The Care Coordination Working Group is responsible for accomplishing the goals outlined in the priority areas of Expanded Case Management, Discharge Planning and Street Outreach.

Homelessness and housing instability seem like insurmountable community challenges. But this is not true. It just demands teamwork and countywide coordination. This working groups creates collaborative solutions to identify those that are at risk of or are experiencing homelessness, direct them to the correct entry point into the homelessness prevention or response systems and offers stability and support as families and individuals move through those systems. This group relies an Diversion and Housing First guides in the way in which it offers care coordination. This means that permanent and stable housing is always the first goal and if households can be kept from entering the homelessness response system, that option is preferred. 

The three priority areas that are addressed in this working group are:

Expanded Case Management

Support is essential to maintaining housing for many households. Sometimes, something as simple as understanding a lease or help with bills is the missing piece to ending homelessness for households. Weld’s Way Home will create a system for accessing these supportive case managers for households that do not fit into the program requirements currently in place.

Discharge Planning

Homeless individuals leaving institutions (hospitals, institutional care facilities, jail, etc.) are sometimes discharged to the streets without plans for safety, follow-up, etc. Current systems do not have capacity to assist individuals or families experiencing homelessness once they are released from care. Often, it is incredibly expensive to keep these folks in care beyond their treatment plan, jail time, etc. Additionally, institutions do not have the capacity to look at the systematic release of individuals to identify improved ways for assisting those experiencing homelessness. Weld’s Way Home will work with institutions to better identify individuals that are vulnerable to homelessness upon release and create a streamlined response to getting that person into permanent housing through connection to the homelessness response system. 

Street Outreach

Individuals sleeping on the streets often have distrust of shelters, programs, etc. and find they have no other option than to sleep outside. These individuals are most at risk of violence, trauma, or health disasters that are exacerbated due to lack of shelter. Often, their only contact with the system is with police or emergency response systems that are utilized incorrectly and can contribute to their distrust of the system. Street Outreach staff work to intentionally identify individuals sleeping out of doors, create trusting relationships with them, and connect them to the homelessness response system when they are ready to do so. They can also act as service brokers, offer conflict resolution if disputes arise and support emergency response units so as to decrease community costs associated with emergency care often required for those living out of doors.

Care Coordination Working Group Materials