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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
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/
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
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/
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/
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
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
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:
We expect that if
completed, these activities
will lead to the following
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
individuals experiencing
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
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
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):
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.
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):
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.
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):
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/
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
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,
there will be 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 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
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):
Ho
usi
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
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):
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
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
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):
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
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.
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
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:
We expect that if completed,
these activities will lead to
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.
75% of medical respite
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
individuals experiencing
homelessness
Longevity of client’s lives and
limbs
Cultural shift: education
among individuals
experiencing homelessness
for access to other resources
Stabilizing impact of
individuals experiencing
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
85% of medical respite
clients will comply with
doctor’s instructions and
medications.
75% of medical respite
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
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
HOUSING RETENTION PROGRAM LOGIC MODEL
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:
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):
$ – 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?