tiered case management model in a scattered site housing program

Nancy M. Strohminger, LCSW-CSteven L. Dashiell, M.A.

Tiered Case Management Model in a Scattered Site

Housing Program

DisclosuresThis continuing education activity is

managed and accredited by Professional and Education Service Group. The information represents the opinions of the authors. Neither PESG, nor any accrediting organization endorses any commercial products displayed or mentioned in conjunction with this activity.

Commercial support was not received for this activity.

DisclosuresNancy M. Strohminger, LCSW-CSteven L. Dashiell

Has no financial interest or relationship to disclose.

CME Staff DisclosuresProfessional Education Services Group staff have no financial interest or relationship to disclose.

Learning ObjectivesAt the conclusion of this activity, the participant will

be able to:1. Cite the theoretical constructs underlying a tiered

case management model for long term care.2. Construct realistic (housing) program goals that are

based on individual performance and national Ryan White and HUD priorities.

3. Operate a staff practice that can be trained to effectively and efficiently focus on program goals.

4. Assess aggregate program data to identify unmet needs in your target population that can build justification for new program initiatives or partnerships.

Baltimore vs. Statewide Profile (2010)BALTIMORE--Population: 620,961Persons Below Poverty Level: 24.7%Ranked 5th in the nation for newly-diagnosed HIV cases.STATEWIDE--Population: 5,773,000Persons Below Poverty Level: 9.9%

Baltimore is home to 47% of all Marylanders living with HIV/AIDS.

AIRS History and MissionFOUNDED in 1987 as a response to the

AIDS epidemic—originally housing with nursing support for the terminally ill.

MISSION: AIRS provides comprehensive supportive housing services to enhance quality of life, emphasizing self-sufficiency for low-income and homeless individuals and families living with or at risk of HIV/AIDS or other disabilities.

Permanent Housing ProgramsGeneral Adult Population—Singles and

Families—CURRENT TOTAL: 231 Households.

Sub-Populations:Ex-Offender Projects (Transitional and

Permanent)Limited English Proficient (mostly Hispanic)

ProjectYouth Ages 18-25Baltimore County (nearby jurisdiction)

Race Profile

African American

85%

Hispanic9%

Caucasian5%

Other1%

Gender Profile

FEMALE39%

MALE61%

TRANSGENDER0%

Family Configuration Profile

63%

37%

Single Head of Household Families/ 2 Adults

Level of Stability

21%

18%

13%

47%

Length of Time in Housing

12 monthes or less1-2 yrs.2-3 yrs.Over 3 yrs.

Program Intervention Model

IntakeEstablish Eligibility for HousingIntake/ Pre-Housing EducationDrug Screening

HousingStabilize health and income (Earned and govt benefits)Become self-sufficient with housing and financial responsibilitiesGrowth in social/ community connection, leadership activities

"Gold" Standard of Self-SufficiencyCase Managment on DemandPeriodic SupportNeighborhood/ Family/ Peer Support connection Good working relationship with AIRS/EHM

Program Wide GoalsFor all clients to apply for all basic entitlements they

are eligible for—TCA, food stamps, medical insurance—beginning before housing, and continuing throughout. (100% Program Goal)

For all clients not on SSI/SSDI to be involved in work, training or school activity leading to increased income, higher potential. (This affects 50% of the population--100% Program Goal)

For all clients to have verified connection to care—medical—for self and family. (100% Program Goal)

For all clients to utilize mental health and substance abuse treatment as recommended. (This affects 50% of the population--95% Program Goal)

Program Wide Goals (Cont’d)For all clients to pass housing inspection

with no corrections needed. (95% Program Goal)

For all clients to handle finances so there is no late rent/ BGE turn-off notice. (90% Program Goal)

For all clients to develop positive working relationships with AIRS/ EHM, as shown by independently being able to contact for assistance. (Level 4, 5 only—100% Program Goal).

Federal Funding PrioritiesHUD

Clients must be homeless and meet the HUD definition of homeless as proven by scenario or a 3rd party

Clients must be disabled and meet the HUD definition of disability

Clients’ income cannot exceed a state-sanctioned levelHousing is permanent, but working towards client self-

sustainability

Ryan WhiteProvision of services in two categories for HIV+ clientele

(98% of our population)Proof of funder of last resort (given HUD requirements, not

a challenge in the grand majority of our clients)

Supportive Case Management ModelCompletely Individualized Service PlanningCompletely Client-DrivenVariability of approach from one Case

Manager to anotherOnly measurement of change was tied to

completion % of Goals.“Successes” described in anecdotal terms

only.Imperfect understanding of client’s barriers

around change.

Case Management VisionUnrealistic to stay “in a program” mode

indefinitely.Desire to focus their work where it is most

needed—at the beginning, with high-risk clients.

Desire to reinforce residents who reach the “Gold Standard” of Self-Sufficiency through recognition, allowance of independent judgment with regard to Individual Service Plan Work.

Model more closely approximates non-program coping behaviors.

Deciding on VariablesMust be measureable and discreet.Must connect to your funder’s/ agency’s mission.Must reflect some of the actual barriers you are

overcoming.

For Example, which is the most measurable? Realistic?Increase income.

vs.Maintain financial obligations.

Towards a Targeted Housing Case Management ModelIndividual needs are assessed.Client Self-Determination is always

respected.However, Program/ Agency Goals are

introduced, along with training of Case Management Staff.

Case Manager is to offer, endorse best option for their self-sufficiency, based on their risk profile.

Annually, Case Manager assess and evaluate where individual client is with respect to those goals.

Case Management Level of Contact is then re-calibrated to reflect those needs.

MODEL APPLICATIONWhat We Learned

Theoretical ContributionsTran theoretical Model of Change

(DiClemente, Procraska, & Norcross)AIDS Institute Models of Case Management

ComprehensiveSupportive

Targeted (Triaged) Case ManagementHUD National Benchmarks—Supportive

Housing ProgramsOutcomes Management for Program

Effectiveness (R. Pena)

Intervention Variables

• Life Skill Training

• Nursing Support

• Housekeeping Support

• Ryan White Housing Support

• Access to Care

• Wraparound Services

• Transportation Services

• Workforce Development

Time In Housing Health

StabilityAge

Housing/ Lease Complia

nce

Level I (Basic) Service ElementsServices Received Qualitative GoalsIndividual Service

PlanWeekly contact

with case manager—2/ month face-to-face—1 home visit/month

Targeted health education or support group available

1:1 Meeting with GEAR Coordinator

100% verified connection to care (medical, mental health, substance abuse recovery)

90% No Late Rent/BGE Turn-off Notice

GEAR Involvement goals-set by individual sub programs.

100% completion of Life Skills Education curriculum (Youth only)

Level II (Intermediate) Service ElementsServices Received Qualitative GoalsIndividual Service

Plan2/monthly contact

with case manager—1/ face-to-face—1 home visit/quarter

2 Mandatory Workshops—Money Management, Passing a Housing Inspection

90% Medical Care Compliance

90% No Late Rent/BGE Turn-off Notice

100% Pass Housing Inspection (Year 1, Year 2)

Has put self on all eligible housing lists (Section 8, HOPWA)

Level IIIA (CM FOCUS-FINANCIAL/ HOUSING NEEDS) Service Elements

Services Received Qualitative GoalsIndividual Service

Plan, with same level of contact as Level 2.

2 Mandatory Workshops—Money Management, Passing a Housing Inspection

Encourage utilization of GEAR services.

Case Manager to focus on all barriers to Financial Health, on a case by case basis.

 Measure:90% No Late Rent/BGE

Turn-off Notice100% Pass Housing

Inspection 100% verified full

entitlements

Source of Income Profile

Emplo

y...

No Inco

meSS

DISS

I

TCA/

T...

Other0

102030405060708090

Num

ber

of C

lient

s

Level IIIB (CM FOCUS—HEALTH/ FAMILY NEED ) Service ElementsServices Received Qualitative GoalsIndividual Service

Plan, with same level of contact as Level 2.

Maximize contact with Medical Case Manager/ Provider.

Utilize community wrap-around services for maximum protection.

Case manager to pick priority areas in case plan (health maintenance, workforce development, financial responsibility, housing maintenance)

MEASURE:100% verified medical

insurance100% verified full

entitlements90% Medical Care

Compliance—focus area

Co-Morbid Health Conditions

89%

11%

YesNo

Level IIIC (AGE-RESTRICTED) Service ElementsServices Received Qualitative GoalsServices Plan to

reflect individual needs of client

Utilize wrap-around services that maximize growth and independent living in scattered site

Emphasize activities to keep clients socially connected to community

Case Managers to focus on health maintenance, watch for increased oversight need, income maintenance.

MEASURE:100% verified medical

insurance100% verified connection to

care (medical, mental health, substance abuse recovery)

90% No Late Rent/BGE Turn-off Notice

Age Profile

AGE 18-30

AGE 31-40

AGE 41-50

AGE51-60

AGE 61-OVER

0 10 20 30 40 50 60 70 80 90

Level IV (CASE MANAGEMENT ON-DEMAND) Service Elements

Services Received Qualitative GoalsCase Management on

demand, or problem-focused with time limits

1 contact per monthAutomatic invitation to

Consumer Advisory Board with leadership, volunteer services to the agency/ other clients possible

Encourage utilization of GEAR services.

90% Medical Care Compliance

90% No Late Rent/BGE Turn-off Notice

100% Pass Housing Inspection

Has put self on all eligible housing lists (Section 8, HOPWA)

75% utilizing GEAR resources towards employment opportunities and income growth

Annual Check Up CommentsDone Annually as a Point-In-Time Snapshot or UpdateChanges are noted based on client’s relation to:

Length of Time in the ProgramHealth Stability (or Not)Financial Stability (or Not)Age-Sensitive

Report notes individual achievement with respect to Program Goals.

Changes are noted in aggregate data in our program software.

This does not supersede/ replace the Individual Service Planning work.

Tiered Case Management Profile

LEVEL 1 LEVEL 2 LEVEL 3A

LEVEL 3B

LEVEL 3C

LEVEL 40

10

20

30

40

50

60

Training Comments for StaffNeed to understand and apply Agency

goals. Front Line Staff rarely knew even the funder’s expectations.

“Teaching” objective point-in-time thinking. Case Manager often very affected by the event of the moment.

Anxiety regarding “who” is being measured. Supervisor needs to assist with the focus on client “choice” without reflection on good or bad Case Manager.

Case Manager bias around favorite or “non-favorite” clients. Supervisor review often needed to challenge/demand the actual achievement.

Training ChallengesChange is hard, especially with established

professionals.“Definitions” in the system have taken

longer to understand than expected.Client complexity and variability throughout

the year can force a reversal of course. Age of our clients makes us question how

much change is possible.“Missed” opportunities for intervention with

Case Management on Demand group can worry an Agency/ Staff.

Effect on Case ManagementCase Managers are better trained on the

pathways to success, best practice knowledge.Client needs are easier to identify, plan out

strategically in a service continuum toward self-sufficiency.

Role definition between Housing Case Management vs. Medical Case Management improved.

Clients motivation has been strengthened as we identify (and deliver) needed services.

Effect on Agency Data now informs programming, with stronger

reportable outcomes.“Old line” assumptions have been dropped in the

Agency/ Program story line.Service Partnerships stronger, with their

understanding of our model.Move toward measuring average client contact

helps define proper caseload size during expansion/ contraction .

Case Management Model adaptable to new/ different housing projects, with understanding of caseload needs.

Using Outcome Information to Identify Needed ResourcesAnnual Check can isolate bigger-than-

average issues that the aggregate struggles with.Example:

Poor income growth identified the need for in-house workforce development services.

Increase in fatalities in scattered site homes point to the need for nurse partnership/ in-house service.

Observed client motivation highest at start of housing, causing Program to front-load health care intervention, life skills and housing readiness learning while on Wait List.

Contact InformationAIRS/ Empire Homes of Maryland:Nancy Strohminger, Executive VP, Programs

410-576-5070 x12 nancy@airshome.org

Steven Dashiell, M.A., Permanent Housing Program Manager

410-576-5070 x36 steven@airshome.org

Website: www.airshome.org

Obtaining CME/ CE CreditIf you would like to receive continuing

education credit for this activity, please visit:

http://www.pesgce.com/RyanWhite2012