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Housing the Whole Person: Lessons learned, what worked, what didn’t

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Presentation on theme: "Housing the Whole Person: Lessons learned, what worked, what didn’t"— Presentation transcript:

1 Housing the Whole Person: Lessons learned, what worked, what didn’t
Regina Shasha, MS, FNP, PMHNP, BC, ANCHORS Elizabeth Dunn, BA, Development Manager, Sarah’s Circle

2 Objectives 1. Describe four domains of need that impact health and housing linkages to services 2. Discuss the Tiered Level of Need Model as a tool to help identify and address the needs of the whole person 3. Discuss program development process, factors contributing to inter- and intra-agency silos, and strategies to improve integration

3 What we can share Program development-developed two programs
Learn about a new tool, and model, to assess patients-Tiered Level of Need Model Hear what we learned from the program-Health Access ANCHORS Data summary Discuss lessons learned

4 Our team Meredith Garafolo, MA, LCPC
Sarah Shapleigh, LCSW, CADC, MISA II Megan Libreros, BA, Housing Coordinator Kassie Weber, MA, LPC Annie Pothour, MSW, LCSW Emily McKernan, LSW Elizabeth McNair, MA, LPC, Housing Coordinator Elizabeth Clark, BSW Stephanie Williams, MSW

5 Program development ANCHORS Sarah’s Circle Health Access
Linkage of these programs

6 ANCHORS©: A Nursing Case management Housing Outreach Resource and Support
Assessing and Addressing Individuals' Needs Using a Tiered System of Assessment, Implementation, and Care©

7 Goals of the program See the whole person
ANCHORS©: A Nursing Case management Housing Outreach Resource and Support Goals of the program See the whole person Link the whole person to help her successfully find and maintain housing

8 Sarah’s Circle Sarah’s Circle is a refuge for women who are homeless or in need of a safe space. By providing housing assistance, case management, referral services, and life necessities, we encourage women to empower themselves by rebuilding both emotionally and physically; realizing their unique potential.

9 Sarah’s Circle Whom we serve, according to intake:
100% women and low-income 70% currently homeless 50% no income 52% mental illness 40% survivors of domestic violence 29% chronic medical health problems 12% physical disabilities 80% racial or ethnic minorities

10 ANCHORS Problem identification
Problems and needs to be address Is housing enough? Where are the gaps? Why are there gaps? (E.g. lack of resources or access to resources)

11 ANCHORS Problem identification
Whom are we serving? Characteristics of the people who are being housed Demographic data: Age range, gender, ethnicity, and family status

12 ANCHORS Problem identification
What health problems and needs are documented for this population? Severe mental illness Domestic violence Substance abuse Veterans with physical and mental disabilities Chronic health problems, eg HIV/AIDS, Hypertension/CVD/Diabetes/Skin/Respiratory/GI/Dental/Vision problems Health illiteracy High mortality (25 years shorter life expectancy for SMI)

13 ANCHORS Problem identification
What are the barriers to maintaining housing? Physical health problems Mental health problems Poverty Substance use

14 ANCHORS Problem identification
What level of functioning and independence exists and is possible for each individual? See the whole person, link the whole person

15 ANCHORS Goal setting Program goals
1. Engage agencies housing homeless individuals 2. Utilise Tiered Level of Need Model to help these individuals maintain housing 3. Assess health and well being through an initial biopsychosocial assessment 4. Refer to and link with community resources PCP/FQHC home Clinical Case manager Mental health service if appropriate

16 ANCHORS Objective setting
Program objectives 1. Identify housed and homeless individuals at risk using the Tiered System 2. Perform initial biopsychosocial assessment 3. Assess for benefits eligibility 4. Link with PCP and FQHC 5. Link with Clinical Case Manager 6. Maintain housing > 1 year

17 ANCHORS Resources 1. What resources are needed to accomplish goals and objectives? Staff Facility Equipment and Supplies 2. Identify available funding Apply for grant funding

18 ANCHORS Program Implementation
Hire staff: Clinical case manager, Advanced Practice Nurse (APN) Purpose statement: Write a description of the program to give to clients Who is eligible? Communicate what services will be provided Engagement Teaching Mental health, physical health, substance use, violence screening Counseling Smoking cessation Referrals/Linkage with community resources

19 ANCHORS Program Implementation
Documentation: Develop template notes Initial screening notes for case manager and APN Treatment plan form, do every 3 months Progress note for every visit

20 ANCHORS Program Implementation
Develop health indicators within the Tiered Level of Need Model to guide determination of level of need; examples of indicators Strengths Safety PCP Date last annual exam Mental health provider Chronic barriers (including health problems) Benefits status

21 ANCHORS Program Implementation
Assess each individual’s health and wellbeing and organize engagement around level of need using the Tiered Level of Need Model© Adjust case management and APN support based on level of need

22 ANCHORS Program Implementation
Outcome measures Utilise quality of life and mental health rating scales Perform baseline, quarterly, at discharge

23 ANCHORS Program Implementation
Accountability Evaluate goals in grant and assess if objectives are being met Develop a system for reporting to funding agencies Address systems for program to remain viable

24 ANCHORS Program Implementation
Staff responsibilities Obtain malpractice insurance Recruit collaborating physicians Develop collaborative relationships within the agency and with community resources

25 ANCHORS Plan of Care 1. Identify the client while in shelter
Engage and prepare for the transition to housing Clinical case manager does initial engagements 2. Identify individual specific barriers to wellness and health problems through initial screening Hypertension and diabetes screening Mental illness screening Substance abuse screening, including tobacco, drugs, ETOH Safety screening Pain screening Nutrition screening Eligibility for benefits screening

26 ANCHORS Plan of Care Identify individual specific strengths and successes Identify level of need based on tiered system Identify resources available to address the needs and gaps in services Case management Community clinics and mental health centers Healthy nutrition options-Food pantries Substance abuse treatment referrals Employment referrals

27 ANCHORS Plan of Care Linkage: Match needs with existent resources
Link community resources Community housing agencies Community healthcare agencies Community support systems

28 ANCHORS Plan of Care Monitor, reassess and evaluate individual’s status within tiered system Adjust intensity of services as tier status changes

29 ANCHORS Evaluation Ongoing evaluation of program Team meetings
Monitor individuals’ status, functioning, intensity of services and support needed using the Tiered Level of Need Model Assess if objectives are being met

30 Tiered Level of Need Model©
A fluid model of assessing an individual’s level of need for resources and services. Need is determined during individual assessments, reevaluated each visit, and changes are implemented and incorporated into the plan of care. Level 3 High need-maximum services and support required Level 2 Moderate need-fluctuating services and support required, periods of high and low, more and less, need Level 1 Low need- minimal services and support required

31 TIERED LEVEL of NEED MODELS
Tiered models have been used since Maslow identified the tiered model of needs that informs the beginning of every nursing program. Tiered models have been used in education to structure classrooms to better provide education to a diverse level of students. These models date back to 1980 and provide a well researched system of interventions by identifying student skills and classroom strengths to best utilize the resources

32 TIERED LEVEL of NEED MODELS
Minnesota public health has used a three tiered model to group patients with medical needs into different tiers that translated into different service levels. This model is used to focus limited public health monies to attain the best outcomes for the greatest number of patients.

33 TIERED LEVEL of NEED MODELS
Assesses the overall complexity of patients by grouping them into “complexity tiers” based on the number of major chronic condition categories that apply to them. Assessing complexity allows a more complete picture of complexity not limited by diagnosis codes Ensures more accurate payment through the use of complexity to approximate the time and work of care coordination Also helps shape programs and helps care coordination agendas

34 TIERED LEVEL of NEED MODELS
A seven tiered model of need has been used successfully in Australia to coordinate services for a population with dementia. "Our model provides the basis for comprehensive planning of service delivery. We believe that it is representative of the prevalence of different severities of behavioural and psychological symptoms of dementia (BPSD). Current funding is very sparse for intervention at tier 1 and tier 7 levels, even though the resource need per patient is greatest at the top and the population to be served is greatest at the bottom of the triangle.” Targeting funding to lower levels may reduce the demand for higher-level services — this is the principle of preventive medicine. Education for all staff working in residential-care settings has the potential to reduce the prevalence and severity of BPSD and the subsequent demand for more specialised (and more expensive) services

35 Alternative Assessment Tools
Vulnerability Assessment Tool, Vulnerability Index, Service Prioritization Decision Assistance Tool, VI-SPDAT: Used to determine who should be placed in RRH, PSH, or no additional support Denver Acuity Scale: used to determine case management service intensity Camberwell Assessment of Needs: Focused on SMI Outcome Star, Arizona Self-Sufficiency Matrix: designed to be used collaboratively with client SPDAT has 4 domains: wellness, risks, socialization& daily functions, & history of housing Outcome star has 10 points and AZ matrix has 17

36 Tiered Level of Need Model© Four Domains
Domains of need impacting health and housing linkages to services and success Medical Risks Mental Health (MH) Social Risks and Supports Financial Resources

37 Tiered Level of Need Model© Score Key
Level 3 High need-maximum services and support required Level 2 Moderate need-fluctuating services and support required, periods of high and low, more and less, need Level 1 Low need- minimal services and support required

38 Tiered Level of Need Model© Medical Risks
(Linked=visit in past 12 months) Level 3 Level 2 Level 1 *No PCP visit >3 yrs *PCP visit >1yr *Linked with Primary care provider (PCP *High mortality risk health problem *AIDS, Renal or Liver disease *Pregnancy *Uncontrolled chronic diseases, e.g. HTN, Diabetes, Asthma, Chronic uncontrolled pain *No health problems or controlled chronic health problems, includes Controlled pain /No pain *Chronic disease AND >60 *> 60 years old *20-40 years old (using contraception) *ER >3 visits in 6 months *ER 1-2 visits within 6 months *ER visit 1 visit/ year or less *Active substance use with impairment *Substance use management or *Substance use goals attained or *Active Mental and Physical health problems AND substance use No use <6 months No use >6 months or No substance use

39 Tiered Level of Need Model© Mental Health
Mental Health (MH) Risks (Linked=visit in past 6 months) Level 3 Level 2 Level 1 *No MH provider (MHP) visit >3 yrs *MHP visit >6 months *No MH problems/Linked with MHP *Deteriorating MH symptoms (sxs) *Unstable MH symptoms *Stable MH symptoms *Active Suicidal Ideation, hx attempts *Depression w/o active SI *Functioning with Depression/MH sxs *No insight, no reality testing *Poor insight, impaired reality test *Adequate insight, intact reality testing *ER >3 visits in 3 months *ER 1-2 visits within 6 months *ER visit 1/ year or less

40 Tiered Level of Need Model© Social Risks and Supports
*Harmful/negative support system *No/limited support system *Positive/strong support system *Not engaged and safety risk, DV *Not engaged, no DV risks *Engaged

41 Tiered Level of Need Model© Financial Resources
*Homeless *Housed 0-6 months *Housed >6 months *No Income or benefits *High risk or inadequate income *Working/Adequate Income *Needs disability *Benefits Pending/Inadequate *Adequate Benefits *No budgeting skills *Poor budgeting skills *Budgets well/Access to (healthy) food

42 Health Access ANCHORS Pilot program
Sarah Circle links with ANCHORS to develop Health Access program for Women who are formerly homeless

43 Health Access ANCHORS Pilot program
Resources 292 (430) hours for Advanced Practice Nurse (APN) 822 (1209) hours for Clinical Case Manager (CCM) Initial steps Select initial clients Explain the program Complete initial assessment Documentation required: Physical/MH assessments, Specific Case management notes (Treatment Plans)

44 Health Access ANCHORS Pilot program
Initial steps (cont’d) Homes visits Introduce clients to CCM Coordination with CMs from supportive housing programs Schedule visits Determine data to be collected

45 Health Access ANCHORS Pilot program Year 1
Year 1 Program goals 70 women receive initial screenings 70 women connected to FQHC home 70 women assessed for benefits, for eligible women, process to be started 80% remain housed after 12 months

46 Health Access ANCHORS Pilot program Year 2
Year 2 Program goals 70 women receive initial holistic screening 70 women connected to long-term sustainable primary care and psychiatric care as needed 80% remain in housing for 12 months 85% of the clients scored at moderate to low risk on the holistic health assessment by the time they exit the program

47 Health Access ANCHORS Pilot program
Data Summary 139 (Y1 74, Y2 65) women housed and entered into Health Access ANCHORS program Number of women with mental illness 93% (129/139 clients)

48 Health Access ANCHORS Program goals
Year 1 Year 2 Objectives Goal N (%) Received initial screening 70 clients (74 housed) 74 (100) (65 housed) 65 (100) Connected to FQHC home 72 57 Assessed for benefits, process started 64 Housed 1yr 80% 85% Still gathering data

49 Health Access ANCHORS Program Data summary per the 4 Domains
Medical Risks Initial assessment Beginning of program Final Assessment End of program Clients’ needs Percent per Tier (n) High need 27% (37) 11% (10) Moderate need 42% (59) 20% (18) Low need 31% (43) 69% (61) 39 women not assessed b/c program ended, 7 refused to participate

50 Health Access ANCHORS Program Data summary per the 4 Domains

51 Health Access ANCHORS Program Data summary per the 4 Domains
Mental Health Risks Initial assessment Beginning of program Final Assessment End of program Clients’ needs Percent per Tier (n) High need 18% (25) 9% (8) Moderate need 47% (66) 17% (15) Low need 35% (48) 74% (66)

52 Health Access ANCHORS Program Data summary per the 4 Domains

53 Health Access ANCHORS Program Data summary per the 4 Domains
Social Risks and Supports Initial assessment Beginning of program Final Assessment End of program Clients’ needs Percent per Tier (n) High need 17% (24) 6% (5) Moderate need 46% (64) 20% (18) Low need 37% (51) 74% (66)

54 Health Access ANCHORS Program Data summary per the 4 Domains

55 Health Access ANCHORS Program Data summary per the 4 Domains
Financial Resources Initial assessment Beginning of program Final Assessment End of program Clients’ needs Percent per Tier (n) High need 44% (61) 11% (10) Moderate need 51% (71) 27% (24) Low need 5% (7) 62% (55)

56 Health Access ANCHORS Program Data summary per the 4 Domains

57 Health Access ANCHORS Program Data summary
% of women moving from Tiered level 3 High need at beginning of program to level 1 Low need at end Medical risks: 16% of women went from high to low Mental health risks: 14% Social risks and supports: 14% Financial resources: 20%

58 Health Access ANCHORS Program Data summary
% of women moving from Tiered level 2 Moderate need at beginning of program to level 1 Low need at end Medical: 26% of women went from moderate to low Mental health: 36% Social risks and supports: 34% Financial resources: 38%

59 Health Access ANCHORS Program Data summary
% of women at Tiered level 1 Low need at beginning of program and at the end of the program Medical: 27% Mental health: 25% Social risks and supports: 27% Financial resources: 3%

60 Data summary: Comparing needs across domains
For the Initial and Final Risk Assessments compare level of need (high, moderate, low) in each domain (Medical, Mental, Social, Financial) with each other 1stAssmt Final Financial High Financial Moderate Financial Low MH High 14 11 MH Mod 30 27 3 MH Low 17 33 4

61 Data summary: Comparing needs across domains
Initial assessments showed Social need high when Medical need high Financial need high irrespective of Medical needs Financial need high irrespective of MH needs When Medical need low MH need low Social needs do not impact Financial needs and Financial need does not impact Social needs Social support and MH needs reciprocally impact each other, e.g low-low, mod-mod, high-high

62 Data summary: Comparing needs across domains
Final assessments showed When Medical need low Social support needs low, when Social support need low Medical need low When Financial need low Medical need low, when Medical need low Financial need low When MH need low Financial need low, when Financial need low MH need low When MH need low Medical need low When MH need moderate, Social supports need moderate, when Social need low MH need low When Social supports need low Financial need low, but low Financial need has no impact on Social supports need

63 Data summary: Comparing clients’ needs from initial intake to discharge

64 Data Summary Compared changes in Grid scores between initial assessment and final assessment and with Benefits status, Mental Health linkage, Health care linkage, Case Management

65 Data summary: Comparison of change in scores from initial intake to discharge with CM support
7/34 clients with no case management had scores improve 1-9 points 2/60 clients with no Case Management had scores improve points (10 points and 16 points) 58/60 clients had Case Management support and high improvement of scores (10-39 points)

66 Data Summary: Percent Linkage by discharge
72% Clients linked in a behavioral health or support program 93% Clients linked with Primary care (4 refused)

67 Lessons Learned –Implementation at Organizational Level
Consortium on Chicago School Research, Five Essentials for School Improvement

68 Lessons Learned –Implementation at Organizational Level
Five Essentials for Homeless Service Program Implementation

69 Lessons Learned –Implementation at Organizational Level
1. Leadership Inclusive leadership with vision, continuity, power to make decisions, and strong understanding of intervention model and staff needs Management wanted internal leader but program manager turnover and lots of organizational change E.g. Initially had clinical case manager do initial engagement of the women, with leadership changes the APN did the initial engagement of the client and referred clients needing counseling to CCM

70 Lessons Learned –Implementation at Organizational Level
2. Community Ties (Issue of interagency silos) Importance of community context and external relationships If >90% clients have SMI, need linkages with behavioral health programs and agencies Lack of clinical services and programs to transition to Helpful to have staff member to talk across systems APN able to communicate with health service providers Addressing cracks in service or turnover at other agencies sensitively but effectively

71 Lessons Learned –Implementation at Organizational Level
3. Professional capacity: Development Staff in various roles need to understand purpose, strategy, tactics, outcome measures, etc. Even though expert staff, still need support and professional development pertaining to model Staff training-took time, and not prioritized, given experienced project staff. Engagement different in time-limited program

72 Lessons Learned –Implementation at Organizational Level
3. Professional capacity: Collaboration Silos intra-agency With a new program and with this population, the unexpected will occur, need to be able to collectively adapt Funding flexible, but must communicate progress and changes Agency growth and change. Overall positive, but Clients separate between programs (4), buildings (2) and shifts (3) - new need for centralized intake/referrals Staff turnover Move to new building impacted housing #s second year Individual vs. team approach Misunderstanding about meaning of objective

73 Lessons Learned –Implementation at Organizational Level
4. Client-centered, Trauma-informed Climate Client-centered at all stages and levels Design, direct service, and evaluation Making sure there is enough support for staff around trauma

74 Lessons Learned –Implementation at Organizational Level
5. Quality Service Provision Great staff! Enough time per client?

75 Lessons Learned – Project Specific
Housing the whole person worked Improved health and housing retention Getting housing retention data at 12 months for those who needed lower levels of service difficult, but 85% of women placed in first year of program confirmed housing retention at 12 months NONE confirmed as losing housing within 12 months

76 Lessons Learned – Project Specific
Process for referrals and engaging clients before move How the program was framed to clients (initially as a separate program, but later as a standard continuation of services) Ability to provide these types of services for a limited amount of time when other supports were not available in the community to transition to Who should engage client first, CCM or APN? APN was opening newly housed clients and closing “graduating” clients who were housed for a year. Clients did not want to close. Time constraints made this difficult Clients not wanting engagement initially and then not having working phones

77 Lessons Learned – Project Specific
Staffing limitations-only 2 part-time staff, limited time and funding Better housing placements on front end (e.g. 3rd floor no elevator not ok for woman with mobility issues) Clients often geographically dispersed, people go where the housing is, which was difficult due to limited staff time

78 Lessons learned Ethics questions
Developing implementation and evaluation goals to meet objectives: What if objectives change? Ethics questions When to speak up? Who to talk with when there is no manager? How to process and deescalate after trauma with staff?

79 Lessons learned Quotes from staff
“never feeling like I was alone in the work, team approach which made us look at the whole person b/c we all had different education, backgrounds, experience” “this program made a lot of us clinicians better clinicians and that’s something that isn’t possible in a lot of other agencies” “Now we are all going in different directions and making other agencies better than they already are” “I wouldn’t be as skilled and knowledgeable without you and that program”

80 Contact info Elizabeth Dunn Regina Shasha


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