Implementing the Self-Sufficiency Matrix

Updated 8/1/2011

Staff Training ToolFor Minnesota LTH Programs

• Based on Abt Associates Training and Michigan’s Implementation

Training Overview

• What is the self-sufficiency matrix? • Using the matrix assessment• Minnesota implementation• Self-sufficiency domains and flowcharts• Reporting• Next steps

Background• One of many assessment tools used to

measure need, target services, and evaluate supportive service provision.

• First implemented by The Arizona Homeless Evaluation Project and now used by many other states, cities and counties.

• This Self-Sufficiency Matrix was tested for validity and reliability.

Types of Assessments

• Assessments are completed for each adult and unaccompanied youth in the household

• 3 types of assessments:» Entry» Interim» Exit

The Self-Sufficiency Matrix

Two Key Features:• 18 domains• Client’s status on each domain is measured on

a 5-point scale

Note: The domains do not cover every possible life domain. The 5-point scale will not fit all unique situations – choose the closest response.

Domain Scale1. Housing 1 = In Crisis

2 = Vulnerable

3 = Safe

4 = Building Capacity

5 = Empowered

2. Employment

3. Income

4. Food

5. Childcare

6. Children’s Education

7. Adult Education

8. Health Care Coverage

9. Life Skills

10. Family/Social Relations

11. Mobility

12. Community Involvement

13. Parenting Skills

14. Legal

15. Mental Health

16. Substance Abuse

17. Safety

18. Disabilities

Using the Matrix

• Who: All adults and unaccompanied youth.

• When: Complete assessments upon program entry, and then at specified time intervals, and at exit.

• Why: The matrix can be an excellent engagement tool and will provide valuable information on participant needs and outcomes, as well as program benchmarks and outcomes.

How to complete the matrix:

Different programs have different guidelines:

▪ Long-term Homelessness Programs (LTH)

▪ Family Homelessness Prevention and Assistance Program (FHPAP) – details explained in separate PowerPoint

Assessment Timelines - LTH1. Initial assessments should be completed

for all new participants effective July 1, 2011.

2. Back date initial assessments for existing participants (based on entry date) by September 30, 2011. Use case notes and information from other service staff for scoring.

3. The interim assessment should be scheduled for the next 6 month anniversary of the participant entry date.

4. Refer to the timeline chart for participants already in the program.

How to complete the matrix: Entry

▪ At entry: Complete within 3 weeks of program entry. Measure the person’s status before entering the program.

▪ Select one and only one status level in each of the domains.

▪ If you or the participant feel that the best score is somewhere between two numbers, score using the lower number.

How to complete the matrix: Interim

▪ Interim: Assess every 6 months after entering program.

▪ Recommend adapting the assessment into existing service practice.

▪ Best practice is to complete the assessment with the participant.

▪ If you and the participant feel that the best score is somewhere between two numbers, score using the lower number.

How to complete the matrix: Exit

▪ Exit: Complete as close to actual program exit as possible.

▪ Assessment based on domain status after exit from the program.

▪ If a participant re-enters the same program, the exit assessment should be re-entered in HMIS as an interim assessment. Then complete a new interim assessment for the re-entry date.

Matrix Assessment Tips▪ The process for completing the assessment

may vary. It may be entered directly into the computer or done on paper; in conversation with the participant, by observation and case notes. Do what works best!

▪ After working with a participant for a time, service providers sometimes find that they did not score a participant accurately on the initial entry assessment (because of undisclosed information, e.g., chemical health). Assessment scores should be re-done if the provider discovers new information.

Minnesota Matrix Implementation

• Minnesota Pilot – select implementation from July 2010 through June 2011. Feedback from users to inform broader implementation.

• July 2011 – all LTH programs and FHPAP programs begin matrix assessment.

• Data from the matrix will be entered in HMIS.

• Reports due twice a year (Feb. and Aug.)

Self-Determination and Skills

The 18 Domainsin the Self-Sufficiency Matrix

1. Housing

1. Homeless or threatened with eviction

2. In transitional, temporary or substandard housing; and/or current rent/mortgage payment is unaffordable

3. In stable housing that is safe but only marginally adequate

4. Household is safe, adequate, subsidized housing

5. Household is safe, affordable w/o assistance, adequate, unsubsidized housing

Self-Determination and Skills - Housing

Is the client housed and not at imminent risk of losing that housing?

No

Is the housing adequate?

Is the housing stable and/or affordable?

#1

Is affordable housingunsubsidized?

No

No

No

#2

#3

#4

#5

2. Employment

1. No Job

2. Temporary, part-time or seasonal; inadequate pay; no benefits

3. Employed full-time; inadequate pay; few or no benefits

4. Employed full-time with adequate pay and benefits

5. Maintains permanent employment with adequate income and benefits

Self-Determination and Skills - Employment

Does the client have a job?

No

Does the full-time job pay adequately with benefits?

Is the job full-time?

#1

Is the full-time job permanent?

No

No

No

#2

#3

#4

#5

3. Income 1. No Income 2. Inadequate income and/or spontaneous or

inappropriate spending. 3. Can meet basic needs with subsidy;

appropriate spending. (If the client is receiving income supports like SSI, but still lacks enough income to meet all basic expenses, use a 3 rating)

4. Can meet basic needs and manage debt without assistance. (If the client is receiving income supports like SSI, and is able to balance their budget use 4)

5. Income is sufficient, well managed; has discretionary income and is able to save.

Self-Determination and Skills - Income

Does the client have income?

No

Can client meet basic needs without assistance?

Is the income adequate to at least meet basic needs?

#1

Does client have discretionary income and can save?

No

No

No

#2

#3

#4

#5

4. Food and Nutrition 1. No food or means to prepare it. Relies to a

significant degree on other sources of free or low-cost food.

2. Household is on food stamps (limited to meet all food needs)

3. Can meet basic food needs but requires occasional assistance (includes lives at a site with food

service) 4. Can meet basic food needs without assistance

5. Can choose to purchase any food household desires

Self-Determination and Skills - Food

Does the client have food and means to prepare it?

No

Can the client meet basic food needs without any assistance? (

Can the client meet basic food needs without food stamps/food banks?

#1

Can client satisfy any food need?

No

No

No

#2

#3

#4

#5

Food Domain: Food Stamp Use• If the person is using food stamps to meet

all or most of their food needs, score at 2.• If the person is just using a small amount

of food stamps as a supplement, but otherwise meets most of their food needs through their own income, score at 3.

• If the person is not receiving food stamps and can afford to buy food, score at 4.

5. Childcare

1. Needs childcare, but none is available/accessible and/or child is not eligible

2. Childcare is unreliable or unaffordable; inadequate supervision is a problem for childcare that is

available 3. Affordable subsidized childcare is available but

limited 4. Reliable, affordable childcare is available; no need

for subsidies

5. Able to select quality childcare of choice

(skip if no age appropriate children)

Self-Determination and Skills - Childcare

Does the client have access to some form of child care?

No

Is the child care unsubsidized?

Does the client have access to reliable or affordable child care?

#1

Can client select any type of child care?

No

No

No

#2

#3

#4

#5

6. Children’s Education

1. One or more eligible children not enrolled in school 2. One or more eligible children enrolled in school but

not attending classes

3. Enrolled in school, but one or more children only occasionally attending classes

4. Enrolled in school and attending classes most of the time

5. All eligible children enrolled and attending on a regular basis and making progress.

(Kindergarten through high school)

Skip if no school age children

Self-Determination and Skills – Children’s Education

Is one or more eligible children enrolled in school?

No

Is one or more children attending classes most of the time?

Is one or more children attending classes?

#1

Are all children attending class regularly & making progress?

No

No

No

#2

#3

#4

#5

7. Adult Education

1. Literacy problems and/or no high school diploma/GED are serious barriers to

employment 2. Enrolled in literacy and/or GED program and/or has sufficient command of English to where

language is not a barrier to employment 3. Has high school diploma/GED 4. Needs additional education/training to improve

employment situation and/or to resolve literacy problems to where they are able to function effectively in society

5. Has completed education/training needed to become employable. No literacy problems

Self-Determination and Skills – Adult Education

Does the client have a high school diploma or GED?

No

#1

#2

Is literacy a serious barrier to employment?

Does the client have the education/literacy skills to function effectively in society?

No #3

Has the client completed education/training needed to become employable?

No #4

#5

Yes

8. Health Care (coverage)

1. No medical coverage with immediate need

2. No medical coverage and great difficulty accessing medical care when needed. Some household

members may be in poor health

3. Some members (e.g. children or disabled) but not all household members have coverage

4. All members can get medical care when needed but may strain budget

5. All members are covered by affordable, adequate health insurance

Self-Determination and Skills – Health Care

Does the client have medical coverage?

No

Does the client or some household members have health care coverage

Is the health insurance affordable?

Yes

No

#3

#4

#5

#1

#2

Does the client or household member have an immediate health care need?

Yes

9. Life Skills

1. Unable to meet basic needs such as hygiene, food, activities of daily living

2. Can meet a few but not all needs of daily living without assistance

3. Can meet most but not all daily living needs without assistance

4. Able to meet all basic needs of daily living without assistance

5. Able to provide beyond basic needs of daily living for self and family

(use most frequent rating for various skill areas described in the next slide).

Skill areas to consider in developing a rating. Select most frequent rating from the list below and apply to the overall Life Skills Rating.

• Hygiene• Food Preparation• Time Management• Maintain living space• Money Management• Basic

Communication including responses to authority

• Anger Management

1 = In Crisis

2 = Vulnerable

3 = Safe

4 = Building Capacity

5 = Empowered

Life Skills Examples• A man doesn’t know how to cook, but has a partner

who does all of the cooking. Even though he may earn a “1”, this is not a crisis situation overall. All other ratings reflect good knowledge. The case manager decides the overall rating is “4” with a need for him to improve in this area.

• A person has good ratings in all areas but money management. However, the degree of crisis generated from that single issue has resulted in homelessness. The person is anxious to improve and most issues can be addressed with training. The case manager wishes to recognize both the significant deficit and the desire to change and gives a “3” rating.

Self-Determination and Skills – Life Skills

Can client meet some basic living needs without assistance?

No

Can client meet all basic living needs without assistance?

Can client meet most basic living needs without assistance?

#1

Is client able to provide beyond basic living needs to self (and family)?

No

No

No

#2

#3

#4

#5

10. Family/Social Relations 1. Lack of necessary support from family or friends;

abuse (DV, child) is present or there is child neglect 2. Family/friends may be supportive but lack ability or

resources to help; family members do not relate well with one another; potential for abuse or neglect

3. Some support from family/friends; family members acknowledge and seek to change negative

behaviors; are learning to communicate and support 4. Strong support from family or friends; household

members support each other's efforts 5. Has healthy/expanding support network;

household is stable and communication is consistently open

Self-Determination and Skills – Family Relations

Does client have support from family or friends?

No

Does client have strong support from family/friends and do family/friends support one another?

Do family/friends relate well and are active in changing negative behaviors?

#1

Is the support network expanding?

No

No

No

#2

#3

#4

#5

11. Transportation / Mobility 1. No access to transportation, public or private; may

have car that is inoperable 2. Transportation is available (including bus) but

unreliable, unpredictable, unaffordable; may have car but no insurance, license, etc

3. Transportation is available (including bus) and reliable but limited and/or inconvenient; drivers are licensed and minimally insured

4. Transportation (including bus) is generally accessible to meet basic travel needs

5. Transportation is readily available and affordable; car is adequately insured

Self-Determination and Skills – Transportation / Mobility

Does client have access to transportation?

No

Is the transportation generally accessible and/or convenient?

Is the transportation is reliable?

#1

Is the transportation affordable?

No

No

No

#2

#3

#4

#5

12. Community Involvement

1. Not applicable due to crisis situation; in "survival" mode

2. Socially isolated and/or no social skills and/or lacks motivation to become involved

3. Lacks knowledge of ways to become involved or new to community.

4. Some community involvement (church, advisory group, support group) but has barriers such

as transportation, childcare issues

5. Actively involved in community (church, etc.)

Self-Determination and Skills – Community Involvement

In the client in crisis mode?

No

Is the client involved at some level?

Does client have the skills, motivation and knowledge to become involved?

#1

Is the client actively involved?

No

No

#2

#3

#4

#5

No

Community Involvement• Question: What if someone has the ability or

knowledge, but has no interest or may be better off not to be around people?

• Answer: The person should still be scored on the domain, even if they are choosing not to be socially involved; however, also take into account a person’s personality and ability when assessing what might be considered ‘community involvement’ for them.

13. Parenting Skills (for participants who are actively parenting)

1. Parenting skill are lacking and there is no extended family support.

2. Parenting skills are minimal and there is limited extended family support.

3. Parenting skills apparent but not adequate

4. Parenting skills are adequate

5. Parenting skills are well developed

Self-Determination and Skills – Parenting SkillsFamily is in crisis mode?

No

Safety minimally adequate.

Family is vulnerable and needs support.

#1

Environment appears safe?

No

No

#2

#3

#4

#5

No

14. Legal 1. Current outstanding tickets or warrants or other

serious unresolved legal issues. 2. Current charges/trial pending; noncompliance with

probation /parole / legal issues impacting housing qualifications.

3. Fully compliant with probation/parole terms/ past non-violent felony convictions/ working on plan to resolve other legal issues.

4. Has successfully completed probation/parole within past 12 months; no new charges filed; recently resolved other legal issues.

5. No active legal issues in more than 12 months and/or no felony/significant legal/criminal history.

Types of legal issues impacting participant.

If multiple issues calculate averaged rating or best fit.

• Civil Judgments• Bankruptcy • Family Law

Divorce/Custody/Child Support

• Sex Offender Status• Drug Charges• Violent Crimes

1 = In Crisis

2 = Vulnerable

3 = Safe

4 = Building Capacity

5 = Empowered

Decision Tree for Criminal ChargesThe client has unresolved legal issues in the past 12 months?

Yes

Client has litigation pending?

Client been on parole/probation in court in the past 12 months?

#1

Is client compliant with parole/probation?

No

Yes

#2

#3

#4#5

Yes

Yes Does client have outstanding tickets or warrants?

No

Legal Domain FAQ How to score criminal history for sex offender

or other felonies that stay on a person’s record forever and impact housing access?

• If a person is currently in housing, score at 3 (safe, compliant, but limited in choice).

• If a person loses their housing or are trying to access housing, the rating would be a 1 or 2 depending on their situation.

15. Mental Health 1. Danger to self or others; recurring suicidal ideation;

experiencing severe difficulty in day-to-day life due to psychological problems

2. Recurrent mental health symptoms that may affect behavior but not a danger to self/others; persistent problems with

functioning due to mental health symptoms

3. Mild symptoms may be present but are transient; only moderate difficulty in functioning due to mental health problems

4. Minimal symptoms that are expectable responses to life stressors; only slight impairment in functioning

5. Symptoms are absent or rare; good or superior functioning in wide range of activities; no more than every day

problems or concerns

Self-Determination and Skills – Mental Health

Does client have mild or no mental health symptoms?

No

Do the symptoms impair functioning only slightly?

Are the symptoms rare and does the client have good/superior functioning?

No

No

#2

#3

#4

#5

Is the client a danger to self or others?

Yes #1

Mental Health FAQ

Timeframe of measure- is it today or the last 6 months?» It is how the person is currently doing at the

time of the assessment. If they fluctuate quite a bit over time, consider how they have been doing for the last month for an overall rating. If they are between two scores, chose the lower one.

16. Substance Abuse 1. Meets criteria for severe abuse/dependence; resulting problems

so severe that institutional living or hospitalization may be necessary

2. Meets criteria for dependence; preoccupation with use and/or obtaining drugs/alcohol; withdrawal or withdrawal

avoidance behaviors evident; use results in avoidance or neglect of essential life activities

3. Use within last 6 months; evidence of persistent or recurrent social, occupational, emotional or physical problems

related to use (such as disruptive behavior or housing problems); problems that have persisted for at least one month

4. Client has used during last 6 months (including social use) but no evidence of persistent or recurrent social,

occupational, emotional, or physical problems related to use; no evidence of recurrent dangerous use

5. No drug/alcohol abuse in last 6 months

Self-Determination and Skills – Substance Abuse

Is the client seriously dependent on drugs or alcohol?

Yes

Does client show evidence of recurrent social, emotional, or physical problems associated with drug or alcohol use?

Client is free from substance abuse problems during past 6 months

Yes

No

#2

#3

#4

#5

Does client require hospitalization or institutional living?

Yes #1

Some episodic issues?

17. Safety

1. Home/residence is not safe, lethality is high, possible CPS involvement.

2. Safety is threatened, temporary protection is available, lethality is high.

3. Safety is minimally adequate, safety planning is essential

4. Home is safe, however future is uncertain, safety planning is important.

5. Home is apparently safe and stable.

Self-Determination and Skills – SafetyIn the client in crisis mode?

No

Safety minimally adequate.

Threat is high/protection available?

#1

Environment appears safe?

No

No

#2

#3

#4

#5

No

Disability Domain

• Includes any type of disabling condition (physical health, physical disability, emotional, cognitive, mental health, etc.) that impacts the person’s ability to access or maintain housing, employment and social interactions.

18. Disability 1. Acute or chronic symptoms affecting

housing, employment, social interactions. 2. Periodically has acute symptoms affecting

housing, employment, etc. 3. Rarely has acute symptoms affecting

housing, social interactions, etc. 4. Asymptomatic – condition controlled by

services or medication5. No identified disability

Self-Determination and Skills – DisabilitiesDoes client have few or mild symptoms?

No

Do the symptoms impair functioning only slightly?

Is the client without any identified disability?

No

No

#2

#3

#4

#5

Are symptoms chronic and constant?

Yes #1

Periodic symptoms

Rare symptoms

Controlled symptoms

Scoring Key

1. In crisis

2. Vulnerable

3. Safe

4. Building Capacity

5. Empowered

If struggling to determine how to score a participant on any domain, refer to the scoring key descriptor:

Collecting Good Quality Data

Effective Services and Data Quality

The ability to address the needs of people experiencing homelessness depends largely on the quality of information collected at intake.

» Plan services» Make appropriate referrals» Educate stakeholders» Secure funding to address service needs

Next steps at your agency:1. Determine who will conduct the assessment

with which participants and how.2. Determine when initial assessments will

take place for new participants– e.g., 3rd week of care.

3. Determine how and when back dated assessments will be completed – for LTH clients who entered prior to 7/1/11.

4. Determine timeline for follow up assessments for current participants

5. Develop internal record keeping practices for tracking assessment dates

Next steps at your agency:6. Determine who will enter data into HMIS.7. Run and review the reports prior to the due

date.8. Investigate and correct entry problems. 9. Report any questions/concerns to state

staff.10.Schedule check-in meetings with your

organization staff to discuss issues and consistent scoring.

11.Management staff should be involved in the matrix assessment practices and reporting.

Matrix Data Entry and Reporting in HMIS

Minnesota Matrix Reports

ART Reports• Individual Participant

» Client Progress (1P) and Client Achievement (2P)

• Program Summary» Domains at Population Entry (3S) and Exit

(4S)» Progress Summary (1-2S)

• Data Checking

Snapshot of Provider Progress Reports

# of clients / average # of days in program

Initial assessmost recent

assesschange % +/-

Clients: 8 / Days 263 2.83 2.92 0.07 2%

Clients: 10 / Days 324 2.65 2.97 0.32 12%

Clients: 11 / Days 517 3.08 3.62 0.50 16%

Clients: 4 / Days 1006 2.81 3.33 0.50 18%

Clients: 50 / Days 521 2.66 3.16 0.50 19%

Clients: 11 / Days 462 2.69 3.28 0.59 22%

Clients: 11 / Days 396 2.69 3.30 0.60 22%

Clients: 7 / Days 498 2.87 3.52 0.66 23%

Clients: 25 / Days 1033 2.19 2.89 0.57 26%

Clients: 38 / Days 722 2.41 2.79 0.73 30%

Clients: 12 / Days 450 2.59 3.38 0.79 31%

Clients: 92 / Days 689 1.69 3.17 1.29 76%

Clients: 6 / Days 1183 1.57 3.84 2.28 145%

Thank you! Questions?

Please contact the appropriate state staff.

LTH Programs