Sonoma County Continuum of Care

Action Plan

Goal 1: Completing Applications and Training
1. Establish 10 FTEs who are dedicated to completing SOAR applications.
2. Hold 2-3 SOAR Online Course training cohorts in 1st year
Measurable Objective / 2015 / 2016 / 2017
Increase the number of applications per year
Increase the quality of applications
Increase the number of trained and active SOAR providers / 10
Action Steps / Lead Person / Timeframe
Top Priorities:
§  Continuum of Care will reach out to agency leadership to make the fiscal case for SOAR.
o  Use SOAR Outcome Summary: http://soarworks.prainc.com/article/2014-national-soar-outcomes
o  Collect data from current SOAR providers in Sonoma
§  Identify funding for full time FTEs
o  Use funding resources on the SOAR website: http://soarworks.prainc.com/article/funding-and-sustainability-tools
§  Identify amount of time needed to complete SOAR applications.
§  Conduct a survey of current SOAR activities in the area; who is doing SOAR applications?
§  Identify Professional Practice group of SOAR trained people for support
Other Priorities:
§  Identify agencies/locales/structure to house the FTEs throughout county.
§  Create a resource map
§  Identify who should be involved in creating and completing a SOAR cohort
§  Engage CoC Board and membership for buy-in for SOAR
§  Contact California State University Long Beach Social Work Program to recruit interns
§  Review each other’s apps for quality
o  Use the Quality Review Checklist: http://soarworks.prainc.com/sites/soarworks.prainc.com/files/QualityReviewChecklist021215.doc
Goal 2: Collaborations
1. Identify liaisons at SSA & DDSD
2. Establish Key Contacts at each medical/MH facility & provider champions to retrieve records more efficiently
Measurable Objective / 2015 / 2016 / 2017
Action Steps / Lead Person / Timeframe
SSA and DDS
Top Priorities
§  Determine who will be appointed liaisons at the supervisory level from SSA & DDSD (Marv & Deo)
Other Priorities
§  Identify liaison at San Rafael hearing office
Medical Providers
Top Priorities
§  Identify a county champion to/Czar that can create a list of medical, mental health and jail partners
§  Identify the supervisor of medical records to each agency
§  Model -- PHC/COTS
o  Use tips from the Online Course: http://soarworks.prainc.com/article/soar-key-component-collecting-medical-evidence
Other
Top Priorities
§  Create a linkage with coordinated intake (recommended questions/coordinated intake)
Goal 3: Tracking Outcomes, and Sustainability
1. All SOAR assisted applications will be tracked in OAT and reported quarterly to local lead
2. Create sub work group to identify funding strategies & cost savings studies
Measurable Objective / 2015 / 2016 / 2017
Action Steps / Lead Person / Timeframe
Top Priorities
Fiscal year – July 2015
§  Perform a cost savings study to build case and look to partially fund a person to identify funding.
§  Identify community partners (with funding) that will benefit from the SOAR process.
§  Demonstrate “cost savings” within programs
§  Michael will monitor outcomes in OAT for quality.
§  Register and educate everyone in OAT who is completing SOAR applications
o  Use tutorials and guides on SOAR OAT homepage: https://soartrack.prainc.com/
Other Priorities
§  Determine who will set up the training structure
§  Address permanent supportive housing, and determine a health care workgroup
§  Explore Medicare/MediCal reimbursement
Goal 4: Local Leadership Team
1. Establish steering committee that includes key stakeholders and consumer representation that meets monthly.
Measurable Objective / 2015 / 2016 / 2017
Action Steps / Lead Person / Timeframe
Top Priorities
§  Determine key agencies to be involved in the SOAR Steering Committee – Sonoma County Behavioral Health, Interlink, Wellness Center, General Assistance, Community Foundation, United Way, Board of Supervisors, United Way, Health Services, Federally Qualified Health Centers (FQHC) (all clinics), Hospital Foundations, HOST, CC, Social Advocates for Youth, VOICES Committee on the Shelterless (COTS), Community Action Partnership, Cloverdale community Outreach, Sonoma Overnight Support, LaLuz, Redwood Gospel Mission, Buckelew, Community Support Network
§  Determine the mission/goals of the steering committee
§  Limit the time frame/life span of the steering committee
§  Engage hospital medical records departments
§  Consult with current SOAR providers to identify consumers
§  Locate/identify transportation/compensation for consumer participation
Other Priorities
§  Identify meeting location for the SOAR steering committee meeting and cohort
§  Identify a community resource person at SSA
§  Engage the Sheriff’s Department as well as law enforcement and jails
When / Our Monitoring Plan
Monthly / Lead person(s) for each priority area will update status of action items to ensure we are making progress. This update will take place during a monthly SOAR steering committee meeting, or virtually if the lead is unable to attend. The steering committee lead will compile updates and send a performance update to all members of the committee.
Quarterly / The Leadership Team will meet to review status of action steps and progress on objectives. The team will decide which current strategies to continue or stop and what new strategies to start. The team will adjust objectives as warranted based on issues and priorities.
Annually / The Leadership Team will meet to review progress for the year, identify what is working well and any new challenges, change objectives, and re-establish priorities and action plans.

SSI/SSDI Outreach, Access and Recovery (SOAR) Technical Assistance Center June 24, 2015