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 Traditional Housing, no services Emergency Shelter Transitional Housing Supportive Housing

MODIFICATIONS TO THE CONTINUUM OF CARE   MODIFICATIONS TO THE CONTINUUM OF CARE Service-Enriched Permanent Housing Outreach Intake Assessment Emergency Shelter Transitional Housing Supportive Housing Traditional Housing, no services 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 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 short- term case management. Once in permanent housing, families benefit from case management that helps them transition to stability. Services are intensive, but time- limited, 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 short-term 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: __________________________________ _______________________________

Specific Tasks/ Responsibilities What we plan to do to meet these objectives/ achieve goals: ___________________________________

& Moving Into Permanent Housing 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

LINKING FORMERLY HOMELESS Infant & Enrichment & Family Child Care Recreation Counseling Employment & Pre - School Programs & Support Job Readiness Services Health Care & Nutrition Transportation Services Mental Health Family Services Preservation/ LINKING FORMERLY HOMELESS Reunification FAMILIES TO Family Planning COMMUNITY SERVICES Services for Prenatal Care Children’s Special Needs Family Counseling and Support/DV Teen Prevention Services & Leadership Development Crisis Intervention   Parole/ (personal or Elementary, Alcohol & Drug Grocery, Probation financial) Middle, High, Prevention/ Laundromat,   Continuation Treatment bank, etc . Schools

Case Management Issues    

Distrust. Listlessness. Manipulation. Failure to Follow Through & Self-Sabotage. 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 follow-up 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 short- and 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

Short-Term Outcomes – For Families 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

Short-Term Outcomes – Children OUTCOME EVALUATION Short-Term Outcomes – Children Regular school attendance Improved health assessment/care Reduction of behavioral/school problems

Intermediate Outcomes – Mothers 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

Intermediate Outcomes – Children 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 Achieve residential stability Psychiatric stability 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