Theory of Change Narrative

1) Header & Impact Statement Youth Trades Launch Theory of Change — Northside Neighbors Collective V1.0 | 2025-11-02 | Aisha Thompson, Program Manager

Impact statement: Black and Latino youth ages 16–24 in Milwaukee’s Sherman Park and Lindsay Heights who are not in school and not working, including youth with prior justice involvement, gain skilled trades jobs and steady earnings within five years, reducing youth disconnection and unemployment in these neighborhoods.

2) Problem & Root Causes (100–150 words) Milwaukee has a high share of youth disconnected from school and work. The 2023 American Community Survey shows roughly one in five 16–24-year-olds citywide are disconnected, with higher rates for Black and Latino youth and in North Side ZIP codes that include Sherman Park and Lindsay Heights. The 2024 City of Milwaukee Workforce Dashboard shows youth (16–19 and 20–24) have the highest unemployment rates and the most barriers to re-entry. At the same time, the 2024 Wisconsin Department of Workforce Development postings show steady demand for construction trades, with hundreds of openings in Milwaukee County and starting wages commonly $20–26/hour. Our 2024 listening sessions with 42 local youth cited key barriers: lack of credentials and references, transportation, court records, childcare, and few paid “on-ramps.” Root causes include structural racism in hiring and training selection, credential and driver’s license requirements that screen out youth, and weak local bridges between neighborhoods and unions or contractors. These factors persist due to fragmented services and limited paid, entry-level training slots.

3) Pathway of Change (250–350 words) Activities (what we do) - Recruit 50 Black and Latino youth (ages 16–24) per year from Sherman Park and Lindsay Heights who are out of school and work; prioritize youth with prior justice involvement. - Provide 8 weeks of paid readiness: weekly coaching, soft-skills labs, ID support, and OSHA-10 delivered by WRTP/BIG STEP; stipends of $15/hour for up to 80 hours. - Place youth in 6–8 week paid work-based learning slots through Employ Milwaukee; provide tools/PPE and bus passes. - Rotate interested youth through 2–3 union jobsites with IBEW Local 494 mentors; support applications to pre-apprenticeship or entry-level employment. - Offer wraparound supports: court navigation, childcare referrals, and driver’s license vouchers; 12 months of follow-up coaching.

Outputs (what we produce) - 50 enrolled per year; 90% complete intake and baseline assessments. - 45 earn OSHA-10 and complete 80 hours of readiness. - 35 start paid work-based learning; 30 complete at least 120 site hours. - 30 complete at least two jobsite mentor rotations.

Short-term outcomes (6–12 months) - If youth complete paid readiness plus OSHA-10, then at least 80% will gain work readiness skills (rubric pre/post) within six months, because paid time, practice, and a recognized safety credential build confidence and employer trust. Assumes consistent attendance and credential acceptance by host sites. Evidence: our last cohorts and national studies find paid work-based learning increases soft skills and placement rates. - If youth complete 120+ site hours with weekly coaching, then 70% will secure a job offer or pre-apprenticeship interview within 12 months, because supervisors observe real performance and coaches address barriers in real time. Assumes hosts provide meaningful tasks and feedback. Research on work-based learning shows employer evaluation predicts hiring.

Intermediate outcomes (1–3 years) - If youth are placed and supported for 12 months, then 60% will retain employment at 6 months and 50% at 12 months, and 30% will enter a registered apprenticeship within 24 months. Assumes steady local demand and continued partner slots. Rationale: DWD data show sustained openings; mentoring improves retention in trades. - If partners institutionalize fair-chance screening, then more justice-involved youth will be eligible. Assumes contractor buy-in; we will secure MOUs.

Long-term outcomes (3–5+ years) - 50% of graduates employed full-time at $20+/hour at 24 months; 40% in union roles or apprenticeships by 36 months. Assumes wage floors track posted rates and completion of probationary periods.

Impact (population-level change) - Contribute to a 2–3 point reduction in youth disconnection and youth unemployment in Sherman Park and Lindsay Heights over five years. Assumes city labor demand stays stable and referral pipelines scale.

4) Preconditions & External Factors (75–100 words) Preconditions: signed MOUs with Employ Milwaukee, WRTP/BIG STEP, and IBEW Local 494; funding for stipends, tools, and bus passes; safe training space; data-sharing agreements; referral pipelines with schools, juvenile justice, and CBOs. Within our control: recruitment, coaching quality, stipends, case management, and scheduling. External: construction cycle, union entry timelines, expungement policies, transit reliability, childcare access. We will monitor DWD postings monthly and the City Workforce Dashboard quarterly, review partner slot commitments monthly, and adjust cohort size, pacing, and trade focus each quarter.

5) Attribution & Partnership (75–100 words) Northside Neighbors Collective recruits, coaches, covers stipends and supports, and tracks outcomes. We can credibly claim outputs, short-term skill gains, and placements we broker. Employ Milwaukee provides referrals and paid work-based learning slots tied to WIOA; this drives placement and early retention. WRTP/BIG STEP delivers pre-apprenticeship elements and OSHA-10 that employers recognize. IBEW Local 494 hosts jobsite rotations and mentors, linking to apprenticeship entry. System outcomes (fair-chance hiring, expanded slots) require collective work. Joint MOUs and supervisor training spread youth-friendly practices beyond our program.

6) Risks & Mitigation (75–100 words) - Retention: life crises, court dates, and housing instability. Mitigation: stipends tied to milestones, bus passes, emergency supports, flexible scheduling, and trauma-informed coaching. - Transportation and childcare gaps. Mitigation: MCTS passes, driver’s license vouchers, childcare referrals, and aligning shifts with transit. - Background checks limiting access. Mitigation: expungement/record sealing clinics with legal partners; fair-chance host agreements; match youth to roles without prohibited tasks. - Staff turnover. Mitigation: cross-training, documented playbooks, caseload caps (max 12–15 youth/coach), and weekly case reviews with the 5-person team.

7) Learning & Measurement (100–150 words) Indicators - Outputs: enrollments; completion of OSHA-10; hours completed; number of rotations; placement count. - Short-term (6–12 months): % with soft-skill gains (pre/post rubric); % with OSHA-10; % with completed career plan; % with job offers/interviews. - Intermediate (1–3 years): 6- and 12-month job retention; wage at placement and at 12 months; % entering pre-apprenticeship or registered apprenticeship. - Long-term (3–5 years): % earning $20+/hour at 24 months; % in union roles/apprenticeships at 36 months; alumni job stability. - Impact (contribution): trend in youth disconnection and youth unemployment in target ZIPs.

Data sources and cadence: intake forms; attendance; coach observations; partner reports; pay stubs; 30/90/180/365-day check-ins; annual alumni survey; quarterly partner debriefs; ACS and City dashboard annual pulls. Use: monthly output huddles; quarterly outcome reviews to adjust recruitment, coaching dosage, and host mix; semiannual training for supervisors; escalate system barriers to partner leadership.

8) Boundaries & Sustainability (40–75 words) We do not provide mental health therapy, housing, or legal defense; we refer. Sustainability rests on braided funding: grants, Employ Milwaukee/WIOA reimbursements, union/host cost-share, and philanthropy for stipends and tools. For lasting impact, the ecosystem must expand fair-chance hiring, stabilize apprenticeship entry windows, and improve transit and childcare access. Signed: Aisha Thompson, Program Manager, 2025-11-02

9) Visual Diagram Outline (text flowchart) Box 1: Problem — High youth disconnection in Sherman Park and Lindsay Heights; strong trades demand but access barriers (ACS 2023; City Workforce Dashboard 2024; DWD postings 2024) ↓ Box 2: Activities — Paid readiness + OSHA-10 (WRTP/BIG STEP); paid work-based learning (Employ Milwaukee); union jobsite rotations and mentors (IBEW 494); coaching and supports [Assumption: funding for stipends/tools; MOUs in place; youth can attend] ↓ Box 3: Outputs — 50 enrolled; 45 OSHA-10; 35 placed; 30 complete 120+ site hours [Assumption: hosts provide meaningful tasks and feedback] ↓ Box 4: Short-term (6–12 months) — 80% soft-skill gains; 70% secure offer or pre-apprenticeship interview [External: transit reliability; court dates] ↓ Box 5: Intermediate (1–3 years) — 60% 6-month retention; 50% 12-month retention; 30% enter registered apprenticeship [Assumption: steady construction demand; fair-chance policies honored] ↓ Box 6: Long-term (3–5+ years) — 50% earn $20+/hour at 24 months; 40% in union roles by 36 months [External: wage trends; economic cycles] ↓ Box 7: Impact — Contribute to 2–3 point drop in youth disconnection/unemployment in target neighborhoods (tracked via ACS and City dashboard)

1) Header & Impact Statement Healthy Beginnings Home Visiting — Theory of Change Narrative Version V2.1 | 2025-11-02 | Owner: Dr. Elena Ruiz, Director of Programs

Impact statement: Pregnant people and new parents ages 15–34 at or below 200% FPL in McDowell, Mitchell, and Yancey Counties, including Appalachian, Latina, and Cherokee families, experience healthier pregnancies, safer infant care, and stronger parent wellbeing within five years, contributing to better birth outcomes in rural Western North Carolina.

2) Problem & Root Causes (STANDARD) Problem: Rural Western North Carolina continues to see preventable gaps in maternal and infant health. The 2024 County Health Rankings report higher teen birth rates and more low birthweight births in McDowell, Mitchell, and Yancey than the state average, alongside limited access to obstetric care. NC DHHS reports that North Carolina’s infant mortality rate remains about 7 deaths per 1,000 live births, with persistent racial and geographic disparities (2023). North Carolina PRAMS 2022–2023 highlights show that many birthing people report depressive symptoms postpartum (about 1 in 5) and challenges meeting basic needs during pregnancy, both linked with adverse birth outcomes. Our 2024 maternal listening sessions (n=58) in the three counties surfaced practical barriers: long travel to prenatal care (often 30–60 minutes), missed appointments due to transportation and childcare, limited Spanish-language support, and anxiety about paying for care even with Medicaid.

Root causes: - Structural access gaps: Few local OB providers, long distances, limited evening/weekend appointment options, and inadequate transportation. - Economic stress: High rates of low-wage work and food insecurity at or below 200% FPL, affecting nutrition and the ability to attend care. - Structural inequities: Language access barriers for Latina families, cultural mismatches for Cherokee families, and historic distrust of systems. Coverage lapses and confusing benefits navigation also drive late or inconsistent care.

Why this persists locally: Rural provider shortages, fragmented referral systems, limited care coordination, and policy constraints (e.g., transportation coverage and benefit churn) continue to limit timely, continuous prenatal and postpartum support.

Sources cited in plain language: 2024 County Health Rankings; NC DHHS 2023 infant mortality and prenatal care data; 2022–2023 NC PRAMS highlights; our 2024 maternal listening sessions (n=58).

3) Pathway of Change (STANDARD) Activities (what we do) - Home visiting: Nurse and community health worker (CHW) home visits biweekly during pregnancy and monthly until infant age 12 months; flexible evening/weekend options; tele-visits as needed. - Screening and education: EPDS/PHQ‑9 and anxiety screening each trimester and at 6 weeks/6 months postpartum; tobacco/substance screening; safe sleep, injury prevention, and lactation coaching; birth and postpartum plan development. - Care coordination: Schedule prenatal care, pediatric well-baby visits, and WIC appointments; provide warm handoffs to MountainCare FQHC for prenatal care; coordinate with McDowell County Health Department nurses for consults; link to WIC for nutrition and breastfeeding support; arrange transportation and interpretation. - Material supports: Breast pumps, safe sleep kits, car seat checks, and gas cards for medical visits.

Outputs (what we produce) - 150 families enrolled/year; 85% complete at least 6 home visits within 12 months. - 95% receive a prenatal care appointment within 14 days of enrollment; 80% attend it within 30 days. - 90% complete depression/anxiety screening each trimester and postpartum; 70% of those screening positive receive a follow-up plan within 14 days. - 90% receive safe sleep education; 85% have a documented safe sleep plan by 36 weeks; 90% receive a WIC referral; 80% complete WIC enrollment.

If-then links, assumptions, and rationale - If we deliver consistent nurse/CHW home visits with culturally responsive education and planning, then families will gain timely information and support, because trusted, repeated contact builds knowledge and confidence. Assumes stable staffing and bilingual capacity. Evidence from home visiting models shows gains in prenatal health behaviors and parenting practices. - If we schedule appointments, provide warm handoffs to MountainCare FQHC, and offer transportation/interpretation, then more clients will start and keep prenatal care, because we remove practical barriers that cause late entry or missed care. Assumes partner capacity and reliable transport. County Health Rankings and PRAMS link timely prenatal care with better outcomes. - If we screen for depression/anxiety and act on positive screens within two weeks, then more parents will engage in mental health care, because quick follow-up reduces drop-off after identification. Assumes coverage continuity for behavioral health and available providers. PRAMS highlights the burden of perinatal mood symptoms; early connection helps. - If we provide safe sleep kits and coaching, then parents will adopt safer sleep practices within 6 months postpartum, because hands-on tools plus simple cues drive behavior change. Assumes housing stability sufficient for a separate sleep surface. CDC guidance and prior program data show high uptake with combined education and equipment. - If we connect to WIC and offer lactation coaching and pumps, then more parents will initiate and continue breastfeeding at 8 weeks, because practical support and nutrition benefits address common barriers. Assumes timely WIC appointments and employer flexibility for pumping. WIC participation is associated with higher breastfeeding initiation.

Short-term outcomes (6–12 months) - 80% show gains on a prenatal/infant care knowledge checklist within 3 months. - 85% adopt a safe sleep plan by 36 weeks; 75% report consistent safe sleep at 2 months. - 70% of those screening positive for depression/anxiety start treatment, peer support, or coaching within 30 days. - 85% attend first prenatal visit within 30 days of enrollment.

Intermediate outcomes (1–3 years) - 75% achieve “Adequate/Intermediate” prenatal care utilization (APNCU index) across pregnancy. - 65% maintain breastfeeding at 8 weeks; 50% at 3 months. - 80% complete a 6–8 week postpartum visit; 70% select a desired contraception method (if wanted). - 85% of infants complete recommended well‑baby visits in first year; 80% on-time immunizations.

Long-term outcomes (3–5+ years) - Participant preterm birth rate at least 20% lower than county baseline (e.g., from 10% to 8%) over rolling 3‑year cohorts. - Participant low birthweight rate at least 15% lower than county baseline over rolling 3‑year cohorts. - 25% reduction in preventable infant injury ED visits among participants by 12 months. - 30% reduction in moderate/severe depressive symptoms at 6 months postpartum compared to intake.

Impact (population level) - Over five years, counties show improved trends: higher timely prenatal care, fewer low birthweight births, and lower infant mortality, to which our cohort outcomes contribute alongside system partners.

4) Preconditions & External Factors (STANDARD) Preconditions: Stable funding for home visiting; executed MOUs and data-sharing with McDowell County Health Department, MountainCare FQHC, and WIC; transportation vouchers; bilingual staff/interpretation; secure data systems; Medicaid billing set-up; referral pipelines from clinics and schools.

Within our control: Home visit quality and cadence; screening and follow-up; scheduling and warm handoffs; transportation and material supports; staff training.

External factors: Insurance coverage continuity (e.g., Medicaid postpartum extension), provider capacity at MountainCare and WIC, transportation network, housing stability, and broader economic stress. We will monitor monthly partner capacity, track canceled appointments, and adapt with tele-visits, group visits, or mobile clinics when external constraints rise.

5) Attribution & Partnership (STANDARD) Blue Ridge Community Health Partners’ role: We deliver home visiting, education, screening, coordination, and supports. We can credibly claim participant-level outcomes tied to our services (e.g., timely prenatal entry, safe sleep adoption, screening and follow-up). We will not claim sole credit for county-level trends.

Partner contributions: - McDowell County Health Department: Referral hub, public health nurse consults for high-risk cases, and data exchange on prenatal care starts; they strengthen our screening and care plans. - MountainCare FQHC: Reserved prenatal slots and warm handoffs ensure rapid access to clinical care; they are essential to our “timely prenatal care” outcome. - WIC offices: Nutrition benefits, breastfeeding counseling, and pump access; critical to our breastfeeding and food security outcomes.

System outcomes that require collective effort: County-level low birthweight and infant mortality trends depend on provider capacity, coverage policy, and social supports. Our joint work with public health and FQHCs, plus shared data and coordinated referrals, can shift systems (e.g., standard warm-handoff workflows and priority scheduling for high-risk pregnancies).

6) Risks & Mitigation (STANDARD) - Participant retention and scheduling conflicts: Mitigation—offer evening/weekend and tele-visits; provide gas cards and childcare stipends for clinic visits; use reminder texts in English/Spanish; assign consistent nurse/CHW teams. - Staff turnover or burnout: Mitigation—competitive pay, reflective supervision, manageable caseloads (~12–15 families/staffer), and cross-training to ensure coverage. - Language and cultural barriers: Mitigation—hire bilingual staff; contract interpreters; develop Spanish and culturally grounded materials; partner with Cherokee community advisors; use teach-back methods. - Policy or partner capacity shifts (e.g., Medicaid changes, clinic slot shortages): Mitigation—monthly partner huddles, escalation protocols, backup telehealth prenatal education, and mobile clinic days with public health.

We will maintain beneficiary voice through quarterly pulse surveys (text-based), a parent advisory group meeting bimonthly, and rapid feedback loops after visits. We will adapt protocols when clients report barriers.

7) Learning & Measurement (STANDARD) Indicators - Outputs: # enrolled; % completing 6+ home visits within 12 months; % scheduled and % attending first prenatal visit within 30 days; # WIC warm handoffs and completions. - Short-term: % scoring higher on prenatal/infant care knowledge checklist (pre/post); % with documented safe sleep plan by 36 weeks; % screened for depression/anxiety; % with follow-up plan within 14 days after a positive screen. - Intermediate: % Adequate/Intermediate APNCU; % breastfeeding at 8 weeks and 3 months; % attending postpartum visit by 7 weeks; % infants completing well-baby schedule and on-time immunizations. - Long-term: Preterm birth and low birthweight rates among participants vs county baseline; % with moderate/severe depressive symptoms at 6 months vs intake; participant infant injury ED visit rate by 12 months. - Impact (contribution): County trend lines for timely prenatal care, low birthweight, and infant mortality (County Health Rankings; NC DHHS).

Data sources and frequency - Administrative and EHR/visit logs: Weekly; monthly output dashboard. - Client surveys (pre/post knowledge; EPDS/PHQ‑9; safe sleep): At enrollment, each trimester, 6 weeks, 6 months; quarterly roll-up. - Partner reports (MountainCare, WIC, Health Department): Quarterly debrief and slot/utilization summaries. - Listening sessions/focus groups: Semiannual.

Key learning questions - Which visit elements (transport + warm handoff, safe sleep kit, lactation support) most strongly predict timely prenatal care and breastfeeding at 8 weeks? - Are outcomes equitable across Appalachian, Latina, and Cherokee clients? Where do we see gaps? - What volume/timing of visits is “enough” to shift preterm/low birthweight risk? - How do policy or partner capacity shifts affect completion of care plans, and what workarounds are most effective?

Use of findings - Monthly: Adjust caseloads, visit cadence, and transportation supports. - Quarterly: Update partner MOUs and slot allocations; target staff training (e.g., lactation, motivational interviewing). - Annually: Revise goals, budgets, and advocacy priorities; publish a simple results brief to the board and partners.

Team capacity fit - With 12 staff and a moderate annual survey budget, we will keep tools short (checklists, EPDS/PHQ‑9), use simple dashboards, and prioritize a small set of high-value indicators.

8) Boundaries & Sustainability (STANDARD) Scope limits: We do not provide clinical prenatal care, deliver babies, provide emergency transport, or long-term mental health therapy. We do not offer legal or immigration services.

Sustainability assumptions: Blend of grants, Medicaid reimbursement for home visiting and screening, county support, and in-kind partner services; stable staffing; maintained MOUs. For impact to last, the ecosystem needs durable OB capacity, transportation funding, and robust WIC/food supports. We will advocate with partners on these system needs.

Signature: Dr. Elena Ruiz, Director of Programs, 2025-11-02

9) Visual Diagram Outline Box 1: Problem — Rural maternal/infant health gaps (late prenatal care, low birthweight, high stress; travel and language barriers) ↓ [Assumes community trust and referral flow] Box 2: Activities — Nurse/CHW home visits; screenings; education; scheduling + warm handoffs (MountainCare, WIC); transport/interpretation; safe sleep and lactation supports ↓ [Assumes partner capacity and Medicaid coverage continuity; external: transportation availability] Box 3: Outputs — 150 enrolled/year; 85% complete 6+ visits; 90% screened each trimester; 80% attend first prenatal within 30 days; 80% complete WIC enrollment ↓ [Assumes consistent contact and reliable communication] Box 4: Short-term — Higher knowledge; safe sleep plans; treatment started after positive screens; timely prenatal entry (6–12 months) ↓ [External factors: housing stability for safe sleep; provider access for MH care] Box 5: Intermediate — Adequate prenatal care use; breastfeeding at 8 weeks/3 months; postpartum visit; well-baby visits/immunizations (1–3 years) ↓ [Assumes continued partner slots and family stability] Box 6: Long-term — Lower preterm and low birthweight among participants; fewer infant injury ED visits; lower maternal depressive symptoms (3–5+ years) ↓ [External: county provider supply and economic stress] Box 7: Impact — County trends improve: more timely prenatal care, fewer low birthweight births, lower infant mortality (collective contribution)

Why this is a Theory of Change This narrative explains how and why our activities lead to change, states assumptions and external factors, and sets testable targets so we can learn and adapt, not just list activities.

1) Header & Impact Statement Keys to Stability Rapid Re-Housing — Theory of Change | V3.0 | 2025-11-02 | Monica Patel, Senior Director of Impact Impact: Families with children experiencing homelessness in King County, Washington—heads of household 18+; disproportionately Black and Latino; many survivors of domestic violence; earning ≤30% of area median income—secure safe, stable housing for 24+ months and see fewer returns to homelessness, narrowing racial gaps in housing stability.

2) Problem & Root Causes King County’s housing market is tight and costly. The 2023 American Community Survey shows about 45% of renter households in King County are cost-burdened and about 22% are severely cost-burdened, leaving little room for emergencies. The Washington Office of Financial Management’s 2024 rental and vacancy report shows apartment vacancy around 4–5% in urban King County and median two-bedroom rents near $2,400, far out of reach for families at ≤30% AMI. The 2024 King County Regional Homelessness Authority (KCRHA) HMIS dashboard indicates family inflow to homelessness continues to exceed exits in parts of the county, and returns to homelessness within a year remain a concern. In our 2024 client feedback survey (n=312), 68% reported landlord screening barriers (credit, eviction records, income multiples) and 57% reported discrimination based on race, vouchers, or family size when searching for housing.

Root causes include a structural wage–rent gap; low vacancy that strengthens landlord screening and raises deposits; and racial inequities in both the homelessness system and the rental market that disproportionately affect Black and Latino families. Domestic violence also drives homelessness; survivors need quick, confidential placements and trauma-informed support. The problem persists locally because deeply affordable units are scarce, time-limited rent help often ends before incomes stabilize, and families face fragmented access to legal aid, landlord mediation, and flexible funds.

Sources: 2024 KCRHA HMIS dashboard; 2023 ACS/Census; WA OFM 2024 rent and vacancy report; PSFHA 2024 client feedback survey (n=312).

3) Pathway of Change Activities (what we do) - Rapid Re-Housing with progressive engagement: up to 12 months of rent and utility assistance, tapering as income rises; average planned assistance 9–10 months. - Housing navigation and landlord engagement: unit search, application support, landlord negotiation; use the Landlord Liaison Program (Catholic Community Services) for unit access and mediation. - Flexible funds: application fees, deposits, arrears, moving costs; disbursed within 3 business days. - Case management: weekly contact for first 90 days, then biweekly; tenancy skills, budgeting, benefits enrollment, DV safety planning, school stability. - Legal access: referrals to Northwest Justice Project for eviction prevention, record sealing, and fair housing enforcement. - Data and coordination: enrollments via KCRHA Coordinated Entry; all services tracked in HMIS.

Outputs (what we produce) - 220 families enrolled annually; 90% complete a housing plan within 30 days; 80% placed in housing within 60 days; average assistance $1,200/month; 150 landlord partners engaged; 120 legal referrals; 200 safety plans completed for DV survivors.

If-then link 1: If families receive fast housing navigation, landlord matchmaking, and flexible funds, then most will secure a lease in 60 days because reduced screening barriers and quick fee coverage make applications competitive in a low-vacancy market. Assumes landlords honor commitments and flexible funds are disbursed within 3 business days. Rationale: Our last year’s median time-to-housing was 58 days under these conditions, and KCRHA HMIS shows faster exits when rent assistance plus landlord mediation are combined.

Short-term outcomes (6–12 months) - 90% complete tenancy skills and rights training; 85% enroll in all eligible benefits (SNAP, TANF, child care); 80% have a written budget and savings plan; 95% of DV survivors have a current safety plan; 85% of school-age children remain in their home school through year-end.

If-then link 2: If families receive tenancy training, budgeting support, and benefit enrollment while housed, then they will increase knowledge and reduce crisis moves within 6–12 months because practical skills and cash-like supports stabilize monthly costs. Assumes consistent case manager contact and language access. Rationale: Our client survey found 72% reported better landlord communication and 66% reported fewer missed bills after training and benefits enrollment.

Intermediate outcomes (1–3 years) - 75% remain stably housed at 12 months post-enrollment; 65% increase earned or unearned income by ≥10% within 12 months; 90% avoid any eviction filing during program and within 6 months of exit; 80% maintain the same school or district through the next school year; county returns to homelessness within 12 months among our exit cohort at or below 15%.

If-then link 3: If rent support tapers as income and benefits rise, with legal support when needed, then families will maintain housing for 12–24 months because financial gaps narrow while tenants learn to navigate rights and responsibilities. Assumes basic labor demand and benefit continuity. Rationale: HMIS trend data locally shows better 12‑month stability for households receiving at least 6 months of stepped rent help plus mediation access.

Long-term outcomes (3–5+ years) - 70% remain housed 24 months after enrollment; 55% maintain housing without ongoing subsidy by 24 months; the racial gap in exits to permanent housing between Black/Latino and white families narrows by 10 percentage points among our participants.

If-then link 4: If families secure leases, build tenancy records, and avoid court filings, then long-term stability increases because positive rental history and reduced debt improve unit choice and renewals. Assumes credit repair and landlord references are obtainable. Rationale: Practice experience and partner reports show fewer court records correlate with renewals and lower move-out rates.

Impact (population-level change) - Contribution to county-wide reductions in families entering homelessness and in 12‑month returns, especially for Black and Latino families. As our annual placements scale to 220 families and landlord participation grows, more family units remain available to coordinated entry.

Assumption: System capacity (units and subsidies) holds steady; partners maintain service coverage. Rationale: Collective exits must exceed inflow to shift county trend lines; our placements and reduced returns contribute to that balance.

4) Preconditions & External Factors Preconditions: Stable funding for rent assistance and flexible funds; signed MoUs with KCRHA, Landlord Liaison Program, and Northwest Justice Project; trained staff (48) with manageable caseloads; language access and trauma-informed practices; HMIS access; secure DV protocols. External factors: rent inflation, vacancy rates, wage trends, child care access, state tenant laws, and voucher availability. Within our control: service quality, speed of payments, landlord relationships, participant supports. Outside our control: macro housing supply and labor market. We will monitor KCRHA dashboards monthly, WA OFM rent/vacancy quarterly, and adjust subsidy length, tapering, and landlord incentives when market conditions tighten.

5) Attribution & Partnership Puget Sound Family Housing Alliance (PSFHA) will directly deliver housing navigation, rent/utility assistance, case management, and flexible funds. We can credibly claim outputs and short‑term outcomes, and a direct contribution to intermediate outcomes for families we serve. KCRHA provides coordinated entry referrals and HMIS infrastructure, enabling quick enrollments and shared outcome tracking. The Landlord Liaison Program at Catholic Community Services expands unit access, offers risk mitigation to owners, and mediates disputes—key to the activities-to-output link and to avoiding eviction filings. Northwest Justice Project provides eviction prevention, record sealing, and fair housing enforcement, which underpins the maintenance-of-housing outcomes. County-level impact (reduced inflow and returns, narrowed disparities) requires collective effort across these partners and the broader housing ecosystem. Our joint work increases the share of available units accepting assisted tenants and reduces harmful legal records, nudging system practice toward fairer screening and faster exits.

6) Risks & Mitigation - Unit scarcity or rent spikes: Mitigation—deepen landlord pipeline with sign-up targets, offer risk mitigation funds and holding fees, prioritize lease-up in high‑opportunity neighborhoods, and adjust assistance length based on market scans. - Screening discrimination (race, vouchers, family size): Mitigation—pair tenants with fair-housing education, route cases to Northwest Justice Project, conduct landlord trainings, and track denials by reason to intervene. Provide translation, childcare, and transportation stipends for showings. - Participant retention and trauma: Mitigation—use flexible scheduling, text-based check‑ins, mobile visits, and survivor‑led safety planning; offer culturally responsive services and motivational interviewing. - Staff turnover or burnout: Mitigation—maintain caseload targets (no more than 20–25 families per case manager), reflective supervision, secondary trauma supports, and competitive pay; cross-train to prevent service gaps. Beneficiary voice: We run quarterly SMS surveys, a Family Advisory Council (10–12 parents), and case review panels that include alumni; we change practices based on this feedback.

7) Learning & Measurement Indicators - Outputs: number enrolled; median days from enrollment to lease; average and total assistance per family; number of landlord partners; number of legal referrals; percent completing housing plan in 30 days. - Short-term (6–12 months): percent completing tenancy training; percent with benefits enrollment; percent with written budget; percent of DV survivors with active safety plan; student school stability rate by semester. - Intermediate (1–3 years): percent stably housed at 6 and 12 months; percent with ≥10% income gain by 12 months; percent with no eviction filings during program and within 6 months post-exit; 12‑month returns to homelessness rate for exit cohort. - Long-term (3–5+ years): percent housed at 24 months; percent housed at 24 months without subsidy; racial gap in permanent housing exits among our participants; landlord renewal rate at first lease end.

Key learning questions - What level and duration of assistance yields the best 12‑ and 24‑month stability for families at ≤30% AMI? - Which landlord practices (incentives, mediation) most reduce screening denials for Black and Latino families? - Which participant supports most predict “no eviction filing” (legal aid timing, arrears coverage, safety planning)? - How should we adjust tapering when rents rise faster than incomes?

Data sources and frequency - HMIS and internal case management system: monthly output review; quarterly outcome checks. - Client surveys (SMS/web) and focus groups: semiannual. - Partner reports (Landlord Liaison Program; Northwest Justice Project): quarterly. - KCRHA dashboard; WA OFM rent/vacancy; ACS updates: annual. Use of findings - Monthly huddles to adjust caseloads and payment timing. - Quarterly learning sprints to revise subsidy tapering and landlord incentives. - Annual partner debrief to refine referral criteria and dispute-resolution protocols; escalate policy issues to KCRHA.

8) Boundaries & Sustainability Scope limits: We do not provide permanent supportive housing, long-term subsidies beyond 12–18 months, mental health or substance use treatment, or immigration legal services; we refer to partners. Sustainability assumes blended public contracts, philanthropy for flexible funds, and stable partner infrastructure. Durable impact requires more deeply affordable family units, fair-chance screening, child care access, and livable wages. Signed, Monica Patel, Senior Director of Impact, 2025-11-02

9) Visual Diagram Outline Box 1: Family Housing Stability Pathway—PSFHA (Problem: high rents, low vacancy; families ≤30% AMI; racial disparities; DV) ↓ Box 2: Activities (RRH rent/utility aid up to 12 months; housing navigation; flexible funds; case management; DV safety planning; landlord mediation; legal referrals; HMIS coordination) ↓ [Assumes flexible funds paid within 3 business days; landlord partners honor unit offers] Box 3: Outputs (220 families enrolled; 80% housed in 60 days; 150 landlord partners; 120 legal referrals) ↓ [Assumes consistent case contact and language access] Box 4: Short-term (6–12 months: 90% tenancy training completed; 85% benefits enrollment; 80% budgeting plans; 85% school stability; 95% DV safety plans) ↓ [Assumes basic labor demand and benefit continuity; external factor: child care availability] Box 5: Intermediate (1–3 years: 75% housed at 12 months; ≥65% income gain ≥10%; 90% no eviction filings; returns ≤15%) ↓ [Assumes mediation and legal aid capacity; external factors: rent inflation, vacancy] Box 6: Long-term (3–5+ years: 70% housed at 24 months; 55% without subsidy; racial exit gap narrows by 10 pts) ↓ Box 7: Impact (County-level contribution: fewer family entries and returns; narrowed racial disparities) [External factors alongside Boxes 5–7: housing supply, wages, tenant laws, voucher availability]