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Recommendations for a National Mass Patient and Evacuee Movement, Regulating, and Tracking System

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Shelters

Shelter Typologies and Definitions

Homeless shelters (assistance providers) are organized at the State and  county level into Continuums of Care (CoCs).  CoCs are essentially local networks that provide services appropriate to the range of homeless needs in individual communities, and coordinate the delivery of care across various provider types. These can include: Prevention and Outreach/Assessment Services, Emergency Shelters, Transitional Housing Programs, Permanent Supported Housing and other, population-specific homeless assistance programs.  CoCs typically rely on Federal Department of Housing and Urban Development (HUD) Supportive Housing Program (SHP) grant funding for a significant portion of their budgets, and report data to HUD. Individual shelters depend on a mix of public and private (foundation and faith-based) funds to maintain operations. CoC lead agencies can be either nonprofit or governmental organizations.

Emergency Shelters are typically the points of entry into the homeless service system. Emergency shelters provide up to sixty days of temporary housing. Many are congregate facilities, but emergency housing can also include hotel or motel vouchers and short-stay apartments. CoCs typically dedicate separate facilities to single men, single women, and families.67 In addition, more specialized shelters cater to specific subpopulations such as homeless veterans, victims of domestic abuse, mental health and HIV/AIDS patients, homeless or runaway youth, and teen parents. Nationally, the size of emergency shelters and the number and types of clients served vary by geographic location.68

  • Transitional Housing Programs provide homeless persons or families with housing and case management for up to 9 months (6 months in some jurisdictions). Transitional housing programs typically offer on-site case-management services, which range from alcohol and drug abuse treatment to financial counseling and job training.
  • Permanent Supported Housing is affordable rental housing with support services for limited-income people or homeless persons (and their families) with disabilities, severe mental illness, chronic substance abuse problems, or HIV/AIDS and related diseases.
  • Disaster Shelters are activated in schools, town halls, stadiums and other open-spaces and often are run by nonprofit organizations such as the Red Cross, the Salvation Army and United Way working with State and local officials after an emergency. Some disaster shelters are designated as "special needs" shelters, for persons who have medical needs but who do not require hospitalization. Recent efforts to improve communication among the various local and national aid organizations have resulted in the formation of the Coordinated Assistance Network (CAN)69 and the affiliated National Shelter System.  CAN contains person-level records for each person sheltered by any of the participating voluntary organizations (American Red Cross, National Voluntary Organizations Active in Disasters, Safe Horizon, Salvation Army, 9-11 United Services Group, and United Way of America).  The National Shelter System contains information about tens of thousands of disaster shelters, including their capacity (number of evacuees who can be sheltered) and facilities such as food preparation, back-up generators, etc.

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Homeless Shelter Intake and Discharge Processes

Homeless Shelter Intake. Shelter intake processes, although varied, generally consist of assigning clients to a bed and performing some sort of needs assessment, tasks which are usually assigned to trained shelter staff or social workers. Intake staff will collect basic identifying and demographic information on persons making use of shelter services and are responsible for assigning client IDs to all new users.70 In some cases, the attempt to determine a person's prior use of the shelter's services is verbal and self-reported. In others, staff may query an electronic database to search for existing client files as a means of preventing duplication. According to shelter administrators, the attempt to re-use unique identifiers and verify prior admission is a key component of the log-in procedure given clients' frequent reluctance to provide personal identifying data such as name, social security number or date-of birth. Unlike at the larger urban shelters, where admission or login most often occurs via a Web-based information management system, staff at many of the smaller, less well-funded shelters continue to rely on paper-based systems to collect data on the people they house. Under these circumstances, persons seeking shelter are assigned to a bed and given a questionnaire or data sheet to fill out, which, once completed, is entered into the shelter's database for tracking and reporting purposes by either full-time staff or shelter volunteers. Desk staff and caseworkers typically spend time with program participants to either help them complete the login procedure or answer any questions they may have. Data-entry at these smaller organizations typically occurs within 72 hours but may vary depending on staff size and resource availability. Use of census information technology (IT) systems and reporting requirements for the various shelter types are discussed in greater detail below.

Although most smaller shelters do not distribute physical devices to program entrants that allow them facility access, large shelters servicing a sizeable portion of a local homeless population or those providing both emergency and transitional housing services will sometimes generate badges or tags to facilitate admission. For clients staying at a shelter longer than one night, a photo ID or badge with a bar code is used to re-enter the program and allows easy access to meals and other social services.71 While there is a recognized need among administrators and intake personnel for a simpler intake process, a majority of shelters do not have the resources or funding to purchase ID generating technology. Loss of IDs and badges—which can link to an individual's personal data—is also of great concern to shelter staff and managers alike and, as one participant stated, "Issuing badges in the midst of a crisis would most probably not be ideal".  

Discussions with shelter administrators indicated that while medical personnel are typically not part of the intake process, shelter staff do receive training to help them determine whether clients require emergency medical attention or specific assistive devices. In some cases, CoCs have adopted information-sharing policies that allow intake staff to view a client's file and history of service use within the local continuum; under these circumstances, shelter staff are capable of assessing a person's health and referral needs upon program entry. Interviewees indicated however that a majority of shelters have not adopted this approach, noting that comprehensive needs assessment is typically separate from intake and that caseworkers—as opposed to intake staff—are most often involved in this process. The extent to which shelters collect health status information varies according to the type of services a shelter provides: homeless assistance programs serving persons with HIV/AIDS will, for instance, collect more detailed and complete information on a clients' health status than on an emergency housing program. As one participant noted, intake workers at most shelters will simply ask clients if they have special needs. When trained medical professional are available, intake will ask program entrants if they would like to make an appointment to speak with whoever is on premises. Although most shelter programs do not collect information on whether a person is ambulatory, intake staff are more likely than not to make that determination due to the nature of the beds available (ie: bunk beds vs. cots or mats).

Although emergency shelters and temporary housing programs are not required to maintain open-door policies, many of these organizations will provide individuals with housing regardless of bed availability, either in the form of hotel vouchers or floor-space when demand is high or when receiving clients from sister shelters in need of extra beds. When helping other facilities with overflow, shelters may not necessarily log all arrivals into their own system because no actual services are being provided beyond helping to fill another program's gap for a night or two. People in transition from one shelter to another can therefore easily slip through the cracks should there be high demand for housing or other homeless assistance services.

Homeless Shelter Discharge.  While shelters are generally good at collecting data upon a person's entry into a program, exit data can be more difficult to collect. Formalized departure processes are implemented only in transitional or permanent housing programs. Emergency shelters in particular, which clear out on a nightly basis, have trouble gathering information from clients before they leave as many simply abandon their beds without checking out. If a bed is unoccupied, it is assumed to be no longer in use. As one participant stated, "Nothing about the shelter environment encourages people to check out or inform intake personnel of their plans". Transitional and permanent housing programs do however make a more concerted effort to document a person's health and housing status at the end of that person's stay. Clients are typically asked to provide information on their next destination, and workers will check to see if a person's economic, employment, or health status has changed. The frequency with which entry and exit data is documented depends on the type of services provided: Whereas emergency shelters make use of bed-lists and document the number of people on location daily, transitional and permanent housing programs collect data at the beginning and end of a person or household's stay. Files are updated periodically during caseworker follow-up sessions, but there are no Federal requirements or protocols for the frequency of these visits. Clients in permanent or supported housing programs are not required to login or out intermittently and program staff have no way of tracking or monitoring their whereabouts.

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Shelter Information Technology Systems

Homeless Shelters.  CoCs receiving State and Federal Supported Housing Program (SHP) funds are required to collect client-level data on assistance use and the characteristics of homeless persons within their community via Homeless Management Information Systems (HMIS). An HMIS is a Web-based software application that can encompass information from disparate providers in geographic areas ranging from a single county to an entire State. Although intake and discharge processes vary by shelter type, all participating homeless assistance providers must collect a standard set of data elements. These include: name, date of birth, Social Security number, unique ID, and program entry/exit date. Programs with annual progress reporting requirements and providers funded through Housing Opportunities for Persons with AIDS must also supply detailed information on the health and socio-economic status of clients and the types of services received during their stay. The table below provides more detailed information on the client-level information captured by HMIS.

Although response categories for both universal and program-specific data elements are HUD mandated, providers have flexibility in terms of how the data is collected and when it is entered into an HMIS. For shelters with Internet connectivity and available workstations, data may be entered real-time at intake; however, a majority of participating shelters at present are simply documenting user data through existing paper-based or legacy systems and entering it into the HMIS later. More specifically, providers are allowed to collect universal and program-specific elements via client interviews or questionnaires and can submit data to their local HMIS soon thereafter (Although CoCs can establish their own data entry protocols; discussants noted that most providers transfer data with 2-to-3 business days of intake). HMIS administrators at the CoC level receive information from all participating providers for de-duplication on a quarterly basis; aggregate (de-identified) data is then reported to HUD annually.

HMIS prevalence and market concentration: Of the 469 CoCs that applied for Federal SHP funding in 2005, nearly three-quarters (72%) reported that they were collecting client-level information. According to HUD, there are currently 351 HMIS implementations in the country. 72 Of these, 32% reported having achieved at least seventy-five percent bed coverage for each of the three main shelter types (emergency, transitional and permanent housing). An additional 34 % of communities anticipated achieving this goal by the end of 2005.73 While HUD expects HMIS participation to become a normative practice for homeless-service providers across the country, information gathered in discussions with HMIS vendors and administrators indicates that users currently represent approximately sixty percent of shelters nationwide and are more likely to be found in urban than rural locales. Nonusers typically are private or faith-based organizations that rely on either homegrown or paper-based systems to meet homeless assistance needs of the populations they serve. While providers within a single continuum all use the same HMIS product or application to capture client-level information, a CoC can choose from many HMIS solution providers. HUD maintains a Web page of vendors with registered HMIS products to help communities identify potential partners; presently, 48 vendors advertise on HUD's site. Despite the proliferation of software vendors, the market for HMIS systems seems to be relatively concentrated in that the largest vendor covers nearly 70% of all participating providers. 

HMIS data quality and reporting issues:  Because HMIS implementation is a relatively new Federal requirement; homeless assistance providers are facing a variety of issues relating to data quality and de-duplication. Some of the issues raised by participants during discussions include: how to deal with missing or incomplete client records, the provision of false information (i.e., when a client is unwilling to provide shelter staff with accurate data), delayed data entry or record transfer, transcription errors, and lack of specified and timely data-entry protocols for specific data elements that are subject to change. When asked whether it would be possible for providers to generate daily status reports using HMIS in the event of a natural disaster or mass casualty incident, most discussants responded that although technically possible, participating HMIS shelters are not yet able to produce timely or accurate person-level data on a moment's notice for the reasons noted above. Lack of resources, training, and the time involved to produce accurate, de-duplicated counts are barriers to conducting a daily census. In addition, should daily reporting by providers become a requirement during such an event, there would be no way to track clients or evacuees in transition from one CoC to another or from one region to the next since identifiers are unique to individual communities.

Universal Data Elements

Data Element Use & Disclosure Frequency

Name

Current and previous names

Intake

Social Security Number

Required for unduplication and to access previous records

Intake

Date of Birth

Age at program entry and for unduplication

Intake

Ethnicity and Race

Ethnicity and race recorded separately (two ethnicity categories and five race categories)

Intake

Gender

To determine number of homeless men and women

Intake

Veteran Status

Service in the U.S. Armed Forces

Intake/as needed

Disabling Condition

Disabling conditions determined from client interview, self-administered form, observation or formal assessment (conducted separately from intake unless information required to determine program eligibility)

Intake/as needed

Residence Prior to Program Entry

Where the person slept the night before program entry. There are separate fields for type of residence and length of stay in that residence

Intake/as needed

Zip Code of Last Permanent Address

Five-digit zip code of the apartment, room, or house where the client last lived for 90+ days

Intake/ as needed

Program Entry Date and Exit Date

Month, day, and year of first day of service. Used to calculate length of stay and homeless episodes

At each entry/exit

Personal Identification Number

Permanent and unique number generated by the HMIS software for every client in the system

Computer generated upon client's first contact with local HMIS

Program Identification Number

Assigned by HMIS for every program event for every client. Includes FIPS code for geographic location of provider; locally determined facility code; HUD-assigned CoC code; and program type code.

Computer generated at each entry

Household Identification Number

Defined as a group of persons who apply together for homeless assistance services. Used to differentiate between persons receiving services as individuals and persons in households.

Computer generated at each entry


Disaster Shelters.  CAN and the National Shelter System, jointly developed by the American Red Cross Association and the Federal Emergency Management Administration (FEMA), is a nationwide, Web-based, registry of disaster-related shelters, services, and agency resources, as well as a records system for persons sheltered during an evacuation.  It also supports referrals from shelters to numerous social service agencies. The National Shelter System currently contains information about some 40,000 disaster shelters, as well as the roads and transportation networks leading to them.  The National Shelter System is supported by software that allows participating communities and agencies with pre-existing, formalized agreements with the Red Cross to upload facility and resource specifications both prior to and during a natural disaster or incident.  A 3-year pilot program is currently being implemented in six cities to test usability and develop an emergency preparedness model applicable for the rest of the nation.  Shelter location, capacity, utilities, accessibility, food prep, and Americans with Disabilities Act (ADA) compliance are all documented; additional data and files can also be loaded manually into the system or over the phone during a disaster as facilities open their doors to the public. Hospitals and nursing homes are not currently included in the system even though these may occasionally become shelters in the event of a natural or man-made disaster.  A mapping tool allows those operating the system to identify best possible routes to and from designated facilities. 

The CAN client service management software application allows shelters to match evacuee needs with available resources.  It tracks disaster shelter residents' individual and household information while identifying evacuee health, housing and social service needs.  Plans for this component of the system include collecting person-level data such as name, date of birth, age, gender, room or cot number, arrival and departure date and relocation address or phone. Additional information on health needs, housing needs and legal assistance will also be collected. This application can be used on a daily basis as new evacuees enter the system and will remain activated during a community's recovery phase.

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Shelter Privacy and Confidentiality Issues

Data sharing among participating providers at the CoC is limited to HMIS baseline privacy standards as stated in HUD's Final Notice on HMIS Privacy and Technical Standards. Organizations wishing to adopt open systems or share client-level information for referral purposes within their CoC must also comply with more stringent State and local confidentiality laws. Baseline standards require providers to 1) inform clients of the reasons for collecting information in the form of a privacy posting at intake and 2) develop a privacy notice that is available to all those who wish to see it. Privacy notices describe the uses and disclosures of personal identifying information, protocol for client access to and correction of personal identifying information, provider efforts to ensure client accountability and data quality, certification of staff confidentiality training and a statement noting the possibility of amendment. According to HUD's Final Privacy notice, providers may not use or disclose personal identifying information for purposes not listed in their own notices without first obtaining individual client consent. Should a shelter choose to adopt more stringent privacy protections regarding use and disclosure of protected information such as seeking written or oral consent or limiting disclosure to the minimum necessary, these protections become mandatory as opposed to merely suggestive. Although most homeless assistance providers are not subject to Health Insurance Portability and Accountability Act (HIPAA) regulations, this may be a concern for particular programs providing targeted health services to homeless persons in the community. The recently re-authorized Violence Against Women Act may also limit domestic violence providers' ability to disclose person-level information, let alone participate in an HMIS. As stated in HUD's Final Notice, access to person-level data is restricted to local CoCs and is not intended for distribution at the national level.

Despite these restrictions, discussants noted the need for more open information-sharing and referral policies, especially in the face of a natural disaster or Katrina-like incident. Although providers "walk a fine line between trying to both honor the people [they] serve and maintaining a good working relationship with different agencies and providers", many seemed to think that if HIPAA-like provisions were relaxed and measures were taken to safe-guard the identity of specific homeless sub-populations that information sharing would be possible in the event of national emergency. Because HMIS applications can be customized to meet the needs of a specific program or shelter, safeguards to limit access to personal identifying information to specific providers and ensure confidentiality already exist.

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Shelter Perceptions: Benefits of Evacuation Tracking

Perceived benefits of implementing a national system among shelter administrators are mainly related to improved evacuation procedures and coordination of disaster relief resources transportation in the event of a mass casualty incident. Shelters located on the Gulf coast, and those having previously been on the receiving end of evacuations, were particularly interested in the possibility of better-coordinated transportation and referral services. Nearly every participant we spoke to indicated that they would consider this as an incentive to participate in a national system.  According to the information gathered during these conversations, most shelters do not have enough resources to provide clients with safe and easily accessible transportation to another location—large shelters may have vans at their disposal but most would rely on their local 211 or cab companies for aid. Despite their limited resources, homeless assistance providers consider themselves responsible (or are considered responsible by the county) for arranging for clients' transportation needs. Moreover, while individual agencies may have pre-established agreements with other facilities in a nearby locales should evacuation be required, continuum-wide disaster planning appears to be in its infancy as there is limited information sharing regarding bed or other resource availability among providers today. There is however a recognized need for this type of communication—local 211 agencies, emergency-responders and county representatives in many States are in the process of holding discussions regarding this particular issue. HUD itself is currently providing technical assistance to regions directly affected by Hurricane Katrina to establish a case management and tracking system for shelter residents and is working with HMIS vendors to provide region-wide resource directories for use by local providers.


67. U.S. Department of Housing and Urban Development (HUD), Office of Policy Development and Research; "Evaluation of Continuums of Care for Homeless People Final Report." May 2002.
68. HUD's 2002 CoC Evaluation discusses the variation in both style and intensity of emergency services provided by communities across the country.
69. CAN is a formal partnership among seven leading disaster relief nonprofit organizations: Alliance for Information and Referral Systems (AIRS), American Red Cross, National Voluntary Organizations Active in Disaster (NVOAD), Safe Horizon, Salvation Army, 9-11 United Services Group, and United Way of America. The CAN IT vendor is responsible for maintaining the National Shelter System and its related applications during an evacuation.
70. Family programs will collect information by household and maintain one file per family as opposed to collecting data on individual family members.
71. The Salvation Army Emergency Shelter in Sarasota, FL and the Shreveport-Bossier Rescue Mission in Louisiana both generated badges for their clients during recent mass evacuations. Both indicated that badges only work at their individual shelters and cannot be used to log in at other locations.
72. CoCs can choose to implement HMIS on their own or in conjunction with other CoCs. Of the 351 HMIS currently implemented, 314 represent a single CoC, 31 implementations include between 2 and 4 CoCs, and 6 include 5 or more CoCs.
73. U.S. Department of Housing and Urban Development, Office of Community Planning and Development: "Report to Congress: Fifth Progress Report on HUD's Strategy for Improving Homeless Data Collection, Reporting and Analysis." March 2006.


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