What information should be gleaned from a needs assessment?

A thorough needs assessment implemented in conjunction with a client-centered approach enables the Service Coordinator to develop an in-depth understanding of the resident’s challenges and strengths. Service Coordinators should tailor the assessment to address the unique circumstances of the individual or family. In addition to identifying any urgent needs (e.g., resolving an acute medical issue), the assessment should identify long-term challenges that could be addressed through participation in ROSS. 

The needs assessment serves as a starting point from which the Service Coordinator and client can together develop a comprehensive Individual Training and Services Plan (ITSP). The ITSP should include goals to guide the client’s participation in the ROSS program over time and identify the service providers needed to help the client achieve those goals. The ITSP is discussed in more detail later in this module.

Special considerations by household type

When using an existing assessment tool or developing questions for your own assessment tool, it is important to take into consideration the type of household being assessed and how that may affect service needs. For example, an elderly or disabled participant will have different needs than a household with children.

Housing and Transportation: Household composition - Number and age of people living in the household, as well as any important characteristics, such as disability status. Housing stability - Ability to make rent and utility payments on time, access to basic household needs.Transportation and mobility - Ability to afford and access local transportation options, whether anyone in the household requires special mobility accommodations. Education: Adult basic education/literacy - Educational achievement, literacy, education-related goals of the household’s adults. Children and youth education and development - Ages, child care needs, school enrollment, behavioral development, executive functioning skills, learning needs of the household’s children. Health and Wellness: Health-related services and safety - Basic hygiene, health care coverage, any requirements for current health conditions, need for annual or regular check-ups. Social and emotional health - The household’s social network, history with mental illness, coping strategies for stressful situations. Food and nutrition - Ability to access and prepare nutritious meals. ReEntry: Benefits enrollment - Eligibility for enrollment in food assistance, Medicaid, Social Security retirement, survivors or disability benefits. Employment: Restrictions related to previous incarceration, need for basic or specialized job skills Criminal records management Need to expunge, seal, or correct criminal records or secure certificates of rehabilitation. Employment: Digital literacy Job training and placement Job history, employment goals, need for basic or specialized job skills Job search Résumé writing, interviewing techniques, career advancement planning Job-related needs Professional clothing or uniforms, transportation, child care services. Financial literacy: Budgeting Ability to build and maintain savings, pay bills, manage a budget Credit Ability to access credit, need for credit and debt counseling, credit management and repair Banking Access to a checking and savings account, . Elderly/disabled: Health and well-being Health care coordination, home health services, assistance with activities of daily living, meal services Housing stability Need for home modifications, housekeeping assistance. Substance Abuse: Treatment for drug and alcohol abuse Referrals to drug and alcohol abuse treatment programs, transportation to treatment History of abuse Coping strategies for stressful situations, access to ongoing support.

Springfield Housing Authority

Springfield Housing Authority (Springfield, IL)

For each part of the assessment, it can be helpful to ask if the resident is currently connected to any other programs related to that section. This information will help the Service Coordinator identify areas in which the resident is already well supported, and areas in which the resident could use more support.  

Service Coordinators should take notes during their conversations to record critical observations, such as signs of malnutrition or domestic violence, which could influence the needs assessment and connection to services.

Many of these topic areas involve sensitive situations for residents. Service Coordinators should take steps to build trust with residents and create a confidential and safe environment in which residents are comfortable discussing personal issues. To learn more about ways to approach sensitive subjects and effectively communicate with residents, see the section Recommendations for creating and maintaining a confidential and welcoming environment for residents.