These actions are informed by four months of primary and secondary research conducted by our team. Our team analyzed national best practices and global innovations as well as the policies, organizational structures, regulatory authorities, and performance reports of local stakeholder agencies to understand the systems-level structures that drive performance. We consulted with more than 100 local and national public officials, system administrators, and technical experts to understand the challenges and opportunities at hand.
Our ability to develop these actions also required an understanding of the current state of services derived from the experiences of frontline staff and people experiencing homelessness. Our research team leveraged a mix of design workshops, interviews, and site visits across King County. Our lines of inquiry identified the most pressing challenges for accessing and delivering services and the dynamics between service providers, customers, and the system.
True accountability to customers1 will be rooted in increasing customer power. Providers and customers alike recognize customers do not have agency in determining their own service paths or in shaping the system as a whole. System transformation requires that customers have power throughout the system to ensure the services, approaches, and outcomes that they seek and experience meet their stated needs.
To become accountable to customers, the new regional authority must establish system-wide structures and processes to prioritize customers’ perspectives as key data points in the redesign process, as well as in all systems and program improvement initiatives.
Please note that this team refers to “people with lived experience” or “people experiencing homelessness” as “customers” to accurately reflect their status placement within the system. ↩
This community-based participatory research process engaged 123 customers who relayed a deep and nuanced understanding of the homeless service system. Collectively, customers uncovered a path toward a more robust, representative, and reliable system, underpinned by proposals for customer-driven continuous quality improvement. In workshops, one-on-one interviews, and during site visits, people shared their experiences with service access and delivery. Analysis of that research is reflected throughout this action and includes recurring troubling patterns and themes about the emotional and psychological impact of experiencing homelessness, homogenized treatment options, difficulties navigating systems of care, and struggles with establishing stability (as defined in their terms based on their personal needs).
These insights framed the strategies here that are focused on systematically creating a holistic understanding of customer need that drives personalized care.
Customers also indicated that the region has not universally adopted best practices to center customers’ needs. These practices are woven throughout these actions, namely, implementing trauma-informed care and Housing First approaches in programs across the system, employing peer supports, and prioritizing community connections to combat isolation for people experiencing homelessness.
Trauma-informed services are necessary, cost-effective, and evidence-based.1 After receiving training in trauma-informed care, service providers report more effective collaboration with customers, who then experience an increased sense of safety, better collaboration with staff, and a more significant “voice.”2 Initial studies also suggest that trauma-informed care has a direct positive effect on housing stability.3
Housing First is a widely accepted and evidence-based, systems-level orientation that operationalizes the principle that people experiencing homelessness—like all people—need the safety and stability of a home to pursue their own goals for their health, socio-emotional well-being, education, and employment.4 Systems that are Housing First-oriented prioritize housing for individuals experiencing homelessness, without preconditions or service requirements. Access to programs should not be “contingent on sobriety, minimum income requirements, lack of a criminal record, completion of treatment, participation in services, or other unnecessary conditions.”5 Connections to sober living communities or other housing settings with similar policies are an important resource for many, but should not be the only option for any individual experiencing homelessness.
Effective Housing First approaches include: prioritizing people experiencing homelessness for new and existing affordable housing; providing rapid re-housing to families and individuals; and providing supportive housing opportunities to people with the most intense needs.6
Peer supports and co-planning give agency to people experiencing homelessness. In our research, customers frequently mentioned they felt it was easier to relate to people with lived experience, who they felt could better understand their own experiences in a non-judgmental way. This dynamic also enabled customers and providers to more easily co-plan the steps they need to take to access services and build stability, as defined by the customer. Peer supports who co-plan with customers are particularly effective in locating appropriate resources for that customer and in increasing opportunities for targeted care. Peer supports can supplement caseworkers by providing support in both daily activities and decision-making.
Peer supports have also been shown to reduce customers’ own sense of isolation, ease integration their into permanent housing, and support them in improving their social skills.7 Peer supports have been proven to be especially successful in improving outcomes for customers engaged in drug and alcohol treatment and supporting improvements in customers’ mental and physical health, often acting as a social support through those experiences.8 For all of these reasons, the region should increase opportunities to hire individuals with lived experience to bolster relationships and improve service offerings system-wide.
Community-oriented connections to combat isolation for people experiencing homelessness are a core element of supporting individuals in overcoming crisis and regaining stability in housing. As customers repeatedly expressed, social and physical isolation are key contributors to stress and declines in behavioral health. Customers described feeling happier when they were part of a community, when they had entertainment, and when they had companionship in pets, partners, and friends. Emotional support from close friends has also been found to reduce stress, health problems, and depression in people experiencing homelessness.9 Other studies show that “perceived emotional support” is related to “better mental health status” for people experiencing homelessness.10 However, shelters often turn away groups, couples, and pets due to limited space and inadequate resources. This forces people to make difficult choices between important relationships and necessary shelter. The region should incentivize social supports and community-focused care across services.
Each of these orientations and approaches are fundamental elements of a customer-oriented system. The region, however, will require additional work to create system-wide accountability to customers, and more specifically, build customer power into system-wide decision-making structures as well as improve staff conditions to help them be more accountable to customers.
Hopper, E. K., Bassuk, E. L., & Olivet, J. (2009). Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. The Open Health Services and Policy Journal, 3(2), 80-100. ↩
Ibid. “A multi-site study of TIC for homeless families found that, at 18 months, 88% of participants had either remained in Section 8 housing or moved to permanent housing. An outreach and care coordination program that provided family-focused, integrated, trauma-informed care to homeless mothers in Massachusetts found that the program led to increased residential stability.” ↩
United States Interagency Council on Homelessness. (December 2017). The Evidence Behind Approaches that Drive an End to Homelessness. ↩
Groundswell. Homelessness and Health: Resources to support peer activity. ↩
Barker, S. L., & Maguire, N. (2017). Experts by Experience: Peer Support and its Use with the Homeless. Community mental health journal, 53(5), 598-612. ↩
Hwang, S. W., Kirst, M. J., Chiu, S., Tolomiczenko, G., Kiss, A., Cowan, L., & Levinson, W. (2009). Multidimensional social support and the health of homeless individuals. Journal of Urban Health, 86(5), 791-803. ↩
Build customer power into system-wide decision-making structures.
1. Implement an overall continuous quality improvement (CQI) framework driven by customer voice.
For customer experience and needs to be accurately represented, methods to collect customer data need to be improved significantly. A regional authority should redesign intake points to be customer-centered, connected to available and necessary resources, and radically accessible. That process should be facilitated by a digital transformation process that makes it easier to integrate customer data across services and systems to improve experience, coordination, and the ability of system administrators to identify and respond to strengths and weaknesses.
To build customer decision-making power, the Office of the Ombudsperson must facilitate ongoing community engagement through systematized feedback mechanisms that integrate the daily lived experiences of customers and their perspectives.
These mechanisms must be designed with equity in mind, to ensure all customers have the opportunity to participate in the ways that they find most useful. Options should include flexible operating hours, and multiple languages and locations throughout the county. Sampling should explicitly target customers who are black, Native, LGBTQI, and living with disabilities, as they are overrepresented. Additionally, customers must be paid for their time in formats that don’t limit choice (e.g. not through store-specific gift cards). Customers should be compensated in sums that reflect the value of the expertise they offer, commensurate with rates paid for any staff that have specialized knowledge that cannot be gained without substantial investment of time and energy.
There are many mechanisms that this office could use to engage the community including, but not limited to, workshops, interviews, service reviews, and focus groups, as well as tools for customers to engage directly in system-wide planning. Customers had no shortage of ideas for how feedback could be collected, including in-shelter kiosks, online rating systems, and building feedback mechanisms into routine service interactions. Additionally, the Office should expand the use of follow-up assessments to understand how needs evolve over time and to flag and prevent potential bounceback into the system. At the most basic level, the Ombudsperson should respond to the immediate needs of individual customers in coordination with service providers. It should also develop a system dashboard that tracks specific customer input to be used in longer-term planning and provider performance management.
In workshops and interviews, many customers wanted to be notified if their expertise contributed to a particular outcome or decision. It is very important that this office ensure transparent and proactive communication with customers about the ways in which their voices are or are not being used. It’s paramount that the region create environments that encourage authentic sharing so that customers will re-engage.
The new regional authority will have a flow of rich information to direct decision-making processes if these steps are taken to improve data quality by developing and strengthening mechanisms for customer input.
2. Create metrics for a holistic understanding of customer need that drives personalized care.
Customers frequently expressed feeling unseen by the service system. Many felt that services are not tailored to their unique needs or circumstances and that the system homogenizes them into a single representation of ‘the homeless.’ This plays out across many different types of services, where customers are assumed to need the same things, delivered in the same way. While some of this is due to bias and stigma, much of it is a result of the data used to inform the architecture of the system.
To truly ground planning and performance management in customer voice, the metrics used for evaluating services and providers must be reoriented around customers and how they experience the system. Currently, metrics often fail to reflect the reality of service delivery, as many of them focus on outcomes, such as exits to permanent housing, that assume the availability of those scarce resources. The most desired and consequential resources are typically unavailable for customers, which necessitates multi-year wait times and forces customers and staff into a dynamic where they tread water while waiting.
Given resource scarcity, metrics such as shelter referral or the completion of administrative tasks such as acquiring an ID are now outcomes that are consequential for organizations. The importance of these metrics is due to their attachment to funding sources, which drives a top-down prioritization of service delivery that is not connected to customer need. Staff frequently found the outcomes they track are disconnected from the outcomes their customers care about. They experience perverse incentive structures that drive behavior towards cherry-picking clients who are easiest to serve, increasing the odds that they’ll renew their funds the following year. Many staff felt that these metrics prevented customer-centric case management and the ability to respond to an articulated need in an agile and flexible way.
Because providers have to support customers as they wait on long lists for housing, provider performance must be evaluated based on their ability to stabilize customers and keep them on the path to security, and eventual permanent housing. Frontline staff specified customer retention and appointment attendance rates as useful metrics that typically indicate progress toward stability among customers. The regional authority should also review with customers whether there are psychosocial and other quality-of-life metrics they see as reflective of their experiences. Many customers expressed a desire to be understood holistically, and for metrics to be aligned with their sense of self-worth, dignity, and agency. Particularly for Native and transgender customers and staff, the assessments, forms, and metrics they engage with fail to account for their identities, needs, and notions of healing.
This shift to customer-centric metrics would represent an important change in how quality and success are measured in this system, and bring it closer to representing the realities customers experience. However, capturing meaningful service metrics is only the first step to driving transformation in the system. Staff articulated the desire to leverage customer-centric metrics to drive service priorities, and eventually, shape the funding streams that are actually needed to deliver against service needs. This is a use-case meant to illustrate how a CQI framework could add value to all actors in a system by collecting and acting on customer voice.
Reshape staff conditions to help them be more accountable to customers.
We saw distinct patterns in our research where customers often attributed successful experiences with an organization or service to a dedicated, supportive relationship they formed with an individual staff member. This is particularly true of youth customers.1 Those relationships can be transformative in providing emotional support and connections to the services that people need to stabilize their lives.
Because of the importance of staff and customer relationships, understanding this dynamic was a major line of inquiry in our work. In workshops with staff and customers, we used a profile-building activity to understand the most important criteria for building successful customer/staff relationships. This profile was framed as a part of a fictitious matchmaking service, that would help customers and staff get to know one another before their first interaction. Read more about our process in the methods section.
For customers, results showed that it is vital staff be non-judgmental, friendly, transparent, and committed to their wellbeing. They were likely to avoid staff or disengage from services if they experienced judgment, condescension, or sensed that staff weren’t willing to invest in a relationship. These are elements needed to support any relationship outside of a service context, but they revealed some of the challenges that customers face in their interactions with staff. Customers are often met with inconsistent treatment across and within service organizations, citing inexperience, challenging power dynamics, and disrespect as commonplace. While some of these things can be attributed to personnel, both customers and staff spoke directly to the structural barriers that give rise to these dynamics. This is in part due to metrics that homogenize customer goals and prevent tailored services that are response to customers’ unique strengths and needs.
1. Invest in support for staff to improve the customer experience and the health of the system.
Frontline staff frequently cited poor pay, long hours, and insufficient resources to serve customers well. Few staff are able to afford to live within Seattle city limits and some frontline staff even report being on the edge of homelessness themselves. Though they are the frontline for dealing with individuals in crisis, they receive little training in how to respond to crises, trauma, and co-occurring disorders, not to mention little to no regular support for their own emotional and psychological well-being. This is compounded by the fact that organizations tend to be resource constrained, which limits their ability to hire multidisciplinary teams that could meet the dynamic needs of clients with targeted services. Given these factors, staff turnover is incredibly high, resulting in abrupt relationship changes that disrupt the delivery of services and engender a sense of abandonment for customers.
Turnover has a significant impact on the ability of the system to deliver quality services. Institutional knowledge is difficult to develop without consistent staff, resulting in organizations that struggle to maintain consistent procedures, practices, and partnerships, let alone evolve and improve them. Many staff discussed the burdensome process of coordinating care with other service providers, often spending hours attempting to find someone they could trust to provide quality care to their customers. This challenge will continue to exist if there is not a focus on retaining talent across providers.
An investment in frontline staff is simultaneously an investment in customer experience and system performance. In addition to addressing inadequate compensation, service staff should be provided with the training they seek to better serve customers, as well as the flexibility to more easily route resources to customers at their time of need.
2. Increase opportunities to hire individuals with lived experience to bolster relationships and improve service offerings.
Low pay often means these critical roles are staffed as entry level positions, resulting in employees who lack the requisite experience to succeed in a role that requires them to understand nuanced needs. Customers frequently cited how much easier it was to build trust with staff who had direct experience with housing instability, substance use disorder, and the myriad challenges related to both. Many customers also preferred staff who share similar life experiences due to race, gender identity, or sexual orientation. This was particularly true for the Native and Transgender customers we spoke with, who struggle to engage with staff who don’t understand the unique communities of which they are a part. Overall, customers perceived staff with lived experience as more likely to be empathetic and possess strategies and guidance born from experiential knowledge. In general, frontline staff are often more representative of the communities they serve than managerial staff,2 yet there are still barriers to demonstrating lived experience as a qualification on par with academic degrees. The system must recognize and resource this expertise in order to drive towards more equitable and successful outcomes.
Recognizing the essential role that frontline staff have in customers’ lives, the King County homeless provider system must develop mechanisms for staff to be held accountable to customers and for better, more experienced staff to be hired and retained. In addition to developing customer-oriented program metrics, as described above, frontline staff salaries must be significantly increased to reflect their expertise and the value of their work, multi-disciplinary teams with mental health clinicians should be funded, and staff should receive robust emotional and psychological supports.
From correspondence with Carrie Lippy, the research lead of the King County Youth of Color Needs Assessment Report. She emphasized the importance of programs like arts programs and drop-in centers that provide youth people of color with a space to go regularly. Those programs are especially useful because of the consistency of staff, who are there as needed. The young people only opened up to the staff after a long time of seeing the same people there every week. ↩