Please select the answer chice that best describes the prcess and structure that this prgram ffers its (Questins 1-7). 1. Hw des the prgram determine the type f in which a participant will live? Prgram cnducts a Prgram assigns participant t the first unit clinical assessment and determines the mst apprpriate based n participant s clinical need / Prgram assigns based n a clinical assessment, but with input frm the participant regarding their preference Participant chses the type f they want t live in OR All have the ptin f a scatter-site apartment functining 2. Hw des the prgram determine the neighbrhd in which a participant will live? Prgram autmatically assigns participant t the neighbrhd with the first unit OR all is in the Prgram cnducts a clinical assessment and determines the mst apprpriate neighbrhd based n participant s clinical need Prgram assigns based n a clinical assessment, but with input frm the participant regarding their preference Participant chses the neighbrhd they want t live in, given what they can affrd same neighbrhd / functining 3. Des the prgram assist with furniture? Prgram assists Prgram des nt assist with btaining furniture t find furniture in the cmmunity (e.g., Prgram assists by purchasing furniture dnatins) 4. T what extent des this prgram have ready access t affrdable thrugh the use f subsidies? Prgram des nt have access t Prgram des nt have Prgram has direct subsidies r subsidized Prgram has ready direct access t access t units, but access t subsidies r subsidized subsidies and/r prvides advcacy and subsidies and/r prvides units, and des subsidized units, fr subsidized units nt prvide fr but there is a waiting t btain fr all t btain them perid fr subsidies r subsidized units O 5. What percent f pay 30% r less f their incme twards their rent (excluding csts fr ther such as fd, husekeeping, and nursing) in permanent ed? 0-14% 15-29% 31-45% 46-60% 60-84% 85-100% 6. On average, hw lng des it take t mve frm enrllment int permanent? Within 1 year Within 6 mnths Within 3 mnths Within 1 mnth Within 2 weeks O
7. What percent f live in the fllwing types? (Fill in % fr each) a. Emergency shrt-term, r transitinal b. Htel c. Cngregate / Grup Hme d. Scial Husing; n e. Scial ; with n-site f. Scial ; with ff-site g. Supprtive (specialized fr persns with psychiatric disabilities with n-site) h. Independent apartments rented frm cmmunity landlrds i. Other type fill in: % % % % % % % % % 8. What percent f share a bedrm with ther tenants? 0-14% 15-29% 30-44% 45-59% 60-84% 85-100% Please select the answer chice that best describes hw and are related in this prgram (Questins 8-12). 9. What requirements d prgram have t meet in rder t gain access t a permanent, independent scatter-site apartment? (chse all that Willingness t Cmpletin f cmply with a a perid f plan time in Sbriety r Meeting transitinal Cmpliance Psychiatric that addresses Agreeing t abstinence respnsibilities, with symptm sbriety, face-t-face frm alchl f a standard utpatient, medicatin and/r drugs stability abstinence, visits with staff lease inpatient, r and/r residential medicatin cmpliance 10. What requirements d have t meet in rder t stay in permanent? (chse all that Cmpliance with plan and/r Sbriety r Meeting Cmpliance Psychiatric participatin in Agreeing t abstinence respnsibilities with symptm frmal face-t-face frm alchl f a standard medicatin and/r drugs stability activities (e.g., visits with staff lease attending grups, seeing a psychiatrist, etc. 11a. D the majrity f have any lease r ccupancy agreement that specifies their rights and respnsibilities f tenancy? Yes N
11b. If yes, which f the fllwing prvisins des the lease r agreement cntain? (chse all that Prvisins regarding Prvisins regarding Prvisins regarding Prvisins regarding adherence t medicatin, creating behaviral adherence t prgram adherence t face-tface visits with staff sbriety, and/r a disturbances with respect t rules, such as curfews plan ther tenants 12. Which statement best describes prgram actins regarding when lse their? Prgram des nt ffer a new unit and des nt assist with finding utside the prgram Prgram des nt ffer a new unit, but helps find utside the prgram Prgram ffers a new unit after they meet readiness criteria, cmplete a perid f time in mre supervised, and/r prgrams has set limits n the number f relcatins Prgram ffers a new unit and decisins t re-huse are individualized and minimize cnditins that need t fulfill prir t receiving a new unit 13. Which statement best describes prgram actins regarding when lse their? Participants are Participants cntinue t discharged frm receive prgram Participants are discharged Participants cntinue t if they lse, but if they lse, but frm if they lse receive prgram there are explicit criteria may be discharged frm if they lse utlining ptins fr reenrllment if they d nt meet certain criteria Please select the answer chice that best describes the service philsphy f this prgram (Questins 13-21). 14. Hw des the prgram determine the type, sequence, and intensity f n an nging basis? Participants have sme Participants have sme Services are chsen by the Participants chse, say in chsing, say in chsing, service prvider, generally mdify, r refuse mdifying, and refusing mdifying, r refusing based n clinical and s at any time,, but staff and participant assessments and except ne face-t-face determinatins usually preferences usually participant functining visit with staff a week prevail. prevail. 15. What are the requirements fr with serius mental illness (SMI) t take medicatin r participate in psychiatric such as attending grups r seeing a psychiatrist? Mst with All with SMI Participants with SMI wh Participants with SMI are SMI are required t take have nt achieved symptm are required t take nt required t take medicatin and/r stability are required t take medicatin and/r participate in, medicatin and/r medicatin and/r participate in but exceptins are made participate in participate in
16. What are the requirements fr with substance abuse (SA) disrders t participate in SA such as inpatient, attending grups, r cunseling with a substance use specialist? Participants with SA Participants with SA All with SA disrders wh have nt disrders wh are Participants with SA disrders, regardless f achieved a specified currently actively using disrders are nt required current use r abstinence, perid f abstinence must substances must t participate in SA are required t participate participate in SA participate in SA in SA 17. What is the prgram s apprach t substance use amng? Participants are required t abstain frm alchl and/r drugs at all times and/r prgram impses negative fr use (e.g., mving the persn t mre supervised ) Participants are required t abstain frm alchl and/r drugs while they are in their residence Participants are nt required t abstain frm alchl and/r drugs, but staff wrk with t achieve abstinence Participants are nt required t abstain frm alchl and/r drugs, but staff wrk with t reduce the negative cnsequences f use and/r utilize apprpriate stage matched interventins 18. Which f the fllwing activities des prgram staff use t prmte adherence t a plan? (chse all that Paying Cautin the Cautin the Cautin the Requiring Requiring withhlding f withhlding withhlding f Engaging in urine daily visits t take participant s f participant participant s quid pr qu screening with staff medicatin incme/allwance 19. Which f the fllwing are included in a participant s plan and fllw-up? (chse all that Gals that are Gals that are Gals that are Participant and Barriers t chsen by staff r chsen by staff chsen by the Participant prgram actins achieving autmatically set with input frm participant with strengths taken t gals by the prgram the participant input frm staff gals O 20. Which life areas des the prgram systematically address with specific interventins? (chse all that Interventins that Interventins that Interventins Interventins target mental Interventins Interventins target cmmunity that target that target health and that target that target integratin, scial emplyment and substance use physical health financial needs, spirituality, educatin symptms recreatin O O Please select the answer chice that best describes the service array f this prgram (Questins 21-40).
21. What des the prgram ffer t help maintain such as ffering assistance with neighbrhd rientatin, landlrd relatins, budgeting, and shpping? (chse all that Prgram ffers nging Prgram ffers Prgram ffers nging, during prperty management Prgram des nt ffer such as neighbrhd mve-in, such as, assistance with rientatin, landlrd neighbrhd rientatin rent payment, and relatins, budgeting, and and shpping csigning f leases shpping 22. What types f psychiatric, if any, are t? Prgram des nt assist with access t psychiatric care Prgram refers t psychiatrists r nurse practitiners in the cmmunity, but des nt have frmal r infrmal linkages with these prviders Prgram refers t psychiatrists r nurse practitiners in the cmmunity and has frmal r infrmal linkages with these prviders Prgram has a psychiatrist r nurse practitiner n staff that prvides directly t 23. What types f, if any, are t wh are in need f substance use? (chse all that Substance use are nt Systematic and integrated screening and assessment Interventins / Cunseling tailred t participant s readiness t change Outreach r mtivatinal interviewing CBT, relapse preventin, r ther EBP r Prmising Practice (e.g. BRITE) O 24. What types f, if any, are t wh are interested in paid emplyment pprtunities? (chse all that In huse wrk Emplyment Individualized shrt Cmmunity based Vcatinal experience r are nt term emplyment emplyment assessment sheltered wrk (e.g. (e.g. day labr) Gdwill) O 25. What types f, if any, are t wh are interested in educatin? (chse all that Adult schl, Supprted educatin Educatinal In huse educatin Educatinal vcatinal training, in the cmmunity are nt (e.g. literacy assessment trade schl / (e.g. cmmunity remediatin) apprenticeship cllege) O 26. What types f, if any, are t wh are interested in vlunteering? (chse all that Vlunteering Vlunteering In huse vlunteer Individualized shrt Cmmunity based are nt capability and experience r term vlunteering vlunteering interest assessment sheltered experience O
27. What types f, if any, are t wh have medical (physical health) issues? (chse all that Screening fr Health On-site diagnsis Managing Cmmunicating Medical/physical medical prmtin, and f medicatin and crdinating health prblems r preventin, physical health related t with ther are nt medicatin educatin cnditins physical health medical prviders side effects activities 28. Des the prgram have a paid peer specialist n staff wh prvides directly t?. 25 FTE t.49 FTE peer.50 FTE t.99 FTE peer 1.0 FTE peer specialist r There is n paid peer specialist fr every 100 specialist fr every 100 mre fr every 100 specialist n staff 29a. What types f scial integratin, if any, are t? (chse all that? Scial integratin are nt Basic scial skills training (e.g., maintaining eye cntact, hlding a cnversatin) Grup recreatinal/ leisure activities (lunches, sprting events, senir center) One-n-ne fr develping scial cmpetencies (e.g., help with empwerment, reslving prblems with members f scial netwrk, establishing trust) Services t help r expand scial rles (e.g., emplyee / vlunteer, sibling / parent / grandparent, neighbr) Supprt fr activities pertaining t citizenship r civic participatin (e.g., help with advcacy, vting, cmmunity invlvement, faith cmmunity invlvement) O 29b. Generally, where d prgram and pprtunities fr scial integratin ccur? Within the prgram / prgram ffices Within the cmmunity Bth equally 30. What percent f have experienced a psychiatric hspitalizatin in the past 6 mnths? 0-14% 15-29% 30-44% 45-59% 60-84% 85-100% Please select the answer chice that best describes the team structure/human resurces f this prgram (Questins 41-46). 31. D mre than 50% f prgram have histries f any f the fllwing (chse all that : Street Hmelessness Shelter stays Severe Mental Illness Psychiatric Hspitalizatin Substance Abuse/Dependence Disrders O 32. Hw des service staff perate with respect t caselads? Staff have individual caselads (ne staff Staff have shared caselads (multiple staff member wrks regularly with a participant) wrk regularly with a participant)
33. What participant/staff rati des the prgram typically maintain, excluding prescribing MDs and nurse practitiners & administrative? 36 r mre 10 r fewer 26-35 16-25 11-15 per 1 per 1 per 1 FTE staff. per 1 FTE staff. per 1 FTE staff. FTE staff. FTE. O 34a. Is there a plicy regarding the minimum number f face-t-face cntacts that are required t have with staff in a mnth? N minimum requirement 1 2-3 4-5 6-10 11-14 15+ 34b. On average, what is the actual number f face-t-face cntacts have with staff in a mnth? <1 1 2-3 4-5 6-10 11-14 15+ 35. Hw ften d prgram staff meet t plan and review fr? Prgram staff meet Prgram staff Prgram staff meet Prgram staff meet less than ne day a meet 1 day per 1 day per week 2-3 days per week mnth mnth Prgram staff meet at least 4 days per week O 36. T what extent des the prgram use its team meetings t meet the fllwing functins? (chse all that Cnduct a brief, but Cnduct a review clinically-relevant f the lng-term Develp a staff Discuss need fr review f any gals f all schedule based n Review previus staff practive cntacts with clients n a participant assignments fr t prevent future whm they had regularly schedules and fllw thrugh crises cntact in the past 24 scheduled basis emerging needs hurs O 37. What types f pprtunities are fr participant input int prgram peratins and plicy? (chse all that Prgram has a Prgram Prgram frmal grievance rutinely Prgram frmally ffers Prgram prcess fr includes emplys persns pprtunities includes t n with lived fr participant n express cncerns planning / experiences in feedback (e.g. gverning r dissatisfactin implementatin regular staff cmmunity bdies cmmittees, psitins meetings) advisry bards O 38. Is there anything else that yu wuld like t mentin that wuld be imprtant t knw abut yur prgram? Citatin: Gilmer, T., Stefancic, A., Sklar, M., & Tsemberis, S. (2013). Develpment and validatin f a Husing First Fidelity survey. Psychiatric Services, 64 (9), 911-914.