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A New and Unique Resource Opportunity

Cross Sector Case Conferencing (CSCC)

*New* Case Management Tool for Homeless Service Providers

Provides shared knowledge and bridges resource connections for homeless service providers to support participants in accessing the healthcare and related services needed to improve housing stability and quality of life.

*Note: Are you a provider looking for CSCC forms? Please scroll to the bottom of this page under Case Management Tools to access them.*

"Connecting people experiencing homelessness with healthcare they need."

What Is Cross Sector Case Conferencing?

  • Opportunity for Homeless Service Providers to receive support with identifying resources for participants with unmet health care needs
  • Facilitates the ability for Homeless Services Providers to case conference with healthcare and social service systems at one table
  • Simplify navigation of multiple systems and enable real time health navigation, care coordination and wraparound support

Scope 

  • *Open to any homeless service provider in the homeless services continuum within Multnomah County including Youth, Family and Adult systems, Permanent Supportive Housing, Rapid Rehousing, Shelter, Outreach, CoC Programs, RLRA etc.)
  • *New* open to City of Portland and Multnomah County departments (ADVSD, IDD, BHD) who provide homeless services/outreach
  • People aged 55+ are prioritized; clients of all ages can be referred
  • Please note that no housing resources will be discussed/offered in this space*

Requirements

  1. Signed Release of Information and discussion with identified participant for consent to process (ROIs Provided in Case Management Tools link below) and ability to upload into HMIS (Homeless Management Information Software) with Homeless Services Department Contracted Providers in HMIS
  2. Submit Referral Form

How often is CSCC Available

Case Conferencing Sessions:

  • Every 2nd and 4th Wednesday
  • 11:00 am to 12:30 pm
  • Virtual Google Meeting Atmosphere

Resources to Connect Participants and Front Line Staff to:

  • Referral to Primary Care Doctor/Physical Health (who is my doctor? Eyes, ears, memory)
  • Durable Medical Equipment/Mobility Tools (wheelchair replacements, mobile scooters, etc)
  • Dental Health
  • Medication Access (what pharmacy)
  • Substance Use support (peer supports, recovery options, medication assistance, harm reduction)
  • Mental Health/Behavorial Connection Support/Appointments
  • Aging, Disability, Veterans Services Review/Pathways
  • Chronic Disease or Surgery Supports
  • Supports for Daily Living Activities (bathing, toileting, grooming, etc)
  • Home Health Care
  • Medical Transportation 
  • Wound Care
  • Dementia/Higher Levels of care pathways
  • Intellectual and Developmental Disabilities Review/Pathways

Health Care Coordination Services

  • Primary care providers
  • Mental health providers
  • Specialists
  • Pharmacy
  • Social Services (through health plans)
  • Develop and implement personalized care plans 
  • Ensures participants are optimizing health plans and care and receiving tailored solutions

Partners Who Come to the Table

Questions? 

Contact:

Jenny Greenberg, HSD Coordinated Access: Health and Housing Program Specialist Sr: Jenny.Greenberg@multco.us

Adam Peterson, Health Share Portfolio Manager Health Care and Homeless Services Integration: PetersonA@healthshareoregon.org

Consulting Group: Community Solutions

Case Management Tools for CSCC

Optional Documents:

Steps in the process:
  1. Homeless or housing service providers meet with the participant to discuss Cross- Sector Case Conferencing (CSCC), goals for engaging in the process, and collects the required Release of Information (ROI) from participant.   Note* Referrals can be submitted before ROI is collected, but household cannot be discussed at a CSCC session without the ROI in place and uploaded into HMIS.*
  2. Submit referral Form
  3. Homeless Services Department CSCC Coordinator, Jenny, reaches out to schedule a meeting within 3 business days to discuss the referral and next steps.
  4. Staff member(s) who submitted the referral attend a CSCC Session to discuss the participant’s goals and needs and get support from our cross-sector partners.
We ask that staff members who submit the referral be available and present for any meetings with Homeless Service Department staff and be part of the Case Conferencing Session, and provide follow up support with connecting participants to resources offered in the space.
Quick Notes about the ROIs:
  • There are 2 ROIs  (Releases of Information/Consent).
  • However, only the General ROI is legally required
  • The ROI will need to be uploaded into HMIS
  • The 42CFR ROI is (optional). The 42CFR is regarding any substance use if the participant would like assistance regarding recovery or harm reduction options, etc
Questions?  Contact: Jenny.Greenberg@multco.us for assistance

Feedback from Case Managers/Providers who have submitted referrals

  • “Cross Sector Case Conferencing was incredibly helpful. It provided an opportunity to bring more service providers to the table at once to create a web of support that-even if I could have figured it all out on my own- would have otherwise taken a very long time.”
  • “This is a wonderful resource that I have personally used to help better serve my program participants.”
  • “Cross Sector Case Conferencing was surprisingly helpful, guiding and encouraging”
  • “What you are doing is vital, in getting care providing solutions to those who are most vulnerable “
  • ” All these resources give us a great guideline for continuing this process with the Pt. Our team has had nothing but positive experiences with CSCC; we definitely feel supported and welcomed to the space, and we look forward to the continued collaboration between our orgs.”

CSCC Pilot Across Tri-Counties

Pilot History, Goals, HRAP, and Expansion 🚀

Cross Sector Case Conferencing, in its pilot phase in Multnomah County, has focused on serving aging households enrolled in Permanent Supportive Housing programs but is in the process of expanding to serve people in shelter, street outreach, rapid rehousing and other homeless services.

Health Share is also working collaboratively with the County to scale the ability for systems to share information between Cross Sector Case Conferencing sessions, enabling client support to continue outside of and between CSCC sessions, as well as evaluating positive outcomes for individual clients and the effectiveness of the pilot program as a whole. Clackamas and Washington Counties also conduct Cross Sector Case Conferencing, and the three counties meet monthly to share lessons learned and plan for adjustments to the process of Cross Sector Case Conferencing with the goal of improving the pilot’s efficacy in meeting client needs and addressing system barriers to meeting those needs

The goal of Cross Sector Case Conferencing is to create better outcomes for those experiencing homelessness in the following ways:

  • Address unmet health needs to allow for people to move from homelessness to housing faster, with fewer barriers
  • Reduce inappropriate emergency room utilization. Early data has revealed that clients who have participated in CSCC use emergency rooms and lower rates. Early data also shows an increase in primary care utiliziation amongst clients who have participated in CSCC. 
  • Change the way that healthcare and homeless service providers work together, creating shared accountability across systems for member outcomes.
  • Build the knowledge and connections of homeless service providers to support their participants in accessing the healthcare and related services needed to improve housing stability and quality of life.