2018-012 RFSQ – Exhibit B ICMS Provider SOQ

Flexible Supportive Rehousing Program (FSRP)

Intensive Case Management Services (ICMS) Provider Statement of Qualifications

Agency Name:

Statement of Required Qualifications
NOTE: Your agency must have at least three (3) years of experience in the last ten (10) years providing the following services to a chronically or long-term homeless population. /
  1. Check “X” in the appropriate box to indicate “Yes” if your agency is qualified or “No” if your agency is not qualified to administer this service.
  2. If you respond “Yes”, please briefly describe your agency’s experience providing this service to a chronically or long-term homeless population.
  3. If you respond “No”, your agency will not be considered for a Master Agreement for the FSRP.

Yes / No / Yes-briefly describe your agency’s experience providing this service to a chronically or long-term homeless populationwith complex behavioral health and other needs.
  1. My agency can conduct field outreach and engagement to the target population in community based locations, health and behavioral health facilities, interim and bridge-housing settings, criminal justice and custody facilities, and other locations as needed to engage clients.
/ ☐ / ☐ /
  1. My agency can assist clients with rental applications including paperwork required by property owners.
/ ☐ / ☐ /
  1. My agency can assist with mental health and life skills services or referrals for these services.
/ ☐ / ☐ /
  1. My agency can establish a case management plan including but not limited to establishing future goals, improvement of behaviors associated with past criminal histories, drug use, reduction in frequency and quantity of drug and alcohol use, coping with mental health disorders, coping with chronic medical problems, improvement of interpersonal relationships.
/ ☐ / ☐ /
  1. My agency can help clients with accessing public benefits, educational, vocational and employment service opportunities, as appropriate and requested by the client.
/ ☐ / ☐ /
  1. My agency can provide assistance with budgeting and money management.
/ ☐ / ☐ /
  1. My agency can provide assistance with substance use disorder services or referrals for these services with a focus on harm reduction.
/ ☐ / ☐ /
  1. My agency can coordinate referrals to primary medical care, mental health services, and other community services, as needed and requested by the client.
/ ☐ / ☐ /
  1. My agency can provide assistance in obtaining clothing and food.
/ ☐ / ☐ /
  1. My agency can provide assistance with domestic violence and safety planning services or referrals for these services.
/ ☐ / ☐ /
  1. My agency can provide or arrange for transportation assistance.
/ ☐ / ☐ /
  1. My agency can assist clients with maintaining medication regimen.
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  1. My agency can provide/coordinate assistance with temporary housing until client moves into permanent housing.
/ ☐ / ☐ /
  1. My agency can provide assistance with monitoring any legal issues and making appropriate referrals while addressing any barriers to accessing and maintaining housing and services (e.g., credit history, criminal records, pending warrants, etc.).
/ ☐ / ☐ /
Statement of Required Qualifications
NOTE: If all other required qualifications are met, your agency must be willing to commit to the following services. / Yes / No / If your agency has qualifying experience, please provide a brief explanation.
  1. My agency can commit one full-time case manager (who is experienced working with persons experiencing chronic or long-term homelessness, with mental illness, health issues and substance use disorders) per 20-25 clients.
/ ☐ / ☐ /
  1. FSRP case managers will have some degree of access to a licensed social worker or clinical staff within my agency for consultation.
/ ☐ / ☐ /
  1. My agency will collaborate with the provider(s) of Property Related Services and property owner to ensure individuals provide authorization to receive the support they need to remain housed and stable, including attending and/or convening periodic meetings with partners to problem-solve around behavioral, building, and community issues.
/ ☐ / ☐ /
  1. My agency is committed to the provision of on-going training to ICMS staff to ensure services are appropriate and to promote continuous quality improvement.
/ ☐ / ☐ /
  1. My agency is committed to the maintenance of program and client records and participation in the Sacramento County Homeless Information Network Ecosystem (SHINE) database and participation in Homeless Management Information System (HMIS).
/ ☐ / ☐ /
  1. My agency is committed to the submission of reports and invoices as requested and in a timely manner and provide all required supporting documentation.
/ ☐ / ☐ /
  1. My agency is committed to complying and delivering services in accordance with Master Agreement and Work Order deliverables and objectives.
/ ☐ / ☐ /

I affirm that I am an authorized signatory of my agency, (insert agency name here), and that I have read and accept the terms of the scope of work for the Flexible Supportive Rehousing Program (FSRP). I understand that should I meet the required qualifications, my agency will be issued a Master Agreement, however, I am not guaranteed any minimum amount of work and will not receive funding until the County has issued a Work Order to my agency. I understand the issuance of a Work Order is at the County’s discretion. If my agency is issued a Work Order, I certify my agency’s ability to perform the necessary intensive case management services, as described in this request, at the rate of $450 per client/per month for as long as the client is enrolled in the FSRP.

Agency Name:

Printed Name of Authorized Signatory:

Title of Authorized Signatory:

Date Submitted: