Broward County Human Services Department

Rapid Rehousing Service Delivery Model (SDM)

The Service Delivery Model serves as a minimum set of standards to be followed by all providers of Rapid Rehousing (RRH) services under the Broward County Human Services Department (HSD).

Service Category Description: RRH is a housing intervention designed to help individuals and families exit homelessness or divert them from experiencing homelessness through the provision of housing throughout the community. Participating programs are expected to serve all households referred through the Homeless Continuum of Care (“HCoC”) Coordinated Entry and Assessment (“CEA”) System. The primary focus of assessments and assistance should be to resolve the participant’s current housing crisis with an emphasis on the household’s barriers to obtaining and maintaining housing. RRH resources and services must be tailored to the unique needs of the household.

Definitions and Concepts:

• Housing First: the concept that the first and primary need of individuals and families experiencing homelessness is to obtain stable housing and that other challenges can be addressed after stable housing is obtained.

• Continuum of Care (CoC): a process designed to promote communitywide commitment to the goal of ending homelessness; provide funding to rehouse individuals and families experiencing homelessness while minimizing the trauma and dislocation caused to individuals, families, and communities by homelessness; promote access to effect utilization of mainstream programs by individuals and families experiencing homelessness; and optimize self-sufficiency among individuals and families experiencing homelessness.

• Coordinated Entry and Assessment System: a centralized process designed to coordinate program participant intake, assessment, and provision of referrals across a geographic area.

• Community Based Outreach: a program that establishes a visible presence in the community, providing information, education, services and supports where members of the underserved population live, work, spend time and access services.

• Community Collaboration: a program that works to build strong partnerships among health and social service organizations frequently accessed by families experiencing homelessness.

• Family: A family includes, but is not limited to the following, regardless of actual or perceived sexual orientation, gender identity, or marital status: (1) a single person, who may be an elderly person, displaced person, disabled person, near-elderly person, or any other single person; or (2) a group of persons residing together, and such group includes, but is not limited to: (i) a family with or without children (a child who is temporarily away from the home because of placement in foster care is considered a member of the family); (ii) an elderly family; (iii) a near elderly family; (iv) a disabled family; (v) a displaced family; and (vi) the remaining member of a tenant family. (24 CFR 5.403).

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• Disabling Condition: according to HUD: (1) a condition that: (i) is expected to be of indefinite duration; (ii) substantially impedes the individual’s ability to live independently; (iii) could be improved by providing more suitable housing conditions; and (iv) is a physical, mental, or emotional impairment, including an impairment caused by alcohol or drug abuse, posttraumatic stress disorder, or brain injury; or a developmental disability, as defined above; or the disease of Acquired Immunodeficiency Syndrome (AIDS) or any conditions arising from AIDS, including infection with the Human Immunodeficiency Virus (HIV). (24 CFR 583.5).

• Person (Family) Focused: a list of national guidelines that focus on what family homeless street outreach programs can do to ensure that individuals, families, and small groups found within underserved populations are fully supported.

• Participant: an individual or family who is engaging in services provided by the County to end their episode of homelessness.

• VI-SPDAT for Families: is an evidence-informed approach to assessing an individual’s or family’s acuity. The tool prioritizes who to serve while concurrently identifying the areas in the individual’s/family’s life where support is most likely necessary in order to avoid housing instability.

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STANDARDS FOR SERVICE DELIVERY Standard Measure

1. Participant is screened for program 1.1. Documentation of eligibility in participant’s eligibility and entered within 16 hours in the file. Homeless Management Information System (“HMIS”) and the participant’s file upon receipt.

2. Participant is requested to provide 2.1. Documentation of signed Informed Consent expressed and Informed Consent and and Release of Information (“ROI”) is in HMIS Release of Information within 2 hours of and participant’s file. signing.

3. Participant engages in an intake/orientation session relative to services provided and inclusive of participant rights, grievance procedures, expectations of participant engagement and attendance, and discharge criteria. This must be completed within three (3) calendar days, as defined by your contract and the Written Standards of Care.

3.1. Documentation of participant’s receipt of orientation (via signature) on agency intake form in participant’s file.

4. Provider completes a Housing Barrier Assessment with each participant. Packet is to be reviewed and signed by the case manager and case manager supervisor. Must be completed no later than three (3) calendar days after admission and must be consistent with the participant’s immediate needs.

4.1. Documentation of completed Housing Barrier Assessment in HMIS and participant’s file.

5. Provider works with each participant to develop a detailed individualized housing plan which contains attainable goals, within thirty (30) calendar days after admission. plan is to be signed by participant, case manager and case manager supervisor.

5.1. Documentation of completed Housing Barrier Assessment in HMIS and participant’s file.

6. Provider works with each participant to develop a detailed individualized housing plan which contains attainable goals, within thirty (30) calendar days after admission. Plan is to be signed by participant, case manager and case manager supervisor.

6.1. Documentation of completed Housing Barrier Assessment in HMIS and participant’s file.

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Standard Measure 7. Provider assesses and evaluates needs

assessment and individualized housing plan to submit progress and referrals made toward achieving goals. To be documented within three (3) calendar days in HMIS.

7.1. Documentation of progress and referrals given and/or discussed with participant in participant’s file, including referral refused by participant.

8. A formal review of the individualized housing plan and recertification of RRH is conducted every three (3) months or sooner when significant changes occur. Plan is to be signed by the case manager and the participant at least every three (3) months.

8.1. Documentation of an updated individualized housing plan and RRH recertification in participant’s file, as applicable.

9. Communication with or on behalf of the 9.1.Detailed documentation of communication in participant is documented in participant’s participant’s file. file to include date, length of time spent with participant, person(s) included in the encounter, and summary of communication with in three (3) calendar days.

10. Progress is noted in participant file reference relevant link to an individualized housing plan goal. Case Managers will evaluate participants progress, determining a need for possible reassessment and development of new service linkages or referrals, or other dispositions as indicated with in three (3) calendar days.

10.1.Detailed documentation of participant’s progress in participant’s file.

11. Provider assists participants with application to federal, state, and local benefits, but not limited to Social Security, SNAP, etc. and document within participant’s file within three (3) calendar days.

11.1. Documentation in participant’s file.

12. A case closure note is completed within thirty (30) calendar days of participant accomplishing the individualized housing plan goals or within ninety (90) calendar days of participant inactivity.

12.1. Case closure note is documented in participant’s file.

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Key Service Components and Activities

Providers are expected to comply with applicable State and Federal standards and guidelines relevant to services delivered within this service category. Providers shall also adhere to standards and requirements set forth in the Broward County Human Services Department, Community Partnerships Division Provider Handbook for Contracted Services Providers, individual contracts, and applicable work authorizations.

For the purposes of this document, “participant file,” as referenced in the standards, refers to the Human Services Software System (“HSSS”). This is the Client Services Management System and other participant information collection method and data exchange system designated by the County. For the Homeless Initiative Partnership, the system is HMIS.

Funds may be used to provide housing relocation and stabilization services and short- and/or medium-term rental assistance as necessary to help a homeless individual or family move as quickly as possible into permanent housing and achieve stability in that housing.

Eligibility Verification The provider must verify participant program eligibility for services prior to participant receiving services. Each provider must refer to their individual contract for participant eligibility guidelines. Verification of participant eligibility is accomplished by examining supporting documentation. The provider must review participant eligibility for all funding streams and services for which participant may qualify. The provider must provide all supporting documentation in the participant’s file and note the outcome of the eligibility verification.

1. Eligibility Criteria:a. Participants must be over the age of eighteen (18) and experiencing

homelessness defined by Category 1 or 4 of the Homeless Emergency Assistance and Rapid Transition to Housing Act of 2009 (HEARTH ACT) as indicated in the Provider Handbook at https://www.broward.org/HumanServices/CommunityPartnerships/Pages/Contract ServicesProviderHandbook.aspx

b. A criminal background check may be completed to identify any potential outstanding warrants or other issues that may impact the rehousing process. Outstanding warrants may be addressed by the household prior to move in.

Participant Intake Participant must be requested to give expressed and informed consent for admission into services. A signed Release of Information is to be uploaded to HMIS. The provider must collect participant data using the agency intake form and each participant must receive an orientation of services provided by the agency. Completed release of confidential information and records forms for referrals and/or disclosures with signature must be in the participant file.

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Each participant must complete a Housing Barrier Assessment and an intake assessment in HMIS, consistent with the participant’s immediate needs, no later than three (3) calendar days after admission. The assessment must be reviewed and signed by the case manager and case manager supervisor. The assessment, at minimum, must include the following:

• Source of referral. • Presenting needs. • Barrier to housing. • History of the presenting needs/problem. • History as it relates to the services needed. • Relevant personal and family history. • Need for referrals and further evaluation by other professionals.

Individualized Housing Plan The provider shall work with each participant to develop a detailed individualized housing plan based on participant needs identified in the Housing Barrier Assessment and the Intake Assessment. The plan of care must be jointly developed by the participant and the provider. The plan must be participant-centered and consistent with the participant’s identified abilities, needs, and preferences. The housing plan and the plan of care must be reviewed and signed by the Participant, case manager and case management supervisor.

If the participant is under the age of eighteen (18) years of age, a parent or legal custodian should be included in the development of the participant’s individualized housing plan. Each provider must refer to their individual contract for participant’s eligibility requirements and guidelines. Service and individualized plans for participants under eighteen (18) years of age that do not include the participant’s parent, custodian or legal guardian requires a documented explanation.

The plan must contain, at minimum, the following components: • The participant’s presenting need(s). • A list of the services to be provided to participants (service plan development,

individualized plan review, and evaluation or assessment services provided to gather information for the development of the individualized plan).

• The amount, frequency, and duration of each service for the individualized housing plan • Goals that are individualized, strength-based, and appropriate to the participant’s

diagnosis, age, culture, strengths, abilities, preferences, and needs, as expressed by the participant.

• Measurable objectives with target completion dates identified for each goal. • Dated signature of the participant or participant’s parent, guardian, or legal custodian,

if participant is under eighteen (18) years of age. • Dated signature of case manager and case manager supervisor. • Case closure criteria. • The participant’s presenting housing needs and barriers.

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Supportive Services Providers will ensure that both Housing Navigation and Case Management Services are provided to those participants of Rapid Rehousing Services.

Housing Navigation The goal of housing identification is to find housing for people quickly. Providers should recruit landlords continuously, even before you have people who need housing. Providers should also use the “Landlord Tenant Guidebook”.

The provider will match participants to appropriate housing. Housing must comply with the Fair Market Rent standards; Rent Reasonableness standards and the property must pass a Quality Housing Inspection.

The Applicant Agency is responsible for ensuring its staff receives annual training on the basic program philosophy of RRH. Programs must have a well-defined written screening process using a consistent and transparent decision criterion. Additionally, program eligibility criteria do not require sobriety, commitment to participate or other “predictive” criteria. All Programs must participate in the Homeless Management Information System (HMIS) and the local Coordinated Entry and Assessment.

Case Management Rapid re-housing program must include case management, Case management services in rapid re-housing programs must help individuals and families select among various permanent housing options based on their unique needs, preferences, and financial resources, address issues that may impede access to housing (such as credit history, arrears, and legal issues), negotiate manageable and appropriate lease agreements with landlords, and make appropriate and time-limited services and supports available to families and individuals—and to the landlords who are partnering with the rapid re-housing program. Case management services must also monitor participants’ housing stability after securing housing and during program participation, ideally through home visits and communication with the landlord, and be available to resolve housing-related crises should they occur.

Expected Outcomes The provider shall assist the participant to define goals for housing needs and other identified needs addressed in the housing plan and individualized plan. The provider shall document participant strategies to achieve goals, and the progress and assistance provided to the participant in the participant file. Progress notes must be documented in the participant file within three (3) calendar days of meeting with the participant. For the purpose of this ESG Service Delivery Model (“SDM”) the DCF deliverables will be used as the formal outcomes.

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Review/Follow-up The provider must conduct a formal review of the service plan and individualized housing plan and recertification of eligibility for Rapid Rehousing (RRH) at least every three (3) months. The individualized plan may be reviewed more than once every three (3) months when/if significant changes occur. Activities, notations of discussions, findings, conclusions, and recommendations must be documented during the individualized housing plan review. Any modifications or additions to the service plan or individualized housing plan must be documented based on results of the review. The service plan and individualized housing plan must be reviewed and signed by the participant, case manager and case manager supervisor. Documentation must be entered in the participant’s file within three (3) calendar days of meeting with the participant.

The formal individualized plan review must contain, at minimum, the following components: • Participant’s progress toward meeting service plan and individualized housing goals and

objectives. • Participant’s progress toward meeting service plan and individualized housing case

closure criteria. • Participant needs assessment. • Updates to aftercare plan, if applicable. • Findings/interpretive summary. • Recommendations. • Dated signature of the participant or participant’s parent, guardian, or legal custodian (if

participant is under eighteen (18) years of age). • Dated signature of case manager and case manager supervisor who participated in review

of the plan.

Referrals and Coordination of Care The provider must refer participants to appropriate resources to assist in the resolution of other participant needs. Open referrals must be followed up at least quarterly. Coordination of participant care shall be documented in the individualized plan and participant file. Case manager must assess participant needs by completing a Housing Barrier Assessment. The analysis of the Housing Barrier Assessment must assist the case manager in determining the referrals needed. An individualized housing plan shall be developed by the case manager based on the identified needs. Referrals must be documented in the individualized housing plan and the Progress Notes. Case manager must follow-up and document the results of the referral in the Progress Notes. Case manager and provider that receives the referral must communicate to update each other on the status of the referral.

No Show Case manager must contact “no show” participants to assess potential barriers and/or conditions leading to the “no show.” Case manager and participant shall determine future steps to resolve the situations that triggered the “no show”. Provider must establish coordination with the agency that received the initial referral to re-activate it after participant’s consents.

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Retention in Rapid Rehousing Services The provider must assist the participant to adhere to Rapid Rehousing Services and establish missed appointment protocols for participants who miss scheduled appointments. The provider must discuss with the participant the reasons for not adhering to services, and with participant participation, discuss strategies to ensure adherence to services. The provider must document the assistance provided in the participant’s file. Documentation must be signed and dated by the provider and entered in the participant’s file within three (3) calendar days of meeting with the participant.

Case Closure Rapid Rehousing services are based on the participant’s current needs and level of services can change if needs change. When determined that these services are no longer required, a case closure note must be completed within 30 calendar days of participant accomplishing the individualized housing plan goals or within 90 calendar days of a participant who has fallen out of the Rapid Rehousing Services. Completion/discontinuation of services can be determined based on the following criteria including, but not limited to:

• Successful completion of all individualized plan goals. • Case manager determines participant is no longer adherent to plan. • Participant is transferred to another provider. • Participant exerts disruptive behavior. • Participant is non-compliant. • Participant dies, declines services, or relocates.

Providers who have a case closure due to termination because of disruptive behavior must refer and provide due diligence to successfully link the participant to a new provider. This must be documented in the participant’s file and signed by the case manager and case manager supervisor. If it is a successful completion of the individualized housing or service plan, the case closure note must be signed by the participant, case manager and case manager supervisor. Case closure notes must include a summary in participant’s file including, at minimum:

• Date and reason of case closure. • Summary of services provided. • Completion date of individualized plan goals. • Referrals provided. • Benefits obtained or applied. • Participant housing needs assessment at time of case closure. • Documentation of post-discharge continuity of care.

Continuous Quality Improvement The provider must conduct chart sample reviews of participants’ files in HMIS shall be conducted monthly to ensure all required documentation of provided services, such as: housing barrier assessment, participant notes, entry and exit data, demographics, income verification, standard lease agreement, rent reasonableness information, quality safety inspection, and an updated Release of Information. This information must be discussed on the monthly provider calls to ensure outcomes and data quality are discussed frequently.

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The provider must have a policy and procedure that outlines a Quality Improvement Plan that includes how quality of service delivery, participant satisfaction and staff training will be conducted. The provider must also Data Quality Plan for HMIS that outlines how frequently data will be reviewed for errors in System Performance Measures, Annual Performance Reports, and other key areas and be submitted to the County within thirty (30) calendar days of contract execution.

Providers will run the Annual Performance Report and the HMIS 262 Art report monthly (some projects quarterly) to ensure error rates are below 5% in all data elements. This report is to be reviewed by the section Quality Assurance Team.

Provider calls are monthly and are mandatory to ensure clear and consistent communication around the contracts, invoicing, utilization, quality and timeliness of data, outcome barriers, and monitoring follow up. This is the providers opportunity to discuss any concerns or barriers they are having with any element of the contract. These are scheduled at a consistent time each month and cannot be cancelled without the prior approval of the Homeless Initiative Partnership Administrator.

Professional Requirements Providers of Rapid Rehousing services must adhere to the required minimum credentials outlined in the Broward County, Human Services Department, Community Partnerships Division Provider Handbook for Contracted Services Providers.

Outcomes and Indicators

Outcomes Indicators Data Sources Data Collection Methods 1. Participant(s)

achieve permanent housing status.

1.1. 80% of Participant(s) will obtain permanent housing.

Homeless Information System (HMIS), Service Point Broward Multi-Service Report; Participant(s) and Agency Files, Case Management logs, Discharge Plans, Leases, landlord verification and/or rental subsidy agreement.

Provider staff updates housing status in HMIS. Provider staff compiles the data and reports quarterly.

Calculation: Number of Participant(s) who obtain housing during the current term of the contract / Total number of Participant(s)s served during the period under review.

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Outcomes Indicators Data Sources Data Collection Methods 2. Participant(s) 2.1. 60% of Participant(s) Primary Data Source: Provider staff completes an

maintain or 18 years or older, HMIS APR or the initial income assessment increase maintain their total Broward Service during program entry and income. income (from all Summary Report updates income status in the

sources) by the end annual assessment 30 days of each period under review or program exit.

Secondary Data Source: Verifiable third-party documentation, including check stubs, W-2 and/or benefit award

before or after the anniversary entry date in the program in HMIS. Provider staff compiles data and reports quarterly.

letter(s), Participant(s) files, Case Management Calculation: Number of logs, discharge plans. Participant(s) who maintain or

increase income (from all sources) by the end of the current term of the contract or program exit / Total Number of Participant(s)s served, with or without income, during the period under review.

3. Participant(s) 3.1. 80% of Participant(s) Primary Data Source: Provider staff updates housing remain who exited the HMIS, 700 Series Report status in HMIS upon exit to permanently program to a positive permanent housing and housed. HUD living situation

and remain permanently housed for a minimum of six (6) months after program exit.

Secondary Data Sources: Participant(s) and Agency files, Case Management logs, Discharge Plans, Leases, landlord verification, and/or rental subsidy

confirms six (6) months from exit. Provider staff reviews the Participant(s) status in HMIS to ensure they have not reentered the system. Provider staff compiles the data and reports quarterly.

agreement. Calculation: Number of Participant(s) who exit the program to a positive HUD housing destination and remain permanently housed for a minimum of six (6) months from program exit / Total number of Participant(s)s who exit to a positive HUD housing destination

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