City of Lethbridge

City of Lethbridge

City of Lethbridge

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A. Core Concepts:

The Community Based Organization (CBO) will provide information and training on the basic concepts of Housing First to all funded agencies and their staff. All funded Housing First agencies must ensure that all staff members are oriented to Housing First philosophy for the Lethbridge Housing First Enterprise. All funded programs must also, by official Board motion and day to day operation adopt the Housing First philosophy and key concepts identified by the CBO and remain in compliance with them.

Everyone is considered “housing ready”

Housing is a basic human right and services to support a Housing First participant in obtaining housing are not denied or withheld based on

  • History of housing
  • Rental history
  • Criminal history
  • Credit or financial history
  • Behavioral history
  • Behaviors and/or even assessments that could indicate a lack of “housing readiness”
  • A lack of income
  • A lack of involvement, follow through, or interest in treatment of any kind or abstinence

Housing and supports are provided to participants based on participant choice not coercion

Housing and supports are not refused or withheld based on Housing First is

Housing First is strength-based and participant-centred and works from a recovery orientation

It is the goal to move participants into greater levels of independence

Participants are prioritized by complexity and acceptance eligibility for Housing First or agency case loads is not first come first served.

Participants are prioritized and referred based on a common assessment. In this case the primary tool used will be the VI_SPDAT, and Individual and Family SPDAT full version 3.0.

Harm reductions is embraced and used as a foundational principle.

  1. All Housing First workers must have access to and read the Alberta 10 Year Plan and the Lethbridge 5 Year Plan to ending homelessness.
  2. All Housing First workers must read prescribed articles regarding Housing First. (Recommendations will be given by Housing First Specialist and may vary depending upon the most recent information available).
  3. All Housing First workers will participate in a Housing First 101 session provided by the CBO
  4. The CBO and Housing First Agencies will adhere to and promote key Housing First concepts.

A.1. Intake, Prioritization, & Referral

  1. All clients must first go through Centralized Intake to determine:
  2. Housing First eligibility. This is defined by a client being:
  3. Chronically Homeless
  4. Homeless for one year or more OR4 episodes of homelessness in the last 3 years.
  5. Multi-barriered
  6. Physical health issues and/or
  7. Mental health issues and/or
  8. Addictions
  9. SPDAT scores congruent with Housing First funded agency mandates
  10. Participant would benefit from Intensive Case Management
  11. Participant wants the Housing First service and supports
  12. Has been in Lethbridge for 3 months or longer
  13. Special Criteria
  14. Transitioning from the Reserve to urban life
  15. Being discharged from Psychiatry or acute care in hospital into homelessness
  16. Being released from corrections into homelessness
  17. Most appropriate Housing First agency for referral. The centralized intake agency will triage Housing First Participants based on:
  18. A common assessment tool (SPDAT)
  19. Specific mandates of the each funded housing agency.
  20. Availability of space on funded agency case load.
  21. Prioritization of Participant service. Participants are prioritized for service at both the intake level and the agency level. Prioritization is based on:
  22. Most complex, highest needs and acuity served first. As a general rule, these Participants should always take priority.
  23. Agency case load availability
  24. Case load profile of individual workers at the agency level. A balance should be created to prevent worker burnout by having too many complex clients.
  25. The centralized intake agency will complete a Universal Intakewith all Housing First eligible Participants to eliminate the need to repeatedly tell his or her story which could cause additional traumatic repercussions. This intake will also prevent the funded agency receiving the referral from having to go through another intake process as the Universal Intake will incorporate all necessary elements of each agencies original intake package.
  26. Once a Participant is deemed appropriate for Housing First and the agency best suited to provide case management has been identified, Central Intake will deliver the referral package to that agency. If Central intake has deemed the Participant a fit for the criteria of that agency it is the expectation that the agency accepts the referral unless there is question about the criteria fit. That agency will then have 48 hours to:
  27. Provide Central Intake with a response to indicate acceptance of the referral
  28. To ask additional questions about the Participant meeting their criteria.
  29. To indicate that they will not be accepting the referral.
  30. If the agency chooses to accept the referral, a “Warm Transfer will be arranged.
  31. The ETO referral must be made just prior to or within 15 minutes of the warm transfer occurring.
  32. The acceptance of the participant into the new site and program must occur prior to the warm transfer meeting.
  33. If the agency does not accept the referral, they must indicate the reasons on the “Referral Denial” form which should be signed by both the central intake agency and the agency not accepting the referral and a copy must be provided to the CBO.

A.2. Integration into Community

  1. All work done both in the process of housing a client and the providing the follow-up after they are housed, must involve the incorporation of the client into as many community supports and connections possible. Each agency must adhere to the belief that the more the client is connected the more successful the client will be. Therefore ensuring this connection and not creating a dependence on the Housing First worker is best practice.
  2. Prior to housing, each “Outreach” workers primary role will be to assist the client in creating community connections related to solidifying income for the client. These connections would include Alberta Works, AISH, and other employment programs. This means that these workers must create an understanding of how these programs work and relationships with their staff.
  3. Once housed, the “follow-up” workers will assist clients in creating community connections with the wrap around supports and services related to their ability to maintain housing. These could include addiction and mental health support, medical support or doctors, and programs associated with the interests of the client.

A3. Landlord Relations

  1. Housing First workers will establish positive relationships with current landlords of housed clients and facilitate the establishment of a positive relationship between the client and the landlord
  2. Contact information
  3. Grievance/complaint processes
  4. Expectations
  5. Property /neighbor rules
  6. Housing First workers will establish a regular system and schedule of communication with each landlord of a currently housed client that includes minimally once per month direct contact with each landlord associated with their case load.
  7. Housing First workers will provide current landlords with education and information about Housing First and what to expect from their follow-up support in writing, preferably prior to the participant moving in but at least within one week of move in.
  8. Housing First agencies will on an ongoing basis make connections with potential landlords and provide education and information about Housing First and what can be expected from Housing First agencies.

A.4. Housing & Placement

  1. All Housing First funded agencies will work toward the goal of housing all new participants within 30 days of receiving the referral from the Centralized Intake agency.
  2. Housing First agencies will adhere to housing participants primarily under the scattered site market housing model, however some project based models may be acceptable.
  3. Housing First agencies will ensure that all Participants will be supported in having choice regarding their housing. This will be adhered to as much as it is feasibly possible in terms of type of housing, location of housing, and cost of housing.
  4. Housing First agencies should attempt to not go beyond the saturation point of having 15% Housing First clients in any one building unless that building is the site of a specific project based housing model such as Permanent Supportive/Supported Housing.
  5. Housing First agencies will make every effort to ensure they are housing their clients scattered within the community as a whole so as to avoid saturation in any one part of the community individuals with complex issues.

A.5. Interim & Transitional Housing

  1. Both interim and transitional types of housing are only acceptable when:
  2. They are part of a specific mandate of a program designed to provide a beneficial stabilization period which will enable a client to acquire what is necessary to secure permanent housing.
  3. The client has the choice to accept or deny the interim or transitional option
  4. The client chooses to utilize one of these options.

A.6. Re-housing

  1. Once a client is housed, if that housing is lost for any reason, the Housing First agency has the responsibility to:
  2. Work with that client to get him or her re-housed as soon as possible with the goal being not to have that participant be without housing for longer than 7 days.
  3. Re-housing of participants will occur as many times as necessary. Ceasing efforts to re-house a participant in some form of market housing will only occur with the approval of the CBO.

B. Training

Each funded agency will ensure all staff members attend and complete training in the standard core competencies for Housing First identified by the CBO. The CBO will ensure that these trainings are made available to the Housing First teams and cover the cost of the training from the CBO budget.

B.1. Within 3 Months of Being Hired

FOIP Training (within 1 week)

ETO 101

SPDAT 101

Intensive Case Management

Case Notes/Documentation

B.2. Within 6 Months of Being Hired

Motivational Interviewing Basics (SCOLR)

Landlord/Tenancy Relations Basics (SCOLR)

Harm Reduction

Critical Intervention (CIT)

B.2. Within 1 Year of Being Hired

Motivational Interviewing

Assertive Engagement

Mental Health 101 (SCOLR)

Assertive Engagement

Trauma Informed Care

Stages of Change Process

Cultural Competency

LGBTQ2

All standard trainings provided by the CBO are available for subsequent attendances at the discretion of the agency team lead.

C. Monitoring

The CBO will put in place rigorous monitoring practices with the funded agencies to ensure compliance to Housing First philosophy, expected Housing First outcomes, recidivism, and client satisfaction. This will be accomplished through multiple methods.

C.1. Housing Retention

  1. The CBO will achieve a housing retention rate of 85% or better in each fiscal year.
  2. Each agency is expected to achieve a housing retention rate of 85% or better each fiscal year.

C.2. Monthly Reporting

  1. The CBO will provide a template to all funded agencies that will allow them to report requested information necessary for determining effectiveness of the program, and adherence to expected outcomes. This report is expected to be completed by each agency and provided to the CBO by the 10th of the month following the reporting month. The CBO will have that data verified and sent to Human Services by the 15th of the same month.

C.3. ETO

  1. The CBO will use Efforts to Outcomes (ETO) as their method of data collection and electronic monitoring. Reports from ETO provide information relating to effectiveness of the work being done by each agency, housing retention, progress of each client, satisfaction of clients, and number of graduates.
  2. The CBO will follow the guidelines for ETO as outlined by Human Services and in conjunction with any changes or adjustments that come about through the established data committee.
  3. Three month follow-up assessment reports (completed every three months with each housed client.
  4. SPDAT assessments (completed every three months with each housed client)
  5. Exit interviews (completed when a client is exiting the HIMD program
  6. Graduation
  7. Un-housed for 3 months
  8. No contact for 3 months
  9. Relocated away from the community
  10. Chooses to not participate in the program
  11. ETO Service Plans for both Outreach and Follow-up Workers(completed for each client to track points of service, effectiveness of ICM, and show progress being made by the client
  12. Dismissal report (completed when a client is no longer active with Housing First agency)
  13. All funded programs and agencies utilizing ETO, for client data entry and hard copy client case files for Housing First Service Participants, must have the front line outreach or follow-up worker responsible for the interaction with a particular client, be responsible for the entry of the data. Surrogates for data entry must not be used if at all possible.

C.4. Client Retention

  1. All Housing First clients will remain on active case loads for one year or longer until:
  2. Reaching the point of “Graduation”
  3. Active for a year or more
  4. They have maintained permanent housing for 6 consecutive months or longer
  5. SPDAT scores have consistently been reduced
  6. The client and follow-up worker agree together that services are no longer need
  7. The client is dismissed due to being un-housed for three consecutive months or longer.
  8. The follow-up worker is unable to make contact with the client for three consecutive months or longer.
  9. The client relocates to another community.
  10. The client chooses to longer be a part of the Housing First Program.

C.5. Case Loads

  1. Housing First agencies will maintain appropriate case loads as directed by the CBO and monitored by the Housing First Specialist. All case load ratios shall remain intact and consistent across the Housing First Enterprise unless:
  2. A follow-up or outreach worker is new in which case they will have 3 months to build into a full case load.
  3. For other extenuating circumstances an adjustment in the case load ratio is requested and permission is granted by the CBO (Housing First Specialist)
  4. If a participant has a current SPDAT score of 45-50, it shall count as 1.5 participants in terms of case load numbers unless otherwise determined and approved by the CBO (Housing First Specialist)
  5. If a participant has a current SPDAT score of 50-60 that participant shall count as 2 participants in terms of case load numbers unless otherwise determined and approved by the CBO (Housing First Specialist).
  6. The Housing First Specialist will review case loads monthly at a minimum.
  7. Case loads should be equal to but not exceed 15 participants to one follow-up worker unless otherwise determined and approved by the CBO (Housing First Specialist).
  8. Team Leads shall monitor and manage case loads based on these criteria and a balance of complexity, worker/participant fit, and worker strengths.
  9. Case loads of all outreach workers should be equal to but not exceed 20 participants to one

worker unless otherwise determined and approved by the CBO (Housing First Specialist)

  1. Team Leads shall monitor and manage case loads based on these criteria and a balance of complexity, worker/participant fit, and worker strengths.
  1. Each worker should carry a case load that is specific to either Follow-up or Outreach responsibilities unless:
  2. The size of the team requires a shared responsibility in both outreach and follow-upand the adjustment to have a joint Outreach/Follow-up case load has been approved by the Housing First Specialist
  3. The mandate of the worker is to work with youth up to 24 years of age and the adjustment to have a joint Outreach/Follow-up case load has been approved by the Housing First Specialist
  1. If an agency or worker is balancing a shared follow-up/outreach case load then that ratio should be kept at 15:1 with the before mentioned formula considered.

C.6. Case Files

  1. Case files should be kept for every outreach and follow-up participant on the case load of a Housing First funded agency.
  2. Case files should be kept current both in ETO and in hard copy.
  3. The Housing First Specialist will review case files of each agency monthly at a minimum to ensure proper documentation and components exist. (see Case File Checklist)
  4. A minimum of 1 file per month will be reviewed by the Housing First Specialist.
  5. Team leads of each agency will review case files on a weekly basis at a minimum of one file per worker per month.
  6. All Participant files, when not in use by a worker for the purpose of adding content, must be stored in the following manner:
  • In an organized and systematic manner that is easy to follow and locate specific files
  • In a consistent type of file folder or binder
  • In a locked filing cabinet in a locked office in a locked building.
  1. Files should not be transported out of the office location of the agency that holds the file. In rare circumstances if this must occur, files should be placed in a locked brief case or bag.

Based on Government of Alberta regulations and guidelines, “the Service Providers DO NOT have legal authority to keep any information from the client’s files, nor can they take photocopies of the files for their own archiving. They may only keep copies of the Consent to Client File Transfer forms, and they may receive a copy of anonymous, aggregated data sets from the CBO upon request.

  1. In the event that the contract of a particular funded program is moved to a new agency all complete active files must be moved with the contract and a Consent to Client File Transfer form (See Appendix___) should be completed.
  2. There may be circumstances when the case management of a Participant needs to shift from one funded agency to another. This could be due to changing circumstances for the Participant, a change in mandate of an agency, or due to a referral to a supportive or supported housing program with case management supports build in. In these cases, the same procedure as above for that active file must be followed. The complete hard copy file must be transferred to the new agency and the Consent to Client File Transfer form must be completed.
  3. Inactive files are not to be kept indefinitely. According to best practice and Government regulations, all inactive files should be destroyed after 7 years but not without consent to do so from the Minister of Human Services. Therefore if an agency is in possession of an inactive file that is 7 years old, it must be brought to the attention of the CBO who then must contact the Minister for permission to dispose of the records.

C.7. Case Consultation

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