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We are our neighbors' keeper: an innovative field kit of outreach and assessment tools to help end homelessness

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We are our neighbors' keeper: an innovative field kit of outreach and assessment tools to help end homelessness

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Content Running head: WE ARE OUR NEIGHBORS’ KEEPER 1

We Are Our Neighbors’ Keeper:

An Innovative Field Kit of Outreach and Assessment Tools to Help End Homelessness

Keren Lowenstein, LCSW, MPA
Doctor of Social Work
University of Southern California
December 18, 2019

WE ARE OUR NEIGHBORS KEEPER 2

Dedication

To my father, Ronald William Sheddrick (06/06/1940 to 10/26/19)

Throughout this doctoral process you offered emotional and financial support without
question or complaint. Your military service and veteran status was my inspiration for entering
the social work field in the first place. As a child, I remember when our small town experienced
an influx of unhoused Vietnam veterans. I also remember feeling hopeless and helpless about
the situation as I watched those men rummage through dumpsters. When I entered the MSW
program at UMKC, I thought I could help others by working in a clinical setting with unhoused
veterans. Instead, I discovered I could offer hope by working in a public policy setting
monitoring and advocating for legislation to increase monies in the Missouri Housing Trust
Fund. Your enthusiasm for model trains and railways was my inspiration for developing the
Stage of Change Outreach and Utilization Tool (SCOUT). As a teenager, I remember how you
transformed the garage into a scale model of a railroad system. I also remember feeling awed as
I witnessed your attention to detail and ability to design an electronic control panel to power the
model. As I approach the end of the DSW program, I am saddened to know that I will celebrate
this milestone achievement without you. Your work ethic has shaped my work ethic. Your
cleverness and inventiveness have informed my ingenuity and creativity. Your humility,
veracity, and authenticity will live on in your family and the countless neighbors with whom you
worked and laughed with over the years. I miss you dearly, Dad, and dedicate my Capstone
project to you.

WE ARE OUR NEIGHBORS KEEPER 3

Acknowledgements

To Dr. Diandra Bremond, Phillip Browning, Irv Katz, Dr. Paul Maiden, Dr. Ron
Manderscheid, Dr. George Orras, Dr. Michael Rank, Dr. Marvin Southard, Stephanie Wander,
Jim Wind, and Col. Jeffrey Yarvis. Thank you for leadership and guidance. Your lectures have
made an impact on my life and my education. I am proud to say that I learned from the best!
To the class of 2019 doctoral students and my Cohort 5 Tribe. Thank you for your
support and camaraderie. The late-night texts, Facebook posts, phone calls, and flowers were
much appreciated. Your friendship means a lot to me.
To my mother, brother, and in-laws. Thank you, Mom for your emotional and financial
support. Thank you, Kevin for your usually inappropriate sense of humor. Thank you, Steve,
Crystal, Patty, Linda, Corey, and Marcus for your emotional support.
To my partner and best friend. Thank you, Kathi for taking care of the kids while I have
been immersed in this doctoral journey. Thank you, Carl for your pep talks, especially during
tough times.

WE ARE OUR NEIGHBORS KEEPER 4

List of Figures

Figure 1.0: Individual and Contextual Limits that Negatively Impact Social Need 12

Figure 2.0: Lowenstein’s Stages of Support Conceptualization 27

Figure 3.0: SCOUT 120

Figure 3.1: SCOUT Top Panel 121

Figure 3.2: SCOUT Rear Panel 123

Figure 3.3: SCOUT Side Panel 123

Figure 4.0: SCOUT v1.0 Conceptualization 130

Figure 4.1: SCOUT v1.0 Prototype in “Off” Position 130

Figure 4.2: SCOUT v1.0 Prototype in “Not Ready” Position 131

Figure 4.3: SCOUT v1.0 Prototype in “Sort of Ready” Position 131

Figure 4.4: SCOUT v1.0 Prototype in “Totally Ready” Position 131

Figure 5.0: SCOUT v1.0 Survey and Algorithm 140

Figure 6.0: SCOUT v1.0 Stage-Matched Service Provision Matrix 141

Figure 7.0: SCOUT v2.0 Conceptualization 143

Figure 7.1: SCOUT v2.0 Prototype Top Panel 143

Figure 7.2: SCOUT v2.0 Prototype Rear Panel 143

Figure 7.3: SCOUT v2.0 Prototype Side Panel 144

Figure 8.0: SCOUT v2.0 Survey and Algorithm 144

Figure 9.0: SCOUT v2.0 Stage-Matched Service Provision Matrix 150

WE ARE OUR NEIGHBORS KEEPER 5

Table of Contents

Dedication 2
Acknowledgements 3
List of Figures 4
Table of Contents 5

Executive Summary 7
Introduction 9
Conceptual Framework 9
Problem Statement 9
Literature and Practice Review 11
Social Significance 18
Logic Model and Theory of Change 19
Problems of Practice and Innovative Solutions 22
Proposed Innovation and Its Effect on the Grand Challenge 23
View of Key Stakeholders 27
Evidence and Current Context for Proposed Innovation 29
Comparative Opportunities for Innovation Analysis 30
Proposed Innovation Linkages to Logic Model and Theory of Change 31
Likelihood of Success 31
Project Structure, Methodology, and Action Components 32
Capstone Artifact 33
Comparative Market Analysis 33
Capstone Implementation Methods 34
WE ARE OUR NEIGHBORS KEEPER 6

Financial Plans and Staging 38
Capstone Impact Assessment Methods 38
Stakeholder Engagement Plan 40
Communications Strategies and Products 40
Capstone Project and the Social Problem 46
Ethical Considerations 47
Conclusions, Actions, and Implications 48
References 51
Capstone Appendices 83
Capstone Appendix A: Theory of Change 83
Capstone Appendix B: Logic Model 84
Capstone Appendix C: Comparison of Stage Models and Lowenstein’s 86
Stages of Support
Capstone Appendix D: Capstone Prototype 87
Capstone Appendix E: Implementation Plan 150
Capstone Appendix F: Gantt Chart 151
Capstone Appendix G: Financial Plan 152

WE ARE OUR NEIGHBORS KEEPER 7

Executive Summary

Our unhoused neighbors are aging too early and dying too soon. Homelessness is a
wicked problem in America. One and a half million adults (Padget & Henwood, 2018) and 4.2
million children are homeless each year in America (Fadel & Figueroa, 2017). The target
population of study is unhoused neighbors over the age of 50 experiencing homelessness because
more than 50 percent of our unhoused neighbors are over the age of 50 (Brown et al., 2015), and
five percent are over the age of 70 (Nagourney, 2016). The purpose of the Capstone project is to
improve access to needed supports and services and end homelessness. The Capstone project is
a diverse set of standalone and nested innovations designed to help end homelessness by
engaging in specific activities to achieve specific outcomes related to an innovative policy,
program, practice, and product. The social problem this Capstone project is trying to resolve is,
our unhoused neighbors encounter difficulties accessing needed services due to no-door, wrong-
door, and closed-door systems of care. The wicked problem is directly linked to the Grand
Challenge to End Homelessness because other social problems perpetuate homelessness, borrow
from homelessness, and contribute to vicious cycles that intersect them and spread homelessness.
One of the supernorms that holds the wicked problem in place is “treat ‘em and street ‘em”
(Warshaw, 2017). The Capstone project dissolves fragmented systems of care, resolves the issue
of barriers to care, and helps break the cycle of homelessness through a Field Kit of Outreach
and Assessment Tools; which encompasses a new policy, program, practice, and product
designed to disrupt social norms around homelessness service provision. The Capstone
prototype fits state advocacy brief, model protocol, tip sheet, user manual, and quick start guide
formats to address the social problem. The formats are supported by conceptual drawings, user
manuals, gaming components, algorithms in development, and scale examples of prototypes. As
WE ARE OUR NEIGHBORS KEEPER 8

a user manual, the Field Kit of Outreach and Assessment Tools outlines a new practice and
demonstrates proof of concept via the following components: Universal Standards of Street
Outreach Advocacy Brief, Evidence-Based Street Outreach Model Protocol, Evidence-Based
Street Outreach Memorandum of Understanding, Field Kit of Outreach and Assessment Tools
Tip Sheet, and Stage of Change Outreach and Utilization Tool (SCOUT) QuickStart Guide. The
Capstone project aims to change organizational, structural, financial, and sociopolitical
processes; to adapt readiness to change assessments to our unhoused neighbors; stimulate current
thinking about ending homelessness through street outreach and assessment; and disseminate the
innovation from local and state to federal levels. The Capstone project aims to dissolve
fragmented systems of care through community learning and resource sharing. The Capstone
project aims to transform existing policies, programs, practices, and products into new policies,
programs, practices, and products (Christensen, Raynor, & McDonald, 2015). Future action
steps include designing a quality assurance plan, utilizing feedback loops to shape outcomes and
quality improvement, testing SCOUT in the field, manufacturing and licensing SCOUT, and
packaging and selling the Field Kit of Outreach and Assessment Tools. The Capstone project
represents an innovative step forward by introducing a deviant norm to make it the predominant
norm, which has potential implications beyond the local context because it disrupts social norms,
informs public policies, and disseminates the innovation from local and state to federal levels.
The Capstone project is a disruptive innovation because it changes social norms around
homelessness service provision by infusing the field kit with SCOUT, street outreach model, and
universal standards. The Capstone project has clear financial benefits. Our unhoused neighbors
over the age of 50, organizations, communities, and society will be different as a result of the
activities and outcomes of the Capstone project.
WE ARE OUR NEIGHBORS KEEPER 9

We Are Our Neighbors’ Keeper:
An Innovative Field Kit of Outreach and Assessment Tools to Help End Homelessness

Homelessness is a complex, wicked problem that affects and is affected by many other
intricate social problems. This Capstone project paper delineates a comprehensive approach to
ending homelessness by examining the Grand Challenge to End Homelessness (GC2EH) through
the lens of needs assessments, fragmented systems, evidence-based practices (EBPs), moral
injury, bootstrap mentality, and throwaway culture. The paper explores the most prominent
elements of this change management plan, including discussing the conceptual framework,
problems of practice and innovative solutions, and project structure and methodology. The paper
concludes with a summary of project plans, actions, and implications.
Conceptual Framework

The conceptual framework of the Capstone project consists of the purpose, problem
statement, literature and practice review of the problem and solution, social significance of the
innovation, theory of change, logic model, and financial model. The purpose of the Capstone
project is to improve access to needed supports and services and end homelessness.
Problem statement.

Our unhoused neighbors are aging too early and dying too soon. Homelessness is a
wicked problem in America. One and a half million adults (Padget & Henwood, 2018) and 4.2
million children are homeless each year (Fadel & Figueroa, 2017). Homeless or unhoused
describes a neighbor who is living in a space not meant for human occupancy, in an emergency
shelter, in transitional housing, or is leaving an institution where they temporarily stayed; a
neighbor who is losing their main nighttime dwelling; or a neighbor who is escaping or
attempting to escape domestic violence, has no other dwelling, and lacks the resources or support
WE ARE OUR NEIGHBORS KEEPER 10

to secure a permanent dwelling (National Alliance to End Homelessness (NAEH), 2012).
Seventy-one percent of our adult unhoused neighbors are over the age of 24 (U.S. Department of
Housing and Urban Development (HUD), 2018), and nearly 25% are chronically homelessness
(HUD, 2018). Chronically homeless or chronically unhoused describes a neighbor who is
literally homeless, has a disability, and has regular episodes of homelessness or is steadily
homeless for at least one year, and does not have a safe, consistent, and adequate nighttime
dwelling (HUD, 2015). In Missouri, nearly 18,000 neighbors experience homelessness per year
(HUD, 2018). Sixty-four percent of our unhoused neighbors are over the age of 24, and 17
percent are chronically unhoused (NAEH, 2018). In Joplin, nearly 1,500 neighbors experience
homelessness per year (Institute for Community Alliances (ICA), 2018). Eighty-two percent of
our unhoused neighbors are over the age of 24, and 12 percent are chronically unhoused (ICA,
2018). The target population of study is unhoused neighbors over the age of 50 experiencing
homelessness because more than 50 percent of our unhoused neighbors are over the age of 50
(Brown et al., 2016), and five percent are over the age of 70 (Nagourney, 2016). Our chronically
unhoused neighbors over the age of 50 are considered elderly because they live with the health
difficulties of a 70-year-old (Fessler, 2018), including behavioral health and substance use
disorders, dental disease, malnourishment, and infectious and age-related diseases such as
respiratory disorders, diabetes, chronic pain, and heart failure (Centers for Disease Control and
Prevention (CDC), 2017). As a result, our chronically unhoused neighbors face an average life
expectancy of 47 years of age, as compared to 78 years of age for you and I (Brown et al., 2016).
The social problem this Capstone project is trying to resolve is, our unhoused neighbors
encounter difficulties accessing needed services due to no-door, wrong-door, and closed-door
systems of care. No-door, wrong-door, and closed-door systems of care are disjointed,
WE ARE OUR NEIGHBORS KEEPER 11

specialized, and siloed systems that promote preconceived programs and service models believed
to be needed by unhoused neighbors (U. S. Department of Health and Human Services (DHHS),
n.d.). These contextual factors preserve health and behavioral health inequalities; public health,
human rights, and social justice disparities; housing and economic injustices (Piat et al., 2015;
Polcin, 2016; O’Toole, Johnson, Aiello, Kane, & Pape, 2016; Okiwelu & Noutcha, 2016); rivalry
for resources, and a muddled approach to ending homelessness (Padgett & Henwood, 2018).
Literature and practice review.

Research indicates that the parthood and history of homelessness in America dates to the
arrival of settlers who displaced native residents during the 1700s (Moser Jones, 2015). During
the colonial era, unhoused neighbors were noted in urban areas after the Revolutionary War, and
the industrial development of the North lead to the formation of Skid Row neighborhoods
(Moser Jones, 2015). Since that time, America has witnessed increasing numbers of unhoused
neighbors. The Civil War produced a substantial number of unhoused neighbors nationwide, and
the effects of the Great Depression combined with World War I (WWI) and World War II
(WWII) saw an increased need for shelter housing (Moser Jones, 2015). However, it was not
until the Vietnam War that unhoused veterans became a focus of public discourse and,
ultimately, the concept of modern homelessness developed (Moser Jones, 2015). In 1981,
President Reagan repealed the Omnibus Budget Reconciliation Act, which successfully ended
the federal government’s role in providing services to neighbors with significant mental health
concerns and contributed to increases in homelessness across the nation (Moser Jones, 2015).
During the mid-1980s, public outcry against homelessness, in general, became so loud that
President Reagan reluctantly signed the McKinney Act in 1987, which became the first
momentous federal legislative response to homelessness that provides federal money to shelter
WE ARE OUR NEIGHBORS KEEPER 12

programs (Moser Jones, 2015). Actual practice in the topical area tends to focus on the
configuration of individual and contextual limits associated with homelessness. Individual limits
include co-occurring behavioral and physical health disorders, emotional and physical trauma,
childhood violence, isolation, and involvement with law enforcement (Harcourt, 2011; Baker
Collins, 2013; O’Toole, Johnson, Aiello, Kane, & Pape, 2016; Padgett & Henwood, 2018).
Contextual limits include treatment as usual (TAU), the criminalization of homelessness,
transinstitutionalization, and not-in-my- backyard-ism (NIMBYism). TAU involves the use of
shelters and temporary or permanent housing units, drop-in centers, case management services,
talk therapies, substance use or harm reduction programs, and mediation assisted services (Piat et
al., 2015) to treat unhoused neighbors. The criminalization of homelessness encompasses
inequitable practices, programs, and policies that castigate our unhoused neighbors for living in
public spaces (Hecth, 2016). Moreover, the criminalization of homelessness feeds
transinstitutionalization and penalizes our unhouses neighbors for “acts of living” (HUD, 2018)
such as panhandling (Thomassen, 2015); climbing, sitting, or laying on public property (Cohen,
2017); and living or sleeping in cars or public spaces (Lindsay, 2016). Traninstitutionalization is
the practice of placing our unhoused neighbors in jails, prisons, and institutions (Burling, 2018;
Knoll, 2011), which is rooted in deindustrialization and deinstitutionalization.
Deindustrialization feeds homelessness by shifting jobs from the manufacturing sector to
the finance and service sectors, which contributes to socioeconomic inequalities (Hopper, Susser,
& Conover, 1985). Likewise, deinstitutionalization feeds homelessness by displacing neighbors
from specialized housing services to generalized treatment programs (Hopper, Susser, &
Conover, 1985), which contributes to health and well-being disparities. NIMBYism contributes
to a pejorative depiction of homelessness and disagreement among community members to any
WE ARE OUR NEIGHBORS KEEPER 13

proposed service expansion due to self-interests, interdependent politics, and competition for
limited resources (Esaiasson, 2014). TAU, the criminalization of homelessness,
transinstitutionalization, and NIMBYism excludes and isolates neighbors and preserves the
discrimination, stigmatization, and marginalization of our unhoused neighbors. Figure 1.0
presents a graphic of the impact of limits associated with homelessness on social need.
Individual Limits Contextual Limits

Social Need

Figure 1.0. Individual and Organizational Limits that Negatively Impact Social Need.
(Adapted from Ventur, 2012)

The limits are built on social norms that hold the wicked problem in place, which further
isolates our unhoused neighbors and simultaneously spreads social fear, stigmatization, and
marginalization. One of the supernorms that holds the wicked problem in place is “treat ‘em and
street ‘em” (Warshaw, 2017). “Treat ‘em and street ‘em” manifests in the form of no- to low-
quality health care (Warshaw, 2017), which divides the “haves” and “have-nots” (Calvo,
Teasley, Goldbach, McRoy, & Padilla, 2018). The supernorm governs homelessness service
provision and creates barriers to needed programs and services, which contributes to the
development of street-based support networks that offer privacy and a sense of community for
Biological and Psychological
Safety
Belongingness
Esteem
Actualization
Self-
Exclusion
Poverty
Health
Housing
Ineffective Services and Supports
Inequality
Moral Injury
Trust
Access
Physical and Behavioral
Health
Isolation
WE ARE OUR NEIGHBORS KEEPER 14

our unhoused neighbors (Smith, 2014). However, research indicates that 30 percent of our
unhoused neighbors spend their days isolated because they have been separated from the
community (Bissell Centre, 2016). Our unhoused neighbors encounter challenges associated
with living life at the margins of society, including being bullied, called names, harassed,
excluded, ignored, and abused (Bissell Centre, 2016), which dehumanizes our unhoused
neighbors (Sinsky, 2014). The supernorm endorses social stigma, discrimination, rejection, lack
of acceptance, violence, exploitation, abuse (National Coalition to End Homelessness (2017),
increased rates of co-occurring disorders, mortality, imprisonment, and increased rates of social
distrust (Smith, 2014). The social problem and supernorm are associated with a throwaway
society, bootstrap mentality, and moral injury, which compounds future expectations
surrounding how the wicked problem will continue to evolve, leading to psychic damage.
As a result of universal consumerism, we live in a throwaway society (Charlton, 2015).
From digital technology and ballpoint pens to household pets and even human beings, our
culture tends to discard the old, broken, and outdated from our homes, agencies, and
neighborhoods. At times, the monetary costs of repairing everyday items or attending to the
health of others surpass the social costs, which is one reason why scrapheaps, nursing homes,
humane societies, penitentiaries, and homeless shelters are full (Gorelick, 2017). In our
throwaway culture, neighbors are deemed a commodity that can be used up and thrown away
(Tasnadi, Alexandru, Ustinescu, & Bradu (2018). Moreover, our throwaway society devalues
and is disinterested in our vulnerable neighbors who “have entered in the category of excluded”
(Tasnadi, Alexandru, Ustinescu, & Bradu, 2018, p. 103). More importantly, our unhoused
neighbors are one of society’s most vulnerable populations because they lack basic, fundamental
WE ARE OUR NEIGHBORS KEEPER 15

needs, such as access to quality care and human interactions (Sinsky, 2014); which contributes to
noteworthy morally harmful events and compounds the cycle of isolation (Bissell Centre, 2016).
Due in part to the American Dream, the bootstrap mentality is an emblematic ideal that
encourages neighbors to pull themselves up the axiomatic socioeconomic ladder without any
assistance through hard work, tenacity, and accountability (Calvo, Teasley, Goldbach, McRoy, &
Padilla, 2018; Rooks, 2012). The bootstrap mentality criticizes neighbors when they are unable
to rise from scarcity and hardship or when they can with assistance from others (Calvo, Teasley,
Goldbach, McRoy, & Padilla, 2018; Rooks, 2012). Moral injury is a deep and lasting adversity
that intrudes upon neighbors’ moral standards over the lifespan (Maugen & Litz, 2015). Moral
injury happens when conditions and communications interfere with personal dignity, worth, and
choice (Alford, 2016), including not having a decision about where to eat, sleep, or use the
restroom (Hecht, 2016) or being disparaged, villainized, or ostracized for one’s unhoused status
(Murray, 2018). Moral injury ensues when our unhoused neighbors experience betrayal, blame,
and anger and leads to shattered trust and psychosocial suffering (Sherman, 2015).
Other future expectations surrounding how the wicked problem will resolve is grounded
in innovations in the topical area, such as building affordable housing units in India and Pakistan,
utilizing vacant housing in the Philippines, merging homelessness programs in New York City
(NYC), opening more shelters and hiring more outreach workers in Los Angeles, utilizing the
Veterans Administration’s (VA) functional zero metric, and adopting Pathway’s Housing First
(HF) model. Globally, nearly 100 million neighbors experience homelessness per year
(Homeless World Cup Foundation (HWCF, 2018). In India, 78 million neighbors are
homelessness per year (HWCF, 2018). By constructing more affordable housing units, the
Union Government of India is combating homelessness in low-income parts of the country (India
WE ARE OUR NEIGHBORS KEEPER 16

Today, 2016). In Pakistan, more than 20 million neighbors are homeless per year (HWCF,
2018). By building more affordable apartments, the Pakistani government is combating
homelessness (Daily Pakistan Global, 2016). In Manila, Philippines, more than three million
neighbors experience homelessness annually (HWCF, 2018). By relocating unhoused neighbors
into vacant housing units, the Philippines is working to end homelessness (Chandran, 2018).
In NYC, more than 75,000 neighbors are homeless on any given night (HUD, 2017). By
merging cash assistance programs with shelter systems, opening quality shelters, and building
more affordable housing units, NYC is combating homelessness through such coordinated
programs as General Educational Development (GED) courses, vocational training curricula,
childcare services, and asset development programs (Jacobs, 2018; Quinn, 2016). In Los
Angeles, California, more than 55,000 neighbors are homeless on any given night (HUD, 2017).
By implementing the functional zero metric that compares the number of unhoused veterans
against the number of available homelessness services during a specific period in time, usually
30 days, securing funding from Measure H and Proposition HHH, opening more shelters, and
hiring street outreach workers, Los Angeles is working to end homelessness (Smith & Smith,
2018). Nationally, approximately 25 percent of our unhoused neighbors are veterans (HUD,
2018). The VA has been successful in ending veteran homelessness through needed services,
including street outreach, affordable housing, behavioral and medical care services, and a
functional zero metric (Ventur, 2012; VA, 2009). The functional zero metric is a social approach
to ending homelessness through broad-minded policies, programs, and practices (Ventur, 2012).
Many cities across the nation have adopted the VA’s plan to end veteran homelessness, including
78 communities and three states (Connecticut, Delaware, and Virginia) have successfully ended
veteran homelessness (Ventur, 2012; VA, 2019). Pathway’s HF utilizes a harm reduction
WE ARE OUR NEIGHBORS KEEPER 17

approach to housing that focuses on housing as a fundamental right (Schaffer, 2004); neighbor
choice in housing and service provision, and access to needed services (Kirst, Zerger, Misir,
Hwang, & Stergiopoulous, 2015). HF is an evidence-based approach to ending homelessness
through research-based policies, programs, and practices (U.S. Interagency Council on
Homelessness, 2016). Many organizations and communities across the nation have adopted the
HF approach to end homelessness (U.S. Interagency Council on Homelessness, 2016)
The above-stated limits and futures inform the design criteria of the Capstone project and
identify opportunities for implementation and diffusion (Solomon, 2016; Gabriel-Petit, 2016).
Moreover, based on gaps in the literature, a Field Kit of Outreach and Assessment Tools that can
be adapted to various circumstances, geographic sites, or segments of our unhoused population
does not yet exist. While many standards of street outreach are based on funding stream
requirements, such as engagement, case management, physical and behavioral health services,
transportation, and emergency shelter (Pasadena Partnership to End Homelessness, 2016;
EscaRosa Coalition on the Homeless, 2016; Cornell Law School, n.d.), Universal Standards of
Street Outreach that are more focused on guiding principles of outreaching vulnerable neighbors
does not yet exist. While many versions of street outreach currently exist, such as food outreach,
shower and hygiene, medical outreach, and ministry outreach (Olivet, Elstad, Kenney, & Jassil,
2010); an Evidence-Based Street Outreach Model that integrates an EBP with a smart stage of
change ruler does not yet exist. While many readiness to change rulers and stage models exist,
such as stages of grief, stages of treatment, stages of change, wellness coaching, and co-
occurring disorders (McHugo, Drake, Burton, & Ackerson, 1995; Thornton, Migdole, &
Corniello, 2007; Mueser, Noordsy, Drake, & Fox, 2010; Substance Abuse and Mental Health
Services Administration (SAMHSA), 2010; Lester, 2013; Prochaska, 2013), a smart stage of
WE ARE OUR NEIGHBORS KEEPER 18

change ruler, SCOUT, that integrates a Likert scale, evidence-based survey, game play
mechanics, technology from the maker movement, and algorithms does not yet exist. Based on
guiding principles of the GC2EH, the Capstone project assures that EBPs come alongside access
to housing programs (Padgett, Henwood, & Culhane, 2016) and healthcare services. Moreover,
the focus on individual, organizational, and social health and well-being comes alongside the
United Nations’ Sustainable Development Goal of Good Health and Well-being through
comprehensive capacity building intended to increase access to services (United Nations, 2018).
As a result, the Capstone project connects with the current environmental context by
understanding geographic perspectives (Rodin & Steinberg, 2003), identifying communities and
cultures (Steinberg, 2003), and employing the language of the GC2EH actors (Ryfe, 2003).
Social significance.

The problem is socially significant because it underscores the fact that society has yet
to ameliorate the underlying contextual challenges associated with the premature aging and
untimely death of our unhoused neighbors (Nagourney, 2016). Homelessness is a social justice
concern because a neighbor’s unhoused status is leveraged as a justification for criminalizing and
institutionalizing a vulnerable portion of our society. The problem is important to real people
because multiple stakeholders have developed and implemented complex and serious solutions
that have great potential to end homelessness (Nordquist, 2017; Ammer, 2011), yet fail to move
the needle on any contextual factors related to the wicked problem. For example, food baskets
and pantries lead to increased malnourishment, drug-related arrests increase drug-related crimes,
“three strikes” prison terms increase violent crimes, job training programs increase
unemployment, and homeless shelters increase homelessness (Stroh & McGah, 2011). The
WE ARE OUR NEIGHBORS KEEPER 19

problem has applied implications via the target population, partnerships, and the type of
resources needed for social change (National Council on Crime and Delinquency, 2009).
Logic model and theory of change.

The Capstone project, the Field Kit of Outreach and Assessment Tools, includes
Universal Standards of Street Outreach, an Evidence-Based Street Outreach Model, and SCOUT.
The Field Kit of Outreach and Assessment Tools is designed to inform street outreach efforts,
service provision options, and change motivation assessments. The Universal Standards of
Street Outreach are guiding principles that drive an Evidence-Based Street Outreach Model. The
Evidence-Based Street Outreach Model integrates EBPs and community-shared, peer provider-
led street outreach teams with SCOUT that have been adapted for use with our unhoused
neighbors. SCOUT integrates a stage-matched service provision matrix based on readiness to
change algorithms that, in turn, is based on an empirically based survey instrument. The peer
provider assesses an neighbors’ change motivation during street outreach and determines the
appropriate intervention based on survey responses, algorithms, and neighbor preference.
The theory of change (Appendix A) defines and depicts how and why planned change is
anticipated to occur in the context of the GC2EH. The theories, models, EBPs, and approaches
behind the Capstone project include Maslow’s hierarchy of needs, Trauma-Informed Care (TIC),
Motivational Interviewing (MI), the rejection-identification model, Trauma and the Continuity of
Self: A Multidimensional, Multidisciplinary Integrative (TCMI) framework, transtheoretical
theory of change, game theory, Brief Negotiated Interview (BNI), Likert scale, gameplay
mechanics, micro-technology from the maker movement, Artificial Intelligence (AI), and
Machine Learning (MI). Maslow’s hierarchy of needs looks at the impact of homelessness on
scarcity and need (Henwood, Derejko, Couture & Padgett, 2015). TIC is recognized by
WE ARE OUR NEIGHBORS KEEPER 20

SAMHSA, 2014 as an EBP rooted in trust, peer support, and self-determination. MI is
recognized by the Center for Evidence-Based Practices (2011) as an evidence-based approach
designed to recognize and mobilize a neighbor’s intrinsic values and goals to bring about
behavior change. The rejection-identification model identifies the impact of shame and
judgment on unhoused neighbors (Johnstone, Jetten, Dingle, Parsell, & Walter, 2015).
The TCMI framework emphasizes the intricate interplay between a neighbor’s unhoused
identity, response to social avoidance, rejection, and indifference of homelessness; vulnerability
and immovability associated with enduring deep and persistent trauma; and ability to adapt to
life afterward (Danieli, Norris, & Engdahl, 2016). The transtheoretical theory of change
measures progress via a set of principles based on the pros and cons of the change process
(DiClemente, Nidecker, & Bellack, 2008); which drives change by evaluating motivation and
describing how chronicity impacts a neighbor’s behavior change (DiClemente, Nidecker, &
Bellack, 2008). Game theory views goal attainment through the lens of how neighbors interact
with one another and how these exchanges influence individual and organizational change
motivation (Jolly, 2014; Myerson, 1999). When viewed through the lens of gameplay, SCOUT
predicts the stage of change, which informs service provision and leads to behavior change.
Therefore, the more times an unhoused neighbor is assessed with SCOUT, the more probabilities
that neighbor has to increase their stage of change score and intervention (Rouse, 2001; Jolly
2014). SAMHSA (n.d.) also recognizes the BNI as an EBP designed to assess behavior change
in emergency department (ED) settings (Boston University, n.d.). A Likert scale scores a level of
agreement with a survey item (Solli-Saether & Gottschalk, 2010). Gameplay mechanics engage
neighbors with SCOUT in contemplating their homelessness (Van Grove, 2011) using scores and
“leveling up” their stage of change. Micro-technology from the maker movement informs the
WE ARE OUR NEIGHBORS KEEPER 21

hardware design of SCOUT using arcade-style buttons and software codes (Bajarin, 2014). AI
and ML algorithms identify change motivation, predict stage of change, and guide service
intervention (Marr, 2016).
The logic model (Appendix B) demonstrates the key functionalities of the Capstone
project by operationalizing and connecting the inputs and main activities of the logic model.
Starting with the bottom row and moving upward, the logic model begins with an accounting of
the inputs of the innovation. If the first row of the logic model represents the inputs of the
Capstone project, which are the fundamental resources needed to implement the field kit of tools,
universal standards, street outreach model, and SCOUT, then the inputs influence the main
activities in a logical progression. If the second row of the logic model defines the main
activities of the innovation, which are the critical actions that the Capstone project engages in,
then the main activities are related to the corresponding immediate outputs that link the main
activities and immediate outputs in a logical progression. If the third row of the logic model
illustrates the immediate outputs resulting from the main activities of the innovation, which are
measurable, then the immediate outputs correspond to the initial outcomes and connect to
immediate outputs and initial outcomes in a logical progression. If the fourth row of the logic
model delineates the initial outcomes, which embody the determinate properties of the Capstone
project’s main activities and immediate outputs, then the initial outcomes and the equivalent
intermediate outcomes are connected to the initial outcomes and intermediate outcomes in a
logical progression. If the fifth row of the logic model explains the intermediate outcomes,
which denote the thematic aims of the innovation and include the anticipated impact of inputs,
main activities, immediate outputs, and initial outcomes, then the intermediate outcomes and the
corresponding impacts are linked to the intermediate outcomes and impacts in a logical manner.
WE ARE OUR NEIGHBORS KEEPER 22

If the last row of the logic model typifies the impacts the Capstone project seeks to achieve, then
the selected inputs, activities, outputs, outcomes, and impacts are best given the social problem
and wrong-door, no-door, and closed-door systems of care (Funnell & Rogers, 2011).
Problems of Practice and Innovative Solutions

The problems of practice and innovative solutions are directly related to change

motivation, which reflects environmental opportunities for innovation. Research indicates the
number one barrier for our unhoused neighbors is shattered trust of service systems (O’Toole,
Johnson, Aiello, Kane, & Pape, 2016). Problems of practice tend to advance a pessimistic view
of the determinants associated with homelessness, such as individual behavioral and physical
health problems, incarceration, and poverty (Piat et al., 2015; Padgett & Henwood, 2018). When
discussing health problems, public discourse looks for further evidence that homelessness is an
individual concern, including anger problems and relationship conflicts (Piat et al., 2015),
addiction, chronic pain, diabetes, hypertension, and cardiovascular disease (Fessler, 2013). On
an individual level, our unhoused neighbors over the age of 50 have high unmet needs due to
such limits as fear and aging (Nagourney, 2016), isolation (Padgett & Henwood, 2018),
incarceration (Winkler et al, 2016; Aykanian & Lee, 2016), and moral injury (Alford, 2016).
By narrowly focusing on the individual limits associated with homelessness, public
discourse discounts the contextual limits that influence and perpetuate homelessness and create
barriers to individual, organizational, and social change. Moreover, problems of practice tend to
be advanced by the contextual determinants associated with homelessness, including
NIMBYism, stigmatization, marginalization, and criminalization of homelessness; health and
behavioral health disparities; socioeconomic inequality; the depiction of homelessness in the
media (Piat et al., 2015); rivalry for resources, segmented systems of care, discombobulated
WE ARE OUR NEIGHBORS KEEPER 23

approaches to ending homelessness (Padgett & Henwood, 2018); and traditional approaches to
homelessness, such as housing, employment, social services, education, and health care (Stroh &
Goodman, 2011). Contextual limits to change are found in organizational structure, culture, and
workload pressure or disruptions, and unrealistic timeframes for job completion (Arnold, 2010;
Galbraith, 2014). On a contextual level, our unhoused neighbors over the age of 50 have higher
unmet needs due to such limits as access to services, support, and resources to meet basic needs
due to oligarchy and self-interest costs, which perpetuate resistance to change, an inability to
identify new opposition or support, and respond to difficult interfaces in the culture of the
GC2EH (Nagourney, 2016; Arnold, 2010). Thus, innovative ways to measure change
motivation and bring readiness to change assessments into the twenty-first century were
conceptualized and operationalized. As a result, the purpose of the Capstone project is to
improve access to needed supports and services and end homelessness. As a pilot project in
Missouri, the Capstone project is a diverse set of nested and standalone innovations designed to
help end homelessness by engaging in specific activities of street outreach and assessment to
achieve explicit outcomes related to the innovative policy, program, practice, and product.
Proposed innovation and its effect on the Grand Challenge.
As a new practice to implement, the Field Kit of Outreach and Assessment Tools
includes Universal Standards of Street Outreach, Evidence-Based Street Outreach Model, and
SCOUT. The Field Kit of Outreach and Assessment Tools is designed to guide street outreach
efforts and is utilized by peer providers during street outreach to determine service provision
options and change motivation assessments with SCOUT. As a new policy to enact, Universal
Standards of Street Outreach are guiding principles that serve as the foundation for an Evidence-
Based Street Outreach Model and SCOUT. The Universal Standards of Street Outreach consist
WE ARE OUR NEIGHBORS KEEPER 24

of the following: build positive relationships; create a safe presence; make weekly visits to
camps, tent cities, shelters, parks, and other places where our unhoused neighbors congregate;
develop trust (EscaRosa Coalition on the Homeless, 2016); create open dialogue; individualize
approaches and interventions; follow policy, program, practice, and product fidelity (National
Council on Crime and Delinquency, 2009); give homeless neighbors choice and voice in service
provision (Padget & Henwood, 2018); remember, one size does not fit all (Padget & Henwood,
2018; National Healthcare for the Homeless Council, 2016); assess baseline stage of change;
determine housing and healthcare readiness; remain responsive to homeless neighbors’ needs;
promote transdisciplinary teamwork; coordinate access to care; ensure the Field Kit of Outreach
and Assessment Tools is driven by quality improvement (QI, National Healthcare for the
Homeless Council, 2016); conceptualize unhoused neighbors in a person-first, strengths-based
manner, such as identifying neighbors who may not have a permanent home by using the term
“unhoused” over “homeless” (Biagiotti, 2016) and identifying who may access services by using
the term “deserving” over “undeserving” (Petrenchick, 2006); remember, needed services will
not apply seamlessly to all unhoused neighbors; understand unhoused neighbors will vacillate
between stages of change; provide time unlimited services; and acknowledge that interventions
may not explain behavioral change for any unhoused neighbor (SAMHSA, 2005).
As a new program to be adopted, the Evidenced-Based Street Outreach Model integrates
best practices and community-shared, peer provider-led (individuals who have lived experience
with chronic homelessness) street outreach teams with a Field Kit of Outreach and Assessment
Tools and SCOUT adapted for use with our homeless neighbors. As a new product to be
utilized, SCOUT brings readiness to change assessments into the twenty-first century by
integrating a survey, Likert scale, gameplay mechanics, algorithms, microtechnology, and stage-
WE ARE OUR NEIGHBORS KEEPER 25

matched service provision matrix into a portable device. The stage-matched interventions
correspond to central concerns for each stage of change, which suggests there is a pattern of
primary concerns within each stage (Solli-Saether & Gottschalk, 2010). Figure 2.0 offers a
graphic conceptualizing the proposed stages of support model.

Figure 2.0. Lowenstein’s Stages of Support Conceptualization
(Adapted from McHugo, Drake, Burton, & Ackerson, 1995; Thornton, Migdole, & Corniello,
2007; Mueser, Noordsy, Drake, & Fox, 2010; SAMHSA, 2010; Lester, 2013; Prochaska, 2013)

Based on a review of the literature, various stages models were compared, and an
alternative model, Stages of Support, emerged as the stage-matched intervention process when
working with unhoused neighbors (Appendix C). When designing the Capstone project, it was
imperative to explore past and current failures, challenges, and opportunities others have
encountered on the quest to end homelessness; which yielded ways to build on floundering
innovations, revealed value in failed interventions, and identified areas for improvement in the
GC2EH (Prosci, 2018). Beginning with the end in mind, conducting an environmental scan to
WE ARE OUR NEIGHBORS KEEPER 26

assess need, elucidate goals and objectives, and develop a sound strategy to improve the GC2EH
and make clear what the situation currently was, is, and will be was fundamental.
The wicked problem is directly linked to the GC2EH because other social problems
perpetuate homelessness, borrow from homelessness, and contribute to vicious cycles that
intersect them and spread homelessness. Social responses to homelessness, such as NIMBYism
and transinstitutionalization, manifest as harassment, displacement, and containment, which
intensifies social isolation and pontificates communal safety (Smith, 2014). TAU and the
criminalization of homelessness are unproductive sociopolitical responses to treatment, poverty,
unemployment, and insufficient housing (Epperson, Pettus-Davis, Grier, & Sawh, 2018). Due in
part to socioeconomic disparity, the number of older unhoused neighbors is expected to increase
significantly (Martin, 2016). To make matters worse, due to the passing nature of life on the
streets, our unhoused neighbors face difficulties keeping social connections, which contributes to
further isolation (Hecht, 2016). Natural disasters tend to dislocate and disband our marginalized
neighbors due to socioeconomic injustices and structural insufficiencies (Kemp, Palinkas, &
Mason, 2018). For example, the 2011 Joplin tornado devastated one-third of the housing stock
in the city, which dramatically compounded the wicked problem (Jonsson, 2011).
The Capstone project creates a common language for behavior change that is specific to
our unhoused neighbors and the organizations that serve them (DHHS, n.d.). By developing a
common language and putting concrete steps into motion to change the behavior of both users
and beneficiaries through an innovative approach, standardized drivers of change, and universal
standards of support, the Capstone project is innovative, improves the landscape of homelessness
(Traube, Begun, Okpych, & Choy-Brown, 2017), and creates value for society (Phills,
Deiglmeier, & Miller, 2008). The Capstone project is innovative because it seeks to change
WE ARE OUR NEIGHBORS KEEPER 27

organizational, contextual, financial, and sociopolitical processes; adapt readiness to change
assessments to our homeless neighbors; stimulate current thinking about ending homelessness;
bring readiness to change assessments into the twenty-first century, and disseminates the
innovation from local and state to federal levels (Christensen, Raynor, & McDonald, 2015). The
Capstone project is significant because it dissolves fragmented systems of care through
community learning and resource sharing. The Capstone project is a disruptive innovation
because it reverses service models and changes social norms around homelessness service
provision to create a different and improved user experience by infusing SCOUT and the Field
Kit of Outreach and Assessment Tools with an Evidence-Based Model of Street Outreach and
Universal Standards of Street Outreach (Waters, 2017; The Nielsen Company, 2014). The
Capstone project alters existing policies, programs, practices, and products into new policies,
programs, practices, and products (Christensen, Raynor, & McDonald, 2015).
Views of key stakeholders.

The work that has been done on pre-testing and obtaining feedback from multiple
stakeholders involved piloting the Capstone project prototypes, including the Universal
Standards of Street Outreach and Evidence-Based Street Outreach Model. The Universal
Standards of Street Outreach was developed in collaboration with the Missouri Housing
Development Commission (MHDC). Through this testing, multiple stakeholders learned that
while most standards of street outreach are based on funding stream requirements, standards that
are more focused on foundational principles for outreaching vulnerable neighbors do not yet
exist. The standards are undergoing further revision with the Governor’s Committee to End
Homelessness (GCEH). Scaling the innovation includes disseminating and diffusing the
WE ARE OUR NEIGHBORS KEEPER 28

intervention from Balance of State (BoS) CoCs to other BoS CoCs and then national levels
(Kirchner, Waltz, Powell, Smith, & Proctor, 2018; Proctor, Powell, & McMillen, 2013).
The Evidence-Based Street Outreach Model was developed in collaboration with the
Joplin Homeless Coalition, Economic Security Corporation, Salvation Army of Joplin, Career
Center, Children’s Haven, Ozark Center, and ICA. Piloting and refining the model consisted of
training street outreach teams on TIC, deploying street outreach teams, collecting and assessing
data, monitoring progress, and making modifications (Kirchner, Waltz, Powell, Smith & Proctor,
2018; Powell et al., 2015; Proctor, Powell, & McMillen, 2013). Through this testing, multiple
stakeholders learned that the homeless management information system (HMIS) is rigid in terms
of data collection and data entry requirements, which informed the approach of deploying
outreach teams in pairs (i.e., one staff member from a HUD-funded agency and one staff member
from a non-HUD funded agency). The model continues to be piloted and will be re-evaluated in
May 2020. Scaling the innovation includes disseminating and diffusing the intervention from
BoS CoCs to other BoS CoC and then national levels (Kirchner, Waltz, Powell, Smith, &
Proctor, 2018; Powell et al., 2015; Proctor, Powell, & McMillen, 2013). The Field Kit of
Outreach and Assessment Tools will be piloted in collaboration with the Joplin Homeless
Coalition, Economic Security Corporation, Salvation Army of Joplin, Career Center, Children’s
Haven, Ozark Center, and ICA January 2020. Scaling the field kit includes training street
outreach teams and insuring, licensing, marketing, and distributing the field kit (Kirchner, Waltz,
Powell, Smith, & Proctor, 2018; Powell et al., 2015; Proctor, Powell, & McMillen, 2013).
SCOUT will be piloted in collaboration with the Joplin Homeless Coalition, Economic Security
Corporation, Salvation Army of Joplin, Career Center, Children’s Haven, Ozark Center, and ICA
January 2020. Scaling the innovation includes attesting, manufacturing, packing, and selling
WE ARE OUR NEIGHBORS KEEPER 29

SCOUT (Kirchner, Waltz, Powell, Smith, & Proctor, 2018; Powell et al., 2015).
Evidence and current context for proposed innovation.

The Capstone project is well-positioned to be successful and have the desired impact with
respect to empirical evidence regarding the broader landscape of history, policy, practice, and
public knowledge and discourse, including the local contextual environment. Previous attempts
to address the intractable problem include such evidence-based psychosocial interventions as
Critical Time Intervention (CTI) and Integrated Treatment for Co-Occurring Disorders (ITCD).
CTI is a harm reduction approach to prevention for neighbors who may be at risk of becoming
homeless when experiencing difficult transitions, such as being released from incarceration,
being discharged from a psychiatric institution, or relocating to independent housing (Padgett,
Henwood, & Culhane, 2016). Outcomes associated with CTI include the prevalence of
homelessness, number of nights spent homeless, prevalence of psychiatric rehospitalization,
number of nights spent in psychiatric rehospitalization, and quality of supportive relationships
(Center for the Advancement of Critical Time Intervention, n.d.). ITCD is a harm reduction
approach to co-occurring substance use and mental health treatment that is designed to match
services to a neighbor’s stage of change and treatment (SAMHSA, 2010). Outcomes related to
ITCD include reduced substance use, reduced psychiatric symptoms, decreased hospitalization,
decreased arrests, improved housing stability, improved functioning, and improved quality of life
(SAMHSA, 2010). The Capstone project is well positioned to be successful and have the desired
impact with respect to promising practices, including the Collective Impact (CI) model, Frequent
Users Systems Engagement (FUSE) model, and Intentional Peer Support (IPS) model.
The CI model is based on a shared agenda, outcomes, activities, communication, and
infrastructure (Flood, Minkler, Lavery, Estrada, & Falbe, 2015). CI works to break down silos
WE ARE OUR NEIGHBORS KEEPER 30

and eliminate duplication of services while addressing the social problem from many angles.
Outcomes associated with CI include community- and policy-level change, improved health and
well-being, and increased ability to scale policies, programs, practices, and products (Flood,
Minkler, Lavery, Estrada, & Falbe, 2015). IPS is a peer provider-led process wherein peer
providers provide support and share their recovery story with unhoused neighbors (Barker &
Maguire, 2017). Common elements of IPS include shared experiences, role modeling, and
coaching (Barker & Maguire, 2017). Outcomes associated with IPS include improved quality of
life, increased social support, and improved behavioral health (Barker & Maguire, 2017). The
FUSE model is designed with unhoused neighbors (labeled “super users,” “emergency non-
emergencies,” or “high frequency users”) in mind who access ED for all of their dental and
behavioral and physical health care needs (Community Supported Housing, 2018). FUSE works
by addressing the complex needs of unhoused neighbors through traditional case management
programs, data-driven problem-solving, public and contextual reforms, targeted HF services,
collaborative partnerships, diverse funding, and proactive engagement with homelessness service
providers (Community Supportive Housing, 2018). Outcomes related to FUSE include
improved behavioral and physical health, improved employment and housing stability, decreased
ED visits, and decreased rates of incarceration (Community Supportive Housing, 2018).
Comparative opportunities for innovation analysis.
The Capstone project reflects careful consideration of real-world opportunities for
innovation, especially with regards to the application of AI and ML. SCOUT employs AI and
ML through image recognition (Frost, 2018) and adds cognitive engagement with stage of
change as a predictive element based on a series of decision rules in response to survey items
(Petering, Rice, & Rhoades, 2016; Bhartiya, 2017; Willard, 2017; Davenport & Ronanki, 2018).
WE ARE OUR NEIGHBORS KEEPER 31

The American Academy of Social Work and Social Welfare (AASWSW) and the United Nations
goals to address social problems through the innovative use of AI and ML are exemplified by the
University of Southern California (USC) Center for Artificial Intelligence in Society (CAIS).
CAIS project areas include leveraging AI and ML algorithms to end homelessness (Yadav,
Wilder, Chan, Jiang, Xu, Rice, & Tambe, 2018), promote health and well-being, prevent suicide,
challenge inequalities, prevent and treat substance use, promote conservation and sustainability,
and prepare for disasters (CAIS, 2019). Based on gaps in the literature, the Capstone project was
selected as the best innovation to pursue in terms of needs, originality, and innovativeness.
Proposed innovation linkages to logic model and theory of change.

The Capstone project aligns with the theory of change and logic model presented in the
Conceptual Framework. The theory of change depicts the design of the innovation. The logic
model identifies the units of service employed to measure outputs, outcomes, and impacts of the
Capstone project, which are linked to the application of the inputs and main activities of the logic
model. Implementation of the main activities leads to outputs, which are anticipated to result in
outcomes that are ordered into categories to define the logical sequence in which outcomes are
realized. To obtain measurable outcomes, the activities of the Capstone project are external
processes that typify neighbors in diverse stages of change (Batras, Duff, & Smith, 2014).
Likelihood of success.

The Capstone project’s overall likelihood of success is high because the Field Kit of
Outreach and Assessment Tools resonates with multiple stakeholders, fits within any
sociopolitical and organizational divide, creates a universal language that shares resources and
promotes community learning, standardizes mechanisms of change, establishes universal
WE ARE OUR NEIGHBORS KEEPER 32

standards, creates value for society, can be diffused from local to state to federal levels, and
enhances existing policies, program, and practices, (Phills, Deiglmeier, & Miller, 2008). The
critical impacts resulting from the Capstone project include introducing the Field Kit of Outreach
and Assessment Tools, Evidence-Based Street Outreach Model, Universal Standards of Street
Outreach, and SCOUT into the field and demonstrating clear financial benefits. For example, it
costs $150,000 to sustain one neighbor in homelessness per year, yet it costs only $25,000 to exit
one neighbor from homelessness per year (Padgett & Henwood, 2018).
Project Structure, Methodology, and Action Components

The Capstone prototype fits a user manual format through the Field Kit of Outreach and
Assessment Tools, which encompasses the following to address the social problem: Universal
Standards of Street Outreach Advocacy Brief, Evidence-Based Street Outreach Model Protocol,
Evidence-Based Street Outreach Model Memorandum of Understanding and Partner Agreement,
Field Kit of Outreach and Assessment Tools Tip Sheet, and SCOUT QuickStart Guide. The user
manual format is supported by conceptual drawings, gaming components, algorithms in
development, and scale examples of prototypes. Other routes to operationalize concepts from
the logic model were considered, including a business plan, a contract proposal, an
organizational redesign plan, pilot evidence, a patent, or copyright. The Field Kit of Outreach
and Assessment Tools format was selected as opposed to alternate options because it coherently
houses the nested and standalone innovations, highlights the product SCOUT, and offers
additional policy, program, and practice guidance as needed related to what the Capstone project
is doing in the innovation to address the identified problem. Other action-oriented materials for
future consideration include a business model and plan for OneGirl Enterprises and Blue Ocean
Innovations, data from the Evidence-Based Street Outreach Model pilot program, and
WE ARE OUR NEIGHBORS KEEPER 33

copyrights, trademarks, and patents for logos, written and visual materials, taglines, and SCOUT.
Capstone artifact.
The Capstone project artifact (Appendix D) demonstrates proof of concept under the

Field Kit of Outreach and Assessment Tools via the following components: Universal Standards

of Street Outreach Advocacy Brief, Evidence-Based Street Outreach Model Protocol, Evidence-

Based Street Outreach Model Memorandum of Understanding and Partner Agreement, Field Kit

of Outreach and Assessment Tools Tip Sheet, and SCOUT QuickStart Guide. Other evidence

built into the Capstone project includes the use of focus groups to discuss the theory of change

and logic model and to build support and tabletop exercises with users and beneficiaries to

critique the Field Kit of Outreach and Assessment Tools. The Capstone project will include

first-person accounts of unhoused neighbors who succeeded in using the innovation and expert

testimony. Modeling and simulation of the innovation will be utilized to develop a predictive

model of how many neighbors had a concern that could be addressed by the innovation. Based

on actual numbers, behaviors, and accidental findings, the data will help identify unknown

problems when the innovation is applied to different settings, contexts, and cultures.

Comparative market analysis.

The current market for the Capstone project relative to alternative options includes
nonprofit organizations, homeless coalitions, BoS CoCs, and state and federal government. The
need is to implement a mechanism to identify unhoused neighbors’ stage of change, which drives
service provision and behavior change. The Capstone project relates to this need by
incorporating SCOUT, Universal Standards of Street Outreach, and Evidence-Based Street
Outreach Model with a Field Kit of Outreach and Assessment Tools into the current street
outreach process. Competition exists at the federal, state, and city levels, including the VA, BoS,
WE ARE OUR NEIGHBORS KEEPER 34

and CoCs. Stakeholders should choose the Capstone project because the Field Kit of Outreach
and Assessment Tools employ predictive analytics to assess change motivation. While other
stage of change rulers and stage models exist, none leverage an evidence-based survey, Likert
scale, AI and ML, micro-technology from the maker movement, game play mechanics, and a
stage-matched service provision matrix to identify change motivation.
Capstone implementation methods.

The Capstone project’s methods for project implementation includes an analysis of
obstacles and alternative pathways and leadership strategies to facilitate the acceptance,
implementation, and sustainability of the innovation. The Capstone project’s implementation
plan is grounded in the Expert Recommendations for Implementing Change (ERIC) framework
(Appendix E). Moreover, the implementation plan includes a Gantt Chart (Appendix F) to
illustrate a realistic timeline for the attainment of the goals sought. The ERIC framework was
selected based on its theoretical simplicity, elasticity, adaptability, and relevance to the
innovation (Kirchner, Waltz, Powell, Smith, & Proctor, 2018; Powell et al., 2015; Proctor,
Powell, & McMillen, 2013). The Capstone project’s implementation strategy is a set of
interconnected actions that are neighbor-centric, peer provider-led, mission-driven, community-
shared, participation-based, and results-oriented (Minkler, Salvatore, & Chang, 2018; Vinson,
Stamatakis, & Kerner, 2018; Proctor, Powell, & McMillen, 2013). The implementation plan
involves conducting a needs assessment and identifying the social problem, exploring the
GC2EH and identifying a solution, conducting a strengths, weaknesses, opportunities, and
threats (SWOT) assessment, operationalizing the innovation, creating the prototype, designing
and launching a quality assurance (QA) plan, utilizing feedback loops to shape impacts and
WE ARE OUR NEIGHBORS KEEPER 35

quality improvement (QI), piloting and refining the innovation, and scaling and disseminating
the innovation (Powell et al., 2015; Proctor, Powell, & McMillen, 2013).
Conducting a needs assessment involved collecting and analyzing data and identifying a
need for the Capstone project (Kirchner, Waltz, Powell, Smith & Proctor, 2018; Powell et al.,
2015; Proctor, Powell, & McMillen, 2013). Examining the GC2EH and identifying an
innovation included reviewing the literature to explore associations with homelessness, public
discourse, and responses to homelessness, and other solutions to end homelessness (Kirchner,
Waltz, Powell, Smith & Proctor, 2018; Powell et al., 2015; Proctor, Powell, & McMillen, 2013).
Conducting a SWOT analysis and identifying obstacles and alternate pathways consisted of
assessing coalition readiness, identifying strengths and weaknesses, and spotting opportunities
and threats (Kirchner, Waltz, Powell, Smith & Proctor, 2018; Powell et al., 2015; Proctor,
Powell, & McMillen, 2013). Operationalizing the innovation and creating the prototype
included developing a theory of change, logic model, financial model, timeline; designing
SCOUT, enclosures, packaging, logos, and software; and preparing the prototype for pre-test
(Kirchner, Waltz, Powell, Smith & Proctor, 2018; Proctor, Powell, & McMillen, 2013).
Developing a QA plan will involve developing, implementing, and evaluating a system to
monitor process, outcome, and performance measures (Kirchner, Waltz, Powell, Smith &
Proctor, 2018; Powell et al., 2015; Proctor, Powell, & McMillen, 2013). Utilizing feedback loops
to shape outcome and QI will include developing plans for stakeholders to shape implementation
processes and outcomes that measure the success of the innovation and its impact on service
accessibility and utilization (Kirchner, Waltz, Powell, Smith & Proctor, 2018; Powell et al.,
2015; Proctor, Powell, & McMillen, 2013). Piloting and refining the innovation included
training and deploying street outreach teams, collecting and analyzing data, and making
WE ARE OUR NEIGHBORS KEEPER 36

adjustments (Kirchner, Waltz, Powell, Smith & Proctor, 2018; Powell et al., 2015; Proctor,
Powell, & McMillen, 2013). Scaling the innovation will include copyrighting, trademarking,
and patenting the Field Kit of Outreach and Assessment Tools, Evidence-Based Street Outreach
Model, Universal Standards of Street Outreach, and SCOUT; certifying and manufacturing
SCOUT; insuring, licensing, and shipping the field kit and SCOUT: and disseminating the
innovation from local and state to national levels (Proctor, Powell, & McMillen, 2013).
Based on the Exploration, Preparation, Implementation, and Sustainment (EPIS)
framework (Moullin et al., 2011), internal obstacles include coalition structure and culture,
fragmented systems, readiness to change, role confusion, outreach inertia, specialization,
coordination, collaboration, training, innovation ideals-congruence, coalition fidelity to and
adaptation of the Universal Standards of Street Outreach and Evidence-Based Street Outreach
Model, federal incentives, state homelessness service agencies, local ordinances, and
compatibility with service resources (Damschroder et al., 2009; Glisson et al., 2012; Hamilton &
Mittman, 2018; Gelhert, Hall, & Palinkas, 2017; Palinkas, Short, & Wong, 2015; Green, et al.,
2009; Glisson & Schoenwald, 2005; Frink & Klimoski, 2004; Shortell, 2004). External
obstacles include startup costs, social norms, different definitions of homelessness based on
revenue sources, gaps in research, jumbled approaches to end homelessness, reimbursement
procedures, legislative policies and incentives, fiscal setting of the coalition, and infrastructure
(Damschroder et al., 2009; Hamilton & Mittman, 2018; Gelhert, Green, et al., 2009; Palinkas et
al., 2008; Glisson & Schoenwald, 2005; Frink & Klimoski, 2004; Shortell, 2004).
Alternative internal pathways include adaptability, community learning and training,
shared resources and expectations, clear role descriptions, peer providers, belief in utility of the
innovation, target population needs, Evidence-Based Street Outreach Model, innovation
WE ARE OUR NEIGHBORS KEEPER 37

consultant contracted activities, Field Kit of Outreach and Assessment Tools, coalition capacity,
networks, local CoC, affinity, process monitoring, outcome evaluation, receptivity, SCOUT,
internal validity, and differentiation (Gelhert Hall, & Palinkas, 2017; Schoenwald & Hoagwood,
2001; Hamilton & Mittman, 2018; Cabassa & Baumann, 2013; Glasgow, 2003; Powell et al.,
2012; Anonymous, 2004). Alternative external pathways include outcome evaluation, process
monitoring, external validity, HMIS, HUD technical assistance, agreed-upon aim and objectives,
legislative milieu, target population support, gaps in networks, alliances, Department of Mental
Health, MHDC, GC2EH, USC, shared resources, support for prototype, existing programs (i.e.,
medical respite, HF, and Permanent Supportive Housing (PSH)), BoS CoCs, and diffuse the
standards from local and state to federal levels (Gelhert Hall, & Palinkas, 2017; Schoenwald &
Hoagwood, 2001; Powell et al., 2012; Anonymous, 2004; Palinkas et al., 2008; Glisson &
Schoenwald, 2005; Hamilton & Mittman, 2018; Cabassa & Baumann, 2013; Glasgow, 2003).
Relevant political, organizational, and community actors and allies include the VA,
homeless coalitions, Department of Mental Health, MHDC, GCEH, Salvation Army, Career
Center, Children’s Haven, Ozark Center, the shelter system, Economic Security Corporation,
coordinated entry, recovery housing, homeless neighbors, police departments, peer providers,
city and county agencies, faith-based organizations, the business community, probation and
parole, and city, state, and federal legislators. Relevant political, organizational, and community
obstacles include NIMBY proponents, traditional outreach workers and service agencies,
institutions that treat and street unhoused neighbors, such as correctional facilities and
psychiatric hospitals, and city, state, and federal ordinances that criminalize homelessness.
Leadership strategies required to develop allies and overcome obstacles include communication
and coordination before, during, and after project implementation; identify process management,
WE ARE OUR NEIGHBORS KEEPER 38

outcome evaluation, and performance measures; monitor fidelity to and adaptability of the
innovation; and develop transparent policies and procedures (Glisson et al., 2012; Palinkas,
Short, & Wong, 2015; Palinkas & Soydan, 2012; Soydan & Palinkas, 2014).
Financial plans and staging.

The Capstone project’s financial plan (Appendix G) consists of the general structure to
house the innovation, revenues and expenses, and staging. The general structure to house the
innovation is a Limited Liability Corporation (LLC, pending application approval). The pilot is
projected to cost $880,00 in the first year of operation and $1.9 million in the second year of
operation. The general scale of the revenue required for the project’s first year of operation is
$1.1 million and $2.1 million for the project’s second year of operation. The top four sources of
expenses are staff, technology/equipment, prototyping and manufacturing SCOUT, and testing
and marketing the Field Kit of Outreach and Assessment Tools.
Capstone impact assessment methods.

The Capstone project is piloted in collaboration with the Joplin Homeless Coalition,
Missouri Housing Development Commission, Governor’s Committee to End Homelessness, and
Department of Mental Health. The following research questions are utilized to measure the
impact of the innovation: Is there improvement in unhoused neighbors outreached with the Field
Kit of Outreach and Assessment Tools? Is there behavioral change in unhoused neighbors
assessed with SCOUT? Is there behavioral change in organizations that participate in the
Evidence-Based Street Outreach Model? Is there behavioral change in legislators that amend
public policies relevant to the Universal Standards of Street Outreach? Is there improvement in
exits from homelessness? An interrupted time series pretest-posttest model is utilized to analyze
outcomes of interest and identify causal trends as the innovation interrupts the time series at a
WE ARE OUR NEIGHBORS KEEPER 39

known point in time (Landsverk et al., 2018). Neighbors are recruited using random sampling so
that everyone has an equal chance of being included in the sample (Green & Nasser, 2018).
Sampling is obtained during street outreach, coalition meetings, and community events by
collecting basic data and observing trends. The selection criteria for inclusion and exclusion into
the study include unhoused neighbors who are experiencing homelessness and organizations and
legislative bodies who are invested in ending homelessness. The sample size is contingent on the
number of neighbors outreached, organizations at coalition meetings and community events, and
legislators working on public policies related to homelessness.
Neighbors will be assessed at pretest (baseline) and then posttest (after implementation,
every week). Instruments to measure process data include Joplin Homeless Coalition attendance
indicators, HUD Emergency Solutions Grants (ESG) Universal Data Elements (UDE; HUD,
2018), Likert scale surveys, and semi-structured interviews. The top four outputs measured are
the number of public policies amended relative to homelessness, number of collaborating
agencies recruited, number of exits from homelessness, and number of returns to homelessness.
Instruments to measure outcome data include HUD Annual Community Report (ACR) annual,
trend, and point-in-time (PIT) data (HUD, 2018); Empower Missouri task force briefings
(Empower Missouri, 2019); and SCOUT data as compared to data from the BNI (SAMHSA,
n.d.; Boston University; n.d.). The reliability and validity of SCOUT are measured by
comparing pretest-posttest data from SCOUT with the BNI instrument. The top four outcomes
measured are improved well-being, improved collaborative community learning and resource
sharing, increased cost-effective services, and increased exits from homelessness. Collected
data is documented on an Excel spreadsheet (Benjaminsen, Munoz, Vazquez, & Panadero,
2005), and the data are analyzed utilizing Grounded Theory (GT) to examine non-numerical and
WE ARE OUR NEIGHBORS KEEPER 40

statistical means (Glaser, 2008). Each stage of the pilot program is assessed using SWOT.
Results are communicated via annual reports, dashboards, scorecards, articles, and social media.
Stakeholder engagement plan.

The Capstone project’s plan for stakeholder involvement that includes relevant
constituents takes into consideration the context of GC2EH and the culture of the coalition where
the innovation is implemented. The stakeholder engagement plan focuses on developing
relationships and nurturing the culture along the way to unite others to subvert the supernorm
that holds the social problem in place (Peters, 1987). The plan also adopts an entrepreneurial
approach to leveraging resources by influencing and shaping social and mobile media to reframe
public discourse surrounding homelessness (Heimans & Timms, 2014). The stakeholder
engagement plan engages in collaborative partnerships through linkages with stakeholders,
including peer providers, community service providers, homeless neighbors, business leaders,
legislators, faith-based organizations, policymakers, the media, housing agencies, coordinated
entry, child welfare, criminal justice, coalitions, hospitals, clinics, recovery housing, shelters,
foundations, education and early childhood providers, data and technology agencies, pet shelters,
landlords, and employers. While working with collaborators on shared goals and motivations,
these partnerships are conscious of diversity and inclusion (Rainey & Bozeman, 2000; Flynn,
2017). As a result, the stakeholder engagement plan recognizes ways to utilize generational
differences, social justice, and diversity to minimize unhealthy conflicts and guide its work with
partners (Twenge, Campbell, Hoffman, & Lance, 2010). The plan acknowledges the fact that in
many instances, when healthy conflict occurs, it can be leveraged to bring about positive change.
Communication strategies and products.

WE ARE OUR NEIGHBORS KEEPER 41

The communication strategies and products are based on building awareness of
homelessness; reducing the stigmatizing and marginalizing interplay between our homeless
neighbors, community members, and the media; and disseminating the communication plan via
social networks (Effie® Awards, 2007). The #SEEME campaign is utilized to combat
stigmatization and marginalization of our unhoused neighbors, to garner engagement and support
for the Capstone project, and to disseminate the positive outcomes of the innovation for broader
impact. The #SEEME campaign works to raise public discourse and educate individuals,
organizations, and communities about homelessness (Long et al., 2011), to reframe homelessness
(Patel & Tomkins, n.d.), and to utilize exemplars to influence others and to show how
homelessness can happen to anyone (Nejad, Sherrell, & Babakus, 2014). The idea behind
#SEEME is to challenge social views of homelessness, shine a light on structural limits
associated with homelessness, and alter social stigma and social commentary (Vallone, Smith,
Kenney, & Greenberg, 2016). The #SEEME campaign utilizes theory and previous research to
guide the communication plan, including deontological theory and disruptive innovation theory.
Deontological theory explores the rights of any neighbor (Barroso, 2012).
When examined through this theory, access to needed services is a fundamental right for
all our neighbors, including our unhoused neighbors (Barroso, 2012). Deontological theory
guides the value theory of the fundamental right to service utilization by advocating that our
homeless neighbors stake a claim to this right in the community; developing a commitment from
federal, state, and local neighbors to endorse and approve this right; and creating a duty for
federal, state, and local organizations to address any violation of this right (Barroso, 2012).
Disruptive innovation theory considers organizations that are flourishing and examines how they
maintain their position in the market (Yu & Hang, 2010). When viewed through this theory,
WE ARE OUR NEIGHBORS KEEPER 42

utilization of needed services is focused on process-oriented transformational change that values
association over antagonism, fortitude over cynicism, and adjusting over failing to bring about
planned change (Yu & Hang, 2010). Disruptive innovation theory recognizes that change is
dependent on organizational culture and structure, which are influenced by such contextual limits
as regulations and economic conditions (Yu & Hang, 2010). Based on the research, the
#SEEME campaign is effective because it focuses on the strengths of neighbors, agencies, and
communities (Flynn, 2017). The primary message appeal focuses on reciprocity (Cialdini,
2009), emotions, similarity, goodwill, and hope (Cockrill & Parsonage, 2016; World Advertising
Research Center (WARC), 2011). The #SEEME campaign envisions raising the visibility of our
unhoused neighbors and their accessibility to needed services. It is the mission of the #SEEME
campaign to change social responses to homelessness, to share resources, and to end
homelessness through communication strategies, community learning initiatives, and
technological avenues (WARC, 2016). The objective of the #SEEME campaign is to motivate
neighbors, agencies, and communities to refuse to accept the stigmatization and marginalization
of our unhoused neighbors (Grearson, 2016). The main message is designed to elicit emotions
by centering on human suffering as the main cost generated by homelessness (Perloff, 2017).
The primary message is designed to garner goodwill by considering alternatives to
traditional homelessness policies, programs, practices, and products, such as the use of
technology, big data, partnerships with nontraditional actors, and personal narratives of homeless
neighbors (Perloff, 2017). The main message is designed to instill hope by containing cues to
action to keep the conversation moving and to change the dialogue (Perloff, 2017). The
#SEEME campaign is designed to accomplish the primary message by introducing as an
interactive online interview with speakers and influencers who receivers consider to be
WE ARE OUR NEIGHBORS KEEPER 43

trustworthy experts because the speakers share personal experiences with homelessness (Petty &
Cacioppo, 1986). The online interview was selected as the initial interactive medium based on
its ability to attract speaker and receiver involvement, to raise publicity (East, 2014), to focus on
the celebrity culture, to produce immediate feedback and results, and to harness social
networking and word of mouth marketing (Euromonitor International, 2011). Speaker source
features include online influencers, exemplars, and dynamic speakers with charisma who are
experts that are honest, agreeable, and like receivers (WARC, 2016; Precourt, 2015). During the
#SEEME campaign interviews, speakers share their experiences with homelessness, and
receivers are given the opportunity to interact with these online influencers via smartphones,
tablets, Skype, applications, or other types of mobile media (WARC, 2016). The target
audience includes our neighbors and community members. The evangelists include speakers,
receivers, and the media (Jathanna et al., 2017). Policymakers include community leaders and
legislators (Jathanna et al., 2017).
As an interactive interview experience, #SEEME is designed to raise awareness of
homelessness and barriers to services and well-being and have a strong positive impact on
relevant audiences (Patel & Tomkins, n.d.). Key speakers include homeless neighbors, peer
providers, experts, opinion leaders, and celebrities from YouTube, music, and other industries
who have personal lived experience with homelessness. The #SEEME campaign employs visual
images, messages, logos, color palettes, prototypes, fonts, symbols, signs, and taglines in its
purpose-driven channels of communication to gain immediate visibility, virality, seedability,
stickability, and spreadability (Jenkins, Ford, & Green, 2013; WARC, 2016; Thompkins, 2012;
Effie® Awards, 2007; McComiskey, 2004). Channels of communication include print and
online, outdoor, merchandise, community, broadcast, and social and mobile media. The
WE ARE OUR NEIGHBORS KEEPER 44

#SEEME campaign utilizes branded rack cards, leaflets, brochures, business cards, postcards,
letterhead, loyalty cards, presentation folders, product labels, annual reports journal articles,
opinion editorials, news analyses, and online newspaper and magazine articles to integrate print
and online materials into the communication strategy (Twose & Jones, 2011; Long, Taubenheim,
Wayman, Temple, & Yu, 2010; Rank, 2018). The #SEEME campaign employs branded posters,
billboards, banners, yard signs, pop-up displays, flags, and car magnets to incorporate outdoor
materials into the communication plan (Twose & Jones, 2011; Long, Taubenheim, Wayman,
Temple, & Yu, 2010). The #SEEME campaign employs branded scratchpads, pens, sunglasses,
flashlights, power banks, blankets, water bottles, umbrellas, backpacks, hats, t-shirts, and
outerwear to integrate merchandise into the communication strategy (Twose & Jones, 2011;
Taubenheim, Wayman, Temple, & Yu, 2010).
The #SEEME campaign utilizes online and offline networks, focus groups, public
education forums, conferences, panel discussions, oral presentations, town hall meetings, and
TED talks to incorporate community into the communication plan (Thompkins, 2012; Rank,
2018). The #SEEME campaign utilizes traditional television and radio, and public service
announcements and advertisements to integrate broadcast media into the communication plan
(Thompkins, 2012; Rank 2018). The #SEEME campaign utilizes social and mobile media
platforms, competitions, blogs, vlogs, short-form videos, viral advertisements, odd-vertisements,
pictures, emojis and phatic culture, YouTube channels, Facebook post and ads, Twitter tweets,
internet search engines, email marketing and newsletters, local online listings, digital public
service announcements, mobile applications, micro-web pages, netroots, cyberspace initiatives,
internet radio, and digital murals to drive activity to the #SEEME campaign’s website, and to
WE ARE OUR NEIGHBORS KEEPER 45

incorporate social and mobile media into the communication plan (Taubenheim, Wayman,
Temple, & Yu, 2010; Rank, 2018; Miller, 2017; Steinberg, 2003; Appleby, 2003).
The #SEEME campaign will be launched as an interactive, socially conscious, purpose-
driven business-to-consumer and peer-to-peer type of consciousness-raising campaign that
includes sociopolitical goals and objectives to engage audiences (WARC, 2017; Geraci, 2005;
Cui et al., 2003). Receivers can access live interviews during scheduled time slots via the On the
Edge channel on YouTube and interact with speakers who have experienced homelessness and
who leverage their experiences to endorse individual and social well-being (Howell, 2017).
Throughout the #SEEME campaign, receivers are provided with information about homelessness
and services available through Blue Ocean Innovations and OneGirl Enterprises. Each #SEEME
campaign segment ends with receivers requesting or referring speakers for upcoming On the
Edge interviews. Receivers are cued to action, both internally and externally (Carpenter, 2010).
Receivers are directed to get involved, educate themselves and others in a trickle-down manner
(Rampal & Agrawal, 2016), donate, and like and subscribe to the On the Edge channel to
increase social responsibility (Rahman, Rodriguez-Serrano, & Lambkin, 2017). Receivers are
also encouraged to go online, contact homelessness services organizations or government
officials, and share the #SEEME campaign on social and mobile media to help grow community
and raise awareness of homelessness, Blue Ocean Innovations, and OneGirl Enterprises (Clark,
2019). In addition, the #SEEME campaign directs receivers to call 417-621-5884 or visit
www.blueoceaninnovations.org or www.one-girl-enterprises.com for more information.
The #SEEME campaign is evaluated utilizing receptiveness, awareness, and
remembrance and the impact of changes over time in knowledge and attitudes concerning our
unhoused neighbors and homelessness (Vallone, Smith, Kenney, & Greenberg, 2016). The
WE ARE OUR NEIGHBORS KEEPER 46

#SEEME campaign is evaluated employing the following outputs: number of receivers that view
the #SEEME campaign, amount of time spent watching the #SEEME campaign, number of
countries where the #SEEME campaign is viewed, number of shares of the #SEEME campaign
on social media, number of speakers interviewed through the #SEEME campaign, number of
subscribers to the On the Edge YouTube channel, number of shares of the On the Edge YouTube
channel, number of Blue Ocean Innovations page boosts on Facebook, number of OneGirl
Enterprises retweets on Twitter, number of email click-throughs to OneGirl Enterprises website,
number of conversations about homelessness through diverse communication channels, amount
of monetary donations raised, amount of time volunteered, amount of media impressions,
amount of airtime and pro bono services donated, and amount of merchandise sold. The
#SEEME campaign is evaluated by monitoring and mapping communal and conversational
patterns that emerge as a result of the On the Edge interviews (Rayner & Findlay, 2017; Thomas,
Kumar, & Agrawal, 2016). The #SEEME campaign is also evaluated on the amount of impact it
has on homelessness through such persuasive outcomes as improved access to services, health,
and well-being, increased public discourse, and exits from homelessness. (Cialdini, 2009).
Capstone project and the social problem.

As a collection, the Capstone components address the stated problem of practice through
practical approaches taken to disseminate the innovation for broader impact and to ameliorate the
social problem. The Capstone project addresses the issue of no-door, wrong-door, and closed-
door systems of care and reduces barriers to services through community learning and resource
sharing, including the Field Kit of Outreach and Assessment Tools. The innovation works to
change the way unhoused neighbors encounter service providers through Universal Standards of
Street Outreach and Evidence-Based Street Outreach Model. The Capstone project helps break
WE ARE OUR NEIGHBORS KEEPER 47

the cycle of homelessness by identifying change motivation with SCOUT. The Capstone project
explicitly addresses the GC2EH because it is consistent with what is commonly understood
about ending homelessness via street outreach.
Ethical considerations.

The Capstone project has carefully considered ethical concerns and possible negative
consequences of the project. The existing “treat ‘em and street ‘em” supernorm poses potential
ethical concerns grounded in the social work principle of social justice. As a result, the Capstone
project acknowledges that stakeholders who adopt this innovation are obligated to practice,
model, and follow the ethical values of service, equity, respect, relationships, trustworthiness,
expertise, and competence (National Association of Social Workers (NASW), 2017; Theoharis,
2007). Moreover, public discourse can help further the innovation and the GC2EH by advancing
solution-focused cultures and grass- and net-roots collaboratives; sharing values, resources, and
accountability; breaking down silos; learning as a community (Putnam, 2000); and ethically
engaging with multiple stakeholders to bring about change (Monahan, 2012). Possible negative
consequences include working with our vulnerable and medically fragile unhoused neighbors.
As a result, the Capstone project will obtain voluntary, informed consent, protect confidentiality
(Petrila, n.d), and ensure benefits justify risks (Currie, 2013; Dubois & Prusaczyk, 2018). Since
the Capstone project consists of policy, program, practice, and product components, it is doubtful
that Institutional Review Board (IRB) approval is needed. However, if the Capstone project
were to collect data for research purposes, then IRB approval would be obtained.

WE ARE OUR NEIGHBORS KEEPER 48

Conclusions, Actions, and Implications

The Capstone project aims to inform potential future decisions and actions through
progressive thinking, creativity, and innovation (Kuhn, 2012) In collaboration with the Missouri
Department of Mental Health, Governors’ Committee to End Homelessness, Missouri Housing
Development Commission, and the Joplin Homeless Coalition CoC, the state of Missouri is
combating homelessness by launching, growing, and gaining traction with the Field Kit of
Outreach and Assessment Tools (Jenkins, Ford, & Green, 2013). While using the Field Kit of
Outreach and Assessment Tools to help end homelessness is an innovative idea, providers have
experienced an “it can’t be done” mindset along the way, which is a natural part of the change
process (Kuhn, 2012). Model drift occurred when introducing the Universal Standards of Street
Outreach and Evidence-Based Street Outreach Model into what is commonly understood about
ending homelessness in the Missouri BoS CoC, which has propelled multiple stakeholders to
reconsider the GC2EH and learn new ways of doing street outreach (Kuhn, 2012).
Under the current paradigm, our unhoused neighbors traditionally have not had big voice
or big choice with regards to service provision. “Treat ‘em and street ‘em” practices emphasize
the social costs of homelessness and individual limits associated with homelessness, yet
minimize the contextual limits associated with homelessness. However, the implementation of
the Universal Standards of Street Outreach and Evidence-Based Street Outreach Model has
reshaped what is commonly understood about homelessness, and ultimately the Field Kit of
Outreach and Assessment Tools and SCOUT will be accepted as the new policy, program,
practice, and product associated with street outreach and assessment (Kuhn, 2012). Implications
of the Capstone project for practice and further action within social work exist on micro-, mezzo-
, and macro-levels. As a new product, adapting SCOUT to other populations will improve
WE ARE OUR NEIGHBORS KEEPER 49

service provision, especially when measuring change motivation is essential, such as when
working with domestic violence survivors, neighbors in substance use and mental health
recovery, and health care recipients. As a new practice, the Field Kit of Outreach and
Assessment Tools will serve as a springboard to advance the manualization of emerging and
promising practices. As a new program, adapting the Evidence-Based Street Outreach Model to
other contexts will improve engagement and retention approaches in such programs as substance
use treatment and offender re-entry. As a new policy, building on Universal Standards of Street
Outreach will expose a new paradigm that will offer several positive solutions for ending wicked
problems; will lead to more comprehensive plans to leverage resources, knowledge, and
influence; and will tie old values into new paradigms (Heimans & Timms, 2014).
The limitations and risks of the Capstone project include the study design and sampling

strategy, design, sunk costs of prototype development, working with vulnerable neighbors,

infrastructure development to meet the health care and housing needs of unhoused neighbors

over the age of 50, model drift, coalition conflict over and competition for resources, and local,

state, and federal regulations and definitions of homelessness. Recommendations for future

work regarding the social problem include utilizing big data to identify themes and patterns and

predict readiness to change (Cuccaro-Alamin, Foust, Vaithianathan, & Putnam-Hornstein, 2017),

further refining SCOUT, and identifying technological substitutes for SCOUT, including an

iPhone or Android application. The Capstone prototype is ready to be shared with relevant

stakeholders politically, financially, and operationally as it resonates with multiple stakeholders;

fits within any political, social, or organizational divide; creates a universal language that shares

resources and values community learning, standardizes mechanisms of change, establishes

Universal Standards, and creates value for society. Moreover, SCOUT is grounded in the BNI,
WE ARE OUR NEIGHBORS KEEPER 50

which is a valid and reliable EBP that has been psychometrically tested by SAMHSA

(SAMHSA, n.d.; Boston University, n.d.) and has been demonstrated in multiple peer-reviewed

studies to be effective at facilitating positive health behavior changes (Boston University, n.d.).

A concrete plan for advancing the next steps of the Capstone project includes designing a
QA plan, creating and utilizing feedback loops to shape outcome and QI, testing SCOUT in the
field, manufacturing and licensing SCOUT, and packaging and selling the Field Kit of Outreach
and Assessment Tools. Designing a QA plan involves developing, implementing, and evaluating
a system to monitor process, outcome, and performance measures (Kirchner, Waltz, Powell,
Smith & Proctor, 2018; Powell et al., 2015; Proctor, Powell, & McMillen, 2013). Creating and
utilizing feedback loops to shape outcome and QI includes developing plans for stakeholders to
shape implementation processes and outcomes that measure the success of the innovation and its
impact on service accessibility and utilization (Kirchner, Waltz, Powell, Smith & Proctor, 2018;
Powell et al., 2015; Proctor, Powell, & McMillen, 2013). Sustainability plans include testing
SCOUT in the field by collaborating with the Joplin Homeless Coalition, Missouri Housing
Development Commission, Governor’s Committee to End Homelessness, and Missouri
Department of Mental Health to pilot and revise SCOUT. Upon completion of the pilot, SCOUT
will be scaled across the Missouri BoS CoC through partnerships with Missouri legislators, and
then diffused to the federal level through the Missouri Department of Mental Health and state
and federal legislators. Our unhoused neighbors over the age of 50, organizations, communities,
and society will be different as a result of the activities and outcomes of the innovation.

WE ARE OUR NEIGHBORS KEEPER 51

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Capstone Appendices
Capstone Appendix A: Theory of Change

Needs Assessment
Problem Identification
Grand Challenge to End Homelessness
Capstone Project
SWOT Analysis
Barriers and Facilitators
Nested Intervention

Stages of Change

(Precontemplation Contemplation Preparation Action Prevention)
Noise Voice Poise Choice Control

Operational Measures

Operational Measures
Innovation Outcomes and Impacts

Policy Program Practice Product
Universal Standards Evidence-Based Field Kit SCOUT
of Street Outreach Street Outreach of Outreach and
Model Assessment Tools
Organizational
Interventions
Individual
Interventions

Communal/Social
Interventions
Target
Population
Increased
coalition
learning,
collaboration,
and resource
sharing

Increased
access
to services
Increased
connection,
health,
and
wellness
Increased
public
policy and
funding
stream
changes
Increased
exits
from
homeless-
ness
Prochaska’s Stages of Change, Maslow’s Hierarchy of Needs, Game Theory, Rejection-
Identification Model, Trauma-Informed Care, Trauma and the Continuity of Self: A
Multidimensional, Multidisciplinary Integrative (TCMI) Framework, Motivational Interviewing Feedback
Loops
Feedback
Loops
Increased
cost-
effective
services
Running head: CAPSTONE PROJECT PAPER
84

Capstone Appendix B: Logic Model

ULTIMATE
IMPACTS

INTERMEDIATE
OUTCOMES

INITIAL
OUTCOMES

IMMEDIATE
OUTPUTS

MAIN
ACTIVITIES

INPUTS

Implementation, evaluation, and sustainment milestones; Increased
coalition learning, collaboration, and resource sharing; Increased access to
services; Increased individual connection, health, and wellbeing; Increased
public policy and funding stream changes; Increased cost-effective
services; Increased exits from homelessness

Coalitions advocate for shared resources and best practices; Community
agencies coordinate and consolidate services; Unhoused neighbors use
street outreach as a steppingstone into chosen services; Intervention is
disseminated and diffused to the federal level

Coalitions collaborate to share knowledge and resources; Community
agencies adopt intervention; Unhoused neighbors are aware of street
outreach team and have self-determination in service provision; Legislators
amend public policies and create new funding streams

Degree of implementation; Problem and solution identification, best
practices, rate of prototype development and refinement,
piloting/marketing innovation, and diffusion milestones; Fidelity and
cultural adaptability; Number of collaborating organizations, Number of
shared funding streams, Number of unhoused neighbors outreached and
assessed, Number who dropped out, Number of community resources
accessed and materials distributed, Number of legislators for and against
standards, Number of agencies and states to adopt standards

Identify the problem and potential solution; Engage in collaborative
relationships with stakeholders; Share emerging, promising, and best
practices; Prototype and refine field kit of tools; Pilot intervention policy,
program, practice, and product to test innovation; Create materials to
support innovation; Disseminate and diffuse the innovation

Team, team officers, chief visionary officer (CVO), board of members;
Coalition partners; Street outreach vehicles; Technology; Equipment;
Prototyping SCOUT, universal standards, field kit of tools, street outreach
model; Travel and training; Contracts; Supplies and marketing; Building
expenses; Startup costs and profits

CAPSTONE PROJECT PAPER 85

Capstone Appendix C: Comparison of Stage Models and Lowenstein’s Stages of Support

Prochaska’s
Stages of
Change
Maslow’s
Hierarchy of
Needs
Dartmouth’s
Stages of
Treatment
Boston
University’s
Stages of
Recovery
Lowenstein’s
Stages of
Support
Precontemplation:
Unhoused
neighbor does not
acknowledge that
homelessness is a
problem or need
for change
Psychological:
Breathing,
food, water,
shelter,
clothing, and
sleep
Engagement:
Unhoused neighbor
has irregular contact
with peer provider and
has difficulty
establishing trust and
rapport, yet meets
criteria for
homelessness
Overwhelmed:
Unhoused neighbor
is overwhelmed by
their homelessness
Noise: Unhoused
neighbor distracted,
does not have a peer
provider and is reluctant
to trust peer provider.
Peer provider engages
in assertive outreach,
meets unhoused
neighbor where they are
at, provides practical
assistance to meet basic
needs, offers hope,
develops trust, and
completes SCOUT
assessment.
Contemplation:
Unhoused
neighbor
acknowledges
homelessness is a
problem but is not
sure if they are
able or willing to
change
Safety and
Security:
Health,
employment,
property,
family, and
social stability
Persuasion: Unhoused
neighbor has regular
contact with peer
provider, trust and
regular contacts build,
unhoused neighbor is
willing to change and
is making limited
changes on their own,
and still meets criteria
for homelessness
Stressed:
Unhoused neighbor
is stressed by their
homelessness
Voice: Unhoused
neighbor has been
working with peer
provider for less than
one month, is
identifying needs, and is
thinking about options
for support and services.
Peer provider completes
SCOUT assessment,
shares recovery story,
offers information and
education, continues to
develop the relationship
and trust, and provides
practical assistance to
meet safety and security
needs.
Preparation:
Unhoused
neighbor is
getting ready for
change
Love and
Belonging:
Friendship,
family,
intimacy; and
sense of
connection
Early Active
Treatment: Unhoused
neighbor is engaged
with peer provider, is
receiving support and
accessing services,
continuation of
changes, overcoming
barriers, and still
meets criteria for
homelessness
Decided:
Unhoused neighbor
has decided to pick
a support or service
goal
Poise: Unhoused
neighbor has been
working with peer
provider for at least one
month, is agreeing to
engage in support and
services, and is taking
steps to meet identified
needs. Peer provider
offers supportive
services, collaborates on
CAPSTONE PROJECT PAPER 86

goals, helps neighbor
consider what causes
and carries
homelessness for them
individually. Peer
provider completes
SCOUT assessment.
Action:
Unhoused
neighbor is
changing
behaviors
associated
homelessness
Self-Esteem:
Confidence,
achievement,
and respect of
others
Late Active
Treatment: Unhoused
neighbor continues to
engage with peer
provider, yet has not
met criteria for
homelessness for the
past one to five
months
Developed:
Unhoused neighbor
has developed new
skills and resources
to promote support
and access services
Choice: Unhoused
neighbor has been
working with peer
provider for one to five,
is overcoming barriers,
and working on routines
and resources that
promote independence
and confidence. Peer
provider offers
additional skills and
supports and completes
SCOUT assessment.
Maintenance:
Formerly
unhoused
neighbor is
maintaining
changes
Self-
Actualization:
Morality,
creativity,
spontaneity,
and acceptance
Relapse Prevention:
Formerly unhoused
neighbor is still
engaged with peer
provider, yet has not
met criteria for
homelessness for the
past six to 12 months
Sustained:
Formerly unhoused
neighbor has
continued support
and services and is
living beyond their
homelessness
Control: Formerly
unhoused neighbor has
been working with peer
provider for more than
six months, is realizing
their hopes and dreams,
and is living their best
life. Peer provider
completes SCOUT
assessment, works with
neighbor on prevention
plan, identifying cues to
homelessness, and
outlining ways to avoid
or handle these cues.
Figure 3. Comparison of Stage Models and Lowenstein’s Proposed Stages of Support
(Adapted from McHugo, Drake, Burton, & Ackerson, 1995; Thornton, Migdole, & Corniello,
2007; Mueser, Noordsy, Drake, & Fox, 2010; SAMHSA, 2010; Lester, 2013; Prochaska, 2013)

CAPSTONE PROJECT PAPER 87

Appendix D: Capstone Prototype

We Are Our Neighbors’ Keeper:
An Innovative Field Kit of Outreach and
Assessment Tools to
Help End Homelessness
Keren Lowenstein CRAADC, LCSW
DSW Candidate
CAPSTONE PROJECT PAPER 88

Capstone Prototype Table of Contents

Table of Contents 88
Congratulations 89
Package Contents 89
Blue Ocean Innovations® and OneGirl Enterprises 90
Our Infrastructure 91
Our Guiding Beliefs 92
Our Mission 93
Our Vision 93
Our Values 93
Our Services 94
Help and Hope When You Need It 95
The Wicked Problem 95
The Supernorm 95
Creative Solutions to Life’s Problems 97
Practices: Field Kit of Outreach and Assessment Tools 97
Policies: Universal Standards of Street Outreach 98
Programs: Evidence-Based Street Outreach Model 100
Products: Stage of Change Outreach and Utilization Tool (SCOUT) 101
Prototypes 102
Field Kit of Outreach and Assessment Tools Tip Sheet 102
Universal Standards of Street Outreach Advocacy Brief 106
Evidence-Based Street Outreach Model Protocol 109
Evidence-Based Street Outreach Model Memorandum of Understanding 115
and Partner Agreement
Stage of Change Outreach and Utilization Tool (SCOUT) QuickStart Guide 118
Prototype Testing 123
Prototype Appendices 124
Prototype Appendix A: The Evidence 124
Prototype Appendix B: SCOUT Version 1.0 128
Prototype Appendix C: SCOUT Version 2.0 140

CAPSTONE PROJECT PAPER 89

We Are Our Neighbors’ Keeper:
An Innovative Field Kit of Outreach and Assessment Tools to
Help End Homelessness

Congratulations on your purchase of our Field Kit of Outreach and Assessment Tools. At Blue
Ocean Innovations and OneGirl Enterprises, your satisfaction is as important to us as it is to you.
That is why we design products, practices, programs, and policies with one thing in mind – to
give you the help and hope you need when you need it.

Package Contents

• Field Kit of Outreach and Assessment Tools
• Stage of Change Outreach and Utilization Tool (SCOUT)
• USB Charging Adapter
• Micro-USB Cable

CAPSTONE PROJECT PAPER 90

Blue Ocean Innovations

OneGirl Enterprises

Blue Ocean Innovations is a trademark (pending application approval) of OneGirl Enterprises.
OneGirl Enterprises is a membership association that embraces:

• Structural flatness
• Transorganizational shared approach
• Societal goals first
• Ecological goals second
• Fiscal goals third
• Inclusion
• Diversity
CAPSTONE PROJECT PAPER 91

Our Infrastructure

Blue Ocean Innovations and OneGirl Enterprises is proud to offer the needed infrastructure to
support our innovative solutions, including:

• Limited Liability Corporation (LLC) documentation
• Copyrights
• Trademarks
• Licenses
• Patents
• Support

Limited Liability Corporation (LLC) documentation.

OneGirl Enterprises is registered in the U.S. and other countries (pending application
approval).

Copyrights.

The copyrights to the Universal Standards of Street Outreach Advocacy Brief, Evidence-
Based Street Outreach Model Protocol, Field Kit of Outreach and Assessment Tools Tip Sheet,
and Stage of Change Outreach and Utilization Tool (SCOUT) QuickStart Guide are owned by
OneGirl Enterprises and Blue Ocean Innovations (pending application approvals).

Trademarks.

OneGirl Enterprises, Blue Ocean Innovations, Stage of Change Outreach and Utilization
Tool (SCOUT), Help and Hope When You Need It, Creative Solutions to Life’s Problems,
OneGirl-Many Innovations, and #SeeMe are trademarks of OneGirl Enterprises (pending
application approvals).

Licenses.

All other product names, company names, trademarks, or trade names are those of their
respective owners.

Patents.

Stage of Change Outreach and Utilization Tool (SCOUT) patent is registered in the U.S.
(pending application approvals).

CAPSTONE PROJECT PAPER 92

Support.

• Important! Please read this before returning the product!
• We want to help! If you are having problems installing or using your product, our
support team can help troubleshoot, walk you through product and software installation,
and help with spare and replacement parts.
• Email us! Please email us at helpandhope@blueoceaninnovations.org for additional
product or technical support. We are happy to help you get up and running as quickly as
possible.
• Visit our website! Please visit https://blueoceaninnovations.org/ for the latest
information about this product:

o Documentation
o Technical specifications
o System requirements
o Compatibility information
o Troubleshooting guides
o Video tutorials
o Software updates
o Driver updates
o Product manuals
o Product registration

• Call us! Please call us at 417-621-5884 for support Monday – Friday (except holidays)
9:00 am – 4:00 pm, CST. Before calling:

o Please have your product and its manuals with you
o If possible, have your product powered on and running

Our Guiding Beliefs

All members of Blue Ocean Innovations and OneGirl Enterprises are committed to the mission,
vision, and values that guide our membership association. Adherence to these specific ideals
ensures that we offer the very best, most innovative policies, programs, practices, products, and
services to every neighbor in our organization and provides the foundation for our association’s
dynamic development.

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Blue Ocean Innovations and OneGirl Enterprises invest in:

• Skill-based compensation
• Reasonable revenues
• Societal, ecological, and fiscal accountability
• Shared knowledge, capital, and influence
• Leveraging interconnected associations

Blue Ocean Innovations and OneGirl Enterprises promote:

• Green
• Good (transparent and responsible)
• Information exchange
• Participation of internal and external members
• Communication through all-inclusive feedback loops

Our Mission

Blue Ocean Innovations and OneGirl Enterprises offer neighbors creative solutions to life’s
problems.

Our Vision

Blue Ocean Innovations and OneGirl Enterprises envision neighbors getting the help and hope
they need when they need it.

Our Values

At Blue Ocean Innovations and OneGirl Enterprises:

• We deliver innovative designs.
• We are dedicated to our neighbors.
• We are each accountable for providing the highest level of policies, programs, practices,
products, and services to our neighbors.
• We constantly improve our performance to attain innovation.
• We create new policies, programs, practices, products, and services to meet the needs of
our neighbors and communities.

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Our Services

At Blue Ocean Innovations and OneGirl Enterprises, we offer:

• Individual and Organizational Consultation
• Professional Development
• Innovative Technology Design
• Intervention Design
• Public Speaking
• Grant Writing
• Ghost Writing
• Illustration
• Logo Development
• Graphic Design
• Training

CAPSTONE PROJECT PAPER 95

Help and Hope When You Need It

Blue Ocean Innovations and OneGirl Enterprises envision neighbors getting the help and hope
they need when they need it.

The Wicked Problem

Our unhoused neighbors are aging too early and dying too soon. Homelessness is a wicked
problem in America. One and a half million adults (Padget & Henwood, 2018) and 4.2 million
children are homeless each year (Fadel & Figueroa, 2017). Nearly 25 percent of our unhoused
neighbors experience chronic homelessness (HUD, 2018). More than 50 percent of our
unhoused neighbors are over the age of 50 (Brown et al., 2016). Our chronically unhoused
neighbors face an average life expectancy of 47 years of age, as compared to 78 years of age for
you and I (Brown et al., 2016). Our unhoused neighbors encounter difficulties accessing needed
care due to no-door, wrong-door, and closed-door systems of care.

The Supernorm

The supernorm that holds the wicked problem in place is, “treat ‘em and street ‘em”, which
manifests in the form of no- to low-quality health care (Warshaw, 2017) that divides the “haves”
and “have-nots” (Calvo, Teasley, Goldbach, McRoy, & Padilla, 2018). The wicked problem and
supernorm are associated with a throwaway society, bootstrap mentality, and moral injury; which
leads to broken trust and psychological damage.

Throwaway society.

As a result of universal consumerism, we live in a throwaway society (Charlton, 2015).
From digital technology and ballpoint pens to household pets and even human beings, our
culture tends to discard the old, broken, and outdated from our homes, agencies, and
neighborhoods. At times, the monetary costs of repairing everyday items or attending to the
health of others surpass the social costs; which is one reason why scrapheaps, nursing homes,
humane societies, penitentiaries, and homeless shelters are full (Gorelick, 2017).

Bootstrap mentality.

Due in part to the American Dream, the bootstrap mentality is an emblematic ideal that
encourages neighbors to pull themselves up the axiomatic socioeconomic ladder without any
assistance through hard work, tenacity, and accountability (Calvo, Teasley, Goldbach, McRoy, &
Padilla, 2018; Rooks, 2012). The bootstrap mentality criticizes neighbors when they are unable
to rise from scarcity and hardship or when they can with assistance from others (Calvo, Teasley,
Goldbach, McRoy, & Padilla, 2018; Rooks, 2012).

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Moral injury.

Moral injury is a deep and lasting adversity that intrudes upon one’s moral standards over
the lifespan (Maugen & Litz, 2015). Moral injury happens when conditions and communications
interfere with personal dignity, worth, and choice (Alford, 2016), including not having a decision
about where to eat, sleep, or use the restroom (Hecht, 2016) or being disparaged, villainized, or
ostracized for one’s unhoused status (Murray, 2018). Moral injury ensues when our unhoused
neighbors experience betrayal, blame, and anger and leads to shattered trust and psychosocial
suffering (Sherman, 2015).

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Creative Solutions to Life’s Problems

Blue Ocean Innovations and OneGirl Enterprises offer neighbors creative solutions to life’s
problems. Blue Ocean Innovations and OneGirl Enterprises offer a diverse set of standalone and
nested innovations to solve a variety of life’s problems.

Practices: Field Kit of Outreach and Assessment Tools

The Field Kit of Outreach and Assessment Tools is used by peer providers (individuals who have
lived experience with homelessness) during Evidence-Based Street Outreach to measure change
motivation with SCOUT. SCOUT is utilized in conjunction with a stage-matched service
provision matrix that informs interventions, which guides behavior change. The empirical
evidence behind the innovation includes:

• The rejection-identification model identifies the impact of shame and judgment on
unhoused neighbors (Johnstone, Jetten, Dingle, Parsell, & Walter, 2015).
• Trauma and the Continuity of Self: A Multidimensional, Multidisciplinary Integrative
(TCMI) framework emphasizes the intricate interplay between individual unhoused
identity; response to social avoidance, rejection, and indifference of homelessness; and
vulnerability and immovability associated with enduring deep and persistent trauma and
adapting to life afterward (Danieli, Norris, & Engdahl, 2016).

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Policies: Universal Standards of Street Outreach

Universal Standards of Street Outreach are guiding principles that serve as the foundation for the
Evidence-Based Street Outreach Model and Field Kit of Outreach and Assessment Tools. The
guiding principles include the following:

• Build positive relationships
• Create a safe presence
• Make weekly visits to camps, tent cities, shelters, parks, and other places where our
unhoused neighbors congregate
• Develop trust (EscaRosa Coalition on the Homeless, 2016)
• Create open dialogue
• Individualize approaches and interventions
• Follow policy, program, practice, and product fidelity (National Council on Crime and
Delinquency, 2009)
• Give unhoused neighbors choice and voice in service provision (Padget & Henwood,
2018)
• Remember, one size does not fit all (Padget & Henwood, 2018; National Healthcare for
the Homeless Council, 2016)
• Assess baseline stage of change
• Determine housing, health care, and social service readiness
• Remain responsive to neighbors’ needs
• Promote transdisciplinary teamwork
• Coordinate access to care
• Ensure Universal Standards of Street Outreach are driven by quality improvement
(National Healthcare for the Homeless Council, 2016)
CAPSTONE PROJECT PAPER 99

• Conceptualize unhoused neighbors and homelessness in a person-first, strengths-based
manner, such as identifying individuals who may not have a permanent home by using
the term “unhoused” over “homeless” (Biagiotti, 2016) or identifying who may access
services by using the term “deserving” over “undeserving” (Petrenchick, 2006)
• Remember, needed services will not apply seamlessly to all unhoused neighbors
• Understand unhoused neighbors will vacillate between stages of change
• Provide time unlimited supports and services
• Acknowledge that interventions may not explain behavioral change for any unhoused
neighbor (Substance Abuse and Mental Health Services Administration (SAMHSA),
2005).

CAPSTONE PROJECT PAPER 100

Programs: Evidence-Based Street Outreach Model

The Evidenced-Based Street Outreach Model integrates best practices and community-shared,
peer provider-led street outreach teams with a Field Kit of Outreach and Assessment Tools
adapted for use with our unhoused neighbors. The empirical evidence behind the innovation
include the following:

• Maslow’s hierarchy of needs looks at the impact of homelessness on scarcity and need
(Henwood, Derejko, Couture & Padgett, 2015).
• Trauma-Informed Care (TIC) is recognized by SAMHSA as an evidence-based practice
(EBP) rooted in trust, peer support, and self-determination (SAMHSA, 2014).

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Products: SCOUT

SCOUT brings readiness to change assessments into the twenty-first century by integrating an
evidence-based survey, Likert scale, gameplay mechanics, algorithms, microtechnology, and
stage-matched service provision matrix into a portable device. The empirical evidence behind the
innovation include:

• Prochaska’s stages of change theory measure progress via a set of principles based on the
pros and cons of the change process (DiClemente, Nidecker, & Bellack, 2008).
• Game theory views goal attainment through the lens of how neighbors interact with one
another, and how these exchanges influence individual and organizational change
motivation (Jolly, 2014; Myerson, 1999).
• Brief Negotiated Interview (BNI) is recognized by SAMHSA as an EBP rooted in
motivational interviewing (MI) to assess behavior change (SAMHSA, n.d. & Boston
University, n.d.).
• Likert scale scores a level of agreement with a survey item (Solli-Saether & Gottschalk,
2010).
• Gameplay mechanics engage neighbors with SCOUT in contemplating their
homelessness (Van Grove, 2011).
• Micro-technology from the maker movement informs the hardware design and software
code of SCOUT (Bajarin, 2014).
• Artificial intelligence (AI) and machine learning (ML) algorithms identify change
motivation, predict stage of change based on survey responses, and guide service
intervention (Marr, 2016).

CAPSTONE PROJECT PAPER 102

Prototypes

Field Kit of Outreach and Assessment Tools Tip Sheet

Our tip sheet outlines how the Field Kit of Outreach and Assessment Tools is employed by peer
providers during street outreach to measure change motivation with SCOUT. The Field Kit of
Outreach and Assessment Tools Tip Sheet includes an outreach and assessment workflow, peer
provider responsibilities, known unhoused neighbor locations, safety tips, and a street
outreach/homelessness verification form.

Outreach and assessment workflow.

• Unhoused neighbor is identified
• Peer providers follow Universal Standards of Street Outreach
• Peer providers utilize the Field Kit of Outreach and Assessment Tools, including SCOUT
during Evidence-Based Street Outreach
• Notice of Neighbor Rights form (under development) is signed by our neighbor
• The completed form is entered into the homelessness management information system
(HMIS) by a peer provider
• Peer providers accompany unhoused neighbors to appropriate area programs and
services, if requested by our unhoused neighbor
• Completed assessments, verification forms, and Neighbor Rights forms are turning into
the Housing Connect/Coordinated Entry Coordinator

Peer provider responsibilities.
CAPSTONE PROJECT PAPER 103

• Locate unhoused neighbors in camps, cars, tent cities, and shelters on a weekly basis
• Assess unhoused neighbors for change motivation using SCOUT at baseline (initial
contact) and weekly or monthly, depending on unhoused neighbor preference
• Assist unhoused neighbors with immediate needs, such as food, water, clothing, shelter,
health care
• Assist unhoused neighbors with a letter to verify homelessness
• Accompany unhoused neighbors to needed resources and referrals, such as Housing
Connect/Coordinated Entry, food banks, clothing services, medical services, behavioral
health services, and Veterans Administration (VA) services
• Collaborate with local agencies and volunteers to create a partnership that cultivates
shared resources, services, and community learning
• Assist unhoused neighbors in locating suitable housing
• Provide coaching and case management
• Complete HMIS on unhoused neighbor
• Advocate for unhoused neighbor

Known unhoused neighbor locations.

• North Joplin area:

o Spiva Park
o 9
th
and Iowa
o Murphy Boulevard by railroad tracks
o 10
th
and Maiden Lane behind Budget Inn and Guitars
o Joplin Animal Adoption and Resource Center
o Joplin Depot area
o Watered Gardens area
o Between 12
th
and 14
th
East Iowa
o Ewert Park
o Schifferdecker Park near the baseball fields
o 7
th
Street Walmart near the greenhouse area and by the road
o Frisco Trail
o Wooded area near Northpark Apartments

• South Joplin area:

o Wooded area behind Sam’s Club and Victory Ministries
o Wooded area behind what used to be the Juke Box Bar
o Shoal Creek/Low Water Bridge
o Wooded area behind Walmart on 15
th
and Rangeline
o Petro truck stop area
CAPSTONE PROJECT PAPER 104

o Flying J truck stop area
o Wooded area near Walmart on Maiden Lane
o Osborn Cemetery
o Behind what used to be Price Cutter on Maiden Lane
o Under overpass on Interstate-44 South Joplin
o Wooded area near Irving School

• Webb City:

o Walmart area

• Neosho:

o Lime Kiln Road/Allen Bridge

Safety tips.
• Be your authentic and genuine self
• Get comfortable with being uncomfortable
• Remember, every unhoused neighbors’ story is different so, do not say, “I know what
you are going through,” “I understand,” or “I’ve been there” even if you have
• Bring a flashlight and wear layers
• Be approachable and sincere
• Do not get defensive or reactive
• Remember, this is not about you
• Think before you talk
• Keep yourself safe and do not go into emotional or physical territory that may trigger you
• Know your limits
• Do not assume anything
• Remember to stay hydrated and protect yourself from the wind, rain, snow, and sun
• Give out survival packs to give out, including gloves, hats, socks, toiletries, non-
perishables, condoms, flashlights, fingernail clippers, etc. (Olivet, 2008)
Street outreach/homelessness verification form.

Neighbor Name:____________________________________________ Date:_____________

DOB:____________________________________ SS#:______________________________

Race:_______________ Gender:______________ Head of Household:________________

Veteran:_____________ Health Insurance:____________ Last Stable Zip Code:_________

CAPSTONE PROJECT PAPER 105

Phone Number or Contact Information:______________________________________________

Type of Disability:___________________ Domestic Violence/Currently Fleeing:___________

Income Type and Amount:________________________________________________________

Non-Cash Benefits and Amount:___________________________________________________

Housing Status:_________________________________________________________________

Current Living Situation:_________________________________________________________

Sleeping Location:_________________________ Number of Nights at this Location:_______

Number of Nights Homelesss:__________ How Many Times Homeless (three years):_______

Notes:________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

__________________________________________ ______________________________
Outreach Worker Name Position or Title
__________________________________________ ______________________________
Agency Phone Number
---------------------------------------------------------------------------------------------------------------------

__________________________________________ ______________________________
Outreach Worker Name Position or Title
__________________________________________ ______________________________
Agency Phone Number

References.

Olivet, J. (2008). Tips for outreach workers by outreach workers. Retrieved from
https://www.homelesshub.ca/resource/tips-outreach-workers-outreach-workers

CAPSTONE PROJECT PAPER 106

Universal Standards of Street Outreach Advocacy Brief

Our advocacy brief argues in favor of guiding principles of outreach and assessment that serve as
the foundation for the Evidence-Based Street Outreach Model, Field Kit of Outreach and
Assessment Tools, and SCOUT. The Universal Standards of Street Outreach Advocacy Brief
includes the issue history, program history, available services, and ways to learn more.

Issue history.

• Homelessness is a wicked problem in America.
• Our unhoused homeless neighbors are aging too early and dying too soon.
• One and one half million adults (Padget & Henwood, 2018) and 4.2 million children are
homeless each year (Fadel & Figueroa, 2017).
• Nearly 25 percent of our unhoused neighbors experience chronic homelessness (HUD,
2018).
• More than 50 percent of our unhoused neighbors are over the age of 50 (Brown et al.,
2015).
• Our chronically unhoused neighbors face an average life expectancy of 47 years of age,
as compared to 78 years of age for you and I (Brown et al., 2015).
• Our unhoused neighbors encounter difficulties accessing needed services due to no-door,
wrong-door, and closed-door systems of care.

Program history.

• To increase exits from homelessness, Blue Ocean Innovations and OneGirl Enterprises
established Universal Standards of Street Outreach.
CAPSTONE PROJECT PAPER 107

• As a new practice, the Field Kit of Outreach and Assessment Tools is employed by peer
providers during Evidence-Based Street Outreach to measure change motivation with
SCOUT. SCOUT is utilized in conjunction with a stage-matched service provision
matrix that informs service interventions, which guides behavior change.
• As a new policy, the Universal Standards of Street Outreach are guiding principles that
serve as the foundation for the Evidence-Based Street Outreach Model, Field Kit of
Outreach and Assessment Tools, and SCOUT.
• As a new program, the Evidence-Based Street Outreach Model integrates best practices
and community-shared, peer provider-led street outreach teams with the Field Kit of
Outreach and Assessment Tools adapted for use with our unhoused neighbors.
• As a new product, SCOUT brings readiness to change assessments into the twenty-first
century by integrating an evidence-based survey, Likert scale, gameplay mechanics,
algorithms, micro-technology, and stage-matched service provision matrix into a portable
device.

Available services.

• Street-based outreach and education
• Readiness to change assessments
• Trauma-informed support
• Referrals and resources
• Crisis intervention and prevention
• Follow-up support

Learn more.

• Blue Ocean Innovations and OneGirl Enterprise, LLC
PO Box 3474
Joplin, MO 64803
• 417-621-5884
• helpandhope@blueoceaninnovations.org
• www.blueoceaninnovations.org

References.

• Brown, R. T., Goodman, L., Guzman, D., Tieu, L., Ponath, C., & Kushel, M. B. (2016,
May 10). Pathways to homelessness among older homeless adults: Results from the
HOPE HOME study. Plos One. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4862628/pdf/pone.0155065.pdf
• Fadel, L. & Figueroa, A. (2017, November 16). New study finds that 4.2 million kids
experience homelessness each year. National Public Radio. Retrieved from
CAPSTONE PROJECT PAPER 108

https://www.npr.org/sections/ed/2017/11/15/564370605/new-study-finds-that-4-2-
million-kids-experience-homelessness-each-year
• Padget, D. K. & Henwood, B. F. (2018). End homelessness. In R. Fong, J. E. Lubben, &
R. P. Barth (Eds.), Grand challenges for social work and society. New York, NY:
Oxford University Press.
• United States Department of Housing and Urban Development, Office of Community
Planning and Development (2018, December). The 2018 annual homeless assessment
report (AHAR) to Congress. Part 1: Point-in-time estimates of homelessness. Retrieved
from https://www.hudexchange.info/resources/documents/2018-AHAR-Part-1.pdf

CAPSTONE PROJECT PAPER 109

Evidence-Based Street Outreach Model Protocol

Our Evidence-Based Street Outreach Model Protocol integrates best practices and community-
shared, peer provider-led street outreach team with the Field Kit of Outreach and Assessment
Tools adapted for use with our unhoused neighbors. The Evidence-Based Street Outreach Model
Protocol governs the Jasper and Newton County Continuum of Care (CoC) Street Outreach
program, which include the components associated with implementation, operation, and
evaluation. The Street Outreach program collaborates with local agencies and volunteers to
create a partnership that leverages resources and services for our neighbors experiencing
homelessness. The Evidence-Based Street Outreach Model Protocol includes geographic area,
target population, definition of homelessness and chronic homelessness, outreach and assessment
tools, resource materials, intake and referral workflow, role of peer providers, neighbor choice,
nondiscrimination, evaluation, and training.

Geographic area.

The Evidence-Based Street Outreach Model covers the entire (CoC) geographic area of
Jasper and Newton Counties. Identification of outdoor locations occurs in all cities within the
CoC geographic area by following up with local law enforcement and service providers.

Target population.

Unsheltered neighbors over the age of 50 experiencing homelessness.

Definition of homelessness.

CAPSTONE PROJECT PAPER 110

The Evidence-Based Street Outreach Model Protocol follows the HUD (2012) definition
of homelessness, which describes a neighbor who is living in a space not meant for human
occupancy, in an emergency shelter, in transitional housing, or is leaving an institution where
they temporarily stayed; a neighbor who is losing their main nighttime dwelling; or a neighbor
who is escaping or attempting to escape domestic violence, has no other dwelling, and lacks the
resources or support to secure a permanent dwelling.

Definition of chronic homelessness.

The Evidence-Based Street Outreach Model follows the HUD (2015) definition of
chronic homelessness, which describes a neighbor who is literally homeless and has a disability
and regular episodes of homelessness or is steadily homeless for at least one year, and does not
have a safe, consistent, and adequate nighttime dwelling.

Outreach and assessment tools.

Peer providers utilize the Field Kit of Outreach and Assessment Tools and SCOUT.

Resource materials.

A variety of resource materials are utilized during street outreach, including:

• Area meal sites
• The Homeless Coalition Pocket Pal
• Housing Connect/Coordinated Entry tear-offs and documentation requirement sheets
• The Salvation Army’s Shower the People program flyer
• Other local social service information, flyers, and cards

Intake and referral workflow.

• Unhoused neighbors are identified
• Peer providers utilize the Field Kit of Outreach and Assessment Tools, including SCOUT
to engage neighbors with street outreach teams and assess change motivation
• Notice of Neighbor Rights form (under development) is signed by the neighbor
• The completed form is entered into HMIS by a peer provider
• Peer providers accompany unhoused neighbors to appropriate area programs and
services, if requested by our unhoused neighbor
• Completed assessments, verification forms, and Neighbor Rights forms are turning into
the Housing Connect/Coordinated Entry Coordinator

Role of peer providers.

CAPSTONE PROJECT PAPER 111

• Locate unhoused neighbors in camps, cars, tent cities, and shelters on a weekly basis
• Assess unhoused neighbors for change motivation using SCOUT at baseline (initial
contact) and weekly or monthly, depending on unhoused neighbor preference
• Assist unhoused neighbors with immediate needs, such as food, water, clothing, shelter,
health care
• Assist unhoused neighbors with a letter to verify homelessness
• Accompany unhoused neighbors to needed resources and referrals, such as Housing
Connect/Coordinated Entry, food banks, clothing services, medical services, behavioral
health services, and Veterans Administration (VA) services
• Collaborate with local agencies and volunteers to create a partnership that cultivates
shared resources, services, and community learning
• Assist unhoused neighbors in locating suitable housing
• Provide coaching and case management
• Complete HMIS on unhoused neighbor
• Advocate for unhoused neighbor

Neighbor choice.

Unhoused neighbors have the freedom to choose the type of housing, health care, and
social service programs in which they want to participate.

Nondiscrimination.

The Evidence-Based Street Outreach Model Protocol is intended to serve all neighbors,
regardless of race, color, national origin, religion, sexual orientation, gender identity, disability,
age, sex, familial status, or marital status. All programs receiving federal and state funds comply
with applicable civil rights and fair housing laws and requirements, and recipients and sub-
recipients of CoC program and Emergency Solution Grants (ESG) program-funded projects
comply with the nondiscrimination and equal opportunity provisions of federal civil rights law,
including the following:

• The Fair Housing Act prohibits discriminatory housing practices based on race, color,
religion, sex, national origin, disability or familial status (HUD, n.d.).
• Section 504 of the Rehabilitation Act prohibits discrimination based on disability under
any program or activity receiving federal financial assistance (Disability Rights
Education and Defense Fund, n.d.).
• Title IV of the Civil Rights Act prohibits discrimination on the basis of race, color, or
national origin under any program or activity receiving federal financial assistance
(FindLaw, 2019).
• Title II of the Americans with Disabilities Act prohibits public entities, which include
state and local governments, and special purpose districts, from discriminating against
individuals with disabilities in all their services, programs, and activities, including
CAPSTONE PROJECT PAPER 112

housing, and housing-related services such as housing search and referral assistance
(ADA National Network, n.d.).
• Title II of the American with Disabilities Act prohibits private entities that own, lease,
and operate places of public accommodation, including shelters, social service
establishments, and other public accommodations providing housing, from discriminating
on the basis of disability (ADA National Network, n.d.).
• HUD’s Equal Access Rule at 24 CFR 5.105(a)(2) prohibits discriminatory eligibility
determination in HUD-assisted or HUD-insured housing programs based on actual or
perceived sexual orientation, gender identity, or marital status, including any projects
funded by the CoC program, ESG program, and Housing Opportunities for Persons With
AIDS (HOPWA) program (National Alliance to End Homelessness, 2019).
• The CoC program interim rule also contains a fair housing provision at 24 CFR 578.93
(Cornell Law School, n.d.). For ESG, see 24 CFR 576.407(a), and for HOWPA, see 24
CFR 574.603 (Cornell Law School, n.d.).

At any time during the street outreach process, unhoused neighbors have the right to file a
complaint, should they feel that this principle has been violated. All unhoused neighbors are
provided with the process for filing a complaint. All complaints are addressed and resolved in a
timely and fair manner.

The following contacts are provided to address discrimination or grievance related concerns:

• For nondiscrimination complaints: contact HUD
400 State Avenue, #200
Kansas City, KS 66101
913-551-5462
https://portal.hud.gov/hudportal/HUD?src=/program_offices/fair_housing_equal_opp/onl
inecomplaint
• For housing program-related complaints: grievances are directed to the appropriate
housing provider for resolution.
• For street outreach related complaints: grievances are directed to the Executive
Committee of the Homeless Coalition.

Evaluation.

The Homeless Coalition evaluates the effectiveness of the Evidence-Based Street
Outreach Model. The Street Outreach Committee gathers quantitative data elements included on
the homelessness verification form, such as:

• Number of homeless neighbors assessed
• Number of homelessness verification letters written
• Unsheltered locations
CAPSTONE PROJECT PAPER 113

• Number of individuals who are housed that were assessed with SCOUT and received a
homelessness verification letter
• Stage of change

Training.

Training for all peer providers includes:

• Data collection standards
• Evidence-Based Street Outreach Model Protocol
• Overview of Housing Connect/Coordinated Entry
• Trauma-Informed Care (TIC)

References.

• ADA National Network (n.d.). What is the Americans with Disabilities Act (ADA)?
Retrieved from https://adata.org/learn-about-ada
• Cornell Law School (n.d.). Electronic code of federal regulations title 24. Housing and
Urban Development subtitle B. Regulations relating to Housing and Urban Development
chapter V. Office of Assistant Secretary for Community Planning and Development,
Department of Housing and Urban Development subchapter C. community facilities part
576. Emergency solutions grants program subpart B. Program components and eligible
activities section 576.101. Street outreach component. Retrieved from
https://www.law.cornell.edu/cfr/text/24/576.101
• Cornell Law School (n.d.). Electronic code of federal regulations title 24. Housing and
Urban Development subtitle B. Regulations relating to Housing and Urban Development
chapter V. Office of Assistant Secretary for Community Planning and Development,
Department of Housing and Urban Development subchapter C. community facilities part
576. Emergency solutions grants program subpart E. Program requirements section
576.407. Other federal requirements. Retrieved from
https://www.law.cornell.edu/cfr/text/24/576.407
• Cornell Law School (n.d.). Electronic code of federal regulations title 24. Housing and
Urban Development subtitle B. Regulations relating to Housing and Urban Development
chapter V. Office of Assistant Secretary for Community Planning and Development,
Department of Housing and Urban Development subchapter C. community facilities part
574. Housing opportunities for persons with AIDS subpart G. Other federal requirements
section 574.603. Nondiscrimination and equal opportunity. Retrieved from
https://www.law.cornell.edu/cfr/text/24/574.603
• Disability Rights Education and Defense Fund (n.d.). Section 504 of the rehabilitation
act of 1973. Retrieved from https://dredf.org/legal-advocacy/laws/section-504-of-the-
rehabilitation-act-of-1973/
• FindLaw(2019). Title IV of the civil rights act of 1964. Retrieved from
CAPSTONE PROJECT PAPER 114

https://civilrights.findlaw.com/discrimination/title-iv-of-the-civil-rights-act-of-1964-
desegregation-of-public.html
• National Alliance to End Homelessness (2019, August 12). HUD’s equal access rule.
Retrieved from https://endhomelessness.org/resource/huds-equal-access-rule/
• United States Department of Housing and Urban Development (n.d.). Fair housing act.
Retrieved from
https://www.hud.gov/program_offices/fair_housing_equal_opp/fair_housing_act_overvie
w
• United States Department of Housing and Urban Development, Office of Community
Planning and Development (2015, December). Homeless emergency assistance and rapid
transition to housing (HEARTH): Defining chronically homeless final rule. Retrieved
from https://www.hudexchange.info/resource/4847/hearth-defining-chronically-
homeless-final-rule/

CAPSTONE PROJECT PAPER 115

Evidence-Based Street Outreach Model
Memorandum of Understanding and Partner Agreement

The Evidence-Based Street Outreach Model Memorandum of Understanding (MOU) and Partner
Agreement delineates the purpose, mission and guiding principles of street outreach, governance,
and role and responsibility of partners.

Memorandum of understanding and partner agreement.

This Memorandum of Understanding (MOU) is effective on _________________________

between the Joplin/Jasper and Newton County Homeless Coalition and ____________________

_____________________________________ regarding the Evidence-Based Street Outreach

Model.

Purpose.

One of the vital tools that HUD recognizes for combating and decreasing homelessness is
for CoCs to have in place an effective street outreach program. Goals and procedures for street
outreach are outlined in the Evidence-Based Street Outreach Model Protocol.

Mission and guiding principles.

The mission of the Evidence-Based Street Outreach Model is to improve the quality of
CAPSTONE PROJECT PAPER 116

life for neighbors in the CoC impacted by all aspects of homelessness through community
education, resource sharing, and service coordination. The guiding principles of the Evidence-
Based Street Outreach Model are grounded in the Universal Standards of Street Outreach, which
aims to reach out to neighbors who are experiencing unsheltered homelessness in the CoC, to
assess change motivation, and to offer assistance in accessing needed care and services.

Governance.

The Evidence-Based Street Outreach Model is piloted under the direction of the Street
Outreach Committee of the CoC.

Role and responsibility of partners.

Partners determine a monthly schedule for conducting street outreach in the region.
Partner peer providers follow the adopted Evidence-Based Street Outreach Model Protocol,
which includes:

• Locate unhoused neighbors in camps, cars, tent cities, and shelters on a weekly basis
• Assess unhoused neighbors for change motivation using SCOUT at baseline (initial
contact) and weekly or monthly, depending on unhoused neighbor preference
• Assist unhoused neighbors with immediate needs, such as food, water, clothing, shelter,
health care
• Assist unhoused neighbors with a letter to verify homelessness
• Accompany unhoused neighbors to needed resources and referrals, such as Housing
Connect/Coordinated Entry, food banks, clothing services, medical services, behavioral
health services, and Veterans Administration (VA) services
• Collaborate with local agencies and volunteers to create a partnership that cultivates
shared resources, services, and community learning
• Assist unhoused neighbors in locating suitable housing
• Provide coaching and case management
• Complete HMIS on unhoused neighbor
• Advocate for unhoused neighbor

The below named agency agrees to the above partner terms:

Partner Agency
Agency Name: _________________________________________________________________

Authorized Personnel: ____________________________________ ____________________
(Print Name) (Title)

Signature: ______________________________________________ Date: ______________
CAPSTONE PROJECT PAPER 117

Homeless Coalition
Authorized Official: ____________________________________ ____________________
(Print Name) (Title)

Signature: ______________________________________________ Date: ______________

CAPSTONE PROJECT PAPER 118

SCOUT QuickStart Guide

Our SCOUT QuickStart guide brings readiness to change assessments into the twenty-first
century by combining an evidence-based survey, Likert scale, gameplay mechanics, algorithms,
microtechnology, and stage-matched service provision matrix into a portable device. The
SCOUT QuickStart Guide includes setup, features, and operation.

Setup.

Items not listed under Congratulations > Package Contents are sold separately.

Figure 3.0. SCOUT.

CAPSTONE PROJECT PAPER 119

Features.

• Top Panel

Figure 3.1. SCOUT Top Panel

1. Touchscreen Display: The Wi-Fi enabled custom touchscreen interface displays
survey questions.
2. Momentary Response Pushbuttons: These LED illuminated buttons toggle
between normally open and closed to capture survey responses. The appropriate red,
yellow, or green LED will illuminate when the button is selected.
3. Camera Board: The NoInfraRed (NoIR) v2 is a high quality 8-megapixel Sony
IMX219 image sensor featuring a fixed focus lens. The camera board has a filter on
the lens that makes it perfect for image recognition in low light environments.
4. Mini Analog Joystick: The joystick has two 10KΩ potentiometers, so you record
“yes” and “no” responses in both X and Y directions.
5. Thermal Printer: A mini thermal receipt printer is embedded into the enclosure to
print text, stage of change score, the actual stage of change (i.e., precontemplation,
contemplation, preparation, or action), or a prediction of change motivation based on
responses.

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• Rear Panel

Figure 3.2. SCOUT Rear Panel

1. Latching Start/Stop Pushbutton: This white LED illuminated button toggles
between start and stop to initiate the survey portion of SCOUT. The LED will
illuminate when the SCOUT survey is started.
2. Latching Off/On Pushbutton: This blue LED illuminated button toggles between
off and on to power SCOUT off or on. The LED will illuminate when SCOUT is
powered on.
3. Speaker Set: Two 2.8" x 1.2" enclosed speakers provide audio volume and quality.
4. Micro-USB Port*: Use the included micro-USB cable to connect this port to a
computer or power adapter (DC 5 V) to charge SCOUT.
5. HDMI Port: Use an HDMI cable (sold separately) to connect this port to a monitor
or television.
6. Auxiliary Input: This stereo 1/8” (3.5mm) input can be used to connect to an
external audio source (sold separately).

*Note: For the fastest charging, power off SCOUT before connecting

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• Side panel.

Figure 3.3. SCOUT Side Panel

1. USB Ports*: Use a USB cable (sold separately) to connect the two ports to a
computer or other devices for endless capabilities.
2. Ethernet Port: Use an ethernet cable (sold separately) to connect this port to WiFi
or ethernet.

Operation.

Using SCOUT:

• Power SCOUT using the blue pushbutton
• To load the survey, press and release the white pushbutton
• Survey questions are displayed on the touchscreen monitor
• Ask or assist our unhoused neighbor with “yes” and “no” responses to demographic
questions using the mini joystick
• Ask or assist our unhoused neighbor with Likert scale responses to survey questions
using one of the red, yellow, or green pushbuttons, which correspond to the stages of
change:

o Red 1 = Precontemplation
o Red 2 = Contemplation
o Yellow = Preparation
o Green 1 = Action
o Green 2 = Prevention

• Upon completion of the survey, survey responses are printed via the mini printer using
the mini joystick to toggle through print options:
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o Text
o Stage of change score
o Actual stage of change
o Prediction of change motivation based on responses

CAPSTONE PROJECT PAPER 123

Prototype Testing

The work that has been done on pre-testing includes piloting the innovation as follows:

• Field Kit of Outreach and Assessment Tools will be piloted in collaboration with the
Joplin Homeless Coalition, Salvation Army of Joplin, Career Center, Children’s Haven,
Ozark Center, Economic Security Corporation, and Institute for Community Alliances
January 2020. Scaling the field kit includes insuring, licensing, and distributing the field
kit of tools (Kirchner, Waltz, Powell, Smith, & Proctor, 2018; Powell et al., 2015;
Proctor, Powell, & McMillen, 2013).
• Universal Standards of Street Outreach Advocacy Brief was developed in
collaboration with the Missouri Housing Development Commission (MHDC). Through
this testing, we learned that while most standards of street outreach are based on funding
stream requirements, such as engagement, case management, physical and behavioral
health services, transportation, emergency shelter (Pasadena Partnership to End
Homelessness, 2016; EscaRosa Coalition on the Homeless, 2016; Cornell Law School,
n.d.), standards that are more focused on guiding principles of outreaching vulnerable
neighbors does not yet exist. The standards are undergoing further revision with the
Governor’s Committee to End Homelessness (GCEH). Scaling the standards includes
disseminating and diffusing the intervention from Balance of State (BoS) CoCs to other
BoS CoC and then national levels (Kirchner, Waltz, Powell, Smith, & Proctor, 2018;
Powell et al., 2015; Proctor, Powell, & McMillen, 2013).
• Evidence-Based Street Outreach Model Protocol was developed in collaboration with
the Joplin Homeless Coalition, Salvation Army of Joplin, Career Center, Children’s
Haven, Ozark Center, Economic Security Corporation, and Institute for Community
Alliances. Piloting and refining the protocol consisted of training and deploying street
outreach teams, collecting and assessing data, monitoring progress, and making
modifications (Kirchner, Waltz, Powell, Smith & Proctor, 2018; Powell et al., 2015;
Proctor, Powell, & McMillen, 2013). Through this testing, we learned that the homeless
management information system (HMIS) is rigid in terms of data collection and data
entry, which informed our approach to deploying outreach teams in pairs (i.e., one staff
from a U. S. Department of Housing and Urban Development (HUD)-funded agency and
one staff from a non-HUD funded agency). The outreach model continues to be piloted
and will be re-evaluated in May 2020. Scaling the protocol includes disseminating and
diffusing the intervention from BoS CoCs to other BoS CoC and then national levels
(Kirchner, Waltz, Powell, Smith, & Proctor, 2018; Powell et al., 2015; Proctor, Powell, &
McMillen, 2013).
• SCOUT will be piloted in collaboration with the Joplin Homeless Coalition, Salvation
Army of Joplin, Career Center, Children’s Haven, Ozark Center, Economic Security
Corporation, and Institute for Community Alliances January 2020. Scaling innovation
includes attesting and manufacturing SCOUT (Kirchner, Waltz, Powell, Smith, &
Proctor, 2018; Powell et al., 2015; Proctor, Powell, & McMillen, 2013).
CAPSTONE PROJECT PAPER 124

Prototype Appendices

Prototype Appendix A: The Evidence

Alford, C. F. (2016). Depoliticizing moral injury. Journal of Psycho-Social Studies,
9(1), p. 8. Retrieved from http://www.psychosocial-studies-association.org/wp-
content/uploads/2017/01/Fred-Alford-Depoliticizing-Moral-Injury.pdf

Bajarin, T. (2014, May 19). Why the maker movement is important to America’s
future. Time Magazine. Retrieved from http://time.com/104210/maker-faire-maker-
movement/

Biagiotti, L. (2016). On the streets: A feature documentary on homelessness in L.A. Retrieved
from https://www.youtube.com/watch?v=WUsJcPc8g0A

Boston University School of Public Health (n.d.). Brief negotiated interview (BNI).
Retrieved from https://www.bu.edu/bniart/sbirt-in-health-care/sbirt-brief-negotiated-
interview-bni/

Brown, R. T., Goodman, L., Guzman, D., Tieu, L., Ponath, C., & Kushel, M. B. (2016,
May 10). Pathways to homelessness among older homeless adults: Results from the
HOPE HOME study. Plos One. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4862628/pdf/pone.0155065.pdf

Calvo, R., Teasley, M., Goldbach, J., McRoy, R., & Padilla, Y. C. (2018). Achieve
equal opportunity and justice. In R. Fong, J. E. Lubben, & R. P. Barth (Eds.), Grand
challenges for social work and society. New York, NY: Oxford University Press.

Charlton, C. (2015, February 28). Pope Francis in attack on “throwaway” culture of
world economy and financial inequality. Daily Mail. Retrieved from
https://www.dailymail.co.uk/news/article-2973570/Pope-Francis-attack-throwaway-
culture-world-economy-financial-inequality.html

Cornell Law School (n.d.). Electronic code of federal regulations title 24. Housing and
Urban Development subtitle B. Regulations relating to Housing and Urban Development
chapter V. Office of Assistant Secretary for Community Planning and Development,
Department of Housing and Urban Development subchapter C. community facilities part
576. Emergency solutions grants program subpart B. Program components and eligible
activities section 576.101. Street outreach component. Retrieved from
https://www.law.cornell.edu/cfr/text/24/576.101

Danieli, Y., Norris, F. H., & Engdahl, B. (2016, January 14). Multigenerational
legacies of trauma: Modeling the what and how of transmission. American Journal of
CAPSTONE PROJECT PAPER 125

Orthopsychiatry. Retrieved from
https://www.researchgate.net/publication/290442153_Multigenerational_Legacies_of_Tr
auma_Modeling_the_What_and_How_of_Transmission/download

DiClemente, C., Nidecker, M., & Bellack, A. S. (2008). Motivation and stage of
change among individuals with severe mental illness and substance abuse disorders.
Journal of Substance Abuse Treatment 34(1), 25-35. Retrieved from
https://www.researchgate.net/publication/6261919_Motivation_and_stage_of_change_a
mong_individuals_with_severe_mental_illness_and_substance_abuse_disorders

EscaRosa Coalition on the Homeless (2016, July). Written standards for service
providers regarding street outreach, emergency shelter, rapid rehousing, homeless
prevention, and permanent supportive housing activities. Retrieved from
https://escarosa.files.wordpress.com/2016/07/coc-written-standards.pdf

Fadel, L. & Figueroa, A. (2017, November 16). New study finds that 4.2 million kids
experience homelessness each year. National Public Radio. Retrieved from
https://www.npr.org/sections/ed/2017/11/15/564370605/new-study-finds-that-4-2-
million-kids-experience-homelessness-each-year

Gorelick, S. (2017, September 26). Our obsolescent economy: Modern capitalism
and “throwaway culture.” Ecologist: The Journal for the Post-Industrial Age. Retrieved
from https://theecologist.org/2017/sep/26/our-obsolescent-economy-modern-capitalism-
and-throwaway-culture

Hecht, C. (2016, September 29). A third of the homeless people in America are over
50. I’m one of them. Vox. Retrieved from https://www.vox.com/first-
person/2016/9/29/12941348/homeless-over-50-statistic

Henwood, B. F., Derejko, K. S., Couture, J., & Padgett, D. K. (2015). Maslow and
mental health recovery: A comparative study of homeless programs for adults with
serious mental illness. Administration and Policy in Mental Health and Mental Health
Services Research, 42(2), 220-228. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/24518968

Johnstone, M., Jetten, J., Dingle, G., Parsell, C., & Walter, Z. C. (2015, June).
Discrimination and well-being amongst the homeless: The role of multiple group
membership. Frontiers in Psychology, 6, 1-9. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450171/pdf/fpsyg-06-00739.pdf

Jolly, T. (2014 September 29). Using game theory to design games. League of
Gamemakers. Retrieved from http://www.leagueofgamemakers.com/using-game-theory-
to-design-games/
CAPSTONE PROJECT PAPER 126

Maguen, S. & Litz, B. (2015) Moral injury in the context of war. U.S. Department of
Veterans Affairs, National Center for PTSD. Retrieved from
https://www.ptsd.va.gov/professional/co-occurring/moral_injury_at_war.asp

Marr, B. (2016, December 06). What is the difference between artificial intelligence
and machine learning? Forbes. Retrieved from
https://www.forbes.com/sites/bernardmarr/2016/12/06/what-is-the-difference-between-
artificial-intelligence-and-machine-learning/#540f47162742

Murray, A. (2018, January 16). What if LA’s homeless population were a city? Los
Angeles Times. Retrieved from http://www.latimes.com/opinion/op-ed/la-oe-murray-
city-homelessness-20180116-story.html

Myerson, R. B. (1999). Nash equilibrium and the history of economic theory. Journal
of Economic Literature, 37(3), 1067-1082. Retrieved from https://www-jstor-
org.libproxy2.usc.edu/stable/2564872?seq=1#metadata_info_tab_contents

National Council on Crime and Delinquency (2009, October). Developing a successful street
outreach program: Recommendations and lessons learned. Retrieved from
https://www.ci.richmond.ca.us/DocumentCenter/View/8054/Street-Outreach-
Final?bidId=

National Health Care for the Homeless Council (2016, October). Standards for
medical respite. Retrieved from https://nhchc.org/clinical-practice/medical-respite-
care/standards/

Padget, D. K. & Henwood, B. F. (2018). End homelessness. In R. Fong, J. E. Lubben,
& R. P. Barth (Eds.), Grand challenges for social work and society. New York, NY:
Oxford University Press.

Pasadena Partnership to End Homelessness (2016, August). Street outreach:
Written standards. Retrieved from https://pasadenapartnership.org/wp-
content/uploads/2015/10/Street-Outreach_Written-Standards.pdf

Petrenchik, T. (2006). Homelessness: Perspectives, misconceptions, and considerations for
occupational therapy. Occupational Therapy in Health Care, 20(3-4), 9-30. Retrieved
from http://www.tandfonline.com/doi/abs/10.1080/J003v20n03_02

Rooks, N. M. (2012, September 07). The myth of bootstrapping. Time Magazine.
Retrieved from http://ideas.time.com/2012/09/07/the-myth-of-bootstrapping/print/

Sherman, N. (2015, April 24). The deepest war wound may be the anguish of moral
CAPSTONE PROJECT PAPER 127

injury. Los Angeles Times. Retrieved from http://www.latimes.com/nation/la-oe-
sherman-moral-injury-veterans-20150426-story.html

Solli-Saether, H. & Gottschalk, P. (2010). The modeling process for stage models.
Journal of Organizational Computing and Electronic Commerce, 20(3), 279-293.
Retrieved from https://www-tandfonline-
com.libproxy1.usc.edu/doi/pdf/10.1080/10919392.2010.494535

Substance Abuse and Mental Health Services Administration (n.d.) Brief negotiated
interview and active referral to treatment: Provider training algorithm. Retrieved from
https://www.integration.samhsa.gov/clinical-practice/sbirt/Brief-
negotiated_interview_and_active_referral_to_treatment.pdf

Substance Abuse and Mental Health Services Administration (2014). Trauma-
informed care in behavioral health services. Treatment Improvement Protocol (TIP)
Series, No. 57. Rockville, MD: Center for Substance Abuse Treatment. Retrieved from
https://store.samhsa.gov/shin/content//SMA14-4816/SMA14-4816.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA, 2005). Substance
abuse treatment: Group therapy. Treatment Improvement Protocol (TIP) Series, No.
41. Rockville, MD: Center for Substance Abuse Treatment.

United States Department of Housing and Urban Development, Office of Community
Planning and Development (2018, December). The 2018 annual homeless
assessment report (AHAR) to Congress. Part 1: Point-in-time estimates of
homelessness. Retrieved from
https://www.hudexchange.info/resources/documents/2018-AHAR-Part-1.pdf

Van Grove, J. (2011, July 28). Gamification: How competition is reinventing
business, marketing, and everyday life. Retrieved from
https://mashable.com/2011/07/28/gamification/#JX4DLhQ6gkqo

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Prototype Appendix B: SCOUT® Version 1.0

For optimal performance, use SCOUT with the enclosure securely in place. Battery life may
fluctuate based on environment, age, and usage of SCOUT.

Components.

SCOUT® v1.0 was created utilizing:

• One microprocessor
• One additional power supply
• Two breadboards
• Ten LED bulbs
• Ten button switches
• 50 resistors

SCOUT® v1.0 conceptualization.

o o o o o o o o o o
1 2 3 4 5 6 7 8 9 10
I’m Not
Ready
I’m Sort of
Ready
I’m More Ready I’m Totally
Ready
▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪
Precontemplation/Noise Contemplation/Voice Preparation/Poise Action/Choice
Figure 4.0. SCOUT v1.0 Conceptualization.

SCOUT® v1.0 hardware.

Figure 4.1. SCOUT v1.0 Prototype in “Off” Position.
CAPSTONE PROJECT PAPER 129

Figure 4.2. SCOUT v1.0 Prototype in “Not Ready” Position.

Figure 4.3. SCOUT v1.0 Prototype in “Sort of Ready” Position.

Figure 4.4. SCOUT v1.0 Prototype in “Totally Ready” Position.

SCOUT v1.0 software.

A code was written to instruct the prototype on what functions to perform for both
SCOUT version 1.0 utilizing Arduino. Future iterations may include an application that can be
accessed on an iPad or Android device.

//Variables
int Button1 = 40;
int Button2 = 38;
int Button3 = 36;
int Button4 = 34;
CAPSTONE PROJECT PAPER 130

int Button5 = 32;
int Button6 = 30;
int Button7 = 28;
int Button8 = 26;
int Button9 = 24;
int Button10 = 22;

int LED1 = 11;
int LED2 = 10;
int LED3 = 9;
int LED4 = 8;
int LED5 = 7;
int LED6 = 6;
int LED7 = 5;
int LED8 = 4;
int LED9 = 3;
int LED10 = 2;

void setup()
{
pinMode(Button1, INPUT);
pinMode(LED1, OUTPUT);
pinMode(Button2, INPUT);
pinMode(LED2, OUTPUT);
pinMode(Button3, INPUT);
pinMode(LED3, OUTPUT);
pinMode(Button4, INPUT);
pinMode(LED4, OUTPUT);
pinMode(Button5, INPUT);
pinMode(LED5, OUTPUT);
pinMode(Button6, INPUT);
pinMode(LED6, OUTPUT);
pinMode(Button7, INPUT);
pinMode(LED7, OUTPUT);
pinMode(Button8, INPUT);
pinMode(LED8, OUTPUT);
pinMode(Button9, INPUT);
pinMode(LED9, OUTPUT);
pinMode(Button10, INPUT);
pinMode(LED10, OUTPUT);
}

void loop() {
CAPSTONE PROJECT PAPER 131

if (digitalRead (Button1) == HIGH)
{
digitalWrite (LED1, HIGH);
}else
{
digitalWrite (LED1, LOW);
}

if (digitalRead (Button2) == HIGH)
{
digitalWrite (LED2, HIGH);
}else
{
digitalWrite (LED2, LOW);
}

if (digitalRead (Button3) == HIGH)
{
digitalWrite (LED3, HIGH);
}else
{
digitalWrite (LED3, LOW);
}

if (digitalRead (Button4) == HIGH)
{
digitalWrite (LED4, HIGH);
}else
{
digitalWrite (LED4, LOW);
}

if (digitalRead (Button5) == HIGH)
{
digitalWrite (LED5, HIGH);
}else
{
digitalWrite (LED5, LOW);
}

if (digitalRead (Button6) == HIGH)
{
digitalWrite (LED6, HIGH);
CAPSTONE PROJECT PAPER 132

}else
{
digitalWrite (LED6, LOW);
}

if (digitalRead (Button7) == HIGH)
{
digitalWrite (LED7, HIGH);
}else
{
digitalWrite (LED7, LOW);
}

if (digitalRead (Button8) == HIGH)
{
digitalWrite (LED8, HIGH);
}else
{
digitalWrite (LED8, LOW);
}

if (digitalRead (Button9) == HIGH)
{
digitalWrite (LED9, HIGH);
}else
{
digitalWrite (LED9, LOW);
}

if (digitalRead (Button10) == HIGH)
{
digitalWrite (LED10, HIGH);
}else
{
digitalWrite (LED10, LOW);
}
}

SCOUT v1.0 survey and algorithm.

The SCOUT survey and algorithm are adapted from the Boston University School of
Public Health (n.d.) and SAMHSA (n.d.) Brief Negotiated Interview (BNI). The 19 items in the
survey are presented using a ten-point Likert response format, (one through three equals “I’m not
CAPSTONE PROJECT PAPER 133

ready” (precontemplation), four through five equals “I’m sort of ready” (contemplation), six
through seven equals “I’m more ready” (preparation), and eight through ten equals “I’m totally
ready” (action). The algorithm is grounded in Prochaska’s stages of change theory (DiClemente,
Nidecker, & Bellack (2008).

Step Question Response Stage of Change
Build Trust
and Discuss
Hi, my name is
___________.
I’m doing
street outreach
today. What is
your name?

I want to learn
a little bit more
about you.
What is a day
like for you?
Unable to give their name: _______
Able to give their name, document
their name here:
_____________________________
_____________________________
_____________________________

Unable to talk about their day: ____
Able to talk about their day,
summarize their day here:
_____________________________
_____________________________
_____________________________
_____________________________
Unable to give their
name =
Precontemplation
Able to give their
name =
Contemplation

Unable to talk
about their day =
Precontemplation
Able to talk about
their day =
Contemplation

Share Your
Story
I have some
personal
experiences
with
homelessness,
would you
mind if I
shared them
with you?
No: ____________ Yes: _________

Share your recovery story and offer
information: Being homeless can
put you at risk for illness and injury.
It can also cause health problems
like infections and dental diseases.
No =
Precontemplation
Yes =
Contemplation
Check for
Feedback
What are your
thoughts on
that?

Unable to share thoughts: ________
Able to share thoughts, summarize
them here:
_____________________________
_____________________________
_____________________________

Unable to share
thoughts =
Precontemplation
Able to share
thoughts =
Contemplation
Talk about the
Advantages
and
Disadvantages
Do you see any
advantages to
being
homeless?

No: __________ Yes: _________

Unable to list advantages: ________
No =
Contemplation
Yes =
Precontemplation

CAPSTONE PROJECT PAPER 134

Do you see any
disadvantages
to being
homeless?

Able to list advantages: _______
List the advantages here: _________
_____________________________
_____________________________

No: __________ Yes: _________

Unable to list disadvantages: ______

Able to list disadvantages: _______
List the disadvantages here: ______
_____________________________
_____________________________

Count the number of advantages and
enter the number here: ___________

Count the number of disadvantages
and enter the number here: _______

Unable to list
advantages =
Contemplation
Able to list
advantages =
Precontemplation

No =
Precontemplation
Yes =
Contemplation

Unable to list
disadvantages =
Precontemplation
Able to list
disadvantages =
Contemplation

Compare the
number of
advantages against
the number of
disadvantages:

More advantages
than disadvantages
= Precontemplation

More disadvantages
than advantages =
Contemplation

Equal number of
advantages and
disadvantages =
Contemplation
Assess Current
Situation

Would you like
help to get out
of
homelessness?
No: ___________ Yes: __________

No =
Precontemplation
Yes =
Contemplation
CAPSTONE PROJECT PAPER 135

Are you
looking to get
off the streets?

No: ___________ Yes: __________

No =
Precontemplation
Yes =
Contemplation

Scale of
Support
This Scale of
Support is like
the marks on a
ruler. On a
scale from one
to ten with one
being not ready
at all and ten
being totally
ready, how
ready are you
to change your
situation?
Record their response on the Scale
of Support here: ____________

Calculate readiness to change:
Scale response divided by 10 times
100 = percentage
Enter percentage here: ___________
10 percent to 30
percent =
Precontemplation

40 percent to 50
percent =
Contemplation

60 percent to 70
percent =
Preparation

80 percent to 100
percent = Action

Focus on
Strengths
You scored
___________.
That’s great!
That means
you’re _____
percent ready
to change your
situation.
Why did you choose that number
and not a lower one like a one or
two? Record their answer here:
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________

Create a Plan Are you
interested in a
homeless
shelter?

Do you want to
get into your
own housing?

No: ___________ Yes: __________

No: ___________ Yes: __________

No =
Precontemplation
Yes = Preparation

No =
Precontemplation
Yes =
Contemplation

CAPSTONE PROJECT PAPER 136

If yes, what
type of housing
interest you?

Unable to list type of housing: ____

Able to list type of housing,
summarize here:
_____________________________
_____________________________
_____________________________

Unable to list
housing =
Precontemplation
Able to list housing
= Contemplation
Identify What
Worked and
Didn’t Work
Have you tried
getting off the
streets before?

If yes, what
worked or
didn’t work?
No: __________ Yes: __________

Unable to identify what
worked/didn’t work: ____

Able to identify what worked/didn’t
work: ______

List what worked here: __________
_____________________________
_____________________________
_____________________________

List what didn’t work here: _______
_____________________________
_____________________________
_____________________________

Count the number of what worked
and enter the number here: _______

Count the number of what didn’t
work and enter the number here: ___
No =
Precontemplation
Yes =
Contemplation

Unable to list what
worked or didn’t
work =
Precontemplation
Able to list what
worked or didn’t
work =
Contemplation

Compare the
number of what
worked against the
number of what
didn’t work:

More what didn’t
work than what
worked =
Precontemplation
CAPSTONE PROJECT PAPER 137

More what worked
than what didn’t
work =
Contemplation

Equal number of
what worked and
what didn’t work =
Contemplation
Offer
Resources and
Support
Do you
currently
receive
services from
any agency or
organization?

Have you ever
been to
Housing
Connect or
Coordinated
Entry?
Do you need
some referrals
or resources
today?

Do want an
outreach
worker to see
you again?

If yes, what is
a good phone
number or
address or
location for
you?

No: ____________ Yes: _________

List agencies or organizations here:
_____________________________
_____________________________
_____________________________

No: ___________ Yes: __________

Provide contact information for
Housing Connect or Coordinated
Entry

No: ____________ Yes: _________

List referral or resources provided
here:
_____________________________
_____________________________

No: ____________ Yes: _________

Unable to provide phone number or
address or location: __________

Able to provide phone number or
address or location:____________

No =
Precontemplation
Yes = Action

No =
Precontemplation
Yes =
Contemplation

No =
Precontemplation
Yes =
Contemplation

No =
Precontemplation
Yes =
Contemplation

Unable to provide
phone number or
address or location
= Precontemplation

Able to provide
phone number or
CAPSTONE PROJECT PAPER 138

Document phone number or address
or location here:
_____________________________
_____________________________
_____________________________
________________________
address or location
= Contemplation

Thank the
Person
Thank you for
sharing with
me today.
Scoring: Add all stage categories
and select category with the highest
score. If there is a tie between
categories, then select the lower of
the two categories. For example, if
the person had 3 precontemplation
responses and 3 contemplation
responses, then select
precontemplation as the overall
Stage of Support.
Precontemplation:
________________
Contemplation:
________________
Preparation: ____
Action: _________

Overall Stage of
Support:
______________

Figure 5.0. SCOUT v1.0 Survey and Algorithm.

SCOUT v1.0 stage of motivation service provision matrix.

The stage-matched service provision matrix is modeled after SAMHSA’s (2010)
Integrated Treatment for Co-Occurring Disorders (ITCD) stages of treatment and core processes.

Stage of Motivation Service Intervention
Noise (Precontemplation): The unhoused
neighbor is distracted, does not have a peer
provider and is reluctant to trust peer
provider.
The peer provider engages in assertive
outreach, meets unhoused neighbor where they
are at, provides practical assistance to meet
basic needs, offers hope, and develops trust
Voice (Contemplation): The unhoused
neighbor has been working with peer
provider for less than one month, is
identifying needs, and is thinking about
options for support.
The peer provider completes street outreach
contact survey, shares recovery story, offers
information and education, continues to
develop the relationship and trust, and provides
practical assistance to meet safety and security
needs
Poise (Preparation): The unhoused
neighbor has been working with peer
provider for at least one month, is agreeing
to engage in services, and is taking steps to
meet identified needs.
The peer provider offers services, collaborates
on goals, helps neighbor consider what causes
and carries homelessness for them individually
CAPSTONE PROJECT PAPER 139

Choice (Action): The unhoused neighbor
has been working with peer provider for
more than six months, is overcoming
barriers, and working on routines and
resources that promote independence and
confidence.
The peer provider offers additional skills and
supports, continues to collaborate with
neighbor on their goals
Control (Prevention): The formerly
unhoused neighbor has been working with
peer provider for more than nine months, is
realizing their hopes and dreams, and is
living their life as they see fit.
The peer provider works with the neighbor on
prevention planning, identifying cues to
homelessness, and outlining ways to avoid or
handle these cues.
Figure 6.0. SCOUT v1.0 Stage-Matched Service Provision Matrix.

CAPSTONE PROJECT PAPER 140

Prototype Appendix C: SCOUT Version 2.0

For optimal performance, use SCOUT with the enclosure securely in place. Battery life may
fluctuate based on environment, age, and usage of SCOUT.

Components.

SCOUT v2.0 was created utilizing:

• One Raspberry Pi 3B+ microprocessor
• One Raspberry Pi NoIR camera board v2
• One Raspberry Pi camera board case
• One Raspberry Pi 2.8” touchscreen display
• One Google Coral USB accelerator
• One female DC power adapter
• One micro-USB charger for LiPo/LiIon battery
• One LiIon polymer battery
• One mini 5V cooling fan
• One mini analog joystick
• One mini thermal printer
• One thermal paper roll
• One stereo enclosed speaker set
• One HDMI cable
• One USB cable
• One USB port power supply
• One micro-SD card
• One 5V 2A switching power supply
• One acrylic sheet (black)
• Two arcade bonnets for Raspberry Pi with JST connectors
• Two latching pushbuttons (blue and white)
• Five momentary pushbuttons (red, yellow, and green)
• 25 arcade button quick-connect wire pairs

SCOUT v2.0 conceptualization.

CAPSTONE PROJECT PAPER 141

Figure 7.0. SCOUT v2.0 Conceptualization.

SCOUT v2.0 hardware.

Figure 7.1. SCOUT v2.0 Prototype Top Panel.

Figure 7.2. SCOUT v2.0 Prototype Rear Panel.
Touchscreen
display
Button
Speaker Speaker
Accelerator
Camera
Buttons
Joystick
Printer
Button
CAPSTONE PROJECT PAPER 142

Figure 7.3. SCOUT v2.0 Prototype Side Panel.

SCOUT v2.0 software.

A code was written to instruct the prototype on what functions to perform for SCOUT
version 2.0 utilizing both Raspberry Pi and TensorFlow. Future iterations may include an
application that can be accessed on an iPad or Android device

SCOUT v2.0 survey and algorithm.

The SCOUT survey and algorithm are adapted from the Boston University School of
Public Health (n.d.) and SAMHSA (n.d.) Brief Negotiated Interview (BNI). The 13 items in the
survey are presented using a five-point Likert response format, (one = “definitely won’t”
(precontemplation), two = “probably won’t” (contemplation), three = “maybe” (preparation),
four = “probably will” (action), and five = “definitely will” (prevention; adapted from Brown,
2010).The algorithm is grounded in Prochaska’s stages of change theory (DiClemente, Nidecker,
& Bellack (2008).

Step Question Response Stage of Change
Ask: Discuss
and Build
Trust
Hi, my name is
___________.

I’m doing
street outreach
today. 1. What
is your name?

Definitely won’t give their name: __

Probably won’t give their name: ___

Might give their name: __________

Probably will give their name: ____

One = definitely
won’t
(precontemplation)
Two = probably
won’t
(contemplation)
Three = maybe
(preparation)
Four = probably
will (action)
CAPSTONE PROJECT PAPER 143

I want to learn
a little bit more
about you.
2. What is a
day like for
you?
Definitely will give their name,
document here:
_____________________________

Definitely won’t talk about their
day: _________________________

Probably won’t talk about their day:
_____________________________

Might talk about their day: _______

Probably will talk about their day:
_____________________________

Definitely will talk about their day,
document here:_________________
_____________________________

Five = definitely
will (prevention)

One = definitely
won’t
(precontemplation)

Two = probably
won’t
(contemplation)

Three = maybe
(preparation)
Four = probably
will (action)

Five = definitely
will (prevention)

Advise: Share
Your Story
I have some
personal
experiences
with
homelessness.
3. Would you
mind if I
shared them
with you?
Definitely won’t listen: __________

Probably won’t listen: ___________

Might listen: __________________

Probably will listen: ____________

Definitely will listen: ____________

Share your recovery story and offer
information (i.e., Being homeless
can put you at risk for illness and
injury. It can also cause health
problems like infections and dental
diseases).
One = definitely
won’t
(precontemplation)
Two = probably
won’t
(contemplation)
Three = maybe
(preparation)

Four = probably
will (action)
Five = definitely
will (prevention)

CAPSTONE PROJECT PAPER 144

Ask: Check
for Feedback
4. What are
your thoughts
on that?

Definitely won’t share their
thoughts: _____________________

Probably won’t share their thoughts:
_____________________________

Might share their thoughts: _______

Probably will share their thoughts:
_____________________________

Definitely will share their thoughts,
document here:
_____________________________
_____________________________

One = definitely
won’t
(precontemplation)

Two = probably
won’t
(contemplation)

Three = maybe
(preparation)
Four = probably
will (action)

Five = definitely
will (prevention)

Ask: Talk
about the
Good and Not
So Good
5. Do you see
any good
things about
being
homeless?

6. Do you see
any not so
good things
about being
homeless?
Definitely won’t share good things:
_____________________________

Probably won’t share good things:
_____________________________

Might share good things: _________

Probably will share good things: ___

Definitely will share good things,
document here:
____________________________
_____________________________

Definitely won’t share not so good
things:
___________________________

One = definitely
won’t
(precontemplation)
Two = probably
won’t
(contemplation)
Three = maybe
(preparation)

Four = probably
will (action)
Five = definitely
will (prevention)

One = definitely
won’t
(precontemplation)

CAPSTONE PROJECT PAPER 145

Probably won’t share not so good
things:
___________________________

Might share not so good things: ___

Probably will share not so good
things: _______________________
Definitely will share not so good
things, document here:
_____________________________
_____________________________

Two = probably
won’t
(contemplation)

Three = maybe
(preparation)
Four = probably
will (action)
Five = definitely
will (prevention)
Assist: Assess
Current
Situation

7. Would you
like help to get
out of
homelessness?

8. Are you
looking to get
off the streets?
Definitely won’t want help to get out
of homelessness: _______________

Probably won’t want help to get out
of homelessness: _______________

Might want help to get out of
homelessness: _________________

Probably will want help to get out of
homelessness: _________________

Definitely will want help to get out
of homelessness : _______________

Definitely won’t want to get off the
streets: _______________________

Probably won’t want to get off the
streets: _______________________

Might want to get off the streets: __

Probably will want to get off the
streets: _______________________

Definitely will want to get off the
streets: _______________________

One = definitely
won’t
(precontemplation)
Two = probably
won’t
(contemplation)
Three = maybe
(preparation)

Four = probably
will (action)

Five = definitely
will (prevention)

One = definitely
won’t
(precontemplation)
Two = probably
won’t
(contemplation)
Three = maybe
(preparation)
Four = probably
will (action)

Five = definitely
will (prevention)

CAPSTONE PROJECT PAPER 146

Assist: Create
a Plan
9. Are you
interested in a
homeless
shelter?

10. Do you
want to get
into your own
housing?

Definitely won’t want to get in a
homeless shelter: _______________

Probably won’t want to get in a
homeless shelter: _______________

Might want to get in a homeless
shelter: _______________________

Probably will want to get in a
homeless shelter: _______________

Definitely will want to get in a
homeless shelter: _______________

Definitely won’t want to get into
their own housing: ______________

Probably won’t want to get into their
own housing: __________________

Might want to get into their own
housing: ______________________

Probably will want to get into their
own housing: __________________

Definitely will want to get into their
own housing: _________________
_________
One = definitely
won’t
(precontemplation)
Two = probably
won’t
(contemplation)
Three = maybe
(preparation)

Four = probably
will (action)

Five = definitely
will (prevention)

One = definitely
won’t
(precontemplation)
Two = probably
won’t
(contemplation)
Three = maybe
(preparation)

Four = probably
will (action)

Five = definitely
will (prevention)
Ask: List
What Worked
and Didn’t
Work
11. What
worked or
didn’t work
when you tried
to get off the
streets before?
Definitely won’t want to list what
did/didn’t work: _______________

Probably won’t want to list what
did/didn’t work: ________________

Might want to list what did/didn’t
work: ________________________

Probably will want to list what
did/didn’t work: ________________
One = definitely
won’t
(precontemplation)
Two = probably
won’t
(contemplation)
Three = maybe
(preparation)

Four = probably
will (action)
CAPSTONE PROJECT PAPER 147

Definitely will want to list what
did/didn’t work: _______________

Five = definitely
will (prevention)
Assist: Offer
Referrals or
Resources
12. Do you
need some
referrals or
resources
today?

13. Do want an
outreach peer
to see you
again?

Definitely won’t want referrals or
resources: ____________________

Probably won’t want referrals or
resources: ____________________

Might want referrals or resources:
_____________________________

Probably will want referrals or
resources: _____________________

Definitely will want referrals or
resources,, document referrals or
resources given: _______________

Definitely won’t want to be
outreached again: ______________

Probably won’t want to be
outreached again: ______________

Might want to be outreached again:
_____________________________

Probably will want to be outreached
again: ________________________

Definitely will want to be
outreached again, document good
phone number or address or
location: _____________________
_____________________________
_____________________________
_____________________________

One = definitely
won’t
(precontemplation)
Two = probably
won’t
(contemplation)
Three = maybe
(preparation)

Four = probably
will (action)

Five = definitely
will (prevention)

One = definitely
won’t
(precontemplation)
Two = probably
won’t
(contemplation)
Three = maybe
(preparation)

Four = probably
will (action)

Five = definitely
will (prevention)
CAPSTONE PROJECT PAPER 148

Appreciate:
Thank the
Neighbor
Thank you for
sharing with
me today.
Scoring: Add all stage categories
and select category with the highest
score. If there is a tie between
categories, then select the lower of
the two categories. For example, if
the neighbor had 3
precontemplation responses and 3
contemplation responses, then select
precontemplation as the overall
stage of change.
__________ One =
definitely won’t
(precontemplation)
__________ Two
= probably won’t
(contemplation)
__________ Three
= maybe
(preparation)

__________ Four
= probably will
(action)

__________ Five =
definitely will
(prevention)

Overall Stage of
Change:
________________

Figure 8.0. SCOUT v2.0 Survey and Algorithm.

SCOUT v2.0 stage of motivation service provision matrix.

The stage-matched service provision matrix is modeled after SAMHSA’s (2010)
Integrated Treatment for Co-Occurring Disorders (ITCD) stages of treatment and core processes.

Stage of Motivation Service Intervention
Noise/Definitely Won’t (Precontemplation):
The unhoused neighbor is distracted, does
not have a peer provider, is reluctant to trust
peer provider, or does not view
homelessness as a problem.
The peer provider engages in assertive
outreach, meets the unhoused neighbor where
they are at, provides practical assistance to
meet basic needs, offers hope, and develops
trust
Voice/Probably Won’t (Contemplation):
The unhoused neighbor has been working
with a peer provider for less than one
month, is identifying needs, or is
considering social service options.
The peer provider completes SCOUT
assessment with the unhoused neighbor, shares
their recovery story, offers information and
education, continues to develop a trusting
relationship, and provides practical assistance
to meet safety and security needs
CAPSTONE PROJECT PAPER 149

Poise/Maybe (Preparation): The unhoused
neighbor has been working with a peer
provider for at least one month, is agreeing
to engage in services, or is taking steps to
meet identified needs.
The peer provider offers services, collaborates
on hopes and dreams, and helps the unhoused
neighbor consider what is associated with
homelessness for them individually
Choice/Probably Will (Action): The
unhoused neighbor has been working with a
peer provider for more than six months, is
engaging in services, or is working on
routines and resources that promote
independence and confidence.
The peer provider offers additional skills and
supports and continues to collaborate with the
unhoused neighbor on their hopes and dreams
Control /Definitely Will (Prevention): The
formerly unhoused neighbor has been
working with a peer provider for more than
nine months, is realizing their hopes and
dreams, and is living their life as they see
fit.
The peer provider works with the neighbor on
prevention planning, identifying cues or
triggers to homelessness, and outlining ways to
avoid or handle these cues or triggers
Figure 9.0. SCOUT v2.0 Stage-Matched Service Provision Matrix.

CAPSTONE PROJECT PAPER 150

Capstone Appendices (continued)
Capstone Appendix E: Implementation Plan
ERIC FRAMEWORK
Strategy Definition
Needs Assessment and
Problem Identification
Collect and analyze data and identify need for intervention
Relevance to GC2EH and
Capstone Project
Determine relevance to Grand Challenge(s) and identify
potential solution
SWOT Analysis
Barriers and Facilitators

Assess for coalition readiness, strengths, and limitations to
adopt the innovation and identify barriers to and facilitators of
implementation
Nested and Standalone
Intervention Implementation
Strategy
Theory of Change
Logic Model
Procedures and Timeline
Operationalize Capstone project; develop implementation
goals and strategies, including aim and significance of the
intervention, timeframe and milestones; training, resource
sharing, and partner agreements; and process, outcome, and
performance measures
Performance Monitoring
Tools
Measures
Develop, test, and implement plan to monitor the process,
outcome, and performance measures related to implementation
Performance Monitoring
Plan
Develop, organize, and implement a QA strategy and QI plan
to monitor process, outcome, and performance measures
Feedback Loops Develop plans for stakeholders to shape implementation
outcomes that measure the success of the process and its
impact on service delivery
Develop Prototype Design the Field Kit of Outreach and Assessment Tools,
Universal Standards of Street Outreach, Evidence-Based Street
Outreach Model, SCOUT and SCOUT enclosure and
packaging, prototype the Field Kit of Outreach and
Assessment Tools and packaging; refine and program SCOUT;
and prepare prototype for pilot/trial
Pilot Intervention Conduct training, deploy teams, increase demand, and collect
and evaluate data
Refine Intervention Monitor innovation progress and make continuous
improvement adjustments
Scale Intervention Disseminate and diffuse the Capstone project to state and
national levels; certify, manufacture, and secure intellectual
property rights; and insure, license, and ship the products
Monitor Intervention Continuously monitor innovation process, outcome, and
performance measures
CAPSTONE PROJECT PAPER 151

Capstone Appendix F: Gantt Chart

CAPSTONE PROJECT PAPER 152

Capstone Appendix G: Financial Plan

Category Year 1 Year 2
Revenues:
Membership Dues $325,000 $425,000
Licensing and Consulting Fees 525,000 745,000
Earned Revenues/Product Sales 143,800 563,000
Franchising 0 270,000
Total Anticipated Revenues $1.1M $2.1M
Expenses:
Personnel $300,000 $997,000
Fringe 55,000 209,370
Travel and Training 16,000 27,000
Vehicles 15,900 31,000
Equipment 45,000 42,000
Other Supplies & Marketing 16,000 86,000
Contracts 2,100 39,000
Building Expenses 0 15,500
Prototype Development 260,000 $430,000
Prototype Implementation and Testing 170,000 $85,000
Total Anticipated Project Costs $880,000 $1,961,870
Surplus/Deficit $10,120 $141,130

Abstract (if available)

Abstract Our unhoused neighbors are aging too early and dying too soon. Homelessness is a wicked problem in America. One and a half million adults (Padget & Henwood, 2018) and 4.2 million children are homeless each year in America (Fadel & Figueroa, 2017). The target population of study is unhoused neighbors over the age of 50 experiencing homelessness because more than 50 percent of our unhoused neighbors are over the age of 50 (Brown et al., 2015), and five percent are over the age of 70 (Nagourney, 2016). The purpose of the Capstone project is to improve access to needed supports and services and end homelessness. The Capstone project is a diverse set of standalone and nested innovations designed to help end homelessness by engaging in specific activities to achieve specific outcomes related to an innovative policy, program, practice, and product. The social problem this Capstone project is trying to resolve is, our unhoused neighbors encounter difficulties accessing needed services due to no-door, wrong-door, and closed-door systems of care. The wicked problem is directly linked to the Grand Challenge to End Homelessness because other social problems perpetuate homelessness, borrow from homelessness, and contribute to vicious cycles that intersect them and spread homelessness. One of the supernorms that holds the wicked problem in place is “treat ‘em and street ‘em” (Warshaw, 2017). The Capstone project dissolves fragmented systems of care, resolves the issue of barriers to care, and helps break the cycle of homelessness through a Field Kit of Outreach and Assessment Tools

Linked assets

University of Southern California Dissertations and Theses

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Asset Metadata

Creator Lowenstein, Keren Elisheva (author)

Core Title We are our neighbors' keeper: an innovative field kit of outreach and assessment tools to help end homelessness

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 12/17/2019

Defense Date 11/22/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag algorithms,Homelessness,innovation,machine learning,microtechnology,Motivation,OAI-PMH Harvest,readiness,stage of change

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Manderscheid, Ron (committee member), Orras, George (committee member), Rank, Michael (committee member)

Creator Email klowenst@usc.edu,klowenstein@sbcglobal.net

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-255381

Unique identifier UC11674965

Identifier etd-Lowenstein-8086.pdf (filename),usctheses-c89-255381 (legacy record id)

Legacy Identifier etd-Lowenstein-8086.pdf

Dmrecord 255381

Document Type Capstone project

Rights Lowenstein, Keren Elisheva

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA