Empowerment and Support for Residents Facing Vulnerability

Community Outcome Area: Empowerment and Support for Residents Facing Vulnerability

Fairfax County is a place where all residents facing vulnerability are empowered and supported to live independent lives to their fullest potential.




Fairfax County is fully committed to providing residents facing vulnerability with a safe place to receive necessary services, in a way that mitigates challenges through a holistic, streamlined, respectful and individualized approach. The role of local government is to identify people who need support in order to reach their personal level of “self-sufficiency,” which is related to various factors including health (mental and physical), age and varying levels of personal ability.

While there are basic human needs that must be met, individual circumstances may require a number of supports, representing multiple, overlapping challenges that may emerge, evolve and resolve over time. Therefore, it is critical to ensure a close connection with people facing vulnerability, so situations can be monitored and responded to in an effective manner. The role of caregivers should also be elevated when needed, so that people who want to empower caregivers to advocate for their needs can do so, to the extent possible by law.

While the pandemic enabled many community members to connect using new technology tools, many of our most vulnerable residents suffered from a lack of in-person support, as well as reduced oversight in some situations that compromised their safety, especially those impacting the elderly and children.

The proposed strategies in this section seek to improve the way people facing vulnerability are identified, connected with, served and supported over time.

Challenge Questions

  1. How will we ensure that we identify residents facing vulnerability?
  2. How will we proactively engage residents facing vulnerability?
  3. How will we identify and mitigate factors that impede residents facing vulnerability from living independent lives to their fullest potential?
  4. How do we ensure that residents facing vulnerability are able to access needed services within a system that is comprehensive, responsive and built around hearing their story one time?
  5. How will we ensure that residents facing vulnerability are stewarded on a path to self-sufficiency in a way that recognizes their existing strengths?
  6. How will we promote sustained self-sufficiency among residents facing vulnerability in our community?


  • All People Are Respected, Understood and Connected
  • Services Are Easy to Access and Use
  • Services Are High Quality and Coordinated
  • All People Can Meet Their Basic Needs

Proposed Strategies

These proposed strategies were developed based on the extensive background work completed by the Countywide Strategic Planning Teams. The Board will determine which strategies will be pursued, as well as when they might be undertaken. This process will be highly flexible and will adapt to respond to community conditions as they evolve over time.

Identify, Respect and Proactively Engage Residents Experiencing Vulnerability

  • ESRFV 1. Develop targeted marketing and outreach strategies, in coordination with community-based partners, to proactively engage residents facing vulnerability.
  • ESRFV 2. Foster a county workforce culture that emphasizes a person-centered, integrated and comprehensive approach to meeting the needs of residents facing vulnerability.
  • ESRFV 3. Identify the root causes of vulnerabilities affecting residents and use those insights to inform policy and practice and target interventions to prevent vulnerability.
  • ESRFV 4. Use all available sources of data to identify and understand emerging and existing vulnerabilities, in order to proactively engage impacted residents, identify service gaps and efficiently allocate resources.

Mitigate Barriers and Improve the Access and Utilization of Service

  • ESRFV 5. Pursue legislative initiatives to amend federal, state and local laws and regulations that create barriers to the provision of programs and services for residents facing vulnerability.
  • ESRFV 6. Implement a standardized, coordinated approach to data collection and sharing among county agencies and contracted service providers that incorporates best practices for data governance.
  • ESRFV 7. Facilitate better access and utilization of services frequently needed by those facing vulnerability through greater co-location of county departments and community-based organizations and through the use of access points in community locations such as schools and libraries, as well as recreation, shopping and community centers.
  • ESRFV 8. Redesign and implement a comprehensive intake, interview and screening process so that residents are only required to “tell their story” to county government one time.
  • ESRFV 9. Evaluate all county programs and services that have waiting lists to determine whether capacity within our network of community partners can be expanded through system redesigns, public-private partnerships and/or resource leveraging.

Provide High Quality, People Centered, Integrated Services

  • ESRFV 10. Build upon the existing framework and county agency cross-collaboration efforts in order to ensure a comprehensive system that connects residents facing vulnerability to the information and services they are seeking regardless of which organizational door they enter.
  • ESRFV 11. Use system navigators to perform needs assessments of residents seeking assistance and help them navigate the multitude of services and programs offered by all county agencies and community-based partners.
  • ESRFV 12. Close critical service gaps by coordinating county safety-net efforts with state, regional and community-based partners to ensure that services are integrated, efficient and non-duplicative.
  • ESRFV 13. Evaluate existing service in comparison to industry best practices to ensure the most effective, people-centered approaches are utilized to meet the needs of residents facing vulnerability.

Sustain Self-Sufficiency

  • ESRFV 14. Evaluate and revise county-controlled program eligibility requirements to ensure that residents do not fall off the “benefits cliff.”
  • ESRFV 15. Maintain ongoing engagement with residents who have faced vulnerability and been served by the county in order to proactively mitigate potential setbacks.

Sample Metrics

Indicator: All People Are Respected, Understood and Connected

  • # of residents who accessed and utilized Fairfax County Government services and programs as a direct result of targeted outreach initiatives
  • % of residents utilizing services who report feeling respected and supported when receiving county- and community-based services
  • % of residents who report feeling a stronger connection to their community through their participation in Fairfax County Government services and programs
  • % of residents utilizing services who feel that their input is strongly considered as part of designing the services they receive

Indicator: Services Are Easy to Access and Use

  • % of residents who feel needed services are easy to access
  • % of residents who feel they experience barriers in accessing and utilizing Fairfax County Government services to the point that it limits their ability to live their life to its fullest potential
  • % of residents who apply for a county service who are initially placed on a waiting list
  • % of residents placed on a waiting list who do not begin receiving services within the applicable mandated time frame and/or agency benchmark
  • % of residents who are scheduled for and/or receive a screening or assessment for services within the applicable mandated time frame and/or agency benchmark
  • % of residents who begin receiving services within the applicable mandated time frame and/or agency benchmark

Indicator: Services Are High Quality and Coordinated

  • % of residents who report they received the information and/or connection to the services they were seeking during their initial contact with county staff
  • % of residents receiving county services who report that those services improve their ability to be self-sufficient
  • % of residents receiving multiple services who report that they experience those services as well integrated

Indicator: All People Can Meet Their Basic Needs

  • % of households with income/wages below the following:
    • 100% of the federal poverty level
    • 200% of the federal poverty level
    • MIT Living Wage Calculator for Fairfax County
  • % of people completing a county-funded employment readiness program who become and remain employed for at least 90 days
  • % of Coordinated Services Planning (CSP) clients who do not seek basic needs assistance for the same service from CSP within six months of receiving assistance
  • # of county households whose income falls below the MIT living wage but exceeds the federal poverty level
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