Category Archives: Continuum of Care

A Housing System Built for Zero Part Two: Assessment and the Role of By-Name Lists

The second part of a three part post from the Zero 2016 campaign:

A Housing System Built for Zero Part Two: Assessment and the Role of By-Name Lists

Last month, many of the 71 communities participating in Zero:2016 launched their local participation during the federal Point-in-Time (PIT) Count. This annual count of sheltered and unsheltered people experiencing homelessness gathers important data for tracking federal trends, setting policy and allocating national resources – but this anonymous count does have some drawbacks. It does not provide the necessary information that housing and service workers need in order to follow up with people experiencing homelessness in their communities and connect them to housing. That’s why 49 Zero: 2016 communities across the country went the extra mile this year, taking care to meet all federal count standards while also using the PIT count as an opportunity to implement the first of four components of a coordinated assessment and housing placement system: assessment.

Experience has shown us that a community cannot gather the necessary information to house its homeless neighbors solely by counting them anonymously once a year. As New Orleans’ successful drive to end veteran homelessness has shown, a local team must know the names and unique needs of every person on its streets and in its shelters. That’s where assessment comes in. By learning names, documenting stories and understanding the most urgent needs of each of their homeless neighbors, communities can take a critical step toward moving people off the streets and into housing.

In order to collect this by-name information, many communities across the country are selecting, or have already selected, a Common Assessment Tool (CAT).

A CAT is a standard set of questions used by all agencies and organizations in a community that allows the local team to quickly assess people based on their unique circumstances and needs. Additionally, it helps outreach workers and service providers find the best housing match to fit these needs. CAT data creates the foundation of an informed CAHP system, offering a birdseye view of everyone experiencing homelessness in a community and providing a way to connect each person to the most appropriate housing option, in line with research, chronic and veteran status and other local priorities.

If a connection to permanent housing and services is the output of a well functioning CAHP system, then by-name CAT data is the critical input. Without it, it’s hard to connect people to housing in a strategic or comprehensive way.

In order to maximize the impact of a CAT, communities should choose the best tool for their local circumstances and then integrate it into their PIT counts, day-to-day street outreach and service operations. This complete integration allows communities to create a comprehensive, continuously updated, by-name list of all those experiencing homelessness. This list should be stored in a central, HIPAA-compliant database, which then forms the basis of a community’s CAHP system.

A Common Assessment Tool helps community leaders:

  • Know everyone experiencing homelessness by name
  • Understand the history and needs of these people in order to refer them to appropriate housing and services as quickly as possible
  • Create a systematic way to consistently update and track important information on each person experiencing homelessness
  • Improve planning and optimize the allocation of resources based on a clearer breakdown of local homeless populations

While there is no single acceptable CAT – popular choices include the VI-SPDAT and the NAEH Comprehensive Assessment Tool - a community should select a tool that is research informed and that can make effective recommendations across a variety of housing options. These options include permanent supportive housing, rapid re-housing and affordable housing, as well as time limited interventions, including emergency shelter beds, that can be used as a bridge to permanent housing. A community’s CAT should meet several requirements that help guarantee that it will be an effective tool in working to end homelessness.

A strong CAT must:

  • Be available for all subpopulations
  • Be worded in a way that clients can understand and respond to accurately
  • Be able to be implemented by non-clinical staff (such as volunteers)
  • Use a housing first frame to help get people off the streets and into housing as quickly as possible

The use of a CAT is not a one time event, but rather an ongoing process. A successful community should use its CAT to constantly update its by-name list in real time. This information can then be used to help track progress toward zero and to develop and refine a community’s Take Down Target – the total number of homeless veterans and individuals that will need to be housed in order to end veteran homelessness by the end of 2015 and chronic homelessness by the end of 2016.

Next Friday, February 27, is Zero: 2016 Take Down Target Day, when communities will be confirming and committing to their veteran and chronic Take Down Targets. We’ll be using this blog to discuss these Take Down Targets in more detail next week, so be sure to check back soon!


Zero 2016: A Housing System Built for Zero

Community Solutions, the entity behind the Zero 2016 campaign, is posting a three-part series on coordinated intake and assessment. The information is so critical to what we do that I am copying the posts in their entirety. Part one is below, and parts 2 and 3 will follow in the next several days.

Part 1: A Housing System Built for Zero

Ending homelessness is about breaking down barriers. Nothing should stand in the way of providing our neighbors experiencing homelessness with the dignity and necessity of a home. Through Zero: 2016, we’re committed to working with communities to break down any barriers that may stand in the way of meeting our goal and ending veteran and chronic homelessness in the next two years.

Among the most imposing of these barriers is the often disorganized and inefficient process that an individual or family experiencing homelessness must navigate in order to access stable housing in their community. Fraught with roadblocks and the often challenging task of coordinating across multiple agencies and non-profit groups, local housing placement processes can often take more than a year to lead to a home– a year that many people experiencing homelessness simply can’t spare.

The process of connecting available housing to people in need doesn’t have to be so complicated. It remains so in most communities due to a series of design flaws. Traditionally, those that are the first seek out help are the first to receive it, leaving the most vulnerable, who are often least able to navigate the bureaucratic housing placement process, either unidentified or stuck at the back of the line. Once in line, these people are forced to navigate a patchwork of agencies, each with its own separate systems and protocols, that even trained social workers often struggle to understand. To make matters worse, there is no guarantee that an individual who successfully navigates his or her local housing bureaucracy will be matched to the right kind of housing assistance for their needs at the end of the day– a disabled or mentally ill individual may end up in housing without appropriate social services, for example, or someone whose needs are fairly marginal may be connected to housing with intensive, built-in services that might be better suited for someone else.

To address this problem, we are focused on helping the 71 communities participating in Zero: 2016 to design and improve their local housing placement systems. These communities are committed to creating systems that are built for zero, meaning systems that are coordinated, data driven, and optimized to end and maintain an end to veteran and chronic homelessness.

These communities are reimagining their existing systems as Coordinated Assessment and Housing Placement (CAHP) Systems. A CAHP system removes unnecessary barriers and streamlines the housing process by identifying the names and needs of individuals experiencing homelessness and matching them with the best housing options for their circumstances.

Much like an emergency room, a CAHP system can help community leaders thoughtfully triage individuals based on their housing needs in accordance with research and local priorities. Just as an emergency room doctor wouldn’t prescribe the same treatment to all patients, a well functioning CAHP system doesn’t match everyone to the same housing services. Instead, the system draws on available research to match individuals with the housing options that are the most likely to end their homelessness at the lowest cost, ensuring that limited local housing resources can end homelessness for as many people as possible. This data-driven process functions in real time to expedite housing placements and increase coordination and communication among all partners working to end homelessness in a community.

A CAHP system also provides a community with a big-picture, by-name snapshot of everyone experiencing homelessness on its streets and in its shelters, helping community leaders make better decisions about strategy, advocacy and ways to allocate housing dollars.

There is no step-by-step guidebook or mandatory approach to implementing a well functioning CAHP System; in fact, the best systems are flexible enough to incorporate new ideas and efficiency improvements that a community may discover along the way. However, there are a number of concepts and processes that have proven fundamental, especially in leading efforts like the ones pioneered by Home for Good in Los Angeles and a variety of organizations working together in Nashville, TN:

All CAHP systems can be divided into four key areas:

  • Assessment
  • Navigation and Case Conferencing
  • Housing Referral with Choice
  • Data Collection and Communication

Later this week, we’ll be exploring these phases and components in more detail and highlighting how each of them fits into the overall strategy of Zero: 2016. Be sure to check back soon for more on assessment, data collection and the critical role that by-name registries play in ending homelessness.

Here’s what a coordinated system looks like

Like the Hampden County CoC, Arlington, VA is a Zero 2016 Community.  But Arlington is ahead of us, because they participated in the 100,000 Homes campaign. The Washington Post describes the system they have put in place–and what we are working toward.  The full story is copied below:

Arlington’s no-silos approach has housed hundreds of chronically homeless adults

January 31 at 5:01 PM

Late at night, David Clark wakes up and goes to the kitchen to choose from the boxes of cereal atop his refrigerator. He pours cold milk into the bowl and counts his blessings.

Toilet paper, which he keeps in abundant supply. Body wash that lathers up nicely. A machine to shampoo the rugs in his immaculate one-bedroom apartment.

“When I come in, I can sit right there on that couch and turn on the television,” said Clark, 57, pointing to the worn beige sofa. “Don’t have nobody telling me when to get up or go to sleep.”

Clark has lived in his apartment in Arlington County for the past two years, after 26 alcohol-soaked years on the streets, when he frequently slept under Key Bridge. He is one of close to 300 chronically homeless men and women whom Arlington has placed in housing since 2011, using a rigorously organized, all-hands-on-deck approach that experts say could also work in cities with much larger homeless populations. The county found housing for about 100 homeless families during the same four-year period.

“Arlington is not alone, but they’re on the leading edge,” said Jake Maguire, a spokesman for Community Solutions, an anti-homelessness group. “It shouldn’t be unusual. It’s startlingly simple.”


Arlington has a master spreadsheet that lists homeless individuals by name, drawing from an annual survey of people living on the streets and carefully cultivated contacts at food distribution sites, shelters and other places where the vulnerable gather. The spreadsheet includes whether the people want housing, what health problems they have, their income sources and anything that might help or hinder their search for a home.

Once a month, there is a meeting of a task force that includes advocates and specialists in physical and mental health, as well as county social service workers. One person takes responsibility for each name on the spreadsheet. They go line by line, brainstorming about which public and private treatment programs and funding can be tapped to help each homeless person.

The process ignores agency divisions. The official in charge of federal Section 8 housing vouchers, for example, isn’t allowed to disregard someone on the spreadsheet who doesn’t qualify. Neither can the employee who tracks veterans’ housing disregard a nonveteran. Those who specialize in families can’t ignore the mental health needs of single adults.

“Breaking down all our silos and focusing on individuals by name was a huge thing,” said Kathleen Sibert, executive director of the Arlington Street People’s Assistance Network (A-SPAN). “You have to find programs they fit into.”

Clark’s path to his apartment began when one of the A-SPAN workers who offer food, blankets or shower vouchers to homeless people on the street identified him as especially vulnerable. She persuaded him to enter a residential detox program, where he worked on sobering up and was prescribed medication for diabetes, neuropathy and other health problems.

Ayana Bellamy became Clark’s case manager. She helped him get a state identification card, using the address of the residential program. (In Virginia, a permanent address is required for a government-issued ID, which often is needed to apply for apartments. Obtaining an ID can be the hardest part of the process, Bellamy said, because, by definition, homeless people don’t have a fixed address.)

Clark had trained as a cook at D.C. Central Kitchen and worked in kitchens at the Ritz-Carlton and Hilton hotels. But his drinking and his health problems kept him from finding a job and housing on his own. “I used to drink to wake up, and drink to go to sleep,” Clark said.

He already received Social Security disability insurance income. Bellamy helped him fill out paperwork to qualify for food stamps and a federal housing subsidy. But Clark was turned down when he applied for a one-bedroom apartment — because of decades-old credit problems and a long-ago criminal record. With Bellamy, he successfully appealed to the landlord. He moved in on Feb. 1, 2013.

“We set out to house the hardest people, and we’ve done that,” said Robert Sharpe, assistant director of Arlington County’s Department of Human Services. “Because we’re meeting monthly, people follow up.”

Arlington employs a “housing first” philosophy — clients don’t have to overcome addictions or mental illnesses before the county will help them find a place to live. Housing, their biggest problem, is fixed first. Then, other issues are addressed.

Social service officials say the rent subsidies and other assistance needed to house one chronically homeless person generally cost the county about $22,000 a year, compared with $45,000 for that person to bounce between shelters, jail and hospital emergency rooms — what usually happens when a person is living on the streets. Caseworkers pay close attention to the newly housed and step in when needed.

For example, Clark was tempted to go out drinking after he moved into his apartment. But Bellamy was there waiting for him — with paperwork and a U-Haul full of donated furniture. While they were moving him in, another truck arrived with a new bed — something the organization buys for all its clients.

Clark’s desire for a drink, he says, slipped away.

Arlington, like other jurisdictions in the region, does an annual census of its homeless population. This year’s count happened Wednesday night, though the numbers won’t be released until sometime in April.

In recent years, the county’s homeless tally has declined, dropping from 531 in 2010 to 451 two years later. It fell last year to 291, a surprisingly low number that may be attributable in part to the county’s all-out effort to house people like Clark, but almost certainly reflects some homeless people seeking shelter at friends’ homes on last year’s census date, because the weather was bitterly cold.

Of the 278 individuals and approximately 100 families housed by the county since 2011, about 95 percent remain in their homes or apartments, officials say. (The others have been evicted; jailed; found shelter with family or friends; or left the area.)

The District, which has thousands of homeless residents, won praise for adopting a “housing first” approach under former mayor Adrian Fenty (D). But the effort slowed under Fenty’s successor, Vincent Gray (D), when federal funding dried up. Newly inaugurated D.C. Mayor Muriel Bowser (D) has hired Laura Green Zeilinger, who directed the city’s former effort, to direct the Department of Human Services and help revive the approach.

Karen Booker, 49, found her apartment with Arlington’s help in 2012. She had survived a harrowing childhood in the District, including sexual abuse by a stepbrother, and spent years raising her siblings and half-siblings while struggling with mental illness. She held jobs sporadically: receptionist at Walter Reed Army Medical Center; personal-care aide at a nursing home; janitorial worker. A drug habit drew her into a descending spiral of petty crime, prostitution and jail. “I had to do some horrible stuff to stay alive,” she said.

Booker’s children, now grown, were raised by their father. She was living at a women’s shelter when her name made the spreadsheet. “She was ready for housing,” Bellamy said.

Previous evictions made it difficult to find a landlord who would take her. And she had an outstanding debt that she believed she could not pay. Bellamy found out the debt was $96, low enough for Booker to cover with funds from her Social Security Disability Insurance. Federal money for permanent supportive housing was available to subsidize rent at a new place.

Booker’s apartment is an oasis from her previous life. Bright sunshine streams through the mini-blinds in the living room that she’s turned into a bedroom, after deciding the actual bedroom was too small and dark. A stuffed tiger sits on a queen-sized bed. There are red artificial roses on a side table.

Like Clark, she has slipped at times, But, she says, she has been clean since the fall. She earned a certificate as a home health aide, and is looking for a job in that field. She is proud that she worked as a cashier at Nationals Park on New Year’s Day during the National Hockey League’s Winter Classic. She is in touch with her children every day.

And Booker is getting used to having some financial stability. When she got her electric bill recently, she was puzzled by a line at the bottom: $200, with a two-letter code next to it. So she called Bellamy. Together they figured out that the low-income energy assistance Bellamy had sought on her behalf had kicked in.

That CR code? Clark had never before seen a credit on one of her bills.

Continue reading

Hampden & 3 County CoCs reschedule point-in-time count to Jan. 29

Due to potential snow complications for the unsheltered/street count, the Hampden County and Three-County CoCs have both rescheduled the date for the 2015 point-in-time count to this Thursday, January 29.

This means that HMIS data will be pulled for the night of January 29, non-HMIS providers should submit summary data reports for that night, and the street count will take place that night.