LOGIC MODEL - thepoverellocenter.orgThe Poverello Center Logic Model is a product of many hands,...

LOGIC MODEL

July, 2020

ACKNOWLEDGEMENTS

The Poverello Center Logic Model is a product of many hands, hearts and minds over several

years, if not decades, at the Poverello Center. Problem statements, goals, and program designs

have been an ongoing team effort, and the language and photographs herein are a product of

the work of directors, board members, direct care staff, associates, clients, and grant writers of

the Poverello’s past and present. The design, compilation, editing and some research and

writing in this document was undertaken as a practicum project of University of Montana

School of Social Work Graduate Student Gavin Wisdom under the direction of Development

Director Jesse Jaeger.

MISSION

The Poverello Center provides food, shelter, help and hope to all who ask.

VISION

The Poverello Center believes all people deserve to be treated with dignity and respect,

regardless of their housing status. We envision a collaborative and supportive

community in which everyone has a safe place to call home.

PHILOSOPHY OF CARE

The Philosophy of Care aims to unify the diverse employees of the Poverello Center to

accomplish the organization’s mission and vision through:

Maintaining a humble awareness that we are gatekeepers to resources,

responsible for opening doors, not keeping them closed.

Compassionate engagement, empathizing with people in the environment in

which they survive.

A stabilizing place for resources and relationships centered on accountability and

trust.

Cultivating socially just relations among all people regardless of status or identity.

Recognizing people as dignified individuals and advocating for human agency.

Exercising compassion for oneself and one another

9 CORE PROBLEMS addressed by the Poverello Center:

1. Homelessness in Montana

In January 2019, the annual Point in Time (PIT) survey of homelessness on one night in

Montana counted 1,357 individuals experiencing homelessness across our state (down from

1,405 in 2018 and 1,529 in 2017). On the same night, our community gathered surveys for a

moment-in-time snapshot of 367 individuals who were experiencing homelessness in the

City and County of Missoula, meaning 27% of everyone experiencing homelessness that

night in Montana resided in Missoula County. 52% of the Missoula County individuals were

residing in emergency shelter. In Missoula County, 13% reported being homeless and also

dealing with mental health issues and 17 % reported dealing with both substance use and

mental health challenges while homeless. 59% reported that they had been homeless for

twelve months or longer while 30% of those had been homeless for less than a year.

2. Missoula’s Lack of Affordable Housing

The high price and limited availability of suitable housing adds to the challenges of

addressing homelessness in Missoula. The Missoula Housing Authority reports that there is

effectively a 0% housing vacancy rate in the low-income housing market in Missoula. MHA’s

Section 8 housing voucher wait-list in 2018 totaled 1,777 households for 744 vouchers,

while no additional affordable housing units were built that year. The Missoula Organization

of Realtors 2019 report also indicated that renters’ median income decreased by 4%, while

a high rate of Missoula renters were also “cost burdened,” meaning they paid more than

30% of household income on rent and housing costs. In an expensive market with low

rental availability, moving from homelessness into housing presents multiple complex

challenges.

To add to these challenges, the city and county has literally run out of land upon which to

build new affordable housing units. According to a recent report1, land developers struggle

to find land with the right zoning requirements for housing units, especially land that would

priced low enough to make those housing units affordable.

3. Lack of Mental Health Resources

In Montana, mental illness and substance use disorders are higher than the national

average. 42,600 Montanans (approximately the population of Bozeman) have a serious

mental health issue, and 73,000 Montanans (or about the population of Missoula) report

1 WGM Group, paid for by the Missoula Organization of Realtors and the Missoula Building Industry Association. “Balancing Agricultural Land Conservation and Residential Development in Missoula County”. Referenced in the Missoulian: https://missoulian.com/news/local/ag-lands-vs-development-report-looks-to-inform-missoulas-tough-choices-in-housing-crisis/article_5a1cf4a0-4641-5695-98b0-913b4d476081.html

https://missoulian.com/news/local/ag-lands-vs-development-report-looks-to-inform-missoulas-tough-choices-in-housing-crisis/article_5a1cf4a0-4641-5695-98b0-913b4d476081.html

https://missoulian.com/news/local/ag-lands-vs-development-report-looks-to-inform-missoulas-tough-choices-in-housing-crisis/article_5a1cf4a0-4641-5695-98b0-913b4d476081.html

symptoms of a substance use disorder2. The National Alliance to End Homelessness reports

that people with mental health and substance use disorders and who are homeless are

particularly vulnerable, as they are more likely to have immediate, life-threatening physical

illnesses and live in dangerous conditions.

While Montana’s numbers remain higher than the national average, funding to address

these challenges continues to decrease. In November of 2017, state legislature cut $120.7

million in funding to Health and Human Services. The Montana Budget and Policy Center

reports that such cuts almost always imply a significant loss in Federal funds, totaling over

$200 million lost to services funded through DPHHS. Included in this $200 million loss is $32

million in targeted case management for people with developmental disabilities and those

experiencing mental health and substance use disorders. Mental health issues and

substance use disorders are inextricably linked to homelessness, particularly when they

go untreated. More than 10 percent of people who seek substance abuse or mental health

treatment in our public health system are homeless. Separately, the cuts have closed 19

offices of public assistance in rural Montana, impacting many families’ ability to access

assistance and services including SNAP, Medicaid, Healthy Montana Kids, and TANF3. What

is needed, therefore, is organizations such as the Poverello Center and other “front door”

agencies to help fill in this gap.

4. Disproportionate Homelessness Among Marginalized Communities

Marginalized communities experience homelessness more often, more frequently, and for

longer periods of time than their white, cis-gendered and/or heterosexual counterparts.

Racial inequity is a known cause of homelessness. Although Blacks/African Americans

make up 13% of the population of the United States, they compose 40% of all individuals

experiencing homelessness4. Unsheltered homelessness is elevated among Native

Americans, as 56 percent of Native Americans experiencing homelessness are sleeping in

locations not meant for human habitation5. According to the National Alliance to End

Homelessness, Black Americans are 3 times as likely to enter homelessness as the general

population, Native Americans are 4 times as likely, and Pacific Islanders are 9 times as

likely.

2 The Montana Gap Project, in partnership with the Solutions Journalism Network. “Chasing the curve: As budgets churn, can Montana get its mentally ill care before they hit crisis?” Data from Substance Abuse and Mental Health Services Administration (SAMHSA), as reported by the National Survey on Drug Use and Health, 2015, 2016. 3 Montana Budget & Policy Center: “Budget Cuts Devastate Health and Human Services.” February, 2018. 4 National Healthcare for the Homeless Council. “Anti-Racism”. https://nhchc.org/clinical-practice/homeless-services/ethical-and-cultural-issues/anti-racism/ 5 NAEH, “State of Homelessness: A Look at Race and Ethnicity”. https://endhomelessness.org/state-of-homelessness-a-look-at-race-and-ethnicity/

https://nhchc.org/clinical-practice/homeless-services/ethical-and-cultural-issues/anti-racism/

https://nhchc.org/clinical-practice/homeless-services/ethical-and-cultural-issues/anti-racism/

https://endhomelessness.org/state-of-homelessness-a-look-at-race-and-ethnicity/

https://endhomelessness.org/state-of-homelessness-a-look-at-race-and-ethnicity/

5. Low Wages in Montana

The Alliance for a Just Society reported that a living wage for a single adult in Montana is

around $14.40 – and that is just to cover basic living expenses6. A single adult with two

children would need to make $25.82 per hour on a full time schedule to meet their family’s

basic needs, and for a family of four with two working adults, each adult would need to

make $18.17 per hour to make ends meet. The minimum wage in the state of Montana, at

$8.50 per hour, leaves many individuals and families coming up short when it times to pay

rent, the grocery bill, utilities, and other needs required for survival.

6. Hunger in Montana

Hunger relief is one of the most critical problems facing Missoula. In their bi-annual report, the Montana Food Bank Network (MFBN) reported that in 2018, one in nine Montanans experienced “food insecurity”, meaning that they do not have enough financial resources to consistently purchase food for themselves. The report, “Hungry in Montana,” shared that one in ten Montanans received food through an agency of the MFBN.

7. Inadequate Discharge Planning

Inadequate discharge planning, whether from a state or federal prison, jail, treatment

facility, nursing home, or other institution, too often results in homelessness as an

unintended consequence. Formerly incarcerated individuals are 10 times more likely to

experience homelessness than the general public7. After they are discharged, not only do

formerly incarcerated individuals face severe barriers to employment, but they also

encounter harsh discrimination by landlords and property managers. Challenges for

individuals reintegrating back into society extend to beyond those exiting the prison system;

numerous challenges await many who leave nursing homes, treatment facilities, and

hospitals without adequate discharge planning only to enter homelessness, often for the

first time.

8. Community Costs of Homelessness

Individuals who are unsheltered and/or chronically homeless cost the community a

significant amount of money. Between 11 and 15% of the population experiencing

homelessness in Missoula is chronically homeless, but this group reportedly uses 50% of

the financial resources allocated to homelessness in the community8. The 2015 report on

6 Alliance for a Just Society: The Montana Organizing Project, as cited by The Missoulian. “Minimum wage isn’t a living wage in Montana”. https://missoulian.com/news/opinion/columnists/minimum-wage-isn-t-a-living-wage-in-mt/article_589c1638-b85c-568c-9a96-4ed0db714feb.html 7 The Prison Policy Initiative. “Nowhere to go: Homelessness among formerly incarcerated people”. https://www.prisonpolicy.org/reports/housing.html 8 The City of Missoula, 2012. Reaching Home: Missoula’s 10-Year Plan to End Homelessness. https://www.ci.missoula.mt.us/DocumentCenter/View/37773/Reaching-Home-Missoulas-10-Year-Plan-to-End-Homelessness-PDF

https://missoulian.com/news/opinion/columnists/minimum-wage-isn-t-a-living-wage-in-mt/article_589c1638-b85c-568c-9a96-4ed0db714feb.html

https://missoulian.com/news/opinion/columnists/minimum-wage-isn-t-a-living-wage-in-mt/article_589c1638-b85c-568c-9a96-4ed0db714feb.html

https://www.prisonpolicy.org/reports/housing.html

https://www.ci.missoula.mt.us/DocumentCenter/View/37773/Reaching-Home-Missoulas-10-Year-Plan-to-End-Homelessness-PDF


Reaching Home: Missoula’s 10-Year Plan to End Homelessness estimated that one individual

experiencing homelessness can cost a city $25,000 annually. The majority of those costs are

associated with regular emergency and medical services calls, as well as law enforcement or

judicial and corrections system involvement.

9. Homelessness and COVID-19

People experiencing homelessness are uniquely vulnerable to COVID-19. They tend to be

older, have compromised immune systems and live in communal settings. Homeless

shelters across the country, like the Poverello Center, have been working hard to adapt

their protocols to make sure they can continue to deliver their essential and life-saving

services, while at the same time protecting their clients’ health from COVID-19. See the

note at the end of this section for adjustments to service delivery the Poverello has made to

ensure the safety of its guests, volunteers and staff.

To address these problems, the Poverello Center has the following GOALS:

1) To provide food, three meals a day, 365 days a year, to anyone who is hungry.

2) To provide shelter as a stepping stone on the pathway toward permanent stable housing.

3) To provide help by being an access point for community resources, by providing the basic necessities of survival for people experiencing unsheltered homelessness, and by lending a listening ear and support to our community’s most vulnerable individuals when they are in crisis.

4) To provide hope by building strong relationships and accompanying guests and clients

on their journeys toward long-term housing success.

THEORY OF CHANGE – WHY and HOW we expect to accomplish our GOALS

The Poverello Center works in partnership with the City of Missoula on a collaborative

community project known as “Reaching Home: Missoula’s 10 Year Plan to End

Homelessness”. As endorsed by Missoula’s plan, “Opening Doors: The Federal Strategic Plan

to Prevent and End Homelessness” provides the following definition of ending

homelessness:

An end to homelessness does not mean that no one will ever experience a housing crisis

again. Changing economic realities, the unpredictability of life, and unsafe or

unwelcoming family environments may create situations where individuals, families, or

youth could experience, re-experience, or be at risk of homelessness. An end to

homelessness means that every community will have a systematic response in place that

ensures homelessness is prevented whenever possible or is otherwise a rare, brief, and

non-recurring experience.

Specifically, every community will have the capacity to:

o Quickly identify and engage people at risk of and experiencing homelessness.

o Intervene to prevent the loss of housing and divert people from entering the

homelessness service system.

o Provide immediate access to shelter and crisis services, without barriers to entry,

while permanent stable housing and appropriate support are being secured.

o When homelessness does occur, quickly connect people to housing assistance

and services—tailored to their unique needs and strengths—to help them

achieve and maintain stable housing.

As part of Reaching Home, The Poverello Center is a leader in the Missoula Coordinated

Entry System (MCES), launched in 2017. MCES is a streamlined effort which connects people

experiencing homelessness to resources, reduces duplication of services, and provides

system-level data helping to make homelessness rare, brief, and non-recurring.

THEORY OF CHANGE (Cont’d): GUIDING MODELS FOR PRACTICE

The Housing First Model

The Poverello Center believes that the solution to homelessness is a home. Program

design under the Housing First model means building programs built on the belief that

“people need basic necessities like food and a place to live before attending to anything less

critical, such as getting a job, budgeting properly, or attending to substance use issues.”9

The Housing First model does not have preconditions or require participation in certain

activities before a guest or client is able to access housing. The model recognizes that clients

are more successful when they choose to participate in such programs, rather than when

they are required to do so. The model recognizes safe, stable housing as foundational for

individual well-being.

Under the umbrella of the Housing First Model is the Rapid Re-Housing (RRH) and

Permanent Supportive Housing (PSH) models. The aim of RRH is to re-house individuals new

to homelessness as quickly as possible. PSH models are programs that provide long-term

supportive services so that once individuals enter into housing, they have the necessary

supports to remain there. While the Poverello does not provide funding for RRH or PSH

services, it connects guests and clients to existing RRH and PSH resources.

Client-Centered Approach

In line with the Housing First model, the Poverello believes in the value of client choice in

housing selection and service participation, and that because of having that choice, clients

will be more successful in remaining housed and improving their quality of life. The

Poverello Center’s Case Managers take a client-centered approach, prioritizing client choice

when identifying goals and needs, creating a culture that fosters shared accountability. Case

Managers utilize strengths-based practice, are empowerment-focused, and enhance client’s

housing success by facilitating timely access to the necessary supports.

Trauma-Informed Care

Homelessness itself is a traumatic experience. Additionally, many people experiencing

homelessness have gone through other previous traumas – an abusive domestic

relationship, a traumatic experience while serving in the military, or as a victim of elder

abuse, among them – and live with their traumas’ after-effects. Without a TIC perspective

(and sometimes, even with one!) many well-meaning services providers can often re-

traumatize clients who need understanding, support, and individually-conscious care.10

The Poverello Center embraces the Trauma Informed Care (TIC) service perspective, as it

9 https://endhomelessness.org/resource/housing-first/ 10 National Coalition for the Homeless. “Trauma Informed Care”. https://nationalhomeless.org/trauma-informed-care/

https://endhomelessness.org/resource/housing-first/

https://nationalhomeless.org/trauma-informed-care/

https://nationalhomeless.org/trauma-informed-care/

emphasizes understanding, compassion, and responding to the effects of all types of

trauma.

The Harm Reduction Perspective

In order to successfully meet the mission of the Poverello Center of providing food, shelter,

help and hope to all who ask, the organization has prioritized the harm reduction

perspective, which aims to lower barriers to service by using the following set of core

principles as guidelines, as set forth by the Harm Reduction Coalition11:

Accepts, for better and or worse, that licit and illicit drug use is part of our world and

chooses to work to minimize its harmful effects rather than simply ignore or

condemn them.

Understands drug use as a complex, multi-faceted phenomenon that encompasses a

continuum of behaviors from severe abuse to total abstinence, and acknowledges

that some ways of using drugs are clearly safer than others.

Establishes quality of individual and community life and well-being–not necessarily

cessation of all drug use–as the criteria for successful interventions and policies.

Calls for the non-judgmental, non-coercive provision of services and resources to

people who use drugs and the communities in which they live in order to assist them

in reducing attendant harm.

Ensures that drug users and those with a history of drug use routinely have a real

voice in the creation of programs and policies designed to serve them.

Affirms drugs users themselves as the primary agents of reducing the harms of their

drug use, and seeks to empower users to share information and support each other

in strategies which meet their actual conditions of use.

Recognizes that the realities of poverty, class, racism, social isolation, past trauma,

sex-based discrimination and other social inequalities affect both people’s

vulnerability to and capacity for effectively dealing with drug-related harm.

Does not attempt to minimize or ignore the real and tragic harm and danger

associated with licit and illicit drug use.

Housing is Healthcare

The Poverello Center recognizes that housing is healthcare. The global COVID-19 pandemic

has made this even easier to recognize, as it is known that the most effective way to stop

the spread of the virus is by staying home. For those without a home, this is an

impossibility, and in their experience of homelessness, they have become even more

vulnerable. COVID-19 aside, individuals experiencing homelessness suffer all illnesses at

three to six times the rates experienced by others, have higher mortality rates, and have

11 The Harm Reduction Coalition. “Principles of Harm Reduction”. https://harmreduction.org/about-us/principles-of-harm-reduction/

https://harmreduction.org/about-us/principles-of-harm-reduction/

https://harmreduction.org/about-us/principles-of-harm-reduction/

dramatically lower life expectancy.12 According to the National Coalition for the Homeless,

life expectancies are 20-30 years less for individuals experiencing homelessness than the

general population.

A Note Regarding COVID-19 and the Poverello Center Logic Model

COVID-19 has impacted every facet of the Poverello Center, and the organization has made

preparations for both the short and long-term impacts of the pandemic. This logic model,

created both before and during the pandemic, outlines programs as of July 2020, and notes

COVID-related changes that have been made during a time that necessitates rapid

adaptation.

Utilizing the best practices that have emerged from other shelters across the country, the

Poverello Center has implemented the following actions:

Homelessness Task Force: We have formed a COVID-19 COAD (Community

Organizations Active in Disaster) Homelessness Task Force to respond to the current

challenges and are working closely with the Health Department. The task force

includes representatives from the Poverello Center, Partnership Health Center,

YWCA, Hope Rescue Mission, Missoula Interfaith Collaborative, Missoula

City/County Health Department, and Senator Tester’s Office.

Guest Screenings: We have been doing screenings with our guests several times per

week with Partnership Health Center for COVID symptoms. Once they have been

screened and do not have symptoms requiring testing, they are given a wristband to

wear. The color rotates so we know that they have been recently screened. If

someone meets the criteria for testing, they are tested by Partnership Health Center

and placed in Q/I at an off-site location by the Health Department.

Cleaning Protocols: We are following CDC guidelines for cleaning and have

implemented a daily deep clean protocol that involves cleaning our high traffic

areas, bathrooms, and sleeping spaces, and then we apply a fine mist of diluted

bleach solution with a sprayer.

New Meal Protocols: We began a new mealtime protocol that involves limiting the

number of guests in the dining room for mealtime, which will allow each guest to be

6 feet from another person. This will require folks to eat in shifts but will reduce the

number of folks in the dining room at one time.

12 National Health Care for the Homeless Council. “Housing Is Healthcare”. https://nhchc.org/wp-content/uploads/2019/08/Housing-is-Health-Care.pdf

https://nhchc.org/wp-content/uploads/2019/08/Housing-is-Health-Care.pdf

https://nhchc.org/wp-content/uploads/2019/08/Housing-is-Health-Care.pdf

Homeless Outreach: Shelter numbers have gone down as folks are feeling fearful of

being in a congregate setting, which means more folks are sleeping unsheltered in

our community. This shift will create many unintended consequences in our

community and is requiring our Homeless Outreach Team to respond accordingly.

We are working with our Coordinated Outreach Team to do targeted outreach and

supply drops at this time.

De-intensifying Shelter: We have reduced our capacity for the shelter to allow for

appropriate social distancing. We are closing the building for periods of time during

the day while allowing limited numbers of guests to stay in the building to access

daytime services such as the bathroom, showers, and mail. We have also reduced

our capacity for overnight shelter to 98 people so that every sleeping space is at

least 6 feet away from each other. The COVID-19 COAD Homelessness Task Force is

working on securing extra space for people experiencing homelessness to shelter in

place.

THE POVERELLO CENTER LOGIC MODEL

Inputs/Resources Activities Outputs Short & Long Term

Outcomes Impact

In order to accomplish our

set of activities we will

need the following (i.e.,

number of staff, financial

resources, etc.):

In order to address our

problem and meet our

goals, we will conduct the

following activities:

We expect that once

completed or underway,

these activities will

produce the following

evidence of service

delivery:

We expect that if

completed or ongoing,

these activities will lead to

the following changes in 1–

3 then 4–6 years

We expect that if

completed, these activities

will lead to the following

changes in 7–10 years:

$1,600,000 million (actual)

$2,600,000 million (ideal)

Emergency Shelter

Valor House

35 to 50 FTE Staff

Volunteers

Individuals experiencing

homelessness

In kind donations

Financial donations

Shelter Program Food Programs Homeless Outreach Team Veteran Programs Medical Respite Program Housing Retention Program

Nights of shelter

Meals served

People being housed

Referrals to community

services

Transitional housing –

connection to permanent

stable housing

Direct client services:

Materials we hand out,

housing navigation, case

management

HOT – camping gear

distributed

Poverello guests will gain a

baseline of stability and be able

to move into housing as it

becomes available.

Missoulians experiencing food

insecurity will become more

stable due to access to

nutritious meals

Unsheltered individuals will

meet their basic survival needs

and have access to services

Veterans will quickly access

available housing options

Individuals experiencing

homelessness who are being

exited from hospital care will

have a safe space to recover

Cases of recurring homelessness

will decrease

Ending homelessness;

reaching ‘functional zero’

Ending Veteran

homelessness

Long-term decrease in

mortality rate of

individuals experiencing

homelessness

Fewer lost limbs

A community in which

food security is a non-

issue; in which its

members will not wonder

where their next meal will

come from

SHELTER PROGRAM

The PROBLEMS addressed by the Poverello’s Shelter Program:

See problem statements “Homelessness in Montana,” and “Missoula’s Lack of Affordable

Housing,” among others, as listed in the section, “Problems addressed by the Poverello

Center.”

GOALS of the Shelter Program:

1) To provide emergency shelter to individuals

experiencing homelessness in Missoula County

365 days a year.

2) To help individuals meet other basic needs by

facilitating access to the emergency shelter’s

supportive services, such as showers, restroom,

laundry, phone, mail, and meal services.

3) To maintain a safe space for all individuals who access services at the emergency facility.

4) To refer individuals experiencing homelessness to benefit programs, mental health resources, substance use treatment facilities and other human services as needed/as they are available, making homelessness in Missoula brief.

5) To prevent homelessness altogether, helping individuals explore their own existing resources, making homelessness in Missoula rare.

6) To identify and prioritize services for the most vulnerable individuals experiencing homelessness.

These goals are measured using the following tools:

1) Homeless Management Information System (HMIS)

a. Shared database among MCES partners

b. Emergency shelter guests sign a Release of Information for data inclusion

c. Demographic data collection

d. Tool used to administer and record Stability Plans, VI-SPDAT, other assessments

e. Measures length of time individuals experience homelessness, sheltered or

unsheltered (and how often)

2) Stability Plan

a. Creates a road map of action steps for clients to take upon entrance into the

Poverello Shelter Program

b. Guests will revisit their stability plans with Poverello staff once a month

3) Vulnerability Assessment (VI-SPDAT)

a. Measures individuals’ vulnerability for service prioritization in the Missoula

Coordinated Entry System (MCES)

4) Referral Tracking – Not yet established

a. Challenges/questions include:

i. Defining what a referral is

ii. What referrals should be tracked

iii. How does 211 track this?

5) Diversion tracking – Not yet established

a. Diversion trainings could be tracked and recorded as evidence of the Poverello’s

diversion efforts (i.e.; one training per quarter)

b. Diversion funding – Salvation Army pilot

ASSUMPTIONS of the Shelter Program:

The mentality that people experiencing homelessness should be able to “pull

themselves up by their boot-straps”

That staff provide more services than they actually do (i.e., case management)/ that

staff are heavily trained

The expectation that people should live with 200 other roommates in peace

That the Pov has capacity to provide services for everyone experiencing

homelessness

That the Pov has capacity to store all of people’s belongings

Assumption that people don’t want to go to treatment – some people wanting to go

to treatment but there are no available options

Assumption that people can get a private room at the Pov

Assumption that the Pov has a lot of funding/ that Pov is funded by the government

SHELTER PROGRAM LOGIC MODEL


Outcomes Impact

In order to accomplish our

set of activities we will

need the following (i.e.,

number of staff, financial

resources, etc.):


problem and meet our

goals, we will conduct the

following activities:

We expect that once


these activities will

produce the following

evidence of service

delivery:

We expect that if

completed or ongoing,


the following changes:

We expect that if

completed, these activities


long-term changes:

1 FTE Shelter Manager

2 FTE Lead staff

10 FTE Direct Care Staff

(23.5 Winter Shelter)

1 FTE Maintenance

Technician

1 FTE Janitor

X FTE UM Practicum

student(s)

$160k Winter Shelter

$ - General Budget

In-kind donations (trash

bags, toiletries, non-food

supply donations)

Emergency facilit(ies) w/

capacity > 200

Upon guest intake, staff

attempt to divert the

person away from

homelessness. If the guest

cannot be diverted, staff

create a Stability Plan with

client then plan follow-up

once a month

Staff conduct Vulnerability

Assessments when guest

meets qualifying criteria.

Vulnerability scores given

to MCES team for service

prioritization.

Staff refer clients to other

agencies that may best fit

their unique needs (mental

health case management,

medical care, addiction

treatment, domestic

To divert 3% of individuals

assessed away from

homelessness, per quarter

To maintain the median

length of stay in the

emergency shelter at 30

days or less.

To offer ongoing

assessment and referral to

an average of 100 shelter

guests each month by staff

(3 assessments per day).

To assess every client

receiving a Stability Plan

for benefit eligibility,

including Veteran status,

age, income, dependent

status, disability, domestic

violence survivors and

Fewer individuals will

enter into homelessness

There will be fewer deaths

of people experiencing

unsheltered homelessness

due to lack of shelter

Decrease in unsheltered

homelessness/ homeless

encampments in Missoula

community

Because of access to safe

shelter, food, and other

supportive services,

individuals who do enter

into homelessness will

quickly begin to stabilize

and access housing as it

becomes available in the

Missoula community.

Creating sense of inclusive

community where


homelessness can easily

restore their dignity

Community attitudes

toward homelessness will

shift toward being more

solutions-based rather

than criminalizing

homelessness

Former guests of the

Poverello Center will heal

from past traumas, be able

to manage mental illness,

and provide leadership/

peer support

Restrooms, showers,

laundry facilities,

Computers, phones, office

supplies

Staff safety equipment

(radios, panic alarm

system)

HMIS/ HMIS Accounts

violence shelter, clothing

pantry, etc.)

Staff facilitate guest access

to mail, phone, messaging,

laundry, showers,

bathroom and other

emergency shelter services

as they are available

Staff intake/sort donations

Staff help oversee

Resident Volunteers

Crisis response/

management as needed

UM Practicum Student via

SOAR program (when

available) conducts

eligibility screening for

SNAP/TANF/SSI/SSDI/

other benefits.

Staff assist guests in

acquiring proper forms of

identification

Maintenance Technician/

Janitor maintain facility

beyond guests’ chores

other factors and refer to

appropriate sources for

application for benefits.

Shelter numbers will

decline relative to

Missoula’s growth and

availability of affordable

housing.

Poverello guests will

acquire a source of

income, through either

employment or benefit

eligibility.

The Poverello will develop

positive relationships with

employers and will more

easily be able to refer

guests for work

opportunities

FOOD PROGRAMS

The PROBLEM addressed by the Poverello Center’s Food Programs:

Hunger relief is one of the most critical problems facing Missoula. In their bi-annual report, the Montana Food Bank Network (MFBN) reported that in 2018, one in nine Montanans experienced “food insecurity”13, meaning that they do not have enough financial resources to consistently purchase food for themselves. The report, “Hungry in Montana,” shared that one in ten Montanans received food through an agency of the MFBN.

THE FACTS:

236 food bank-utilizing respondents across Montana, representing 673 household members, said they had to pay for necessities other than of food.

Eighty-five percent of these households needed help with food due to low wages and/or living on a fixed income.

Of the households surveyed, 44% of them had at least one family member currently employed.

In 2018, half of all households surveyed had at least one adult employed and 49% said they had delayed medical care due to a lack of funds.

Three out of four households included a child, senior or adult who were unable to work due to disability.

13 Montana Food Bank Network. “Hungry in Montana: Factors Contributing to Emergency Food Needs” https://mfbn.org/wp-content/uploads/2019/04/2018-Hungry-in-Montana-Report.pdf

https://mfbn.org/wp-content/uploads/2019/04/2018-Hungry-in-Montana-Report.pdf

https://mfbn.org/wp-content/uploads/2019/04/2018-Hungry-in-Montana-Report.pdf

Hunger is an especially serious situation for children, the elderly and people who are ill or disabled because hunger affects immunity, may worsen chronic illness, and can create physical and cognitive challenges, or even delays, in growing children. According to the MFBN, nearly 120,000 Montanans utilize SNAP benefits in our state. Share Our Strength: No Kid Hungry reported that 22% of Montana kids are food insecure and are not sure where their next meal will come from. Food access for children is also a problem when school is not in session. The MFBN reports that 80% of households with school age children utilize the Free or Reduced Price Lunch during the school year, whereas only 20% of those same households utilize the Summer Food Service Program, resulting in increased access to Poverello food programs. The data also reflected that 50% of those surveyed said that at least one family member had specific dietary needs, adding yet another barrier to hunger relief for those in need.

Food waste and local environmental concerns are also a major problem addressed by the Poverello Center’s Food Programs. According to the U.S. Environmental Protection Agency, approximately 31 percent (133 billion pounds) of the nation’s overall food supply is wasted on an annual basis. The EPA reports that more food goes into the country’s landfills and incinerators than any other material in our daily garbage. More food entering landfills equates to more harmful carbon dioxide and even potent methane emissions being released into the atmosphere.

GOALS of the Poverello Center’s Food Programs:

1) To provide nutritious and readily available food to anyone who asks.

2) To prevent homelessness and financial crisis by providing the basic need of food, thereby freeing community members’ financial resources for housing, healthcare, and other needs.

3) To rescue and redistribute edible, delicious and nutritious food from restaurants, grocery stores and other local food sources free of charge.

To achieve the above goals, the Poverello Center’s Food Programs are divided into four separate programs: The Soup Kitchen Program, Food Pantry Program, Sack Lunch Program, and the Food Rescue Program

These goals are measured using the following tools:

1. Soup Kitchen sign-in sheets – Soup Kitchen clients complete a brief survey before accessing lunch and dinner meals

2. Food Pantry Program sign-in sheets – Food Pantry recipients complete a brief survey each time they pick up a box of food.

3. Sack lunch tracking sheet – NEED TO GENERATE

4. Food donation log – Measures non-Food Rescue Truck food donations, by pound and type of food

5. Food Truck donation log – Measures poundage of food donated from local grocers, restaurants and other food producers

ASSUMPTIONS of the Food Programs:

1) The Poverello’s Food Programs play a major foundational role in all five of the other programs the

Poverello offers: the Shelter Program, Housing Retention Program, Medical Respite Program, the

Homeless Outreach Team, and Veteran Programs.

2) The money saved by users of the Poverello’s Food Program will go toward savings for housing and/or

paying rent or bills

PROGRAM INPUTS/RESOURCES

ACTIVITIES OUTPUTS SHORT & LONG

TERM OUTCOMES IMPACT

In order to accomplish our set of activities we will need the following:

In order to address our problem and meet our goals, we will conduct the following activities:

We expect that once completed or underway, these activities will produce the following evidence of service delivery:

We expect that if completed or ongoing, these activities will lead to the following changes:

We expect that if completed, these activities will lead to the following community impacts (7–10 years):

Sou

p K

itch

en

Pro

gram

Food Programs Manager (1 FTE) Volunteer Coordinator (1 FTE) Resident Volunteers/ Volunteers (X FTE) $1 million in-kind donations in food products $20,000: Pumpkins Fundraiser $6,500: HRC

The Poverello Soup Kitchen will provide three meals a day, 365 days a year. These meals will include a continental breakfast and a hot and healthy lunch and dinner. The kitchen will be kept a clean and safe environment for workers and volunteers Workers and volunteers will ensure rescued food from the Food Rescue Program is suitable for human consumption The Soup Kitchen will provide vocational training opportunities, in addition to ServSafe training, to qualifying Resident Volunteers.

Individuals experiencing homelessness and/or hunger in the Missoula community will have access to three nutritious meals a day, 365 days a year. Because of the vocational training provided by the FPM and VC, Resident Volunteers will have both job references and resume building experience, increasing their access to employment

Poverello Food Programs will help create immediate agency for individuals experiencing homelessness and/or hunger Having basic needs met will enable individuals to focus efforts on acquiring employment in the Missoula community Newly housed individuals will be better equipped to retain their housing because their scarce financial resources will be used to pay for rent and other necessary bills instead of food Because individuals' basic need of food is met, crime will decrease in the community

The Poverello's Food Programs will help prevent a generation of individuals in the future who will not have to face poverty and homelessness. The Poverello's Food Programs provide the basic need of food to Missoulians experiencing hunger and homelessness, and in so doing provides one of the most essential tools needed for individuals to re-gain stability. Malnourishment leads to a multitude of health issues which can impact an individual's daily functioning on a myriad of levels–from an inability to access gainful employment and/or education; to being able to complete Activities of Daily Living (ADLs) and impairment in making decisions.

PROGRAM INPUTS/RESOURCES ACTIVITIES OUTPUTS SHORT & LONG







Foo

d P

antr

y P

rogr

am

Food Programs Manager (1 FTE) Volunteer Coordinator to supervise Food Pantry volunteers Resident Volunteers/ Volunteers to operate pantry Pantry space, freezer, refrigerator, dry storage

The Poverello Food Pantry will be stocked daily by the Food Rescue Truck Driver and volunteers with food rescued from Missoula's grocery stores, restaurants and other food producers. The Poverello's Food Pantry, operated by volunteers and overseen by the Volunteer Coordinator, will be open from 5:30-7 pm, Monday, Wednesday and/or Friday. Individuals who are not guests of the emergency shelter may stop by the Food Pantry to pick up a box of food.

Through our Food Pantry Program, low-income families and individuals (at least 2,300 households, annually) who are not guests in the emergency shelter will have access to perishable, prepared and fresh foods.

Because of access to the Food Pantry Program, newly housed individuals as well as individuals at risk of losing their housing will have the added support of the Food Pantry to provide them with nutritious meals while lessening their financial burden. Low-income families and individuals will therefore have increased resources to put toward retaining their housing.

The Poverello's Food Pantry acts as an important lifeline to low-income Missoulians facing hunger. As Missoula's cost of living continues to rise and the number of households that are "cost burdened" continues to increase, the Poverello Center's Food Pantry will continue to be a vital resource and safety net for individuals struggling to make ends meet. This simple community service can ultimately help make the difference between being "housed" and "homeless" for many years to come.


ACTIVITIES OUTPUTS

SHORT & LONG TERM OUTCOMES

IMPACT






Sack

Lu

nch

Pro

gram

Food Programs Manager (1 FTE) Sack lunch supplies as provided by the Food Rescue Program Resident Volunteers/ Volunteers to assemble staff lunches 24hr/day Direct Care Staff to distribute sack lunches

Guests and volunteers will prepare up to 100 sack lunches per day Direct Care Staff will distribute sack lunches to individuals who are unable to access meal services at the Poverello due to employment or appointment conflicts The Homeless Outreach Team will distribute sack lunches to individuals who, for whatever reason, are unable or do not want to access meal services at the Poverello.

100 sack lunches for distribution per day

Guests of the Poverello will not have to go to work or appointments without anything to eat, and instead of buying food, they will be able to save their money to address a variety of financial barriers, including those related to acquiring housing. Individuals who are either newly housed or at risk of losing their housing and are unable to access meals at the Poverello Soup Kitchen due to a time conflict (such as employment) will continue to benefit from Poverello's meal services, saving their limited financial resources for other pressing financial needs. Individuals who, for whatever reason, are unable to access the Soup Kitchen can obtain a sack lunch for the Homeless Outreach Team

Having unconditional access to food enables individuals to address other urgent needs. In addition to simply keeping individuals alive, the Poverello's Sack Lunch Program will aid individuals as they focus their energies on employment, attending appointments, and other tasks necessary in building a stable, sustainable lifestyle.


ACTIVITIES OUTPUTS

SHORT & LONG TERM OUTCOMES

IMPACT






Foo

d R

esc

ue

Pro

gram

Food Programs Manager (1 FTE) Food Rescue Truck Driver (1 FTE) Food Rescue Truck Relationships with local grocers/restaurants and food suppliers Financial resources Resident Volunteers/ Volunteers Food storage space

Food Rescue Truck will pick up discarded and outdated (yet edible) foods from 12-15 grocery stores and restaurants 5 days per week. Food Programs employees will weigh the amount of donated food and keep record of what is rescued from the landfill

Over 10,000 pounds of rescued food, weekly (In 2019, the Food Rescue Program rescued 619,906 pounds total) The majority of food used in the Poverello's other three Food Programs (the Soup Kitchen, Sack Lunch Program, and Food Pantry Program) will be made available.

The Poverello's other Food Programs have limited funding, which goes toward staple food items, program staff, as well as kitchen equipment and maintenance. The Food Rescue Program, which brings in an estimated value of over $1 million in food donations in kind, provides enough food to offset the programs' high cost. With the demonstrated success of the Food Rescue Program, the Poverello hopes it will serve as a model for other communities to emulate.

The Poverello's Food Rescue Program makes a huge impact in reducing local methane and carbon dioxide emissions. In 2019, the program rescued approximately 620,000 pounds of food in 2019 alone. According to one food waste greenhouse gas calculator*, that amount of food in the landfill would generate 1,177,998 pounds of CO(2) emissions– or enough to provide 130 years of electricity to an entire household. *watchmywaste.com.eu

THE HOMELESS OUTREACH TEAM

The PROBLEM addressed by the Poverello Center’s Homeless Outreach Team:

In 2019, the annual Point in Time survey counted over half a million individuals in the United States

experiencing homelessness on a single night in January. Approximately 35% (or 200,000) of these

individuals were unsheltered, meaning they were sleeping in places not meant for human habitation, in

places such as parks, cars, or abandoned buildings14. That night in Montana, the survey counted 367

individuals experiencing homelessness in Missoula County, 20% (74 individuals) of whom were

unsheltered. 16 individuals met the HUD definition of “chronically homeless,” and 27% had been homeless

four times or more. 59% reported that they had been homeless for twelve months or longer15.

Before the Poverello Center established the Homeless Outreach Team (HOT), there were few programs

offering resources and assistance directly to people living on the streets and camping nearby in Missoula

County. Many chronically homeless individuals faced difficulty accessing healthcare, shelter, food and

other services because of barriers associated with mental illness, addiction and long-term homelessness.

Many of them are still wary and distrustful of service providers – so much so that they do not receive the

mental health, medical, and/or sexual assault services they may deeply need. In addition to the services

offered by the Poverello’s HOT, outreach efforts are needed by other professionals (such as Nurses,

Mental Health Practitioners, and DV Survivor Advocates) to aid those who may be most in need but least

willing or able to reach out for help.

14 The Council of Economic Advisors, September, 2019. “The State of Homelessness in America.” Executive office of the President of the United States. 15 U.S. Department of Housing and Urban Development. Data accessible at http://mthomelessdata.com/ For more information see HUD Exchange: https://www.hudexchange.info/programs/hdx/pit-hic/

http://mthomelessdata.com/

https://www.hudexchange.info/programs/hdx/pit-hic/

Challenges facing Individuals Experiencing Unsheltered Homelessness

Challenges for the county’s unsheltered individuals are many, extending beyond Missoula’s lack of

affordable housing and includes a lack of available land on which to camp. Local law enforcement

repeatedly asks many of these individuals to move along with nowhere left for them to go. Unsheltered

individuals are often unable or unwilling to access Poverello Center services on-site due to a mental illness

(congregate shelter can be a triggering environment for individuals living with PTSD, for example),

substance use (as the Poverello is seasonally a zero-tolerance facility), or unsafe behavior. It is estimated

that nearly 35% of individuals experiencing homelessness struggle with untreated addiction and mental

illness16. Furthermore, there is a demonstrated need for community education regarding homelessness in

Missoula, as many businesses and residents operate on misinformation to the detriment of unsheltered

individuals. Together, these challenges make trained, skilled outreach staff highly necessary for effective

services.

High Community Cost of Unsheltered Homelessness

The target population of the HOT – people who are unsheltered and/or chronically homeless – costs the

community a significant amount of money. Between 11 and 15% of the population experiencing

homelessness in Missoula is chronically homeless, but this group reportedly uses 50% of the financial

resources allocated to homelessness in the community17. The 2015 report on Reaching Home: Missoula’s

10-Year Plan to End Homelessness estimated that one homeless individual can cost a city $25,000 annually.

The majority of those costs are associated with regular emergency and medical services calls, as well as

law enforcement or judicial and corrections system involvement. In collaboration with the Missoula

Coordinated Entry System (MCES) partners, the Poverello Center’s HOT reaches out to the most vulnerable

individuals in our county while also increasing public safety, decreasing taxpayer expense, and working

with our community – especially within the MCES – to develop long-term solutions to chronic

homelessness.

COVID-19 and Unsheltered Homelessness

COVID-19 has caused a significant number of individuals who formerly sought shelter at the emergency

facility to leave, socially distancing themselves outdoors. The growing number of unsheltered individuals in

Missoula includes individuals who are newly entering homelessness due to the pandemic’s economic

impact. Should a member of the unsheltered community contract the virus, COVID-19 could spread rapidly

and the result would be devastating. While COVID-related challenges for unsheltered individuals

experiencing homelessness are different than those for people in a congregate shelter, it is best practice to

continue prioritizing the connection of unsheltered individuals to permanent stable housing.18

16 Substance Abuse and Mental Health Services Administration (SAMHSA), 2013. Behavioral Health Services for People Who Are Homeless. Treatment Improvement Protocol (TIP) Series, No. 55 17 The City of Missoula, 2012. Reaching Home: Missoula’s 10-Year Plan to End Homelessness. https://www.ci.missoula.mt.us/DocumentCenter/View/37773/Reaching-Home-Missoulas-10-Year-Plan-to-End-Homelessness-PDF 18 Center for Disease Control, 2020. “Interim Guidance on Unsheltered Homelessness and Coronavirus Disease 2019 (COVID-19) for Homeless Service Providers and Local Officials.” https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/unsheltered-homelessness.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fneed-extra-precautions%2Funsheltered-homelessness.html


GOALS* of the Homeless Outreach Team:

1) Direct Client Outreach: The HOT will support individuals who are chronically homeless and/or unsheltered in the City and County of Missoula with the resources and assistance they need to meet basic human needs and to move into stable, permanent housing in support of MCES and Reaching Home goals.

2) Community Outreach and Education: Through in-person services, HOT Line phone calls, and

community meetings, the HOT will provide education and support to the wider community in the City and County of Missoula by responding to individual and systemic issues of homelessness, reducing barriers to housing through advocacy, and strengthening our collective ability to diminish the number of individuals experiencing homelessness in the City and County of Missoula.

3) Coordinated Outreach: The HOT will guide and inform the Coordinated Outreach Team, a collaboration of service professionals from agencies across the community spanning Mental Health Professionals to local Rescue Mission outreach workers. The aim of the Coordinated Outreach Team is to make it easier for unsheltered individuals to access services by working together to remove barriers as a unified, solid outreach branch of the MCES.

*Note on the Homeless Outreach Team’s COVID-19 Response

In addition to the above goals, COVID-19 has required the HOT to expand their efforts through the

Poverello’s COVID-19 Homeless Outreach Project. The intent of the project is to increase the HOT’s

capacity so it may provide outreach services to those who have left the emergency shelter to socially

distance themselves outdoors, as well as to the increasing number of individuals who are entering

homelessness due to the pandemic’s economic impact.

The goals of the project are to 1) conduct street-level screenings for COVID-19 to unsheltered

individuals experiencing homelessness; 2) provide unsheltered individuals with COVID-19 education;

and 3) continue to support individuals who are unsheltered in Missoula with the resources and

assistance they need to meet basic human needs and to move into stable, permanent housing.

MEASUREMENT TOOLS:

1) The HOT Log

c. Metrics tracked:

i. Day-to-day outreach activities

ii. Releases of Information signed

iii. Some (but not all) referrals to services (such as mental health/substance use treatment)

iv. Client transportation

v. HOT Line calls

vi. Community meetings attended

2) Data spreadsheet

a. Metrics tracked:

i. Face-to-face contacts with clients, businesses and community members

ii. Client’s “active” status in MCES

iii. Number of unduplicated clients served

3) Point In Time Count

a. National annual count of individuals experiencing homelessness on one night in January

b. Includes unsheltered count, for which the HOT takes the lead every January

4) Needed to be tracked:

a. Hours doing outreach as well as hours spent in meetings

i. More likely to hit desired outcomes

ii. Should always be more than meetings

iii. So much of what HOT does is qualitative and relationship-based; counting outreach

hours could be a good way to quantify

b. Referrals

i. System needed to track these referrals

c. ID Support

i. A large part of the HOT’s work with clients which goes untracked.

d. Contact hours with law enforcement/ trainings, CIT trainings

ASSUMPTIONS of the Homeless Outreach Team:

If unsheltered individuals are willing and able to receive services, there actually are services

available/accessible

That a better network of inter-agency relationships will provide more effective, accessible and efficient

service delivery

Helping an individual meet their basic needs will be enough to help them stabilize

That the HOT will have a consistent donated supply of cold weather gear and camping supplies to

distribute to unsheltered individuals

Some clients assume the HOT works 7-days a week; The need for over-night winter outreach

THE HOMELESS OUTREACH TEAM LOGIC MODEL


Outcomes Impact

In order to accomplish our set

of activities we will need the

following:


problem and meet our goals,

we will conduct the following

activities:

We expect that once


there will be the following

evidence of service delivery:

We expect that if completed

or ongoing, these activities


changes:

We expect that if completed,


the following changes in 7–10

years:

1 FTE Outreach Coordinator

4 FTE Outreach Workers

UM Practicum Students

$X – Program Budget

HOT Van (for staff/client

transportation, delivery of

equipment)

Office at Poverello

emergency facility

HOT Phone, computer, iPad

(for Outreach Grid), office

supplies

Donated camping equipment

(i.e., tents, sleeping bags,

backpacks, hats, gloves,

toiletry kits)

Sack lunches (Approx. 50 per

week)

Conduct routine outreach in various locations in the City and County of Missoula. Distribute sack lunches, backpacks, warm clothing, socks and other items and gear during outreach. Meet with unsheltered individuals at the Poverello for housing assessment, case updates and other supports. Help coordinate targeted clean-ups with city, county and nonprofit entities. Guide and inform the MCES Coordinated Outreach Team with partners. Conduct Coordinated Outreach drop-in hours at easily accessible locations. Establish Releases of

To serve 65 unduplicated

chronically homeless and/or

unsheltered individuals

annually with MCES partners.

To conduct 1,200 face-to-

face client contacts (with 170

unduplicated individuals)

annually in order to meet

basic needs, build trusting

relationships, and respond to

community concerns about

nuisance behavior.

To make at least 100 face-to-

face contacts with neighbors,

business owners and other

residents for education,

support and communication.

To provide transportation for

50 unduplicated individuals

to appointments with

medical, public benefit,

Because the HOT established

relationships built in trust

with their clients, those with

mental health issues are

better able and/or willing to

get the help they need

HOT clients with substance

use disorders are more likely

to enter treatment programs;

the rise of completion rates

of such programs

HOT clients have better

health outcomes

Mortality rates of individuals

experiencing unsheltered

homelessness decrease

Clients attain housing/are

connected to housing

vouchers at higher rates

Camping in Missoula

public/private spaces reduces

The HOT plays a key role in

Reaching Home: Missoula’s

10-Year Plan to End

Homelessness in ensuring the

community’s unsheltered,

and/or chronically homeless

individuals are able to access

services.

The HOT has a reputation in

the community for being a

safe, trustworthy access

point for services and

meeting basic needs, rapidly

connecting newly homeless

individuals to available

housing resources.

Missoulians will feel safe and

knowledgeable of community

resources for homeless

services and will be

comfortable calling the HOT

Line in non-emergency

situations

Information with MCES partners and clients. Collaborate with the Partnership Clinic at the Pov and the Medical Respite Program to provide transportation as available. Staff and answer the HOT Line cell phone. Respond to calls with advice, referral or in-person response. Schedule and attend community or business meetings to share HOT/Poverello updates and tools for working with HOT clients. Distribute fliers with information about HOT services and when to call the HOT Line vs. 911. The HOT will communicate clearly, respectfully and frequently with law enforcement and first responders to build positive relationships, acting as a resource and support. Connect clients with pets to

resources that can help with

the well-being of their animal

Log meetings, calls, and contacts made.

housing and other service

providers.

To collaborate and

communicate with

concerned community

groups and neighbors at 30

community meetings

annually.

To provide real-time

response to 250 HOT Line

calls annually and respond to

community concerns to

decrease nuisance behaviors.

To provide at least 20 contact

hours annually (via CIT-

Training or first responder in-

service trainings) with local

law enforcement and other

first-responders

as individuals are better

equipped to access available

resources for shelter, housing

or otherwise

The community cost of care

for unsheltered individuals

decreases, as some of the

most vulnerable, chronically

homeless individuals access

supportive resources through

the HOT and use fewer

EMS/law enforcement

services.

Law enforcement officers

and other first-responders

have an increased ability to

respond most effectively to

calls involving chronically

homeless individuals; the

HOT, officers and first-

responders form

relationships among one

another, increasing positive

outcomes for HOT clients.

Because HOT has connected

clients with pets to resources

for the pet’s well-being, the

client’s well-being increases

in turn.

VETERAN PROGRAMS

The PROBLEM addressed by the Poverello Center’s Veteran Programs:

According to the U.S. Department of Housing and Urban Development, on one night in January in 2019,

37,085 Veterans were experiencing homelessness nationwide, 205 (.5%) of which were in Montana. The U.S.

Department of Veterans Affairs (VA) states that the nation’s homeless veterans are predominantly male, with

roughly 9% being female. According to the National Coalition for Homeless Veterans (NCHV), about 11% of the

adult homeless population are veterans. While people of color make up only 18.4% of the general Veteran

population, they represent 43.2% of Veterans experiencing homelessness, 3% of which are Native American

or Alaska Native19.

The NHCV reports that while the United States’ homeless Veterans have served in all of the nation’s many

wars dating back to World War II, nearly half of homeless Veterans served during the Vietnam era. While

Vietnam and post-Vietnam War-era Veterans are most likely to enter homelessness, Veterans who have

served in Iraq, Afghanistan, and the many other parts of the world where the U.S. has had a military presence

more recently are also at high-risk, as many live with “invisible wounds of war,” such as moral injury,

traumatic brain injuries and post-traumatic stress disorder as a result of their service20.

19 National Alliance to End Homelessness. “People of Color Make Up a Disproportionate Share of the Homeless Veteran Population”. October 22, 2018 Retrieved from: https://endhomelessness.org/resource/people-color-make-much-larger-share-homeless-veteran-population-general-veteran-population/ 20 National Coalition for Homeless Veterans. “Background and Statistics”. 2016. Retrieved from: http://nchv.org/index.php/news/media/background_and_statistics/

Leaders in the Homeless Veteran Services sector have made significant progress in ending Veteran

homelessness in communities across the nation21, and the City and County of Missoula is not far from

joining them. Veteran homelessness decreased by 2.1% nationwide between 2018 and 2019, as reflected by

HUD’s Annual Homelessness Assessment Report. The National Alliance to End Homelessness reports that in

2019, the HUD-VASH program was able to house more than 11,000 veterans.

Despite this progress, more is needed to ensure that no veteran is homeless. As the NCHV notes,

approximately 1.4 million currently housed Veterans are considered at risk of homelessness due to poverty,

lack of support networks, and poor living conditions in overcrowded or substandard housing. As stated by the

NAEH, “all communities need a system in place that provides every Veteran who becomes homeless with a

temporary place to stay while permanent housing and any needed services are being arranged.”

GOALS of the Poverello Center’s Veteran Programs:

1) To give Veterans a safe, secure space to expediently transition out of homelessness and into housing.

2) To provide access to benefits available to Veterans and assistance in making connections to those benefits.

3) To see Veterans as a whole person, facilitating community connection to other Veterans as well as to the larger community.

4) To foster the development of life skills by providing life coaching and social reintegration services to Veterans exiting correctional facilities and other institutional settings, thereby reducing recidivism rates among Veterans in our community.

In order to delegate available physical and financial resources, the Poverello Center’s Veteran Programs are

composed of three programs: Housing Montana Heroes, Valor House and the Veteran Shelter Program. Separated by program, the following pages include the inputs, activities, outputs, outcomes and impacts which

aim to achieve the above goals.

21 National Alliance to End Homelessness. “Ending Veteran Homelessness”. November, 2019. Retrieved from:

https://endhomelessness.org/homelessness-in-america/who-experiences-homelessness/veterans/

MEASUREMENT TOOLS: 1) Veteran Programs Spreadsheet

e. Measures tracked:

i. 100% of Veterans are screened for benefits

ii. 100% get their DD214

iii. Positive Discharges (definition of this is arguable, follows VA Standards meaning

discharge into housing – VA likes to see 70% rate of positive discharge)

iv. Measurement of community connection? More work needed on this.

v. 4 hours per week, participating Veterans are supposed to be actively

seeking/participating in employment, education or volunteer work

2) VA Feedback and evaluation

3) Screening tool

4) Squares – program eligibility

ASSUMPTIONS of the Veteran Programs:

The community assumption that every Veteran qualifies for VA healthcare. To qualify for

HUD/VASH assistance Veterans must first qualify for VA healthcare

The VA assumption that housing is success – that housing is an answer. Veterans continue to

struggle with social isolation, loneliness, mental health and substance use issues.

Client goals are sometimes not housing-focused and they have different definitions of success.

People don’t realize how in depth case management can be

Immediate service delivery

The assumption that being in the program automatically gets Veterans housing

That PTSD comes from Veterans’ service in the military. While this is sometimes true, many Veterans’ live with PTSD incited by traumatic incidents in childhood.

VETERAN PROGRAM

INPUTS/ RESOURCES








Ho

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ng

Mo

nta

na

He

roe

s (H

MH

)

Vet. Programs Director .33 FTE Case Managers, 1 FTE Pov. Direct Care Staff, .5 FTE VA Liaison Veterans who meet program qualifications, approved by the Transitional Housing Committee, and considered eligible by the Department of Veteran's Affairs. Only single Veterans without dependents are eligible. $500,000 VA Grant Participating Veterans' monthly rent payments 10 semi-private rooms in the Poverello emergency facility to accommodate 18 men and 2 women, as well as a shared Veteran lounge Poverello Center Soup Kitchen

Provide shared semi-private rooms (2 Vets per room) in addition to community laundry and shower facilities Provide case management services, including therapeutic services, employment assistance, and legal assistance Connect Veterans to other agencies/ services providers for housing vouchers, mental health services, substance use treatment Host skill building groups, healthy recreation outings, art therapy classes Host 4 community events annually Provide access to Poverello Soup Kitchen/ Food Pantry Participating Veterans will have 50% of their monthly payments returned to them upon exit of the program

Over 35 Veterans served, annually 100% of participating Veterans will have been screened for benefits 100% of Veterans will receive their DD-214 Positive discharges from the program will remain above 70% Veterans will have resources needed to stabilize and will therefore graduate from their treatment programs (such as anger management or substance use treatment) Veterans will increase their income through employment and/or benefits Veterans will have access to health and dental insurance as well as connection to a primary care provider

Upon program exit, Veterans will have money to put toward securing permanent, stable housing and other expenses related to their stability Veterans will be able to expediently access housing vouchers and secure permanent stable housing Veterans will have learned who and where to ask for help if/when needed Better health outcomes for Veterans Veterans will be better connected to their peers and the wider Missoula community Veterans will develop valuable life skills (such as cooking, budgeting, etc.) Veterans will have increased autonomy; feelings of life satisfaction; increased SDOH and lasting friendships

The long-term impact of the Poverello Center Veteran Programs will be in helping Veterans in need to restore their dignity in our community Ultimately, these activities will guide state efforts to ending Veteran homelessness. Veterans will become active citizens in the community; some getting into community leadership roles or taking on mentorship/ peer support As resource knowledge and connection among Montana's Veterans grows, we anticipate the reduction of Veteran recidivism rates, breaking the sometimes-cycle of homelessness to the penitentiary and back again for Montana Veterans.

VETERAN PROGRAM

INPUTS/ RESOURCES








Val

or

Ho

use

Veteran Programs Director, .33 FTE Program Manager, 1 FTE Direct Service Staff, 3 FTE Facility with 17 private apartment units, including four community spaces and an outdoor green space Montana Housing Authority - Provides the physical building and owns the grant VA Liaison Food items provided by Poverello Food Rescue Program Computers, phones, office supplies

Provide a private apartment unit in a facility staffed 24 hr./day, 7 days/week Provide case management services, including therapeutic services, employment assistance, and legal assistance when appropriate Connect Veterans to other agencies/ services providers for housing vouchers, mental health services, substance use treatment Host skill building groups, healthy recreation outings, art therapy classes Host 4 community events annually Provide access to food resources through the Food Rescue Program Participating Veterans will have 50% of their monthly payments returned to them upon exit of the program

Over 25 Veterans served, annually 100% of participating Veterans will have been screened for benefits 100% of Veterans will receive their DD-214 Positive discharges from the program will remain above 70% Veterans will have resources needed to stabilize and will therefore graduate from their treatment programs (such as anger management or substance use treatment) Veterans will increase their income through employment and/or benefits Veterans will have access to health and dental insurance as well as connection to a primary care provider

Upon program exit, Veterans will have money to put toward securing permanent, stable housing and other expenses related to their stability Veterans will be able to expediently access housing vouchers and secure permanent stable housing Veterans will have learned who and where to ask for help if/when needed Better health outcomes for Veterans Veterans will be better connected to their peers and the wider Missoula community Veterans will develop valuable life skills (such as cooking, budgeting, etc.) Veterans will have increased autonomy; feelings of life satisfaction; increased SDOH and lasting friendships


VETERAN PROGRAM

INPUTS/ RESOURCES








Ve

tera

n S

he

lte

r P

rogr

am (

VSP

)

Veteran Programs Director, .33 FTE Case Managers, 1 FTE Poverello Direct Care Staff, .5 FTE Poverello Center emergency facility/ dorm bunk beds and/or floor mats Poverello Center Soup Kitchen services Computers, phones, office supplies

Provide a dorm bed and/or floor mat in Poverello emergency shelter Provide case management services, including therapeutic services, employment assistance, and legal assistance when appropriate Connect Veterans to other agencies/ services providers for housing vouchers, mental health services, substance use treatment Host 4 community events annually Provide access to food resources through the Poverello Soup Kitchen

Over 10 Veterans served, annually 100% of participating Veterans will have been screened for benefits 100% of Veterans will receive their DD-214 Veterans will have some resources needed to stabilize which will therefore assist them in graduating from their treatment programs (such as anger management or substance use treatment) Veterans will increase their income through employment and/or benefits Veterans will have access to health and dental insurance as well as connection to a primary care provider

Veterans will be able to expediently access housing vouchers and secure permanent stable housing Veterans will have learned who and where to ask for help if/when needed Better health outcomes for Veterans Veterans will be better connected to their peers and the wider Missoula community Veterans will develop valuable life skills (such as cooking, budgeting, etc.) Veterans will have increased autonomy; feelings of life satisfaction; increased SDOH and lasting friendships


MEDICAL RESPITE PROGRAM

The PROBLEM addressed by the Poverello Center’s Medical Respite Program:

Medical respite for homeless patients serves people who are ill and injured and who, if they were not homeless, would be discharged from medical facilities to recover at home. Due to inadequate housing options (such as camping out or accessing emergency shelter only at night), many individuals experiencing homelessness face increased challenges and increased mortality when recovering from illness or injury. Without housing and added supports, individuals’ recovery times and risk of re-hospitalization increase, ability to follow health care providers’ instructions and access follow-up care diminish, and overall mortality rates rise. According to the National Healthcare for the Homeless Council, individuals experiencing homelessness die an average of 20-30 years earlier than those who are housed. Homelessness itself increases a person’s susceptibility to illness and injury, exacerbates underlying health issues and delays overall recovery.

Discharge from hospitalization into homelessness or unsafe housing increases community costs and health risks. In Missoula, where hospital census is frequently high, re-allocation of appropriate medical services can benefit the entire community, especially people who are homeless and facing higher overall health risks and disparities.22

22 Ciambrone S & Edgington S. (2009). Medical Respite Services for Homeless People: Practical Planning. Nashville: Respite Care Providers Network, National Health Care for the Homeless Council, Inc. https://www.nhchc.org/resources/clinical/medical-respite/tool-kit/

GOALS of the Poverello Center’s Medical Respite Program:

1) To improve medical outcomes for individuals experiencing homelessness, specifically for those recovering from acute illness or injury.

2) To reduce the impact and cost of medically unnecessary nights of hospital stay on the medical system and the Missoula community.

3) The Medical Respite Care Coordinator will meet with medical respite clients routinely to connect them to appropriate resources, medical or otherwise, and increase the number of clients who have a primary care provider.

4) The Medical Respite Care Coordinator will connect medical respite clients to the Coordinated Entry System if they have not been entered already; vulnerability assessments and stability plans will be administered as appropriate.

MEASUREMENT TOOLS used to assess the achievement of the above goals:

5) Client, staff and medical provider surveys – Formstack / StatCrunch

a. Improved medical outcomes: self-reported and observed by MR Care Coordinator

b. Client surveys: Needed question regarding primary care

c. Should program use gift cards as incentive for clients to complete survey?

6) Hospital Data – Collected from MR referral forms and medical provider surveys

a. Organized I MR Data excel sheet

b. Log-in to St. Pat’s system

c. ED and inpatient visits

d. Medical chart

7) Homeless Management Information System

a. Used in meeting Goal 4

ASSUMPTIONS of the Medical Respite Program:

o Individuals experiencing homelessness who are discharged from the hospital are interested in staying

at the Poverello o Individuals experiencing homelessness in Medical Respite have been referred o Level of care needed beyond the program; there is a gap in the community that still needs to be filled o Definition of “acute”

MEDICAL RESPITE PROGRAM LOGIC MODEL


Outcomes Impact

In order to accomplish our set

of activities we will need the

following (i.e., number of

staff, financial resources,

etc.):


problem and meet our goals,

we will conduct the following

activities:

We expect that once


these activities will produce

the following evidence of

service delivery:

We expect that if completed

or ongoing, these activities


changes:

We expect that if completed,


the following long-term

impacts:

.75 FTE Medical Respite

Coordinator

$ - Program budget

Med Respite

Evaluation/Consultation

(Leary Consultants/ MTHCF)

Med Respite Care

Coordinator - .75 FTE

Direct Care staff time

Administrative Support

Food services

3 Semi-private rooms (9

beds)

Utilities

Relationship building w/

medical providers

In addition to providing

clean, semi-private rooms for

client recovery, the Medical

Respite Care Coordinator

facilitates high quality post-

acute care through

coordination among the in-

house clinic and

transportation to other

medical services with the

Poverello’s Homeless

Outreach Team as needed.

Care Coordinator facilitates

connection to other

community resources as

appropriate.

Clients have access to three

nutritious meals per day at

the Poverello’s soup kitchen.

The Care Coordinator,

provides coaching around the

appropriate use of ED

75% of medical respite

clients will report improved

health outcomes upon exit of

the Medical Respite Program.


clients given referrals to a

primary care provider if they

do not already have one.

Provision of medical respite

shelter and care coordination

for 55-60 medically referred

individuals annually for

recovery in a semi-private

room not otherwise available

To annually divert more than

150 medically unnecessary

nights of stay out of

Missoula’s medical facilities

and into medical respite care,

for an estimated annual

community cost savings of

$367,200.

Improved health and faster

recovery times for individuals

recovering from acute illness

or injury while also

experiencing homelessness

Opportunities for the

Medical Respite Coordinator

to provide housing referrals

and/or other supportive

services.

Lower mortality rate among


homelessness

Longevity of client’s lives and

limbs

Cultural shift: education

among individuals

experiencing homelessness

for access to other resources

Stabilizing impact of


homelessness on costs on

community

Efficient long-term

relationship between

Poverello Center and medical

providers

services; referrals to primary

care providers, housing

resources and/or other

supportive services when

applicable

Care Coordinator conducts

client surveys upon program

exit, as well as annual

surveys with staff and

medical providers for

ongoing program assessment


clients will comply with

doctor’s instructions and

medications.


clients will receive referrals

to additional services to

alleviate housing instability.

HOUSING RETENTION PROGRAM

The PROBLEM addressed by the Poverello Center’s Housing Retention Program:

Many individuals experiencing chronic homelessness have problems that make it difficult for them to

retain housing without additional support. Challenges extend beyond a housing search and the lease-up

process, and may include being able to manage their money, arrange for basic needs such as food and

utilities, and maintain positive relationships with landlords and neighbors. Needs may also include access

to mental health and/or substance use counseling. Research shows that a lack of support in helping to

solve such problems is directly related to formerly homeless individuals’ inability to retain housing23.

According to another study, individuals experiencing chronic homelessness often cycle from homelessness

to housing and back again 5 to 6 times before securing a stable living arrangement24.

Like any other major life transition, moving from homelessness into housing has multifaceted challenges and can be quite stressful. Transitioning individuals are apt to feel anxious about the change, angry or sad about leaving the familiarity of and relationships made in their encampment and/or shelter staff; they may be worried about failure, and/or frustrated that their transition is not exactly how they planned it would be25. Clients may also have positive emotions such as elation about obtaining their own place, but no matter who the person may be, leasing up has a variety of stressors and moving from homelessness into housing is a big adjustment that can be made easier and long-lasting with the right support.

23 National Academies of Sciences. July, 2018. “Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness.” https://www.ncbi.nlm.nih.gov/books/NBK519591/ 24 Wellesley Institute. July, 2009. “Keeping the Homeless Housed: An exploratory study of determinants of Homelessness in the Toronto community.” https://www.wellesleyinstitute.com/wp-content/uploads/2011/11/Keeping-the-Homeless-Housed-final-report.pdf 25 Center for Urban Community Services. “Making the Transition to Permanent Housing.” Corporation for Supportive Housing, U.S. Department of Housing and Urban Development. https://files.hudexchange.info/resources/documents/SHPTransitionPermanentHousing.pdf

https://www.ncbi.nlm.nih.gov/books/NBK519591/

https://www.wellesleyinstitute.com/wp-content/uploads/2011/11/Keeping-the-Homeless-Housed-final-report.pdf

https://www.wellesleyinstitute.com/wp-content/uploads/2011/11/Keeping-the-Homeless-Housed-final-report.pdf

https://files.hudexchange.info/resources/documents/SHPTransitionPermanentHousing.pdf

GOALS of the Poverello Center’s Housing Retention Program:

1) To ensure that homelessness in Missoula is non-recurring. When instances of homelessness do happen, they are quickly resolved and because of the efforts of the Housing Retention Program and MCES team, they are one-time only.

2) To improve the health and well-being of formerly homeless individuals while decreasing community costs of care.

3) To assist clients leaving a rental situation in avoiding eviction and retaining Housing Choice Vouchers.

4) To maintain vital supportive relationships with individuals who are either newly housed, at-risk of losing their housing, or are experiencing a recurring episode of homelessness.

MEASUREMENT TOOLS:

1) The Homeless Management Information System (HMIS) b. Housing Retention Specialist collects release of information from clients if they do not

already have one c. Used for data sharing in the Missoula Coordinated Entry System

2) Housing Retention Program client information spreadsheet a. Client demographics b. Housing entry date c. Housing exit date (if applicable) d. Income source (employment and/or benefits) e. Self-report of improved sense of well-being

i. Needs to be added to the spreadsheet 3) Case notes

a. Daily case work documentation b. Housing Retention Specialist observations, including client well-being c. Documentation of interactions with landlords/housing liaisons d. Assess whether or not a client gains/maintains income sources

4) Client Wellness Survey a. Needs to be generated b. A self-reported wellness survey administered upon entry into program then 4 months after

being housed c. Gift cards used as incentive to complete surveys.

5) Frequent User System Engagement (FUSE) Data sharing a. Can this data track use of emergency services by Housing Retention clients? Pre/post

program entry? i. Hypothesis is that it would demonstrate decrease in community costs of care-goal 2

6) Individual Service Plan (ISP) a. Tool used in housing retention for Veteran Programs

The Poverello Center’s Housing Retention Program: History and Rationale

The Poverello Center’s Housing Retention Program assists individuals in Western Montana through the sometimes-cycle of housing to homelessness and back again and produces positive individual and community outcomes. Individual health and well-being improves the longer people remain housed. As we are able to keep more people in housing longer and prevent homelessness altogether, community costs of homelessness will decline. Some cities report a savings of $20-30,000 per housed individual per year on emergency services under a Housing First model,26 on which program practices are loosely based. Under the Housing First approach, two separate program models have evolved: Permanent Supportive Housing (PSH) and Rapid Re-Housing (RRH). The Poverello Center’s Housing Retention Program uses the RRH model and incorporates a Critical Time Intervention (CTI) strategy, tapering client support over time.

According to the National Alliance to End Homelessness (NAEH), PSH has a housing retention rate of up to 98 percent; RRH programs demonstrate between 75 and 91 percent retention rates for households after one year of being re-housed27. In spite of their lower retention rates, one study showed that individuals who participated in RRH programs experienced homelessness for an average of only two months. The NAEH adds that typically, a majority of clients elect to participate in optional supportive services after entering housing, resulting in greater housing stability. PSH models are “permanent” because they acknowledge that many individuals experiencing chronic homelessness will likely not ever be able to retain housing without support and they will not be well served by time-limited RRH models, in which they would cycle back into homelessness. While PSH programs demonstrate higher rates of housing retention, they also require more intensive program supports and resources – those which the Poverello has not yet acquired.

In 2018, Missoula Coordinated Entry System (MCES) partners, who span a variety of services throughout the county, agreed on a need to transition from a housing navigator at the Poverello Center to a Housing Retention Program to serve the whole MCES. In conjunction with the recent addition of a Landlord Liaison to MCES, the Housing Retention Specialist, a position unique to the Poverello throughout the Missoula community, has the potential to powerfully strengthen the entire coordinated entry system by preventing future episodes of homelessness once people obtain housing, and enables us to turn the momentary excitement of signing a lease into long-term housing success.

ASSUMPTIONS of the Housing Retention Program:

The assumption that people want support after acquiring housing (research shows that most do).

That the HR Program will have capacity to work with every newly-housed individual needing support

The assumption that moving from homelessness into housing is easy for individuals. There tends to be

a general lack of acknowledgement that the transition can actually be quite stressful, as is any major

life transition.

26 City of Missoula. “Reaching Home: Missoula’s 10-Year Plan to End Homelessness.” https://www.ci.missoula.mt.us/DocumentCenter/View/37773/Reaching-Home-Missoulas-10-Year-Plan-to-End-Homelessness-PDF 27 National Alliance to End Homelessness. April, 2016. “Rapid Re-Housing Fact Sheet: Housing First.” http://endhomelessness.org/wp-content/uploads/2016/04/housing-first-fact-sheet.pdf


http://endhomelessness.org/wp-content/uploads/2016/04/housing-first-fact-sheet.pdf

HOUSING RETENTION PROGRAM LOGIC MODEL

INPUTS/RESOURCES





Once completed or underway, these activities will produce the following evidence of service delivery:



$ – Program expense budget

1 FTE Housing Retention

Specialist

Physical office space at the

Poverello Center emergency

facility

Computer, telephone, office

supplies

HMIS Account

Invest time in building rapport and relationships based in trust with clients

Aid clients in the lease-up and move-in process; help clients access resources to acquire basic furnishings

Help clients build and maintain relationships with landlords and neighbors; assist them in resolving minor conflicts

Assist clients in budgeting; paying rent on time/ in required format; gaining or maintaining a source of income, through either employment or entitlement benefits; accessing food; establishing other routine habits necessary to retain housing Work with clients to find

To provide services based on

the Rapid Re-Housing and

Critical Time Intervention

case management models to

30% of the individuals

housed through the Missoula

Coordinated Entry System.

To ensure that < 30% of

those who moved into

housing and received housing

retention services return to

homelessness.

To ensure that at least 50%

of the individuals supported

either gain or maintain a

source of income, through

either employment or

benefits.

To have 20% of housing

retention clients who stay

housed for four months or

more self-report improved

Recurring episodes of

homelessness in Missoula

County will decrease.

Decrease in rates of chronic

homelessness throughout

Western Montana

Individuals in Missoula

County will be more willing

to access services

Landlords will have better

working relationships with

individuals who formerly

experienced homelessness

and will be more willing to

lease properties to housing-

ready clients.

Newly housed individuals will

obtain higher levels of well-

being and better health

outcomes because they are

retaining housing

Clients will better manage

The Housing Retention Program will become a homeless services staple in the Missoula Community and will develop a reputation for being able to provide necessary supports as soon as individuals acquire housing. Given housing availability in the City/County of Missoula, the Housing Retention Program will become a demonstrated safety net for individuals who would otherwise enter the sometimes-cycle of homelessness to housing and back again.

The Missoula community will have seen the value and need for the Housing Retention Program and will invest in expanding the program so it may adopt the

ways to manage loneliness, disability, mental health and/or substance use issues and provide transportation to services as needed. Use the Critical Time Intervention (CTI) model of case management to collaborate with clients on a schedule of diminishing support over time (i.e. more meetings and intensive supports take place when case management is first established, tapering toward less intervention at the end of a period of 8-12 months).

Coordinate with the Poverello’s Homeless Outreach Team and other community partners to assist clients in accessing housing, building relationships that reinforce supports.

health and/or feelings of

improved well-being (lower

stress/anxiety, greater sense

of safety and security, etc.)

mental illnesses, substance

use disorders, physical

disabilities and/or loneliness

due to Housing Retention

Program support

Clients will avoid evictions

and maintain housing

vouchers, therefore avoiding

a potentially long episode of

homelessness as they wait

for another opportunity to

access a voucher.

Community costs of care will

reduce

PSH model, increasing housing retention rates to nearly 100 percent.

RECCOMENDATIONS & REVEALED GAPS

General recommendations:

Fairly significant gap in data collection systems

Physical space – not enough room in emergency facility. Building is not big enough.

Finding a balance between low-barrier service delivery and safety

The need in our community is larger than our capacity to address it

Shelter Program:

• Tracking diversion trainings rather than quantity of clients diverted to measure diversion success

• Tracking the median length of stay rather than the average length of stay would more accurately

reflect our progress toward reducing length of time individuals spend homeless in Missoula.

• Using annual averages rather than quarterly goals in order to accommodate seasonal differences in

numbers.

• Budget number still needs to be added to shelter model.

Food Programs:

• Ideas for future exploration – Swipe cards? • Sack lunch tracking system

• Data tracking within the food programs has historically been a challenge. Presently, a system needs to

be put into place to track sack lunches. Staff have been strategizing ways to better measure meals

served, as the current manual meal sign-in is inaccurate at best.

• Resident Volunteer’s service hours in Food Programs must be better tracked on the

daily/weekly/monthly and annual basis.

Homeless Outreach Team:

The demand for the HOT’s services has grown over the years, under all three of its focus areas: direct client outreach, community outreach and education, and coordinated outreach. Team members report that because of this growth, they feel that they are not getting enough client outreach done, and too much time is being spent in community meetings. To help regulate and refocus this work, team members recommend tracking outreach hours alongside meeting hours, ensuring that outreach hours do not exceed those spent in meetings.

Relationships are paramount within HOT’s work. Among team members, there is a desire to establish peer support as an offshoot of the HOT. Some team members feel this added activity would increase positive outcomes.

The need to expand outreach and collaborative efforts beyond the city/county limits to more remote areas, including agencies in hard-to-reach communities. Outcomes could include preventing homelessness in neighboring communities; decreasing need for unsheltered individuals to travel to Missoula to access services

Deeper development/ integration of the Housing Retention Program; Need for an At-Risk Housing Outreach Team

Need for mobile services; service delivery to more remote areas

HOT members’ concern regarding the continuity of care, specifically: Accessing housing, housing retention, advocacy for low-income individuals, safety

Veteran Programs:

• No recommendations or gaps to report. The Poverello’s Veteran Programs, being very much tied to the VA, follow external guidelines and must meet objectives set forth by the VA. If anything, this reveals the desirability of being financially autonomous, operating separately from the VA in order to set objectives that the Poverello feels would best meet the needs of its Veteran clients.

Medical Respite Program:

• Should program use gift cards as incentive for clients to complete survey?

• How often should staff and providers complete surveys?

• Are Formstack/ StatCrunch tools that the rest of the organization could benefit from using?

• There is a level of care needed beyond the Medical Respite Program, particularly for those who are

chronically ill and experiencing homelessness. This is a gap in our community that still needs to be

filled.

Housing Retention Program:

• Is there a way to illustrate how much the Housing Retention Program is saving the community? Something like: each client served in the program X the amount of months spent in the program = $X savings. The "Reducing cost" outcome will be difficult to measure unless we have some sort of formula like we have for Med Respite.

• Would it be reasonable to tally or measure how many evictions the HRS helped avoid, and/or how many vouchers the HRS helped retain? This metric is messy, but could be something.

• The City of Berkeley's Housing Retention Program provides grant assistance to help pay back-rent to prevent Berkeley residents from being evicted. Thoughts on exploring a similar structure with the Pov?

• While the Housing Retention Program currently follows a Rapid Re-Housing model (and CTI), it seems desirable to eventually move toward the Permanent Supportive Housing model – I suppose that’s what the Trinity project is moving toward, yeah? Moving the Housing Retention Program to the PSH model would certainly require a lot of additional capacity which just might not be in the Pov’s wheelhouse.

• “Warm hand-off” from HOT to the HRP – Staff concerns regarding the continuity of care. The HOT addresses individuals’ immediate needs, helping them stabilize so they may work toward a long-term housing solution. After a HOT client enters into housing, theoretically, their case is transferred to the Poverello’s Housing Retention Specialist. Staff report client push-back on this. Does this segmentation benefit the system or person?

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