Transcript Stabilizing Homeless Families: Case Management Before & After The Move Into Permanent Housing Presented by Beyond Shelter 1200 Wilshire Blvd, Suite 600 Los Angeles, CA 90017

Stabilizing Homeless Families:
Case Management Before & After
The Move Into Permanent Housing
Presented by
Beyond Shelter
1200 Wilshire Blvd, Suite 600
Los Angeles, CA 90017
Emergency shelters and transitional
housing are simply “stepping stones.” If at
the end of our interventions and our
support, the homeless are still homeless –
or at risk of another episode of
homelessness – then what have we really
accomplished?
Homelessness ends when an individual or
family is stabilized in permanent, affordable
housing, whatever that permanent housing
type may be – and whatever the support
systems that must be in place to help them
stay there.
HUD CONTINUUM
OF CARE MODEL
Outreach
Intake
Assessment
Emergency Shelter
Traditional Housing,
no services
Transitional Housing
Supportive Housing
MODIFICATIONS TO THE
CONTINUUM OF CARE
Outreach
Intake
Assessment
Emergency Shelter
Traditional Housing,
no services
Transitional Housing
Supportive Housing
Service-Enriched
Permanent Housing
Indicates Modifications
Permanent Housing with
Time-limited,
Home-Based
Case Management
ADDITIONAL HOUSING OPTIONS

Service-Enriched Housing – Private or
nonprofit rental housing, with crisis
intervention and services coordination (&
often program activities) available to all
residents, regardless of special needs.

Permanent Housing with Home-Based Case
Management – Available through outside
sources, either time-limited or long-term.
COMPONENTS OF
CASE MANAGEMENT

Crisis Intervention and Stabilization

Intake and Assessment

Assistance Moving into Permanent
Housing

Home-Based Case Management
(time-limited & transitional or long-term)
STEP 1: CRISIS INTERVENTION
& SHORT-TERM STABILIZATION
This phase usually includes emergency
shelter services and short-term transitional
housing geared to special needs, i.e.
domestic violence, substance abuse
treatment, etc.
STEP 2: INTAKE, SCREENING,
& NEEDS ASSESSMENTS
The “needs assessment” results in an
Action Plan, including short and long-term
goals and objectives with concrete action
steps.
Can occur immediately or after stabilized in
emergency shelter or other temporary
housing.
STEP 3: HOUSING SEARCH ASSISTANCE & RELOCATION
TO PERMANENT, AFFORDABLE HOUSING




Overcoming barriers to accessing affordable, rental
housing.
Assistance applying for housing assistance, rent
subsidies, move-in funds, etc.
Tenant education.
Assistance conducting housing search,
presentation to owners, negotiating.
STEP 4:
PROVISION OF HOME-BASED
CASE MANAGEMENT

Intensive during the first 90 days.

Intensifies during crises.

Includes connecting people to community
resources and services to meet their
particular needs.

May include longer-term case
management for vulnerable and at-risk
families and individuals.
Case Management
Before the Move into
Permanent Housing
PRIMARY FUNCTIONS
OF CASE MANAGEMENT

Assessment

Planning

Linking

Monitoring

Advocacy
The primary functions of case
management while families are homeless
are to address their immediate shelter
and social service needs and to ensure
that they have access to all services and
resources for which they are eligible.
While in a homeless state, families
require crisis intervention and shortterm case management. Once in permanent
housing, families benefit from case
management that helps them transition to
stability. Services are intensive, but timelimited, depending upon need.
Developing
a Family
Action Plan
Individual Family Action Plan
 Developed before or after
stabilization in emergency services
 Serves as the blueprint for shortterm case management and
transitional or long-term case
management once the family moves
into permanent housing
General Questions
 What does the family need?
 What should the priorities be?
 How will they achieve these goals?
 What are the barriers they are
confronting?
 How will they attain permanent
housing?
 How could their income situation be
improved?
 What are the issues for the
children?
 Are there mental health or recovery
issues that should be addressed?
Family Action Plan
The objectives for the period from _______
to ________ are:
1. __________________________________
2. __________________________________
3. __________________________________
4. __________________________________
5. _______________________________
Specific Tasks/
Responsibilities
What we plan to do to meet these objectives/
achieve goals:
1. ___________________________________
2. ___________________________________
3. ___________________________________
4. ___________________________________
Assistance Accessing
& Moving Into
Permanent Housing
THE HOUSING PLAN
The objective is to assist the family to obtain
decent, affordable permanent housing in
which they can stabilize and rebuild their
lives. This requires a match between the
housing unit and the family’s needs.
Suitable means decent housing in an
environment which will be conducive to the
family’s stability in permanent housing.
THE HOUSING SPECIALIST
If possible, a Housing Specialist helps the
family to identify and off-set (as much as
possible) barriers to securing housing.
The Housing Specialist also works with the
client to identify appropriate, and reasonable,
housing search goals. When no Housing
Specialist is available, the case manager
addresses these issues, working together with
the family to resolve them.
ACCESSING SECTION 8
Recognizing the high cost of rental
housing in most rental markets, it often
becomes essential to develop working
collaborations with local housing
authorities in order to facilitate the move
into permanent housing for families who
are homeless.
Sometimes there are special “set asides”
that can be developed (particularly for
families and/or people with special
needs). In some states, TANF-related
subsidies can be utilized. It is vital to
explore possibilities with housing
authority administration and not to
assume that it cannot be done.
Examples of
HOUSING ASSISTANCE

Landlord/tenant education

Advocacy for housing subsidies

Transportation and coaching to meet
potential property owners

Referral to specific owners willing to rent
to homeless families

Assistance in overcoming bad credit, no
credit or eviction histories, etc.

Assistance in obtaining move-in funds

Follow up to ensure stable relationship
with property owner.
Case Management
After the Move into
Permanent Housing
Goal of Home-Based
Case Management

A major goal for formerly homeless
families is to integrate stable living
patterns into their daily lives.

All benefit from assistance in developing
a support network in the community
responsive to their individual needs and
available to be called in times of future
crisis.
The primary functions of home-based case
management are to assist families in making
the transition from homelessness to stability in
permanent housing and to link families to other
community resources and services which they
might need. A subgroup of homeless families
will also benefit from assistance in the
development of basic life skills.
Provision of Home-Based
Case Management

Intensifies during crises.

Includes connecting people to
community resources and services to
meet their particular needs.

Should be intensive for some families
during the first 90 days in permanent
housing.

May include longer-term case
management for vulnerable and at-risk
families with special needs or long
histories of homelessness.
THE FIRST THREE MONTHS
Experience has shown that formerly
homeless families are most at risk
for another episode of homelessness
during the first 90 days in permanent
housing.
Generally, the case manager provides the
core level of services and refers families
to “mainstream” programs for specialized
services (i.e., substance abuse
intervention, mental health services,
family counseling, child care, etc.).
Some families require more intensive
home visits that may include
demonstrations of housekeeping skills,
money-management and budgeting,
development of grocery lists,
assessments and referrals for parenting
support, etc.
The majority of families, however, will
simply need assistance in identifying
resources in the community and
periodic monitoring and support during
the first few months in permanent
housing, to insure a smooth transition.
EXAMPLES OF SERVICES
BY CASE MANAGERS






Household management
Money management
Problem solving/survival skills
Advocacy with CalWORKs, DCFS,
GAIN, legal issues
Resource referrals & monitoring
Crisis intervention
Infant &
Child Care
Pre-School
Enrichment &
Recreation
Programs
Family
Counseling
& Support
Services
Employment &
Job Readiness
Health
Care & Nutrition
Services
Transportation
Mental
Health
Services
LINKING FORMERLY HOMELESS
Family
Planning
Prenatal Care
FAMILIES TO
COMMUNITY SERVICES
Services for
Children’s
Special Needs
Family
Counseling and
Support/DV
Prevention
Crisis
Intervention
(personal or
financial)
Family
Preservation/
Reunification
Teen
Services &
Leadership
Development
Elementary,
Middle, High,
Continuation
Schools
Alcohol & Drug
Prevention/
Treatment
Grocery,
Laundromat,
bank, etc
.
Parole/
Probation
Case Management
Issues

Distrust.

Listlessness.

Manipulation.

Failure to Follow Through & SelfSabotage.

Poor Judgment & Lack of Responsibility.

Substance Abuse.

Family Violence.

Child Maltreatment.

Crisis Orientation.

Denial.

Refusal to participate.

Anger.
Steps to Effective
Case Management
ENGAGEMENT: The first and most important
task of the case manager is to engage the
client. During the phase when case
management is likely to be a mandatory
program component, developing trust and
establishing a relationship (to both the case
manager and the agency) is very important.
Access to the client and the ability to followup on the case plan, once they have moved
into housing (and services are voluntary)
depends upon this relationship. Initial
engagement is even more important when you
are establishing a relationship when the client
is already in housing or in any voluntary
setting.
ASSESSMENT: Effective case management
requires the ability to thoroughly and
accurately assess your client. The ability to do
this effectively depends upon the relationship
between the client and case manager, since
some issues are not easily or readily
identifiable. These issues may only be known
through disclosure.
SETTING PRIORITIES: Once the basics have
been addressed – safety, food, shelter, and
clothing, the client and case manager together
must prioritize other issues needing to be
addressed. NO matter what your sense of the
priorities, if the client does not really believe
the issue is a priority, he/she is not going to
follow through with the plan.
DEVELOPING A REASONABLE PLAN: It is
important to divide the case plan into shortand long-term goals. Each goal is divided into
several tasks, with clearly delineated
responsibilities for the client and the worker.
Every meeting these tasks are reviewed for
follow-up and revised accordingly.
BUILDING ON CLIENT STRENGTHS: Although the
word empowerment is an overused phrase in
social work today, the concept of helping people
to help themselves is still a key principle in our
profession. One of the best ways to do this is to
assist clients in identifying strengths they already
bring “to the table” which can help them to
accomplish their goals.
MAINTAINING THE RELATIONSHIP: All
relationships require ongoing maintenance.
Sometimes, as case managers we start to think
the client needs us, and forget this basic premise.
However, especially once a client is in housing,
we also have a vested interest in maintaining the
relationship to ensure family stability, and
maintain our commitment to the clients, landlords
and property managers.
IDENTIFYING RESOURCES: All case
management programs are only as strong as
your service linkages. Next to maintaining a
relationship with your clients, the
relationships you have with specialized
service providers – substance abuse, mental
health, D.V., youth programs – are essential to
effective case management.
EXPECTED OUTCOMES
Families Integrated
into the Community,
Striving towards Improved
Social and Economic Well-Being
OUTCOME EVALUATION
Short-Term Outcomes – For Families




Movement from homelessness to
temporary or permanent housing
Decrease in psychological distress
Decrease in substance use/abuse
Participation in treatment, support, and
training programs
OUTCOME EVALUATION
Short-Term Outcomes – Children
Regular school attendance
 Improved health assessment/care
 Reduction of behavioral/school problems

OUTCOME EVALUATION
Intermediate Outcomes – Mothers
Increased residential stability
 Continued improvement in psychological
functioning and reduction in symptoms and
symptoms of distress
 Continued reduction in substance use/abuse
 Improved life management skills, including
job/vocational skills and goal setting
 Increase self-esteem and feelings of
empowerment

OUTCOME EVALUATION
Intermediate Outcomes – Children

Continued reduction in behavioral and school
problems

Improved school performance and regular school
attendance

Regular health check-ups, inoculations, &
improved health status
OUTCOME EVALUATION
Long-term Outcomes






Achieve residential stability
Psychiatric stability
Abstinence/continued reduction in
substance use/abuse
Competency in life management
Employment or engagement in productive
activity
Stability as a family unit