Housing-Based Case Management

Case management. I suspect service providers, funders, CoCs, policy wonks, elected officials and a whole whack of others have used the phrase or even deliver a case management service but have never defined what it means in their context.

The problem with not defining what case management means for your organization and community is that it is open to gross misinterpretation if you don’t. It will be defined for you by others, probably implicitly, and likely incorrectly (or at least differently than how you internally defined it).

I will spare you the full academic breakdown of the phrase. (You’re welcome.) BUT…I do want to cover the basics briefly from that perspective. There is no single defined history of case management in the literature. We can’t point to just one point in time and say “aha – that’s when case management started”. Because there isn’t a single defined history or point of origin, there is an absence of absolute consensus on what case management is (and isn’t). There also isn’t one dudette (or dude) considered (or at least universally accepted) to be the pre-eminent pioneer of case manager when it comes to housing and life stability.

Want to complicate things further? Once you start adding qualifiers like “intensive” as in “intensive case management” things get even messier. Does it mean more time with people? Does it mean a smaller caseload? Both? How small of a caseload? How much time? More intensive compared to what – ”case management”?

Interventions like Assertive Community Treatment have it somewhat easier in the definition department. We can trace back to when it started. We know what it is and what it isn’t. We can measure fidelity to the preferred effective approach to practice. (Though here is the complicating factor…sometimes ACT is referred to as a subset of case management practice in the literature without “case management” being defined…but I digress.)

Chances are, many of the people your organization works with – especially episodic and chronic homeless persons – have encountered case managers before. They are seemingly everywhere in services that interact with people. Schools have them. Hospitals have them. Prisons/jails have them. Youth programs have them, as do programs for older adults. Developmental disability services have them. Addiction treatment has them. A bunch of community services have them. Oh, and it seems just about every facet of the homeless and housing service delivery system has them.

Enough background. On to how we need to define housing-based case management in the pursuit of excellence in housing supports and work on ending homelessness. I think every organization should have their own clearly defined outline of what case management services means to them and the people they serve. These are the sorts of things your definition should include with some commentary on each:

Professional – trained, educated people deliver case management services who have a solid foundation of practice and theory. If volunteers are involved, they should be professionally trained people working in a voluntary capacity. Well-intentioned, compassionate people without training and theory should not be delivering case management services. As I have said many times before, do not confuse having a big heart with having a big brain.

Active – sometimes when phrases like “meeting people where they are at” or “person-centered” becomes an excuse to be passive, as if both phrases mean that case managers have to wait for individuals/families to come to them. Nay, not so. The case manager must be active and deliberate. This ranges from preparing information to conducting home visits. Case management is proactive in its activity in the spirit of promoting greater independence. Sometimes being active means being persistent and using assertive engagement as necessary.

Empowers choice – case managers provide the service users they are supporting enough information to support that service user in making an informed decision on all matters related to life. Case managers do not make decisions for service users. Yes, this means service users will choose to do things that the case manager her/himself would not do. This may even be labeled a “mistake” by some. Well, a mistake is just another way of doing things…it is neither good nor bad; neither right nor wrong.

Objective – being objective is a struggle for just about anyone, let alone a case manager. Suffice to say, the people being supported will have a different world view…different values and perspectives on matters. Objectivity in practice requires case managers to have completed their own “values inventory” and know who they are as a person to be able to distance themselves/supportive being objective in their practice. Case management is not about having service users subscribe to the values, principles, thought processes or even spirituality of the case manager.

Organized – excellence in case management requires being highly organized. There is a strong sense of where every interaction with service users is headed and why. There is an assembly of resources and information to support this pursuit. There are objectives (usually three) established for every interaction with a service user. There is a documented case plan to provide a framework to where the interaction is going. Too often case managers rely on “check ins” or a relaxed conversational approach to engaging with service users on her/his caseload. This is not appropriate for keeping the conversation on track and moving forward with supporting greater independence over time.

Brokers and advocates – case management is a care structure. It is not the delivery of care itself. Too often case managers confuse their role as being counselor or therapist or crisis intervention worker or chaplain or nurse. No. The case manager helps the service user connect to the resources required based upon the assessed needs of the service user, where the individual/family is in their case plan, and the personal preferences of the service users.

Community-based/In Vivo – know where housing-based case management needs to occur? In housing. Plain and simple. You cannot deliver effective housing-based case management by having service users come to an office in a service provider environment. The best housing-based case managers are the ones that spend their days having effective home visits with service users that are prioritized based upon assessed needs and acuity, not tucked away in an office waiting for service users to come. Want to teach/model life skills? Don’ t expect people to sign up for courses in your organization and be successful in their personal life…teach and model it in their housing. Want people to do better at budgeting for rent, utilities and other life costs? Do so in an environment where it is tangible – their apartment. And so on. The only times of the day I really think case managers should be in an office is at the start of the day to get organized, lunch hour, and at the end of the day to document their day and get ready for the next day.

Working with people – case managers have to work with people, not for people. Case managers help steer towards resources and opportunities. They do not tell people what to do. They do not give advice. They do not see service users as subjects that they exercise power over. Service users are capable of making decisions on their own. Working with people instead of for them also helps distance case managers that somehow they are “employees” of the service user (perhaps you have encountered service users that tell their case manager that they are fired?).

Promoting greater independence – the greatest reward a case manager can ever experience is the service user that is stable in housing and does not need him/her anymore. All of the case manager’s work with a service user should ultimately focus on “how do I help this person/family get to a place where they don’t need me anymore?” Does that mean the individual/family is somehow healed or fixed? Nope. They will remain imperfect, perhaps even remarkably imperfect. News flash – you are imperfect too and likely stably housed. Imperfect people can and do remain housed.

Express empathy, not sympathy – the foundation of case management is not sympathy. Case managers cannot and should not feel sorry for the people they are working with. Instead, they must focus on a communication exchange that favors a greater appreciation of the service user’s life experience, thoughts, and emotions. From that empathy becomes a possible pursuit, and with empathy comes far less judgment or implicit/explicit desire to have the service user subscribe to the case manager’s own values, principles or beliefs.

Focused first on housing stability – we are not in the business of healing or fixing people. Yet so often case managers will think that somehow people have to get better or hit “rock bottom” before they are ready for life changes that will allow for success in housing. Can someone please provide me a clinical definition of “rock bottom”? Oh wait, there isn’t one. There is overwhelming proof outlined in peer-reviewed academic literature that people have a much greater likelihood at making significant life changes such as substance use AFTER they have the stability and security of housing, not before.

Solution-focused – a case manager can use their creativity, passion and skills to overcome barriers and focus on solutions, or they can come up with all of the excuses on why the case management intervention is not working, or why the person they are supporting has lost their housing repeatedly, or why health care or income supports or the justice system or family courts or employers or whomever makes life difficult/impossible for her/his service users. Perhaps my favorite excuse (I say sarcastically) is when a case manager tells me that there is no housing in their community and therefore they have a large caseload of people they can really do nothing with because there are no addresses that they can suggest for their clients to move into. Suck it up, buttercup – if there is truly no housing (highly unlikely) then really you shouldn’t have a job…no point paying you to do a job that you can’t do! (Which in my example means that there is affordable housing available in just about every community that has ever claimed to not have any housing…something we have proven time and again with the communities we work with.)

Process – case management is a process, not a destination. Because it is a process, while there are some progress milestones that we aim to achieve, it is impossible to have a singularly defined linear approach that is going to work the same for every single person in every single situation and life history. The process of case management, therefore, is one that requires the case manager to have a clear sense of where each person they are supporting is at in the journey so as to cater supports and resources to that specific state of where they are at.

Documented – case management is not something that is made up as you go along, nor does what is occurring in the relationship between the case manager and service user exist solely in the heads of the parties involved. Case management is a highly documented process – not just on where the service user has been, but also where they hope to be and how they intend to get there. Without documentation there is no accountability to the supports. Also, while I hope it never occurs to anyone, case management is a lawsuit waiting to happen (and lost) if there is not timely, accurate documentation of all that is happening and is intended to happen in the case management process.

Promoting change – I have said in various training workshops (called “Excellence in Housing-Based Case Management” if you are wondering) that I would love all “case managers” to go back and tell their boss that they want to change their job title to “Change Agent”. Because that is what we are asking case managers to be – agents, catalysts, champions and practitioners of change. If people are going to promote change, however, they need to know how change occurs, how people respond to change, how change becomes routine/practice, and how to respond when that which is being changed reverts to historic behavior. A case manager is not in the business of making “business as usual” cozier. A case manager is in the business of promoting positive change with each person they work with believing steadfastly that without change a return to homelessness and life instability is likely.

Catered to the needs of the individual/family based upon objective assessment – important in the case management process is not what the case manager thinks; it is important what they know. Often what we think is different than what we know. Knowledge is formed through an objective assessment that is grounded in facts. Using the most appropriate evidence-informed assessment tool for your case management work is critical if you are going to be an evidence-informed practitioner using data instead of hunches and anecdotes to drive forward towards lasting housing and life stability.

Non-judgmental – the people receiving case management services live a life different than the case manager. It is neither worse nor better. It is just different. When there is judgment (for example, “Tom isn’t housing ready!” or “Jill’s drinking is too out of control to be stably housed!” or “Charlie’s sabotaging his apartment!” or “Christine couldn’t solve a housing crisis if her life depended on it!”) the case manager loses the ability to truly figure out how best to offer supports and information to where people are at in their life journey. For the case manager to be successful, they must accept each person for who they are and where they are, and then provide options, information and choices that allow for stimulating change.

Neither crisis focused nor crisis driven – a case manager does case management. A crisis response worker deals with crises. A case manager that drops everything to respond to a crisis is no longer doing case management. And who is disadvantaged the most when/if they do? All of the other households on her/his caseload that they postpone meeting with to respond to the so-called crisis. Yes, everybody that is supported should have a crisis plan. Yes, case managers can respond after the crisis has subsided and update the case plan as necessary. BUT, the case manager is NOT the crisis response.

Not without conflict – being a case manager means being professional and cordial. It does not mean becoming the friend of each person on the caseload. People on the caseload do not have to like you personally; they simply must trust that you have the professional experience, training and wisdom to fulfill your half of the case management relationship. There will be conflict in a strong case management relationship. That doesn’t mean being a prick or being argumentative. It simply means that case managers will be transparent in acknowledging instances where they see discrepancies between what an individual/family says they want to achieve and what they are actually doing. Case managers should never mistake confidence in professional competency with being liked. Positive tension helps foster change.

Transparent – “nothing about us without us” is an often used phrase from the mental health personal advocates, and a good one to keep in mind and use in the case management relationship. Each person/family being supported in the case management relationship should know how to and have the right to have copies of every single assessment, note or piece of documentation pertaining to the case management relationship. They should be made aware of why certain information and options for decision-making are being presented and why for every step along the journey. If the case manager practices in a transparent fashion it will change (revolutionize?) how she/he completes case notes, the language used when documenting interactions, the perspective taken when performing assessments, when and how they organize case conferences, and how they engage from an objective-based perspective with each encounter with the households on his/her caseload.

The last reminder I’d like to provide is that people are not “cases”. People are people. Case management (the “case” that is being managed) is about activities, appointments, interactions with service delivery systems, and the like. Case managers do not manage people.

Hope this blog helps you form a good definition of case management for your community or organization. Keep this type of orientation towards the delivery of your case management services and success in helping people achieve greater housing and life stability is likely to increase.

Iain De Jong

About Iain De Jong