With the release of new guidelines on coordinated entry systems by the U.S. Department of Housing and Urban Development (HUD) in January 2017, communities around the country are working hard to increase the efficiency of their local crisis response systems, ensuring fair and easy access to resources for individuals experiencing homelessness.

A critical aspect of coordinated entry systems is assessing an individual or family’s eligibility for a variety of income supports, such as disability benefits or employment. Incorporating assessments for Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) eligibility into coordinated entry systems and connecting eligible individuals to providers utilizing the SSI/SSDI Outreach, Access, and Recovery (SOAR) model ensures timely access to life-saving financial benefits and health insurance.

We are excited to highlight the accomplishments of two HUD Continua of Care (CoCs) that exemplify holistic, person-centered care through SOAR integration into their coordinated entry system:

The Way Home, Houston, Pasadena/Harris, Fort Bend Counties Continuum of Care, Texas

Gary Grier, Project Manager, Coalition for the Homeless, Houston, Texas

“Income Now,” oh how I like the sound of that phase.  To a person or family experiencing homelessness, income is a life-line to housing and health.  At The Way Home Continuum of Care (serving Houston, Harris, and Fort Bend Counties), we launched the Income Now Initiative in 2016 to coordinate access to not only housing, but income as well.

The single assessment (housing and income) generates a direct connection with one of our three income interventions:  SOAR/disability income, supported employment, or public workforce for mainstream competitive employment.  Through the assistance of the SAMHSA SOAR Technical Assistance Center team, we participated in the SOAR Leadership Academy, and in May 2016 we hosted a SOAR Forum for 50 community stakeholders.  Research from the Homeless Management Information System (HMIS) told us that our community would experience a need for 350 SOAR applications per year—mostly related to permanent supportive housing.  So we launched a capacity building effort to go from 1 SOAR staff taking outside referrals to between 7 t 10 dedicated SOAR caseworkers.  We now have two in place and four on the way.

In October, The Way Home launched the SOAR workflow in HMIS.  The client is immediately referred for a SOAR income plan when matched with the criteria. As such, they can pursue income even while on the street or in shelter as housing is being identified. We track all cases and outcomes through HMIS and the SOAR Online Application Tracking (OAT) system.  This informs the entire system and enhances care coordination for housing and income case managers, thus, contributing to the overall success and well-being of our clients.  The effort has helped us establish great relationships with crucial partners, including the Social Security Administration (SSA), Disability Determination Services (DDS), health care providers, legal assistance, the mental health authority, the U.S. Department of Veterans Affairs (VA), and Ticket to Work among many others.  We are eternally grateful to the SAMHSA SOAR TA Center for the expertise in launching this ambitious initiative and for the continued support to help it grow.

The Community Partnership for the Prevention of Homelessness, District of Columbia Continuum of Care, Washington, D.C.

Kate Baasch, Senior Case Manager & Art Therapist, and Emily Buzzell, CABHI Director, Miriam’s Kitchen, Washington, D.C.

The relationship between SOAR and the Coordinated Entry System (also known as Coordinated Assessment and Housing Placement or CAHP) within the District of Columbia (D.C.) is through a referral process. The D.C. Cooperative Agreements to Benefit Homeless Individuals (CABHI) Outreach Teams receive referrals from CAHP and utilize the SOAR model with eligible individuals. In the beginning of CABHI in D.C. ,the CABHI providers discussed how to use limited outreach resources and determined that the most strategic approach would be to target those identified as high-priority for housing, as identified by CAHP’s Vulnerability Index-Service Prioritization Decision Assistance Tool (VI-SPDAT) and SPDAT assessment tools. CABHI fills a gap in outreach resources: outreach workers provide support with everything that needs to happen between assessment and lease-up (e.g., locating people in the community, building relationships, collecting identification documents, going to medical and mental health appointments, acting as liaisons with housing providers, and providing recovery-centered activities, such as SOAR).

At Miriam’s Kitchen the CABHI Outreach Team plays an essential role in providing wrap around recovery resources to unhoused individuals. Without CABHI many of the individuals served by Miriam’s Kitchen’s drop-in center would still be experiencing homelessness, sleeping rough in the neighboring community. Additionally, the CABHI team at Miriam’s has identified many individuals living out of sight, unknown to local service providers, because these individuals do not seek site-based services.

One of the individuals served by CAHP and both the SOAR Specialist and Outreach Specialist on the Miriam’s Kitchen CABHI team is named Tracy (name changed). Here’s her story, as told by the CABHI SOAR Specialist:

Tracy is one of the guests we were most worried about as the weather turned colder: she lives with paranoid schizophrenia, often experiences suicidal ideation, and has been involuntarily hospitalized multiple times due to mental health crisis. When she was 14, Tracy began to hear voices that told her things like “you are worthless” and “kill yourself.” As the voices got worse, Tracy—who had been a star student and basketball player—began isolating herself, eventually dropping out of school. Her family, unable to cope with her illness, kicked her out; Tracy became homeless. Tracy tried to work, but the voices always got in the way: she was unable to hold a job for more than a few months. For the past few years, Tracy has been wandering the streets of D.C., often being placed in hospital psychiatric wards when her mental illness pushes her to suicidal ideation. This past summer, Tracy started working with Judy, one of the CABHI team’s Outreach Specialists, who made sure Tracy always had clean clothes, a phone, and a safe place to go when she left the hospital ,such as the crisis shelter. Little by little, Tracy began to make positive changes in her life. She started an SSI application with SOAR Specialist, Adriana. Through the CAHP System, she was matched to a housing opportunity that is a Permanent Supportive Housing (PSH) program specifically for women. Judy helped her fill out the application for the program and follow up regularly to complete the entire housing process. Late last year, those positive changes came to fruition; as Tracy was moving into her new apartment, she found out that she had been approved for SSI. Tracy began crying tears of joyshe revealed to Judy that although she was excited about housing, she was extremely worried that she would be unable to afford food and household items without any sort of income. As a result of the hard work of the Outreach Team, Tracy has a warm place to live and an income.

We thank these communities for their hard work in utilizing the SOAR model and for sharing their successes! Inspired by these communities? Review the SOAR TA Center’s guidance on SOAR integration into coordinated entry.