A New Triage Tool Comes to Thurston County!

Here comes The HEAT! 

CHALLENGE
In Thurston County, we follow national best practices of vulnerability-based placement for the precious housing and shelter resources in our community. While we wish beyond our wildest dreams that there was an abundance of shelter beds and affordable apartments for everyone who needed them, we have a continuing lack of options for people and solutions are not keeping pace with the increased costs of housing and income that has remain stagnated or decreased for so many during the pandemic.

PRIORITIZING VULNERABILITY
Since there are so many more people that need resources than there are resources available, we utilize a triage system to prioritize those at the highest risk of death, injury, violence, and exploitation out on the streets. Those prioritized by this system are generally a combination of people who have been experiencing homelessness for a very long time, are living with serious medical fragility, permanent disability, chronic illness, and serious, persistent challenges related to their mental and substance use-related health. Think of it as an Emergency Room -- someone with a heart attack will be seen before someone with a broken leg. Both are serious and deserve attention, time and care, but the resources need to be prioritized for the person with the highest risk of death. In Thurston County, we have used a prioritization tool called the VI-SPDAT or Vulnerability Index – Service Prioritization Decision Assistance Tool since 2014.

After utilizing the VI-SPDAT for three years and using it with so many more people than the original pilot pool (130 people in 2014 for placement into 30 low-barrier shelter beds), it became clear that predominantly white; cisgender males were scoring the highest on the vulnerability index. This created an imbalance in how precious permanent housing and shelter resources were being allocated, and further exposed the large racial disparity in the Thurston County Homeless response system. Nearly 40% of people entering the  system are Black, Indigenous and all People of Color, while the people exiting to shelter and housing at the highest rates are predominately white.

SOLUTION
A group of front-line homeless service providers in Thurston County began a thorough study and revision of the VI-SPDAT assessment tool in 2017 because, after three years of using the tool, these providers consistently saw disparities in housing prioritization. It was evident that predominantly white, cisgender males were scoring the highest on the vulnerability index, which was incongruent with the vulnerability front line workers saw with their own eyes. Thurston County was not the only community to see these disparities; homeless response systems across the US were reporting similar trends.

In 2019, the VI Racial Equity Team aligned their practice in response to the “Coordinated Entry Systems Racial Equity Analysis of Assessment Data” study published by C4 Innovations. The C4 Innovations study examined the following questions:

1. According to CES (Coordinated Entry System) assessment data, are White people more likely to be prioritized for permanent housing compared to BIPOC?
2. Which subscales of the VI-SPDAT predict vulnerability, and thus housing needs, across racial groups? Are there methods or proxy variables that can be transformed to result in more equitable prioritization? (Wilkey)

​The results of the C4 Innovation study showed:

1. On average, BIPOC clients receive statistically significantly lower prioritization scores on the VI-SPDAT than their White counterparts;
2. According to VI-SPDAT data, White individuals are prioritized for Permanent Supportive Housing (PSH) intervention at a higher rate than BIPOC individuals, though this is not true for families;
3. Race is a predictor of receiving a high score (i.e., an assessment for Permanent Supportive Housing/ Housing First), where being white was a protective factor for single adults;
4. VI-SPDAT subscales do not equitably capture vulnerabilities for BIPOC compared to Whites: race is a predictor of 11/16 subscales, and most subscales are tilted towards capturing vulnerabilities that Whites are more likely to endorse. (Wilkey)

To holistically reduce disparities in housing prioritization, the VI Research Team in Thurston County began discussing and evaluating whether certain assessment questions disproportionately impacted higher scoring, giving a predictable advantage to white people. In line with the recommendations from the C4 Innovation study, the VI Research Team worked to incorporate the following vulnerabilities into the new tool: “prior child welfare involvement and foster care history, criminal justice and juvenile justice involvement, history of trauma and adverse childhood experiences, and eviction histories.” (Wilkey) With this information in mind, and a wealth of lived and professional experience, the Thurston County group developed a new assessment tool (The Housing Equity Assessment Tool - HEAT). The tool, authored primarily by Interfaith Works staff, includes a core vulnerability and risk assessment along with four supplemental surveys. These supplemental surveys are triggered upon answers to specific questions. The four supplemental surveys include BIPOC, GNC LGBQ+, Substance Use, and Families. The HEAT was tested on a small but dynamic sample size group and was found to more accurately capture an individual's vulnerability than the VI-SPDAT. The HEAT generates a score of up to 100 for single adults and 106 for families with dependent children, and then people are triaged for shelter and housing resources based on their scores. 

As of March 1st, the Thurston County Coordinated Entry system officially implemented the Housing Equity Assessment Tool (HEAT) and is in the process of converting previous VI-SPDAT scores to the new index. This is a big step forward for equity in our community and we are hopeful to see improvements on a system wide scale that will create more access for the most marginalized people in Thurston County in need of shelter and permanent housing resources. We have a ton of talent and dedication in Thurston County and we are super excited about the work that is emerging!