Regina Shasha, MS, FNP, PMHNP, BC, ANCHORS Elizabeth Dunn, BA, Development Manager, Sarah’s Circle

Housing the Whole Person: Lessons learned, what worked,

what didn’t

Regina Shasha, MS, FNP, PMHNP, BC, ANCHORSElizabeth Dunn, BA, Development Manager, Sarah’s Circle

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

Objectives

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

What we can share

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

Our team

ANCHORS Sarah’s Circle Health

Access Linkage of these

programs

Program development

Assessing and Addressing

Individuals' Needs Using a Tiered System of Assessment, Implementation, and Care©

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

ANCHORS©: A Nursing Case management Housing Outreach Resource and Support

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.

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

Sarah’s Circle

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)

ANCHORSProblem identification

Whom are we serving?

Characteristics of the people who are being housed

Demographic data: Age range, gender, ethnicity, and family status


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)


What are the barriers to

maintaining housing? Physical health problems Mental health problems Poverty Substance use


What level of functioning

and independence exists and is possible for each individual?


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

ANCHORSGoal 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

ANCHORSObjective setting

1. What resources are needed to

accomplish goals and objectives? Staff Facility Equipment and Supplies

2. Identify available funding Apply for grant funding

ANCHORSResources

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

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


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


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


Outcome measures

Utilise quality of life and mental health rating scales

Perform baseline, quarterly, at discharge


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


Staff responsibilities

Obtain malpractice insurance Recruit collaborating physicians Develop collaborative

relationships within the agency and with community resources


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

ANCHORSPlan 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

ANCHORSPlan of Care

Linkage: Match needs with

existent resources Link community resources Community housing agencies Community healthcare agencies Community support systems

ANCHORSPlan of Care

Monitor, reassess and evaluate

individual’s status within tiered system

Adjust intensity of services as tier status changes

ANCHORSPlan of Care

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

ANCHORSEvaluation

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

Tiered Level of Need Model©

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

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.


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


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


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

Alternative Assessment Tools

Domains of need impacting health

and housing linkages to services and success Medical Risks Mental Health (MH) Social Risks and Supports Financial Resources

Tiered Level of Need Model©Four Domains

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

Tiered Level of Need Model©Score Key

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

Tiered Level of Need Model© Medical Risks

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

Tiered Level of Need Model©Mental Health

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

Tiered Level of Need Model©Social Risks and Supports

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

Tiered Level of Need Model©Financial Resources

Sarah Circle links with

ANCHORS to develop Health Access program for Women who are formerly homeless

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)


Initial steps (cont’d) Homes visits

Introduce clients to CCM Coordination with CMs from supportive housing

programs Schedule visits

Determine data to be collected


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

Health Access ANCHORS Pilot program Year 1

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

Health Access ANCHORS Pilot program Year 2

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)


Year 1 Year 2

Objectives Goal N (%) Goal N (%)

Received initial screening

70 clients(74 housed)

74 (100) 70 clients(65 housed)

65 (100)

Connected to FQHC home


72 70 clients (65 housed)

57

Assessed for benefits, process started


72 70 clients (65 housed)

64

Housed 1yr 80% 85% 80% Still gathering data

Health Access ANCHORS Program goals

Medical Risks Initial assessment

Beginning of program

Final AssessmentEnd of program

Clients’ needs Percent per Tier (n) Percent per Tier (n)

High need 27% (37) 11% (10)

Moderate need 42% (59) 20% (18)

Low need 31% (43) 69% (61)

Health Access ANCHORS Program

Data summary per the 4 Domains

High Moderate Low0

20

40

60

80

Medical Risks

Initial AssessmentFinal Assessment

Level of Need

% o

f clien

ts



Mental Health Risks

Initial assessmentBeginning of program



High need 18% (25) 9% (8)

Moderate need 47% (66) 17% (15)

Low need 35% (48) 74% (66)



High Moderate Low0

20

40

60

80

Mental Health Risks


Level of Need

% o

f clien

ts



Social Risks and Supports




High need 17% (24) 6% (5)

Moderate need 46% (64) 20% (18)

Low need 37% (51) 74% (66)



High Moderate Low0

20

40

60

80

Social Risks


Level of Need

% o

f C

lien

ts



Financial Resources




High need 44% (61) 11% (10)

Moderate need 51% (71) 27% (24)

Low need 5% (7) 62% (55)



High Moderate Low0

10203040506070

Financial Risks


Level of Need

% o

f C

lien

ts



% 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%


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%


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%


Data summary

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

1stAssmtFinal

Financial High

Financial Moderate

Financial Low

MH High 14 11 0

MH Mod 30 27 3

MH Low 17 33 4

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


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


Data summary: Comparing clients’ needs from initial intake

to discharge

1-9

10-19

20-29

30-39

0 5 10 15 20 25 30 35 40

% Improvement in Grid scores from Initial to Final Assessments

% Improvement in Grid scores from Initial to Final Assess-ments

% of Clients

% I

mpro

vem

ent

in G

rid S

core

Compared changes in Grid scores

between initial assessment and final assessment and with Benefits status, Mental Health linkage, Health care linkage, Case Management

Data Summary

7/34 clients with no case management

had scores improve 1-9 points 2/60 clients with no Case Management

had scores improve 10-39 points (10 points and 16 points)

58/60 clients had Case Management support and high improvement of scores (10-39 points)

Data summary: Comparison of change in scores from initial intake to discharge

with CM support

72% Clients linked in a behavioral

health or support program 93% Clients linked with Primary

care (4 refused)

Data Summary: Percent Linkage by discharge

Lessons Learned –Implementation

at Organizational LevelConsortium on Chicago School Research, Five Essentials for School

Improvement

Five Essentials for Homeless Service Program 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



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



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



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



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



5. Quality Service Provision Great staff! Enough time per client?



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

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


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


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?

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”

Lessons learned

Elizabeth Dunn [email protected]

Regina Shasha [email protected]

Contact info

mailto:[email protected]



Documents

Regina Shasha, MS, FNP, PMHNP, BC, ANCHORS Elizabeth Dunn, BA, Development Manager, Sarah’s Circle