Regina Shasha, MS, FNP, PMHNP, BC,
ANCHORS
Elizabeth Dunn, BA, Development Manager,
Sarah’s Circle
Objectives

1. Describe four domains of need that impact
health and housing linkages to services
2. Discuss the Tiered Level of Need Model as
a tool to help identify and address the needs
of the whole person
3. Discuss program development process,
factors contributing to inter- and intra-agency
silos, and strategies to improve integration
What we can share

Program development-developed two
programs
Learn about a new tool, and model, to
assess patients-Tiered Level of Need
Model
Hear what we learned from the programHealth Access ANCHORS Data summary
Discuss lessons learned
Our team

 Meredith Garafolo, MA, LCPC
 Sarah Shapleigh, LCSW, CADC, MISA II
 Megan Libreros, BA, Housing Coordinator
 Kassie Weber, MA, LPC
 Annie Pothour, MSW, LCSW
 Emily McKernan, LSW
 Elizabeth McNair, MA, LPC, Housing Coordinator
 Elizabeth Clark, BSW
 Stephanie Williams, MSW
Program development

ANCHORS
Sarah’s Circle Health
Access
Linkage of these programs
ANCHORS©: A Nursing Case management
Housing Outreach Resource and Support

Assessing and Addressing
Individuals' Needs Using a Tiered
System of Assessment,
Implementation, and Care©
ANCHORS©: A Nursing Case management
Housing Outreach Resource and Support

Goals of the program
See the whole person
Link the whole person to help her
successfully find and maintain
housing
Sarah’s Circle

Sarah’s Circle is a refuge for women who
are homeless or in need of a safe space. By
providing housing assistance, case
management, referral services, and life
necessities, we encourage women to
empower themselves by rebuilding both
emotionally and physically; realizing their
unique potential.
Sarah’s Circle

Whom we serve, according to intake:
 100% women and low-income
 70% currently homeless
 50% no income
 52% mental illness
 40% survivors of domestic violence
 29% chronic medical health problems
 12% physical disabilities
 80% racial or ethnic minorities
ANCHORS
Problem identification

Problems and needs to be address
 Is housing enough?
Where are the gaps?
Why are there gaps? (E.g.
lack of resources or access to
resources)
ANCHORS
Problem identification

Whom are we serving?
Characteristics of the people
who are being housed
Demographic data: Age
range, gender, ethnicity, and
family status
ANCHORS
Problem identification

 What health problems and needs are documented
for this population?
Severe mental illness
Domestic violence
Substance abuse
Veterans with physical and mental disabilities
Chronic health problems, eg HIV/AIDS,
Hypertension/CVD/Diabetes/Skin/Respiratory/GI/De
ntal/Vision problems
 Health illiteracy
 High mortality (25 years shorter life expectancy for SMI)





ANCHORS
Problem identification

What are the barriers to
maintaining housing?
Physical health problems
Mental health problems
Poverty
Substance use
ANCHORS
Problem identification

What level of functioning
and independence exists and
is possible for each
individual?
ANCHORS
Goal setting

Program goals
 1. Engage agencies housing homeless individuals
 2. Utilise Tiered Level of Need Model to help these
individuals maintain housing
 3. Assess health and well being through an initial
biopsychosocial assessment
 4. Refer to and link with community resources
 PCP/FQHC home
 Clinical Case manager
 Mental health service if appropriate
ANCHORS
Objective setting

Program objectives
 1. Identify housed and homeless individuals at risk
using the Tiered System
 2. Perform initial biopsychosocial assessment
 3. Assess for benefits eligibility
 4. Link with PCP and FQHC
 5. Link with Clinical Case Manager
 6. Maintain housing > 1 year
ANCHORS
Resources

1. What resources are needed to accomplish
goals and objectives?
Staff
Facility
Equipment and Supplies
2. Identify available funding
Apply for grant funding
ANCHORS
Program Implementation

 Hire staff: Clinical case manager, Advanced Practice Nurse
(APN)
 Purpose statement: Write a description of the program to give
to clients
 Who is eligible?
 Communicate what services will be provided
 Engagement
 Teaching
 Mental health, physical health, substance use, violence
screening
 Counseling
 Smoking cessation
 Referrals/Linkage with community resources
ANCHORS
Program Implementation

Documentation: Develop template
notes
Initial screening notes for case
manager and APN
Treatment plan form, do every 3
months
Progress note for every visit
ANCHORS
Program Implementation

 Develop health indicators within the Tiered Level of
Need Model to guide determination of level of need;
examples of indicators







Strengths
Safety
PCP
Date last annual exam
Mental health provider
Chronic barriers (including health problems)
Benefits status
ANCHORS
Program Implementation

Assess each individual’s health and
wellbeing and organize engagement
around level of need using the Tiered
Level of Need Model©
Adjust case management and APN
support based on level of need
ANCHORS
Program Implementation

Outcome measures
Utilise quality of life and
mental health rating scales
Perform baseline, quarterly,
at discharge
ANCHORS
Program Implementation

Accountability
Evaluate goals in grant and assess if
objectives are being met
Develop a system for reporting to
funding agencies
Address systems for program to
remain viable
ANCHORS
Program Implementation

Staff responsibilities
Obtain malpractice insurance
Recruit collaborating physicians
Develop collaborative relationships
within the agency and with
community resources
ANCHORS
Plan of Care

 1. Identify the client while in shelter
 Engage and prepare for the transition to housing
 Clinical case manager does initial engagements
 2. Identify individual specific barriers to wellness and
health problems through initial screening







Hypertension and diabetes screening
Mental illness screening
Substance abuse screening, including tobacco, drugs, ETOH
Safety screening
Pain screening
Nutrition screening
Eligibility for benefits screening
ANCHORS
Plan of Care

 Identify individual specific strengths and successes
 Identify level of need based on tiered system
 Identify resources available to address the needs and
gaps in services





Case management
Community clinics and mental health centers
Healthy nutrition options-Food pantries
Substance abuse treatment referrals
Employment referrals
ANCHORS
Plan of Care

Linkage: Match needs with existent
resources
Link community resources
Community housing agencies
Community healthcare agencies
Community support systems
ANCHORS
Plan of Care

Monitor, reassess and evaluate
individual’s status within tiered
system
Adjust intensity of services as tier
status changes
ANCHORS
Evaluation

Ongoing evaluation of program
Team meetings
Monitor individuals’ status,
functioning, intensity of services and
support needed using the Tiered
Level of Need Model
Assess if objectives are being met
Tiered Level of Need Model©

 A fluid model of assessing an individual’s level of need
for resources and services.
 Need is determined during individual assessments,
reevaluated each visit, and changes are implemented and
incorporated into the plan of care.
 Level 3 High need-maximum services and support
required
 Level 2 Moderate need-fluctuating services and support
required, periods of high and low, more and less, need
 Level 1 Low need- minimal services and support required
TIERED LEVEL of NEED MODELS

 Tiered models have been used since Maslow
identified the tiered model of needs that informs the
beginning of every nursing program.
 Tiered models have been used in education to
structure classrooms to better provide education to a
diverse level of students.
 These models date back to 1980 and provide a well
researched system of interventions by identifying
student skills and classroom strengths to best utilize
the resources
TIERED LEVEL of NEED MODELS

 Minnesota public health has used a three tiered
model to group patients with medical needs into
different tiers that translated into different service
levels.
 This model is used to focus limited public health
monies to attain the best outcomes for the greatest
number of patients.
TIERED LEVEL of NEED MODELS

 Assesses the overall complexity of patients by grouping
them into “complexity tiers” based on the number of
major chronic condition categories that apply to them.
 Assessing complexity allows a more complete picture of
complexity not limited by diagnosis codes
 Ensures more accurate payment through the use of
complexity to approximate the time and work of care
coordination
 Also helps shape programs and helps care coordination
agendas
TIERED LEVEL of NEED MODELS

 A seven tiered model of need has been used successfully in
Australia to coordinate services for a population with dementia.
 "Our model provides the basis for comprehensive planning of
service delivery. We believe that it is representative of the
prevalence of different severities of behavioural and psychological
symptoms of dementia (BPSD). Current funding is very sparse for
intervention at tier 1 and tier 7 levels, even though the resource
need per patient is greatest at the top and the population to be
served is greatest at the bottom of the triangle.”
 Targeting funding to lower levels may reduce the demand for
higher-level services — this is the principle of preventive medicine.
 Education for all staff working in residential-care settings has the
potential to reduce the prevalence and severity of BPSD and the
subsequent demand for more specialised (and more expensive)
services
Alternative Assessment Tools

 Vulnerability Assessment Tool, Vulnerability Index,
Service Prioritization Decision Assistance Tool, VISPDAT: Used to determine who should be placed in
RRH, PSH, or no additional support
 Denver Acuity Scale: used to determine case
management service intensity
 Camberwell Assessment of Needs: Focused on SMI
 Outcome Star, Arizona Self-Sufficiency Matrix:
designed to be used collaboratively with client
Tiered Level of Need Model©
Four Domains

Domains of need impacting health and
housing linkages to services and
success
Medical Risks
Mental Health (MH)
Social Risks and Supports
Financial Resources
Tiered Level of Need Model©
Score Key

 Level 3 High need-maximum services and support
required
 Level 2 Moderate need-fluctuating services and
support required, periods of high and low, more and
less, need
 Level 1 Low need- minimal services and support
required
Tiered Level of Need Model©
Medical Risks

Medical Risks
(Linked=visit in past
12 months)
Level 3
Level 2
Level 1
*No PCP visit >3 yrs
*PCP visit >1yr
*Linked with Primary care
provider (PCP
*High mortality risk health
problem
*AIDS, Renal or Liver disease
*Pregnancy
*Uncontrolled chronic
diseases, e.g. HTN, Diabetes,
Asthma,
Chronic uncontrolled pain
*No health problems or
controlled chronic health
problems, includes
Controlled pain /No pain
*Chronic disease AND >60
*> 60 years old
*20-40 years old (using
contraception)
*ER >3 visits in 6 months
*ER 1-2 visits within 6
months
*ER visit 1 visit/ year or less
*Active substance use with
impairment
*Substance use management
or
*Substance use goals attained
or
*Active Mental and Physical
health problems AND
substance use
No use <6 months
No use >6 months or No
substance use
Tiered Level of Need Model©
Mental Health
Mental Health (MH)
Risks

(Linked=visit in past 6
months)
Level 3
Level 2
Level 1
*No MH provider
(MHP) visit >3 yrs
*MHP visit >6 months
*No MH
problems/Linked with
MHP
*Deteriorating MH
symptoms (sxs)
*Unstable MH
symptoms
*Stable MH symptoms
*Active Suicidal
Ideation, hx attempts
*Depression w/o active
SI
*Functioning with
Depression/MH sxs
*No insight, no reality
testing
*Poor insight, impaired
reality test
*Adequate insight,
intact reality testing
*ER >3 visits in 3
months
*ER 1-2 visits within 6
months
*ER visit 1/ year or less
Tiered Level of Need Model©
Social Risks and Supports

Social Risks and
Supports
Level 3
Level 2
Level 1
*Harmful/negative
support system
*No/limited support
system
*Positive/strong
support system
*Not engaged and
safety risk, DV
*Not engaged, no DV
risks
*Engaged
Tiered Level of Need Model©
Financial Resources

Financial Resources
Level 3
Level 2
Level 1
*Homeless
*Housed 0-6 months
*Housed >6 months
*No Income or benefits *High risk or
inadequate income
*Working/Adequate
Income
*Needs disability
*Benefits
Pending/Inadequate
*Adequate Benefits
*No budgeting skills
*Poor budgeting skills
*Budgets well/Access
to (healthy) food
Health Access ANCHORS
Pilot program

Sarah Circle links with ANCHORS
to develop Health Access program
for Women who are formerly
homeless
Health Access ANCHORS
Pilot program

Resources
 292 (430) hours for Advanced Practice Nurse (APN)
 822 (1209) hours for Clinical Case Manager (CCM)
Initial steps
 Select initial clients
 Explain the program
 Complete initial assessment
 Documentation required: Physical/MH assessments,
Specific Case management notes (Treatment Plans)
Health Access ANCHORS
Pilot program

Initial steps (cont’d)
 Homes visits
 Introduce clients to CCM
 Coordination with CMs from supportive housing
programs
 Schedule visits
 Determine data to be collected
Health Access ANCHORS
Pilot program Year 1

Year 1 Program goals
70 women receive initial screenings
70 women connected to FQHC home
70 women assessed for benefits, for
eligible women, process to be started
80% remain housed after 12 months
Health Access ANCHORS
Pilot program Year 2

Year 2 Program goals
 70 women receive initial holistic screening
 70 women connected to long-term sustainable
primary care and psychiatric care as needed
 80% remain in housing for 12 months
 85% of the clients scored at moderate to low risk on
the holistic health assessment by the time they exit
the program
Health Access ANCHORS
Pilot program

Data Summary
139 (Y1 74, Y2 65) women housed
and entered into Health Access
ANCHORS program
Number of women with mental
illness 93% (129/139 clients)
Health Access ANCHORS
Program goals
Year 1

Year 2
Objectives
Goal
N (%)
Goal
N (%)
Received
initial
screening
70 clients
(74 housed)
74 (100)
70 clients
(65 housed)
65 (100)
Connected
to FQHC
home
70 clients
(74 housed)
72
70 clients
(65 housed)
57
Assessed for
benefits,
process
started
70 clients
(74 housed)
72
70 clients
(65 housed)
64
Housed 1yr
80%
85%
80%
Still gathering
data
Health Access ANCHORS Program
Data summary per the 4 Domains

Medical Risks
Initial assessment
Beginning of program
Final Assessment
End of program
Clients’ needs
Percent per Tier (n)
Percent per Tier (n)
High need
27% (37)
11% (10)
Moderate need
42% (59)
20% (18)
Low need
31% (43)
69% (61)
Health Access ANCHORS Program
Data summary per the 4 Domains

Medical Risks
% of clients
80
60
40
Initial Assessment
Final Assessment
20
0
High
Moderate
Level of Need
Low
Health Access ANCHORS Program
Data summary per the 4 Domains

Mental Health Risks
Initial assessment
Beginning of program
Final Assessment
End of program
Clients’ needs
Percent per Tier (n)
Percent per Tier (n)
High need
18% (25)
9% (8)
Moderate need
47% (66)
17% (15)
Low need
35% (48)
74% (66)
Health Access ANCHORS Program
Data summary per the 4 Domains

Mental Health Risks
% of clients
80
60
40
Initial Assessment
Final Assessment
20
0
High
Moderate
Level of Need
Low
Health Access ANCHORS Program
Data summary per the 4 Domains

Social Risks and
Supports
Initial assessment
Beginning of program
Final Assessment
End of program
Clients’ needs
Percent per Tier (n)
Percent per Tier (n)
High need
17% (24)
6% (5)
Moderate need
46% (64)
20% (18)
Low need
37% (51)
74% (66)
Health Access ANCHORS Program
Data summary per the 4 Domains

Social Risks
% of Clients
80
60
40
Initial Assessment
Final Assessment
20
0
High
Moderate
Level of Need
Low
Health Access ANCHORS Program
Data summary per the 4 Domains

Financial Resources
Initial assessment
Beginning of program
Final Assessment
End of program
Clients’ needs
Percent per Tier (n)
Percent per Tier (n)
High need
44% (61)
11% (10)
Moderate need
51% (71)
27% (24)
Low need
5% (7)
62% (55)
Health Access ANCHORS Program
Data summary per the 4 Domains

% of Clients
Financial Risks
70
60
50
40
30
20
10
0
Initial Assessment
Final Assessment
High
Moderate
Level of Need
Low
Health Access ANCHORS Program
Data summary

 % of women moving from Tiered level 3 High need
at beginning of program to level 1 Low need at end
 Medical risks: 16% of women went from high to low
 Mental health risks: 14%
 Social risks and supports: 14%
 Financial resources: 20%
Health Access ANCHORS Program
Data summary

 % of women moving from Tiered level 2 Moderate
need at beginning of program to level 1 Low need at
end
 Medical: 26% of women went from moderate to low
 Mental health: 36%
 Social risks and supports: 34%
 Financial resources: 38%
Health Access ANCHORS Program
Data summary

 % of women at Tiered level 1 Low need at beginning
of program and at the end of the program
 Medical: 27%
 Mental health: 25%
 Social risks and supports: 27%
 Financial resources: 3%
Data summary: Comparing
needs across domains

 For the Initial and Final Risk Assessments compare
level of need (high, moderate, low) in each domain
(Medical, Mental, Social, Financial) with each other
1stAssmt Financial Financial Financial
Final
High
Moderate Low
MH High
14
11
0
MH Mod
30
27
3
MH Low
17
33
4
Data summary: Comparing
needs across domains

Initial assessments showed
 Social need high when Medical need high
 Financial need high irrespective of Medical needs
 Financial need high irrespective of MH needs
 When Medical need low MH need low
 Social needs do not impact Financial needs and
Financial need does not impact Social needs
 Social support and MH needs reciprocally impact
each other, e.g low-low, mod-mod, high-high
Data summary: Comparing
needs across domains

Final assessments showed
 When Medical need low Social support needs low, when
Social support need low Medical need low
 When Financial need low Medical need low, when
Medical need low Financial need low
 When MH need low Financial need low, when Financial
need low MH need low
 When MH need low Medical need low
 When MH need moderate, Social supports need
moderate, when Social need low MH need low
 When Social supports need low Financial need low, but
low Financial need has no impact on Social supports need
Data summary: Comparing clients’
needs from initial intake to discharge

% Improvement in Grid Score
% Improvement in Grid scores from Initial to Final
Assessments
30-39
20-29
% Improvement in Grid scores
from Initial to Final Assessments
10-19
1-9
0
5
10
15
20
% of Clients
25
30
35
40
Data Summary

Compared changes in Grid scores
between initial assessment and final
assessment and with Benefits status,
Mental Health linkage, Health care
linkage, Case Management
Data summary: Comparison of change
in scores from initial intake to discharge with
CM support

7/34 clients with no case management had
scores improve 1-9 points
2/60 clients with no Case Management had
scores improve 10-39 points (10 points and 16
points)
58/60 clients had Case Management support
and high improvement of scores (10-39
points)
Data Summary:
Percent Linkage by discharge

72% Clients linked in a behavioral
health or support program
93% Clients linked with Primary care
(4 refused)
Lessons Learned –Implementation
at Organizational Level

Consortium on Chicago School Research, Five Essentials for School Improvement
Lessons Learned –Implementation
at Organizational Level

Five Essentials for Homeless Service Program Implementation
Lessons Learned –Implementation
at Organizational Level

1. Leadership
 Inclusive leadership with vision, continuity, power
to make decisions, and strong understanding of
intervention model and staff needs
 Management wanted internal leader but program
manager turnover and lots of organizational change
 E.g. Initially had clinical case manager do initial
engagement of the women, with leadership changes
the APN did the initial engagement of the client and
referred clients needing counseling to CCM
Lessons Learned –Implementation
at Organizational Level

2. Community Ties (Issue of interagency silos)
 Importance of community context and external
relationships
 If >90% clients have SMI, need linkages with behavioral
health programs and agencies
 Lack of clinical services and programs to transition to
 Helpful to have staff member to talk across systems
 APN able to communicate with health service providers
 Addressing cracks in service or turnover at other agencies
sensitively but effectively
Lessons Learned –Implementation
at Organizational Level

3. Professional capacity: Development
 Staff in various roles need to understand purpose,
strategy, tactics, outcome measures, etc.
 Even though expert staff, still need support and
professional development pertaining to model
 Staff training-took time, and not prioritized, given
experienced project staff.
 Engagement different in time-limited program
Lessons Learned –Implementation
at Organizational Level

3. Professional capacity: Collaboration
 Silos intra-agency
 With a new program and with this population, the
unexpected will occur, need to be able to collectively adapt
 Funding flexible, but must communicate progress and
changes
 Agency growth and change. Overall positive, but
 Clients separate between programs (4), buildings (2) and
shifts (3) - new need for centralized intake/referrals
 Staff turnover
 Move to new building impacted housing #s second year
 Individual vs. team approach
Lessons Learned –Implementation
at Organizational Level

4. Client-centered, Trauma-informed Climate
Client-centered at all stages and levels
Design, direct service, and evaluation
Making sure there is enough support for staff
around trauma
Lessons Learned –Implementation
at Organizational Level

5. Quality
Service Provision
Great staff!
Enough time per client?
Lessons Learned –
Project Specific

 Housing the whole person worked
 Improved health and housing retention
 Getting housing retention data at 12 months for
those who needed lower levels of service difficult,
but
 85% of women placed in first year of program
confirmed housing retention at 12 months
 NONE confirmed as losing housing within 12 months
Lessons Learned –
Project Specific

 Process for referrals and engaging clients before move
 How the program was framed to clients (initially as a
separate program, but later as a standard continuation of
services)
 Ability to provide these types of services for a limited
amount of time when other supports were not available in
the community to transition to
 Who should engage client first, CCM or APN?
 APN was opening newly housed clients and closing
“graduating” clients who were housed for a year.
 Clients did not want to close.
 Time constraints made this difficult
Lessons Learned –
Project Specific

Staffing limitations-only 2 part-time staff,
limited time and funding
Better housing placements on front end (e.g.
3rd floor no elevator not ok for woman with
mobility issues)
Clients often geographically dispersed,
people go where the housing is, which was
difficult due to limited staff time
Lessons learned

 Developing implementation and evaluation goals to
meet objectives: What if objectives change?
 Ethics questions
 When to speak up?
 Who to talk with when there is no manager?
 How to process and deescalate after trauma with staff?
Lessons learned

 Quotes from staff
 “never feeling like I was alone in the work, team approach
which made us look at the whole person b/c we all had
different education, backgrounds, experience”
 “this program made a lot of us clinicians better clinicians
and that’s something that isn’t possible in a lot of other
agencies”
 “Now we are all going in different directions and making
other agencies better than they already are”
 “I wouldn’t be as skilled and knowledgeable without you
and that program”
Contact info

 Elizabeth Dunn edunn@sarahs-circle.org
 Regina Shasha rmshasha@gmail.com