1. Collaborative Approach to Housing Needs Assessment
Big Bend Continuum of Care
and
Big Bend Community Based Care – Managing Entity

2. Our partners Big Bend Community Based Care Managing Entity
Covers 18 countys with 4 CoCs
Big Bend Continuum of Care
Covering 8 counties including Gadsden, Liberty, Franklin, Wakulla, Leon, Jefferson, Madison and Taylor

3. Where we started
We knew we needed to work together but we weren’t quite sure why or how to best utilize each other
The CoC made a Board seat for the Managing Entity as well as the major mental health provider and substance abuse provider
We started looking at data to identify which consumers were accessing resources through both the homelessness service system AND the behavioral health system in our area
By using the CoC’s Coordinated Entry data and the Managing Entity’s Behavix data we found that 71% of persons experiencing homelessness who scored a 10 or higher on the VI-SPDAT were also being served through Behavioral Health Providers funded by the Managing Entity.
This alarmingly high number told us WHY we should be working together….we still weren’t sure about the HOW we should work together

4. Differences and Similarities in our work
The M.E. and the CoC started attending case staffings together to house the most vulnerable of our crossover population.
We quickly realized that we had different areas of focus and expertise to bring to the table during these staffings.
The M. E. had resources for behavioral health supports to keep someone in housing as well as other housing options the CoC did not traditionally access including Assisted Living Facilities, Nursing Homes, Group Homes and Adult Family Care Homes.
Much of the CoC’s Permanent Supportive Housing residents were in need of an increased level of care as they aged and needed to move on to more appropriate placements like ALFs and Nursing Homes and the M.E. was able to provide contacts and help navigate the world of senior living.
This freed up spots available to clients identified through the ME and the CoC as needing PSH opportunities.

5. Shared interests and outcomes
Both the M.E. and the CoC wanted to see an increase in housing stability among the vulnerable population we serve together
We decided that the best way to know where each of us should focus our efforts was through a collaborative needs assessment that included feedback from housing and emergency service providers as well as behavioral health providers and included data from both areas.
Through the CoC we formed a Needs Assessment and Planning Committee that was chaired by the M.E.
We started looking at the data that we already had access to including Point In Time data, Housing Inventory and Coordinated Entry data available through the CoC. The M.E. looked at the clients who identified housing as a barriers to see if they had been referred to housing options through the CoC Coordinated Entry Process. The M.E. data on client’s housing status was not comprehensive enough to draw conclusions. Now on a case by case instance through care coordination and housing assistance, the M.E. encourages clients to be assessed and referred through the CoC’s Coordinated Entry as soon as possible to better help inform the needs assessment process.
This simple shift started to bring clients and workers on the Behavioral Health side closer to the CoC and more aware of the resources it could offer their clients.

6. Conducting a Housing Needs Assessment from multiple perspectives
We relied heavily upon the CoC Coordinated Entry data as well as previous Point In Time counts and current Housing Inventory and utilization rates among housing providers.
We realized there were systems we did not have input from on housing needs but these systems like Department of Corrections, Inpatient Psychiatric and Substance Abuse Treatment Facilities were regularly serving folks with housing stability issues.
We decided to form a survey that would be sent our to get a better idea on how many of the various subpopulations below were struggling with housing stability. Subpopulations of interest include;
Sexual Offenders, Felons, Substance Abuse, HIV/AIDs, Domestic Violence. Disabled, Violent Criminal History, Mental Illness

7. Who can’t you serve and why
One of the questions we asked as part of the survey to other partners was
“Of the individuals you were unable to assist since January 2017, how many belong to the following subpopulations?”

8. We received feedback that more often then not, agencies were not tracking who the DIDN’T serve and WHY they were unable to serve them. The Needs Assessment and Planning Committee is now creating a tool to help agencies keep track of this info to help us better understand unmet needs.
There were a few agencies that had solid data on this point and shared their data with us we found that there was a great need for increased housing options in the following areas;
Affordable Housing for those with;
Substance Abuse
Felonies or Violent Crime Histories/ Sexual Charges
Mental Illness
Bridge/Transitional Housing for those with
HIV/AIDS
Felonies or Violent Crime Histories/Sexual Charges
Permanent Supportive Housing for those with

9. We also learned that providers were seeing an increased level of care need as it relates to housing options, not typically accessed by the CoC and its providers was needed, including;
Halfway Houses/Boarding Houses
Assisted Living Facilities
Subsidized independent senior living
Group Homes/Adult Family Care Homes
Nursing Homes

10. CoC Coordinated Entry Data (What the VI-SPDAT told us)
We then looked at the CoC’s Coordinated Entry data to see who was needing various types of housing interventions and had not yet received them. Of all those entering the homelessness systems through Coordinated Entry the following were identified as needing the below housing types. We used this in conjunction with our utilization data to determine if there really was an outstanding need in certain types of housing
Individuals
VI-SPDAT Score
Projected Service Need 75
0-4
Self-Resolving or ES only
219
5-9
Transitional and/or RRH 77
10+
PSH
Families (individuals in families)
VI-SPDAT Score
Projected Service Need 40
1-4
Self-Resolving or ES only 71
5-9
Transitional and/or RRH 32
10+
PSH

11. M.E. Housing Needs Assessment Formula

12. Data informed planning
Specify number of permanent housing units needed
Expand SOAR Initiative
Increase Representative Payees
Access Medicaid benefits to cover cost of Peer Support and TCM
Increase collaboration on discharge policy and procedure
Ensure connection to behavioral healthcare supports to chronically homelessness through partnership with Managing Entity.
Measure progress towards independent, unsubsidized, unsupported housing for current PSH clients in order to free up space in PSH for newly identified chronic cases (Moving On Model)
Identify housing options with higher levels of care including Assisted Living Facilities and Nursing Homes targeted towards serving the aging population.
Explore the option, need and potential funding to create a safe haven model where chronic clients can be permanently housed and choose not to embark on treatment for mental health and or substance abuse issues.
Dedicate case management and outreach services to chronic subpopulation.
Provide education on harm reduction best practices through M.E.
Collaborative CoC/ME Housing Needs Assessment
More thorough gaps analysis from multi-system perspective
Change in CoC Homelessness Assistance Plan

13. Want to know more about the details?
Big Bend Continuum of Care
Mia Parker, BBCoC Executive Director
Johnna Coleman
Big Bend Community Based Care
Amanda Wander