When community members told Solid Ground they wanted to be treated as whole people, not a list of unrelated challenges that need addressed, we looked at how we could adapt our service model and developed Every Door Access. “The mission of Every Door is to address the whole health of each individual based upon their needs,” explains Celestine Berrysmith, Supportive Services Manager, who has led its development. The new approach is progressing toward an early October startup at our Wallingford site.

“We will treat every person who comes in the door from a whole health perspective, find out what their needs are, and then direct them – via referral to different programs internally and externally,” Celestine says. “It’s more than just, ‘I need a place to live’ or ‘I am hungry.’ Maybe it is both of those things, and ‘I have a health issue, and my benefits have been cut off.’ Or ‘I am in sanctions for something that I don’t understand – so I need to have all of these things addressed.’ And we want to be able to do that within a reasonable amount of time, so people are served most effectively.”

A typical Every Door Access scenario:

1. A person comes in the door or calls.
2. They are greeted by the front desk staff, who complete a basic intake for them to determine their immediate concerns, and any other issues or barriers affecting their overall stability.
3. Any immediate issues will be addressed at that time, as capacity allows.
4. Within a 48-hour period, the applicant will be contacted by the Peer Resource Coordinator, who completes a more comprehensive assessment to make appropriate referrals to internal or external programs.

“The Peer Resource Coordinator (PRC) position is a new role,” Celestine says. “We will begin hiring for the position soon. It is really kind of an amazing position. They will work closely with not only the front desk office support staff, but with each of the programs across the agency. Each program will have a point person so that referrals can be made and follow-up done as seamlessly as possible.”

Additionally, the PRC will develop partnerships with other organizations to support referrals and act as a liaison between those agencies’ point people and those within Solid Ground. They will also help us pull in all of Solid Ground’s locations, so that if someone rides an Access bus with Solid Ground Transportation (SGT) but needs other support, we can serve them effectively as well.

How is the PRC role different from that of a Case Manager? Celestine explains: “A Case Manager works one-on-one with a client to encourage them to set goals, meeting regularly to lend support in achieving the goals, and making referrals as necessary. The PRC will work to assess the needs of each client and then quickly make referrals to programs best suited to address those needs. The PRC will act as a liaison between the client and the appropriate resources, internally and/or externally. I think this will require a special talent, and I look forward to finding that talent!”

In addition to opening the door to provide internal referrals across Solid Ground services, the program will eventually connect with services across the broader community through the Unite Us platform and our partnership with HealthierHere.

“The mission of Every Door is to address the whole health of each individual based upon their needs.” ~Celestine Berrysmith, Supportive Services Manager

As a Community Action Agency, Solid Ground conducts a Community Needs Assessment (CNA) every three years, reaching out to program participants and others with lived experience of poverty to learn how we can be more responsive to the community. Seeds of the Every Door model were sown by Solid Ground’s most recent 2018 CNA. Clear lessons include that people want to be seen as whole beings, not a collection of isolated problems. They see and understand the connections between housing and health and want the systems that address these issues to work together better. Navigating the social and health services systems is a huge challenge.

Indeed, many of our programs and services are currently limited by their funding as to when and how they can interact with participants. This has created program silos, increased wait times, and more irrelevant or unresponsive referrals. Our Tenant Counselors, for instance, are not currently able to refer hotline callers to Solid Ground’s nutrition education or transportation services.

“I like to say I’ve been a Case Manager for 150 years!” says Celestine. “And what I saw consistently over that time was such fragmentation (as far as getting effective referrals for clients as needed). This provides a perfect platform for us to provide effective support. In the past what we had was 2.1.1, which gives resources. There is a difference between resources and referrals. Resources are: ‘Here are some agencies/programs that may have support for you – try contacting them.’ And it has gotten to the point where, unfortunately, people have become really discouraged about getting effective referrals.”

So the Every Door model, she adds, “gives us a chance to get to a place where we are giving effective referrals instead of just, ‘Here are some ideas, go for it.’ With the PRC, clients will be connected to someone who will be working on your behalf to the best of their ability to align you with some actual services.”

Solid Ground took up this challenge through a collaborative team approach. More than 10 team members – from direct service staff to database designers and – worked together to design the model, map workflows and processes, configure the database, develop staff training, and more to get Every Door ready for rollout.

Funding from the Norcliffe Foundation supported the development, capacity building, and training. Norcliffe, and an anticipated combination of HealthierHere capacity-building funding and Foundational Community Supports revenue, will help sustain Every Door.

“This is innovative in this community,” Celestine says. “But I think it is going to shape the way we serve clients across our agency and our partners for the future.”

Questions?  Please contact Celestine Berrysmith, Supportive Services Manager, at celestineb@solid-ground.org.