Iain De Jong Iain De Jong

Using an Intensive Case Management Approach with Rapid ReHousing Resources

The question comes up time and again – is it possible to serve people with higher acuity using Rapid Re-Housing?

The answer, simply, is yes. However, you need to use an Intensive Case Management approach. What does this mean practically speaking?

You are aiming for housing stability within 18-24 months.

The question comes up time and again – is it possible to serve people with higher acuity using Rapid Re-Housing?

The answer, simply, is yes. However, you need to use an Intensive Case Management approach. What does this mean practically speaking?

You are aiming for housing stability within 18-24 months.

Unlike other approaches to Rapid Re-Housing where the sooner you exit the program participant the better, it is a long-game when applying an Intensive Case Management approach. Start the planning with a year and a half in mind which may expand to two years. This will help you with the sequence of things you work on, the intensity with which you apply supports, and how you measure change. Remember, the goal is to achieve housing stability within this time frame. You are not trying to heal or fix the person.

You are applying the five core principles of Housing First.

If you need a quick reminder, they are:

  1. No housing readiness requirements

  2. Self-determination and choice

  3. Recovery orientation

  4. Individualized service planning

  5. Community and social integration

What does this mean? This means people do not need to be "housing ready" to be a candidate for the ICM approach. Their participation is completely voluntary and they get to determine the type, duration, frequency and intensity of supports. There is a focus on helping people recovery from mental illness, use of substances and their experience of homelessness. All service planning is practical and structured to the unique strengths and needs of the individual. The intention is to have the person integrated with an array of other community resources and meaningful daily activities.

Your caseload is smaller.

Depending on the experience of the worker and the intensity of needs, caseloads tend to be closer to 1:15 or less in an ICM approach, though they can go slightly higher. Caseloads are staggered based upon length of time participants are in the program and their progression towards stability. As people progress out of needing supports, new participants are brought into the program.

Meetings are more frequent and intensive.

In the ICM approach, you can plan on visiting each service participant at least once per week for the most part. Those in the earlier stages of the program may be seen more frequently than that. Those in the latter stages of the program can have their visits spaced out once every two to four weeks.

Each meeting has clear objectives attached to it. There are no "check-ins" or ad hoc engagements to chit chat. The intention is to have clear actions established with each visit that progresses towards enhanced stability.

The service orientation is important.

Delivering the ICM approach requires steadfast alignment to the appropriate service orientation. The biggies are: being person-centred; using a trauma-informed approach; being strengths-based; delivering services in people's natural settings; progressively engaging; reducing harm; promoting recovery and wellness; and, serving compassionately. A deficit in any of these makes the supports less successful.

There are assessments at regular intervals to track progress and amend service plans.

Using the ICM approach requires an assessment process like the SPDAT (the full assessment tool, not the triage VI-SPDAT) at regular intervals. The reason being is to ensure that progress is documented and displayed to the program participant and used in future case planning. Furthermore, the assessment should highlight areas of possible housing instability that need to be addressed, as well as identifying strengths that should be celebrated.

You follow the five essential and sequential steps to housing stability.

The secret sauce is applying the five essential and sequential steps to helping people achieve stability. This means an initial focus on Housing Supports with attention paid to basic needs, supports, safety and relationship impacts. This is followed by Individualized Service Planning with attention paid to life stability, connecting to other systems, increasing social awareness, focusing on employment and education goals, and helping people connect with meaningful daily activities. From there the progression is to Self Awareness focusing on self assessment, triggers and building confidence, and Self Management focusing on control, accountability and maximizing optimism. Finally, the person is in a position where they have Rebuilt/Reframed their life because of a focus on relationship management, social and physical infrastructure, having a purpose and identity not linked to their homelessness, and having achieved the greatest amount of independence possible.

 

Need help understanding how to do it more than this blog? Reach out to us and you can schedule training with the OrgCode team – info@OrgCode.com


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The Cost of Poop

Poop. It happens. For many people, daily. I am talking the real kind – not the metaphoric kind. We all got to go sometime.

Being homeless can mean fewer options of where to take care of this daily need. It is not uncommon in my travels to have people banned from using businesses' and restaurants' restrooms. They may also be banned from the library or city hall. Or it may be after hours and the person has no other options.

Then poop happens. Outside. Sometimes in the most inappropriate places.

Poop. It happens. For many people, daily. I am talking the real kind – not the metaphoric kind. We all got to go sometime.

Being homeless can mean fewer options of where to take care of this daily need. It is not uncommon in my travels to have people banned from using businesses' and restaurants' restrooms. They may also be banned from the library or city hall. Or it may be after hours and the person has no other options.

Then poop happens. Outside. Sometimes in the most inappropriate places.

In one smaller community I do work, they calculated the cost of poop removal to be $300 during daytime hours and double that after hours. It is a biohazard. It needs to be dealt with in a particular fashion to be safe. And all of this could have been avoided if the person had a place to take a dump.

Let’s say there is only one poop clean-up per day. Let us assume they all happened during the day. $300 per poop multiplied by 365 is $109,500 for the year. Depending on your jurisdiction, that is one or two case managers. Or rent subsidy of $500 for almost 20 people for a year. Poop removal is expensive. And it is money that could go elsewhere if we just figure out lower-cost solutions to the public poop issue.

If we cannot come up with a free solution to the poop issue, there are always portable potties. A quick online search shows me they rent for $175-$400 per month depending on how often they need to be cleaned. Yes, portable potties can present their own challenges (for example, drug overdose inside, drug dealing, location for sex work, etc.) but location and management of the portable toilet can mitigate a lot of that. Let’s say in our smaller community we agreed that five portable potties at $400 per month were to be made available. That is still only $24,000 per year, compared to the over $100,000 per year for public poop removal.

In a perfect world, everyone would be housed rapidly and there would be no need to talk about public poop and its costs and alternatives. But that is more of a dream than a reality. People got to go. If they are banned from everywhere that they can poop for free, then communities need to tackle the issue of where people can go in the meantime. Having to poop in a public space should never be the only option people have to take care of their business.

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Should Facial Recognition Be Used in Homeless Service Delivery?

More than one organization in homeless services that we are aware of is considering the use of facial recognition software. I can see the pros and cons of it, but very interested in your thoughts. Here is a guest blog from one of the providers considering the use of facial recognition software.

More than one organization in homeless services that we are aware of is considering the use of facial recognition software. I can see the pros and cons of it, but very interested in your thoughts. Here is a guest blog from one of the providers considering the use of facial recognition software. Please chime in with comments!

To live day-to-day, a person needs to prove who they are to receive the best service and care as possible. Without ID, a person can’t vote, access many social services or join most banking institutions. Even book loans can be restricted.

On the one hand, just like banks and government organizations, emergency shelters require ID because they’re responsible for the well-being and safety of all shelter users. From building evacuations to relationship management, it’s vital that agencies know who’s in their care.

Yet, on the other hand, the lack of ID causes enormous grief for those who don’t have it. Government issued ID can be expensive and agencies require additional forms of proof. For example, to obtain a SIN card in Canada, you first need an original copy of your birth certificate or certification of citizenship or registration.

Technology experts have been working on solutions to this global identification problem in human services, including facial biometric technology. Facial biometrics is a non-invasive, contactless and globally accepted identification tool that helps identify individuals who may not have access to required identification.

There are three key benefits from this technology:

  1. Collect accurate data to better understand people and to better inform programs and system planning

  2. Provide a trauma-informed process to check-in people who require shelter and/or our client services (e.g. laundry, mail services, case management)

  3. Provide staff with more accurate information, so they can focus on helping clients find housing

FREQUENTLY ASKED QUESTIONS:

Q: How does Facial Recognition work?

A: Facial Recognition does not take a photo of a person. Instead it quickly computes a series of measurements between facial features to determine the unique ‘map’ of each client’s face and applies a unique code to that series of measurements. Clients are still recognized when they grow or shave a beard, or experience temporary facial swelling, because the measurements the system chooses are based on skeletal structure under the skin. This micro-measurement process is also what makes the system anonymous and secure, as there is no link between people’s name, photo and facial measurements.

Q: How can facial biometric technology make emergency shelters better?

A: Facial biometric technology is accurate, immediate and non-invasive. This means individuals who need to access services are checked-in more quickly, staff know who’s in the building, and the process has less potential to be a triggering experience.

Q: Why does a more efficient intake process matter?

A: During the winter, the number of people accessing services increases exponentially because of the frigid temperatures. Facial biometric technology can decrease the queue and the amount of time people wait outside in dangerous conditions.

Q: We’re talking about the most vulnerable people in our society. Why do agencies need to know so much information about them?

A: It comes down to service and security. With more comprehensive and more accurate data, an agency will have a much better understanding of who is accessing services. Shelters don’t always have the resources required to track who is accessing client services like the laundry room, housing support, etc. Having a better idea who clients are gives us a far better opportunity to assess and strengthen agency programing.

From a security point of view, shelters are responsible for protecting all shelter users, staff and other stakeholders who enter the building. Rarely are people turned away, however, if a person exhibits threatening or violent behaviour, shelters are obligated to restrict their entry into the building to protect clients, stakeholders and staff. If staff can’t accurately identify each person with government ID, it’s possible for a client to use a fake name -- or many -- and re-enter the building.

Q: What are the safety benefits of Facial Recognition?

A: In some shelters, people register for services, but they do not sign out when they leave. By linking Facial Recognition to a security camera system, the number of people currently in the building will always be known, which will provide critical safety information during building evacuations.

Q: What are the privacy and ethical implications of this software?

A: Once proven and implemented, all information collected about clients will be treated with the same high degree of security as current personal record systems. There is still an expectation and responsibility to adhere to the Freedom of Information and Protection of Privacy (FOIP).

The homeless-serving sector is currently researching best practices about consent and informed consent.

Q: How will this technology help end chronic homelessness?

A: Facial biometric technology will significantly increase the efficiency with which people can access emergency shelter. Yet, front-line staff who are trauma-informed, inherently compassionate and knowledgeable in housing/human services options will continue to lead conversations with clients about how to secure sustainable housing.

Technology is only one part of this solution, but strong policy and front-line staff are crucial contributors.

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Supporting People that Have Complex Challenges and Have or are About to Lose their Accommodation: When is it Okay to Say “That’s enough, we’ve done all we can?”

The OrgCode team get asked this question a lot. As communities find themselves housing and supporting more and more people with higher acuity and unique personalities and behaviors, they are facing an increasing number of challenges. Amidst those challenges, there is a desire on the part of some service providers to draw a line in the sand…a threshold that cannot or should not be passed, and if there is, comes with a consequence of retracting housing and/or support. In performing due diligence in these difficult situations, I think the following questions can provide good guidance:

The OrgCode team get asked this question a lot. As communities find themselves housing and supporting more and more people with higher acuity and unique personalities and behaviors, they are facing an increasing number of challenges. Amidst those challenges, there is a desire on the part of some service providers to draw a line in the sand…a threshold that cannot or should not be passed, and if there is, comes with a consequence of retracting housing and/or support. In performing due diligence in these difficult situations, I think the following questions can provide good guidance:

Are your staff to client ratios sufficient?

Some organizations have started serving higher acute people without adjusting their staff to client ratios. They are still using old ratios of when they had a greater mix of people to support or lower acuity people to support. Maybe the reason the person/family is struggling with maintaining their housing is that there are not enough work hours in the week for you to adequately support people with higher needs. Adjust your caseload and the problem may be fixed.

Do you know whether or not the person/family still wants housing?

Choice is paramount to our work. Too often I have seen well-intentioned service providers make assumptions about a person or family wanting housing or continuing to want housing when there are difficulties. As painful as this may seem, it is still the person/family’s choice of whether or not they want to continue with accessing or maintaining housing. Don’t assume – ask. If they do still want housing, fantastic. If they don’t still want housing, don’t pressure them to accept or want something they have rejected.

Do you believe in Housing First?

Here, I am talking about Housing First as an intervention, not as a philosophy. One of the core tenets of the Housing First intervention is that a person does not lose their supports if they lose their housing, so long as they still want to be housed. As such, there are no limits on the number of times a person/family can be re-housed, so long as they still want supports. There is no “enough is enough”.

What types of cases are you prioritizing through Coordinated Entry for Permanent Supportive Housing?

Imagine a situation where the very people you are struggling to keep housed are, in fact, the same types of people you are making a top priority for Permanent Supportive Housing…why would you keep prioritizing a type of household you don’t know how to support?

What is the nature of the difficulty in sustaining the tenancy – and have appropriate measures been tried to address these issues?

Not all disruptions or issues with a tenancy are equal. And each has different strategies and techniques that can be used to address them. For example, non-payment of rent can potentially be addressed by having a payee. Relatively simple. Another example, a person who performs arson in their own unit may be okay if moved to an older unit made of cinder blocks without other flammables. Relatively hard. Then there are those situations in between. Take for example, a person who uses substances in a challenging or chaotic manner. Perhaps putting harm reduction strategies in place can modify when they use, where they use or who they use with, thereby decreasing impacts on the tenancy. Guest management is also a frequent issue named. Personal guest policies can work, but are not foolproof. Perhaps a move to a 24/7 PSH building with onsite staffing, a concierge, and or restrictions on the number of guests allowed at one time or defined hours for guests would make the difference.

Were program expectations clearly communicated in multiple formats?

There have been instances we have evaluated where the central problem is that program participants never had a conversation regarding what it means to be a responsible tenant before they moved in, didn’t understand (or even review) the lease, or if there were other expectations of participating in the support program, this was not done in advance. We recommend that time is spent discussing or role playing elements of being a tenant in advance of being a tenant. We also recommend that we try to communicate these expectations in different formats – at least in writing and verbally. We have even seen some programs use pictures to demonstrate acceptable and unacceptable ways of meeting expectations. Lastly, when it comes to the lease, we strongly recommend people do not just sign on the bottom line without understanding what they are signing. To that end, we have encouraged many programs to take standard lease clauses and have them rewritten in plain language that program participants have a greater likelihood of understanding.

Was the match to the type of unit appropriate?

Let’s say the program participant likes to party until 4am with their friends. While rare, it may be possible to find an accommodation where this is entirely okay as opposed to, say, a traditional multi-unit residential building filled with families and senior citizens. We have seen instances where the matching process was improper in the first go-round, but having the person move to a trailer in the country was fabulous; and other instances where a person was moved to a building where seemingly all of the tenants would also be up to 4am on a regular basis with their friends, and adding one more to the mix didn’t upset the apple cart.

Is transfer to a different type of support program possible?

Not ideal at a large scale, but possible with individual cases, is transferring people from one type of support program to another. This is not about pushing a “problem” ahead, this is about improving the match. Maybe Rapid Re-Housing isn’t enough and the person would benefit from Intensive Case Management or Permanent Supportive Housing. Maybe Permanent Supportive Housing isn’t enough and the person meets the criteria for an Assertive Community Treatment program or a Long-term Care Facility of Hospice Care. The more communities function as systems of care, rather than a collection of projects, the easier it is to make these sorts of housing-support transitions.

Are there variations in success across different service providers?

This is where a common assessment tool and good data can be your friend. Let’s say you have two (or more) service providers who generally serve people of comparable acuity with comparable staffing levels. If Agency A is achieving long-term housing success with most of its program participants and Agency B is not, what can Agency A teach Agency B so they have similar success?

Do you have the right training?

There are many instances we have encountered where the issue is NOT the program participants, it is that the service staff were never trained on how to adequately, and in many instances proactively, address the types of situations and behaviors that place the tenancy at risk. Every organization needs to review the core competencies required for housing support positions and ensure staff have access to the training that allows them to meet those core competencies.

What types of tools and information are you gathering to enhance supports?

Whether using the SPDAT (not just the VI-SPDAT) or other type of objective assessment tool, mine the information for direction on where best to proactively support people. Couple this with information that is gleaned through the intake process and home visits. Proactively put together a support plan or use tools in your toolbox that can decrease the likelihood of permanent disruptions to the tenancy. Consider things like a Risk Assessment, the Honest Monthly Budget, Crisis Planning, and using the SPDAT to support Stages of Change.

Is there a community table to case conference challenging cases – preferably with the program participant present?

Some of us are usually smarter than one of us. Put together a structure in your system of care where a broad range of service providers and allied professionals come together at set intervals to brainstorm ways to better support program participants that are struggling. The answers may be found in the minds of those around the table. And when the program participant is welcome at the table, they have a direct voice in expressing their current and future needs.

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A Gathering for Senior Leaders

One of the great joys of my career has been the Leadership Academy on Ending Homelessness and Master Class. Ann Oliva and I are shifting things up a bit this year, focusing on having a gathering exclusively for senior leaders…Managers, Directors, Executive Directors, Presidents, Vice-Presidents, CFOs, COOs, CEOs, CPOs and Board Chairs – or comparable positions within your respective organization.

One of the great joys of my career has been the Leadership Academy on Ending Homelessness and Master Class. Ann Oliva and I are shifting things up a bit this year, focusing on having a gathering exclusively for senior leaders…Managers, Directors, Executive Directors, Presidents, Vice-Presidents, CFOs, COOs, CEOs, CPOs and Board Chairs – or comparable positions within your respective organization.

The gathering is set for Pittsburgh November 13, 14 and 15, 2019. It is three full days. Attendees will be placed in a cohort with 9 other people of comparable experience and work through six modules: Leadership Capacity and Momentum; Funding; Awkward Conversations and Conflict; Navigating Politics and Community Interests; Performance; and Relationships. Each module is a half day. Each module has its own senior leader as a facilitator. There are also plenary sessions on Equity, the Psychology of Change, and Why is This So Hard?

Registration is limited to 60 people. First come, first served. Registration up to July 31, 2019 is $779 and you can sign up through our friends at the West Virginia Coalition to End Homelessness www.eventbrite.com/e/orgcode-senior-leadership-gathering-tickets-61821604082 OR wvceh.eventbrite.com If three or more people from your organization are planning on attending, please contact academy@WVCEH.org for a reduced rate.

A block of rooms is available at a discounted rate at the Sheraton Pittsburgh Hotel at Station Square. Call 1-800-325-3535 to make your reservation.

Attendees do not have to have completed the Leadership Academy or Master Class. However, attendees must be in a senior leadership position within their organization, and believe that ending homelessness, while daunting, is possible. You will be a good fit for this event if, even in your position and given your experience, there are still leadership challenges that you are confronted with where skill development and creation of a peer network would be helpful to you.

We are creating a safe space for senior leaders to build a network with other senior leaders that will last beyond the event. It is our intention to delve into each of the topics from a senior leadership perspective, and to equip senior leaders with tools, strategies and critical questions that help propel their work forward. We know that this work is difficult and that those in senior leadership positions are often without a peer group to explore challenges and opportunities.

Prior to the event, each registrant will be required to complete an online survey to help match them to the most appropriate cohort of other attendees. It is not a particularly long survey. You will receive it when we are a couple months out from the event.

If you have questions about content of the event, please contact me (Iain) at idejong@OrgCode.com OR if you have questions about registration or coming as a group, reach out to academy@WVCEH.org 

Don't delay - register today!

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Is Harm Reduction Enabling?

Even though many of us employ harm reduction strategies in our everyday life (wearing a seat belt while in a car, using a crosswalk to get across the street, wearing a helmet when on a bicycle) the thought of employing harm reduction strategies to people who use substances is still often seen as taboo. Erroneously people think it is enabling, an attempt to legalize substances, or even encourages use.

In our field we talk frequently about applying harm reduction to our practices. There are a range of strategies that can be employed, from making sure people have safe storage of their alcohol, drugs and related works to provision of clean needles, pipes and screens; from education and focused conversations on change in use to safe injection sites; from managed alcohol programs to workshops. Even though many of us employ harm reduction strategies in our everyday life (wearing a seat belt while in a car, using a crosswalk to get across the street, wearing a helmet when on a bicycle) the thought of employing harm reduction strategies to people who use substances is still often seen as taboo. Erroneously people think it is enabling, an attempt to legalize substances, or even encourages use.

When wrongly applied, maybe some of these sentiments creep into harm reduction practices when they should not. I would argue that some of the critiques of harm reduction can be valid when harm reduction is misinterpreted and applied incorrectly. For example, I have seen practices that may be better described as harm maintenance rather than harm reduction, and I have witnessed conversations between helping professionals and people who use substances as enabling. But thinking that these shortcomings are widespread is not true. There is no point giving up on harm reduction just because it is sometimes practiced wrong. Let’s face it – many people in our industry are asked to practice harm reduction with the people they support without having ever been trained on harm reduction.

I like the way that the Centre for Addiction and Mental Health responds to suggestions that harm reduction is enabling:

…by respecting these choices and being available to deal with their consequences, the therapist intentionally strengthens the therapeutic alliance. Rather than seeing this as enabling the client to keep harming himself, the therapist understands that he or she cannot realistically prevent a client from making particular choices at the given moment. But by keeping the door open and helping to ameliorate adverse consequences when they occur, the clinician can strengthen the motivation of the client to behave in a less harmful way, and facilitate their engagement in further treatment when the client is ready to move closer to a less harmful pattern of use or abstinence.

In very practical ways, harm reduction is about truly meeting people where they are at, with radical acceptance of the choices they are making in their own life. Good rapport in present reality leads to opportunity for reduction in harm in the future. For every organization that claims to be person-centered, non-judgmental and trauma-informed, practicing harm reduction is an extension of all three of those sentiments.

Harm reduction is a very pragmatic approach to working with people who use substances. I have heard it described as, “It ain’t what’s pretty; it’s what works.” The truth is, substance use in various forms, is part of written and oral history for many cultures. While the drugs may be ever changing and new, drug use is not. We need a range of approaches to respond to drug and alcohol use – especially problematic use – rather than a one-size-fits-all approach. Harm reduction should always be one of the options for people that experience homelessness given the higher propensity of people who are homeless that use alcohol or other drugs. In so doing, we are being responsive to real, in the moment needs. That type of engagement is practically required of us, not an exercise in enabling.

While cessation and abstinence are a choice for some, I reject the notion that we will ever have a drug-free society. I love pulling data from the SAMHSA Behavioral Health Barometer when working with American communities. It clearly demonstrates time and again that slightly less than 10% of the population of any given State has problematic alcohol use and under 5% have problematic use of other drugs – and in both instances, the majority of people in the community receive no treatment or counselling for their problematic use. Closer to home, the Policy Lab at UCLA has analyzed tens of thousands of VI-SPDAT records and found that 51% of the unsheltered homeless population state drugs or alcohol were one of the reasons they lost their housing, and 50% believe their drug or alcohol use limits their ability to be housed. Rather than thinking a treatment or enforcement approach is going to help all of these individuals achieve sobriety, it seems practical to me that harm reduction is the vehicle by which more people will find access to housing and learn to stay housed while also using substances.

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