1. 2014 South Hampton Roads Regional Conference on Ending Homelessness Case Management Professional Development Session Suzanne Wagner March 11, 2014

2. Agenda Background and IntroductionSession 1: Engagement and Housing StabilizationSession 2: Critical Time InterventionSession 3: Supported Employment 2

3. HEARTH – Homeless Emergency Assistance and Rapid Transition to Housing Federal Strategic Plan (FSP), Opening Doors National Trends and Best Practices 3

4. Reduce length of time people spend in the crisis of homelessnessRapidly exit people from homelessness to permanent housing Provide services in the home to achieve housing stability and prevent returns to homelessness Focus on income and employmentUse proven practices HEARTH Objectives 4

5. Decrease numbers of people who are homelessDecrease length of time people are homelessIncrease exits to PH (permanent housing)Increase incomeReduce returns to homelessness HEARTH Performance Measures 5

6. Evidence-Based and Best Practices  Housing First  Rapid Exit from Homelessness  Housing Stabilization and Eviction Prevention  Critical Time Intervention  Supported Employment  Stages of Change 6

7. 2. Exit Strategy Housing Shelter Rapid Exit  Main Goal – Rapid Access to Housing  Focus on Relocation and Stabilization services Source: NAEH Center for Capacity Building 7

8. Housing First  Housing First is a programmatic and systems approach that centers on providing homeless people with housing quickly and then providing services as needed.  Housing is not contingent on compliance with services – participants expected to comply with a standard lease agreement and are provided with services and supports to help maintain housing  Services are provided post-housing to promote housing stability and well-being  No evidence that “prep” pre-housing improves housing outcomes 8

9. Housing First Principles  Choice/Affordability of Housing  Housing is Integrated into the Community  Separation of Housing and Treatment  Service Philosophy and Service Array  Low Barrier and Low Demand Approach  Access to Treatment Resources and Supports  Recovery Principles  Team Structure, Supervision and Resources 9

10. Shelter/TH Day Care Employment Assistance Housing Placement Family Supt Services MH/SA Services Prevailing ModelEmerging Model Housing Stabilization Day Care Employment Assistance Shelter Family Supt Services MH/SA Services Turning the Continuum of Care Inside – Out? Source: Culhane, Homeless Assistance: A Paradigm Shift? 10

11. Strategy to assist each person to maintain housing and establish a base in the community  Priorities: ◦Tenancy and Meeting Lease Obligations ◦Income ◦Services and Supports ◦Achieving self-defined goals 11 Housing Stabilization Services

12. Housing Focused Case Management – Core Elements Clarity and definition of worker and client roleLens of housing stabilityBehavioral focusRights and responsibilities of TenancyServices are designed based on clients’ goals, needs and preferencesMove away from crisisRegular staff supervision 12

13. Expectations of Tenancy Paying Rent Income, Financial Management, Subsidy Administration Logistics: check or money order, timeliness Maintaining Apartment Understanding and Meeting Cleanliness Standard, Managing Repairs Inspections Allowing Others the Peaceful Enjoyment of Their Homes Getting along with neighbors, Visitors Following rules re noise etc. Occupancy Only people on the lease live there

14. Housing Focused CM Core Elements Engagement around Housing PLANAssessment around Housing BARRIERS and STRENGTHS Housing History and Homelessness History Case Planning and Goal Setting around Housing STABILITY and Life GOALS 14

15. Goals of Housing-Focused Case Management Assist people to stabilize their housing arrangementsAssist people to secure stable incomeAssist people to reintegrate into the communityAssist people to access and use mainstream resourcesAssist people to establish and plan for long term goals 15

16. Measures of Success Maintaining housingIncrease/stabilization of incomeRegular school attendance Less emergency interventions: ER visits, hospitalization, incarceration, removal of children 16

17. Core Elements: Housing Stabilization Services 17 Engagement on Common GoalsAssessment Goals, Strengths Understanding barriers to housing stability, use Stages of Change for assessment Education Expectations of Tenancy and Housing Options Available Resources for Support Housing Stabilization PlanLinkages Community, Services, Treatment Resources Evaluate progress

18. Engagement Strategies Introduce yourself and how you can be helpful (provide education about available resources) Repeated, predictable, non-intrusive patterns of interactionListen to felt needs Be aware of the difference between crisis needs and longer term needs Listen to what people wantRespect boundaries 18

19. Engagement Assess riskBe aware that people may tell you what you want to hearAllow people as much control as possible over interactionsGo slowly -- things unfold over timeBe patient and persistentFocus on housing and life 19

20. What do people want? Role$$Future for their kids/grand kidsPartnerBetter lifeFlat screen TV 20

21. Stages of Change Based on research with self-changersMatch intervention to assessment of readiness for changeIntervention can begin before decision to change behaviorNormal for people to try to change several timesRelapse is often part of the processResistance is often the result of not understanding where a person is at Focus in on raising awareness and increasing motivation to change - pros and cons of changing/not changing 21

22. Stages of Change Stage Relationship to Problem Behavior Pre-ContemplationNo awareness of problem ContemplationAware of problem and considering change PreparationMaking plans for how/when to change ActionChanging behavior MaintenanceChange sustained for 3-6 months RelapseReturn to problem behavior 22

23. Jimmy Jimmy has been living in an encampment for the last four years. He and his buddies cook together, drink together and tell stories. Jimmy has a little money from the VA for a 30% service connected disability. He used to pick up odd jobs and has skills in construction. He hasn’t been felling so well lately and hasn’t been able to work. He just got over pneumonia (his third bout this year) and is feeling like he may be too old for this life. The hospital social worker has suggested a housing program but he knows he will never get in. She was nice but just didn’t understand and what about his friends? 23

24. June and her children June has two children and no real place to stay. Her mother helped her for a while but stopped when her second child was born. She got some help from her church, who got her a temporary hotel room. It’s too much trouble to go to work and get the children to school so they mostly stay in the room and watch TV. She is worried she may have to ask the children’s father for help. That’s not a good situation. She never dreamed she would end up like this. 24

25. CTI 25

26. Critical Time Intervention  Critical Time Intervention (CTI) is an Evidence Based Practice (EBP) proven to assist with transitions to community housing for vulnerable populations  CTI is a specialized intervention provided at a “critical time” - when a person/family first moves into housing  CTI connects people with formal and informal community supports  CTI is a time-limited intervention lasting approximately 9 months, divided into 3 specific phases that focus on a limited number of service areas that support housing stability 26

27.  Focused on Housing Retention and Life Goals  Time-limited  Three 3-month phases of decreasing intensity that begin when the person is housed 1.Transition to the community 2.Try out 3.Termination or transition to lower level of service  Focused on Housing Retention and Life Goals  Time-limited  Three 3-month phases of decreasing intensity that begin when the person is housed 1.Transition to the community 2.Try out 3.Termination or transition to lower level of service Critical Time Intervention - 2 27

28. Focused Assessment and Services  1-3 areas from 6 service areas  Based on threat to long-term housing stability  Rent payment  Following rules re visitors, noise etc  Keeping unit healthy and safe  Only allowing those on lease to live there  Other lease requirements  AND  Access to care and supports  Lots of focus on linkages and making them work  Think about natural supports Critical Time Intervention - 3 28

29. Areas of Focus for Assessment and Planning 1.Housing and homelessness history, housing stability barriers 2.Income and financial literacy 3.Life skills 4.Family, friends and other supports 5.Psychiatric and substance abuse issues 6.Health and medical issues See www.criticaltime.orgwww.criticaltime.org Critical Time Intervention - 4 29

30. Provide services in the home and the community Persistent Engagement  Process not an event  Based on tenants expressed needs and aspirations  Offers services and defines worker role Ongoing assessments of housing barriers to prevent housing loss Connect with other mainstream and community-based services – benefits and services Connect with natural supports including spiritual Key Ingredients of CTI 30

31. Focus on eviction prevention and use the structure of the lease to guide your interventions Work with landlords and building managers  Need Assertive approach  Hold person to lease obligations  Coordinate interventions  May accept services if threatens housing Key Ingredients of CTI 31

32. Focus on Self Sufficiency o Goal setting o Connection to high quality sustainable services and supports and o Empowerment Focus on Long-Term Stability o Use lease to structure the work o Role and Expectations o Not symptom or crisis based services o Goal includes sustainability as opposed to acute interventions Strong Expectation that Person becomes Integral Part of Community o Considers purpose and activity as part of life in housing o Role and life transition from “homeless” to “housed” CTI Focus 32

33. Changing Expectations: Role Full rights and responsibilities of tenancy  Using structure of the lease to set expectations Moving from crisis to planning  May be from immediate to 15 minutes from now Critical Thinking  Using strategies and resources that work best for each person Structure and purpose  Developing a structure and purpose to days that are different from when homeless Developing new or changed roles  From homeless person to tenant, parent, worker, advocate

34. o Housing o Financial o Health and Mental Health o Substance Use and Misuse o Family and Other Relationships o Life Skills CTI Assessment & Planning Focus Areas 34

35. Limit the areas of intervention Focus on the most pressing needs that impact housing Relate all interventions to long term goals Be aware this may not be a linear process Be mindful about moving from crisis Focused Housing/Service Planning 35

36. o Goals set as a team of clients and worker o Focus on the issues that affect housing retention – base on what caused the current crisis and previous episodes of housing instability o Immediate and longer term goals clear o Focus by phase o Use the plan for the intervention o Steps to reach goal clearly defined and measurable o Longer term needs require connections to other resources Components of the CTI Plan -- Goals 36

37. Tenant and Worker Role Designs plans for one month intervals Reflects areas that are barriers to housing access and sustainability Prioritizes areas for work Sets time frames for work to be accomplished Components of the CTI Plan 37

38. Resource Identification Clearly defines resources needed to access and/or maintain housing including: income, credit repair, legal services, employment assistance/support, financial planning and management, access to affordable medical services and/or child care, educational support (for Veteran and/or children), access to treatment services as needed for the family Components of the CTI Plan 38

39. Measure Success Uses documented steps to reach goal and benchmarks set Uses timeframes to gauge expectations and progress Identifies need to renegotiate goals and resources Evaluating the Plan 39

40. Building Skills o Educating on rights and responsibilities o Modeling for people to negotiate for services and enlisting the service’s/support’s help o Trying it out and debrief o Establishing regular check-ins to see if it is working o Review cost and benefits – critical thinking o Recognizing strong partners and good skills o Renegotiate the relationship as necessary o Focus on longer term planning ( non crisis based)

41. Assistance in making linkages ◦Meeting with the person and the resource if necessary ◦Refine communication structures with landlord, services and other supports ◦Make a plan for connections to continue Housing planning revision ◦Re-engage, Assess for new needs and revise plan based on current housing and lease compliance. Identify resources needed. Focus on community support, role and activity Skill building for community resources ◦Provide education about rights, responsibilities, and expectations; model negotiation skills Begin termination process and transition needed services o Develop a plan to address issues in housing and community Connections Transition to the Community 41

42. Closing or Step Down Final Meeting to document progress and plan for the future All sustainable services and supports should be included with the Veteran Next Steps together be determined SSVF workers continuing role, if any Closing note Summarize Progress Document final/transition meeting Documents person/families feed back on services Documents strengths and challenges moving forward Next Steps 42

43. Coordination with Partners Assertive Property ManagementMainstream (Non-Homeless) ResourcesNatural Supports 43

44. Working with Housing Providers Landlord and Property Manager Priorities Keeping unit filled Rent Payment No trouble: follow community rules, don’t disturb neighbors Maintain Apartment 44

45. Communication Structures with Housing Providers  Clear guidelines about when to talk (monthly call or visit to landlord/ property manager)  Policies and Procedures for home visits, resolving problems and role, emergencies, on-call  Address tenancy issues in team meetings and supervision  Cross Training, In-Services and Trainings  If resident services available: work together 45

46. Coordination with Housing Providers Using the structure of the lease The lease is the primary contact Property Management oversees lease compliance Supportive Services assists tenants to meet the requirements and assume the benefits PM: Lease must be consistently enforced PM: Lease must be consistent with community standard SS: Assist tenants to understand the lease requirements SS: Provide assessment and support so that people can succeed as tenants SS: Help people to connect to long term benefits of tenancy 46

47. Assistance to meet the expectations of tenancy Drug and alcohol barriers to tenancy: PM: Consistently enforce the lease PM&SS: Start early pay attention to noise complaints, visitor problems, unit issues and late rent Provide staff well trained in assessment and interventions Work with people in the context of their goals Focus on behaviors related to substance use rather than the use itself and identify how they jeopardize housing stability Use stages of change, MI, harm reduction techniques Provide access to high quality treatment on demand Avoid a crisis orientation Recognize sobriety is rarely a one shot deal 47

48. Assistance to meet the expectations of tenancy Psychiatric barriers to tenancy: PM: Consistently enforce the lease PM & CM: Start early pay attention to rent arrears, night time noise complaints, visitor problems, isolation and access problems Provide well trained staff in assessment and interventions Provide access to high quality psychiatric care and medications Work with people in the context of their goals Focus on behaviors related to mental illness use rather than the MI itself and identify how they jeopardize housing stability Use stages of change, MI, harm reduction techniques Avoid a crisis orientation Recovery is a process 48

49. Case Discussions Jimmy has been in housing for 3 months. He has done OK but you think his friend is living with him. He also has frequent emergency requests for food resources since he uses his money for drinking and “dates”. What would you address in the plan? June has been in housing for 5 months. She hardly ever goes out and the kids are absent from school a lot. Her TANF benefits are ending after this month. What would you address in the plan? 49

50. Develop a person focused resource listIdentify Resources by Focus Areas and TasksReview Resources in Current UseAdd resources developed through work with tenantsIdentify Needed ConnectionsIncome, benefits AND services Mainstream and Community Resources 50

51. Ensure knowledge of them – directory, visits to programs, ask tenants, goals of the service and what they provide Introduce yourself and your service, especially if there will be a lot of referralsExplain your role and what they can expectAttempt joint or coordinated service planningGather and share information (with tenant’s consent)Accompany person to assist with engagement with new serviceMaintain regular contact and keep your promises Links to Mainstream Resources 51

52. Joint Service PlansComplementary servicesWarm handoffsTeam meetingsCase conferencing 52 Coordination Strategies

53. Be Persistent, Patient And ReachableSet up regular meetings Provide information about the program and the person that helps them to do their job Recognize each program has their own service & outcome goalsFocus on progress and strengths, work to identify barriers 53 Working Effectively with Other Providers

54. 54 Ask About And Understand Expectations For Participants Be On Time For Appointments And Follow Up With Any Information Require For Eligibility Understand How The Program Interacts With Health Insurance, Entitlements, Patients Rights To Services, & Other Collaterals Assure The Provider Of Your InvolvementIdentify progress

55. Characteristics of Successful Teams ◦Involved leaders ◦Set shared aims ◦Welcome everyone ◦Self-conscious ◦Non-linear ◦Devolve control ◦Manage knowledge with agility *Institute for Healthcare Improvement ◦Reflective and responsive ◦Sense- making ◦Values asking ◦Recognition economy ◦Stimulate affection among members 55

56. Supervision: At least: weekly individual supervision, weekly team meetings with case conferencing Case Conferencing: Highlight best practices, identifies themes around barriers, highlights resources, provides clinical consultation Team Meetings: Team meetings have an informational, monitoring and support function, track where people are in the transition to and identify common barriers, share information and resources amongst team members, alert team to people in distress or crisis, identify best practices Training Support for the Practice: Supervision 56

57. Support for the Practice: Supervision At least: weekly individual supervision, weekly team meetings with case conferencing Learn by doing: participating in assessments, going on home visits and meeting with tenants and case managers as needed Managing caseloads and assignments, managing phases and highlighting need for case conferencing Identifying training needs and resources for professional developmentProviding support and perspectiveManaging resources and access to services 57

58. Support: Case Conferencing Case Conferencing to improve implementation of the practice, manage the phases of care and problem solve around barriers to housing stability May include clinical consultant Supervisor identifies cases in each phase, highlights best practices, identifies themes around barriers, highlights resources Works with case managers to present and follow up on all case and issues discussed 58

59. Support: Team meetings Team meetings have an informational, monitoring and support functionTrack where people are in the transition and identify common barriersShare information and resources amongst team membersAlert team to people and families in distress or crisisIdentify best practicesFollows structure formatReviews every person in the program at least monthly 59

60. Support: Training Provides new skills and resources to existing staffOrients new staff to the practiceTopics Include: Orientation to the model of Housing Stabilization Services and CTI Supporting Interventions Stages of Change, Motivational Enhancement Techniques, Rapid Exit and Re-Housing, Housing Location Working with Landlords: housing resources in your community Developing Community Resources 60

61. Supported Employment (SE) 61

62.  Evidence Based Practice  Recognized by SAMHSA (Substance Abuse and Mental Health Services Administration)  Learning from Other Work Force Initiatives  Based on work with persons who have serious mental illness but applicable to other vulnerable populations  Outcomes 62 Introduction

63.  People want to work  Gives role  Secures $$$$  Important component of successful homeless service systems  Goal in HEARTH and Opening Doors, the federal strategic plan  Performance Measure for CoC Programs Background 63

64.  Eligibility is based on person’s choice  Ready whenever each person is  Rapid job search  Individualized and based on person’s preferences  Focus on competitive employment  Follow along supports are continuous  Available and flexible  Personalized benefits counseling  Competitive employment is the goal  Integrated with services, supports and treatment Principles of SE 64

65.  Employment First / Housing First: offers wrap around services as opposed to pre-employment services  Addresses issues that interfere with functioning in employment  Build on strengths: including tenancy role  Increases income leading to more housing stabilization  Provides opportunities to address housing and service issues SE: Consistent with Housing Goals 65

66.  Supports active life role of “employee” or “worker”  Provides structure and purpose in peoples’ lives  Integrates all service and treatment teams to accomplish each persons self identified goals  Depends on strong communication  Goal based  Believes in each persons ability to grow, recover and gain self defined self sufficiency SE: Consistent with Housing Goals 66

67.  Puts work on the agenda  Supports the benefits of work in helping each person through the recovery process  Raises value of work  Provides a functional barometer for each person to evaluate progress and barriers  Support for progress and overcoming barriers through the team Provides HOPE 67

68.  Integration of employment with other services  Employment Specialists part of the team, share responsibility for job placement, regular contact with providers  Vocational Unit  Employment services functions as a team, shares resources and offers services as a team. Team meetings and case conferencing is consistent  No Eligibility Requirements  No requirements such as job readiness, no substance use, taking medications, intellectual functioning Fidelity - Organization 68

69. Talk about employment with all participants, on-site teams, referral resources and community supports, services and treatment resources. Some programs have used: Kick off meetings Printed materials Alumnae testimonials Participation in regularly scheduled meetings Staff Role - Engagement 69

70. Assessing strengths and barriersAssessing the Needed Supports Designing a web of supports for each person Including treatment providers, supports, employer, community providers, peer support Identifying skills needed to obtain and maintain jobCrisis prevention planning with allPlanning for employment benchmarksNegotiating future employment goals in concert with other planning Staff Role – Assessment & Plan 70

71. Not interested in work Staff Role: Build Motivation, discuss work hx, link to goals Pre-contemplation Thinking about work but no plan Staff Role: Help identify interests/abilities, explore feelings about working Contemplation Working on resume, searching for job Staff role: help w/search and resources Preparation Interviewing for jobs, just starting to work Staff Role: support with clothes, alarm clock, role playing interviews, assist with transition issues Action Working for more than a few weeks to 3 months Staff Role: support as requested by person, monitor benefits and barriers, career planning Maintenance 71 Using Stages of Change

72. Ongoing work-Based Assessment Ongoing and occurs in the community and on the job not through testing. Testing is not a pre-requisite of job placement. Use of problem solving and accommodations Rapid Job search for competitive employment First contact with an employer is within a month of program start. Individualized Job searchEmployer contacts are based on clients individual preferences Fidelity - Services 72

73. Identifying employment interests and goals Exploring feelings of ambivalence, anxiety, anticipation, along with the sense of motivation and strength Discussing employment and education history Assessing skills Addressing benefits/entitlements concerns Continues throughout the course of the work Staff Role - Assessment 73

74. Preparing a resumeDeveloping interviewing skillsGathering appropriate work attireLearning about employer expectationsSending out resumes/applicationsPreparing for call backs/interviewsAccess to phone, computer etc. 74 Supports Needed – Job Prep

75. Diversity of jobs developed Jobs reflect preferences and are in different categories of work Permanence of Jobs developedJobs are competitive and allow for permanenceJobs as TransitionsParticipants are offered other opportunities to improve employment Workers assist in searching for, planning and building skills for next job opportunity Fidelity – Job Selection and Choice 75

76. Job Search Developing contacts and leads, practicing interviews, filling out applications Jobs must be matched to each participant and reflect their goals Access to jobs that allow for permanency. A career path may include several different jobs but it is important residents can progress at their own pace. Developing job opportunities Relationships with local employers Supports Needed – Job Search 76

77. Follow along supports Flexible and consistent follow along supports to both the participant and employer Community Based Services Workers spend 70% or more time in the community Assertive Engagement and Outreach Workers provide support using different modalities as long as each person is engaged in the service. Different levels of “readiness” are assisted with gentle encouragement Fidelity – Ongoing Follow Along Supports 77

78. Providing on the job support/coaching (as wanted or needed) Managing work/life balance (appointments, programs, meetings, medications, education, family obligations etc.) Follow along supports for as long as the participant wants the additional support to maintain their employment. 78 Supports Needed - Retention

79. Ongoing work with the employer to provide education and support Employer may need assistance in dealing with situations that come up, managing accommodations, and education around mental illness for themselves and other employees. Proving ongoing support to each participant Job coaching and assistance to manage tasks, counseling around career goals, support in groups and individually, problem solving around medications schedules, managing doctors visits, transportation and other employees or manager. Developing supports both on the job and in the home Supports Needed 79

80. On the Job supports: Go where the person works, takes breaks, home and community to provide supports and assess the environment Practice real on the job skills including negotiating, conflict resolution and problem solving Proactive outreach. The worker is patient and persistent offering support in whatever way works for each participant. This should include community/job visits, phone support, groups, peer support, mail, email. Staff Role - Maintenance 80

81. Ensure all participants in are aware of Employment Services Ensure all staff are putting work on the agenda in their talks with participants Create expectations for role of each staff in the employment process Gather together to identify strengths of participants in the employment process Schedule regular opportunities to talk about the work and staff’s concerns about the model Structuring the Program: Integration 81

82. Obtain competitive employmentIncrease in income from wagesIncrease in hours worked 82 Measurable Outcomes

83. Staff must believe this can work“Environmentalize” work Celebrate getting and keeping jobs Speaker’s bureau Job boards Tracking progress Structure into program day Support groups for workers Classes and speakers 83 Building Motivation

84. Identify resources in the communityUnderstand referral and eligibilityMeet to coordinate servicesEngage mainstream employment servicesDevelop job contacts and networks 84 Collaborate with Partners

85. No jobsClients not motivatedEmployers not interestedStaff not sure people will get jobsFear of failingOthers? 85 Address Obstacles

86. TeamsResource developmentLearning from participantsAdjust based on experienceSharing successes 86 Overcoming Obstacles

87. Closing Effective case management practice incorporates various interventions Evidence based practices are the standardConnect to what people wantFocus on behaviorsReasonable caseloadsRequires support, supervision and trainingMust believe in possibilities for change 87

88. Discussion Suzanne Wagner ◦swagner@HousingInnovations.usswagner@HousingInnovations.us ◦917-612-5469 88