Colorado Balance of State – Roaring Fork

Spotlight on Outreach Coordination and Coverage

Background

Since joining Built for Zero (BFZ) in the fall of 2019, Roaring Fork, Colorado, has diligently worked towards achieving All Singles Quality Data and reached this milestone in August 2024. Throughout their journey, they have created the Valley Alliance to End Homelessness, a unified tri-county homeless response coalition. Despite facing limited resources and challenging terrain, their focus on fostering partnerships and advancing public education has enabled them to effectively reach and support their unsheltered neighbors. 

Before the Quality Data Process

Roaring Fork, one of several regions in the Colorado Balance of State Continuum of Care, is comprised of Eagle, Garfield, and Pitkin Counties. This largely rural area spans over 5,500 square miles, characterized by canyons and mountainous terrain, making even the most comprehensive outreach complicated. Before joining BFZ, the counties operated independently with minimal coordination. Although the state has a shared installation of Clarity Bitfocus, the region’s low adoption of HMIS hindered their ability to track clients across multiple counties.

Leveraging the BFZ Methodology 

After joining BFZ and utilizing the All Singles Scorecard, Roaring Fork identified cross-county collaboration, data sharing, and establishing service standards as key areas for improvement to better support their unsheltered neighbors.

Eagle County’s Homeless Service Manager, Monica Brutout, noted that “engaging with BFZ methodology taught us a lot about goal setting and ensuring we have standards. It helped us hold each other accountable and make sure processes were actually implemented. Before BFZ, we were kind of all just up in the air. We didn’t have goals and didn’t fully grasp how HMIS could work. Over time, we’ve realized how having measurable outcomes is beneficial to the system as a whole.”

In the spring of 2022, regional leaders attended the BFZ Learning Session in Chicago, marking a turning point in strengthening relationships and building trust. They returned with renewed momentum, leading outreach teams to share by-name data for the first time. Data-sharing agreements were established, and case conferencing meetings were gradually consolidated, leading to the solidification of the Valley Alliance to End Homelessness. 

Utilizing Coalitions to Establish Best Practices

The Valley Alliance to End Homelessness created a platform for providers to develop best practices for supporting unsheltered neighbors across the tri-county area. The coalition effectively broke down silos and established a cohesive outreach approach. This work supported the community’s ability to address the outreach section of the scorecard, including questions 1A, B, C, and D, which require communities to:

• 1A. Define how staff are deployed through the region to connect with individuals experiencing unsheltered homelessness
• 1B. Explain how outreach teams coordinate to most effectively reach individuals experiencing unsheltered homelessness while minimizing duplication of services
• 1C. Document how outreach teams will coordinate to swiftly connect unsheltered individuals to their self-determined needs
• 1D. Demonstrate their ability to connect with at least 90% of the unsheltered population

Defining Geographic Boundaries for Outreach Deployment (1a)

Each of the three counties are supported by their own outreach team: Mind Springs Health in Garfield County, Eagle County Homeless Services in Eagle County, and Recovery Resources in Pitkin County. While historically these teams did not work together to determine outreach maps, the creation of the Valley Alliance to End Homelessness allowed them to define geographic boundaries for each team’s area of outreach coverage. This predefined and agreed-upon deployment system ensures that outreach requests are swiftly directed to the appropriate team and helps prevent gaps in coverage. Previously, if a request for outreach services fell outside a team’s designated area, it would be significantly delayed. Now, with standardized coverage areas, requests are efficiently forwarded to the correct team. This coordination reduces the burden on the individual and creates a no-wrong-door approach that allows the system to quickly connect with their unsheltered neighbors. 

Demonstrating Comprehensive Coverage (1d)

A total of four full-time and one part-time staff — including two Spanish/English speakers and one peer support specialist — provide outreach for the region. Given the limited capacity and complex geography, comprehensive canvassing is impractical. While staff do canvas known hotspots, approximately 75% of clients served are identified and connected to services through referral. The region is mindful to provide referral forms in both Spanish and English because of their large population of Spanish speakers and newcomers. Bilingual referral forms are posted on team websites, and the community has worked to socialize referral pathways. Information events are routinely scheduled with public health, law enforcement, and other adjacent systems where information on available resources and instructions to request outreach support are provided. Flyers are dispersed throughout the community encouraging the public to request outreach if they come in contact with a person in need. Social media campaigns were launched on Facebook and Instagram providing information about the region’s homeless response efforts. Outreach strategies have been shared through local news outlets, and the community is starting to post QR codes, phone numbers, and addresses to access points on local buses. And to ensure even the furthest corners of the region are connected, outreach teams are listed with 211, the Colorado Resource Network, and “Find Help,” a resource navigation tool through the local health department. 

Deduplicating Outreach Services (1b)

Once the three counties began collaborating, they realized that “none of our clients belong to a single county” and that “clients move between all three counties.” Data-sharing agreements have helped identify and mitigate service duplication. Previously, clients might be served by multiple teams across counties, leading to redundant efforts. Data sharing now allows for effective resource allocation while weekly meetings support continuous care as clients move between counties. Pitkin County’s Unsheltered Outreach Program Manager, Wendee Schoon, reflected, “you see those moments for client care that are key — having case conferencing and collaboration allows care continuity where before, the needed next steps would never get accomplished.”

To further strengthen data sharing and care coordination, the teams have committed to utilizing HMIS for data tracking and have started moving away from external by-name lists.

Documenting Outreach Practices (1c)

The Valley Alliance to End Homelessness has made great strides in standardizing outreach systems across the tri-county area. This has made it easier for everyone involved — both community partners and participants — to understand and navigate the services available. With less variation between counties, training new staff is simpler, and there’s less confusion about which team handles what. 

Currently, the community’s outreach policy is included in the Valley Alliance Policies and Procedures. Although the community is still in the process of fully documenting all outreach practices, it hasn’t stopped them from achieving a “yes” on question 1c of the scorecard, asking if the community has a documented outreach policy. This emphasizes the community’s dedication to ongoing improvement and highlights that, although perfect documentation is still in the works, the successful implementation of standardized systems and documented practices can drive significant progress.

Shared Expertise and Brain Trust

Cross-county collaboration provides an opportunity for outreach partners to capitalize on field expertise and share innovative approaches. Collaborative meetings are attended by staff from every level of the organization where boots-on-the ground input is highly valued. A crucial factor in Roaring Fork’s success is the team’s commitment to incorporating diverse perspectives. Hiring staff with lived expertise and promoting from within deepens the team’s understanding of the unique challenges faced by unsheltered populations. Garfield County’s Regional Outreach Director, Hans Lutgring, pointed out that “BFZ has reinforced our high-level awareness and commitment to a diverse team with bilingual and bicultural input. It fits really nicely into a social work lens, and we believe it’s crucial for all the work we do. It’s about having a dedication to diversity and equity.”

Lessons Learned

Reflecting on their journey, outreach teams shared several key lessons learned, including the importance of maintaining patience throughout the process and embracing the discomfort, even when the work seemed insurmountable. Wendee noted, “When I first started, I could feel some of the competition. Each county had their own by-name list, but now we are together and supportive. To do that, we had to sit in some uncomfortable spaces. Conversation and creating the Valley Alliance was key to bringing the work together.” When asked what advice she would give communities getting started in this work, Monica shared that “patience is a virtue, and these processes take time. It’s important to understand that turnover and training happens. Be open to continuously educating and reminding folks of processes, and keep those processes consistent. Systems are in place for a reason, so we really took the time to get it right.” And while there is always more work to be done, Hans emphasized that the team “recognizes this and still celebrates the wins.” 

Net EffectDespite facing limited resources and challenging terrain, Roaring Fork has developed a remarkably effective outreach strategy. Their success stems from a steadfast commitment to the process, strong relationship building, mutual learning, effective data-sharing agreements, and elevating the voices of those with expertise. They have achieved a delicate balance between organizational goals and community needs by fostering genuine collaboration, often setting aside individual ambitions for the greater good of the system. As Hans Lutgring noted, this collaborative spirit involves “not operating by protecting our slice of the pie but genuinely working together as a collection of organizations, sometimes necessitating the shelving of egos and individual goals.” This approach has enabled them to gather accurate data on unsheltered homelessness, swiftly address individuals’ self-identified needs, and ensure that no one falls through the cracks