REGIONAL CONFERENCENORFOLK, VA

MARCH 16, 2009

SUZANNE WAGNERHOUSING INNOVATIONS

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Housing-Focused Case Management

Goals of Housing-Focused Case Management

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Measures of Success3

Jimmy4

June and her children5

Housing Stabilization Services6

Core Elements: Housing Stabilization Services

7 Assessment

Goals Strengths Understanding barriers to housing stability Use Stages of Change for assessment

Engagement on Common Goals Education

Expectations of Tenancy and Housing Options Available Resources for Support

Housing Stabilization Plan Linkages

Community, Services, Treatment Resources Evaluate progress

Expectations of Tenancy

Assessment Domains

What each person wants: where they want to be in 5-10 years

Housing HistoryIncome/BenefitsEducation and EmploymentLegal IssuesHealth, Mental Health, Substance Use and

MisuseParenting and Child CareRecord Keeping

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Assessment Domains

Connections to family and significant others Community supports Religion and spirituality

Potential for and orientation to change

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Stages of Change11

Stages of Change12

Jimmy

Jimmy wants a place where people do not bother him He wants enough money to live on and to not have to hustle all

the time Jimmy left his family because he was no good for them Jimmy lived in SROs for 20 years going from one to the other He says the encampment is the best place he has lived. He says when he is outside he feels closer to god He once had his own roofing company and until recently

worked pick-up construction jobs He does not consider himself homeless Jimmy is worried about being sick so much; sometimes it is

hard to breathe He is proud of his role as the head of the encampment He worries about the other guys there He has a record of assaults He says if you get him housing he will not drink

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June and her children

June wants a place where she and her children can feel safe; maybe with a backyard

June has a trauma history dating from childhood She has never had anyplace she considers her home She has never been responsible for an apartment Junes relationship with the children’s father was abusive She loves her children and they love her She has the symptoms of depression and drinks to feel better She has no income and has been fired from her job, has no

benefits and no health insurance for her children She wants a chance for her children to get ahead She is ashamed of being homeless but sees no way out She draws comfort from her church She does not believe you can help her

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Engagement Strategies

Introduce yourself and how you can be helpful (provide education about

available resources)

Repeated, predictable, non-intrusive patterns of interaction

Listen to felt needs

Be aware of the difference between crisis needs and longer term needs

Listen to what people want

Respect boundaries

Assess risk

Be aware that people may tell you what you want to hear

Allow people as much control as possible over interactions

Go slowly things unfold over time

Be patient and persistent

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Focused Housing Stabilization Services Planning

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Components of the Housing Stabilization Plan -- Goals

Goals set as a team of clients and worker

Focus on the issues that affect housing retention – base on what caused the current crisis and previous episodes of housing instability

Immediate and longer term goals clear Focus by phase Use the plan for the intervention

Steps to reach goal clearly defined and measurable Longer term needs require connections to other

resources.

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Components of the Housing Stabilization Plan

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Components of the Housing Stabilization Plan

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Develop protocolsDevelop protocols Identify ResourcesIdentify Resources

Job training Unemployment Insurance Social Security (SSA, SSI, SSDI) Child Support Assistance Public assistance, TANF Medicare Medicaid Food stamps WIC Child Care subsidy (TANF) Domestic Violence Services Veterans Administration Services for People with Physical

Disabilities

       

Ryan White Program State Children’s Health

Insurance VA Medical Services, VASH

Vouchers TANF Transportation services Medicaid Transportation

Services S+C , SHP, Section 8, Public

housing, HOPWA Chemical Dependency Services Mental Health Services Health Clinics with sliding

scale MRDD Services 

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Resources and Referrals

Evaluating the Housing Plan21

HSS Plan: Jimmy22

HSS Plan: June

Short Term: Access housingLong Term: a better life for her childrenHousing: Identify preferences and what Junes' family

might be eligible for and the requirements of each option. Include school location as a preference question.

Family: Assess if the school attendance puts this family at risk. Support June’s role as a parent including assisting her to set up a school program and transportation. Look at child care issues.

Income: Identify what June and her children might be eligible for. Assist to apply for benefits. Address employment issues ongoing.

DV issues: Safety plan for family. Provide access to resources for trauma and depression issues ongoing

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Working Together with Housing Providers

Landlord and Property Manager Priorities Keeping unit filled Rent Payment No trouble: follow community rules, don’t disturb

neighbors Maintain Apartment

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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

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Property Management / Supportive Services

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

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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

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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

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Other Adjustments

Moving inHoardingLonelinessConstant crisisLack of moneyBeing scaredLeaving

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Crisis

Crisis rarely happens overnightStructure of Tenancy can alert to problemsHave clear protocols in place for crisis

management

Housing: functional Medical Psychiatric Behavior Financial Relating to safety: DV, Children Family

Maintaining Housing

Use the structure of the lease Clear expectations of Tenancy: break it downInformation is key Relationship with the property manager or

landlord is the foundationPrevent CrisisUse your resourcesAssist person to see housing as an assetConnect to long term goals

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 Veterans and their families and case managers as needed

Managing caseloads and assignments, managing phases and highlighting need for case conferencing

Identifying training needs and resources for professional development

Providing support and perspectiveManaging resources and access to services

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Support: Case Conferencing33

Support: Team meetings34

Support: Training

Provides new skills and resources to existing staffOrients new staff to the practiceTopics Include:

Orientation to the model of Housing Stabilization Services Supporting Interventions

Stages of Change CTI Motivational Enhancement Techniques Rapid Re-Housing

Housing Location Working with Landlords: housing resources in your

community Developing Community Resources

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DiscussionThank You!

Housing InnovationsSuzanne Wagner

suzanne.wagner@earthlink.net Tel: (917)612-5469

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