When several branches of a large social services organization are involved in providing a continuum—or sequence—of services, it can be challenging to optimize clients’ care. Communication between branches may be minimal, and individual services may have distinct eligibility criteria. People who are served initially may not be guaranteed access to future services, which can further complicate care coordination. This blog post describes how Central City Concern (CCC), a site in MDRC’s Building Evidence on Employment Strategies (BEES) study, confronts those challenges.

Located in Portland, Oregon, CCC primarily serves individuals who are diagnosed with substance use disorders, many of whom also experience housing instability or homelessness. At CCC-operated facilities, the organization offers many programs that are focused on health care, employment services, and transitional and permanent housing.

One of CCC’s facilities is the Hooper Detoxification Stabilization Center (Hooper). At Hooper, clients undergo substance use disorder treatment for about one week, on average; the length of time varies depending on the client’s unique treatment needs and the detoxification process. During treatment, Hooper staff members work with clients to determine appropriate aftercare options based on their housing, recovery, and other service needs and preferences. CCC supportive housing programs, which provide clients with temporary housing in addition to employment and recovery services, are one common aftercare option.

To address challenges they encountered when providing a sequence of services, CCC leaders sought to implement a formal process for referring clients from Hooper to two of their temporary supportive housing programs (the 8x8 and Blackburn). Over several months, the BEES research team and CCC staff members from both Hooper and the supportive housing programs met to develop this process. This post describes four lessons from their experience designing and implementing the referral process that other large organizations may find useful when developing or refining ways to create a smooth continuum of care.

1. Document eligibility criteria and implement a common eligibility screening tool.

Hooper and supportive housing staff members agreed on eligibility criteria for the 8x8 and Blackburn programs and developed a screening tool that includes these eligibility criteria. Hooper staff members use the screening tool to assess whether supportive housing might be an appropriate aftercare option for clients. The tool offers the following advantages:

• It limits staff discretion when determining eligibility, which could play a role in inequitable access to supportive housing. Without clear guidance, staff members could make referrals based on personal feelings about a client or prioritize different criteria over others.
• It takes into account client needs. For example, some supportive housing programs have limits on when a client can return to work, which may not be the right placement for someone looking to work immediately following discharge.
• It helps facilitate future care. Housing staff members also use the information from the eligibility screening to begin planning each client’s care. It is also useful in rapport-building once they meet the client. If a client returns to Hooper for further treatment, Hooper staff members can refer to documentation from prior eligibility screenings and determine whether they need to reevaluate the client against any eligibility criteria.
• It makes the process easier for clients. It can be burdensome and traumatic for clients to recount information they have already provided, especially sensitive information that is related to mental health and criminal legal system involvement.
• It gets staff members on the same page about a client’s eligibility so they can share consistent information about aftercare options.

Clients who have a history of arson or sex offense convictions are not eligible for supportive housing. But other criteria are flexible. For example, clients with high mental health needs are generally not a good fit for supportive housing, but if their only alternative is a shelter, staff members may still refer them. Practitioners at other organizations might consider which criteria can be flexible, especially when serving clients who do not have access to other services or support.

2. Confirm client interest and overall fit.

Eligibility screening is just one step toward assessing whether a client is a good candidate for the supportive housing program. After screening, supportive housing staff members then visit Hooper to meet prospective clients at a meet and greet. Sometimes the meet and greet occurs by phone, due to travel and scheduling limitations. The meet and greet fosters collaboration between the Hooper and supportive housing staffs and allows housing staff members to build relationships with prospective clients.

Because eligibility has already been established via the screening tool, the meet and greet allows housing staff members to focus on details about the program’s structure and components with prospective clients and set expectations about the types of support the program can provide. The meeting is also an opportunity for clients to share more about their needs. Overall, this conversation gives both clients and staff members an opportunity—before the clients are transitioned to housing—to feel confident about the clients’ aftercare placement. On occasion, a client or staff member may decide not to move forward with the placement following the meet and greet.

In addition, in-person meet and greet sessions can be vital to maintaining relationships between units within a single organization (in this case, Hooper, Blackburn, and the 8x8). At CCC, these regular, in-person interactions help to build trust between Hooper and housing staff members, improve communication, and reveal areas for process improvement.

3. Develop and adhere to a referral schedule.

It is difficult for staff members to accurately predict when a room in supportive housing will be available for a new client because there are many steps involved in preparing a room (such as making repairs, cleaning, painting, and pest spraying) and different teams responsible for each step. Room availability is often limited and can vary week to week. At the same time, Hooper staff members require time to assess client eligibility and readiness to leave Hooper (and clients’ interest in doing so). To address these challenges, staff members jointly develop a schedule for sharing information about program availability and transferring clients from Hooper to the housing facilities.

According to the schedule, on Mondays, Wednesdays, and Thursdays, housing staff members inform the Hooper staff about any currently available rooms. This gives Hooper staff members two to three days to assess which patients are interested and will be ready for discharge by the established move-in day and to host the meet and greet. The table below illustrates how these steps typically play out when the 8x8 staff shares room availability on a Monday.

A predictable schedule can benefit both clients and staff members:

• Staff members can anticipate whether room availability coincides with a client’s expected discharge date and then set expectations about whether supportive housing is a realistic option for a client.
• Predictability can provide comfort to clients during a particularly uncertain time.
• Designated move-in days allow staff members to manage their time efficiently and give them adequate time to plan, perform eligibility assessments, and conduct meet and greets.
• Documented processes help ensure that new staff members do not reinvent the wheel and that future clients will receive the same quality of care.

4. Designate which staff members are responsible for eligibility screening and sharing information with the other organizational units.

CCC designated two Hooper staff members to conduct the initial eligibility screenings, schedule the meet and greets, and finalize the referrals. Similarly, specific staff members at each housing facility are responsible for monitoring program availability, coordinating referrals with the Hooper staff, and attending meet and greets.

Other organizations might consider which existing staff members would be best suited to take on these responsibilities, or whether a new role needs to be created. The responsibilities can be extensive, depending on the overall volume of clients and program slots. Also, since eligibility screening requires clients to disclose sensitive information, organizations should consider which staff members have the right experience to collect this information. At CCC, Hooper staff members play this role, since they have already developed a rapport with clients by the time discharge arrangements are being made.

In summary, coordinating program interest, eligibility, and availability across multiple organizational units can be challenging, especially when serving people who are undergoing treatment for substance use disorders. Hooper and the 8x8 and Blackburn supportive housing programs made important strides forward in addressing referral challenges with mindful coordination and consistent communication, which led to smoother operations. Other social service organizations can draw from these experiences to improve their own continuums of care.

Read more about the BEES studies of programs that serve adults with substance use disorder on the BEES project page.