PART I: Community Participation & Coverage
Question 1
Does your by-name list include all young people currently experiencing homelessness including:
1A.) Unsheltered young people living on the streets or other places not meant for human habitation
All Outreach providers in Skagit County regularly connect with young people living on the streets or other places not meant for human habitation and have projects within HMIS to account for them:
Northwest Youth Services Youth Led Outreach (NWYYHDP)
The Skagit Valley YMCA (OASIS Teen Shelter Street Outreach (OTSSYS)
Community Action, who holds Skagit County’s Coordinated Entry, Outreach providers have the ability to enroll any young person (18+) in Coordinated Entry (SCAHRC Interest Pool)
Weekly check-ins via phone call to Community Action are required to stay in the Housing Interest Pool. Check-in questions discuss current living situations, however, this is not reported in HMIS. All HMIS projects include the data element of living situation prior to project enrollment.
Outreach providers with Community Action refer any youth interested in services to the OASIS Outreach via phone call at the point of identification.
A list of all HMIS projects by Balance of State Counties can be found here
1B.) Young people living in shelter, transitional housing or other time-limited settings?
All of Skagit County’s emergency shelters, transitional housing & other time-limited settings enroll services in HMIS (see list below). YYA receiving these services would be accounted for in HMIS & included on the BNL.
Anacortes Family Center:
Emergency Shelter
Catholic Community Services:
Emergency Shelter
Family Promise:
Homeless Prevention & DIversion
Emergency Shelter
Seasonal Shelter
Transitional Housing
Friendship House:
Emergency Shelter
Hotel Vouchers
Men’s Shelter
Women's Shelter
Helping Hands:
Prevention & Diversion
Mount Vernon Police Dept. Integrated Outreach:
Hotel Vouchers
Northwest Youth Services:
Prevention & Diversion
Emergency Shelter
Vouchers
Transitional Housing
Minors can seek emergency shelter at OASIS Teen Shelter or support through Diversion & Hotel Vouchers.
Anacortes Family Center:
Hotel Vouchers
AFC also acts as the McKinney Vento Liaison for Anacortes School District, directly connecting students in need to this option.
OASIS Teen Shelter:
Prevention & Diversion
Emergency Shelter
A list of all HMIS projects by Balance of State Counties can be found here
1C.) Young people living in unsafe or unstable situations?
Youth and young adults living in unsafe or unstable situations can access services at Northwest Youth Services or Oasis Teen Shelter. These teams are able to assess and connect YYA in these situations to resources, which are documented in HMIS, leading to inclusion on the Skagit BNL. Youth & young adults seeking services at Northwest Youth Services or Oasis are asked at intake whether they were previously living in unsafe or unstable situations, fleeing or attempting to flee unsafe or unstable situations. Services are available regardless of their answers or experiences.
1D.) Young people fleeing or attempting to flee unsafe or unstable situations?
Skagit County’s Domestic Violence & Sexual Assault Services (DVSAS) offer Emergency Shelter to young adults living in unsafe situations or attempting to flee unsafe situations. Their shelter reports service and enrollments in HMIS, leading to inclusion on Skagit’s BNL. Individuals are eligible to seek services with DVSAS if they fall under the Federal (HUD) definition of domestic violence, experiencing dating violence (sexual assault, stalking, and other dangerous or life-threatening conditions that relate to violence against the individual or family member that either takes place in, or him or her afraid to return to, their primary nighttime residence (including human trafficking).
Youth and young adults fleeing or attempting to flee unsafe or unstable situations, regardless of HUD definition eligibility, can access services at Northwest Youth Services or Oasis Teen Shelter. These teams are able to assess and connect YYA in these situations to resources, which are documented in HMIS, leading to inclusion on the Skagit BNL.
OASIS Teen Shelter Intake Packet
Question 2
2A.) Partnerships & Protocols in Place with Child Welfare to quickly identify YYA
WHY:
Young people who are dependents of the state are assumed to be experiencing homelessness when they are “missing from care.” DCYF has protocols and policies in place detailing steps to find a young person missing from care and ensure this is regularly updated. Continuous collaboration and communication with local DCYF staff, through ongoing YBNL case conferencing and the ACI Core Improvement Team, offers learning opportunities and training to strengthen staff ability to identify and address housing needs with YYA.
WA State DCYF Missing from Care Protocols
Skagit Child Welfare & ACI Coordinating Protocol
HOW:
At the launch of the Anchor Community Initiative, the ACI Lead Team in Skagit connected directly to Greg Williamson, Regional Director of Family Support Programs for DCYF. Greg has previous experience working with Skagit’s ACI Lead to understand youth programs offered at the Lead Agency, Skagit Valley YMCA. At this meeting, the ACI Lead Team worked with Greg to identify Regional Supervisors in the Child Welfare System in Skagit County, to make explicit service connections for YYA in foster care identified as needing additional housing support. The ACI Lead Team followed up with Regional Supervisors in Skagit County to develop a shared understanding of commitments with the ACI.
In addition, Youthnet is Skagit’s contracted Independent Living Provider (ILP) and Independent Youth Housing Program (IYHP). These programs are in HMIS, accounting for young people on Skagit’s BNL. Those ineligible for ILP or IYHP will be referred to housing services and accounted for on Skagit’s BNL through the BNL Referral Flier.
2B.) Local School Districts quickly identify YYA?
WHY:
Every school district in Skagit County identifies youth & families as experiencing homelessness through annual registration & questionnaire forms that are sent to addresses on file or filled out during orientations at the start of the school year.
In addition to this practice, Middle and High School staff have committed to building their awareness of youth homelessness; receiving educational support on how to quickly and accurately identify students as experiencing homelessness. One-pagers, tailored to school counselors and support staff, have been developed (Skagit Schools Triage Tool.docx Talking about Housing). These tools and resources describe emergency planning, important definitions, and shelter eligibility. Training on ethical practices, diversion, and navigating the housing system is available for all staff to attend.
Opportunities to be certified and trained in HPDF are shared widely across all districts.
Skagit Co. Public Schools Coordinating Protocol
Skagit Schools Triage Tool.docx
HOW, FOR RESOURCE HUB:
Skagit Co. has six School Districts:
Concrete
La’Conner
Sedro-Woolley
Mount Vernon
Burlington-Edison
Anacortes
The Associate Director of Anacortes Family Center is a member of Skagit’s ACI Improvement Team & acts as the McKinney Vento Liaison for Anacortes School District. In this role, they regularly hold meetings with county-wide McKinney Vento Liaisons & other student/family support staff, a space where ACI Improvement Team Members were able to collaborate on building methods to Skagit’s BNL.
While MKV’s identified a need for deeper connections to local resources & students/staff, many MKV’s held separate roles within the district as well, limiting their capacity. The ACI Team received contacts for others within the district who are able to support: Family Support Staff, Foster Care Liaisons, & Superintendents. All but one district has been responsive at the writing of this narrative.
Feedback from students & Skagit’s Youth Action Board highlighted the importance of having a trusted person within their schools, and that they were not aware of how to connect to a MKV or what they were entitled to as an unhoused student. Often, school staff themselves did not know who their Liaison was or how to connect a student to support. After meetings with all involved, it was decided that students and staff would need more Coordinating Protocols that had to be approved by each district’s school board & legal team. Some edits, by district, were made to the MOUs. Edits included language around liability.
2C.) Protocols & Coordination for YYA in Juvenile Justice to be quickly identified?
Transition planning internally at Skagit’s Juvenile Detention Center begins at least a year prior to a YYA’s date of release, including identifying and addressing any housing needs.
If a young person is released without safe or stable housing, they are referred to DCYF, or staff at the Juvenile Detention Center can connect directly with the Oasis Teen Center & provide transportation to Oasis.
Skagit Co. Juvenile Justice Coordinating Protocol
2D.) Publicly paid inpatient behavioral health quickly identify YYA?
Skagit recognizes the Skagit Regional Health as the biggest publicly paid inpatient behavioral health & Substance Use disorder program provider in the area, serving young people aged 18+.
Clients are referred most often when arriving at the Emergency Unit, where housing status is asked upon arrival. Once moving to the Behavioral Health Unit, YYA undergoes another assessment, including conversations about housing stability and safety. Discharge planning starts upon arrival and YYA stays between 1-7 days.
Skagit County Publicly Paid Inpatient & BNL Coordinating Protocol
2E.) Homeless system & Local Tribal nations have protocol in place to quickly identify YYA?
Samish Indian Nation serves young people across the state of WA, providing various resources to those of Samish descent in need of housing. Any young person can connect with Samish Nation’s Social Services via phone, where they are asked about housing status and referred to HMIS programs and enrollment. Information on Samish’s Resources can be found here.
Swinomish Nation asks about housing status of those served at the didgwálic wellness center.
YYA in Swinomish and Samish Nation can be connected to community services via BNL Referral Flier and/or via any HPDF trained provider or local admin.
Skagit Co. ACI & First Nations Coordinating Protocol
Question 3
3A.) Your child welfare system adds YYA to BNL?
WHY:
The Missing From Care Coordinator and Extended Foster Care have a protocol in place detailing referrals to NWYS Outreach staff through the BNL Referral Flier when a youth is experiencing homelessness. Those referred and interested in receiving services are enrolled in a relevant HMIS project, which includes them on Skagit’s BNL.
Local DCYF Case Managers and staff are offered the opportunity to become trained and certified in HPDF.
In addition, Youthnet is Skagit’s contracted Independent Living Provider (ILP) and Independent Youth Housing Program (IYHP). These programs are in HMIS, accounting for young people on Skagit’s BNL. Those ineligible for ILP or IYHP will be referred to housing services and accounted for on Skagit’s BNL through the BNL Referral Flier.
Skagit ACI & Child Welfare Coordinating Protocol
HOW:
Gaps in accounting for dependents of the state who are experiencing homelessness were identified through conversations with the Regional Supervisor for DCYF.
DCYF staff identified the need to have local housing resources available for young people. Prior to collaboration, DCYF staff solely shared information on how to connect to Youthnet, Skagit’s contracted Independent Living Provider. With the implementation of the BNL Referral Flier, more options for housing services and support became available to young people.
Staff also recommended making these fliers available in places those missing from care may present: libraries, drop-in spaces, and food banks. A social media presence from the Youth Action Board may also develop pathways to housing support for those missing from care.
3B.) Local school districts add YYA to BNL?
WHY:
Protocols to account for unaccompanied youth are conscious of FERPA regulations. Mckinney Vento Liaisons are not able to share any personally identifying information with housing providers. To work around this, Skagit housing providers/ those enrolling YA in the BNL ask for basic contact information of students experiencing homelessness or students in need to disclose information themselves.
There are two pathways for a student in need to connect to housing services:
They are connected to their McKinney Vento Liaison & school supports, either through an annual registration questionnaire or through a teacher/counselor referral.
Those in need of emergency shelter will be immediately referred to OASIS Teen Shelter, where they would enroll in HMIS & be accounted for on Skagit’s BNL.
In the case that a youth is not referred to OASIS, the MKV would email a referral form (linked in Coordinating Protocol), including basic contact information to Skagit’s youth serving agency, NWYS. Outreach staff would connect with the youth, and if consenting, account for them on our BNL through relevant HMIS enrollment. Those who do not need additional services from Skagit Housing Providers may still consent to being accounted for on Skagit’s BNL through entry in the OTSACI HMIS Project.
Students are not connected to their McKinney Vento Liaison (staff are not referring to them or they are not disclosing housing status with staff, etc.).
The BNL Referral Flier has been posted in middle and high schools, allowing for a young person to self-identify, refer themselves to services, and connect with someone directly, including HMIS enrollment & inclusion on Skagit’s BNL.
Skagit Co. Public Schools Coordinating Protocol
HOW:
Feedback from students & Skagit’s Youth Action Board highlighted the importance of having a trusted person within their schools. The YAB shared they were not aware of how to connect to a MKV or what they were entitled to as an unhoused student. Often, school staff themselves did not know who their Liaison was or how to connect a student to support. This feedback highlighted the need for students to seek housing services and emergency support from local housing providers on their own.
One of Skagit County’s youth-specific agencies, Northwest Youth Services already has an online form to connect to services. QR codes on self-referral flier links to this form. Once received, a staff person from NWYS will be in contact, triage the students needs, and provide a warm handoff to services in addition to receiving consent to be accounted for on Skagit’s BNL.
Skagit Co.’s Improvement Team & ACI Lead worked with Commerce to build a “catch-all” HMIS project (OTSACI). This project was built as a method to account for an individual not currently receiving housing services from a HMIS agency. This may include youth who have connected to their MKV and may not be in need of additional services.
3C.) Your juvenile justice system adds YYA to BNL?
WHY:
Partnerships are in place with OJC and Oasis Teen Shelter connecting anyone released to an unstable housing situation to emergency shelter, HMIS enrollment and inclusion on the BNL. OJC staff have access to the BNL Referral flier and may use it to access services and connect to NWYS Outreach at any point in the transition planning period. When services are sought, YYA referrals are enrolled in relevant HMIS projects and included on Skagit’s BNL.
Young people may also be referred to Skagit Co. 's contracted LCYC attorney by OJC staff. When a referral is received by Skagit’s LCYC attorney, after asking about their current living situation, they are able to refer YYA to housing resources and support through their deep collaboration with the ACI.
OJC staff and staff of relevant partner organizations (Skagit Legal Aid) are offered the opportunity to become trained and certified in HPDF.
HOW:
A partnership with LCYC, funded by ACI Service Dollars, brought an attorney dedicated to serving unhoused young people. Skagit’s LCYC attorney acted as the main point person for communicating with Skagit’s Office of Juvenile Courts.
The development of WA’s Youth and Young Adult Housing Response Team (YYAHRT) provides support, collaboration, opportunities and advocacy through accepting referrals for young people exiting any system of care and experiencing or at risk of experiencing homelessness. Referrals may be made after usual methods of accessing housing have been exhausted, and up to 90 days prior to release from a system of care or 90 days after exiting a system of care. Staff working with young people exiting systems of care are able to connect with the Housing Response team via hotline and email.
Outreach Providers are waiting on volunteer application approval to begin working inside of detention centers, identifying and referring young people.
YYAHRT Informational Presentation
3D.) Publicly paid inpatient behavioral health treatment—mental health and substance use disorder programs add YYA to our BNL?
WHY:
Once identified, Skagit Regional Health’s team of social workers begin notifying housing providers of their client. Provider notification is dependent on client needs. Skagit Regional Hospital has identified point people for all major housing providers, including our young adult services (NWYS). Once housing services are sought, YA are accounted for on Skagit’s BNL through HMIS enrollment in relevant projects. Outreach staff are able to connect with clients ahead of discharge in certain cases. Resources, like flyers and business cards are available for all clients in inpatient settings and are offered upon discharge.
Skagit County Inpatient Behavioral Health Protocol
HOW:
Staff of Skagit County’s Public Health Department are part of Skagit’s ACI Improvement Team. They leveraged prior relationships held with the Director of Inpatient Programs at Skagit Regional Health and led the work of building practices and protocols for collaboration.
Prior to connection with the ACI, and in accordance with HB 1905, Social Workers were consistently developing and using information on our youth serving organization (NWYS) in their ongoing care planning with YYA in their services. Passing on direct contact information for staff at NWYS was identified as the best way to ensure a route to our BNL.
3E.) Local Tribal Nations add YYA to our BNL?
WHY:
All of Samish Nation’s social services report to HMIS, accounting for unhoused young people they serve on Skagit’s BNL. Projects include Case Management, Homelessness Prevention and Rapid Rehousing. Young people may also be referred to Skagit’s BNL through HPDF
Swinomish Nation refers any young person in need of additional housing services to Anacortes Family Center, including them on Skagit’s BNL through HMIS enrollment in AFC programs. Swinomish young people may also be referred to Skagit’s BNL through HPDF.
HOW:
Efforts to account for young people of first nation descent were spearheaded by Skagit’s Youth & Community Engagement Coordinator. Skagit’s YCEC began by researching each nation, including speaking with contacts identified by the ACI Improvement Team, recorded in the Skagit Tribal Planning Doc.
There are four Tribal Nations across Skagit County: Swinomish, Samish, Suiax-Seattle, and Upper Skagit.
The Samish Indian Nation has no federally recognized land, causing their people to assimilate and disperse across WA state. Young people in Skagit County can receive Case Management, Prevention, Rapid Re-Housing, & Diversion Services. All of these services submit information to HMIS, accounting for any young person in Skagit receiving these on our BNL.
Swinomish Nation offers many services, including didgwálic wellness center, but does not submit information to HMIS. Skagit’s Lead Agency, the Skagit Valley YMCA, had begun to build partnerships with the Swinomish Nation before taking on the ACI and was able to build upon existing relationships for ACI purposes. While we know young people are accurately identified when entering and connecting with the didgwálic wellness center, available housing options and partnerships with local housing providers remain unknown. Skagit’s ACI team aims to hold respect for Swinomish Nations data sovereignty, and has not asked for Swinomish to be connected to HMIS. Instead, our Youth and Community Engagement Coordinator, alongside our ACI Lead, have committed to developing intentional connections with Swinomish Elders. A “menu of options,” has been built and communicated, including ACI structure and opportunities to become more involved in the ACI.
More information is needed on Suiax-Seattle and Upper Skagit and building relationships with these Nations will take time.
The ACI team is committed to learning the history, strength, and values of each Nation. As efforts progress to end disproportionality and build a system that serves all young people, it is necessary to understand the impacts of colonization and white-centric systems have had on each Nation. The Skagit ACI Lead Team has marked intentional time, quarterly, to learn about each Nation’s history and continue to identify shared spaces with indigenous leaders.
Skagit County Tribes Coordinating Protocol
Ex. Agenda for ACI Continued Education
Skagit ACI Tribal Relationships Planning Doc
4.) Is your community able to track young people exiting the foster care system without stable housing and to ensure that those individuals are added to your by-name list if they are experiencing homelessness (as defined in “Key Terms”)?
WHY:
Young people exiting foster care into unsafe or unstable housing may be identified by:
Exit planning with DCYF Case Managers at 17.5 meetings
Exit planning with DCYF Extended Foster Care Case Managers
Monthly connections with Independent Living Case Managers at Youthnet
Check ins with staff of Secret Harbour, a residential facility for young men 12-18 yr old
Coordinating protocols detail methods to connect those in need and seeking housing services through the BNL Referral Flier, where they will be connected to NWYS Outreach staff, enrolled in a relevant HMIS project, and accounted for on Skagit’s BNL. Opportunities to be certified in Homeless Prevention and Diversion Fund are also communicated to these key contacts.
In addition, Youthnet, Skagit’s contracted Independent Living Provider developed IYHP. This program is in HMIS, accounting for young people on Skagit’s BNL. Those ineligible for IYHP will be referred to housing services and accounted for on Skagit’s BNL through the BNL Referral Flier.
Skagit Co. Child Welfare Coordinating Protocol
HOW:
Conversations with the Youth Action Board and ACI Improvement Team helped identify key players and partners involved in this question.
Youthnet is the contracted IL provider for Skagit County.
Secret Harbour is a residential facility for young men with unsuccessful foster placements.
The development of WA’s Youth and Young Adult Housing Response Team (YYAHRT) provides support, collaboration, opportunities and advocacy through accepting referrals for young people exiting any system of care and experiencing or at risk of experiencing homelessness. Referrals may be made after usual methods of accessing housing have been exhausted, and up to 90 days prior to release from a system of care or 90 days after exiting a system of care. Staff working with young people exiting systems of care are able to connect with the Housing Response team via hotline and email.
YYAHRT Informational Presentation
5.) Do you regularly assess your collaborations with the systems outlined in Questions 2 and 3 to make sure that together you are continuing to improve your reach to young people eligible to receive help from your system?*
The Skagit ACI team believes this question is inherent to the continued work of the ACI. However, coordinating protocols for cross-system collaborations detail methods and commitments to improving. Key contacts within Skagit School Districts, Publicly Paid Behavioral Health, the Juvenile Justice System, First Nations and Publicly Paid Inpatient Behavioral Health attend quarterly ACI Community Team meetings.
Skagit’s Youth Action Board includes young people with lived experience of these systems, and Skagit’s YCEC continues to build collaborations with coalitions or groups specific to each system to provide feedback on ACI practices.
6A.) Is 100% of your community’s geography covered by a documented and coordinated outreach system?*
Skagit’s outreach is designed to ensure anyone experiencing unsheltered homelessness within the entire community will be identified and engaged. Outreach does not necessarily cover every square mile of Skagit County, rather partnerships and capacity is in place to deploy outreach teams where they are needed and respond accordingly.
All of Skagit County’s housing providers have a team of outreach staff, including youth & young adult specific agencies. Providers work in partnership with other agencies and By and For Organizations to bring essential services and needs to those in our community.
Outreach providers involved in all aspects of social services meet bi-weekly in provider meetings organized by Skagit Co. Public Health. Documents with Outreach provider schedules, contacts and points of service are held & updated by the county's Housing Resource Coordinator. These meetings have adopted strategies, similar to Case Conferencing, to coordinate and collaborate on individuals needs and goals.
It is standard for outreach providers to complete Coordinated Entry assessments for unsheltered young people seeking housing support. Providers note that it is very rare to encounter an unsheltered, unaccompanied minor. In those instances, outreach providers connect minors with available emergency shelter at Oasis, or to Case Managers at the Sedro-Woolley Drop in Center. Outreach staff can also implore young people to connect to services on their own with the adoption of Skagit’s BNL Referral Flier.
6B.) Are young people with lived experience of homelessness involved in conducting your outreach and/or informing your outreach strategies and locations? *
Skagit’s youth outreach team with NWYS has staff with lived experience of homelessness on their team, and includes language on job descriptions, encouraging those with lived experience to apply. YAB members have mapped outreach services and gaps/needs, and this plans to continue on a bi-annual basis. Feedback from the YAB has been communicated regularly by the YCEC at Bi-Weekly Outreach Provider Meetings & during Improvement Team Meetings.
Question 7 - Accessibility & Feedback
7A.) Are there youth-specific access points where young people can seek housing and services and be added to your by-name list without having to present at an adult shelter or facility? *
Skagit County has two YYA specific housing and support service providers, Northwest Youth Services (NWYS) and the Skagit YMCA Programs (OASIS & SW Drop in Center.) These organizations access and report to HMIS, including YYA they serve on Skagit’s BNL. Both organizations provide drop-in spaces for YYA to connect to services, seek housing support, receive case management and complete a full assessment.
At NWYS, young people may be eligible to be entered in a HMIS Outreach Project (OTSYS, in partnership with the Skagit Valley YMCA) , Coordinated Entry, or their Youth Interest Pool (YIP). The Youth Interest Pool acts as an internal waitlist, outside of HMIS. YYA who consent may be accounted for on Skagit’s BNL through enrollment in the OTSACI HMIS project, acting as a low-barrier entry point, built through the implementation of the ACI.
Skagit YMCA Programs are able to provide support services for minors. Oasis Teen Shelter offers emergency shelter for minors and reports to HMIS (OTS Oasis Teen Shelter), including those served on Skagit’s BNL. Youth presenting at the Sedro-Woolley Drop In Center may receive case management, referral to Oasis, and other basic needs. Those experiencing homelessness and seeking support services at the SW Drop in Center are accounted for on Skagits BNL through entry into their Outreach HMIS project (OTSYS).
7B.) Does your community use a youth-specific assessment tool to determine homeless status, triage housing and service needs, and support prioritization based on youth-specific needs and vulnerabilities? *
Youth enrolling in Coordinated Entry completes the TAY-VI-SPDAT vulnerability assessment, which is used by Skagit County to prioritize housing placements. Young people 18 years and older can enroll in Coordinated Entry by calling 211 to reach Volunteers of America, Skagit’s Coordinated Entry contract holder (as of March 2023). The TAY-VI-SPDAT is designed to be used by youth seeking housing; results of the TAY-VI-SPDAT are compatible with those produced by the VI-SPDAT used for others in the Coordinated Entry System. The programs and organizations who can complete a CE assessment are:
Individuals 18-24 years old who enroll in Northwest Youth Services' Youth Housing Interest Pool complete the TAY-VI-SPDAT as well as the Y4Y Young Adult CE Prioritization Tool (Y4Y). This is an alternate vulnerability assessment developed by the Youth For Youth board that is intended to minimize perceived faults in the VI-SPDAT system; specifically it is a youth-designed tool meant to be antiracist and to avoid re-traumatizing YYA who complete the survey. Use of the Y4Y tool is optional, the system is being piloted as a possible alternative or replacement for the VI-SPDAT.
7C.) Is your community regularly attempting to improve the reach of your system, by specifically testing things to improve access for people who are currently under-accessing your system?*
Skagit’s Data Workgroup took on this Scorecard question, defining first how to understand who is currently under-accessing our system. The team recognized that those disproportionately experiencing homelessness, BIPOC & LGBTQ+ YYA were under-represented in our data, and must be under-accessing the system.
It was also understood that this question echoes the heart of the Anchor Community Initiative; recognizing trends in our data, testing improvement ideas to improve system responses and reach of services.
Skagit Co.’s ACI Improvement Team has worked to build methods of feedback, both formally and informally.
Skagit’s YCEC held focus groups for LGBTQ+ YYA and YYA of Color to discuss outreach methods & representation in data. These focus groups will be held bi-annually.
Weekly Case Conferencing provides insights on who may be under-served by current systems. Case Managers are able to provide input from their clients & address their needs.
SOGI/E trainings have been built, informed by focus groups of YYA, and are open to the community. These trainings aim to de-stigmatize conversations around gender identity/sexual orientation & provide tools for organizations to be more informed and accessible to these populations.
Referrals to the BNL are actively being tested and implemented in places historically disconnected to housing services.
Skagit Co. is preparing to shift the contract holders of Coordinated Entry in February of 2024. Contracts detail outcomes & measures to track who is accounted for in this system and outcomes data is used to continually approve the reach and response.
7D.) Are the tests referenced in question 7C driven by qualitative data, including direct feedback, on the experiences of both people who have recently accessed your system and those who are eligible to access your system but have not?*
Tests in 7C were supported and defined in focus groups held for BIPOC & LGBTQ+ YYA. Skagit’s Youth Action board has held meetings focused on outreach, mapping areas in need of outreach coordination & ideas on promoting these throughout 2023.
In addition, Skagit ACI Lead Team, including YCEC, has been intentional about setting up the infrastructure for feedback loops between the YAB and ACI Core Improvement Team.
Methods of feedback have been implemented, both formally and informally.
Our YCEC held focus groups for LGBTQ+ YYA and YYA of Color to discuss outreach methods & representation in data. These focus groups will be held bi-annually.
Case Conferencing provides insights on who may be under-served by our current systems. Case Managers are able to provide input from their clients & address their needs.
8A.) Are you confident that from the combined total of providers, programs and systems of care that provide data to your active list, you are accounting for 90% or more of the unaccompanied young people who are currently eligible and asking for help to resolve their homelessness?*
Skagit County has multiple Coordinated Entry access points (which includes mobile outreach teams capable of assessment and data entry in HMIS) that cover Skagit County. The implementation of HPDF has trained community stakeholders across the community, systems of care, and By/For organizations to access funds (resulting in data capture in HMIS) across the County. YYA serving community members who are not able to input data into HMIS connect YYA to the BNL (and thus to necessary services) via referral to NWYS Outreach through the BNL Referral form or via HPDF.
A list of all organizations accessing HMIS & their program projects
8B.) Are 90-100% of federally or publicly funded providers (including CoC Program funded providers and RHY providers) serving unaccompanied youth report data into your by-name list? *
All publicly paid housing providers in Skagit Co. report to HMIS, including YYA they serve on the BNL. HMIS access & entry is required for all publicly funded housing providers, outlined in grant & funding requirements by WA state and OHY.
A list of all organizations accessing HMIS & their program projects
8C.) Are 90-100% of non-federally or publicly funded providers serving unaccompanied youth report data into your by-name list? *
The only non-federally or publicly funded provider in Skagit Co is New Earth Recovery, a faith-based & privately funded non-profit in Skagit County, serving people 18 years and older experiencing substance use disorders with five residential treatment centers. New Earth does not directly report services and enrollments into HMIS. Young people connected to New Earth, if in need of additional housing support are referred to Catholic Community Services (publicly funded housing provider) or served through HPDF and accounted for on Skagit’s BNL.
Skagit County Data Quality Guide includes details of the processes and practices for HMIS data to be included on Skagit’s BNL.
HOW:
When answering this question, it was important to discern the definition of "provider." Skagit County's aim is to demystify the experience of homelessness for everyone across the county, and while it has been recognized that YYA may connect with trusted organizations and people outside of the homeless response system & formalized partners, this question only relates to providers offering housing services to YYA.
PART II: Policies & Procedures
This section is focused on ensuring that you have policies and procedures in place to accurately capture movement on and off your list and to maintain timely and accurate data.
Question 9 - Inactivity
9.) Does your community implement consistent policies for determining inactive status that at minimum:*
Establish a certain number of days after which an individual who cannot be located becomes inactive (i.e. an “inactivity threshold”)
Ensures action is taken to locate individuals on the list before they meet the inactivity threshold
WHY:
If a youth/young adult (YYA) who is experiencing homelessness and has had no contact with any system/provider (i.e. CES access point, system navigators and/or community outreach) for 90 days, they will be moved to Inactive (“No exit interview completed”). This excludes YYAs that are known to be in a publicly-funded institution (e.g., hospital) for 90 days or less AND who had been on the street or in a shelter immediately prior AND who will return to literal homelessness upon discharge.
Within the current capacity of the outreach teams and/or shelter staff and partner agencies, reasonable attempts will be made to locate youth and young adults (YYA) exiting to (“No exit interview completed”) destinations in the period between the exit date and the date they will become inactive if they are not re-engaged.
HOW:
Skagit’s ACI data workgroup took on the work of developing BNL Policies & Procedures.
Prior to this policy, Coordinated Entry's policy required moving someone to inactivity after 60 days, while young people enrolled in Street Outreach & other OHY funded programs had 90 days before being moved to inactive. This discrepancy was addressed by connecting with Skagit Co. Public Health and our CE contract holder. These organizations are represented in our ACI Improvement Team.
Question 10 - Non-consent
10.) Does your by-name list have a way to account for young people experiencing homelessness who have not consented to services and/or assessment? *
Please note that any systems in place should adhere to all applicable privacy and security standards, including HUD’s HMIS privacy and security standards.
The Skagit County Youth and Young Adult By Name List (BNL) works to anonymously track contact with unaccompanied youth and young adults (ages 13-24 years) experiencing homelessness who have not consented to services/assessment to improve understanding of how to engage with them and to use case conferencing to coordinate outreach and engagement for those unable to undergo an assessment, while not disclosing identifying information.
The Youth and Young Adult By-Name-List (BNL) is currently held by Community Action of Skagit County and will not be shared in full in order to protect participant privacy. Encounters with individuals unwilling or unable to complete a full assessment should be entered into HMIS as “Consent Refused,” following HMIS standards for data entry of non-consenting clients, and included in the By-Name List.
Skagit Co. Non-Consenting Policy
WA State Commerce Consent Refused Collection Guide
Question 11 - Timeliness & Accuracy
11A.) Does your community have policies and protocols in place for keeping your by-name list up to date and accurate, including timelines for data submission from providers and ongoing quality assurance protocol? *
HMIS data entry is required within seven calendar days of the event to allow for the appropriate individuals to be added to the By Name List, connected to a CE referral or diversion resources, or removed from the process of connection to permanent housing as appropriate. This expectation is for both HMIS enrollments and exits.
Clients can often disappear from a housing placement for several days or weeks before returning again for services. Projects should exit clients from their housing project in HMIS no more than seven (7) days after their last stay. This helps ensure clients are not perpetually enrolled in a project in HMIS despite no longer being served, which assists in providing exact locations for clients when trying to house them through Coordinated Entry or Case Conferencing. If a client returns to a project, a new Enrollment record should be created.
Exception: Street Outreach Services (SOS) programs should exit young people when their exit destination is known within 7 calendar days of exit. However, for clients that the program loses contact with, clients should be exited at 90 days from the date of last contact.
The acceptable threshold for compliance is 90% for all program types. Every program must follow the timeframe outlined in the plan.
11B.) Do you implement policies and procedures to ensure that data collection takes place in a complete and consistent way across all access points to your system?*
The purpose of completeness is to ensure sufficient data on clients, their demographic characteristics, and service use in order to make system improvements and drive reductions in youth and young adult homelessness and disproportionality for queer, trans and black, indigenous and youth of color.
When exiting clients to destinations that may be ambiguous given the HUD categories offered, providers should reference the following guidance to ensure consistency:
See Skagit Co. Data Quality Guide for more information Skagit County’s data collection and submission standards.
PART III: Case Conferencing
This section is focused on ensuring that you have a list of young people that can be case conferenced (where service providers come together in your community to efficiently prioritize and house young people experiencing homelessness) and that you have started the process of case conferencing your BNL at least on a monthly basis. Case conferencing is a best practice for communities to successfully reduce and end youth homelessness. More resources about case conferencing can be found on the ACI Resource Hub
Question 12
12A.) Do you have a By-name List that can be used for case conferencing on a regular basis?*
On a month-to month basis, Skagit’s Data Lead receives the Canned Looker Report (Skagit’s BNL) from Commerce. For the purpose of Case Conferencing, the Data Lead filters the BNL to specific prioritizations. The Client ID, Agency / Project Enrollment and relevant data element is shared via email with the Case Conferencing Meeting Facilitator. Since this information is coming from a secure system, the facilitator must have HMIS access.
In the months that data was not received by Commerce, Case Conferencing meetings are held using past reports. When that was deemed inefficient by the group, providers were asked to pull/receive their agencies individual looker reports ahead of each meeting.
For specific details on the case conferencing process, including the role of the Data Lead and Meeting Facilitator in Skagit, please reference: Skagit Case Conferencing Guide
12B.) Have you started case-conferencing young people on your community’s BNL on a regular basis?*
Skagit County launched Case Conferencing in Sept. 2023 and hosts weekly case conferencing meetings, facilitated and coordinated by the ACI Lead Agency’s Coalition Coordinator.
Case Conferencing holds meetings for three prioritizations:
Unsheltered YYA: identified as those on our BNL enrolled in HMIS outreach programs with a current living situation (or living situation prior to project enrollment) as place not meant for habitation
Minors
LGBTQ+ and BIPOC YYA
Journey to Yes:
Initial challenges to begin Case Conferencing centered in ensuring those enrolled in HMIS consent to being Case Conferenced. While individuals sign several different consent forms and Releases of Information, none of these papers included specific language around Case Conferencing. All consent forms young people may sign when enrolling in an HMIS project detail the right to share their name with partner agencies (HMIS accessing agencies) for the purpose of coordinating housing support. The idea of adapting new consent forms, including adding releases with language and purposes of Case Conferencing was explored. This was not an easy task when considering BoS standards. Young people also stressed the need for no additional forms to be added to intakes.
HMIS ROI & Informed Consent states:
I understand the above statements and consent to the inclusion of personally identifying information in HMIS about me and any dependents listed below, and authorize information collected to be shared with partner agencies. I understand that my personally identifying information will not be made public and will only be used with strict confidentiality.
While all of our agencies are partner agencies through CE, our 2 minor/YYA specific services do have MOUs and formal partnerships in place. We also never share PII!
Coordinated Entry ROI states:
I authorize Skagit County partner agencies to share housing and related supportive services information. The information shall only be shared for the purpose of coordinating and providing housing and housing support services…
Coordinating & providing housing and housing support = Case Conferencing!
This form also lists all partner agencies- not all of them access HMIS!
The teen shelter, in addition to the HMIS ROI, allows for youth to check which agencies they are comfortable sharing their info with. By holding a separate Case Conferencing meeting for minors, we can ensure these choices are respected.
During Case Conferencing meetings, no names or any personally identifying information is shared, so no additional form consenting to Case Conferencing was implemented. Skagit County adapted confidentiality agreements for anyone attending these meetings to sign from Spokane Co.
All details on facilitation of Case Conferencing meetings & role of the Data Lead can be found in Skagit Co. Case Conferencing Guide.
Case Conferencing Provider Confidentiality Agreement
PART IV: Demographic Data
This section is focused on ensuring that you are collecting race/ethnicity, sexual orientation and gender identity (SOGI) data to a high level of completeness and in a culturally appropriate/responsive manner. Due to systemic racism, homophobia, transphobia and other injustices LGBTQ+, gender expansive, and POC young people experience homelessness at higher/disproportionate rates. Collecting accurate SOGI and race/ethnicity data is necessary to ensure that you are ready to launch into the reducing phase with an accurate and comprehensive BNL. The reducing phase will include significant efforts to transform your homeless response system to end racial/LGBTQ+ disproportionality.
Question 13 - Completeness
13.) On a month by month basis, does your community have demographic data for at least 70-90% of the young people on your By-name list? Including:*
Race and ethnicity data
Gender identity data
Sexual orientation data
Skagit BNL Demographic Data Policy
Skagit Demographic Data Standard 1-pager
SOGI Data Collection Training Slide Deck
The ACI provided clear guidelines on what a yes for this question means for Sexual Orientation data collection standards.. Skagit’s Data Workgroup dove into answering this question.
Skagit County’s Data Lead completed a project level data deep-dive in April 2024. Two projects were identified as not collecting Sexual Orientation, as their data was not present at inflow. Organizations involved were made aware of SO data collection practices and offered targeted SO/GI training. In May of 2024, Sexual Orientation known at inflow increased by 6%, reflecting their commitment to collecting this element.
As a Balance of State Community, Skagit was able to include Sexual Orientation at assessment within HMIS after submitting a Help Desk Ticket to Commerce. As of August 2023, Sexual Orientation is collected at assessment for all projects within HMIS. Additionally, Skagit County Public Health mandated Sexual Orientation collection for Coordinated Entry intakes and (non-OHY funded) Outreach projects have added SO to intake forms.
Skagit BNL Data showed that the top three organizations serving young people were NWYS programs, YMCA’s programs and Coordinated Entry (VOA).
NWYS & OASIS have collected & continue to collect Sexual Orientation information due to funding requirements from the Office of Homeless Youth.
In February 2024, Skagit’s Coordinated Entry contract holder became Volunteers of America. CE contracts did mandate the practice of SO data collection. In the months following, VOA staff were trained in Sexual Orientation & Gender Identity Collection & BNL data policies.
Targeted efforts to involve organizational leadership across Skagit in valuing Sexual Orientation data collection continues through ACI Community Team meetings, Lead Agency Board meetings, and other shared spaces.
Data suppression required the data workgroup to filter through several months of data. The SO mandatory field was implemented in August 2023. As of May 2024 SO knowns at inflow has increased over 14% since February 2024. This is due to SO being added to all HMIS assessments, including Coordinated Entry intake, and providers collectively collect SO at inflow.
Skagit’s data workgroup meets bi-weekly to address policy adherence, data trends, and continue to share feedback in other ACI meeting spaces, including the Youth Action Board. Skagit’s data workgroup continues monitoring demographic data quality and testing system improvements to reach the 70% threshold. As of June 2024, Race/Ethnicity, Sexual Orientation, and Gender Identity are within the 70-90% threshold for knowns.
Question 14 – Universal Collection
14.) Are all your homeless service providers (for all populations) universally collecting sexual orientation data for youth and young adults?
Sexual orientation data collection is particularly emphasized because its collection is not mandated by HUD and as a result has substantially higher rates of unknowns/data not collected than race/ethnicity and gender identity fields.
Sexual Orientation was added as a data element within HMIS assessments by Commerce. Since then, SO collection has become a standard practice for Skagit’s Coordinated Entry Enrollments as well. All providers are required & informed on how to collect this information.
Skagit BNL Demographic Data Policy
Skagit Demographic Data Standard 1-pager
Question 15 – YYA Consultation & Approval
15.) Have BIPOC and/or LGBTQ+ young people and young people with lived experience been consulted on and approved your demographic (race/ethnicity, gender identity, and sexual orientation) data collection procedures? *
Skagit’s Youth & Community Engagement Coordinator held and facilitated focus groups for young people of color, gender expansive young people & LGBTQ+ young people to receive feedback on demographic data collection methods. In addition to incorporating their recommendations in an assessment, members from the focus group also informed and built training for providers to improve their demographic data collection methods. Focus groups will be held bi-annually, in addition to regularly scheduled Youth Action Board meetings.
Focus Group Facilitation Guide: Demo. Data Collection
SOGI Data Collection Training Slide Deck
PART V - CREDIBILITY
Question 16 & 17 – Stakeholder review
16.) Do the critical stakeholders in your community regularly review community data?
Reviewing Community data is a standard practice for:
Lead Team meetings (bi-weekly, starting April 2022)
Data Workgroup meetings (bi-weekly, starting June 2023)
Improvement Team meetings (bi-weekly, starting May 2022)
Case Conferencing meetings (weekly, starting Sept. 2023)
Youth Action Board meetings (bi-weekly, starting Sept. 2022)
and Community Team meetings (quarterly, starting Aug. 2022).
Data review includes comparisons of the BNL Data, system flow data, and feedback from those with experience of the system.
Contacts and partner agencies involved can be found here.
17.) Do the critical stakeholders in your community regularly reviewing your data believe that the system flow data reflects the reality of what is happening on the ground (or if it does not, do they have a shared understanding of why?)*
ACI Lead Team, ACI Improvement team, Case Conferencing team, Data Workgroup, Community team and the YAB all review the data monthly and agree it accurately reflects system flow data. While data review & discussions are standard for each of these meeting spaces, most recent reflections occurred in February 2024, with the implementation of pathways to the BNL (BNL Referral Flier).
PART VI: Data Infrastructure
This section is focused on ensuring that you have developed a data infrastructure that accurately captures and tracks all movement on and off of your list, avoids duplication and facilitates coordination between providers and systems. In particular, these questions focus on accurately tracking data points related to current living situation, inflow and outflow.
Steps to a Yes:
See Skagit Co. Data Quality Guide for more information Skagit County’s data collection and submission standards.
Question 18 – Current Living Situation
Current Living Situation (4.12) is a key part of a community’s BNL logic flow and together with their exit destination is integral to determining a young person’s homeless status.
18.) Does your community’s By-name list track “current living situation” in real-time, including the date each status was last changed and the previous status? In other words, can your BNL track in real time when a young person’s status changes between:*
Homeless, in shelter
Homeless, unsheltered
Homeless, couchsurfing/doubled up
Inactive
No longer meets population criteria
Permanently Housed
Prior living situation and current living situation are data points collected in HMIS and included on Skagit’s BNL. Date is automatically updated in HMIS when a new living situation is reported. Providers update current living situation status based on HUD guidelines. Current Living Situation is pulled from HMIS in a Canned Looker Report, BNL Data created by Commerce, and translated with Tableau.
Those x pulled from Canned Looker Report (by Commerce), data translated with tableau
Projects on BNL collect both to the best of our ability, adhering to HMIS standards
See Skagit Co. Data Quality Guide for more information Skagit County’s data collection and submission standards.
Question 19 – Active list disaggregation
19.) Does your community break down your active list by the following categories to understand who you are serving in your system:
Race
Ethnicity
Gender Identity
Age
Sexual Orientation
HMIS tracks demographic data for young people on Skagit’s BNL, and this data is used to break down the active list based on these elements. The active list is created from an HMIS Canned Looker Report, received monthly by Commerce. BNL data transformed through the Tableau tool to get an active list count.
See Skagit Co. Data Quality Guide for more information Skagit County’s data collection and submission standards.
Question 20 – Unique Identifier
20.) Does your community’s by-name list include a unique identifier (such as an HMIS ID) for each young person to prevent duplication of client records and facilitate coordination between providers and systems? *
HMIS generates a unique number ID for each entry. DV services have additional anonymizing tools as well and client information cannot be viewed for DV survivors by any service provider outside of that agency.
Question 21 - Inflow
21A.) Does the community accurately track the number of people entering your list (inflow) in as close to real time as possible including:*
Households entering the homeless system for the first time
Households returning from inactive status who are either:
Exiting the care of another system
Currently in the care of another system and newly seeking help from the homelessness system in resolving their homelessness
Returning from inactive status for reasons other than the above
Individuals or households returning from being previously housed by your system
HMIS data entry is required within seven calendar days of the event to allow for the appropriate individuals to be added to the By Name List, connected to a CE referral or diversion resources, or removed from the process of connection to permanent housing as appropriate. These data elements are used to categorize YYA as inflow as appropriate on the YBNL.
21B.) Does the community break down inflow data into the following categories to understand if there are different rates of inflow for different groups:*
Ethnicity
Race
Sexual Orientation
Gender Identity
Age
The data elements of project start date, current living situation, and demographics are used to disaggregate inflow.
Question 22 - Outflow
22A.) Do you track the number of people exiting your active list (outflow) in as close to real time as possible including:*
Households connected to non-time limited, safe and stable housing
Households that have become inactive for other reasons, as specified by your community’s inactivity policy
Households that no longer meet population criteria (eg. they turn 25 or become part of a family household)
Projects should exit clients from their housing project in HMIS no more than seven (7) days after their last stay. This helps ensure clients are not perpetually enrolled in a project in HMIS despite no longer being served, which assists in providing exact locations for clients when trying to house them through Coordinated Entry or Case Conferencing. If a client returns to a project, a new Enrollment record should be created.
HMIS tracks outflow for YYA on by name list and this data is used to break down the active list based on these elements. The outflow count is created from an HMIS Canned Looker report, received monthly from Commerce. It is transformed through the Tableau tool to get an accurate outflow count by month.
22B.) Does the community break down outflow data into the following categories to understand if there are different rates of outflow for different groups:*
Race
Ethnicity
Sexual Orientation
Gender Identity
Age
The data elements of project start date, current living situation, and demographics are used to disaggregate outflow.
Question 23 - Length of Time
23A.) Does your community accurately account for historical changes in homelessness status, including the initial date an individual or household was identified by your system, to consistently and accurately calculate the length of time they spend homeless, including length of time on list at any point in time?*
When a YYA is initially entered into a service, a unique HMIS ID is assigned to them that will be continuous throughout their time in HMIS across programs and service providers. This allows HMIS to track length of time for each YYA in each individual program they are entered into. HMIS also collects current living situations before and after time in each specific program to reflect trends more accurately for all living situations and program types.
23B.) Does your community accurately account for historical changes in homelessness status, including the initial date an individual or household was identified by your system, to consistently and accurately calculate the length of time they spend homeless, including length of time from identification to housing after households are permanently housed?*
When families or individuals are housed, their living situation status is changed in HMIS. This generates length of time in all prior living statuses as separate from their current living situation. Data can be aggregated based on length of stay and type of living situation with the Tableau tool.
23C.) Does your community break down your length of time data by the following categories to understand who you are serving in your system:*
Race
Ethnicity
Sexual Orientation
Gender Identity
Age
Data sets can be pulled based on various demographic data points to view the length of time data aggregated by Canned Looker Report, which is then transformed & visualized by Tableau.
Question 24 - Chronic
24.) Does your community collect data to determine whether individuals and households meet criteria for chronically homeless status?*
During enrollment, HUD definition is used to determine whether YYA qualify as chronically homeless based on length of time in living situations that qualify under HUD.
See Skagit Co. Data Quality Guide for more information Skagit County’s data collection and submission standards.
Next Step: Data Reliability
Once you complete the by-name list scorecard, the next step to getting data that is good enough to track progress towards ending homelessness is getting reliable data. For the purpose of by-name list data, we consider your data reliable when the difference between your total inflow and total outflow in a given month is equal (or close to equal) to the difference between the change in active homeless number for those two months. In a given month, we consider data reliable if the difference between these two data points is 15% or less of your most recent active homeless number. Anchor Communities can look at their data reliability progress in the Performance Management Tracker. For more information about data reliability, take a look at our data reliability explanation here.