Private Organization Accreditation

Sweetser, a Maine non-profit agency operating since 1828, provides comprehensive mental and behavioral health and substance abuse treatment services. Statewide, it serves around 15,000 consumers a year, including children, adults, and families in outpatient, office-based, and residential settings.


Jane Bonk, Ph.D., LCSW

Volunteer Roles: Commissioner; Evaluator; Lead Evaluator; Peer Reviewer; Team Leader

Dr. Jane Bonk is a team leader, evaluator, and commissioner who has led over 25 site visits for COA.
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Outreach Services identify and engage youth, adults, and families experiencing homelessness as a first step to accepting care for immediate health and safety needs, gaining access to community services and resources, taking steps toward community integration, and connecting to safe and stable housing. 

PA-OS 3: Assessment and Engagement

Outreach workers build trust with individuals experiencing homelessness and assess their immediate health and safety needs.

Rating Indicators
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions; exceptions do not impact service quality or agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement. 
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.  
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.  
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  
  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.   
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner. 
  • Service quality or agency functioning may be compromised.   
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.  
Please see Rating Guidance for additional rating examples. 

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Description of the techniques and strategies used to engage and assess individuals and families experiencing homelessness 
    • Assessment tools 
No On-Site Evidence
    • Interview: 
      1. Program director
      2. Relevant personnel
    • Review logs, progress notes, or case records for documentation of services applied, as applicable

  • FP
    PA-OS 3.01

    Engagement and assessments are:

    1. sensitive to the willingness of the individual or family to be engaged;
    2. non-threatening;
    3. respectful of the person’s autonomy and confidentiality;
    4. culturally responsive;
    5. trauma-informed
    6. flexible; and
    7. persistent.


    • Revised Interpretation - 10/01/18

    Interpretation: When engaging with minors, the minor must be informed of the outreach worker’s obligations as a mandatory reporter.
    Interpretation: Culturally responsive engagement and assessment practices can include attention to geographic location, language of choice, the person’s religious, racial, ethnic, and cultural background, age, sexual orientation, gender identity, gender expression, and developmental level.
    Interpretation: To ensure that transgender and gender non-conforming service recipients are treated with respect and feel safe, service recipient choice regarding their first names and pronouns should be respected and forms and procedures should allow individuals to self-identify their gender and receive access to services accordingly, in accordance with applicable federal and state laws. 

    Research Note: Establishing a trusting relationship between the outreach worker and the person experiencing homelessness is essential for successful outreach. Engagement is often an ongoing, long-term process, during which the outreach worker builds trust with the goal of linking the person to needed health, mental health, substance use, social, and housing services. Engagement and assessment occur simultaneously and are essentially the same process.

  • FP
    PA-OS 3.02

    Outreach workers assess the individual’s:

    1. safety, including potentially life-threatening situations and risk for suicide;
    2. immediate needs;
    3. level of functioning;
    4. overall mental and physical health; and
    5. strengths and capacities, including the capacity for making decisions.

    Interpretation: Depending on the qualifications of staff doing street outreach, the assessment process may be a two-phased process with elements (a) and (b) addressed by outreach workers in the locales where connections are made with service recipients, and elements (c), (d), and (e) addressed by a case manager or other qualified staff once the service recipient has agreed to accept services at a shelter or drop-in center.

    Interpretation: Agencies should use standardized assessment instruments to ensure that service recipients are connected to the most appropriate services available within the community. The instruments should be evidence-based, person-centered and strengths-based, trauma-informed, facilitate referrals to the full range of services needed to end homelessness (i.e., homelessness programs, affordable housing, mainstream benefits and services, health and mental health services, employment services, etc.), and appropriate for administration by non-clinical staff.
    Interpretation: The agency may respond to identified suicide risk by connecting individuals to more intensive services; facilitating the development of a safety and/or crisis plan; or contacting emergency responders, 24-hour mobile crisis teams, emergency crisis intervention services, crisis stabilization, or 24-hour crisis hotlines, as appropriate.

    Research Note: Some groups of service recipients may be at higher risk for suicide due to past trauma, compounding risk factors, and/or societal stigma, including individuals with public systems involvement (foster care, juvenile justice, criminal justice), military service members, American Indian and Alaska Natives, and individuals who identify as lesbian, gay, bisexual, and transgender (LGBT). Service recipients with alcohol use and/or mental health disorders are also at elevated risk for suicide. 

    Studies have also shown that individuals experiencing a financial crisis, including foreclosure and eviction, are more likely to experience high levels of stress, poor physical health, depression, anxiety, and be at risk for suicide.


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