to coordinated entry. Street outreach staff can provide direct access to coordinated entry, or direct persons experiencing homelessness to the nearest access point and assist with connecting to coordinated entry.
• All members of the NWCoC are responsible for understanding the access locations to ensure clients can easily access an assessor and the homelessness response system.
• If your agency would like to become a site for clients to access the Coordinated Entry System, e-mail the COC Coordinator.
B. Assessment
a. Assessment for Coordinated Entry Services
The NWCoC follows a Progressive Engagement, person-centered approach to ending someone’s homelessness. The assessment stage uses information from the client to understand the housing crisis and tailor assistance to each individual or households needs in assessing what works best for them, with their strengths, and in their specific situation.
All persons served by CES will be assessed using the NWCoC Housing Assessment. All access points must use this assessment to ensure that all persons served are assessed in a consistent manner, using the same process. The NWCoC Housing Assessment documents a set of participant conditions, strengths, needs, and level of vulnerability, allowing the access point and/or assessment staff to identify the appropriate intervention and next steps to resolve the housing crisis and achieve housing stability. Please see NWCoC Website for a copy of the assessment forms.
The NWCoC Administrative Policy sets the referral criteria for each phase of the assessment.
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b. Phases of the Assessment
The NWCoC has adopted a phased approach to the NWCoC Housing Assessment to appropriately identify the correct intervention through a Progressive Engagement approach. The assessment process follows Housing First as an evidenced based best practice to provide housing resources without creating barriers to access housing. Figure 5 Phases of NWCoC Coordinated Entry below provides additional detail of each the phases.
Active Listening
This first phase will focus on identifying the immediate housing crisis, and clarifying that the CoC crisis response system is the appropriate system to address the potential participant’s immediate needs. This may include presenting the client with options for additional mainstream resources that can solve the crisis. Assessors are encouraged to make warm handoffs by assisting the client to contact other resources. Simply providing phone numbers or brochures is discouraged.
Diversion
This phase will focus on identifying the clients existing situation and identify resources that could be used to prevent the client from entering the homeless response system. The Diversion and Rapid Resolution Assessment will assist in determining the appropriate next steps for the client, providing a rapid resolution, assessing for prevention, or referred to the coordinated entry priority list. Clients who are in crisis and unable to access housing should be referred to emergency shelter.
Rapid Resolution
The Rapid Resolution process was designed for clients presenting at access sites who are homeless, and with limited resources can access housing. Assessor and client determined short-term resources will solve the housing crisis. Typically, this involves first/last month rent, security deposits, utility connects, and verification that the client will have long term support through a housing choice voucher, subsidized housing, other long-term support, or sufficient income.
Prevention
Clients who present at access points that are currently housed and can remain housed for fourteen days should be screened for prevention services. The NWCoC uses the Minnesota Prevention and Assessment Tool to screen for eligibility and prioritization for prevention services.
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Coordinated Entry Assessment
In this phase the assessor will seek information to refine, clarify, and verify a participant housing barrier. The information from his assessment supports the NWCoC to evaluate the client’s vulnerability and prioritize for referral to available housing programs.
Interim Assessment
Once assessors place a client on the priority list it is the responsibility of that assessor to maintain contact with the client until the client locates housing. An interim assessment can also be completed during the referral process as a housing provider will contact the client. In the event the assessor attempts to complete an Interim Assessment and is unable to make contact, the assessor should make three attempts over five days to make contact. An assessor should use all methods of contact provided by the client. If unable to contact during this phase the person can be exited from the priority list.
Individuals who choose not to participate in data collection upon initial assessment or project entry may later decide that their information can be collected and entered into HMIS. Participant data in HMIS can be updated after an initial CES data collection period and throughout project enrollment to reflect emergence of new information, corrections to previously collected information, or additions of previously unanswered questions. The CoC will continuously work to improve participant engagement strategies to achieve completion rates of required HMIS data elements that are as high as possible.
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Active Listening
Designed to assist assessors in understanding what services the client may be looking for and what kind of referrals can be made to mainstream resources. Assessor determines the CoC homeless response system is the appropriate system to address the client’s needs. If the client is likely in need of prevention or supportive housing the assessor will move on to the Diversion and Rapid Resolution Assessment.
(Immediately)
First point of contact - after person has identified housing crisis or requested homeless services. Can be completed over the phone or inperson.
Active Listening Guide
Assessor
Diversion and Rapid Resolution
Designed to reduce the number of persons entering the homeless response by diverting to mainstream resources or prevention services. This questionnaire will determine if the person should be referred to:
• Emergency Shelter or Crisis Housing
• Mainstream Resources
• Prevention Services
• Rapid Resolution
• Coordinated Entry Assessment
• Housing Stabilization Services
The Diversion and Rapid Resolution Assessment will assist in determining if a prevention screening or Coordinated Entry Assessment is required.
Prevention Aimed at keeping persons who are at risk of homelessness housed (persons who are either doubled up or in their own housing).
Performed once the assessor determines the client is a likely candidate for prevention or supportive housing resources. Can be completed over the phone or inperson.
ONLY after Diversion and Rapid Resolution Assessment has determined Prevention
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Diversion and Rapid Resolution Assessment in (HMIS) or Alternative Assessment
NWCoC CES Receipt and ROI
Assessor
MPAT (HMIS) Assessor
Coordinated Entry Assessment
Assessment for linkage to the following, but not limited to supportive housing resources (Transitional Housing (TH), Rapid-Rehousing (RRH), Housing Support, Permanent Supportive Housing (PSH) and Long-term Homeless (LTH) Vouchers). Linkage to resources is based on NWCoC prioritization criteria, client-choice, and peer to peer discussion through case conferencing meetings.
NOTE: Being placed on the housing priority list does not guarantee a housing placement. Agencies should do everything possible to resolve the housing crisis without needing supportive housing services (housing with case management).
Services would be appropriate. Can be completed over the phone or inperson.
Only after Triage/Diversion questionnaire has determined supportive housing resources will be necessary. All clients who complete Step 3b are anticipated to be added to the NWCoC Prioritization list. Can be completed over the phone or inperson.
Coordinated Entry Assessment (HMIS)
NWCoC Prioritization List (HMIS)
NWCoC CES Receipt and ROI
Assessor
Once a client is placed on the list it is the assessor’s job to maintain contact with that client.
Interim Assessment
The goal of the interim assessment is to ensure a client’s situation is kept up to date until the client is housed. Or if the client has self-resolved the client should be removed from the NWCoC Priority List to avoid unsuccessful referrals.
Must be completed a minimum of every 90 days, assessors are encouraged to update every 30 days to ensure accurate referrals.
Coordinated Entry Assessment (HMIS)
NWCoC Prioritization List (HMIS)
Assessor
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F Igure 5 S Tages Of Nwc O C C Oordinated E Ntry
c. Assessor Training
The CoC will provide at least annual training for persons who will manage access point processes and conduct assessments for CES. Training will be offered at no cost to the agency or staff, and will be delivered by an experienced and professional trainer who is identified by the CoC. Topics for training will include the following:
• Review of CoC’s written CES policies and procedures, including variations adopted for specific subpopulations;
• Requirements for use of assessment information to determine prioritization;
• Training on the use of the CES assessment tool; and
• Criteria for uniform decision-making and referrals.
An outline of access to training for the NWCoC CES can be found as Appendix B Training Access of this procedure manual.
d. Discrimination Complaint and Appeal Process
The Coordinated Entry Receipt must include the point of contact for filing and addressing any discrimination complaints, which can be filed by participants if they believe the nondiscrimination policy has been violated in their case during the CES process. Additionally, this form will describe and provide contact information on how to access the appeal process if they are not satisfied with or have any questions regarding how their complaints are handled. This form must be reviewed at the access point by CES staff, and must be signed by each participant.
e. Privacy Protections
A participant’s request for housing crisis response assistance initiated through phone or email communication will be considered notification of intent and inferred to be client consent to collect, use, and disclose that PII collected via phone or email. CES participating agencies shall obtain written client consent from the participant when the person comes in and additional data are collected during an in-person assessment.
The CoC must protect all participants’ personally identifiable information (PII), as required by HUD’s HMIS Data and Technical Standards, regardless of whether or not PII is stored in HMIS. All CES participating projects will ensure participants’ PII will only be collected, managed, reported, and potentially shared if those data are able to be secured in compliance with the HUDestablished HMIS privacy and security requirements. Training for CES users on data privacy is provided by the HMIS System Administrator.
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As part of the assessment process, participants will be provided with a copy of the NWCoC Release of Information form, which identifies what data will be collected, what data will be shared, which agencies data will be shared with, and what the purpose of the data share is. Participants have the option to decline sharing data; doing so does not make them ineligible for CES. A copy of the NWCoC Release of Information can be found on the NWCOC Coordinated Entry website under forms.
An individual being assessed through coordinated entry has the right to refuse the entry of their data into the HMIS system. When this happens use the NWCoC Alternative Assessment process. For creating an entry/exit client record in the HMIS, follow the instructions provided by the HMIS or your HMIS Alternative Database provider for entering clients records without personally identifiable information.
All of the forms for the NWCoC Assessment are stored on the NWCoC Coordinated Entry website under forms. Each form includes detailed instructions that guide the assessor through the document based on answers from the client.
Detailed instructions for completing the assessment process, including instructions for entering data into HMIS can be found in Appendix C Diversion and Coordinated Entry Data Instructions of this document. This document is also stored on the NWCoC Coordinated Entry website under implementation.
The NWCoC has developed an Alternative Assessment system for Victim Services providers, youth under age 18 who do not have parental consent, and persons unwilling to share data in HMIS. This Alternative Assessment system is also used for individuals who refuse entry into the HMIS. If an individual refuses entry into the HMIS system is does not impact the individual’s ability to receive services.
If a client does not want to consent to their record being shared statewide in HMIS, you will still create and enter data in the client’s record in the system with identifiable information, including their name and SSN. The MN HMIS ROI is only asking clients to consent to having their HMIS data shared statewide. Imagine it as a record in a filing cabinet in your office that will then only be visible to HMIS users at your agency. In this case the client’s record will simply need to be manually “closed” to the statewide data sharing visibility group in HMIS. When a client’s record is closed their information will only be accessible to users at your project and agency.
Assessors can access the Alternative Assessment through e-mailing the NWCoC Priority List Manager. This is to maintain secure access to the Alternative Assessment system. The Alternative Assessment system does not collect personally identifiable information from the client. Collaboration between the Assessor and Priority List Manager will be required to offer services, without sharing any personally identifiable information. Instructions for completing the Alternative Assessment are
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Additional information regarding data sharing and the HMIS ROI can be found on the MN HMIS website. https://hmismn.helpscoutdocs.com/category/1781-data-sharing-hmis-roi
C. Prioritization
Prioritization is utilized for all dedicated supportive housing programs to help strategically and fairly target available resources, better assuring that those who are most vulnerable receive housing more rapidly than those with who are less vulnerable.
The prioritization process uses the information gathered from the assessment stage to analyze a person’s level of vulnerability. The persons priority is set based on the NWCoC prioritization guiding values and eligibility through discussions at case conferencing meetings. This process values client choice and a strength-based client-centric approach. In order to provide the best possible outcomes, the NWCoC will use a Dynamic Prioritization process. Dynamic Prioritization is a dynamic process that uses prioritization criteria (i.e., assessment result, unsheltered status, length of time homeless) to identify the most vulnerable (preferably through a case conferencing process) based on the number of anticipated housing placements across all resources that will occur in a set number of days.
a. Guiding Values
1. Serve the most vulnerable clients who without supportive services, case management and/or ongoing rental assistance will remain homeless or become homeless.
2. Addressing disparities in the homeless response system and improving access to programs.
3. Clients are referred through a case consultation process to the best available resource.
4. Clients who are not referred to supportive services are offered help problem solving to end their housing crisis.
5. Prioritization is client-centric and strength focused. Clients are referred to services they identified are appropriate to end their housing crisis.
6. Through prioritization clients will be referred to programs they are in fact eligible to receive support from.
The Coordinated Entry System Priority List is a centralized list of persons in need of and seeking designated supportive housing in Northwest Minnesota. It is NOT a Waitlist for those seeking services. The Priority List is meant to be a real time up to date list of the most vulnerable persons in the region seeking services. Persons who are a better fit for less intensive programs should not be on the list.
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The length of time someone has been homeless is an indicator of vulnerability and a factor in being prioritized for services. The length of time a person has been on the priority list is not.
b. Priority List Location
The NWCoC has two priority lists. One is located in the statewide HMIS system, this is the most widely used priority list. Due to requirements from HUD that state a minor (unaccompanied youth under 18 without consent of parent), or person fleeing DV is not allowed to be entered into HMIS another list exists. The Alternative Priority List is in a secure location and can only be accessed through connecting with the NWCoC Priority List Manager.
c. Household Prioritization Criteria d. Barriers and Client Choice
Individuals will be prioritized based on eligibility and NWCoC prioritization criteria for housing vacancies. Prioritization outcomes will be informed by client choice, program eligibility, and a set of client-centric and strength based focused questions to inform housing programs. Final prioritization of clients will be determined through case conferencing, additional details on case conferencing can be found at Section 5. D. Placement and Section 5. C. j Case Conferencing.
The questions are meant to inform the case conferencing process for making a referral to an eligible program opening.
• What households on the priority list are eligible for the particular housing program opening being discussed?
• What is the length of time the eligible households have been homeless? Are any of them Chronic Homeless?
• What households have indicated having the greatest amount barriers to accessing housing?
• Where do the identified households wish to live? Does it align with the program opening location?
• Does the program opening align with the clients identified housing needs? Does it match client choice?
• Of the identified households which household is eligible, has the greatest barriers, and aligns with the program opening?
The following criteria is meant to inform the case conferencing process and assist in prioritization of individuals. Clients who meet these criteria should be determined to be the most vulnerable and prioritized based on the guiding values for prioritization.
Barrier or Client Choice Explanation
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Impact from Societal Issues and Discrimination
Interaction with Institutional Systems
Clients Physical and Emotional Health Needs
Client Choice
School Stability
Client Reported Barriers
The client answers “Yes” to being asked if discrimination or other societal issues have impacted the ability to access housing. This can include but is not limited to racism, medical diagnosis, disability, gender, or sexual orientation.
The client answers “Yes” to being asked if time spent in institutional settings has impacted their ability to find housing. This can include but it’s not limited to, foster care, jail/prison, chemical healthcare, or registered sex offender.
Without housing clients will have difficulty meeting their current and future emotional or physical health needs.
Clients have choice in determining where they want to live, and are offered a variety of supportive housing options to determine what is best for them.
Certain programs in the NWCoC require school aged children for eligibility. Keeping children safe and in a stabile school environment is a consideration for prioritization.
Client may have additional barriers including, but not limited to, communication access, transportation access, and in general unable to access mainstream resources or benefits on their own.
Family Reunification
F
IGURE 6 C LIENT B ARRIERS AND C HOICE e. Eligibility Criteria
Eligibility Criteria
Current Living Situation (Where is someone living the night before being place on priority list?)
Clients may require housing in order to safely reunite with children.
Length of Time Homeless
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Explanation
Where a client is currently living impacts the current level of vulnerability and eligibility of programs. The following current living situations are prioritized for referrals.
1. Literally Homeless (HUD Homeless)
2. At-Risk of Homelessness (Will lose housing within 14 days)
3. MN Homeless (doubled up less than 1 year)
4. Institutional; Situation (jail, foster care, hospital, nursing home, psych. Hosp., substance abuse treatment facility)
The length of time a person remains homeless increases the level of vulnerability and increased the difficulty in accessing stabile housing. The following lengths of time homeless are prioritized for referrals:
1. Chronic Homelessness
2. High Priority Homeless (Long Term Homeless)
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Fleeing Domestic Violence
Veteran Status
Disability Information
Household Type
3. Total Months HUD Homeless
4. Total Months MN Homeless (Doubled-Up, less than one year)
Fleeing domestic violence is a consideration for prioritizing referrals, some programs require this for eligibility.
A person’s veteran status is a determining factor in prioritizing for referrals, the CoC will first look to fill program openings specifically for veterans with homeless veterans before other openings.
A person’s disability status can determine eligibility to certain programs and the definition of homelessness they will be categorized in. When reviewing disability information whether the client has a documented or self-reported disability will not impact prioritization for vulnerability of client, however it may impact whether not the client is eligible for the program.
Household size may determine eligibility for certain projects, it does not determine a client’s vulnerability level for prioritization.
Household Type Household type may determine eligibility for certain projects, it does not determine a clients’ s vulnerability level for prioritization.
