Quality Improvement Intervention Case Studies: Columbus Model

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Toolkits | October 15, 2010

Hypothetical #1: Housing Outcomes & Length of Homelessness
This organization’s performance on housing outcomes and length of homelessness is substandard. The last two quarterly indicator reports show that the length of homelessness for this agency’s clients is one-and-a-half times longer than other agencies serving the same population. This organization is also struggling to help clients obtain permanent housing. A growing number of clients leave the agency prior to receiving housing placement assistance and return to the system seeking homeless assistance.

Intervention
To improve service delivery at this organization, the lead CoC agency and the subject agency completed the following steps for the QII:

  1. Discuss performance outcomes for the last 12 months.
  2. Observe, detail, and chart the agency’s process from intake to housing placement including length of time (in days) it takes to complete each step.
  3. Identify specific areas where processes could be further streamlined.
  4. Review case files of clients who exited the program without housing and/or exited and returned to homelessness.
  5. Conduct client interviews.
  6. Plan and implement changes to agency’s process.

The QII revealed that the organization’s service process is overly linear and lengthens clients’ stays in homelessness. Clients’ length of homelessness significantly impacts their housing outcomes. For example, the organization’s intake and assessment processes take only a couple of hours. However, this information is not reviewed or used to start addressing housing barriers (e.g. linking clients with benefits) until the next case team meeting. Team meetings only occur one time per week, and all the clients that entered the agency that week are discussed. The timing of the case meeting relative to a client’s intake and assessment accounts for approximately one week in length of stay variance.

Housing location for clients does not begin until nearly all the housing barriers (e.g., approval of benefits income, approval of relocation assistance) have been addressed, which takes 30 to 40 days. The housing location process takes an additional 3 to 4 weeks to complete. Many clients voluntarily leave the agency during this time but show up in another shelter program only a short time thereafter. Client interviews revealed that clients leave the program prematurely because they find shelter life stressful and they hear that other programs place clients in housing faster. Additionally, some clients are frustrated because they observe clients entering the program as much as 3 weeks later and placed into housing more quickly.

Outcome
The QII resulted in the following outcomes and changes for this agency:

  • Clients complete a shelter exit/housing plan within 48 hours of intake and assessment.
  • Team meetings occur on a rolling basis, up to 3 times per week, to facilitate faster response and assistance times from staff in helping clients complete their shelter exit/housing plan.
  • Housing location begins within one week of intake.
  • One case manager’s role within the organization shifted to focus on helping clients access mainstream benefits, including assisting clients in obtaining the appropriate documentation to move forward.
  • Clients are connected with the benefits case worker within 24 hours of intake and assessment.
  • Clients are required to schedule and complete meetings with all relevant benefits programs within one week of intake.
  • Intermediate benchmarks and objectives were identified, and follow-up meeting were scheduled to monitor progress.
    • Reduce median length of stay by 3 to 5 days each month for the next 9 months;
    • Improve percentage of successful housing outcomes by 5 percentage points, on average, each month for next 9 months;
    • Within three months of implementing strealined service delivery process, complete tasks related to benefits-income and complete first team case meeting within one week of intake for 100 percent of clients.
  • Participate in progress update meetings, quarterly, for 12 months.

Hypothetical #2: Average Cost Per Household, Housing Outcomes & Income Outcomes
This organization provides scattered site transitional housing. Quarterly indicator reports show that clients served by this organization do not demonstrate better housing stability or increases in income than their counterparts who have the same client profile and are rapidly re-housed directly from shelter. Yet, this organization’s cost per household is significantly higher than organizations serving similar clients, making this program a “program of concern.”

Intervention
To improve service delivery at this organization, the lead CoC agency and the subject agency completed the following steps for the QII:

  1. Discuss performance outcomes for the last 12 months with executive leadership.
  2. 2Conference with senior case manager(s) to learn more about the approach to supportive services.
  3. Comparatively review this organization’s client case files and rapidly re-housed client case files.
  4. Plan and implement changes to agency’s process..

The QII found several areas where this agency could adjust its approach and become more cost-effective. These key areas include targeting practices, client programs, and client support services. Regarding targeting, this transitional program only accepts families with limited housing barriers and a strong likelihood of success. Often, the head of household has some employment history, limited history with substance use, at least six months of “clean time” where substance use has been an issue, and minor criminal history if any. Clients served in the program are required to participate in several classes and programs on topics such as parenting, health and nutrition, and financial management. Clients are also required to participate in a vocational, employment, or other education or training program, and they must demonstrate the development of specific life skills such as cleaning, improved social networks and skills (i.e., better friend choices, limited visitors, etc.), and cooking.

Clients in this transitional program demonstrate strong outcomes. However, review of client files shows that clients with similar profiles achieve the same outcomes when rapidly re-housed directly from shelter and provided with short-term or no home-based case management. In fact, families with this client-profile obtain most of their income and social service resources while they are in shelter and can maintain housing with limited financial assistance in the form of a security deposit, back rent payment, and/or first month’s rent. Case management for these clients in a rapid re-housing program builds on client progress in shelter and focuses on helping clients:

  • Access resources,
  • Quickly access permanent housing,
  • Build a landlord-tenant relationship,
  • Increase benefits and employment income,
  • Develop a housing-focused budget, and
  • Maintain or access new social service resources in their transition to permanent housing.
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The transitional housing agency’s required programs and case management account for most of the difference in cost per household because they are financed only by the agency’s budget and do not leverage community resources. Further, the rapid re-housing programs serve a larger number of households in a fiscal term than the transitional program, which further decreases their cost per household. Finally, the majority of clients in the transitional housing program remain in the program until they obtain a permanent housing voucher. This makes the permanent housing voucher the primary driver of housing stability for this program’s clients and suggests that the programs and services are unnecessary to help the family access and maintain permanent housing.

Outcome
At the conclusion of the QII, the lead agency and subject agency jointly determined several options to improve the cost-efficiency of the transitional housing program. The agency could target its programs and services to families with significantly higher barriers. Examples include families involved with child welfare or in need of family reunification and families in which the head of household has active and severe substance use issues. Alternatively, the agency could shift its service model to a rapid re-housing model that is comparable to that of its peers, or become a short-term (i.e., 3 to 6 months) transitional program that serves households with slightly higher barriers than its current population. Examples of the latter include households in which the head of household has a criminal background that significantly impacts his/her ability to obtain housing and employment, citizenship issues, long-term unemployment, and/or extremely poor housing history.

The agency chose to become a short-term transitional housing program that takes clients with slightly higher housing barriers, making the resources expended more cost-appropriate for the client population served. The agency’s transition took 12 months and resulted in the following outcomes and changes:

  • Target households with the following housing barriers:
    • Long-term unemployment,
    • Very poor housing histories.
    • Significant criminal backgrounds,
    • Citizenship issues, and/or
    • Inability to be rapidly re-housed (based on a referral from rapid re-housing case manager or coordinator).
  • Discontinue required programming and shift to a limited number of required home-based case visits
  • Shift case managers’ roles to emphasize connection to mainstream benefits and services and service “brokering”
  • Expand case managers’ responsibilities to include housing location and working with landlords (this was previously a marginal responsibility)
  • Participate in training sponsored by the lead agency, including:
    • Peer-to-peer learning opportunities and site visits,
    • Housing location and working with landlords training, and
    • Training on coordinating with mainstream benefits and services programs.
  • Participate in quarterly progress update meetings for 18 months.

Hypothetical #3: Data Quality
The lead CoC agency conducts regular data quality reviews with all CoC agencies. The most recent data quality review found that this organization’s client files contained client- and case management information that had not been correctly entered in HMIS. The review also demonstrated that the agency served clients who were not entered in the HMIS. This organization is in violation of its contract with the lead CoC agency and is at risk of losing funding.

Intervention
To improve service delivery at this organization, the lead CoC agency and the subject agency completed the following steps for the QII:

  1. Identify the data quality violations
  2. Review client files for the last 12 months of operation.
  3. Require data quality issues to be addressed within one month.
  4. If issues are unresolved within one month, place the agency in contractual breach and stop funding until the problem is resolved.
  5. Outcome

    • Follow up with agency after one month.
    • Regular monitoring through monthly indicator reports.
    • Conclude the QII once the problem the intervention requirements are met.