Safety Wellness Benchmarks Manual - ORR Adaptation

The Safety & Wellness Benchmarks are a compilation of individual scales that measure observable change during the provision of case management for forcibly displaced populations in the United States.

Key Concepts and Definitions

For the purposes of this tool, case management is defined as a method of providing services in which a professional case worker assesses the needs of a client and the client’s family, when appropriate, and arranges, coordinates, provides, monitors, evaluates and advocates for a package of services to meet the specific client’s complex needs. Case management addresses both the individual’s expressed needs as well as the state of the social system in which the case worker and client operate, therefore interventions occur at both the client and systems levels. This means working with clients on individual level change through accessing needed services and opportunities and working with and without clients on systems level change to improve access, remedy inequitable systems, and create stronger opportunities for clients and communities. Throughout the provision of case management, case workers and clients develop strong relationships that are predicated on mutual respect, equity in care and access, a commitment to do no harm, the right to self-determination, and a client-centered, strengths-based, and trauma-informed approach.

While STAR is not an intensive case management program, case managers play a pivotal role in coordinating and arranging care for STAR clients.

Clinicians are mental health professionals licensed within the state in which programs are administered.

Creation of the Benchmarks

The Benchmarks are a tool to document progress towards client well-being and goals. They are also meant to be used as a tool to help caseworkers or other intake staff in the process of assessing for needs, identifying strengths and resources, setting goals, and providing resources and services.

Frequency of Use

The Benchmarks are meant to be used at least quarterly:

As a part of intake and assessment, and
At quarterly intervals from intake, and
At case closing.

Categories of Support

The Benchmarks are a compilation of 15 categories of support. ORR reduced to seven categories relevant to the STAR program. These categories are meant to represent the main areas of case management work done in medium to long term programs focused on improving safety, health, and power. This means that the seven categories are not exhaustive and do not include all the potential areas in which clients may set goals or seek services. In the goal setting process, you may set a goal with the client to enroll in a mechanics certification course. This goal will not be reflected in a category specific to professional certifications or education; however, it is still an important component of the client’s case management services.

The Benchmarks are meant to support caseworkers in identifying needs and progress and are NOT intended to replace working collaboration with clients to identify their own service goals. Clients may score low on a category of support (i.e. score 1 or 2) and may choose NOT to include that category in their Wellness Plan goals. For example, a client may score 1 or 2 in Physical Health and choose NOT to identify improving physical health as a goal. This self-determination is an important component of the Wellness Plan process and caseworkers are responsible for respecting their clients’ rights to self-determination, especially as it pertains to goal setting.

In this manual, there are sections below each category of support that explain the purpose of measuring the category, define key terms, provide suggested assessment questions to help gather information pertaining to the category, and provide suggested responses for categories in which a response is necessary for scores of 1 or 2.

Levels of Need

Each category of support should be scored based on the level of need. This scoring is defined as:

Significant (1) meaning the client has immediate/imminent unmet needs in this category and/or may be in crisis in the category
Moderate (2) meaning the client has emerging needs in this category
Some (3) meaning the client can meet some of the needs in this category
Minimal (4) meaning the client can meet most or all of the needs in this category.

Each category has specific examples of the criteria for each level of need, meaning that a client in ‘significant needs’ for Community Safety will have different examples and indicators than that same client being in ‘significant needs’ for Mental Health.

All of the individual categories provide an option for “not enough information at this time” and a few of the categories have an option of a specified version of “not applicable”.

What happens if I don’t know enough information to fill out a section?

When working with clients, especially at the time of intake/enrollment, you may not have enough information to assess them in various areas in which case, categories may be scored as “not enough information at this time”. Once you have enough information, that score will change to an actual score during a follow-up assessment. However, intake workers must have enough information to score the Mental Health category in order to enroll the client in STAR.

For example, if a client enrolls in STAR with an urgent need pertaining to mental health care for a chronic mental health condition, you might focus on that health condition initially and not immediately assess for or discuss physical health. At the time of the initial benchmarks, you would then choose “not enough information” for Physical Health with the intent to discuss Physical Health needs and status with the client for future benchmarks.

What do I do if someone falls in between categories?

If you feel a client falls between levels of need, you have the option to choose a half increment. For example, if you’re not sure if a client has moderate needs (2) or some needs (3) in a particular area because they seem to span both levels, you can score them at 2.5.

What if I think a client is a 1 and they think they are a 3?

If you feel there is a discrepancy between the client’s perception of where they are and your assessment of where they are, default to the client’s perception. For example, if a client feels that they are unsafe in their community, but you feel that they are objectively safe in their community, score them according to the client’s perception of safety.

When assessing a client, it is imperative that you focus on ONE CATEGORY at a time. Although some categories may overlap and/or influence each other, you should look at the client through the lens of just the category they are currently evaluating. For example, if a client does not feel safe in a familial relationship, but they have many friends and social supports and are able to navigate their community safely and easily because they live in a supportive community, they will still score 1 in Relationship Safety but will score higher on Community Safety and Support System.

For children ages 0-5: ORR strongly recommends intake staff/case managers administer the Ages and Stages Questionnaire and reference the CDC Developmental Milestones to determine the client’s Safety & Wellness Benchmarks scores.

For children ages 6-16: ORR strongly recommends intake staff/case managers administer the Pediatric Symptom Checklist (PSC) to clients ages 6-10 and the Y-PSC11 to clients ages 11-16 (including self-report) to help determine the client’s Safety & Wellness Benchmarks scores.

According to the age-appropriate assessment listed above (Ages and Stages, PSC, or Y-PSC), select a score of “1 – Significant Needs” if the child reached 0-25% of their milestones, “2 – Moderate Needs” if the child reached 25-50%, “3 – Some Need” if the child reached 51-75%, or “4 – Minimal Needs” if the child reached 76-100%.

Individual and Household Information

The Benchmarks are meant to represent the state of an individual at a moment in time.

In cases in which the individual being served is a caregiver or there are minors in the individual’s home, the relationship safety and mental health of the minors should be considered in the corresponding categories. The assessment may not include the minor in these cases, but you will always want to act on the information received via the caregiver(s). An individual’s household wellness naturally impacts the client’s wellness. However, score based on the individual’s level of need.

Using the Data

On a regular basis, it is important to review and discuss the data collected with your team. The guiding questions below can help you analyze the data:

What is the quality of the data?
- Is it complete and accurate? If not, what can be done to improve the data quality?
What stories does the data tell us?
What trends are we seeing?
- Are trends different by demographic?
Are there any changes in results over time? If so, why?
Are we achieving the results we hoped to achieve, equally for different populations, regardless of gender, age, and race? If not, why not?
What successes do we see?
- Where is there room for improvement?
What action do we need to take to improve results?

Shape1

This category measures the client’s emotional wellbeing, ability to cope with stressors, and substance use. In cases where there are children, it also measures the caregivers’ ability to support the child’s emotional wellbeing.

Key Definitions

Mental health or substance use issues

Any distress experienced by an individual due to diagnosed or undiagnosed mental health needs including extreme stress and harmful use of substances to cope

Actively taking steps to promote mental health and wellness

The actions an individual takes individually or with others to positively influence their current and future mental health and wellness. This could include practicing self-care, regularly exercising, engaging in ongoing therapy, or regularly seeking out support systems

Appropriate to age and development

The act of tailoring expectations, materials, and processes to the age and developmental stage of the individual

Developmental milestones

Acquired functions or skills that children predictably develop as they age. For more age-specific milestones, access the CDC’s Developmental Milestones

Medical/genetic regression

When a child loses an acquired function or fails to progress beyond a prolonged plateau after a period of relatively normal development; in this case, referring to regression caused by a medical or genetic condition or disease

Minor

Anyone under the age of 18 and therefore legally defined as minors

Negative consequences

Negative consequences can include personal harm or harm to others (physical or emotional), damage to property, and interaction with authorities due to substance use

Youth

Applies to young adults and teenagers (generally aged 16 to 24), depending on developmental status and maturity

Suggested Response Actions

Significant Needs (1) & Moderate Needs (2)

Connect client to crisis response services, if necessary; create a coping safety plan, as appropriate; work to develop a plan for sustainability; follow the Suicide Prevention Guidance for clients presenting with suicidal ideation

Category

Not enough information

Significant Needs (1)

1.5

Moderate Needs (2)

2.5

Some Need (3)

3.5

Minimal Needs (4)

Mental Health

Not enough information

Youth & Adult Mental health or substance use issues are interfering with ability to manage day to day functioning, personal safety or safety of others around them; danger to self or others

Youth & Adults Mental health or substance use issues make it more difficult to function but still able to meet activities of

daily living with support; currently in SUDs treatment or recently sober

Youth & Adults Able to effectively manage mental

health symptoms and stressors so that there is little impact on daily life AND no or rare misuse of substances but does not result in negative consequences

Youth & Adults

Able to effectively manage mental health symptoms and stressors so that there is little to no impact on daily life AND actively taking steps to promote mental health and wellness AND no substance misuse

Not enough information/ No minors in the home

Minor

Non-medical/genetic regression in behavior and/or in reaching developmental milestones; unable

to recover from emotional upset appropriate to age and development

Minor

Non-medical/genetic delays in reaching developmental milestones but no regression; difficulty recovering from emotional upset appropriate to age and development

Minor Reaching most developmental

milestones; can identify strategies to manage emotional upset appropriate to age and development

Minor Reaching developmental milestones; successfully

utilizing strategies to manage emotional upset appropriate to age and development

Shape3

This category measures the client’s need for physical and/or dental care, access to healthcare and health insurance.

Key Definitions

Healthcare supports or services

Inclusive of screening, diagnoses, treatment, therapies, medications and healthcare supplies and the means to pay for those services.

Barriers

Any condition, resource, or lack of resource that can negatively impact a person’s ability to access medical care. This can include things like medical/dental coverage, interpretation, unable or unwilling to manage a chronic condition, and inability to access transportation. This can also include beliefs that are barriers to care such as religious beliefs, misunderstanding or mistrust of medical systems, or a lack of confidence or understanding of treatment options and prognosis (i.e. success rates of early detected treatable cancers, such as breast cancer).

Suggested Response Actions

Significant Needs (1)

Connect client to immediate medical or dental care; create a plan for sustained medical/dental care

Moderate Needs (2)

Work to develop a plan with client for sustainability of medical/dental care

Shape4

Category

Not enough information

Significant Needs (1)

1.5

Moderate Needs (2)

2.5

Some Need (3)

3.5

Minimal Needs (4)

Physical Health

Not enough information

Unable to access any needed healthcare supports or services

Able to access some healthcare supports or services but it is insufficient

Able to access needed healthcare supports or services but unable to do so independently

Able to access needed healthcare supports or services and can do so independently;

Support System

This category measures an individual’s sense of connectedness to others in their life, including formal and informal supports such as family, friends, community members, and social organizations such as religious institutions and other community groups.

Key Definitions

Community networks

Consists of a wide range of community-level groups, organizations and collectives that can provide support. This can include affinity groups (LGBTQ, race, ethnic, gender groups), religious groups, community collectives, etc.

Reliable

Able to use and access when wanted/needed.

Suggested Response Actions

Significant Needs (1)

if the client is being actively ostracized by the community, assess their perception of safety and develop a safety plan; work with the client to identify supportive individuals and develop a plan for continued engagement

Category	Not enough information	Significant Needs (1)	1.5	Moderate Needs (2)	2.5	Some Need (3)	3.5	Minimal Needs (4)
Support	Not enough	Individuals and/or		Unable to identify		Can identify individuals		Can identify
System	information	community networks/		anyone who can		and community		individuals and
		systems actively		provide them practical		networks/ systems		community networks/
		causing harm or		or emotional support		who can provide		systems who can
		distress				them practical or		provide them
						emotional support but		consistent and reliable
						they are unreliable or		practical or emotional
						unavailable		support

Shape6

Shape7

This category measures the client’s experience of safety and well-being within relationships. This measures both adults and minors in the home, regardless of whether the minors are enrolled in services. This category includes abuse by an intimate partner, child abuse and neglect, and abuse perpetrated by family members or individuals with access to the client and their family.

Key Definitions

Caregiving skills

Inclusive of age and developmentally appropriate discipline, interaction, communication, nurturing behavior, and skills to promote positive attachment, etc.

Communication patterns and behaviors

Ways in which individuals interact and communicate with each other that are often repeated, cyclical, or predictable. These can be both positive and negative.

Minor

Anyone under the age of 18 and therefore protected under child abuse and neglect laws

Safety resources

Any resources, services or skills that promote, encourage or ensure safety. These often include informal community safety services such as safe individuals and community safety networks and formal services such as domestic violence service providers, child welfare agencies, police, and emergency medical personnel

Safety plan

Personalized, practical plan to help avoid dangerous situations and to know the best way to react when in danger

Unsafe

There is imminent risk of severe physical or psychological harm caused by abuse, neglect (in the case of an adult in need of care or a minor), or exploitation

Youth

Applies to young adults and teenagers (generally aged 16 to 24), depending on developmental status and maturity

Suggested Response Actions

Significant Needs (1) & Moderate Needs (2)

Create a safety plan with the client, including their safe individuals, as appropriate; discuss and connect to formal and informal safety resources, as appropriate. If a child is at risk of imminent harm, follow emergency protocol.

Category

Not enough information

Significant Needs (1)

1.5

Moderate Needs (2)

2.5

Some Need (3)

3.5

Minimal Needs (4)

Relationship Safety

Not enough information

Youth & Adult Household and/or relationship is unsafe AND client does

not have current connection to safety resources and/or a safety plan in place; there are significant barriers to client seeking safety

Youth & Adults Household and/or relationship is unsafe AND client has current connection to safety resources and/or a safety plan; there are no significant known barriers to seeking safety

Youth & Adults Household and/ or relationship is

safe; there are some unhealthy patterns of conflict management, communication and/or behaviors

Youth & Adults Household and/ or relationship is

safe; communication patterns and behaviors are healthy and supportive

Not enough information/ No minors in the home

Minor

Current known child abuse, neglect, exploitation or abandonment; minor is exposed to

violence; caregiver(s) is unable to support child emotionally

Minor

Suspected child abuse, neglect, exploitation

or abandonment; caregiver(s) unable to consistently use caregiving skills

Minor

No known or suspected violence or abuse in the home; caregiver(s) occasionally struggle to use caregiving skills;

caregiver(s) express difficulty with minor

Minor

No known or suspected violence or abuse in the home; caregiver(s) consistently provides healthy/nurturing caregiving

Shape9

This category measures the client’s perceived and actual safety in their community. It includes having knowledge of and willingness to access community safety resources and knowledge of how to navigate and maintain safety in the

community. It is important to note that levels 2 and 3 include a willingness to access community safety resources which is directly related to the individual’s perception of those resources as safe, accessible, and capable of helping. This category includes exploitation and trafficking in community settings as well as feelings of belonging and oppression such as racism, sexism, classism, and xenophobia.

Key Definitions

Community safety resources

Any resources, services or skills within a community that promote, encourage or ensure safety. These often include informal community safety services such as community watch associations and community safety networks and formal emergency response services such as police, firefighters, and emergency medical personnel.

Unsafe

Suggested Response Actions

Significant Needs (1) and Moderate Needs (2)

Create a community safety plan with the client; discuss and connect to formal and informal community safety resources

Shape10

Shape11

Category	Not enough information	Significant Needs (1)	1.5	Moderate Needs (2)	2.5	Some Need (3)	3.5	Minimal Needs (4)
Community	Not enough	Feels unsafe/in		Feels unsafe/in danger		Feels safe in the		Feels safe in
Safety	information	danger of being		of being harmed in the		community most of		community; knows
		harmed in the		community some of		the time; knows about		about community
		community most		the time; knows about		community safety		safety resources
		of the time; active		community safety		resources and is able		and feels confident
		ostracization; no		resources but is unable		and willing to access		in accessing them;
		knowledge of		or unwilling to access		them; knows how to		feels confident about
		available community		them; knows how to		maintain safety in the		navigating and
		safety resources; no		maintain safety in		community and does		maintaining safety in
		knowledge of how to		the community but is		so most of the time		the community
		maintain safety in the		unable or unwilling to
		community		do so

Shape12

This category measures the client’s ability to access the benefits, information, and rights they are entitled to. It also measures the client’s ability to access and control what is done with their resources.

Key Definitions

Rights

Suggested Response Actions

Significant Needs (1)

Provide client with information about their rights and options for remedy; work to develop a plan for sustainability

Shape13

Category	Not enough information	Significant Needs (1)	1.5	Moderate Needs (2)	2.5	Some Need (3)	3.5	Minimal Needs (4)
Rights and	Not enough	Rights are being		Rights are being		No known rights		No known rights
Resources	information	actively violated		actively violated		violations AND		violations AND client
		including being		including being denied		client has limited		knows their rights,
		denied access to		access to personal		understanding of their		how to claim, secure
		personal resources/		resources/documents		rights		and exercise them
		documents		AND client is
				connected to remedies

Shape14

Shape15

After completing all of the other benchmarks, the case manager is meant to reflect on the client’s general sense of self- efficacy and ability to advocate for themselves across all the categories. Because this is a category for reflection, there do not need to be any specific assessment questions, though some suggestions are included if the case manager has a

difficult time discerning the client’s sense of self-efficacy and advocacy. This is a category in which immediate action does NOT need to be taken if a client scores as Significant Needs (1) or Moderate Needs (2).

Key Definitions

Challenges

A task or situation that tests someone’s abilities

Personal rights

The rights an individual has to personal security, liberty, and private property – they include Constitutional rights such as the right to assemble in public places, express one’s views, and determine religious beliefs.

Category	Not enough information	Significant Needs (1)	1.5	Moderate Needs (2)	2.5	Some Need (3)	3.5	Minimal Needs (4)
Self-Efficacy	Not enough	Unable to try		Tries to overcome		Consistently tries to		Able to overcome
& Advocacy	information	to overcome		challenges but		overcome challenges;		most challenges;
		challenges;		inconsistently or		occasionally needs		able to independently
		needs support		ineffectively; needs		assistance advocating		advocate for needs to
		and assistance		assistance advocating		for needs to be met;		be met; knowledge of
		in advocating for		for many needs to be		knowledge of personal		personal rights
		needs to be met in		met; resources; limited		rights
		most areas of life;		knowledge of personal
		no knowledge of		rights
		personal rights

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified	0000-00-00
File Created	2025-05-29

Safety Wellness Benchmarks Manual - ORR Adaptation