Assessment of Pierce County Centralized Intake
Commissioned by Pierce County Community Connections
February 2015
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Pierce County Centralized Intake System SYSTEM ASSESSMENT AND RIGHT SIZING RECOMMENDATIONS Executive Summary ....................................................................................................................................... 1 I.
Background and Purpose........................................................................................................................ 5
II. Overview of Work to Date ...................................................................................................................... 5 III. Analysis ................................................................................................................................................... 6 A. Assessment of Centralized Intake System Strengths and Weaknesses ........................................... 6 1. Initial Call Screening and Intake ................................................................................................ 7 2. Assessment and Document Review .......................................................................................... 8 3. Placement Roster Management/Matching Households to Vacancies ...................................... 9 4. Program Acceptance and Refusal............................................................................................ 13 5. Data Tracking Systems............................................................................................................. 14 6. Side Doors and Parallel Systems ............................................................................................. 14 7. System Flow chart ................................................................................................................... 16 B. System and Program Barriers ........................................................................................................ 17 C. System Inventory and Right-Sizing Analysis................................................................................... 20 IV. Implications for Centralized Intake System Redesign .......................................................................... 26 APPENDICES: A. List of Documents Reviewed ................................................................................................................ 29
EXECUTIVE SUMMARY BACKGROUND AND PURPOSE OF ASSESSMENT Pierce County Community Connections engaged Focus Strategies to assist with the refinement of the existing intake and assessment tools used by the community’s Centralized Intake (CI) system, Access Point for Housing (AP4H). To inform our recommendations for system improvement, Focus Strategies conducted an assessment of the strengths and weaknesses of the current system. The analysis focused on the effectiveness of the AP4H system in conducting intake and assessment and making referrals to housing programs. This report is an intermediate deliverable that lays the foundation for recommendations to refine the CI system. While some general conclusions are provided about the implications of the assessment, this report does not include specific operational recommendations for changes to the CI. Recommendations will be presented as part of the next phase of work. In the course of our review, Focus Strategies also considered issues relating to the capacity of the existing inventory of available shelter and housing programs in the community and the degree to which restrictive program eligibility criteria impedes the effectiveness of the CI system. Examining this larger system context is essential to developing recommendations for improvement of the CI system. While CI can help improve homeless people’s access to assistance by providing a streamlined entry point and standardized process, it cannot be fully effective unless there is an appropriate array of available interventions so that each person who enters the system is also able to exit as quickly as possible to an appropriate permanent housing destination. The work on CI conducted by Focus Strategies is just one piece of an ongoing initiative being undertaken by Pierce County to transform the current collection of homeless programs and services into a system for ending homelessness. In developing our analysis, Focus Strategies considered how it will complement and support parallel efforts, including the Provider Academy that is helping Pierce County agencies develop tools to eliminate barriers to program access, the ongoing process of transitional housing conversion, the implementation of a Diversion pilot, and the High Performing Systems Challenge. METHODOLOGY This report is based on work conducted by Focus Strategies between June and November 2014. To compile this assessment, we pursued several avenues of information gathering and analysis, including: a review of existing documents and reports; a site visit to AP4H; interviews with homeless services and housing providers to understand the existing array of programs and their eligibility criteria; analysis of AP4H Placement Roster data; analysis of system performance data; and research on coordinated and centralized intake systems and lessons learned from other communities. RESULTS Focus Strategies found many ways in which the CI system is working well and improving clients’ experience in accessing services and housing. We also identified a number of weaknesses and areas that could be improved through adjustments to the intake, assessment and referral policies, processes, tools and data systems. Additionally, Focus Strategies also identified a number of inefficiencies in the AP4H process that relate to broader systemic issues of program barriers and the mismatch between the existing inventory of interventions and the needs in the community. These problems cannot be resolved through changes in
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the CI process and tools, but rather must be tackled as part of the larger system right-sizing work underway in the community. Following are key results of our assessment: •
Assessment Tool Inefficiency. The strengths and needs assessment tool used by AP4H is very lengthy and delves into psychosocial personal history that is not relevant in making a determination about a household’s housing barriers or what programs or housing they would be eligible for. Much of what is asked is not designed to be entered as discrete data elements which can be searched and used to match the client to a program, and the information gathered is reportedly not used at the program level to speed the intake process once a client is referred. Programs conduct their own assessment and intake which requires clients to repeat their story and defeats one of the main purposes of CI.
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Lack of Prioritization. Currently the existing AP4H tools and processes do not include any method to prioritize clients for open slots. In many coordinated or centralized intake systems, the responses a client gives to the assessment questions are used to generate a “score” or to place the client in a category or tier for matching and prioritizing (e.g. low, medium, or high barriers). Assigning households to categories can help speed the referral and matching process and ensure that limited resources are provided to those determined to have the greatest needs. Currently the tool being used by AP4H does not generate any outputs that could be used to help in prioritizing referrals and there are no system-level policies or objectives that identify which populations to prioritize.
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Provider-Imposed Eligibility Criteria Create Access Barriers for Higher Need Households. Many people on the Placement Roster who need assistance cannot easily access a program vacancy because they do not meet program eligibility criteria. Focus Strategies found that while some eligibility requirements are established by funding source and therefore not easily removed or modified, many are imposed by providers based on their organizational mission, their assessment about the kinds of factors that make households more likely to become housed, or the way their services are structured. While removing or reducing these barriers can be difficult, it is also essential if Pierce County is to meet its goal of housing everyone who is homeless. In particular, Focus Strategies found that many programs impose barriers relating to residency, sobriety, criminal record, and service participation (e.g. requirements to meet regularly with a case manager, participate in budgeting or life skills workshops, etc.). These criteria tend to screen out higher need clients.
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System Objectives Are Not Client-Focused. As currently designed, the overall goal of centralized intake is to fill provider vacancies using the criteria for acceptance defined by the providers (i.e. the clients the providers want to house). To achieve the objective of ending homelessness, the CI system goal should instead be to find an appropriate placement for every household that goes on the Placement Roster. One significant consequence of having a vacancy-driven system is that AP4H is incentivized to find clients who the providers will accept, which results in those with lower barriers being more likely to receive a referral, while those with greater barriers often get “stuck” and never receive a referral or drop off the list before being referred.
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CI Data Systems Not Integrated with HMIS. Currently the data needed to operate CI is managed in three separate systems: HMIS, an Access database that contains the Placement Roster, and a Google document that contains the daily vacancies. Since these systems are not integrated, it is very difficult to track what happens with clients from the time they contact AP4H until they enter housing. This problem is related to the finding above, namely that the system is vacancy driven rather than client
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driven. The data systems do a good job of tracking how many openings are available each month and how many are filled. However, there is no system set up to track how many people go on the roster each month, what their characteristics are (e.g. sheltered/unsheltered, disabled, family versus single adult), how many receive a referral and how many don’t, and what the characteristics are of those who do. Data collection in this manner is essential to understanding whether the system is achieving the goal of helping people become housed. •
Minimal Requirements for Documenting Denials. The current policy regarding acceptance or denial of referrals essentially places no limits on providers’ ability to reject referrals, even for unspecified reasons. In the first Focus Strategies reviewed data from 2013 on the reasons for rejection and found there was no single criteria or set of criteria that were more likely to lead to referrals being denied. The data shows that 38% of clients who were rejected had no reason listed and 9% simply “did not meet program requirements.” Nearly half of the denials have no specific reason listed.
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Side Doors and Parallel Systems. Currently a large number of programs in the community are participating in AP4H, but the system still has a number of other pathways into homeless-targeted housing and shelter programs, such a permanent supportive housing for mental health clients and same-day shelters. The proliferation of entry points is largely driven by how funding is structured: certain funders have control over the doorway into particular subsets of units and some programs that have no public funding remain outside the system because there is no leverage to require them to participate. Ultimately, to have a fully efficient system in which there is a placement for everyone, these separate pathways will have to merge into the larger Centralized Intake.
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System Inventory is Not Right Sized. Our analysis found that while overall the homeless system of care in Pierce County has sufficient capacity to meet the annual estimated number of people experiencing homelessness, much of the capacity is in emergency or temporary housing rather than permanent solutions. To fully right size the system, there needs to be ongoing work to convert transitional housing to rapid re-housing where possible and to expand the supply of permanent supportive housing, particularly for single adults.
IMPLICATIONS FOR CENTRALIZED INTAKE SYSTEM RE-DESIGN The next phase of the work Focus Strategies will undertake will be to develop a proposed new set of Centralized Intake processes and tools. The system analysis presented in this report forms the basis for the development of this system re-design. Below are our key findings from this assessment that will shape the proposed changes to the system.
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KEY FINDINGS 1. Improve Data Collection and Analysis to Fully Understand System Entries and Exits 2. Establish Prioritization Criteria and New System Objectives To House Priority Populations 3. Remove NonFunder Driven Eligibility Criteria and Develop New Streamlined Assessment Tool
4. Integrate New Assessment Tool and Matching Functions Into HMIS
5. Continue LongTerm Planning to Right Size the System
Pierce County should seek to fully understand who is and is not accessing the programs in the system. Given the state of the data available from the HMIS and AP4H systems, it is difficult to analyze who is being screened in and who is being screened out and why. Developing a clearer picture of the existing system performance will be key to designing an improved system. Pierce County should adopt objectives for CI that include specific goals about how many people/households who go on the Placement Roster are housed within a given time frame. It will also be essential to develop prioritization criteria so that the objectives can be framed in terms of how many people from priority populations (i.e. high need/high barriers) are housed. These revised system goals should also include a goal for percentage of households that are diverted from the Placement Roster, so that those with lower needs to not enter the homeless system at all. The existing CI system cannot work effectively as long as each program is able to establish its own entry criteria. While each program might have a strong set of reasons for doing so, the collective impact of all these criteria is that the system is inaccessible to large numbers of people who have been homeless the longest and have the greatest need for stable housing. We strongly support the County’s ongoing efforts to help providers remove barriers and the planned effort to include new requirements about improving program access in the upcoming round of NOFAs and subsequent contracts. Once there is a much shorter and simpler array of eligibility criteria for programs, Focus Strategies strongly advises that the existing assessment tool be redesigned and simplified to include only the minimum information needed to determine whether a household meets eligibility criteria (e.g. household type, size, veteran status, etc.) and just enough information on homeless history and disability to assign a need score so that the household can be prioritized. Additionally, there will need to be a more restrictive denial policy in which providers have a more limited range of reasons for refusing to accept a client. Focus Strategies highly recommends that the updated assessment tool, prioritization score and process of matching households to vacancies be conducted inside the HMIS system. Integrating all the CI functions together in one system will vastly improve the efficiency of the process and will also ensure that any new system objectives relating to how many people actually become housed can be tracked as people move from intake to diversion/assessment and are then matched to programs. As part of the next phase of work, Focus Strategies will explore integrating these functions into ServicePoint. Significant additional system capacity can be created by continuing to phase out transitional housing and expanding the inventory of rapid re-housing. However, to ensure there is an intervention for all homeless people, there likely will need to be additional investments in the system to expand the supply of PSH. By pursuing a long-range plan to fully bring both rapid re-housing and permanent supportive housing to scale, Pierce County can reach a point where the Centralized Intake system will truly be able to match every homeless person to the correct intervention to end their homelessness.
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I.
BACKGROUND AND PURPOSE
Pierce County Community Connections has engaged Focus Strategies to assist with the refinement of the existing intake and assessment tools used by the community’s Centralized Intake (CI) system, Access Point for Housing (AP4H). To inform our recommendations for system improvement, Focus Strategies conducted an assessment of the strengths and weaknesses of the current system. This analysis focuses on the effectiveness of the AP4H system in conducting intake and assessment and making referrals to housing programs. In the course of our review, we also considered broader issues relating to the inventory of available shelter and housing programs in the community. Examining this larger system context is essential to developing recommendations for improvement of the CI system. While a centralized intake system can help improve homeless people’s access to assistance by providing a streamlined entry point and standardized process, it cannot be fully effective unless there is an appropriate array of available interventions so that so that each person who enters the system is also able to exit as quickly as possible to an appropriate permanent housing destination. Over the past several years, Pierce County has been working on a number of initiatives designed to transform the existing array of homeless programs into a fully realized “housing crisis resolution system.” This includes not only centralized intake but also a “right sized” set of interventions such that all homeless people can receive the housing and services that fit their needs. The initiatives include efforts to build provider capacity to remove barriers to access, provide housing-focused services, and speed the movement of clients into permanent housing. The community has also been engaged in a process of shifting investments towards interventions that achieve the best housing results, and expanding system capacity in key areas such as rapid re-housing. The analysis and recommendations in this report are intended to be understood within the larger context of systems-thinking and system re-design in Pierce County. While Focus Strategies has tailored this analysis to consider how well AP4H is working, we have also explored how the configuration of the larger housing and service system impacts the ability of AP4H to function as intended. II. OVERVIEW OF WORK TO DATE This report is the result of a five month long process that began in June 2014. The work to date includes several avenues of information gathering and analysis: •
A review of existing policies and procedures, reports, and other documents related to the AP4H system (see Appendix A for list of documents);
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A site visit to AP4H conducted on October 15, 2014. Katharine Gale from Focus Strategies visited the AP4H offices and observed the intake, assessment and referral process, interviewed staff and gathered additional information about the system;
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Analysis of Placement Roster data from both the HMIS system and the Access database used by Associated Ministries to manage the roster;
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Interviews with the majority of homeless providers in Pierce County (including providers of emergency shelter, transitional housing, rapid re-housing, and permanent supportive housing), to understand their eligibility criteria for entry and develop an analysis of the most common provider-imposed barriers to access (this work is presented in separate standalone report);
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Review of the Corporation for Supportive Housing (CSH) analysis of the family transitional housing inventory developed by the Corporation for Supportive Housing (CSH) and their
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recommendations for conversion of transitional housing to rapid re-housing and permanent supportive housing (see Appendix A for list of documents); •
Analysis of system performance data, including Performance Improvement Calculator (PIC) data generated by CSH on the family system and system-wide analysis (both families and adult systems) conducted by Focus Strategies;
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Research on coordinated and centralized intake systems and lessons learned from other communities;
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Interviews with members of the Pierce County Diversion Collaborative, research on Diversion in other communities, and development of recommendations for the implementation of a Diversion screening and referral process into the AP4H. These recommendations were delivered in July 2014 and the Diversion pilot will launch in November 2014.
As mentioned above, the work presented here is one piece of an ongoing system re-design initiative being undertaken by Pierce County to transform the current array of programs into a housing crisis resolution system. In developing this analysis, Focus Strategies considered how it will complement and support parallel efforts, including the Provider Academy that is helping Pierce County agencies develop tools to eliminate barriers to program access, the ongoing process of transitional housing conversion, the implementation of Diversion as part of AP4H, and the High Performing Systems Challenge that is offering providers of shelter and rapid re-housing the opportunity to identify how they can support families to access permanent housing faster. III. ANALYSIS Focus Strategies reviewed available documents and data and conducted interviews (by phone and onsite) with AP4H and Pierce County Community Connections to assess the strengths and weaknesses of the existing Centralized Intake system. Overall, we found many ways in which the system is working well and improving clients’ experience in accessing services and housing. We also identified a number of weaknesses and areas that could be improved through adjustments to the intake, assessment and referral policies, processes, tools and data systems. These issues are discussed below in Section A. As part of our assessment, Focus Strategies also identified a number of inefficiencies in the AP4H process that relate to broader systemic issues of program barriers and the mismatch between the existing inventory of interventions and the needs in the community. These problems cannot be resolved through changes in the Centralized Intake process and tools, but rather must be tackled as part of the larger system right-sizing work underway in the community. These issues are discussed in Sections B and C. A. Assessment of Centralized Intake System Strengths and Weaknesses Our assessment of the existing system is organized into the following topic areas, following the “flow” of clients through the system: (1) Initial Call Screening and Intake; (2) Assessment and Document Review; (3) Placement Roster Management/Matching Households to Vacancies; (4) Program Acceptance and Refusal; (5) Data Tracking; and (6) “Side Doors” and Parallel Systems.
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1. Initial Call Screening and Intake Process Description: People in the community who are experiencing a housing crisis hear about AP4H from a variety of sources, including 211, mainstream service providers, homeless service providers, and word of mouth. In the most recent six month period, AP4H received about 1,700 calls per month. Virtually all calls are returned within 2 business days, which is one of AP4H’s contract objectives. Of these calls, about 300 to 400 per month tend to be duplicates. Each individual who calls (or is called back) is screened to determine if they are in HUD Category 1 (literally homeless), 2 (imminently homeless) or 4 (fleeing domestic violence). To qualify as imminently homeless a household has to be at risk of losing their housing within 72 hours. Those that meet these criteria receive a brief 10-20 minute intake interview during which universal HMIS data elements are collected and entered. Callers are also informed that they will require adequate documentation of homeless status, and told how to get such documentation. Screeners may also do some “light” problem solving and refer callers to community resources, but this is not a required part of the interaction. Those that are determined based on the initial screening to be eligible for assistance are scheduled for an assessment appointment within five working days of the call date. In the most recent six month period, AP4H has been making approximately 420 assessment appointments per month. Callers are instructed to bring relevant documents to the assessment (e.g. documentation of homeless status, income information) and also receive referrals for where they can go for help with documents. Associated Ministries’ on-site resource center recently began assisting homeless people with obtaining needed documents (in addition to providing a place to receive mail and payee services). Beginning in November, AP4H will begin implementing a simultaneous Diversion screen as part of the intake process. Using a structured conversation process, intake staff will identify those households that appear likely candidates for Diversion based on having a feasible option to stay in place or move directly to other housing as well as some history of employment or stable housing. Candidates will be referred for a same day Diversion interview at either Associated Ministries or Catholic Community Services. If they are not divertible, they will then be scheduled for an assessment appointment. Analysis: Based on our observations the initial intake process appears to be functioning fairly smoothly. The goal of responding to all calls within two business days is taken very seriously by all staff and the outcome data backs this up. It appears that the initial intake process could be made more effective if there were a more systematic effort to connect callers to available community resources that could solve their problem (e.g. legal aid, getting utilities re-connected, etc.), as this appears to happen somewhat haphazardly. AP4H should also consider collecting information about challenging calls or situations and make sure there is some follow-up if it might be possible to help preserve a caller’s housing. As the Diversion piece is implemented, this follow up could be implemented as a system design element.
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2. Assessment and Document Review Process Description: During the most recent six month period, AP4H has been making about 420 appointments per month for assessments and actually completing about 260 assessments. During this period the “no show” rate of callers not attending a scheduled assessment appoint was approximately 38% though staff reported that typically it is more like 40% to 50%. AP4H has developed a very sophisticated scheduling system to help manage the no show problem. Several assessors are on call for each assessment bloc. Typically two or three staff are scheduled at the same time and are on “on tap” for that block in a certain order. The first person goes to the assessment area and waits to see if a client arrives. If they do, first person takes the client and lets the second person know they are up next if the next person arrives. Up to four people can be expected to work during a two hour bloc, with the staff people who are third or fourth in line typically using that time to cover the phone line or to make referrals. Assessments are also done in multiple locations for better ease of access for consumers and to ensure geographic coverage. The actual assessment is a “strengths and needs” assessment that takes up to 90 minutes. The assessment covers demographic information, a psychosocial assessment, social/cultural/spiritual assessment, employment/education/transportation assessment, strengths/goals/strategies, disability, homelessness history, housing history, domestic violence history, criminal justice history, income sources, employment history, educational history, veteran status and military history. The responses to all questions are entered into HMIS but since many are narrative responses they have to go in as “notes” and thus are not easily searchable. During the interview, the assessor reviews the client’s documentation of homelessness, identification and income verification and lets them know if additional documents are likely to be needed. As noted above, the Associated Ministries Resource Center is available to assist with documentation issues. Currently, a client can make an appointment for another time to be assisted with documentation, but the intent is to have certain hours in which the client who is being assessed at the central office can be immediately supported with documentation issues at the main site. Analysis: The AP4H staff have done some ingenious problem solving to make the assessment process run smoothly, including developing a method for minimizing the impact of no shows and implementing a regular schedule for interviews at sites throughout the community. However, there appears to be a general recognition by AP4H, Pierce County, providers, and clients that there are some significant issues with the assessment tool and process: •
The assessment tool is very lengthy and delves into a lot of personal history that doesn’t appear relevant in making a determination about a household’s housing barriers or what programs or housing they would be eligible for.
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Much of what is asked on the assessment is not designed to be entered as discrete data elements which can be searched and used to match the client to a program or conduct analysis of the client population. (See also III.A.3. Placement Roster Management).
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The information gathered is reportedly not used at the program level to speed the intake process once a client is referred (see also III.A.4. Program Acceptance and Refusal). Programs conduct their own assessment and intake which reportedly repeats much of the information already gathered at the assessment phase but in different ways.
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The tool does not provide a score or a method for matching or prioritizing clients for open slots. In many coordinated or centralized intake systems, the responses a client gives to the assessment questions are used to generate a “score” or to place the client in a category or tier for matching and prioritizing. For example, in Dayton, OH, clients are rated as low, medium or high on a housing barriers scale. Assigning households to categories can help speed the referral and matching process and can ensure that limited resources are provided to those determined to have the greatest needs, provided the community has adopted policies and procedures governing who will be referred to what types of assistance. Currently the tool being used by AP4H does not generate any outputs that could be used to help in prioritizing referrals.
3. Placement Roster Management/Matching Households to Vacancies Process Description: Once a client has been determined to meet the AP4H eligibility criteria and all documents are in order, the household is put on the Placement Roster. The roster is kept in chronological order based on the date of the initial call to the phone screening. AP4H maintains the roster in an Access database. Certain data from the assessment that is relevant to making a match is re-input into Access (after having already been input into HMIS). The Placement Roster is designed to store all data that is needed to determine whether a client is eligible to fill a vacancy and includes such items as household composition and size, income, income sources, disability, and also things like willingness to become employed, willingness to engage in services, sobriety, etc. These are all captured in the assessment but they are translated into the Placement Roster as discrete “yes/no” or other searchable responses, whereas in HMIS many of these factors are input as notes. Shelter and housing providers that participate in AP4H enter their vacancies in a Daily Vacancy and Tracking Form on Google Drive that is shared with AP4H. Providers can enter vacancies in advance when they know about them with an available date, but reportedly more often they enter them as available “immediately.” As openings are submitted, a referral specialist filters the Placement Roster to find households that fit the criteria for the program. AP4H maintains a binder containing a detailed breakdown of all the eligibility criteria for each program which helps them find a match they think the program will accept. Sometimes the referrals specialist will also consult the HMIS record to find additional information about the household. Once the referral specialist has sorted the roster on multiple variables to produce to a list of people who appear to meet the criteria, they begin calling in order of the wait list entry date. They continue calling down the list until they either reach someone or someone calls back. The contract objectives state that they are required to make a referral for 75% of vacancies within two business days. In the most recent six month period, this objective was achieved within six business days, though staff report that in most months it is closer to three business days.
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Staff also track the percentage of the referrals made that are accepted by the provider and client and generally speaking these objectives are being met. However, staff report that they are very careful to only send referrals providers are expected to accept, since this is a contract objective and they do not want a high rate of refusal. This means that clients who appear to the referral specialist to have circumstances or conditions that could make them ineligible for the current opening may be skipped rather than given an opportunity to clarify or address the possible concern. There is ongoing tension with some providers over the “quality” of the referrals, with some providers feeling they are being sent households who do not meet all their criteria and AP4H feeling that providers are not always consistent about what the criteria are and are too stringent in screening the referrals. Staff reported that based on their anecdotal sense of the process, they think that the majority of the people who get “stuck” on the roster and are never referred are the people with higher barriers (see Data Tracking section for more on this topic). Households with higher barriers are also more likely to have difficulty staying in contact with AP4H so even when an opening is available, they often cannot be reached. If after three days no referral is provided by AP4H, the program is allowed to do a “reverse referral” in which the program selects a client from outside the Placement Roster. Based on available information, Focus Strategies was not able to determine precisely how often this occurs; however, judging by our analysis of the Placement Roster data (see III.A.5 Data Tracking Systems) there do appear to be a large number of people entering programs who were never placed on the roster in HMIS. This likely reflects some data quality issues as detailed below, but could also be related to the reverse referral process and other “side door” ways of entering into programs (see also III.A.6. Side Doors and Parallel Systems). Analysis: AP4H has implemented a number of approaches to help make the process of matching clients to vacancies more efficient and more standardized, such as developing the structure of the Placement Roster to include as many searchable fields as possible and developing comprehensive binders of all the program eligibility criteria. They are working hard to find referrals that will meet the provider criteria and mostly meeting the contract objectives in this area. However, there are some significant problems relating to the referral and matching process. Most of these problems are built in to the design of the Centralized Intake, rather than issues that can be resolved with different tools or changes to the work flow. As currently designed, the overall goal of centralized intake is to fill provider vacancies using the criteria for acceptance defined by the providers (i.e. the clients the providers want to house). To actually achieve the objective of ending homelessness, the CI system goal should instead be to find an appropriate placement for every household that goes on the placement roster. While AP4H certainly holds this idea as a goal in theory, in practice there is nothing in the system design that actually enables them to accomplish this because: •
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There have been no systematic efforts made to remove barriers across all programs so that those households with more severe needs can access shelter or housing (see Section III.B for more on barriers). There is no system-wide policy to prioritize people with higher barriers ahead of those who have lower barriers. Although the written policies and procedures for the CI indicates that certain households should be prioritized for assistance (including people who are living outdoors and people with disabilities), in practice the matching process is driven by the available vacancies, which households the providers will accept, and the roster order.
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•
AP4H does not have a contract objective regarding the percentage of households added to the placement roster who are actually placed into housing.
The combination of these factors means that there are households who get on the roster but may never receive a referral; these households will remain on the roster and in need, disappear, or self-resolve because of the time elapsed. Focus Strategies analyzed the characteristics of people on the Placement Roster to see if there were significant differences between those who received a referral and those who did not. We discovered that households with children were significantly more likely to be referred than single adults. Additionally, people with disabilities, criminal backgrounds and a history of eviction were significantly less likely to receive a referral. This was true of both single adults and households with children. The tables below summarize these results:
Household Size Impacts Referral Rate 61.6
75
56.5
65 55
43.5
38.4
45 35 25
Referred
Not Referred 1 Person HH
2/> Person HH
Referral Rates: Single Adults 48.1
50.0
% Yes
40.0
45.5 34.9
31.7
30.0 20.0
8.2
10.0 0.0
2.7 Disability?
Criminal Background? Referred
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Eviction?
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Referral Rates: Households With Two Or More People 39.3 40.0
% Yes
30.0
31.2
26.5 19.1
17.7
20.0
10.1
10.0 0.0
Disability?
Criminal Background? Referred
Eviction?
Not Referred
Focus Strategies also analyzed whether a person’s race had any impact on their ability to get on the Placement Roster or their rate of receiving a referral. Our analysis showed that racial minority groups (African American, Asian, Pacific Islander, Native American) were represented on the roster in numbers that were proportional to their numbers in the general population of homeless people (as counted in the annual point in time count) or in even greater numbers than we would expect based on the PIT. This data does not provide any evidence that being a person of color is a barrier to being placed on the roster. When we compared the rate of referral for people who were white to those of other racial groups, we found that being a person of color actually increased a person’s likelihood of being referred.
Rate of Referral By Race 53.8 54.0
53.0
52.7
52.0
% Yes
50.0 48.0
47.0
46.2
47.3
46.0 44.0 42.0
White (N=1378) Referred
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Not White (N=1238) Not Referred
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4. Program Acceptance and Refusal Process Description: Once a client is “matched” to an available vacancy, the AP4H sends the provider agency their phone number, HMIS ID, family size, and available documentation. The assessment portion of HMIS record for that client is also “unlocked” so the receiving program can see their intake and assessment data. However, when the client shows up to the agency for the referral, he or she will have to go through the intake and assessment process again, since typically the existing assessment information is now out of date and each provider has their own intake process. Each program may decide whether to accept any referral and there are no stated limits on how many referrals an agency may reject. If a rejection is made, the reason is noted on the Daily Vacancy and Tracking Form and the client remains on the Placement Roster. Providers may reject clients for any reason, though typically this is due to their not meeting program eligibility criteria. To address the issue of rejections, a Denial Committee has been established that includes AP4H, Pierce County Community Connections and provider agencies. The committee reviews all denials and determines if they are “appropriate” or not. Inappropriate denials are flagged and discussed with the provider that made the denial. Focus Strategies noted that a denial can be deemed appropriate if the agency has stated that they don’t accept clients with certain conditions or circumstances, even if this results in certain clients being virtually unable to access any program. Staff report that providers have complained that many of the people referred have extensive criminal justice backgrounds that prevent them from being served. However, AP4H recently reviewed the reasons for denial given over the course of the 2013 calendar year and found only 3% were listed as due to criminal history. The breakdown for denials were: • • • • • • • • •
38% unknown 20% could not contact the client/no show 9% did not meet program requirements 5% client wants something else 4% found housing 4% program full 3% criminal history 2% improper documentation 15% other reasons
Analysis: As discussed above, a major structural problem with the CI is that it is driven entirely by provider preferences about who they will serve and not by the needs of the homeless population. This is reflected in the very generous denial policy, which essentially places no limits on providers’ ability to reject referrals, even for unspecified reasons. The data on denial from 2013 shows that 38% had no reason listed, and 9% simply “did not meet program requirements,” suggesting a high degree of inconsistent or arbitrary application of screening criteria. Additionally, the way the process is set up, clients have to go through an assessment process at least twice, once for AP4H and at least once by the program. This defeats one of the primary purposes of Centralized intake which is to prevent clients from having to repeat their story over and over at each program.
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5. Data Tracking Systems As described in Section III.A.3, Focus Strategies conducted an analysis of the AP4H Placement Roster to compare people who received a referral to those who did not. We also attended to analyzed data from the HMIS system and the Placement Roster to see if we could analyze whether the people who received a referral actually entered a program. We looked at data from the Pierce County HMIS system on all people with an open record for any stage of AP4H (intake, assessment, roster) for the period from July 1, 2013 to June 30, 2014. We attempted to match this data with HMIS data on all people entering programs in Pierce County in the same time period. Upon reviewing these datasets, we determined that this analysis was not feasible due to the very small number of records that could be matched. Of the 1,672 records in the AP4H data file that indicate an exit from the roster, only 62 had an associated program entry after or during their roster stay. Overall, only 254 client records whose appear on the roster have a program entry that occurred after they entered the roster. The majority of these (192 or 76%) are for AP4H records that appear to still be open. Of the 62 program entries for clients exiting the roster, most (53 or 86%) have a program entry before roster exit (but after roster entry). While this is only a small portion of the potential program entries, it points to inconsistent use of the roster exit date field, which means there is no way to know how long clients are staying on the roster before being housed/sheltered. Focus Strategies also reviewed an export of the Access Database that AP4H uses to maintain the Placement Roster outside of HMIS. This data also could not be matched to HMIS data on program entries, and there was very inconsistent information recorded on exits from the roster. Our general finding relating to the data issues supports the observations noted above in III.A.3 relating to the goals of the placement roster and program matching functions of Centralized Intake. Since the AP4H has not been set up with any quantifiable objectives relating to how many people enter the roster and then are actually placed into housing, the data systems have not been set up to track this information in an accurate way. There are no data quality procedures in place to ensure that people who are assessed and placed on the roster are also consistently exited, or that there is any consistent system for tracking whether they move from the roster into a program as a result of an AP4H referral. If there were a systemlevel objective of housing a specific percentage of people who enter the roster, rather than just an objective of filling vacancies, then data systems and procedures would have to implemented to allow the system’s performance in meeting those objectives to be evaluated. 6. “Side Doors” and Parallel Systems Process Description: Currently there are a several different side doors and parallel system outside of AP4H: • Any emergency shelter that fills vacancies on a daily basis is not part of the system. Clients access these shelters directly and from there can be referred on to programs that accept referrals from AP4H, including rapid re-housing and transitional housing; • Youth who are homeless go through the AP4H process but are assessed by a specialized youth assessment staff person. While the formal assessment tool and information gathered is the same, youth and young adults are matched to programs using additional criteria than for other households including a process of prioritizing based on safety needs. This prioritization is based on one individual’s judgment and not a formalized process or method;
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• •
Referrals to Housing First (permanent supportive housing for chronically homeless people) are made through the PATH team; and Referrals to permanent supportive housing for mental health clients come through the mental health system.
Analysis: Currently a large number of programs in the community are participating in AP4H, but the system still has a number of other pathways into homeless-targeted housing and shelter programs. The proliferation of entry points in largely driven by how funding is structured: certain funders have control over the doorway into particular subsets of units and some programs that have no public funding remain outside the system because there is no leverage to require them to participate. Ultimately, to have a fully efficient system in which there is a placement for everyone, these separate pathways will have to merge into the larger Centralized Intake. One place this shift could begin soon is with the CoC-funded permanent supportive housing, which is now required to comply with HUD’s CPD Notice 14-012 on Prioritization of Permanent Supportive Housing (PSH) units. One of the requirements of this notice is that all HUD-funded PSH (including beds dedicated and prioritized for chronically homeless and non-dedicated/prioritized beds) must all be accessed using one standardized and coordinated system that uses the same method for prioritization. In Pierce County, as in many communities, it will be necessary to grapple with how PSH is currently accessed and develop a single coordinated entry system for all units.
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Non Participating Shelter
call
AP4H DIVERSION
not literally homeless
Mainstream Resources
Phone Intake Screening
PSH not in AP4H
Diversion Partners
In Person Assessment
find housing
diversion doesn t work diversion works
Placement Roster call household #1
look for housing
don t find housing stay on roster and wait
OPENINGS (search roster for
matching families)
call household #2
Shelter in AP4H call household #X
household #X calls back
not literally homeless
notify of opening
Update Assessment
RRH Program TH/PH
Participating Programs
appears eligible & interested
Appointment NO not eligible for or interested in this resource
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stay on roster and wait
OK
NO stay on roster or start again
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B. System and Program Barriers As previously noted, one of the primary structural problems with the existing Centralized Intake system is that many people who need assistance cannot easily access a program vacancy because they do not meet program eligibility criteria. For some households with multiple barriers, they cannot access any of the existing inventory of units that participate in AP4H. While some eligibility requirements are established by funding source and therefore not easily removed or modified, many are imposed by providers based on their organizational mission, their assessment about the kinds of factors that make households more likely to become housed, or the way their services are structured. While removing or reducing these barriers can be difficult, it is also essential if Pierce County is to meet its goal of housing everyone who is homeless. We understand that Pierce County is aware of this challenge and already has plans to require reduced program barriers through contractual requirements. This section describes the analysis Focus Strategies conducted on existing program barriers; the results are intended to inform system level decision-making about strategies to improve access to existing programs for homeless people who are not currently being served by the system. 1. Purpose of Barriers Analysis In October 2014, Focus Strategies conducted a series of interviews with providers of emergency shelter, transitional housing, rapid re-housing, and permanent supportive housing in Pierce County. The purpose of these interviews was to collect data from all providers and projects listed in the most recent Housing Inventory County (HIC) to understand all the criteria that that impact how clients currently access homeless shelter and housing projects. The interviews further categorized the criteria by who or what imposed the restriction: 1. Requirements imposed by funders (e.g. a project funded by the Veterans Administration must serve veterans); 2. Requirements imposed by the physical plant of the project (e.g. a building with large “dorm” style spaces and only one bathroom generally can only serve one gender); and/or 3. Requirements imposed by the provider or project for programmatic reasons. Understanding the array of requirements to accessing shelter and housing programs helps guide planning for a system level approach. Such an approach must aim to have the fewest access criteria to the extent allowed by funding and physical constraints. 2. Process and Participation Summary To best understand project specific entry criteria, it was important to individually speak with the director or program manager of each residential program in Pierce County. Providers were informed about the interview process by email from Pierce County Community Connections and Focus Strategies. Providers were asked to participate in an individualized interview with Focus Strategies so that we could understand the existing array of programs in the community and, in particular, each project’s eligibility criteria. Interviews were one to three hours in length and involved a series of questions related to the design of the project, intake requirements and funding sources. Once the interview was completed, a project summary was e-mailed to the interviewee. Providers were given the opportunity to make comments and/or corrections before the results were finalized and told that individual project summaries would be shared with Pierce County staff and that the results would be aggregated to detail the extent of different criteria in the system as a whole.
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The list of organizations and projects to be interviewed included 32 providers operating 80 programs. Focus Strategies has been able to collect data on 62 projects operated by 26 different providers. A follow up interview is scheduled with one provider to collect data on five of their projects (interviews on two of their projects have already been completed). Of the remaining 13 projects, one declined to participate, one is closed, eight are operated by a provider who has not responded to our request for an interview, and Focus Strategies is working to schedule interviews for the remaining three. 3. Results The barriers analysis considered eleven common types of eligibility criteria that tend to have the effect (intended or unintended) of screening out homeless people with high service needs and greater challenges to becoming housed. These 11 types of criteria are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Maximum Age Limit for Accompanied Children Residency Minimum income Sobriety Criminal Record Immigration Status Rental History Eviction History Credit History Pets Program Participation
Of the criteria analyzed, Focus Strategies found a high rate of occurrence of barriers established by program policy (as opposed to criteria required by funders) in four of these categories: residency, sobriety, criminal record, and program participation. a. Residency This is a significant barrier in all programs except for emergency shelter. Residency requirements were found in 60% of transitional housing, 50% of rapid re-housing and 93% of permanent supportive housing programs. Looking at beds/units, these requirements are present in 73% of transitional housing beds, 55% of rapid re-housing beds and 81% of permanent supportive housing beds. Although residency requirements are understandable in that they prioritize beds for people who are longer term residents of a community, they have the effect of screening out more recent arrivals who may be living in unsheltered situations and have high service needs. Reducing these barriers can ensure that more unsheltered people are served. Adding some system-wide capacity to help new arrivals return to their community of origin, if a safe and realistic housing plan can be formulated, is another alternative to hard and fast residency requirements.
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b. Sobriety Focus Strategies found that sobriety requirements were particularly prevalent in emergency shelter and transitional housing programs in Pierce County. Of the programs interviewed, 45% of emergency shelters and 67% of transitional housing had program-imposed sobriety requirements. This represented 22% of shelter beds and 44% of transitional housing beds. Providers generally explain sobriety requirements as being intended to insure that programs are safe for all participants and sober residents do not have to contend with those who are actively using. In addition, these requirements reflect provider expectations that those who are not sober will have more difficulty securing housing (meaning programs intend to screen out households that they think will not successfully exit to permanent housing). However, sobriety requirements at intake are highly likely to screen out those with the highest service needs and who have had the longest histories of homelessness; the community goal of ending homelessness is best served by housing these households rather than screening them out of the system. An alternative to sobriety requirements is to impose program rules and lease terms that tenants may not use illegal substances on site. This addresses the behaviors associated with substance use while still allowing those who are actively using to access housing and shelter and eliminating drug tests or other sobriety tests as eligibility requirements. We acknowledge that sharing space with people who are actively using is a real challenge for some people trying to maintain sobriety and creative thinking and flexible use of resources and space will be needed within programs to support all homeless households in moving to permanent housing. c. Criminal Record Program-imposed requirements relating to criminal record were among the most common that Focus Strategies found in Pierce County. Of the programs interviewed, 45% of emergency shelters, 87% of transitional housing and 79% of permanent supportive housing programs had requirements related to criminal record. This represents 64% of emergency shelter beds, 65% of transitional housing beds, and 62% of permanent supportive housing beds. Like sobriety requirements, barriers relating to criminal justice history generally are imposed by providers out of a desire to protect residents from being victimized or negatively affected by fellow program participants. However, in practice, these criteria have the effect of screening out many of the people who are the hardest to serve and have been homeless for the longest periods of time. As an alternative to imposing these requirements, programs can instead establish strong and clear house rules relating to behavior. Another strategy is to allow applicants with past criminal convictions to present documentation of extenuating circumstances at the time of intake/screening showing that they have addressed the underlying issues that might have led to criminal activities (e.g. substance use, untreated mental illness). Alameda County, California has adopted property management guidelines that allow people with complex criminal histories or rental histories to request consideration of mitigating circumstances as part of the application process, rather than through an appeal or request for reasonable accommodation after an application is denied. d. Program Participation Another frequently occurring program barrier in Pierce County is requirements relating to program participation, including requirements to meet regularly with a case manager, participate in budgeting or life skills workshops, pursue employment activities, and other programming. Of the programs we interviewed, 87% of transitional housing, 42% of rapid re-housing and 50% of permanent supportive
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housing programs had entry criteria relating to service participation. This translated to 65% of transitional housing beds, 33% of rapid re-housing beds and 42% of permanent supportive housing beds. Program participation requirements typically are imposed by providers out of a concern that residents who do not participate in services will not secure the stability and income needed to enter housing. However, there is extensive evidence that a “Housing First” approach in which participation in services is voluntary actually leads to better outcomes. For many chronically homeless people and those with high needs and housing barriers, making service participation a condition for securing housing is a significant access barrier. Allowing these households to first secure housing and then using engagement strategies and motivational interviewing to draw people into services will lead to better results. 4. Alignment with CSH Research and Analysis The results described above align with and support the work conducted by the Corporation for Supportive Housing (CSH) as part of their analytical work on conversion of the existing inventory of transitional housing for families in Pierce County, published in November 2013 in the Transitional Housing Project Analysis Report. As part of their assessment of each project, CSH analyzed eligibility criteria and assigned a score on a scale of 1 to 5, with a 1 representing high barriers to access and a 5 being very low or no barriers. Categories considered under this score included policies that agencies have adopted regarding curfew, visitors, sobriety requirements, income, and program-specific requirements such as a number of required meetings with case managers, community service requirements, etc. Out of 27 programs analyzed by CSH, only 6 scored a 4 and none scored a 5. 1 Based on these results, CSH recommended that “Pierce County and its partners review the entrance criteria and program rules of all publically-funded housing and housing programs to improve access to the overall homeless assistance system.” This is a finding with which Focus Strategies concurs, and we have made further recommendations regarding barriers in Section IV of this report. C. System Inventory and Right Sizing Analysis Efforts by Pierce County to modify the Centralized Intake System will be more effective if: (1) the inventory of beds and units is appropriately sized to meet the needs of the homeless populations in the community and (2) all programs are focused on quickly and efficiently housing people. This right sizing concept recognizes that all points of the homeless system – the front door, emergency housing options, and permanent housing options – must all be coordinated and focused on the common goal of ensuring that nobody in Pierce County is homeless longer than 30 days. Pierce County has already recognized this need and is committed to creating a more coordinated and efficient system. The County has previously engaged both the Corporation for Supportive Housing (CSH) and the National Alliance to End Homelessness (NAEH) to provide analysis and recommendations to make appropriate shifts in the system. Because the CSH analysis focused on one piece of the homeless system (system of care for homeless families), Focus Strategies is building upon their work and including the all components (single adult and family households) in our analysis and recommendations.
1
CSH also found that 14 out of 24 programs had 50% or fewer of program entries coming from literal homelessness (unsheltered or living in a shelter), which is consistent with having high barriers to access.
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1. Overview of Current Populations Using program performance, capacity, and budget numbers provided by Pierce County staff, as well as data from the 2014 Point in Time (PIT) count, Focus Strategies estimated the annualized count of homeless persons as compared to the annualized capacity of existing programs. As seen in the next graph and table, the total current capacity for shelter and housing in Pierce County is sufficient for the expected annual count of homeless persons. Given that the current capacity appears to be sufficient to meet the annual need, Pierce County is in the advantageous position of being able to make strategic shifts in investments and program types to significantly reduce the homeless population in the community.
Annualized Homeless Population and Homeless System Capacity Pierce County, WA Adult Only Households
Family Households
#
%
#
%
#
%
4,790
100%
376
100%
5,166
100%
Annualized Unsheltered Population
1,597
33%
15
4%
1,612
31%
Annualized Sheltered Population
2,541
53%
123
33%
2,664
52%
652
14%
238
63%
889
17%
4,877
100%
451
100%
5,327
100%
Total Annualized Population
Annualized Transitional Housing Population Total Annualized Capacity
All Households
Annualized ES Capacity
4,432
91%
297
66%
4,729
89%
Annualized TH Capacity
52
1%
8
2%
60
1%
Annualized RRH Capacity
117
2%
121
27%
238
4%
Annualized PSH Capacity
276
6%
25
6%
300
6%
Annualized population counts calculated using the CSH “Estimating the Need” methodology, with an assumption of 28% of persons staying in Adult Only shelter beds and 20% of persons staying in Family shelter beds have more than one shelter stay annually. Annualized capacity counts for PSH: = HIC capacity * utilization rate and for ES, TH, and RRH= HIC capacity * ((365 * utilization rate) ÷ LOS). Utilization rates averaged across program types from the HIC.
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Annualized Chronic Homeless Population Pierce County, WA Adult Only Households
Family Households
All Households
#
%
#
%
#
%
1,081
100%
46
100%
1,127
100%
Annualized Unsheltered Population
418
39%
5
11%
423
38%
Annualized Sheltered Population
663
61%
2
5%
665
59%
0
0%
0
0%
0
0%
Total Annualized Chronic Homeless Population
Annualized Transitional Housing Population
2. Alignment of Capacity and Needs The overall homeless system of care in Pierce County has sufficient capacity to meet the annual estimated number of people experiencing homelessness, and the capacity is aligned with household types. Specifically, as illustrated in the next graph, the relative proportions of population and capacity in Adult only and Family households are appropriately distributed.
However, when the types of capacity available for different household types is examined, it becomes clear that most of the capacity is temporary rather than permanent (92% of capacity for adult only and 72% for family households is emergency shelter or transitional housing).
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A right sized system should aim to have the majority of resources in permanent housing solutions, with a safety net of emergency services available to support households in crisis. 3. Pierce County Investment in the Homeless System of Care Reviewing the Pierce County Homeless System of Care necessitates an analysis of current expenditures in order to determine how reallocation might be possible. Looking at the system from this perspective, it is evident that Pierce County is running a very cost efficient system. The table below illustrates the average cost per unit by program type in Pierce County as compared to national averages. It is clear that the cost for ES and PSH in Pierce County is much lower than the comparison. The average for TH is also less, although this is primarily due to Adult Only units costing much less (the cost of family units are actually somewhat higher). This information suggests that Pierce County is already running a very cost effective system compared with the rest of the country; however, existing data shows that most other communities are extremely cost ineffective. This finding means that Pierce has different strengths and weaknesses than other communities.
Average Cost per Unit Pierce County Adult Only
Family
National Averages All HHs
Adult Only
Family
Total
ES
$1,181
$7,162
$2,285
$10,000
$13,333
$11,034
TH
$4,954
$15,246
$10,560
$10,588
$12,500
$11,707
PSH
$7,335
$10,763
$7,660
$13,514
$18,750
$15,094
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4. Recommendations for Right Sizing With this understanding of the current system, population, and resources available, we recommend that Pierce County’s first step towards right sizing be reallocation of existing funds from poorly performing temporary housing options to efficient and effect permanent housing solutions. Given the preponderance of transitional housing in Pierce County, and the current performance of these programs as compared to other solutions, it is recommended that Pierce County dis-invest in transitional housing programs in favor of rapid re-housing and permanent supportive housing. Across Adult Only and Family households, Pierce County currently invests $2.5 million annually in 246 transitional housing units (approximately $10,500 per unit). While this is relatively inexpensive compared with national averages, the transitional housing in Pierce County has very long lengths of stay (average of 565 days), and only a moderate rate of permanent housing exits (average of 68%), for a cost of approximately $24,000 per permanent housing exit. This recommendation is in agreement with the focus of the November 2013 CSH report, Transitional Housing Project Analysis Report. CSH described the direction HUD and the HEARTH Act were pointing communities with respect to moving away from the expensive TH models and towards the implementation RRH, increasing the ability to serve more households at reduced cost. The CSH report provided a comprehensive review of each TH project with family units in the CoC, with an eye towards which would be suited for conversion to RRH, PH, or to become higher performing TH. They recommended that all but a set of 39 family units be considered for converted programming. The 39 units were recommended to become higher performing transitional housing. In the year since that report was written a number of changes have occurred in the Pierce County inventory as it is reflected in the HIC. For example, several units have converted to PH or PSH. Currently, based on data provided by Pierce County staff, there are 147 Family TH units on the HIC, of which 17 were previously recommended to become higher performing transitional housing. Therefore, Focus Strategies recommends converting 130 family units, or 88.4% of the current inventory, to more effective forms of housing for families. We have made the assumption that all family inventory to be developed should be RRH rather than PSH, given that there are very few chronically homeless families in the community and the current inventory is able to keep pace with new entries into homelessness. Based on this assumption, Focus Strategies estimates that after retaining 17 TH family units and developing 130 RRH family units, $1,333,708 will be available to reallocate to the Adult Only system. This reallocation amount is derived as follows: • • • •
Budget for 147 family units: $2,042,897 OR $13,897 / unit Retain 17 family units (cost: 17 units X $13,897 = $236,249) Develop 130 RRH to replace TH inventory reallocated (cost: 130 units X $3638 = $472,940) Funds available to reallocate $1,333,708 ($2,042,897 - $236,249 - $472,940)
With respect to Adult only Households, the total funds available to invest in new programming is $1,888,556 ($1,333,708 from the Family system and $554,848 from the Adult only TH units). Funds Diverted from Family System Funds Reallocated from Adult only TH Total Funds to Re-invest in Adult only System
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This funding is obviously insufficient to provide housing opportunities for the whole unsheltered adult only population in Pierce County. The annualized numbers of homeless adult only households indicated there were approximately 4,790 homeless households, of which 1,081 are considered Chronically Homeless and 3,709 non-chronically homeless. In general, for planning purposes, it can be assumed that chronically homeless persons will need permanent supportive housing, while non-chronically homeless persons can be successfully housed through rapid re-housing efforts. Using the annualized population data presented earlier, the cost per unit of RRH ($3,000/unit; estimated) and PSH ($7,335; provided by Pierce County staff), and the amount of money available for investing in new units, the following table illustrates there is sufficient funding for the development of 487 units of RRH and 58 units of PSH. Total Pop Unsheltered Emergency Shelter TH Total Ratio of Units Distribution of Funds Units funded HH without PH
1,597 2,541 652 4,790
Chronic Pop 418 663 0 1,081
RRH Units (total - CH)
PSH Units (CH)
3,709 3.43 $1,462,245 487 3,222
1,081 1 $426,311 58 1,023
National data also suggests that the average length of stay for Adult Only RRH is 122 days (suggesting that each unit can turn over 3 times in a year) and average rate of exit to permanent housing is 75%. Using these rates for Pierce County, the 487 units could permanently house 1,095 non-chronically homeless HH a year. Therefore, in approximately 3 years, the non-chronically homeless adults in Pierce County would be housed. The funding available in this scenario for chronically homeless adults is insufficient to follow a similar course. The 58 units that can be supported with $426,000 only houses about 5% of the chronically homeless population. Another $7,503,705 is needed, or $1,500,000 a year for five years. Alternatively, a policy could be adopted to attempt progressive engagement with this population and see if some can be successfully housed using RRH. After realigning and targeting of existing resources, Pierce County may find there is still insufficient permanent supportive housing to house all the chronically homeless households currently in shelters and unsheltered. A more detailed analysis of the best approach for right sizing in Pierce County will allow for an estimation of how to best divide re-allocated resources among RRH and PSH and where to focus new investments to close any remaining gap. 5. Program Performance Because reallocation alone does not create enough permanent housing options for the current homeless population in Pierce County, Pierce County also needs to commit to improving program performance in the remaining programs. Data provided by County staff shows the current (aggregate) performance of both emergency shelters and rapid re-housing programs.
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Average LOS
Rate of PH Exits
Adult Only
Family
Adult Only
Family
Emergency Shelters
28
104
4%
60%
Rapid Re-Housing
253
72
77%
74%
In general, Pierce County should strive to have lengths of stay that are low, combined with high exit rates to permanent housing to increase the efficacy of their current shelter and rapid re-housing programs. The current performance outcomes highlighted in red above are areas of concern where Pierce County may want to focus initial right sizing efforts. A goal of an average length of stay in family shelters of no more than 45 days and no more than 180 days for adult only households in rapid re-housing could be impactful. In regards to permanent housing exits, Pierce County emergency shelters for adult only households have extremely low rates, and should work to improve this as much as possible; an increase to a rate of 30% over a couple of years would mark significant progress. 6. Determining and Planning Specific Right Sizing Steps While these recommendations provide general guidance on approaches to right sizing that Pierce County can explore, a more thorough analysis of the performance and opportunities in the community is recommended. The data currently available is aggregated and comes from a variety of sources. Average outcomes can be easily skewed by a single project and the true impact of a shift can be lost. Right sizing is an iterative process that takes time and commitment. A more thorough analysis allows for consideration of time, including the phasing in of different strategies and the impacts of populations shifts on these strategies. The ideas presented in this report are best practices for systems similar to Pierce County, and can be refined with project specific data and analysis. IV. IMPLICATIONS FOR CENTRALIZED INTAKE SYSTEM RE-DESIGN The next phase of the work Focus Strategies will undertake will be to develop a proposed new set of Centralized Intake processes and tools. The system analysis presented in this report forms the basis for the development of this system re-design. Below are our key findings from this assessment that will shape the proposed changes to the system. 1. Improve Data Collection and Analysis to Fully Understand System Entries and Exits As an initial step towards improving Coordinated Intake, Pierce County should seek to fully understand who is and is not accessing the programs in the system. Given the state of the data available from the HMIS and AP4H systems, it is difficult to analyze who is being screened in and who is being screened out and why. However, it is clear that there are numerous “side doors” to homeless programs, as evidenced by the many households who access programs without an exit from (or even an entry into) the AP4H Placement Roster. Additionally, data indicates that there may be a significant amount of individual provider discretion in accepting or refusing referrals from the AP4H system.
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2. Establish Prioritization Criteria and New System Objectives To House Priority Populations Once there is improved information available about how is being served and not served by Centralized Intake, Focus Strategies recommends that Pierce County and the Pierce County CoC adopt objectives for CI that include specific goals about how many people/households who go on the Placement Roster are housed within in a given time frame. It will also be essential to develop prioritization criteria so that the objectives can be framed in terms of how many people from priority populations are housed. For example, if the community decides that it will create need categories such as low, medium and high (which is what communities like Dayton, OH have done), then there should also be goals for how many people in each category are housed on a monthly basis through the Centralized Intake. Since we know that currently people with the highest needs are having the most difficulty accessing existing programs, establishing a specific goal that, for example, 50% of people who score as having high need are housed, will ensure that all the parts of the system are working to achieve that objective. These revised system goals should also include a goal for percentage of households that complete the intake process that are diverted from the Placement Roster, so that those with lower needs to not enter the homeless system at all. 3. Remove Non-Funder Driven Eligibility Criteria and Develop New Streamlined Assessment Tool As noted in the section on program barriers, the existing Centralized Intake system cannot work effectively as long as each program is able to establish its own entry criteria. While each program might have a strong set of reasons for doing so, the collective impact of all these criteria is that the system is inaccessible to large numbers of people who have been homeless the longest and have the greatest need for stable housing. We strongly support the County’s ongoing efforts to help providers remove barriers and the planned effort to include new requirements about improving program access in the upcoming round of contracts. Once there is a much shorter and simpler array of eligibility criteria for programs, Focus Strategies strongly advises that the existing assessment tool be re-designed and simplified to include only the minimum information needed to determine whether a household meets eligibility criteria (e.g. household type, size, veteran status, etc.) and just enough information on homeless history and disability to assign a need score so that the household can be prioritized. The tool currently being used in Charlotte, NC uses only 16 questions and is able to both generate a prioritization score and also collect all needed data points to determine program eligibility. Combined with new prioritization policies and a revised assessment tool and matching process, the community will need to agree on a more restrictive denial policy in which providers have a more limited range of reasons for refusing to accept a client. 4. Integrate New Assessment Tool and Matching Functions Into HMIS To the extent possible, Focus Strategies highly recommends that the updated assessment tool, prioritization score and process of matching households to vacancies be conducted inside the HMIS system. Currently the data needed to operate the Centralized Intake is in three separate systems (HMIS, the AP4H Access Database, and the Google Drive containing the daily vacancies). Integrating all these functions together in one system will vastly improve the efficiency of the process and will also ensure that any new system objectives relating to how many people actually become housed can be tracked as people move from intake to diversion/assessment and are then matched to programs. As part of the next phase of work, Focus Strategies will explore the options for integrating these functions into Service Point.
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5. Continue Long-Term Planning to Right Size the System As noted above in regards to system right-sizing, significant additional system capacity can be created by continuing to phase out transitional housing and expanding the inventory of rapid re-housing. However, to ensure there is an intervention for all homeless people, there likely will need to be additional investments in the system to expand the supply of PSH. By pursing a long-range plan to fully bring both rapid re-housing and permanent supportive housing to scale, Pierce County can reach a point where the Centralized Intake system will truly be able to match every homeless person to the correct intervention to end their homelessness.
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APPENDIX A: LIST OF DOCUMENTS REVIEWED
Centralized Intake Policies, Forms and Data Pierce County Community Connections, Homeless Programs Operating Policies and Procedures, Revised June 9, 2014. AP4H, Centralized Intake Screening and Strengths Assessment AP4H, Analysis of Referral Decline Reasons, 2013 AP4H, Outcomes Report, January to September 2014. Pierce County Community Connections, Rapid Re-Housing Requirements by Funding Source February, 2013
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Pierce County Homeless System Plans and System Data Pierce County Homeless Families Plan, Overall System Landscape Assessment, April 2010 Building Changes, Characteristics of Families Experiencing Homelessness , March, 2014 Housing Inventory Chart (HIC) updated September 2014 2013 PIT Workbook
CSH Transitional Housing Conversion Analysis Transitional Housing Project Analysis Report, November, 2013 Homeless System Projection Tool, June 19, 2014 Pierce System Numbers Guide, June 20, 2014 Homeless Systems Map, March 2014 Pierce County Homeless System Analysis CoC Presentation Best Practice Guide for Pierce County, Washington Homeless Prevention and Diversion, 2014
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