The Assessment and Referral Processes: Coordinated Assessment Checklist Addendum


Solutions Brief | January 29, 2013

Files: The Assessment and Referral Processes: Coordinated Assessment Checklist Addendum (DOCX | 40 KB | 5 pages)


 The Assessment and Referral Processes: Coordinated Assessment Checklist Addendum


This document is intended to help answer key questions communities may have about the assessment and referral pieces of coordinated assessment and provide guidance based on work the National Alliance to End Homelessness has done with other communities. The questions below relate to referrals made to programs other than prevention and diversion, as it assumes that a screening for those needs has already been conducted with clients, those resources were deemed insufficient, the household has entered emergency shelter, and additional assessment is being done to determine what type of program or resource is needed to meet the household’s permanent housing needs.

How should communities make referral decisions?

Some communities use a scoring system based on the answers to assessment questions to determine which intervention (e.g., transitional housing or rapid re-housing) is potentially the best fit for a household’s needs. This process usually involves assigning values or weights to assessment questions and then summing up the answers to help determine which intervention would be best. Examples of scoring systems used with assessment tools are available from Hennepin County and the Alliance. Other communities may use trained clinicians to decide on the best fit for different households based on their own extensive knowledge and training. Whatever route a community chooses, prioritization for receipt of services based on need, consumer preference and choice, and an understanding of the best use of different interventions should be the bases of these decisions. Once the assessment process has been completed with a household, Continuums of Care (CoC) are required by the U.S. Department of Housing and Urban Development (HUD) to document what intervention the household best matched with according to their assessment, and, ideally, what intervention they ended received.

Is the referral process consistent with the community’s written standards for prioritization and eligibility?

Under the interim CoC rule it is now mandatory that Continuums develop written standards that establish which households are eligible for and/or should be prioritized for placement in transitional housing, rapid re-housing, and permanent supportive housing programs. Communities must also write out their method for determining how much rent a household will pay if participating in a rapid re-housing program. The design of the community assessment tool and how it determines a household’s program destination should be consistent with these written standards and reflect best practice, local and national data on the effectiveness of different interventions, and attempts to match higher-cost interventions with households with more intensive needs.

What is a basic outline for how the assessment and referral process could work?

  • After a prevention and diversion screen has been conducted and the household has been deemed ineligible for those resources and has entered shelter, the following steps should be taken:
  • An emergency shelter case manager should administer a housing and prioritization assessment that determines which intervention would be most appropriate for a household and how high priority they are to be placed. Households with more urgent and immediate needs will be prioritized for placement over households that have less intensive needs. An example of a housing prioritization tool will be available soon on the Alliance website. A vulnerability index or other prioritization tool may be used in addition to the first housing and prioritization assessment in order to further clarify urgency of need for services among households experiencing chronic homelessness. Alternatively, a trained clinician will administer these assessments.
  • Case managers/clinicians will review the assessment and look at where the household fits best according to the results.
  • Case managers/clinicians will relay the results of the assessment to assessment center staff. Assessment center staff will use the results to determine the household’s place on the waiting list for that intervention (higher priority households will be placed above lower priority ones) in HMIS. If the household is at the top of the priority list, the assessment staff member will check the availability of programs within that intervention that fit the household’s composition (e.g., unaccompanied individual, family or unaccompanied youth).
  • Households will be referred to the program that best fits its needs immediately if a space is available. The assessment center staff will contact the household’s program destination to let them know to expect its arrival. Referrals should be made with the understanding that additional information about the household may come to light that requires asking more questions or conducting additional assessments, and may potentially result in a different intervention than the household was originally assigned.
  • Through HMIS, assessment center staff will share any data collected on the household with its program destination. They will also use HMIS to reserve a bed or beds for the household immediately so that other assessment center staff does not continue to refer people based on an inaccurate number of available beds. An example of a bed reservation system is Cincinnati, OH’s, which uses a system with color-coded beds that are red (occupied), yellow (reserved, but not yet occupied), and green (available).
  • If a household’s best referral is to a program with a long wait list (e.g., a month or more), it may be best to refer them to their next best option (the second-highest intervention match on their results) if it will be available sooner rather than have them wait longer in shelter. Assessment staff should use the assessment results and the community’s agreed upon prioritization standards to determine the household’s place on the waiting list for that intervention (higher priority households will be placed above lower priority ones). Consumer input should always be one of the most important factors when it comes to making a referral decision between different interventions; they should have the opportunity to decide how long they are willing to wait. Communities should use their HMIS to keep track of the wait list. Communities will need to assign specific assessment team or shelter case management staff with the responsibility of notifying households when a spot in a program that fits their needs becomes available.

How will assessment staff know bed availability or wait list size when making a referral?

If programs use HMIS to track their own bed availability, a good data sharing setup can make that information easily available to the assessment center(s). Wait list information can also be shared in HMIS. If HMIS is not currently set up to handle these functions, while waiting for these functions to be built in, programs should be calling in consistently each day to let the assessment center(s) know how many beds they have available or use some other form that will allow them to update this information instantly, such as a document or spreadsheet shared via the Internet.

What happens if a household feels that it can figure things out on its own without a program placement or wants more time to figure out a different housing situation?

If a household feels as though there may be another housing option available to them within a short time or that it will be able to work things out without further assistance from the homeless assistance system, the household should be encouraged to explore those options. Some communities wait several days or a week before administering a housing assessment in emergency shelter to allow consumers time to make these connections and exit on their own. However, communities may want to give consumers more time to exit on their own in some cases, especially if the household self-identifies as feeling confident in being able to exit homelessness without further assistance.

How will referrals be handled in terms of data? What data needs to be shared between the assessment center(s) and the organization to which households are referred?

HUD will soon issue further guidance on what and when data should be entered into HMIS and how it should be shared. Assessment centers should be prepared to use HMIS to share consumer data they have collected with each household’s program destination in order to prevent consumers from having to answer the same questions twice. Assessment centers should have a data release form for clients that informs them of how their data will be used and gives them the option to opt out of sharing certain information and memoranda of understanding (MOUs) with all of the agencies entering data into HMIS that lay out data-related expectations.

How much time will a household have to follow through on the referral before it “expires” and the bed or service is no longer available for them?

Systems will have to make a decision on this based partially on how large the community is; the amount of time, on average, it would take a household to get to a program based on traffic and transportation infrastructure (e.g., availability of public transit); and how long the community feels comfortable restricting access to a bed. Assessment staff should make it clear to each household how much time it has to get to its program destination before its slot will be forfeited, and help problem solve around any transportation barriers a household may have. Escorting consumers to their program destinations may be necessary in the case of large communities or if the household has certain health or transportation issues that may make it difficult for it to make it to the program on its own.

What will be the follow-up process if a household does not show up to their program destination? Will either the assessment center(s) or the program destination make contact a second time?

It is likely easier for staff at the program destination to follow up with clients that do not show up, since they will be the ones to notice people arriving (or not arriving). Once the referral has been made from the assessment center(s), the program destination should have contact information for the household. Follow-up can be done through a brief phone call to consumers to confirm they are on their way or still intending to come. Communities should also have a protocol for which party (the assessment center(s) or the program destination) closes out the client’s case in HMIS if they do not show up, or for extending the reservation for the client in extreme cases if they need more time to get to the agency. In any case, the fact that a consumer does not show up on time should not automatically be taken as an indication that the consumer does not need or would not benefit from the program’s services.

What happens if a program turns away a household who was referred to them? How will this issue be solved so that the clients still receive the services they need?

Expectations of programs and of clients should be made clear from the beginning of the coordinated assessment process. Many coordinated assessment systems have a rule that programs cannot refuse any clients sent to them from the assessment center(s). Programs participating in the assessment process must accept that this may mean relinquishing some control over how their clients are selected. Conversations between different programs, the coordinated assessment staff, and the organizing body of the coordinated assessment process may help alleviate some of the tension that can accompany the switch to a more centrally-driven referral process. These conversations should focus on who each program serves best, the new expected outcomes for homeless programs, and how each program fits into the larger homeless assistance system. For systems that do want to build in some sort of refusal process for providers, Dayton/Montgomery County, OH is a good model. A certain number of refusals on the part of a program trigger a case conference where program staff, assessment center staff, and the consumer meet to determine where else the household could be served. This model keeps the system accountable for finding a place for each household.

What happens if a household refuse the referrals they are given?

The assessment process should allow the household to provide input on what kinds of resources they need to prevent this as much as possible. Systems may also wish to set a maximum number of referrals that a client can decline to safeguard against this issue.

Who is in charge of referring households to resources outside of the homeless assistance system?

It is relatively easy to connect consumers with other resources if the assessment process has a phone or 2-1-1 component that allows staff to transfer clients to contacts at mainstream organizations (agencies that provide benefits or services to the general population). For systems without this feature or for households that must enter the homeless assistance system, each individual organization should ensure their case managers or service coordinators are working to link consumers with mainstream resources as needed.

How will it be handled if, after a referral is made, the person comes back to the system for assistance?

Communities will need to decide whether households should return to the last program that served them, or be reassessed at the assessment center(s). There may be circumstances in which one option is more appropriate than another (for example, if the clients are coming back to the system fewer than 14 days after exiting, they may return immediately to their previous program; if coming back more than 14 days after exiting, they must go back to the assessment center(s) to be reassessed). All rules around these situations, as well as accompanying data entry procedures, should be clearly spelled out in the policies and procedures documents developed for the coordinated assessment process.

How will the referral process be re-evaluated?

Like every other element of a coordinated assessment process, the referral process should be evaluated constantly. Metrics related to the HEARTH Act outcomes (especially length of stay and returns to homelessness) can be run from HMIS and be used to provide immediate feedback to CoC and coordinated assessment staff to inform adjustments to referral protocols, communication strategies, and written standards. If referrals to certain organizations are regularly leading to returns to homelessness, these should be examined closely.

Communities should also use consumer feedback to analyze whether or not the referral and coordinated assessment processes met the consumer’s housing needs. This feedback could be gathered through focus groups or by administering consumer surveys on at least a quarterly basis.