A Qualitative Case Study of the

Coordinated Entry for All

System in King County, WA

U.S. Department of Housing and Urban Development | Office of Policy Development and Research

Disclaimer The contents of this report are the views of the contractor and do not necessarily reflect the views or policies of the U.S. Department of Housing and Urban Development or the U.S. Government.

A Qualitative Case Study of the Coordinated Entry for All

System in King County, WA

Prepared by:

Molly Brown, Ph.D.

DePaul University Department of Psychology

Rachel Fyall, Ph.D.

University of Washington Evans School of Public Policy & Governance

Quinmill Lei, M.A.

Camilla Cummings, M.A.

Cori Cafaro, M. Sc, M.A.

Anh-Dao Tran, M.P.H.

DePaul University Department of Psychology

Sam Tsemberis, Ph.D.

Pathways Housing First

October 2021

Acknowledgments

We thank our funders, the U.S. Department of Housing and Urban Development’s Office of Policy Development and Research, for supporting this study. We are grateful for the time and effort of our collaborating agencies for facilitating participant recruitment, as well as our study participants for sharing their valued perspectives.

Foreword

Since 2012, HUD required each Continuum of Care (CoC) to establish and operate a

“centralized or coordinated assessment system,” commonly referred to as “coordinated entry”

(CE), to increase the efficiency of local crisis response systems and improve fairness and ease of access to resources, including mainstream resources. While some communities began developing and implementing CE systems through the Homelessness Prevention and Rapid Re-Housing Program (HPRP), consolidating disparate homelessness service providers into one coordinated system is a complex systemic change that takes time. In 2017, HUD provided additional requirements for CE and required CoCs to establish or update their CE process per the additional requirements by 2018. At the time of the data collection for this study (2019), CE was still in the early phase of implementation.

This study adds to a growing body of literature about challenges with CE housing assessment measures, which include the Vulnerability Index - Service Prioritization Decision Assistance Tool (VI-SPDAT) and other private tools (not endorsed by HUD) that communities have adopted to assess client needs. Prior studies have identified other challenges related to housing access and housing placement outcomes. This study contributes to the literature by describing the experience of various stakeholders with CE implementation at one CoC.

This research, conducted in 2019, is a case study of the CE system for single adults experiencing homelessness in Seattle-King County, Washington, one of the largest populations of individuals experiencing homelessness in the United States. 1 This qualitative study uses interviews and focus groups with stakeholders—tenants, persons formerly experiencing homelessness who were housed through the CE system, frontline service provider staff, and CE policy and organization leaders—along with a review of relevant meeting notes, presentations, and attendance of meetings. It documents King County’s CE structure, processes, and procedures; examines the benefits and challenges in system implementation; and identifies similarities and differences in perspectives among stakeholders.

This study finds that while CE structures, processes, and procedures at the time aligned with HUD guidance on their face, challenges and barriers led to gaps between guidance and implementation of CE’s four core elements: access, assessment, prioritization, and referral.

Those interviewed raised several issues that could be addressed when making improvements to the CE system, including:

• Perceptions that the system was disempowering, especially for stakeholders with marginalized identities.

1 U.S. Department of Housing and Urban Development. 2021. The 2020 Annual Homeless Assessment Report (AHAR) to Congress. Part 1: Point-in-Time Estimates of Homelessness. Retrieved from

https://www.hudexchange.info/resource/6291/2020-ahar-part-1-pit-estimates-of-homelessness-in-the-us/.

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• Concerns about accuracy, reliability, and racial bias of the psychometric properties of the VI-SPDAT used to assess individual vulnerability and needs. 2

• Concerns about the implementation of case conferencing, including lack of participation by some providers and clients, which resulted in perceptions of unfairness or lack of transparency.

• Challenges with sufficient housing navigation for prioritized individuals, which led some housing referrals to mismatch client needs with their housing preferences, hindering client agency and choice.

• Lack of low-income housing and high community need in King County, which hindered effective implementation and weakened community perception of its efficacy and value.

Even though the study found some significant challenges and barriers, there were benefits to how CE was implemented at every level, including:

• Fostering a sense of community and connection across the CoC for those familiar with CE processes.

• Providing transparency of resources across providers.

• Offering case conferencing that promotes a more human, holistic assessment of vulnerability and strong connections between client and provider to facilitate housing placements and lead to better outcomes.

This study provides insights from CE implementation during calendar year 2019 in one community, including from people with lived experience and direct service staff. This research is in line with what HUD is learning from other grantees implementing CE and highlights the importance of including lived experience in policy and program implementation and research and program evaluation. The themes this study identified highlight issues and potential solutions for CE that could inform future HUD efforts and assist other communities currently implementing CE to improve its effectiveness.

Solomon Greene

Principal Deputy Assistant Secretary for Policy Development and Research U.S. Department of Housing and Urban Development

2 It is important to note that HUD does not endorse or prescribe any specific assessment tool. CoCs have developed their own assessments or adopted existing or “off-the-shelf” assessment tools, including the VI-SPDAT. The prioritization methodology used in King County has not relied on the VI-SDPAT since October 2020 and the VISPDAT has been removed entirely from Coordinated Entry since March 2022.

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Table of Contents

Foreword ........................................................................................................................... iii

Executive Summary ....................................................................................................... viii

Introduction ....................................................................................................................... 1

Overview of Coordinated Entry ...................................................................................... 1

King County’s Coordinated Entry for All System .......................................................... 3

Project Background and Rationale ................................................................................. 4

Method ............................................................................................................................... 5

Sample and Recruitment ................................................................................................. 5

Tenant Sample ............................................................................................................ 5

Staff Sample ................................................................................................................ 6

Policy Leader Sample ................................................................................................. 6

Data Collection ............................................................................................................... 7

Procedure ........................................................................................................................ 9

Analysis .......................................................................................................................... 9

Results .............................................................................................................................. 11

Tenant and Staff Participant Demographics ................................................................. 11

CEA Structures, Processes, and Procedures ................................................................. 14

Overall CEA Structure .............................................................................................. 14

CEA Access and Assessment Processes ................................................................... 16

Dynamic Prioritization and Case Conferencing........................................................ 17

Referrals and Housing Placement ............................................................................. 18

How CEA Benefits and Facilitates Homeless Service Delivery .................................. 19

Overall CEA Structure .............................................................................................. 19

CEA Access, Assessment, and Assessment Process ................................................ 21

Dynamic Prioritization and Case Conferencing........................................................ 22

Referrals and Housing Placement ............................................................................. 24

Challenges and Barriers in CEA Implementation ......................................................... 25

Overall CEA Structure .............................................................................................. 26

CEA Access, Assessment, and Assessment Process ................................................ 30

Dynamic Prioritization and Case Conferencing........................................................ 36

Referrals and Housing Placement ............................................................................. 38

Trade-offs and Tensions from the Policy Perspective .................................................. 41

Overall Systemic Context ............................................................................................. 44

Recommendations for Improving CE Systems ............................................................. 47

Discussion of Findings .................................................................................................... 49

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Threats to Fairness: Street-Level Advocacy and Value Conflict ................................. 50

Exacerbation of Inequity ............................................................................................... 52

Affordable Housing Scarcity ........................................................................................ 53

Adapting to Challenges ................................................................................................. 54

Study Limitations .......................................................................................................... 55

Recommendations ........................................................................................................... 55

Conclusion ....................................................................................................................... 57

References ........................................................................................................................ 58

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List of Exhibits

Exhibit 1. Sample by Focus Group and Interview Participation .................................................... 7

Exhibit 2. Tenant Sample Demographics (N = 18) ...................................................................... 12

Exhibit 3. Staff Sample Demographics and Roles in Coordinated Entry for All (N = 27) .......... 13

Exhibit 4. Overview of the Coordinated Entry for All Process .................................................... 14

Exhibit 5. Themes Related to the Benefits and Facilitators of the Overall Coordinated Entry

for All Structure .................................................................................................... 21

Exhibit 6. Themes Related to the Benefits and Facilitators of the Access, Assessment, and

Assessment Process .............................................................................................. 22

Exhibit 7. Themes Related to the Benefits and Facilitators of Dynamic Prioritization and

Case Conferencing ................................................................................................ 24

Exhibit 8. Themes Related to the Benefits and Facilitators of Referrals and Housing

Placement .............................................................................................................. 25

Exhibit 9. Themes Related to the Challenges and Barriers of the Overall Coordinated Entry

for All Structure .................................................................................................... 29

Exhibit 10. Themes Related to the Challenges and Barriers of the Access, Assessment, and

Assessment Process .............................................................................................. 35

Exhibit 11. Themes Related to the Challenges and Barriers of Dynamic Prioritization and

Case Conferencing ................................................................................................ 38

Exhibit 12. Themes Related to the Challenges and Barriers of Referrals and Housing

Placement .............................................................................................................. 41

Exhibit 13. Themes Related to the Trade-offs and Tensions from the Policy Perspective .......... 44

Exhibit 14. Themes Related to the Broader Systemic Context ..................................................... 46

Exhibit 15. Recommendations for Improving CEA ..................................................................... 49

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Executive Summary

Study Overview

Continuums of Care (CoCs) throughout the United States are implementing coordinated entry (CE) systems in community-wide efforts to address homelessness. CE systems intend to promote access to housing services for households experiencing homelessness through a

“coordinated front door” approach to entering a unified system for prioritizing housing resources. Through the utilization of standardized assessments of vulnerability and service needs, CE systems aim to ensure that adults, youths, and families receive housing and support services commensurate with their needs. Research on CE systems is limited, and this case study of Seattle-King County’s Coordinated Entry for All (CEA) system is the first to examine various stakeholders’ perspectives on how CE facilitates or creates barriers to housing individuals experiencing homelessness. Single adults constitute the largest population of persons experiencing homelessness in the local area (HUD, 2021), involve the largest number of provider agencies, and experience the greatest mismatch between population size and available housing resources. Thus, the study centered on CEA for single adults, specifically, to elucidate implementation issues in a particularly challenging context. The study addressed the following research questions:

1. What are the CEA structures, processes, and procedures for single adults experiencing homelessness?

2. In what ways does CEA benefit or facilitate homeless service delivery for single adults in the Seattle-King County area?

3. What challenges or barriers exist in CEA implementation?

4. In what ways do views on CEA’s facilitators and challenges align and vary across stakeholder groups?

5. How has CEA been adapted over time to address challenges?

6. What recommendations do stakeholders have for improving CE systems?

Method

Study participants represented the following stakeholder groups: (a) tenants who were recently housed through the CEA system ( n = 18), (b) direct service staff working in various roles in the CEA system ( n = 27), and (c) policy leaders involved in CEA leadership and oversight ( n = 11). Purposive sampling was employed to ensure a breadth of representation across service organizations within the samples. Data collection occurred between January 2019

and November 2019. Participants engaged in focus groups and interviews tailored to each participant group. The qualitative data were analyzed to identify common themes. Converging and diverging themes emerging across stakeholder groups were also examined.

CEA Structures, Processes, and Procedures

Participants described CEA as comprising the four U.S. Department of Housing and Urban Development (HUD) coordinated entry core elements of access, assessment, prioritization, and referral. (HUD, 2017a). The core elements were implemented as follows: viii

• People experiencing homelessness had multiple points of access to CEA through Regional Access Points, homeless outreach, shelters, and other services.

• To gain entry to the system, participants were assessed with the Vulnerability Index-Service Prioritization Decision Assistance Tool (VI-SPDAT).

• Individuals assessed to be the most vulnerable based on VI-SPDAT scores and homelessness history received priority for available housing units in the CoC.

• A case conferencing process occurred such that providers across the CoC met to discuss the housing needs of clients on the priority list and nominate them for housing referrals.

• Individuals referred to housing were contacted and assisted with their housing placement.

However, as results will show, there were implementation challenges that led to divergences with HUD’s (2017a) guidance on the four elements.

CEA Benefits and Facilitators

Participants identified benefits and facilitators at every juncture of the CEA system, including the following notable themes:

• Participants felt the system facilitated a sense of community and connection by promoting a collaborative effort among providers across the CoC. They also noted that CEA improved transparency of resources due to information sharing across providers.

• With regard to the assessment process, participants expressed that trusting client-assessor relationships facilitated accurate assessments.

• Participants viewed case conferencing as a superior procedure for allocating housing referrals compared to solely basing referrals on assessment scores, because it promoted humanization and a holistic assessment of vulnerability, which led to better outcomes for matching individuals to appropriate housing opportunities.

• Housing placements were facilitated by strong connections between the client and provider as well as flexibility with housing documentation, such as extending deadlines for clients to submit their housing application paperwork.

CEA Challenges and Barriers

Themes regarding the challenges and barriers in CEA generally outweighed the benefits and facilitators. Select themes are presented below:

• The overall system was perceived to disempower clients, staff, and organizations, as stakeholders at all levels of the system lost control of their ability to advocate for themselves and others and deliver services as preferred. Furthermore, the voices of stakeholders with marginalized identities were hindered by the system.

• Concerns were raised about the psychometric properties of the VI-SPDAT assessment such that there were barriers to gaining accurate assessments and that not all aspects of client vulnerability were captured on the measure. Furthermore, participants described concerns about CEA data indicating that the VI-SPDAT showed bias against Black/African American individuals.

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• There were drawbacks to the implementation of case conferencing, including representation and accessibility issues and missing client voice. Many providers were unable to attend case conferencing due to the time commitment, and clients were not invited to attend.

• Challenges with housing placements included mismatching of client needs and preferences and housing, which also hindered client agency and choice in their housing placements.

• Participants acknowledged that effective CEA implementation was particularly hampered by the lack of affordable housing and the high community need in King County.

Discussion and Recommendations

Study findings suggest that many benefits of CEA were met with parallel challenges. For instance, although CEA was viewed as leveling the playing field for clients to access housing, regardless of their ability to self-advocate or receive advocacy by providers, there were examples of advocacy influencing client housing prospects at every step of the CEA system. Issues of racial equity, and equity for populations with other marginalized identities, were woven through the CEA challenges and barriers themes. For example, the VI-SPDAT and assessment process were viewed as lacking cultural sensitivity, disregarding the impact of racial trauma and oppression on the reliability and validity of the assessment. Thus, this study illustrates mechanisms driving racial disparities in CEA housing placements that were previously reported in King County.

CE systems are intended to be adaptable to unique community contexts and responsive to implementation challenges. In King County, we identified several ways in which the community adapted to emerging concerns. For example, the introduction of case conferencing aided in reducing mismatches between client needs and housing. Additionally, reducing reliance on VISPDAT scores for housing prioritization aimed to address equity issues in the system. The current study points to a series of additional recommendations for CE systems, including: 1. Ongoing monitoring and evaluation for system adaptability and improvement: Regular evaluations should utilize an equity-based framework to ensure that CE systems function equitably for all individuals, meaningfully include groups most impacted by homelessness, and direct service staff in system design decision-making.

2. Reconsider the use of the VI-SPDAT: Given that concerns with the VI-SPDAT have been raised in the King County community for years, and that research calls into question its reliability, validity, and equitability based on race and gender, the use of the tool should be reconsidered. Some participants expressed support of a “multiple pathways”

approach that would move beyond reliance on a single assessment tool for prioritization.

3. Consider the (mis)match between housing stock and needs in CE systems: Participants felt that meaningfully addressing homelessness in the community would require a much broader affordable housing approach that would include permanent supportive housing (PSH) and non-PSH affordable housing stock. Alternatively, dividing the single adult pool into smaller subpopulations (such as those considered chronically homeless), and associating those subpopulations with relevant housing programs, could lead to better outcomes overall.

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4. Increase transparency in the system: Strategies for increasing transparency in procedures and decision-making is needed. Additionally, individuals experiencing homelessness should be provided with clear and accessible information about the system and have access to information about their status on the housing priority list.

5. Acknowledge the cost and added value of CE systems: Implementing a CE system requires resources proportionate to the scale of the population needing services. Greater acknowledgment about the true costs of implementing a CE system—and the extent to which CE resources could be directed to housing provision—should be incorporated into decision-making about whether or not CE systems should be universally recommended.

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Introduction

For nearly a decade, coordinated entry (CE) systems have been implemented throughout the United States in community-wide efforts to end homelessness (U.S. Department of Housing and Urban Development [HUD], 2012). In essence, CE involves a uniform and coordinated process of assessing the housing needs of homeless households within a community and prioritizing and allocating housing resources commensurate with need. This contrasts with previous systems, which primarily rely on individual agencies to determine prioritization and allocation from among their clients. Recent studies have identified challenges with CE housing assessment measures and housing placement outcomes (Brown et al., 2018; Cronley, 2022; Dickson-Gomez et al., 2020); however, no prior studies have examined various stakeholders’

perspectives on how CE facilitates and/or creates barriers to housing and CE implementation.

Moreover, CE systems are adapted to community context, and challenges to effective implementation may be particularly notable in communities with scarce housing resources relative to community need. Thus, the current study expands the literature on CE through an in-depth case study of the CE system for single adults experiencing homelessness in Seattle-King County, Washington, which, by most recent estimates, has the fourth largest population of individuals experiencing homelessness in the United States (HUD, 2021). Drawing from interviews and focus groups with tenants, direct service staff, and CE leaders, the study articulates King County’s CE structure, processes, and procedures; describes facilitators and barriers in system implementation; and identifies convergences and divergences in perspectives among stakeholders, including people with lived experience, direct service staff, and policy leaders.

Overview of Coordinated Entry

A key component of the Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act of 2009 was the codification of the Continuum of Care (CoC) Program.

CoCs are local coordinating bodies that drive local strategies to end homelessness, oversee and integrate services for people experiencing homelessness, and conduct community-wide performance management (HUD, 2012a). The 2012 CoC Program Interim Rule and later HUD

guidance introduced plans to establish greater coordination throughout CoCs by increasing access to housing services for people experiencing homelessness. By 2018, CoCs were mandated to design centralized or coordinated assessment systems, which later came to be known as coordinated entry systems [HUD, 2012a; 2012b, 2017a, 2017b] . Communities were to adopt a common, comprehensive, and standardized assessment tool as a uniform method of intaking people experiencing homelessness into services and assessing their housing and service needs.

They were also charged with developing a centralized priority process for allocating housing resources. People who were the most vulnerable or had the most significant service needs received the highest priority for housing (HUD, 2015a). Moreover, CoCs were enabled to incorporate allocation of shelter beds, access to homelessness prevention assistance, and shelter diversion strategies within the CE system (HUD, 2017a). As such, CE systems were conceived with the intent to more efficiently allocate scarce housing resources based on the support service needs of homeless households and prevent people with significant housing needs from falling through the cracks.

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Permanent supportive housing (PSH; for example, permanent affordable housing with ongoing support services) comprises the largest portion of HUD’s CoC budget and, therefore, is the primary form of housing offered within CE systems. Rapid rehousing and transitional housing programs funded by HUD or local resources may also be included within CE systems (HUD, 2017a). CE systems serve all household types, including single adults, families, and youth experiencing homelessness (HUD, 2017a). Within a given CoC, coordinated entry procedures may vary across household types due to the diversity of needs and housing resources across populations of people experiencing homelessness.

According to HUD (2017a), the core elements of coordinated entry include: 1. Access points through which households experiencing homelessness or other housing crises may enter the service system. Access points may include any combination of hotlines, outreach services, shelter services, or other community resource centers.

2. Assessment of the housing needs and mental health, medical, and social vulnerabilities of people who access the system through a standardized

instrument.

3. Prioritization of households assessed as having the greatest housing needs and vulnerability for appropriate housing services.

4. Referral of prioritized households to vacant housing units or other housing resources available throughout the CoC.

CoCs are afforded flexibility with implementation within the core elements based on the context, needs, and resources in their community (HUD, 2017a).

CE systems are held to Fair Housing Act rules such that housing prioritization cannot be based on an individual having membership in a federally protected class (HUD, 2017b). For instance, prioritization cannot be based upon an individual having a disability. Rather, individuals may be prioritized based upon their vulnerability, which is conceptualized by their level of service need, independent of having a particular disability or other personal characteristics (HUD, 2018).

Though CE systems have proliferated throughout the United States, there is limited research on outcomes and best practices. The preponderance of studies has examined the psychometric properties of the Vulnerability Index-Service Prioritization Decision Assistance Tool (VI-SPDAT; De Jong, 2021) coordinated assessment measure (Balagot, Lemus, Hartric, Kohler, & Lindsay, 2019; Brown et al., 2018; Cronley, 2022; Petry, Hill, Vayanos, & Rice, 2021). Together, the studies show mixed evidence for the reliability and validity of the VISPDAT despite its frequent use in CE systems, including King County’s. Beyond assessment, the immense task of coordinating housing access for all people experiencing homelessness in a community may be prone to a number of challenges at various points in the process, from access to housing referral and placement. Furthermore, the ways in which CE systems facilitate communities’ efforts to end homelessness are poorly understood. To date, research has not fully examined the barriers and facilitators across the four core elements of CE systems.

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King County’s Coordinated Entry for All System

King County faced unique obstacles for meaningfully addressing homelessness through a CE approach. In King County, the initiation of CEA occurred on the heels of a 2015 state of emergency declaration on homelessness (City of Seattle, 2017). By 2019, nearly 16,000 single adults accessed King County’s homeless service system at some point within the year (Ewing and McHugh, 2020). The 2019 Seattle-King County Continuum of Care Housing Inventory Count lists adult-only resources consisting of 3,675 beds of emergency shelter, safe haven, and transitional housing along with 4,518 PSH units, 389 rapid rehousing units, and 383 units of other permanent housing (HUD, 2019).

CEA is overseen by the Seattle-King County CoC and staffed by King County employees. King County staff also hold responsibility for CEA monitoring and evaluation. The CoC’s governing board as well as the CEA Policy Advisory Committee (PAC) share decision-making responsibility with the King County staff responsible for CEA implementation. After extensive deliberation, King County and the City of Seattle signed an interlocal agreement in December 2019, establishing a Regional Homelessness Authority (RHA) to align and consolidate the region’s homeless service system. The transition of programs and oversight to the RHA is underway, with the organization’s first Chief Executive Officer joining the organization in April 2021 (King County Regional Homelessness Authority [KCRHA], 2021a). The RHA now holds responsibility for the work of the Seattle-King County CoC, including CEA, which was previously under the purview of All Home King County (a stand-alone organization dedicated to CoC-related work).

CEA activities began in July 2016, ahead of HUD’s required implementation timeline (HUD, 2017b). The community launched a regional effort to assess all households presenting for service assistance for housing prioritization using the “Housing Triage Tool” composed of the VI-SPDAT and supplemental questions (Ewing and McHugh, 2020). Housing prioritization for single adults began in February 2017. Housing interventions for single adults experiencing homelessness included PSH, rapid rehousing, and transitional housing (Ewing and McHugh, 2020). In the first year of CEA, over 8,000 households (single adults, families, and youth) were awaiting housing referrals, and approximately 728 attained housing (Anderson, Ko, Zadeh, and Thompson, 2018; Focus Strategies, 2019). Earlier reports identified 10 agencies operating 36

programs as CEA’s single adult participating programs (King County, 2018). Current tracking that includes CEA across all populations (single adults, youth, families) lists 48 agencies connected to CEA, including 37 agencies that receive CEA referrals (personal communication).

KCRHA (2021b) presents an overview of the process for how households move through the CEA system.

The Seattle-King County CEA has been the subject of several commissioned and internal quantitative evaluations, often focused on demographic equity (Anderson et al., 2018; Ewing and McHugh, 2020; Focus Strategies, 2019). Findings from previous evaluations raise potential challenges in CEA, particularly regarding disparities within the system for individuals of diverse identities. However, evaluations to date have not systematically examined broader facilitators and barriers within the system from the perspectives of key CEA stakeholder groups.

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Project Background and Rationale

The current study emerged in the wake of a previous research endeavor. Our research team had partnered with HUD’s Office of Policy Development and Research (PD&R) to conduct a randomized trial of two models of Housing First delivered by Downtown Emergency Service Center (DESC), a large homeless service provider and Housing First innovator in Seattle, Washington. The initial study aimed to examine predictors of housing and quality of life outcomes for tenants residing in single-site Housing First (such as PSH with support services on site) versus scattered-site Housing First (such as PSH units in integrated apartment buildings).

However, due to a multitude of complex within- and without-study implementation factors, we were unable to complete the trial (Brown et al., 2020). One of the notable barriers to implementation of our randomized trial was working within the CE system. As the research activities began, King County, Washington initiated its Coordinated Entry for All (CEA) system for the single adult population. The experience of navigating a housing study within CEA revealed questions about how the new system functioned to facilitate housing placements for people experiencing homelessness in the community. We heard about several challenges in the CEA system, from assessment to housing placement, which piqued interest in a systematic assessment. A few concerns highlighting CEA’s complexity included:

● Individuals referred for DESC housing through CEA were perceived by staff as having lower support service needs than the population they formerly served.

● In contrast, DESC staff perceived that highly vulnerable DESC homeless outreach clients were not receiving priority for housing within CEA.

● There were significant delays in filling vacant DESC units through CEA referrals (Brown et al., 2020).

There is a paucity of scholarly research and evidence-based guidance on CE system policy and practice. Moreover, cities such as Seattle that are facing drastically rising rates of homelessness have unique challenges to successful CE system implementation. Although the City of Seattle and King County have commissioned a series of evaluations of their homeless service system, including CEA process and outcomes (Anderson et al., 2018; Ewing and McHugh, 2020; Focus Strategies, 2019; National Innovation Service, n.d.), to our knowledge, no independent research studies have examined King County’s CEA system. Therefore, the current case study sought to describe the CEA system and identify facilitators and challenges in the system from the perspectives of a range of stakeholders involved in CEA. In King County, CEA for single adults, youth, and family populations generally operate independently of one another, with mutually exclusive housing resources reserved for each population. Single adults comprise the largest population of persons experiencing homelessness in the local area (HUD, 2021), involve the largest number of provider agencies, and experience the greatest mismatch between population size and available housing resources. The current study centered on CEA for single adults, specifically, to elucidate implementation issues in a particularly challenging context. The study addressed the following research questions:

1. What are the CEA structures, processes, and procedures for single adults experiencing homelessness?

2. In what ways does CEA benefit or facilitate homeless service delivery for single adults in the Seattle-King County area?

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3. What challenges or barriers exist in CEA implementation?

4. In what ways do views on CEA’s facilitators and challenges align and vary across stakeholder groups?

5. How has CEA been adapted over time to address challenges?

6. What recommendations do stakeholders have for improving CE systems?

Method

The study utilized a blend of focus groups and interviews with stakeholders within the King County Coordinated Entry for All (CEA) system. Researchers also reviewed relevant documents, such as meeting minutes and working group presentation slides, and participated in several meetings where CEA implementation was discussed. To generate a comprehensive view of CEA and identify converging and diverging perspectives among those touched by the system in different ways, three stakeholder groups participated in the study: a) people with lived experience who were recently housed through CEA (referred herein as “tenant sample” or

“tenant participants”), b) staff working directly within various system components (referred herein as “staff sample” or “staff participants”), and c) policy leaders and decision-makers working to design and oversee the CEA system (referred herein as “policy sample” or “policy participants”).

Sample and Recruitment

Sampling and recruitment procedures for each of the three stakeholder groups varied due to the nature of the samples. Purposive sampling was employed to ensure a breadth of representation across service organizations within the samples. Partnering organizations were relied upon to facilitate the recruitment of tenant and staff participants, while the policy participants were largely recruited directly by the research team. Preliminary lists of CEA-participating organizations and key personnel were identified through publicly available online sources (see, for example, King County, 2018). The recruitment lists were further refined through word-of-mouth and clarifications provided through agency contacts regarding their services and roles within CEA.

Tenant Sample

The tenant sample was recruited from housing service agencies. A total of nine CEA-participating agencies contacted for the study indicated that they provided housing services for single adults experiencing homelessness. Of these, five agreed to assist with the recruitment of tenants. Participating agencies included the largest PSH providers in King County, Veteran Affairs housing, and transitional housing.

Tenant participants were eligible to participate if they received their housing unit through a CEA referral. They had received housing prioritization through CEA based on demonstrating a high level of vulnerability on the local Housing Triage Tool. Tenant participants were eligible to participate if they were housed within 4 months of study recruitment to ensure they had recent memory of their experience navigating CEA. Finally, participants were eligible if they were age 18 or older and English-speaking.

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Collaborating housing providers were asked to run a query of their internal database or records to identify tenants housed through CEA within the previous 4 months. Staff provided a recruitment flyer to individuals meeting this initial eligibility criterion. Next, prospective tenant participants contacted the study Research Coordinator to confirm their eligibility for study participation. A total of 18 tenants residing in 11 different housing programs operated by the five collaborating housing providers participated in the study. Sixteen tenants resided in programs located in the city of Seattle, and two resided in the broader King County.

Staff Sample

Staff interfacing with CEA were purposively sampled to include those working within each of the primary system components. Specifically, staff comprised four subsamples: 1. Assessors: staff who administered the VI-SPDAT to single adults experiencing homelessness.

2. Case conference members: staff involved in case conferencing meetings to match prioritized individuals with available housing units.

3. Navigators: staff who assisted potential tenants in navigating CEA and housing referrals.

4. Housing providers: housing program staff members who received CEA housing referrals, including staff from PSH and transitional housing programs.

The staff sample was recruited through a combination of partnering agency referrals and directly by the research team through word-of-mouth or when contact information and CEA role descriptions were publicly available. Six organizations agreed to assist with staff recruitment.

Staff were eligible to participate if they interfaced with CEA in a minimum of one of the four roles listed above. To recruit a sample of staff with adequate familiarity with CEA, participants were eligible if their duties involved interfacing with CEA for a minimum of 4

months. Finally, participants were eligible if they were age 18 or older and English-speaking. For staff recruited by collaborating agencies, agency contacts were asked to identify agency staff who were engaged in CEA-interfacing roles and disseminate a study recruitment flyer.

Prospective participants contacted the study Research Coordinator to confirm study eligibility.

Staff recruited directly by the Research Coordinator were contacted by phone or email with a script. A total of 27 staff participated in the study. Staff participants were derived from a total of eight different organizations within the city of Seattle.

Policy Leader Sample

Participants for the policy sample were purposively recruited to engage a range of perspectives from among those involved in the leadership and oversight of CEA. Specifically, interviewees were recruited from current and recent past members of the CEA Policy Advisory Committee, staff from All Home (King County’s CoC), and other government employees in a position of oversight regarding CEA implementation. Participants were eligible if they were 18

or older and involved in CEA implementation. Policy participants were recruited via email and/or phone at their publicly available professional email addresses and phone numbers. Some participants were recruited based on recommendations from other interviewees and/or re-6

direction or delegation from an initial contact to a more knowledgeable individual from the same organization. A total of 11 policy leaders participated in the study, representing 11 different roles across nine organizations. Of the nine organizations represented, three focus primarily on Seattle, three focus on King County broadly, two are multicounty agencies that include King County, and one is a statewide organization.

Data Collection

Tenant and staff samples completed a brief demographic survey indicating their age, gender, and race and ethnicity. Due to the smaller pool of potential participants in the policy sample, demographic data were not collected to protect confidentiality.

Focus group protocols were developed for tenant and staff participants, and an interview protocol was developed for policy participants. The focus group and interview protocols were designed to address the study research questions and were tailored to each participant group.

Focus groups were not feasible for some tenant participants. For example, some tenants had transportation barriers to attend focus groups located outside of their buildings. In these instances, the focus group protocol was adapted to be carried out as a one-on-one interview.

Focus groups were deemed inappropriate for the policy participants given the existing relationships and power differentials among participants (for example, funding agencies and recipients).

Exhibit 1 breaks down the format of participants’ study participation (such as focus group versus interview) by sample. Nine tenants engaged in focus groups consisting of between two and four participants, and nine tenants engaged in one-on-one interviews. A total of five focus groups were held for staff participants. Seven staff participants engaged in a focus group centered on the assessment process, five engaged in a focus group centered on case conferencing, five engaged in a focus group centered on housing referrals and placements, and five engaged in a focus group centered on navigation within CEA. Staff participants were assigned to their respective focus groups based on their self-identified primary role within CEA. A final focus group was held with a role-diverse group consisting of five participants. Nine policy participants engaged in one-on-one interviews. Two additional policy participants, each with different roles within the same organization, participated jointly in an interview wherein each participant answered the questions relevant to them in turn.

Exhibit 1. Sample by Focus Group and Interview

Participation

Sample

Focus Group

Interview

Tenant Sample

9

9

Staff Sample

27

0

Policy Sample

0

11

7

Tenant participants were provided a list of key terms and definitions (such as

“Coordinated Entry for All,” “assessment tool,” “housing referral”) to ensure a common language and understanding of the CEA system. Tenants were asked to think about the steps they went through to attain their current housing placement for the research team to understand the CEA processes and procedures based on lived experience. Sample questions included, “What was the process of getting on a list for housing?” “What types of information did you have to provide to get on the housing list?” “How did you learn about your current housing opportunity?” “Once you were referred for housing, what steps did you need to take to apply?”

Tenants were asked to reflect on the benefits and challenges they experienced in the system with questions such as, “Was there anything that was particularly helpful to you in navigating this system?” and “What were some of the challenges you had during the entire process to get housed?” Finally, participants were asked to discuss suggestions for improving the system for others moving through it.

Staff participants were provided a visual depiction of the broad components of the CEA process to ensure a common language and understanding of the CEA system and to provide staff an opportunity to offer corrections or nuances about the system. The focus group protocols were tailored for each staff subgroup to center on the CEA system component relevant to the subgroup’s primary role within CEA. For instance, assessors were asked questions focusing on the assessment process, whereas housing staff were asked questions regarding procedures occurring from housing referral to housing placement. However, staff frequently served in multiple CEA roles, so they were invited to discuss other aspects of the system that provided further context to the discussion. Staff were asked to reflect on the step-by-step processes relevant to their role. Further, they were asked about benefits and challenges in the system relevant to their role through questions such as, “What is working well to ensure everyone gets an assessment?” and “What are the challenges with case conferencing?” As discussions with partnering organizations illuminated critical concerns with housing equity in CEA, staff participants were specifically asked to reflect on equity issues (such as, “How do you feel the current system serves a diverse population of single adults?”). Finally, staff were asked to reflect on changes made to the system over time to address challenges and share recommendations for further improvement.

Given the diverse roles and organizations represented by the policy participants, policy interviewees were asked to start by describing their current and recent past relevant professional positions and organizational affiliations, their current and/or former role(s) associated with CEA leadership and/or oversight, and the length of time they have been involved in CEA leadership.

The position and experience of the participant guided the next part of the interview, probing the CEA system component(s) (assessment, prioritization, case conferencing, housing services) most relevant to the participant, with conversations generally focused on how a particular process or component originated and/or has evolved over time. Policy participants were also asked about their perspective on CEA leadership through the question, “Who is ‘in charge’ of CEA?” The next set of questions asked participants to provide a more holistic reflection on the implementation, benefits, and challenges experienced with CEA for single adults in King County. In addition to questions probing the benefits and challenges, the protocol also prompted reflections on the dynamic nature of implementation, such as, “To what extent were these challenges recognized and managed?” and “What are some potential improvements to CEA to 8

make it more effective and/or reduce challenges? Furthermore, participants were asked about the role of HUD in CEA implementation. Several questions asked participants to consider a longer time horizon, asking participants to offer an overall assessment of CEA and reflect on the long-term impact, asking, “Thinking back on homeless service delivery in King County before CEA, what do you think has improved? Do you think implementing CEA was the right decision?”

Finally, participants were asked to offer advice to other communities on how they should go about the design and implementation of CEA in their own communities.

Procedure

Study procedures were approved by the DePaul University and University of Washington Institutional Review Boards. Data collection occurred between January 2019 and November 2019. In collaboration with partnering agencies and the availability of tenant and staff participants, focus groups and interviews were scheduled to occur in housing programs or service agencies. Policy participants were scheduled for interviews at a time convenient for them, and interviews occurred in a private location of their preference. Tenant and staff data collections were co-facilitated by the Principal Investigator and Research Coordinator, and the Co-Principal Investigator conducted data collection for the policy group. Prior to the start of the focus groups, participants provided informed consent. They were given ground rules for the discussion (for example, one person speaks at a time, ensure all have a chance to speak, converging and diverging opinions may be expressed among members, and protect confidentiality of other participants). Interviews and focus groups lasted from 60 to 120 minutes and were audio recorded. Tenant and staff participants were provided a meal and a $25 honorarium for participation. Policy group interviewees were not compensated, but interviews occurred within the course of their paid workday.

Analysis

Audio recordings were professionally transcribed for analysis. The study utilized a mixed deductive and inductive approach regarding thematic analysis. Deductive coding procedures were used to sort the data as they aligned with the study research questions based on whether they were descriptive of CEA or addressed a barrier or facilitator of CEA, as well as the CEA component to which they related (such as assessment, referral, etc.). Inductive coding procedures were employed to allow for the emergence of themes originating from participants as opposed to fitting the data to preconceived themes originating from the researchers. The aim of the analysis was to identify themes—or common ideas—presented among participants as they related to the study research questions and each component of the CEA system. Thematic coding largely followed the steps outlined by Braun and Clarke (2006), was systematic, and involved consensus procedures at each step.

Qualitative data coding for the three participant groups was conducted separately. For the tenant sample, there were a total of 13 transcripts between focus groups and one-on-one interviews. First, an initial seven transcripts underwent an open coding process. All data were broken into smaller chunks, and the information was paraphrased in brief summaries that remained true to the participants’ words. Multiple coders achieved consensus on the open coding process, and once procedural consensus was achieved, coders independently conducted the 9

remainder of the open coding process. Second, open codes were organized into broader thematic concepts. A codebook was developed with the organizing themes, theme definitions, and coding rules. Third, an assessment of inductive thematic saturation was conducted to determine the extent to which the remaining transcripts produced new themes (Saunders et al., 2018). Through this process, the codebook was applied to the remaining six tenant transcripts, and minor modifications to existing themes and major modifications or additions of new themes made to the codebook based on the new data were tracked. No new superordinate themes were added, or major modifications to existing themes made to the codebook, suggesting saturation was achieved based on the new information threshold of ≤ 5% (Guest, Namey, and Chen, 2020).

Finally, all transcripts were coded using the finalized codebook in NVivo Version 11 software.

Two coders codebook coded and reached consensus on the same transcripts until an intercoder reliability of Cohen’s Kappa ≥ .80 was established, suggestive of acceptable to perfect agreement (Lombard, Snyder-Duch, and Campanella Bracken, 2004; MacPhail, Khoza, Abler, and Ranganathan, 2016). Once intercoder reliability was established, each coder was assigned the remaining transcripts to code independently; however, consensus meetings did occur as uncertainties and questions about coding arose.

The same coding strategy was applied to the five staff focus group transcripts. The initial codebook was generated based on themes emerging from open codes of four of the five transcripts. The fifth transcript was utilized for saturation tracking. One overarching superordinate theme was added to the codebook from this final transcript, adding 5.2 percent new information to the codebook, nearly meeting the new information threshold of ≤ 5 percent (Guest et al., 2020). During the NVivo codebook coding process, adequate intercoder reliability of Cohen’s Kappa ≥ .80 was not established due to the complexity of the codebook and variability in topics of focus across the five focus groups. As such, each of the five transcripts were independently coded by two coders, the coding was compared, and consensus was achieved for all coding disagreements.

It was anticipated that the policy sample would yield many of the same themes as the staff participants. As such, the staff codebook and the policy interview guide were utilized as the basis for the policy sample codebook. The policy codebook was applied to a single interview, and then the research team would meet to discuss theme additions, subtractions, and refinements to the codebook based upon themes emerging. This process repeated itself until saturation was achieved (Guest et al., 2020), wherein no new codes were identified by the 5th interview transcript. Based on this strategy, two additional superordinate themes were added. Intercoder reliability of Cohen’s Kappa ≥ .80 was not established through NVivo coding. As such, a parallel consensus process to the coding of the staff transcripts was conducted.

Data analysis and synthesis occurred through a cross-case analysis process in which all data for each theme were summarized in a framework matrix (Miles and Huberman, 1994). This process served to both distill the data and reduce bias in the analytic process by ensuring all data were included.

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Results

Following an overview of tenant and staff demographics, study results are presented in the order of the stated research questions and are organized by components of the Coordinated Entry for All (CEA) system, with some exceptions. Specifically, Research Question 4 seeks to identify the ways in which views on CEA align and vary across stakeholder groups, and Research Question 5 examines how CEA has been adapted over time to address challenges. Both research questions provide nuance and context to describe the CEA processes, procedures, benefits, and challenges; therefore, they are embedded throughout the results. Furthermore, some relevant themes did not explicitly fit within a particular research question but were critical for illustrating CEA implementation. Therefore, themes related to trade-offs and tensions from the policy perspective, as well as the overall systemic context are presented separately. The results conclude by addressing Research Question 6, identifying recommendations for CE systems.

Tenant and Staff Participant Demographics

Demographic information for tenant and staff participants is reported in exhibits 2 and 3, respectively. The 18 tenant participants were an average age of 49.4 years old. More than half were cisgender men (55.6 percent), and the remaining participants were cisgender women (44.4

percent). The sample was racially and ethnically diverse.

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Exhibit 2. Tenant Sample Demographics (N = 18)

Age M

49.4

Gender N (%)

Cisgender Men

10 (55.6)

Cisgender Women

8 (44.4)

Race/Ethnicity N (%)

Non-Hispanic White

6 (33.3)

Non-Hispanic Black

5 (27.8)

Hispanic of Any Race

3 (16.7)

American Indian or Alaska Native

2 (11.1)

Multiracial/Multiethnic

2 (11.1)

The 27 staff participants were an average age of 39.3 years old. The sample was predominantly composed of cisgender women (63.0 percent), and the remaining participants were cisgender men (37.0 percent). Compared to the tenant sample, the staff sample had a greater proportion of participants identifying as non-Hispanic White (66.7 percent). The vast majority of staff ( n = 21, 72.4 percent) served in more than one role within CEA. For instance, case conference members may have also been housing providers and assessors within the system.

In addition to demographics, exhibit 3 presents staff roles within CEA.

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Exhibit 3. Staff Sample Demographics and Roles in Coordinated Entry for All (N = 27)

Age M

39.3

Gender N (%)

Cisgender Men

10 (37.0)

Cisgender Women

17 (63.0)

Race/Ethnicity N (%)

Non-Hispanic White

18 (66.7)

Non-Hispanic Black

1 (3.70)

Hispanic of Any Race

3 (11.1)

American Indian or Alaska Native

1 (3.70)

Multiracial/Multiethnic

4 (14.8)

CEA Role N (%)1

Assessor

18 (66.7)

Case Conference Member

17 (63.0)

Housing Provider

9 (33.3)

Navigator

8 (29.6)

Note. 1Total percentage exceeds 100% as staff frequently operated within more than one CEA role.

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CEA Structures, Processes, and Procedures

Research Question 1 sought to describe CEA structures, processes, and procedures for single adults experiencing homelessness. Study participants were asked to provide information on CEA policies and procedures. In addition to describing the specific components of CEA, participants spoke of the broader service landscape and its interconnectedness with CEA. The description of CEA begins with a birds-eye-view of the overall CEA structure, followed by processes and procedures specific to each component of the system. Participants described CEA as comprising the four coordinated entry core elements of access, assessment, prioritization, and referral. (HUD, 2017a). However, as results will show, there were implementation challenges that led to divergences with HUD’s (2017a) guidance on the four elements. Participants’ perceptions of the CEA system largely aligned with the formal system description published by King County (KCRHA, 2021b). An overview of the CEA process based on the perspectives of study participants is depicted in exhibit 4.

Exhibit 4. Overview of the Coordinated Entry for All Process

Overall CEA Structure

Overall CEA structure referred to the broad goals, leadership, and resources within the system that served as the backdrop for specific processes and procedures. Policy participants articulated a unified perspective on the purpose and goal of CEA, primarily centered on concepts of access and equity. Prior to CEA, potential clients would often make many phone calls—at least one per potential housing provider—in their quest to access housing. CEA is intended to reduce the number of phone calls people have to make in order to seek and/or access housing.

This concept of access is fundamentally linked to accountability for prioritizing the most vulnerable clients. With the prior decentralized model, individual providers were not held accountable for prioritizing those with the highest needs. In contrast, the purpose of CEA is to improve equity through access and transparency. As one policy participant articulated, CEA’s 14

“fundamental philosophy of, how do we make this easier on the people trying to navigate this, and how do we—not to say first come first serve, but really think about equity in that conversation?”

Leadership for CEA draws from a few different sources. While the CoC’s Coordinating Board is often viewed as the official leadership of CEA, members of this group are not as immersed as others in the inner workings of CEA. The CoC’s CEA Policy Advisory Committee is more specifically focused on evaluating and advising on CEA’s policies and processes. In addition to these committees, many policy respondents noted that, in practice, the leadership of CEA lies with the relevant staff at King County who have CEA administration and oversight as a primary part of their job functions. Through their interpretation and implementation of policies and recommendations, the CEA staff (employed by King County) define the specifics of how CEA functions in practice, with some input from CoC staff. In addition, CEA leadership is attentive to HUD guidance and regulations governing the processes and functions of CEA.

Regarding the types of housing offered through CEA, PSH and rapid rehousing were the two housing resources offered. However, rapid rehousing resources were rarely available. A tiering system using the Vulnerability Index-Service Prioritization Decision Assistance Tool (VISPDAT) determined who was eligible for rapid rehousing and PSH, with more highly vulnerable individuals prioritized for PSH. At case conferencing, participants determined appropriate matches for rapid rehousing resources.

There were two services to facilitate the CEA housing process for clients who had high priority for housing services. First, there was a Bridge Shelter, which served as a transitional site that offered beds for individuals in the priority group. It allowed case managers the ability to readily access clients when housing referrals were available. There was also a Navigation Center in the community which served highly vulnerable individuals who most often stayed in unsheltered locations, and thereby were unlikely to agree to stay at the Bridge Shelter. Both services were low-barrier and harm-reduction oriented, so individuals were able to access shelter without requiring engagement in therapeutic services or maintaining abstinence from substances.

In instances in which clients declined a referral for housing, or when the client could not be located to accept a housing referral within a reasonable timeframe (for example, 5 days), housing providers were permitted to conduct “external fills.” That is, housing providers could fill units by clients referred from within their agency, as opposed to referred through CEA. External fills were not intended to remain a permanent aspect of the CEA system, but they were temporarily permitted until challenges and barriers in the system were addressed.

Individuals on the housing priority list were categorized as “active” or “inactive” based on their service engagement and connections. For instance, individuals may have been moved to the “inactive” list if they did not engage with services for 90 days, or their information was not updated in HMIS. Individuals were returned to the “active” list upon reengagement with services.

Finally, there were resources in the community that were separate from, but connected to, CEA. For instance, there were supportive housing programs focused on individuals with serious 15

mental illness and individuals living with HIV/AIDS that were administered outside of CEA but were available to individuals experiencing homelessness. Veterans had access to housing prioritization through either CEA or through Veterans Affairs-administered services. Similarly, older adults experiencing homelessness could access housing through CEA or senior housing services.

CEA Access and Assessment Processes

Prior to gaining access to the CEA system, individuals were screened to identify whether they qualified for the county’s Diversion Program. The Diversion Program sought to divert individuals from initially engaging with the county’s homeless service system by providing funds to help individuals travel back to their city or town of origin.

Individuals accessed the CEA system through the completion of a standardized assessment of their vulnerability and service needs; in King County, the VI-SPDAT was utilized.

The county sought to enroll all persons who could not be immediately diverted to housing opportunities into the CEA system. As such, at the outset of CEA, a large number of service providers received VI-SPDAT administration training. Over time, only select providers tasked with ongoing assessment responsibilities received training.

King County established multiple means for individuals experiencing homelessness to participate in the VI-SPDAT assessment. First, Regional Access Points (RAP) were static resource centers located across the county (King County, 2021). In addition, several CEA-participating shelter and outreach agencies provided the assessments. Outreach-based assessment centered on encampments, and outreach workers were intended to complete assessments with all individuals with whom they encountered. In some instances, police officers facilitated connections for people to gain access to an assessment at a RAP or with an outreach worker.

Participants in the current study who were housed through CEA concurred there were multiple routes through which they accessed the system. Several tenants stated they were connected through police officers. Participants indicated they were also connected through jails, hospitals, shelters, outreach workers, case managers, Veterans Affairs services, and by calling the 2-1-1

resource line.

Assessment data were entered in HMIS, which listed individuals on the “community queue” (for example, the community priority list for housing resources). Given that individuals’

vulnerability and service needs changed over time, there were options for maintaining up-to-date assessment information in HMIS. The county did not require updated assessments at specific intervals (such as yearly). Rather, assessors and case managers were encouraged to update individuals’ assessments as needed upon changes in their vulnerability. In cases in which significant changes in vulnerability were present, a full reassessment may have taken place. The former approach was preferred over the latter because multiple assessments attached to individuals within HMIS might create confusion and may negatively affect their opportunity for housing placement (for example, inaccurate length of homelessness episode, lack of information on most up-to-date location). Staff participants noted that some individuals did, in fact, have multiple assessments on file. Assessors perceived that some individuals may have forgotten they already completed the assessment, or they felt taking the assessment again would increase their 16

chance of attaining a housing placement. Several tenant participants reported having difficulty recalling taking the assessment, which supports the notion that they may have forgotten. Other staff participants described their approach of updating clients’ assessments. For instance, some staff updated assessments every few months to ensure their clients’ current vulnerability and length of homelessness were properly reflected in HMIS.

Trained assessors were instructed that the VI-SPDAT was a self-report measure and to avoid coaching clients on answers or respond on clients’ behalf. Measures were put in place to address potential inaccuracies in client self-report. Specifically, when there was an apparent discrepancy between a client’s VI-SPDAT score and observations or prior knowledge on the part of the assessor, the VI-SPDAT scores could be “flagged” in HMIS. When flagging an assessment, assessors provided a rationale for a recommended change in score.

Dynamic Prioritization and Case Conferencing

Following assessment, the next component of CEA requires using the assessments to identify individuals to be prioritized for the specific housing units currently available. Because the number of individuals assessed to be highly vulnerable vastly outstrips the number of available housing units, CEA adopted an interim prioritization process to determine which of these most vulnerable individuals should be the top priority for housing placement in a given week. This process is informed both by a supplementary scoring process and the specifications of the available housing resources.

Score-based Prioritization. Initially, housing referrals were pulled directly from the CEA community queue, which was sorted by VI-SPDAT score. When housing providers had a vacancy, they could request a referral from the queue to fill the unit. However, due to the large number of individuals scoring at the highest end of the VI-SPDAT, as well as observed challenges with appropriately matching individuals with their needed level of service, a two-step prioritization process was implemented. First, on a weekly basis, an administrative staff member identified the top 40–50 individuals (the number changed over time) who received priority for housing based upon having the highest scores in the community queue. Staff participants explained that, initially, individuals scoring a 16 or a 17 on the VI-SPDAT received priority for PSH. However, to address concerns with equity in relying on VI-SPDAT scores alone for prioritization purposes, the county later developed a more complex formula that also factored in the duration of current homelessness episode and the number of episodes of homelessness experienced in the previous 3 years. After ongoing monitoring of this approach (interim prioritization), the process moved back to using VI-SPDAT only for single adults based on maximizing equity outcomes.

Case Conferencing. As a second step in the prioritization process, the top 40–50

individuals on the housing priority list were discussed in weekly case conferencing meetings during which individuals were matched with referrals for vacant PSH units and, sometimes, rapid rehousing resources. Case conference attendees were a countywide collective of housing providers, case managers, and outreach workers, among other stakeholders in the community who aided in facilitating housing placements. Clients on the priority list were not invited to attend case conferencing meetings. Staff indicated that case conferencing was generally open to 17

any service providers. One staff member estimated there were approximately 90 individuals on the case conferencing invitation list. Because attendance at case conferencing was not required, the composition of attendees varied week-to-week. It was estimated that about 10 individuals attended on a regular basis. Some organizations had multiple attendees, whereas other organizations viewed as key stakeholders did not have any representatives on the case conferencing invitation list. In some cases, organizations sent a single representative to attend case conferencing.

Because there were fewer available housing resources on a week-to-week basis than the number of individuals on the priority list, case conferencing identified which individuals within the priority group would receive housing referrals. During case conferencing, a list of available PSH units across housing agencies was created, and attendees “nominated” clients to receive a referral for a given unit. Next, case presentations of individuals who were nominated for units were delivered by providers with knowledge of individuals’ histories, vulnerability, support service needs, and housing preferences. The case presentations aided in determining the best service fit for individuals who would benefit from housing at an organization with a particular specialization or population served. Over time, CEA implemented a more systematic approach to case presentations to include estimates of individuals’ scores on the Vulnerability Assessment Tool (VAT). This assessment utilized in the local community, which was believed to offer a more in-depth appraisal of individuals’ vulnerability than the VI-SPDAT, due to it having more narrative-based opportunities for input. VAT scores served as a tiebreaker when multiple nominations were made for a given housing unit.

Referrals and Housing Placement

Once individuals were matched for a referral through case conferencing, they were notified of their housing opportunity. Notifications occurred through their case manager, the case conferencing member who nominated them for a housing referral, or a “housing navigator.”

Housing navigators were outreach workers who facilitated housing placements among individuals who had limited extant service connections. Staff indicated they were given around 2

to 3 days to conduct outreach to clients regarding referrals. In the event a client was not found, the referral would be given to another individual, and the client would remain on the priority list for a subsequent referral.

Individuals who were offered a referral for housing had the opportunity to accept or deny the housing referral. Perspectives varied among participants regarding the extent of the information provided to clients in order to aid them in making an informed decision whether to accept a referral. For instance, some case managers communicated detailed information about the housing opportunity. Furthermore, some housing providers indicated that they allowed individuals to tour the unit or building prior to accepting the referral, as articulated by one housing provider: “We wouldn't deny somebody, but we wanna give them the information to deny us because we're not gonna be the right fit for them.” Some individuals turn down an available unit because of preferences related to program rules or building environment.

Individuals who denied a referral were placed back on the priority list.

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Individuals who accept referrals move forward with necessary housing application paperwork with assistance from case managers or housing navigators. This process also confirmed that the individual met the eligibility requirements of the specific unit. One policy participant described it as a “legitimate denial” when a housing provider declines to house a client who does not meet eligibility for the unit. Individuals who were not given an opportunity to view the residence prior to accepting their referral typically received their first tour of the unit and building at lease signing. Housing providers in the study indicated that, on occasion, prospective tenants who completed their housing paperwork did not subsequently move into their units. In such a case, the unit would be held for the client for approximately a week before it would be offered to another person from the priority list.

How CEA Benefits and Facilitates Homeless Service Delivery

Research Question 2 sought to identify the ways in which CEA benefitted or facilitated homeless service delivery in King County. Results from thematic analysis are presented to follow the structures, processes, and procedures of CEA as described above.

Overall CEA Structure

Staff and policy participants expressed a number of positive views of CEA overall, which fell under six broad themes:

1. Aspirations are right.

2. Levels the playing field.

3. Facilitates connection and sense of community.

4. Transparency of resources.

5. Reducing and simplifying eligibility rules.

6. Harm reduction.

7. Streamlining for staff and clients.

With regard to the aspirations behind CEA, some staff and policy participants perceived the endeavor as an admirable and worthy pursuit. As expressed by one participant, a benefit of CEA was “being intentional at creating space where [highly vulnerable individuals] feel loved and cared for and valued.” A policy participant echoed this sentiment, “Philosophically, I think that that’s an important piece of… people should not spend all of their time looking for housing.

That should be a system’s job to connect people who are vulnerable.”

Furthermore, several staff felt that CEA levels the playing field for clients to access services regardless of their service connections. Prior to CEA, referrals were made based on relationships and connections between providers, which privileged seasoned providers and those with more social capital, rather than actual client vulnerability. As such, CEA reduced barriers for newer case managers or those with fewer connections to attain housing opportunities for their clients. A policy participant applauded the logic underlying the system: That our units are sitting next to [another provider’s] units and sitting next to [a third provider] in theory, that high-needs person, whether they 19

be [affiliated with their provider] or otherwise is getting first dibs at all of those units in the community.

In fact, some staff believed CEA facilitated connection and sense of community. Providers across organizations and programs worked collaboratively at various aspects of the CEA system, such as during case conferencing and the housing referral and placement process. Staff developed broader networks. Policy participants noted the inclusivity of CEA in terms of bringing together providers of various sizes.

The enhanced communication facilitated a perception of transparency of resources, as staff gained a more comprehensive view of the landscape of services and client needs in King County. Policy participants spoke about how transparency could lead to reducing and simplifying eligibility rules in cases when CEA pointed out excess regulations put in place by providers. A policy participant noted that funders were not always aware of how housing provider grantees were interpreting their contracts, sometimes more restrictively than intended. Another participant described the diverse eligibility rules pre-existing in the community for housing resources related to criminal history,

There were 80 different iterations… ‘cause some were like, oh, two-year felonies or three-year felonies. Some were two-and-a-half-year, except for this instance. When we laid it all out, it was like, something’s crazy.

Eighty different iterations.

Once the different iterations were understood, policy-level staff helped create and facilitate the adoption of more standardized categories (such as no criminal background, minimal, and more restrictive). CEA’s transparency helped stakeholders identify and solve problems when units were harder to fill, improving access overall.

Themes emerged regarding the ways in which CEA reduced barriers to housing for clients. Specifically, given that CEA emphasized housing for individuals with complex needs, including substance use disorders, housing agencies were forced to adopt a harm reduction approach. Policy participants appreciated that all providers were held accountable to housing those with the highest needs rather than prioritizing those who are easier to serve. Moreover, staff felt that CEA was streamlining for staff and clients compared to the traditional system. The single point of access and standardized intake approach reduced barriers for clients to gain access to housing. Clients and case managers no longer had to fill out “a hundred different applications for a hundred different places,” as stated by a staff participant. Policy participants considered CEA more humane than having to stand in line or win a lottery for a chance at getting housed,

“reducing the number of calls people have to make and the number of agencies they have to go to.”

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Exhibit 5. Themes Related to the Benefits and Facilitators of the Overall Coordinated Entry for All Structure

Theme

Summary

Sample(s) Represented

in the Theme

Aspirations are right

CEA perceived as an admirable pursuit

Staff, Policy

of the service system to actively connect

vulnerable individuals with housing

Levels the playing field

Clients were able to access housing

Staff

regardless of service engagement or

advocacy

Facilitates connection and Providers across organizations and

Staff, Policy

sense of community

programs worked collaboratively at

various aspects of the CEA system

Transparency of

Stakeholders gained a comprehensive

Staff, Policy

resources

view of services and client needs across

King County

Reducing and simplifying Transparency of resources helped to

Policy

eligibility rules

identify excess policies put in place by

housing providers, which facilitated the

adoption of more consistent policies

across the system

Harm reduction

Housing providers were accountable for Staff, Policy

housing those with the highest needs,

thereby necessitating agencies to adopt a

harm reduction service delivery approach

Streamlining for staff and The single point of access and

Staff, Policy

clients

standardized intake approach reduced

barriers for clients to gain access to

housing

CEA Access, Assessment, and Assessment Process

Tenant and staff samples identified two themes regarding facilitators of attaining effective and accurate assessments from clients:

1. High assessor motivation.

2. Client-assessor relationship.

21

Staff participants perceived that some assessors demonstrated high motivation to ensure their assessments were accurate. For instance, assessors would take time to rephrase VI-SPDAT

questions to increase understanding and accessibility to clients. Staff and tenant participants both described the importance of a relationship between the client and assessor. Specifically, assessors were better able to utilize the flagging process when they were familiar with the clients and their background. Staff and tenants both expressed that a trusting client-assessor relationship also facilitated honest responses to the assessment. For instance, a tenant who was reluctant to disclose personal information was better able to endorse the yes/no items on the VI-SPDAT

when assessed by a case manager with whom he developed a trusting relationship. He stated,

“Well, uh, I kinda, uh, trusted [case manager] a little more, not to share the specifics, really. But to, you know, make it more of a yes and no, that I did have problems in that area.” Moreover, assessors felt that individuals who had relationships with service providers were more likely to have their assessments updated regularly and accurately reflect their current situation Participants also expressed general positive comments about the concept of assessment.

For instance, participants noted that the assessment process enabled them to identify individuals who were vulnerable or in crisis and facilitate their housing placements. Another participant liked the “spirit of the VI-SPDAT,” in that it was an attempt at objectivity in identifying housing needs, despite an overall feeling that it was not meeting this goal in practice.

Exhibit 6. Themes Related to the Benefits and Facilitators of the Access, Assessment, and Assessment Process

Theme

Summary

Sample(s) Represented

in the Theme

High assessor motivation Some assessors were perceived as being Staff

highly motivated to ensure their

assessments were accurate

Client-assessor

A trusting relationship between staff and Tenant, Staff

relationship

clients facilitated accurate assessment

Dynamic Prioritization and Case Conferencing

Three themes emerged from staff participants regarding benefits and facilitators of the prioritization procedures utilized in CEA:

1. Learning.

2. Humanization and holistic vulnerability.

3. Better outcomes.

Staff who attended case conferencing felt that the convenings broke down silos of service provision and facilitated learning about services and specializations of providers across the 22

county. Furthermore, providers shared unique perspectives on how they conceptualized vulnerability based on the clients they served.

Regarding humanization and holistic vulnerability, staff expressed that case conferencing provided a space for providers to come together as a "collective" to determine the most vulnerable and take into account client housing preferences during the nomination process.

Clients were humanized through the discussion, rather than simply being ascribed a number via a formula to determine housing prioritization. Providers created a more holistic picture of an individual by highlighting the impact of social identity (such as race) as a type of vulnerability which affected other vulnerabilities in ways not captured on the VI-SPDAT. A case conferencing participant described holistic vulnerability as such:

So, we’re kind of reiterating the idea that humans are very complex

individuals, and that vulnerability is looking at a holistic person and a holistic experience, not, you know, just their medical acuity, not just their mental health, you know, not-one thing is not weighted above another.

Um, so we’re able to kind of bring that in, and we’re also-um, one thing I think is another really great benefit, we’re bringing identity to the table…and looking at how someone’s identity is also a-a area of

vulnerability and how that can impact somebody’s risk of

victimization…um, where the VI-SPDAT does not. Uh, so we’re able to

then say, “You know what, this-this person’s experience and identity and history increases their-their vulnerability.” So, we’re able to kind of wrap that in, um, even though like we’re not-you know, we can’t prioritize based on race because of fair housing pieces, um, but we have a way to bring that to the table so that that holistic person, um, and, you know, their experiences are, um, an-a factor.

Finally, staff participants believed case conferencing contributed to better outcomes for clients’ housing placements compared to the initial CEA prioritization approach, which primarily relied on VI-SPDAT scores. Staff perceived that case conferencing helped that ensure individuals who were the most vulnerable received priority for housing. Furthermore, case conferencing promoted “warm handoffs” of housing referrals, as attendees connected directly with their clients or their clients’ primary service providers to walk through the referral and housing application process.

23

Exhibit 7. Themes Related to the Benefits and Facilitators of Dynamic Prioritization and Case Conferencing

Theme

Summary

Sample(s) Represented

in the Theme

Learning

Case conferencing broke down silos and Staff

promoted information sharing among

staff from different organizations

Humanization and

Case conferencing promoted discussions Staff

holistic vulnerability

about clients’ vulnerability, which was

viewed as more humanizing than simply

prioritizing by assessment score

Better outcomes

Case conferencing was viewed as leading Staff

to better client housing outcomes than the

earlier, community queue, method due to

improved matching of clients to housing

and facilitation of the housing process

Referrals and Housing Placement

A few themes emerged among staff participants regarding facilitators of placing individuals in housing once a referral was given, including:

1. Priority list.

2. Connection between the client and provider.

3. Flexibility with housing documentation.

Overall, staff felt that having a priority list was useful in narrowing down the pool of potential individuals for a housing referral. The priority list was relatively responsive to client circumstances and preferences; individuals who declined a referral or were unable to be located were able to remain on the priority list as long as their homelessness status was maintained.

As with the assessment process, a connection between the client and provider facilitated housing placements. The process of housing clients was easier when case managers were invested in supporting their clients’ success. Supportive actions included communicating with clients and knowing them well enough to ensure that housing options and policies of housing programs were acceptable to clients and their preferences. Furthermore, compared to clients experiencing street homelessness, clients who stayed in shelters were viewed by staff as having a slightly faster housing process due to ongoing relationships with case managers and because they were more readily available to complete paperwork. A housing provider shared this example of effective communication with a case manager whose client received a housing referral, 24

We had someone recently who was referred that pretty much wanted their boyfriend to be a caregiver and to be at the [housing] 24/7, and my—the conversation was they need to know that this is not something that can happen. I gave ‘em a copy of the visitor policy. I said, “Please read this over with them. Make sure that this is—they know what they’re getting into,” and the client denied and said, “No, I don’t’ wanna live there cuz that’s not gonna work for me.” So, I feel like, as long as you know the right questions to ask and everyone is invested in truly helping that client succeed, it’s not—it-it goes a lot more smoothly, I think.

Finally, flexibility with housing documentation on the part of housing providers facilitated successful housing placements. For instance, housing providers were often willing to extend their deadline for clients to accept referrals and for clients and case managers to submit housing application paperwork. Such flexibility was facilitated through close communication between case managers and housing providers.

Exhibit 8. Themes Related to the Benefits and Facilitators of Referrals and Housing Placement

Theme

Summary

Sample(s) Represented

in the Theme

Priority list

Priority list narrowed down the pool of

Staff

clients for available housing referrals

Connection between the

Housing placements were facilitated

Staff

client and provider

when case managers had good

relationships with clients referred for

housing

Flexibility with housing

Housing providers’ flexibility with

Staff

documentation

deadlines for submitting housing

paperwork facilitated housing placements

Challenges and Barriers in CEA Implementation

Research Question 3 aimed to describe the challenges and barriers in CEA implementation from the perspectives of CEA stakeholders. Results from thematic analysis are presented to follow the structures, processes, and procedures of CEA as described above.

25

Overall CEA Structure

Tenant, staff, and policy participants identified several challenges and barriers within the overall structure and process of CEA, including:

1. Prioritizing vulnerability is problematic.

2. Static priority list and community queue.

3. Barriers to case manager job performance.

4. Bureaucracy.

5. communication issues between providers and clients.

6. Lack of communication and transparency with staff.

7. Self-advocacy.

8. Disempowerment of clients, staff, and organizations.

9. Implementation problems.

10. Funding issues.

Some challenges and barriers were converses of the identified benefits and facilitators.

For example, although participants liked CEA’s emphasis on housing people who were highly vulnerable, an emerging theme was prioritizing vulnerability is problematic. Some staff felt that most clients are vulnerable in some respect, but not all aspects of vulnerability are captured or prioritized in the assessment process. A staff participant stated, “We’re just like forgetting a whole other group that really needs a lotta support and help getting into housing.” Furthermore, staff participants expressed that prioritizing based on vulnerability does not “reward people who are trying to do well.”

Despite a perception that CEA leveled the playing field for clients, staff also felt the priority list and community queue were static. That is, individuals who scored in the middle range of the VI-SPDAT never increased their priority ranking, despite their vulnerability. Case conferencing members expressed concern that only a small percentage of clients on the priority list are discussed and nominated for housing on a weekly basis, and that many clients remain on the priority list for a long period of time.

In contrast to perceptions that CEA streamlined some aspects of their work, staff participants also felt there were barriers to case manager job performance. Providers stated that they were “drowning in unnecessary meetings” and felt overburdened by their current workload.

They were uncertain where to best allocate their limited time. For example, missing case conferencing meetings to focus on other work priorities would result in an inability to get needed housing opportunities for clients. Furthermore, staff also felt that the increased communication among providers across agencies working with a particular client negatively impacted their job performance as articulated by a staff participant:

There is a lot of back and forth within CEA. For example, it can be

confusing when a client is connected to three to four agencies and there are multiple emails sent between the agencies and there is no clear point person/someone who is taking lead on the case; it seems either everyone wants to take lead or no one wants to take lead.

26

This issue relates to the policy participants’ focus on bureaucracy, describing a burdensome system that continues to add staff, meetings, and procedures. Policy participants noted that intended improvements tend to add gatekeeping functions, and a growing infrastructure does not lend itself to greater flexibility. As one participant critiqued, referring to the meetings and subgroups put in place to troubleshoot challenges, “there is money going into a bunch of bureaucrats that are doing a bunch of things, having a lot of meetings, and putting together packets.”

Communication issues between providers and clients emerged as a theme. Although structures such as the Bridge Shelter aimed to facilitate connections with clients prioritized for housing, many individuals remained transient and difficult to find. An assessor stated, “…and we may never see that person again. So, then they never get found with a referral.” Staff also perceived that clients are not receiving full and transparent information about CEA processes, or that clients are unable to understand information about the system due to “information overload.”

Concerns were raised as to whether clients were truly providing informed consent to access CEA given they were not provided details about the system, such as the wait time for housing. Staff raised concerns about discussing clients in case conferencing, because protected health information is shared without client consent. Clients only signed the HMIS consent form, which did not cover the depth of information discussed in case conferencing.

Moreover, the effectiveness of communication with clients was viewed as variable across case managers. Several staff expressed concern that some case managers did not adequately consult their clients about their housing preferences before nominating them for a referral for housing during case conferencing. Policy participants shared some similar concerns with regard to CEA making interactions more transactional between clients and service providers because the system interrupts longer-term relationships between clients and providers. As one participant explained, “nobody’s building relationships with people.” This theme of trade-offs of relationships is discussed in greater detail in a subsequent section of this report.

From the tenants’ perspectives, many believed that their own self-advocacy was necessary for their housing placement in the absence of reliable support by their case managers or other service providers. For example, participants reported making regular calls to 2-1-1 to ensure that their place on the priority list was maintained and updated. A tenant stayed in constant touch with service providers. However, in the absence of follow-up by providers, the tenant called coordinated entry directly because the tenant did not know who else to contact.

Another participant described similar persistence in this manner, “I was knocking on every door.

Like I was being my biggest advocate, you know.”

Lack of communication and transparency extended to staff members’ experiences of interfacing with higher level CEA administrators. Some staff expressed confusion over who was responsible for CEA decision-making. There was inconsistent messaging to staff regarding changes to CEA policies and procedures, such as whether the Vulnerability Index-Service Prioritization Decision Assistance Tool (VI-SPDAT) would continue to be utilized as the coordinated assessment instrument. Staff felt there were very few opportunities for them to share their feedback and perspectives on CEA with those in leadership positions. A staff participant stated, “We speak, but I don’t think that they listen. They kinda monitor the feedback we give 27

them. They spin it and tell it in a whole different story rather than what the intent is that we were delivering.”

In spite of many of the policy participants holding formal leadership roles, policy participants also cited confusion in terms of the leadership and authority of CEA. Most agreed that the CoC Coordinating Board had official power, but this group was not sufficiently knowledgeable or involved in the details of CEA to drive decisions. Several participants asserted that the true power lay with the King County staff administering CEA, whereas others lamented various challenges that have prevented the CEA Policy Advisory Committee from taking on a greater leadership function. In describing the tension between the CoC Coordinating Board and the CEA Policy Advisory Committee, one interviewee complained, “We had at least 6 months of delay because nobody knew who could make the decision. It’s so frustrating.”

Staff indicated CEA led to disempowerment of clients, staff, and organizations. Clients were unable to advocate for themselves within the system and were beholden to the advocacy, or lack thereof, of providers representing them in case conferencing. Due to limited supportive housing stock (a problem outside of CEA’s scope and influence), clients had few options and little choice in their housing placements. Staff also felt disempowered to advocate for clients who did not make it on the priority list. Housing providers were disempowered through their loss of control over client placements. For instance, an agency historically serving highly vulnerable individuals were receiving CEA referrals that were poor fits for their housing, leading a service provider to state that CEA, “…took away our ability to fulfill our mission.” Additionally, CEA took away providers’ ability to immediately respond to acute moments where long-term clients were finally ready to accept a housing referral. Finally, the lack of responsiveness from CEA leadership regarding provider feedback on the system led to a sense of helplessness among a staff member who stated:

The most powerful people aren’t listening. The message is not being

conveyed to the places it needs to be conveyed. And so over time you do-you have that like explosion, nothing changes. What’s the point of ever trying to have the explosion...why are you gonna to the fight? That’s-that’s what the-I think over time it’s just this dulling deadening of God, this thing is so, so bad and we can’t change it.

Indeed, even when CEA leadership acknowledged there were problems in system implementation, providers were instructed to continue business as usual as articulated by a staff participant, “…this weird acknowledging that systems are broken and then shove that aside and say, ‘So, do more of them ‘cuz we're gonna try to figure something out.’” Several policy participants also noted that decision-making spaces were overwhelmingly White, professionalized, and structurally supportive of white supremacy, which hindered progress towards incorporating the perspectives of Black, Indigenous, and People of Color (BIPOC) community members and those with lived experience of homelessness.

Regarding implementation problems, there were challenges with the initial assessment process. Specifically, clients who engaged in services at multiple agencies received multiple VISPDAT assessments. Furthermore, with regard to assessment implementation, efforts were not 28

made to match clients with assessors based on demographics, training, or expertise with a specific population. Staff also suggested that clients were often mismatched to housing programs due to the reliance on the VI-SPDAT assessment and ineffective advocacy of clients during case conferencing. Some clients were duplicated in HMIS due to errors in their identifying information, creating confusion regarding whether clients were actively engaged in services.

Finally, the theme funding issues emerged among staff. Housing providers reported that their program funding was contingent on housing retention rates. However, due to issues of mismatching of clients referred to their programs through CEA, their retention rates were negatively impacted. Housing providers expressed that they should not be financially penalized for having to terminate a CEA-referred client’s housing due to safety concerns. Providers within the policy participants also echoed this frustration that the implementation of CEA reduced their ability to fill units quickly.

Exhibit 9. Themes Related to the Challenges and Barriers of the Overall Coordinated Entry for All Structure

Theme

Summary

Sample(s) Represented

in the Theme

Prioritizing vulnerability Not all aspects of vulnerability received Staff is problematic

prioritization for housing, and clients

who are doing well, and are thereby less

vulnerable, were not rewarded by the

system

Static priority list and

Only a small percentage of clients

Staff

community queue

received priority for housing; the

remainder languished on the priority list

or community queue

Barriers to case manager CEA increased the workload for staff

Staff

job performance

Bureaucracy

The system was viewed as burdensome, Policy

adding staff, meetings, and procedures

Communication issues

Effective communication was challenged Staff, Policy

between providers and

by difficulty reconnecting with clients,

clients

lack of client informed consent, providers

not engaging clients about their housing

preferences, and the system interrupting

long-term client-staff relationships

Self-advocacy

In the absence of reliable communication Tenant

with providers, self-advocacy by clients

was necessary to move through the system

29

Lack of communication

A lack of transparency or clarity about

Staff, Policy

and transparency with

personnel responsible for CEA decision-

staff

making, and limited avenues to share

feedback about the system to CEA

leadership

Disempowerment of

Stakeholders at all levels of the system

Staff, Policy

clients, staff, and

lost control of their ability to advocate

organizations

for themselves and others, deliver

services as preferred, and voices of

stakeholders with marginalized identities

were hindered

Implementation problems Aspects of CEA processes, such as

Staff

assessment and matching housing with

client needs, were not carried out

effectively

Funding issues

Funding for housing was contingent on

Staff, Policy

filling units quickly and retaining tenants,

but CEA created challenges to meeting

these funding requirements

CEA Access, Assessment, and Assessment Process

Participants across groups largely spoke of the challenges related to the assessment process and the VI-SPDAT as a measure of vulnerability. Equity issues were woven throughout the discussion of challenges with the assessment process. Themes emerging regarding assessment challenges included:

1. Limited access.

2. Lack of oversight in the assessment process.

3. Low assessor motivation.

4. Misleading process.

5. Not trauma-informed.

6. Objectivity issues.

7. Psychometric properties of the VI-SPDAT.

8. Bias against Black/African American individuals.

Policy participants spoke about limited access as a reference to the many vulnerable people who were not being assessed, or whose assessments failed to indicate their high level of vulnerability. Participants described the need for investments in outreach in order to connect with the most vulnerable individuals. Participants noted that relying on Regional Access Points or 30

contacts in shelters omitted many of the most vulnerable among the single adult homeless population. As one participant critiqued,

The only people who haven't figured out how to game the VI-SPDAT are the people who probably should be prioritized in the first place. The fact that we can't find high-needs, highly vulnerable people to prioritize for housing is mind-blowing ‘cause you can walk out the front door and find 15 at any given time in our city, and somehow, the coordinated entry system by virtue of using the VI-SPDAT as the gatekeeper is incapable of doing that.

With regard to lack of oversight, one staff participant articulated, “There really isn’t like a real like check and balance on what’s being thrown out there.” Staff stated that there was no accountability regarding the extent to which assessors were trained or how the assessment process was being handled. For instance, assessors reported that staff were giving VI-SPDAT

assessments without participating in the assessment training, and that trained assessors were never held accountable for attending refresher training. In other cases, staff reported there was no oversight to ensure that assessment data were being entered in HMIS. There were also concerns that flagged assessments in HMIS were not accounted for, because clients with flagged assessments did not subsequently attain priority for housing. Policy participants pointed out that high turnover among assessors and case managers exacerbated these challenges.

An implication of the lack of oversight was low assessor motivation. Due to numerous challenges with the VI-SPDAT and prioritization process, staff lost motivation to conduct the assessment when they perceived that an individual would not score highly enough to be prioritized for housing. One assessor noted, “We’ve been using it less and less, um, with folks just because it’s problematic in a lotta ways, and it’s really only benefitting certain clients who are gonna score very highly.”

Staff perceived the process of assessment as misleading to clients. For instance, when conducting assessments at encampments, they that felt individuals were led to believe they would be placed on a housing list, when, in reality, they were unlikely to receive high priority for housing due to low VI-SPDAT scores. Clients were also uncertain about what occurred after the assessment, and assessors did not have the answers to questions in this regard. A staff participant stated:

Even though you can explain to the extent that this is just, uh, goin’ into a queue…I mean, I don’t know, at the beginning, that first year, how many people kept sayin’, ‘Well, where am I at? Who do I contact? Where am I on the list?’

A policy participant highlighted the potential for system-wide consequences when clients do not clearly understand the role of an assessment,

The unintended consequence is folks pause their search because they think that CEA is going to be able to resolve their housing crisis or is gonna 31

provide them a resource that’s gonna—they’re gonna move in that

direction. We still get calls from folks that did an assessment two or three years ago that said, “Hey, I’m on your waiting list. I don’t understand what’s goin’ on.”

The assessment and procedures were viewed as not trauma-informed, or insensitive to the trauma histories of people experiencing homelessness. With regard to the process of assessment, an assessor described one concern as such, “I’m going to ask you personal questions, and I’m gonna walk away and leave you here.” Participants acknowledged that some individuals were not comfortable sharing their trauma histories, such as domestic violence or sexual assault, especially with someone they barely knew. Policy participants also noted that the assessment process does not include evidence-based practices, including trauma-informed care, with one respondent stating the assessment process is “.. retraumatizing, and it doesn’t make sense.” Staff and policy participants discussed how the VI-SPDAT did not capture generational trauma, particularly among BIPOC.

Regarding objectivity issues, staff expressed that although the VI-SPDAT was an attempt at objectivity in making tough decisions on allocating scarce housing interventions, the tool and process failed in this regard. A staff participant stated that although the tool was intended to be objective, “…at the end of the day, it comes down to subjectivity and relations...that’s sort of what it’s playing out to be.” The comment acknowledges that issues of assessor motivation and client-staff relationships, among other factors impacting the objectivity of the assessment process.

The quality and effectiveness of the VI-SPDAT as an assessment for determining housing prioritization was also an area of concern among staff participants, who described challenges to its psychometric properties. In terms of reliability, the self-report nature of the VI-SPDAT lent itself to both under- and overreporting by clients.

Policy participants spoke about various ways in which the circumstances of the assessment could affect the client’s score. Participants noted that clients’ responses are based on their level of comfort with sensitive and personal information with the assessor. Several noted that there is often a racial mismatch between the assessor and a client, which one policy interviewee explained, “it’s very hard to work a VI-SPDAT when all White women is talking to African American people” since “we’ve [Black people] been taught what to say to White folks.”

Environmental circumstances can also influence scores, as one policy interviewee described: I do think part of the issue is not just the tool itself, but it also is how and when and by whom is it administered, in what contexts? We have an

example of people getting the VI-SPDAT in a clean and sober shelter

where they’re asking them about their substance use. How can they

answer that question in a way that would be honest? Because that whole context wouldn't allow for them to be honest about it.

Policy participants overwhelmingly articulated concern about how the VI-SPDAT facilitated bias against Black/African American individuals. After initial CEA implementation, data began 32

to emerge indicating that Black/African American individuals were systematically scored lower on the VI-SPDAT than White people, thus leading to fewer Black/African American individuals being prioritized for housing (Ewing and McHugh, 2020). This realization prompted changes in the prioritization process, including a move away from relying exclusively on VI-SPDAT scores and including homelessness history in the prioritization formula.

Individuals who were veterans or who experienced mental health symptoms such as disorganized thinking, substance use disorders, or poor memory were viewed as particularly prone to underreporting due to “pride,” limited “insight” about one’s symptoms, or cognitive impairment. One tenant spoke of life experiences including being raised in a “dysfunctional household” and incarceration, which led him to underreport the first time he was administered the VI-SPDAT. He said, “And the first time I just touched on no details or denied… because I’ve been taught not to share things like that with people.” Moreover, undocumented immigrants were perceived by staff as prone to underreporting—or declining the assessment altogether—for fear of consequences such as deportation. It was further emphasized that due to experiences of racism and discrimination within and outside of the homeless service system, racially minoritized individuals may be reluctant to disclose personal information during the assessment. A staff participant described the assessment process as follows:

[the assessment process] …rewards clients that advocate for themselves and to trust systems. So, it ends up rewarding white males more than anyone…If you are someone that has gone through the world with the

system generally working out for you, you’re gonna trust somebody sitting across the table saying, “Tell me anything you want. You know, nothing bad’s gonna come if you are honest with me.”

Furthermore, staff participants acknowledged that clients might underreport on the assessment due to uncertainty regarding how to gain housing priority. In some cases, assessors may “coach” clients regarding the aim of the assessment. An assessor illustrated these circumstances as follows:

The average person who is fighting to try to get housing and doing, you know, what they think is their best means in is gonna be dishonest or, you know, not answer, and then, yes, if you have an assessor there that’s saying like, “You know, just so you know, like, you need to get a high score.” You can have somebody kinda help them along and maybe answer that.

On the other hand, some individuals were perceived as prone to overreporting on the VISPDAT due to “word on the street” information about how to gain priority for housing through endorsement of assessment items. A staff participant felt that “We’ve created this system that forces them to lie,” in order to access scarce housing resources. Additionally, staff and tenants indicated that some assessors “coached” clients to achieve a high score on the assessment. Some assessors in the community were known to assess clients multiple times until a priority score was achieved. One tenant stated an assessor overtly informed them of the VI-SPDAT score necessary to gain priority for housing:

33

They did [coaching] with me, it’s like, um, if you get 16 or 17, you have a good chance of getting, um, housing. And if you score below that, you’re, uh, don’t have a very good chance of getting housing. The participant went on to say, It did influence the way I answer the questions, for sure...

You know, it’s like I wanna score high...So I took that into account... when I was looking at the questions. It’s like well, um, I’m trying to get my high score...I’m gonna make the high score... I would be lying to you... to tell you that, uh, I didn’t take that into consideration when I was filling out the questions, ‘cause I did know ahead of time.

Reliability issues were further articulated by tenants such that they were unsure how to respond on the assessment or they felt the questions were difficult to understand. One tenant participant expressed feeling confused about how to respond on the assessment to improve chances of housing. For instance, the tenant questioned whether denying items would give the appearance of being difficult to house, or whether showing greater vulnerability would help gain priority reporting. “It’s not what it seems like the question-the answer would be...You have to really think about it because it’s really easy to get deceived with the answer, what you guys would want the answer to be.” Another participant required multiple administrations in order to understand the assessment. That participant stated, “I think by the fourth time that I took it I think I kinda understood what was being looked for. But, um, but I was having a hard time understanding the questions definitely.”

However, barriers to reliable assessments were not universally endorsed by tenant participants. For instance, several tenants stated they did not have reservations about disclosing personal information on the VI-SPDAT, even when they did not have a relationship with the assessor, due to a strong desire to attain housing and for survival. Other tenants indicated they had knowledge that higher scores on the VI-SPDAT would increase their chances of attaining housing; however, they did not overreport on the assessment to achieve this aim.

Policy and staff participants expressed further validity concerns that the VI-SPDAT did not fully capture all aspects of vulnerability among the population of people experiencing homelessness, or that certain vulnerabilities did not carry enough weight in the scoring. A staff participant felt the tool did not capture “the unique and diverse people that we’re having to assess.. That’s why we get such low scores or it doesn’t apply to a.. client.” Another staff participant described having a client who was a 70-year-old veteran with a limb amputation and a substance use disorder who, despite these vulnerabilities, “consistently scored a nine” on the VI-SPDAT. Staff also expressed that the tool is inequitable due to its exclusion of vulnerabilities unique to the experiences of BIPOC and transgender individuals. One policy participant admitted that they grapple with the concept that all tools are “inherently inequitable,” because each diverse community will respond to questions differently based on their diverse backgrounds.

Other policy participants noted that the VI-SPDAT was neither culturally informed nor easily linguistically adaptable.

Staff participants also expressed general negative comments about the assessment process. For example, some assessors felt that the outreach procedures for assessment were insufficient for finding all individuals experiencing homelessness. Specifically, due to the 34

emphasis on outreach and engagement of individuals staying in shelters or encampments, those who were more hidden (such as those sleeping on buses, in the woods, or couch surfing), were likely missed.

Exhibit 10. Themes Related to the Challenges and Barriers of the Access, Assessment, and Assessment Process

Theme

Summary

Sample(s) Represented

in the Theme

Limited access

Many highly vulnerable individuals were Policy

not being reached for assessment

Lack of oversight in the

No accountability for training on the

Staff, Policy

assessment process

assessment or oversight of the

assessment data

Low assessor motivation Staff lost motivation to conduct

Staff

assessments when clients were unlikely

to receive priority for housing

Misleading process

The assessment process misled clients to Staff, Policy

perceive it would lead to housing, which

was not true for most individuals

Not trauma-informed

The assessment process and instrument

Staff, Policy

were retraumatizing for clients and did

not account for trauma experiences

unique to BIPOC individuals

Objectivity issues

Though the assessment tool may intend

Staff

provide objectivity, there were many

variables in the assessment process that

introduced bias

Psychometric properties

There were many factors influencing the Tenants, Staff, Policy

of the VI-SPDAT

accuracy of assessment scores and

limitations to the conceptualization of

vulnerability as assessed by the VI-

SPDAT

Bias against Black/

CEA data showed systematic biases in

Policy

African American

VI-SPDAT scores such that

individuals

Black/African American individuals

scored lower than White individuals

35

Dynamic Prioritization and Case Conferencing

Tenant, staff, and policy participants spoke about challenges and barriers in the process of dynamic prioritization and case conferencing. The following themes emerged: 1. Case conferencing representation and accessibility issues.

2. Uninformed advocates.

3. Deficit approach and exploiting vulnerability.

4. Missing client voice.

5. Tenant perceptions of prioritization.

Regarding case conferencing representation and accessibility issues, staff expressed concerns that a minority of individuals who were invited to case conferencing actually attended.

A staff member indicated that they only attend when they have a client on the priority list to nominate for a housing referral, whereas another participant indicated not being on the invitation list. The primary barrier to attendance was capacity among staff and organizations. Specifically, case conferencing occurred weekly, typically lasting over 2 hours in the middle of the workday, making attendance challenging amid providers’ other work-related priorities. Furthermore, participation by staff in the greater King County region was limited due to the added travel time.

The key implication of low attendance was that clients on the priority list did not have equal advocacy for housing referrals; those whose case managers had capacity and motivation to attend case conferencing received housing referrals.

Client representation in case conferencing was also influenced by the comfort level of attendees in advocating for their clients in the seemingly “professional” and “academic”

environment. Some direct service staff who were new to the field, staff for whom English was not their first language, and staff with lived experience of homelessness were perceived as struggling to feel comfortable presenting in a room with more experienced administrative-level staff or others who were highly vocal in their client advocacy. A staff member stated, “Our staff...have felt very intimidated by the academic nature...and feel like they're being grilled on all these questions.”

Variable advocacy for clients on the priority list also emerged as an issue in the theme of uninformed advocates. Clients on the priority list were sometimes represented by their case manager’s supervisor or colleague. The unavailability of case managers to represent their clients created a barrier to addressing specific questions about clients as they arose. Staff participants further expressed that case conference attendees may not be aware of clients’ housing preferences, creating a challenge for identifying fit for a particular referral. Staff perceived that there was very limited time between their receipt of the weekly priority list and list of available units and the case conferencing meeting, which contributed to a lack of preparedness to present at case conferencing. Specifically, they were not always able to connect with clients on the priority list to vet their interest in being nominated for units. Policy participants also raised the issue that case conference attendees sometimes behave paternalistically, saying that a client would not do well in a unit, which contradicts what the client says when asked directly.

36

Policy and staff participants noted that the prioritization process was based on a deficit approach and exploited individuals’ vulnerability. With regard to exploiting vulnerability, staff participants expressed that case conference members had to “duke it out” when advocating for clients with the same priority score to receive a housing referral or, as a policy participant noted,

“compete with vulnerabilities.” Essentially, clients’ vulnerabilities were named as a rationale for their need for housing priority. A staff member articulated, “They start talkin’ about what client doesn’t have body parts, who’s got this, who’s got that.” Another policy participant called case conferencing “super demeaning,” and not at all person-centered.

Finally, staff participants felt that case conferencing was missing client voice. Clients were not invited to attend the meetings to self-advocate. A staff participant stated: There’s no opportunity for them to even write a narrative, do an interview, like have their case manager write something for them. Their voice is completely excluded 100 percent. They get to answer some yes or no

questions, but that’s it...Even if they wanted to come to the meeting, they couldn’t.

One policy participant echoed this issue, noting that clients are not in the room, which means, “We’re not using choice at all. I just think there’s lots of contradictions that we’re currently upholding around choice and dignity.”

Tenant participants expressed a range of understandings and perceptions of prioritization processes, highlighting challenges with transparency and education about the system. Tenants were generally aware that the system did not function on a first-come, first-served basis. Some believed that income (having or not having), homelessness history, age (younger or older), or incarceration history increased one’s priority for housing. Some tenant participants were aware of the top priority list discussed in case conferencing. A couple of participants felt they received special treatment from their case managers, such as having their assessment scores modified, to help them gain priority for their housing unit.

Overall, tenant participants shared staff participants’ perspectives that the types of vulnerabilities prioritized for housing resources were not fully representative of the breadth of experiences among the homeless population. For instance, tenants often expressed that they perceived themselves as less vulnerable than others in their buildings, so they were uncertain how they were prioritized. Another participant described a concern about the way vulnerability is used as a gatekeeper for deservingness of housing, saying:

Who determines if it’s better for you to be homeless or more need to be housed?...If I’m homeless because of domestic violence, I, uh, of course I’m a risk, but if I’m homeless because I lost my job from something that wasn't my fault, I’m not at risk to be housed. So that's not fair in a certain way.

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Exhibit 11. Themes Related to the Challenges and Barriers of Dynamic Prioritization and Case Conferencing

Theme

Summary

Sample(s) Represented

in the Theme

Case conferencing

Many providers were unable to attend

Staff

representation and

case conferencing due to time

accessibility issues

commitment, travel; and the case

conferencing atmosphere privileged

certain providers’ client advocacy over

others

Uninformed advocates

Providers did not always have direct

Staff, Policy

knowledge of the clients they represented

at case conferencing, and providers were

prone to contradicting client preferences

Deficit approach and

Case conferencing required providers to Staff, Policy

exploiting vulnerability

emphasize client vulnerabilities to

advocate for their housing placement

Missing client voice

Clients were not given the dignity to

Staff, Policy

attend case conferencing

Tenant perception of

Understandings of prioritization varied,

Tenant

prioritization

demonstrating a lack of transparency of

the system for clients

Referrals and Housing Placement

All participant groups indicated several challenges associated with the referral and housing placement process. Emerging themes included:

1. Difficulty locating clients.

2. Communication issues.

3. Mismatching of client needs and preferences and housing.

4. Housing policy and rules.

5. Agency and choice.

Staff expressed that although the Bridge Shelter and Navigation Center facilitated connections for individuals who were willing to utilize these resources, they had difficulty locating clients who were disconnected from services. A staff participant stated, 38

I mean, they get lost out there, and we re—you know, we’re outreachin’

the who—in the city of Seattle, north and south, and sometimes it’s—we’re not able to—or unless they’ve already been housed, and nobody

knows….Sometimes they’ll give us like…you know, we have like six

months, or they have like a couple months left, and, within those six months or a couple months, we’re still looking for this person. And either they went home with relatives, or they’re housing with relatives, or they’ve been housed, or they’re in the hospital, or anything could’ve pos—you know, they’ve al—took an option.

Policy participants also highlighted the challenge of contacting tenants when they have housing referrals because they may not have phones or be connected to services. This barrier was also noted among tenants.

Communication issues further served as a barrier to the referral and housing process. For instance, staff participants reported there was miscommunication about populations who are served in the Bridge Shelter, because shelter beds were reserved for multiple city initiatives and not solely for individuals prioritized for housing through CEA. Furthermore, clients with more than one case manager were thought to receive conflicting information about the housing process. Finally, inconsistent communication with housing providers was observed. A staff participant described challenges communicating with housing providers below: But it does depend on the housing provider, though, I think. And I—like, I just was saying, last week, we had a unit that got filled. The person got referred to the case conferencing, and then, a week later, the housing provider’s like, “Oh, no, there’s no apartment.” So, we’d already told the client that there—this was the apartment. This is where it was, and-and it’s—That’s not—that’s pretty infrequent, but, um—or the housing

provider—w-we’ve had to contact the housing provider directly cuz they don’t reach out, which is the standard… or they don’t tell us what they need in a clear way. So, it really depends. Some providers are better than others.

Mismatching of client needs and preferences and housing emerged across policy, staff, and tenant participant groups. Specifically, there were often discrepancies between clients’

vulnerability and service needs and/or their housing preferences with their assigned housing and service provisions. A staff member reported that mismatches of individuals with appropriate housing has persisted despite enhancements to the prioritization process, such as case conferencing:

Some of the most highly vulnerable folks in our community are still not accessing housing because the tool that we have doesn’t assess

vulnerability. It assesses for medical risk, um, and wasn’t designed to assess vulnerability. Um, so, we’re still not fully capturing that. Um, at a—as a housing provider, you know, we’ve seen people referred through coordinated entry who didn’t need permanent supportive housing, um, and 39

it’s not good for them, and it’s not good for the community that they-they live in. Um, so we’ve seen a lot of, um, increase in predatory behavior in some of the buildings that we have, um, people who are getting evicted because of X, Y, or Z. Uh, so there’s there—there’s still a disconnect and still an inability to-to do that well.

Rather than supportive housing, some tenants expressed a desire to have “regular housing” in a regular apartment building. A tenant describes a perception of being matched to a higher level of service than needed:

I find it odd that I’m the youngest person here with no health issues. They prioritize based on that, right? Every single r—co-resident in here is an elderly person who’s damn near dying or physically or mentally, severely physically or mentally handicapped. And, I mean, I’m not sayin’ I’m better than anybody, but I’m nowhere near any of those things. I am none of those. You know, I have mental illness, but I’m not - I’m not severely mentally ill you know. I’m not elderly. I’m not none of that stuff. And it’s just odd to me that I’m the only person under the age of 40 that’s here.

And I know at least 10 people at my last facility that took the same assessment that would qualify more to be in here, you know. I’m grateful for it. I just hate to see that because somebody’s coverin’ for themselves that I took a spot from somebody else who needed it more than me.

One policy participant described some of the questions from prospective tenants related to parking and WiFi availability as indicators that some of the CEA-referred tenants were less vulnerable than those typically housed by their programs.

Relatedly, staff and tenants spoke of barriers and frustrations regarding housing policy and rules. Restrictive rules within housing programs were a common reason for prioritized individuals to decline a housing referral. Tenants discussed restrictive rules as barriers to their autonomy and choice. For instance, a tenant indicated the tenant’s long-term partner and dog were not allowed to visit, stating, “So now I’m here in an apartment by myself, and he’s back at the other place…and now they—the dog can’t come here to visit. It’s just been a nightmare.”

Tenants expressing displeasure with their housing were generally not provided an opportunity to view the unit and review the rules and policies prior to lease signing, and/or they felt pressure to accept a referral out of concern it would be their only chance to attain housing. Generally, tenants did not feel they had a choice in the type of housing they received.

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Exhibit 12. Themes Related to the Challenges and Barriers of Referrals and Housing Placement

Theme

Summary

Sample(s) Represented

in the Theme

Difficulty locating clients Clients were often difficult to find or

Tenant, Staff, Policy

contact when they had a housing referral

Communication issues

Communication across providers

Staff

involved in housing referral and

placement was inconsistent

Mismatch of client needs There were often discrepancies between Tenant, Staff, Policy and preferences and

clients’ service needs and/or their

housing

housing preferences with the housing to

which they were referred

Housing policy and rules Housing programs’ restrictive rules were Tenant, Staff a common reason for prioritized

individuals to decline a housing referral

Agency and choice

Tenants did not perceive having choice in Tenant

their housing

Trade-offs and Tensions from the Policy Perspective

In addition to the benefits, facilitators, challenges, and barriers mentioned, several themes emerged from the policy participants that inherently address trade-offs and tensions within CEA.

These themes included:

1. Conceptualizing vulnerability.

2. Trade-offs of relationships.

3. Roles for those with lived experience of homelessness.

4. CEA interacting with other systems.

In response to questions about assessment, policy participants expanded well beyond considerations of current assessment processes to consider alternative and/or more expansive ways of conceptualizing vulnerability. Every policy participant articulated weaknesses of the Vulnerability Index-Service Prioritization Decision Assistance Tool (VI-SPDAT) as an assessment tool, but respondents varied widely in their opinions of whether or not the VISPDAT was the best of available approaches. Several participants perceived that the VI-SPDAT

was roughly equivalent to other available tools; as one participant noted, “after our research now for two years, there are no tools to address vulnerability that are built with a racial-equity lens.”

Others articulated that the VI-SPDAT should be promptly discarded in favor of the VAT, a more 41

intensive, locally-developed tool. Still others focused on the inherent limitations of any one tool, advocating instead for an approach honoring “multiple pathways” into the priority pool, such as those referred directly from clinical inpatient discharge. Other potential strategies the participants identified for operationalizing vulnerability included the local creation of a new assessment tool and the adoption of by-name lists. Policy participants held opposing views on a) whether HUD

preferred a single assessment tool, and b) whether that assessment tool was intended to be consistent across population groups.

The trade-offs of relationships emerged as another persistent theme among policy participants, again with a wide range of perspectives. All participants agreed that CEA disrupted the prior relationships between clients and providers, but views were mixed on the extent to which this was a positive or negative change. One set of participants highlighted the drawbacks of the relationship-based approach before CEA, as one participant described: I think my biggest issue with the previous system was that you were

relying—if you were experiencing homelessness and you’ve encountered someone that had the capacity and the expertise and that sometimes the experience or the social or professional network to be able to draw upon, then you would potentially get moved into housing based upon that

random connection.

Instead, CEA requires participants and housing units to be considered at a systems-level. Others regretted this change, tying it to worse client experiences, as described by one participant from an agency serving primarily Black and African American clients:

To me, you took away relationships. You took away where people feel

comfortable going. You tellin’ people where they need to go. You took away choice in a lotta ways for people... I do think there’s advantages to even all culture, people, especially people of color, going to a agency that understands them.

Overall, participants from government agencies tended to view a stronger client-provider relationship approach as problematic, whereas participants from provider agencies articulated that forming strong relationships with clients was a necessary part of their work.

The roles for those with lived experience of homelessness in CEA design and implementation also yielded mixed views among the participants. All participants supported the inclusion of those with lived experience of homelessness, in theory, but several articulated the challenges of incorporating them into CEA’s decision-making spaces, such as tokenization occurring in professional meetings or the difficulty of incorporating their feedback into the work.

One participant noted, “I’ve actually heard bureaucrats critique bringing in folks with lived experience because they’re not systems thinkers, or they don’t understand this other thing. That’s not what they’re there for.” Others spoke about the disconnect between those selected to represent the homeless experience and the perspective of the most vulnerable individuals, as one participant explained:

42

I’m often far more interested in the people who aren't gonna give me that feedback. How do I design something that’s gonna help that group? It’s the people who stand up and tell you what they need we hear from one way or another often. It’s a huge subset of people who can't and don't want to do that, and that’s the voice that I think is super critical for anything like this, and they just get left out. There’s no easy answer to how to incorporate that group, but to say we’re incorporating lived experience it’s not the same lived experience as the target population.

Finally, policy participants frequently raised themes about the external environment, describing CEA interacting with other systems. Often these comments contextualized the challenges of CEA as minor compared to larger system constraints, such as funding systems and structures, a history of housing discrimination, ongoing systemic racism, Fair Housing law infrastructure, and a scarcity mindset. Several participants spoke about the mismatch between CEA’s needs and the housing units within its purview, such as this participant noting: Coordinated entry does not choose the quantity or nature of resources.

Like we did not come in and say, ‘Cool! We need 600 SROs! And we

need…’ You know? The way that affordable housing is built in our

community is not taking a look at people’s preferences and service-match needs. It’s like, ‘Cool. I can get that funding from Department of Mental Health….I can get that funding from King County Capital…’ We are not taking a look at, ‘Here is the full universe of people in our community.

This is the service match they need, and this is their preference. Go build that housing, or go identify that housing.’ It has just been hodge-podged together with good intentions, but no real data-driving movement.

Participants also explained how various housing units continued to operate outside the CEA system, further reducing its impact.

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Exhibit 13. Themes Related to the Trade-offs and Tensions from the Policy Perspective Theme

Summary

Conceptualizing

Participants had diverging perspectives on how to conceptualize

vulnerability

and assess vulnerability, noting there are no tools currently

available that are fully adequate

Trade-offs of

Participants from government agencies and those from provider

relationships

agencies expressed differential views regarding the benefits and

drawbacks of the impact CEA had on relationships between

clients and providers

Roles for those with lived Inclusion of people with lived experience of homelessness was experience of

viewed as an important aspect of the CEA system; however,

homelessness

perspectives varied on the extent to which this could be

authentically implemented

CEA interacting with

CEA’s challenges were viewed as embedded within broader

other systems

system constraints

Overall Systemic Context

Participants across groups identified themes addressing the broader systemic context in which CEA was situated. The systemic context had bearing on the extent to which CEA could function effectively. Themes emerging in this area included:

1. Lack of affordable housing.

2. Definitions and eligibility for housing.

3. Lack of coordination.

4. Bureaucracy of the homeless service system.

In King County, the lack of affordable housing—including permanent supportive housing (PSH), subsidized, and naturally occurring—available to serve the large homeless population was a prominent theme among policy and staff participants. Staff indicated that assessments to prioritize housing were inconsequential given the insufficient housing stock. A staff member described the challenge: “It’s all kinda rearranging the deck chairs on the Titanic. You know, there just isn’t enough housing or resources however you cut it.” Participants expressed frustration that public funding was being directed toward building more shelters rather than affordable housing. Indeed, staff observed that housing placements through CEA occurred due to unit turnover (for example, individuals losing their housing or passing away), as opposed to new units coming online.

44

Policy participants and staff identified implications of the lack of affordable housing on CEA functioning. Every policy participant raised the issue of limited housing resources as a larger limitation than any of the challenges within CEA for the single adult population. Many policy participants pointed to the other CEA populations (such as families, youth, or veterans) as higher functioning because those populations had a better match between the community need and the housing resources available. Meanwhile, the single adult population included many more highly-vulnerable people than could ever be housed with existing housing resources in this community, resulting in a situation where “we’re fighting over scraps.”

Staff noted that housing scarcity created situations in which individuals were a poor fit for their housing because they had to take what they could get in order to exit homelessness.

Staff spoke of a lack of gradation of housing options provided for people experiencing homelessness given that PSH and, rarely, rapid rehousing were the available interventions in CEA. They felt the housing options were “all or nothing,” meaning they were extremely service-rich and deeply subsidized interventions for highly vulnerable individuals without options for people with fewer support service needs. Some housing available through CEA was undesirable for clients, such as single-room occupancy buildings with small cubicle units in buildings of poor condition. Moreover, the lack of affordable housing perpetuated the overall level of vulnerability among individuals in the community due to a growing population of people with prolonged homelessness. Staff and policy participants expressed that many of the challenges observed in CEA would be resolved if adequate housing resources were available.

Federal and organizational policy around definitions and eligibility for housing created additional challenges in serving clients from the perspectives of staff. For instance, individuals were required to meet the federal definition of chronic homelessness to qualify for most housing programs. Individuals lost their chronic homelessness status if they had prolonged incarceration or inpatient hospital stays, or if they resided in transitional housing, thereby disqualifying vulnerable individuals from accessing most PSH programs. Individuals housed through CEA who subsequently left their housing—possibly due to poor fit with their housing—were unable to be rehoused in many programs due to a loss of chronic homelessness status. Eligibility for housing programs was also limited by individuals’ income. For instance, some tenants reported they could not access certain housing programs due to exceeding the income threshold from their Veterans Affairs or Social Security Disability Income benefits. A tenant stated: I know that, uh, if you worked your whole life and you did what you were told to do or, you know, what is expected out of a regular person, it doesn’t help you when you’re homeless. Because I busted my tail my

whole life, and I make a good Social Security disability because I work so much in my life. So they were like, “You overqualified. You make too much money to have any help.”

Furthermore, staff participants identified a lack of coordination of policies and priorities that impacted CEA functioning. For instance, each level of the system (such as county or city, organizations) had its own protocols and different funding programs, leading to poor integration of organizations with the “same overall mission and drive.” On the other hand, staff expressed that the CEA system was forcing a “one size fits all approach,” which disregarded the diverse 45

spectrum of client needs and failed to acknowledge that there was room for different missions, specializations, and programs.

Staff and tenant participants thought of CEA as part of the harmful bureaucracy of the homeless service system. Participants perceived that substantive issues in the broader service system (not limited to CEA) were not directly addressed and instead diverted time, money, and attention from actual solutions to homelessness. For instance, city governments conducted sweeps of homeless encampments with the intention of directing individuals to shelters, but there were insufficient shelter beds to support this aim. Participants referred to the homeless industrial complex in King County. That is, the system was composed of “professional handwringers for the people they work for,” because instead of providing needed housing, they gave reasons for why there was no housing available. A tenant participant expressed:

I call it the…housing industrial complex. They have no incentive to house people because if they house people, people like this lady out here

wouldn't have a job and the janitors around here. And it gets—it’s - it’s just a way…to employ people I believe.

Exhibit 14. Themes Related to the Broader Systemic Context

Theme

Summary

Sample(s) Represented

in the Theme

Lack of affordable

Insufficient affordable housing supply or Staff, Policy

housing

resources (i.e., permanent supportive

housing, subsidized housing, and

naturally occurring affordable housing)

available in King County created an

immense challenge for effective CEA

implementation

Definitions and eligibility Federal and organizational policies

Tenant, Staff

for housing

regarding homelessness history and

income were barriers to addressing

homelessness

Lack of coordination

Inconsistent policies, priorities, and

Staff

funding programs across agencies led to

poor integration of organizations in CEA

Bureaucracy of the

Substantive issues in the broader service Tenant, Staff

homeless service system system were not addressed, and resources

were diverted from solutions to

homelessness

46

Recommendations for Improving CE Systems

To address Research Question 6, participants shared several recommendations for improving CEA and CE systems generally. Recommendations fell into the following thematic areas:

1. Expansion of housing.

2. Changes to the assessment process.

3. Staffing and staff support.

4. Accessibility and outreach.

5. Initiating and designing a CE system.

Staff and tenants felt that an expansion of housing was necessary for system functioning.

Ideas for housing expansion included creating a greater array of housing with specialized services to accommodate diverse client needs and adding housing authority subsidies (such as Housing Choice Vouchers) into CEA. Staff also expressed the importance of increasing housing stock by increasing funding to build affordable housing, expanding housing outside of Seattle, and by converting motels to affordable housing. A tenant expressed that reducing regulations on building affordable housing would reduce barriers to development. Policy participants noted that the other subpopulations—families, youth, veterans—tended to have higher-functioning CE

processes because of the substantially smaller gap between needs and available resources. To that end, several policy participants suggested subdividing the single adult population (for example, into a “chronic” group) associated with relevant housing resources.

Staff and tenants recommended significant changes to the assessment process, including no longer utilizing the VI-SPDAT. They suggested implementing a narrative-based method of assessment that offers a more comprehensive overview of client vulnerability and service needs.

It was recommended the assessment include both self-reported and objective information (such as eviction history). Some staff recommended replacing the VI-SPDAT with the VAT, which was viewed as more narrative-based and accurate. It was recommended that the assessment process be adapted to be culturally sensitive, take into account experiences of oppression, and ensure equitable access to housing resources. Tenants also recommended that the assessment focus more on future prospects, as opposed to past experiences, such as “future vulnerability,”

housing goals, and “chances of affording housing.” Several policy participants favored a

“multiple pathways” approach that allowed for “multiple different pathways to be nominated or to rise to the top as who our community should prioritize,” such as consideration of functional vulnerability, systems utilization, and chronicity.

Staffing and staff support were areas of consideration reported by all three participant groups. Participants indicated that assessors and other providers would benefit from training in assessing various specialized populations of people experiencing homelessness. Tenants also acknowledged the large caseloads of many case managers and recommended that they have smaller caseloads to more effectively serve their clients. Staff and tenants both stated a need for lived experience at the table to inform CEA policies and procedures. Finally, an emphasis should be placed on hiring assessors of diverse backgrounds, including people with lived experience, to 47

better enable matching assessors and clients on aspects of identity to increase parity and promote trust and disclosure.

Based on their experiences navigating CEA, tenant participants recommended greater accessibility and outreach efforts. Tenants did not perceive adequate street outreach was taking place, and some felt they were only connected with housing because they were staying in shelters. Policy participants recommended increased investments in outreach, and ensuring that assessors included people that have “street smarts” and feel comfortable going to locations “that most people don’t wanna go because they’re scary.” Moreover, staff reported it would be helpful if clients’ locations were updated consistently in HMIS to aid in contacting them when a CEA referral became available. Tenants further recommended increased accessibility to service providers and interactions with the CEA system. For instance, they recommended implementing an online portal where they could interact with providers, have access to information about CEA, and check their status on the CEA priority list.

In considering the overarching task of initiating and designing a CE system, policy participants spoke both about the need to learn from other communities and to engage in grassroots work within one’s own community. Providers, those with lived experience of homelessness, and the general community should all be formally incorporated into system design planning. One participant articulated the ideal role for CEA as “facilitator convener,” leading conversations and decision-making processes with stakeholders. Participants noted that this may lead different communities (and different subpopulations) in different directions, but a recommended starting place is to “Get providers around the room to identify who are their highest-needs people and how would they go about measuring that to design the process by which CEA then elevates those people.” Others noted that ground-level collaboration in systems design would also better recognize the constraints of providers, who are held accountable by funders for filling units. As one participant explained, “That’s actually part of our job to make sure we’re filling those units and our obligation to our mission,” so there are organizational consequences if CEA is slow or ineffective in helping them fill units. Finally, participants noted the need for systems thinking, recognizing that this is a different approach than implementation and program thinking.

48

Exhibit 15. Recommendations for Improving CEA

Theme

Summary

Sample(s) Represented

in the Theme

Expansion of housing

Increase amount and array of housing to Tenant, Staff, Policy

address homelessness among clients with

varying levels of service need

Changes to the

Identify an alternative assessment to the Tenant, Staff, Policy

assessment process

VI-SPDAT, include assessment of goals

and future housing stability, and consider

multiple pathways of gaining

prioritization for housing

Staffing and staff support Emphasis should be placed on assessor

Tenant, Staff, Policy

training, reducing case manager

caseloads, and hiring staff with lived

expertise and people of diverse

backgrounds and identities

Accessibility and

Greater resources should be directed

Tenant, Staff, Policy

outreach

toward outreach efforts, regular updates

to client information in HMIS are

needed, and clients need greater access to

staff

Initiating and designing a Policymakers would benefit from

Policy

CE system

learning about CE implementation in

other communities, as well as conducting

local grassroots work and fully

incorporating diverse stakeholders

(including people with lived experience)

into system design and implementation

Discussion of Findings

This study depicts the structure, processes, and procedures of the CE system for single adults in King County, Washington, and it identifies system strengths and areas for improvement from the perspectives of key stakeholder groups, including policy-level staff and decision-makers, direct service staff, and tenants housed through CEA. Triangulation around shared perceptions about the system was achieved by employing thematic analysis in which coalescing perspectives across participants were identified. The formal CEA process outlined by King County (King County, 2018; KCRHA, 2021b) largely aligns with the depiction of the system presented by study participants. Gaining an understanding of the system, however, was a moving 49

target, given that participants discussed procedures in place at the outset of CEA, adaptations that have been made, and adaptations that occurred in the midst of data collection. Effort was made to depict the system as it functioned in 2019, and it should be noted that subsequent adaptations have occurred, particularly in response to the COVID-19 pandemic (Ewing and Reimal, 2021).

Although the study highlights considerations for implementation within a single CoC, findings may translate to other communities working to establish best practices for CE systems.

In light of the growing population of single adults experiencing homelessness in King County, rising to the level of a state of emergency (City of Seattle, 2017), participants in policy and staff roles expressed positive views about CEA, in theory. Specifically, participants noted a need for the service system to more effectively allocate scarce PSH resources to individuals best suited for service-rich housing programs. Furthermore, they perceived CEA as a mechanism for accountability for PSH providers to provide low-barrier housing to individuals with the greatest service needs. In practice, however, according to participants across the three stakeholder groups, there are tradeoffs and pitfalls in each system component.

Threats to Fairness: Street-Level Advocacy and Value Conflict

CE systems endeavor to promote fairness in housing allocation through the systematic utilization of vulnerability assessment tools and housing prioritization procedures (HUD, 2017a).

CEA stakeholders, however, observed both a) numerous challenges to objectivity, and b)

“fairness” sometimes hampered the realization of other values, such as responsiveness, client choice, and timeliness. A primary challenge to objectivity resulted from variable levels of advocacy by client-facing service provider staff on behalf of their clients and the extent to which people experiencing homelessness were willing and able to self-advocate. The autonomy of service providers in their roles creates “street-level bureaucracy,” (Lipsky, 2010) wherein the lack of clear implementation guidance and a high volume of work motivates direct service staff to develop workarounds and coping mechanisms for getting the work done. In this context, the inability of the assessment process to reliably distinguish among highly vulnerable individuals led many staff to advocate for their clients and engage in other practices in conflict with formal policies and procedures.

Tenants and staff reported that some assessors coached clients on how to respond to the VI-SPDAT to increase their likelihood of gaining priority for housing. Some individuals received multiple assessments until a desired score was achieved, and there were no structures in place to ensure that all individuals equally received the same opportunities for reassessment.

Moreover, some staff participants perceived that clients with confident and experienced case managers advocating for them during case conferencing had a greater chance of attaining a housing referral than those whose case managers were inexperienced, interpersonally reserved, limited in English proficiency, or had other reasons for being hesitant to speak up in the case conferencing context. People experiencing homelessness were viewed by staff and tenant participants as needing to be strong self-advocates to move through the system into a housing placement. For instance, tenants described staying in close contact with their service providers, checking in regularly to receive updated assessments, and they were generally willing to stay in the Bridge Shelter or other programs designed to facilitate their locations once a housing referral was available to them. Clearly, the effect of this street-level advocacy undermines CEA’s goals 50

of leveling the playing field and prioritizing housing based on objective measures of vulnerability.

Some of the policies motivated by objectivity ended up exacerbating systemic inequities.

Participants across all groups felt that individuals with fewer service connections, particularly those staying in unsheltered locations outside of encampments, were not able to self-advocate and engage fairly in the system. This meant that those who were most vulnerable and disconnected from services were least likely to gain housing because they could not meet the preliminary condition of obtaining an assessment. Moreover, individuals unwilling or unable to self-disclose personal information on the assessment due to mental illness, cultural values of privacy, pride, or other reasons did not have the same opportunity to self-advocate as people without such barriers. Even for those who ended up in the priority pool, tenuous service connections sometimes impacted the extent to which direct service providers had sufficient knowledge to advocate for clients during case conferencing.

The pursuit of fairness also hampered the realization of other values, including responsiveness and client choice. At the policy level, providers repeatedly noted that their housing programs were funded and developed to accommodate a specific set of needs, whereas the CEA system tended to treat all units as equivalent. Consequently, participants across groups spoke about issues of ineffective matching of individuals to housing programs such that individuals with lower support needs (such as individuals best equipped to self-advocate) were entering PSH, whereas highly vulnerable individuals known in the community were not making it onto the priority list because of low assessment scores. Several tenant participants felt they were triaged to housing offering a higher level of support services than they needed or preferred.

In contrast to the present findings, a study of PSH housing placements before and after Chicago’s CE system was implemented, Dickson-Gomez, Quinn, McAuliffe, Bendixen, and Ohlrich (2020) found that the proportion of individuals with mental illness, substance use disorders, and dual diagnosis housed in PSH did not change. However, through the CE system, individuals were more likely to receive PSH offering more intensive or behavioral health-oriented housing supports versus PSH offering less intensive case management support. These findings suggest that Chicago’s CE system may not prioritize a greater number of persons with high service needs, but persons with high needs are more effectively triaged to the appropriate level of housing support.

Conflicts also arose around culturally-targeted programs, where policy-level decision-makers interpreted Fair Housing laws to mean that CEA could not match clients into units based on race, ethnicity, or cultural identity. This led to inefficient resource allocation and lower quality of service. For example, some providers had to add language support, whereas pre-existing multilingual staff in other programs were underutilized.

The multistep referral and placement process reduced timeliness for the sake of striving for fairness. Providers expressed frustration at the length of time between a unit becoming available and filling that unit through CEA. Leaving units unfilled for weeks at a time felt particularly painful for providers in the midst of the declaration of homelessness as a local emergency. Although CEA procedures adapted to accommodate more “external fills,” these external fills offered no greater guarantee of “fairness” than the system that pre-dated CEA.

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Thus, in practice, housing placement occurred through two parallel paths: 1) CEA, which was centralized and, in theory, favored fairness over timeliness, and 2) external fills, which empowered providers to house clients without consideration of CEA processes, thereby filling units quickly without regard for CEA’s prioritization. Maintaining both of these paths to housing failed to achieve a process that honored both fairness and timeliness simultaneously.

Exacerbation of Inequity

Participants in the current study confirmed data-based findings from locally commissioned evaluations of CEA’s implementation that revealed disparities by age, race, and gender in housing prioritization and referrals among single adults experiencing homelessness in the community. An evaluation by Focus Strategies (2019) found that older adults scored lower on CEA assessments than younger adults. Consistent with research revealing racial disparities in VI-SPDAT scores (Cronley, 2022), the evaluation reported that Black individuals attained lower assessment scores than White individuals or individuals of another race (Focus Strategies, 2019).

A subsequent evaluation showed that American Indians or Alaska Natives and White individuals were more likely to have a housing referral denied (either denied by client or by housing program) compared to other racial groups, whereas Black individuals were less likely to have a referral denied (Ewing and McHugh, 2020). Racial disparities were also observed in wait times for housing, with American Indians or Alaska Natives experiencing the longest waits (Anderson et al., 2018). Finally, disparities by gender have been found within the system. Individuals with gender identities other than cisgender man or cisgender woman were found to have the highest assessment scores (Focus Strategies, 2019), and cisgender women were found to be underrepresented among individuals receiving housing referrals and placements (Ewing and McHugh, 2020). Participants in the current study also identified equity issues with regard to disability status, perceiving individuals without cognitive disabilities or mental illness as better able to advocate for themselves and respond accurately to the assessment. Further research is needed to examine the extent to which CE systems function equitably for individuals across dimensions of identity.

Study findings align with emerging research showing the potential for CE systems to exacerbate racial disparities in homelessness. Dickson-Gomez and colleagues (2020) found that, controlling for mental health and substance use indicators, race significantly predicted the type of PSH to which individuals were prioritized through the Chicago CE system. Specifically, non-Hispanic Black individuals were less likely than other racial/ethnic groups to be housed in PSH

offering intensive case management or behavioral health services, and they were more likely to be housed in low-intensity case management programs in congregate/single-site supportive housing settings. As adequate housing support is critical for residential stability, inequitable allocation of PSH with intensive services may further the cycle of homelessness for Black households. Another study revealed that Indigenous individuals were at significantly greater risk of returning to homeless services following CE housing placement relative to White individuals (Petry et al., 2021).

Extant vulnerability assessment measures have not been adequately studied for their psychometric properties and applicability for housing prioritization in the CE context (HUD, 2015b), which may, in part, drive racial disparities in CE systems. Indeed, a multi-community 52

evaluation of CE systems revealed a general pattern of significantly lower VI-SPDAT scores among BIPOC households compared to White households (Wilkey, Donegan, Yampolskaya, and Cannon, 2019). Moreover, a study utilizing HMIS data revealed significant disparities in VISPDAT scores by gender and race (Cronley, 2022). Specifically, White women were found to score higher on the VI-SPDAT compared to Black women and men of any race. The present study offers context regarding racial disparities in VI-SPDAT scores and the assessment process.

First, participants felt BIPOC individuals may be prone to underreporting their experiences on the VI-SPDAT due to historic oppression creating mistrust with the system. White individuals were not perceived by respondents as experiencing the same hesitancy. Second, tenants, staff, and several policy leaders all viewed the VI-SPDAT as lacking cultural validity and excluding aspects of vulnerability that are uniquely experienced among racially minoritized groups, such as intergenerational trauma. Third, participants identified demographic mismatching between assessors and people experiencing homelessness as a barrier to accurate assessment, mirroring national trends that indicate White women as overrepresented in social work positions in contrast to an overrepresentation of men as well as Black and Indigenous individuals among single adults experiencing homelessness (Ewing and McHugh, 2020; Salsberg et al., 2017). Efforts to match assessors and clients on aspects of identity were not made within the system. Finally, despite efforts among CEA policymakers to remediate disparities in the system through a new formula for prioritization which placed less reliance on VI-SPDAT scores, staff were dismayed that the VI-SPDAT continued to be utilized despite knowledge of the disparities it produced. Beyond the problematic disparities in VI-SPDAT scores, study participants expressed that racial equity goals were hampered by the predominance of White individuals comprising CEA leadership, thereby grounding system design within a Eurocentric perspective. For example, the system did not incorporate the nuances of culturally specific housing into CEA. Taken together, findings from the current study and past research raise concern about racial equitability in coordinated entry assessment, prioritization, and housing referral procedures, thereby reducing the assistance opportunities for Black and Indigenous households who are disproportionately overrepresented in the greater homeless population.

Affordable Housing Scarcity

King County faced particular challenges in designing an effective CE system. Point prevalence estimates from 2020 suggested that King County had the fourth largest population of single adults experiencing homelessness in the United States (HUD, 2021). Compounding challenges to the task of housing a large population of individuals with limited or no income was the skyrocketing cost of rent in King County. One study estimated that Seattle had the greatest increase in rental prices in the nation between 2010 and 2020 (Bringle, n.d.).

Affordable housing scarcity underpinned many of the CEA barriers identified by participants. Participants across stakeholder groups were disheartened about working to implement a homeless service system in the absence of adequate affordable housing resources, with one staff member likening it to “rearranging the deck chairs on the Titanic.” Frustrations were stated about the use of resources for CEA implementation and the creation of new shelters that would be better directed toward the development of more affordable housing. Participants perceived the lack of focus on increasing affordable housing as promoting a “homeless industrial complex” wherein there are systemic incentives to maintain homelessness in the community.

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Indeed, Culhane and An (2021) estimated the national revenue of shelters and temporary housing programs in 2015 at $10.5 billion and employing 160,000 people.

With regard to who gained priority for scarce housing resources, tenant participants were both confused and concerned about the concept of prioritization. Participants were familiar with a first-come first-served approach, so vulnerability-based assessment felt novel to some. Tenants felt prioritization was a way of determining deservingness to housing that did not seem fair or transparent given the myriad factors that contribute to individuals’ homelessness that were not fully captured in the assessment tool. At least one tenant expressed guilt for taking a housing opportunity from someone else despite acknowledging that housing was necessary for their own survival. Staff also reported the assessment was not exhaustive of all aspects of vulnerability, and that certain vulnerabilities, such as health conditions, were given greater weight than others. As such, there was a sense of arbitrariness around which of the many highly vulnerable individuals were prioritized for the few housing resources available.

Adapting to Challenges

It was evident that King County worked to adapt and change in the face of challenges and barriers in CEA. Participants described changes made to the system to improve equitable housing access, such as the implementation of Interim Prioritization vulnerability scores and Dynamic Prioritization within case conferencing. In fact, the system was adapting and changing in the midst of data collection for the current study. The most recent CEA evaluation indicates that training accountability has increased over time, including a more robust tracking system to monitor the number of individuals who have assessment access in HMIS and to track that with when they last completed training (Ewing and Reimal, 2021). Training now includes an online testing component, and testing has improved over time. HUD (2017a) encourages such adaptability and responsiveness. Therefore, it is unreasonable to expect a system as complex as CEA to function at a high level of effectiveness and efficiency at its outset. Furthermore, CoCs have very little evidence-based guidance on best practices for CE. Many of the issues observed in CEA are likely not unique to King County, particularly given the widespread adoption of the VI-SPDAT for coordinated assessment.

King County and the City of Seattle put forth due diligence in evaluating the system to identify areas of improvement (Anderson et al., 2018; Ewing and McHugh, 2020; Focus Strategies, 2019; National Innovation Service, n.d.). At the same time, staff and tenants did not feel their voices were adequately heard and acknowledged by CEA decision-makers, and confusion persisted among decision-makers regarding who was empowered to make decisions.

There was a desire for people with lived experience of homelessness to have meaningful roles in system design and implementation. Staff reported a need for clearer channels for communication of issues observed on the ground, and for changes to the system to be made accordingly. Thus, there were missed opportunities for system improvement by stakeholders most closely involved in, and impacted by, CEA.

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Study Limitations

The study employed purposive sampling to ensure a diverse range of stakeholder voices inclusive of people with lived experience in CEA, direct service staff, and policymakers with representation from varied organizations and programs in King County. Despite efforts to include all participating agencies serving single adults, we did not achieve full representation.

The majority of participating agencies from which staff and tenant participants were recruited were located in Seattle, so representation from the broader county was also limited. Furthermore, CEA included some rapid rehousing resources, but we only had tenant and staff participants from PSH and transitional housing programs, so perspectives on rapid rehousing’s role in CE

were not thoroughly explored. Individuals housed through CEA were recruited for the study with the rationale that they could describe the full experience of progressing through the system; however, the views and experiences of unhoused stakeholders were not included. Finally, our tenant and staff samples did not fully or adequately represent the diverse experiences across the spectrum of identity. Given the disproportionate impact of homelessness on Black and Indigenous communities, and disparities observed in CE systems, individuals sharing these identities should be overrepresented in research studies on CE. Moreover, although Asian Americans account for 15% of the population in Seattle (U.S. Census Bureau, n.d.), neither tenant nor staff samples included Asian American participants unless they identified as multiracial/multiethnic. All staff and tenant participants identified as cisgender, and participants were not asked to identify their sexual orientation, so nuances specific to gender and sexual minoritized groups were not captured in the current study. Therefore, study findings may not fully reflect perspectives and experiences of all stakeholders interfacing with CEA.

Recommendations

Findings point to recommendations for CE systems. Recommendations reflect changes that may improve system implementation and outcomes.

1. Ongoing monitoring and evaluation for system adaptability and improvement CoCs are required to conduct annual evaluations of CE systems (HUD, 2017a), which proved critical for CEA in identifying issues for which adaptations were needed. In particular, evaluations should utilize an equity-based framework to ensure CE systems function equitably for all individuals. National Innovation Service (2020) developed a framework for equity-based decision-making. The framework emphasizes the necessity for groups most impacted by homelessness to have meaningful roles in decision-making. Direct service staff should also have a meaningful voice in system design.

2. Reconsider the use of the VI-SPDAT

Given concerns with the VI-SPDAT have been raised in the King County community for years, and that research questions its reliability, validity, and equitability (Brown et al., 2018; Cronley, 2022), the use of the tool—even in combination with other measures of vulnerability—

should be reconsidered. In fact, the VI-SPDAT developers are transitioning away from the tool in its current form (De Jong, 2020). Some participants felt the locally developed VAT was a 55

better option due to its narrative approach. The VAT was also endorsed in a review of existing coordinated assessment tools (Aubry, Bell, Ecker, and Goering, n.d.). However, caution is needed in the adoption of any assessment measure, because psychometric research has not adequately examined the effectiveness of existing measures for CE systems. Other participants expressed support of a “multiple pathways” approach that would move beyond reliance on a single assessment tool for prioritization.

3. Consider the (mis)match between housing stock and needs in CE systems PSH was instrumental in CEA. However, participants felt that meaningfully addressing homelessness in the community would require a much broader affordable housing approach.

Increasing non-PSH affordable housing stock, and including Housing Choice Vouchers within CEA, may help reduce mismatches in housing referrals. Alternatively, dividing the single adult pool into smaller subpopulations (such as those considered chronically homeless), and associating those subpopulations with relevant housing programs, could lead to better outcomes overall.

4. Increase transparency in the system

There was a general lack of clarity and reluctance to assume authority regarding who the responsible parties were in designing and addressing issues in CEA. There was not a clear channel of communication for staff and clients to report challenges in the system. Even among those with defined leadership roles, confusion persisted regarding which individuals were empowered to do what. Strategies for increasing transparency in procedures and decision making are needed.

There was also a lack of transparency in information provided to people experiencing homelessness about the system. Upon assessment, people were generally given vague information about how the assessment related to their prospects for housing (with the exception of instances of street-level bureaucracy). Individuals with middle range scores could wait for housing in perpetuity. Many tenants in the current study had limited or no understanding of how CEA worked, despite having interfaced with every step of the process. Furthermore, tenants often did not have a chance to view their housing unit before lease signing, so some expressed disappointment with their placement. Transparency is considered a critical element of trauma-informed policy (Bowen and Murshid, 2016). Thus, individuals experiencing homelessness should be provided clear and accessible information about the system. They should have access to information about their status on the housing priority list, and their housing preferences should be better accounted for in the referral and housing placement process.

5. Acknowledge the cost and added value of CE systems

Implementing and operating a CE system requires resources proportionate to the scale of the population needing services. Given the scarcity of housing resources and the extensive resources required to run CEA, the overall value gained by implementing CEA may not be worthwhile. Perhaps the same improvements (or more) could have been achieved by redirecting the implementation costs into additional housing units, while keeping agencies in charge of 56

individual-level prioritization and allocation. Greater acknowledgment about the true costs of implementing a CE system should be incorporated into decision-making about whether or not CE systems should be universally recommended.

Conclusion

Federally-mandated CE systems seek to efficiently and effectively allocate housing resources to persons experiencing homelessness. The current study identified facilitators and barriers to effective CE implementation in King County, many of which may inform CE systems broadly. The study raised concerns that current CE assessments may not encompass all relevant aspects of vulnerability, including factors that are uniquely experienced by individuals with identities targeted for oppression. Such issues pose a significant challenge for CE, as systematic assessment of housing service needs across the homeless population is at the core of these systems. Therefore, rigorous examination of the conceptualization of vulnerability is merited, and the concept of a standardized assessment for housing prioritization should be carefully revisited. Moreover, strategies to reduce system inefficiency caused by mismatches between client needs and preferences and their housing are needed. For instance, fostering client choice in housing may facilitate the housing referral process while also better aligning CE with a Housing First approach and improving client mental health outcomes (Greenwood, Schaefer-McDaniel, Winkel, and Tsemberis, 2005; Tsemberis, Gulcur, and Nakae, 2004).

The importance of creating equitable homeless service systems cannot be understated as most non-White racial groups are overrepresented in the homeless population (National Alliance to End Homelessness, 2020). Along with previous research and evaluation, the current study suggests that CE systems are prone to inequities in housing prioritization and/or placement based on age, race, gender, and disability. Thus, the meaningful leadership of diverse and representative voices in the design of homeless service systems is of utmost importance. The current study especially highlighted the value of gaining the perspectives of direct service staff and people with lived experience of homelessness. These stakeholders are often excluded from policy decision-making yet they interface directly with CE systems and possess uniquely informative experiences and expertise.

In sum, there is significant room for future research and development to inform CE

system best practices. The elements of effective CE systems likely depend, at least in part, on the local context. Findings from this study point to numerous complexities in CE system implementation in communities similar to King County’s in which service systems are strained by mounting homeless populations compounded by affordable housing scarcity. Future research in small and midsize cities and rural communities is needed to identify common and context-dependent facilitators and barriers to CE implementation.

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U.S. Department of Housing and Urban Development

Office of Policy Development and Research

Washington, DC 20410-6000

January 2023

Document Outline

A Qualitative Case Study of the Coordinated Entry for All System in King County, WA

Disclaimer

Acknowledgments

Foreword

Table of Contents

List of Exhibits

Executive Summary

Study Overview

Method

CEA Structures, Processes, and Procedures

CEA Benefits and Facilitators

CEA Challenges and Barriers

Discussion and Recommendations

Introduction

Overview of Coordinated Entry

King County’s Coordinated Entry for All System

Project Background and Rationale

Method

Sample and Recruitment

Tenant Sample

Staff Sample

Policy Leader Sample

Data Collection

Procedure

Analysis

Results

Tenant and Staff Participant Demographics

CEA Structures, Processes, and Procedures

Overall CEA Structure

CEA Access and Assessment Processes

Dynamic Prioritization and Case Conferencing

Referrals and Housing Placement

How CEA Benefits and Facilitates Homeless Service Delivery

Overall CEA Structure

CEA Access, Assessment, and Assessment Process

Dynamic Prioritization and Case Conferencing

Referrals and Housing Placement

Challenges and Barriers in CEA Implementation

Overall CEA Structure

CEA Access, Assessment, and Assessment Process

Dynamic Prioritization and Case Conferencing

Referrals and Housing Placement

Trade-offs and Tensions from the Policy Perspective

Overall Systemic Context

Recommendations for Improving CE Systems

Discussion of Findings

Threats to Fairness: Street-Level Advocacy and Value Conflict

Exacerbation of Inequity

Affordable Housing Scarcity

Adapting to Challenges

Study Limitations

Recommendations

1. Ongoing monitoring and evaluation for system adaptability and improvement

2. Reconsider the use of the VI-SPDAT

3. Consider the (mis)match between housing stock and needs in CE systems

4. Increase transparency in the system

5. Acknowledge the cost and added value of CE systems

Conclusion

References