More Care Required than Home-Based Case Management Can Provide: What to Do

Not every community can afford to have (or wants to have) a Recovery-Oriented Housing-Focused Assertive Community Treatment team. Even if they did, not every program participant situation can be fully served through the ACT team alone. And while Intensive Case Management teams are more plentiful, they can be confronted with health, wellness and care needs that surpass the knowledge, expertise, or time availability of the ICM team. Many times I have had ICM staff approach me in training asking what to do with those program participants that have really complex health needs, struggle to maintain their apartment because of their health, or have even been working on a palliative care plan with a health provider.

Housing based case managers are brokers and advocates to other services, rather than the direct provider of health care services, counselling services, etc. As such, the limitation of housing supports is dictated, at times, by the overall wellness of the person. If there is not home-based health supports that cannot supplement the work of the Housing based case manager in an ICM program, the Housing Based Case Manager cannot be held responsible for the health and wellness of the participant. It is outside their expertise or job responsibilities.

The truth is, not everyone can manage independent living with certain health issues. Sometimes care homes, long-term rehabilitation housing, nursing homes, hospice care, and the like are more equipped to handle the health needs of certain program participants than a scattered site unit with supports that come to the home. Is that a failure of the ICM team or the program? No. It is the reality of how care is provided, to whom and how (which can be very different community to community) when it comes to people with compromised health.

This is not always easy to accomplish in a meaningful way in any community.

Needing more advanced health supports and having access to those supports is not the same thing. Many care facilities have long waiting lists. Some require private payment. Others have really stringent eligibility criteria and a health record verification process that almost requires an army of health professionals to navigate – and uses terminology foreign to a housing worker.

Then there is the matter of fit and expectations of people that use care facilities. Many communities do not have care facilities that tolerate the sorts of behaviours that the participants in a housing program may exhibit. You would be hard pressed, for example, to find a nursing home that is supportive of residents using crack cocaine or a long-term care facility that understands some residents are going to participate in sex work. These are communities that benefit from a core review of health services to be inclusive rather than expecting housing works to provide health care services.

Another concern is that housing workers start to disengage with any program participant with a health concern thinking it is automatically the job of care workers to pick up the slack and take the lead because of the health concern. Butting heads across system is NOT service. And it does not serve the best interests of the program participants either.

We cannot house our way out of appropriate health care, when a more medical treatment residential option is the more prudent course of action. We need to work with the health community to figure out the best support and residence models to meet the needs of our clients rather than laying blame or pointing fingers. And at the same time we cannot blame a housing case manager for not having enough health resources or knowledge when it is beyond the expectation of the position – and some program participants will need more health supports than they could ever broker or advocate to access.

Considerations in Using Competition and Comparison as a Motivation Strategy

A common approach to motivation of an organization, community or person is to use competition and comparison. There is no doubt that for those that are driven by potential accolades of being first or seen as best this is an approach that kickstarts movement at an accelerated pace. There is also no doubt that some people, organizations and community are not motivated by this quest to be first – or become demotivated when they realize that they are not going to succeed in a way that others are. I say this is akin to watching a track race where the slower competitors decrease their pace even further before they get to the finish line because it doesn’t really matter to them what their time ends up being.

Comparison leadership is not transformational leadership. There is not a defined sustainable element to comparison leadership in the way that transformative leaders intentionally embark upon while shifting people, organizations or communities in a new direction. At the core of the comparison approach is one of “us versus them” as a rallying cry. Yes, the “us” tends to perform really well. However, it almost never alters the “them” and so a narrative of friction continues.

Comparison leadership is very difficult at the personal level to perform. In essence people are asked to fit in while standing out. They are asked to be like everyone else but be better. It has a tension of assimilation (are you doing the right things that we want everyone to do) out of balance with performance improvement (and when you do those right things like everyone else do them faster or with better results or with improved efficiency compared to everyone else doing the right thing). Brene Brown is right: Comparison is the thief of happiness and success.

As a stimulating strategy for new action and direction, comparison leadership can get the ball rolling. This is surely a benefit. It can get people to gel around a strategy quickly, without a doubt. It can get people to dig in and want to prove to themselves and others that something new is possible. We should consider comparison and competition as a leadership strategy when it is warranted. However, once the new direction is on firm footing, we need to careful transition to a different approach to leadership that is more inclusive and transformative. If you don’t, people, organizations and communities are at a loss when they are surpassed; or they focus their energy on the “game of process improvement” and lose sight of the end user of their services.

Content such as this is going to be covered at the Leadership Academy on Ending Homelessness this fall. While we are sold out, you can get your name on the waiting list. You can also let us know if you would be interested in attending if we were to host another Leadership Academy next year.

I will…

I will…

Show up everyday ready to make a difference.

Do my work with integrity.

Try my best to get results worthy of the highest esteem of others.

See the big picture.

Be brave enough to speak truth to power.

Offer solutions, not just point out problems.

Embrace evidence.

Be relentless in the pursuit of awesomeness.

Share what I know.

Focus on the speaker while listening.

Be true to my own morals, values and beliefs, while respecting that others have a world view that may differ from mine.

Seek knowledge.

Ask questions.

Focus on justice instead of charity.

Give away as much information and knowledge as I can.

Say sorry when I have wronged others or been wrong.

Know the difference between a job and a vocation.

Find patience on days when I lack it most.

Remember to say “Thank you”.

Make people laugh.

See potential in everyone.

Challenge myths and stereotypes.

Find that any exhaustion from my work comes from my productivity, not just being busy.

Be authentic.

Ask “why”? more.

Make a difference.

Homeless Campuses: What Does the Future Hold?

There was a time when homeless campuses were seen as the best possible approach to working with people experiencing homelessness. Some consultants (experts?) continue to talk about a Housing Fourth approach (read this) as they try to get government officials to choose the campus approach. No doubt, though, there is loads to be learned from existing campuses – and from this learning we can posit what the future may hold.

I have been to MANY homeless campuses. I have been to the big ones like Haven for Hope in San Antonio and what they do for single adults in Phoenix. I have been to smaller and medium sized ones like what they do in Lafayette. I would say that some have made valiant attempts to offer excellent services co-located on one plot of land, and that campuses with a single central service provider would appear to perform better than campuses with multiple, co-located service providers. I do not hesitate to say, however, that I have seen considerably more terrible campuses than decent ones. Whenever asked for my professional opinion, it is a no brainer to me: don’t ever do a campus unless you absolutely have to…and if you have to, you likely need a visionary Chief Programs Officer (or comparable position) to hold it altogether and get results.

First the pains that I have seen from visiting plenty of campuses…

Co-location does not, it seems, result in collaboration in most instances. When more than one service provider is in the same geographic area on the same plot of land it seems to result in competition and suspicion instead of unified, cooperative services. You may think people will want to work with each other to end homelessness. That is not really the case. There is, most often in these instances, a lack of governance or empowerment of a leader to take charge across the campus when there is more than one service provider. What occurs is lots of talk about wanting to work with each other, followed by talk of what another service provider is doing to get in the way of that, followed by inertia. If you go back to the planning phases, and in some instances early stages of operation, there was energy amongst different service providers to be working in lock step. Over time that seems to fade. Senior leaders, then, start spending more time managing relationships across service providers, than doing program improvements to get people out of homelessness.

Funders sometimes think they can whip things into shape by setting expectations of cooperation when there are multiple service providers on the same campus. But what happens is a lot of finger pointing. Organizations want to put their best foot forward, even if it means throwing others under the bus. There is loads of energy expended protecting each organization’s slice of the campus pie that they have no common interest in what funders are trying to achieve.

Prioritization is difficult on a campus. Organizations on a campus can have different mandates, missions or interests. Heck, even when there is just one service provider on the entire campus you can see differences between program areas in how they respond to prioritization. Without central authority, getting to a place where there is agreement on whom to serve in which order is tough – if not impossible. Then you spend all of your time assessing and none of your time housing. Because campuses are magnets for people experiencing homelessness the volume of people seeking assistance can exceed the capacity of intake and assessment.

When there are other homeless services in a community in addition to a campus, communities often struggle with how to put the pieces of the puzzle together. By sheer size and multitude of programs, the campus can see itself AS the system. When there are multiple service locations, the campus is PART of the system, not THE system.

It has also been my experience that on many, many campuses antiquated ideas die a slow death. Employment readiness? Still see it in spades. Focus on transitional housing as a way to prove readiness or worthiness for housing? Tons of it. Reforming the behaviour of people to make them ready for housing? Alive and well. This isn’t necessarily because of poor-intentioned staff. Antiquated programs can come as a result of the built form that exists on the campus. For example, if the original campus built a lot of classrooms and vocational teaching spaces, they can get stuck on employment readiness. If the campus built reams of transitional housing, then they seem to hold tight. If the campus created a “step up” or continuum model between physical spaces on the campus, then amending even one part of the campus creates havoc on the whole model – and, well, keeping things as they were seems easier.

Assets inhibit innovation. Because the campus revolves around the built form, making change is difficult or financially cumbersome. Urban planners would have a field day figuring out what should have happened and why. So much about the campus experience misses the client-centered approach to design and instead focuses on greater ease of service delivery for the service provider. While the scale of the campus plays a role in this, it doesn’t make smaller campuses exempt from the challenges of reforming and changing parts of the built form. To that end, I think of places like Lafayette and the sheer energy and determination it takes to even amend small parts of the campus.

If you track the planning and development cycle of a campus, there is excitement that so much money that has been invested in the campus. There are generally no shortages of celebrations of what has been fundraised and built. But wait a couple years because that elation is often followed by heartache that it does not seem to be panning out. Then there is wonder and consideration if there was just a small thing that was done wrong. Then systemic and systematic review. Many times I have seen this followed by a desire to blow up and start some parts of it (or the whole thing) all over again.

The social impacts of campuses must also be considered. First, let us look at the relationship of the campus to the rest of the community. Often (though not always) the campus is stuck away from other services. In Phoenix, for example, the campus for single adults is on the edge of downtown not far from a somewhat run-down and forgotten cemetery. In San Antonio it is literally on the other side of the tracks. It is isolating. “Out of sight, out of mind” comes to mind. And then after the campus is built there is no shortage of businesses and elected officials that wonder why they see people that are homeless anywhere in the downtown or near businesses or residential neighbourhoods. I have encountered people who think you can legislate and confine people that are homeless to a campus – as if it is a prison of some sort.

The social issues located near the campus when there is such a concentration of people is also an issue. What can be manageable behaviours and expectations of being neighbourly when homeless services are integrated into community goes out the window when the scale gets too large and all concentrated in one place. I have yet to see a campus for single adults that has not seemingly blown its brains out on security costs and measures and/or had ongoing difficulties working with local law enforcement because of social issues near the campus.

Another social impact is what the concentration of people with co-occurring issues sharing the same space on that scale does to people. Spend enough time homeless and the experience of homelessness becomes normal, not abnormal. Spend day in and day out with a social group that reinforces the normalcy, and an exit from homelessness can be much more problematic. Amplify this by 100 and you can see how people get entrenched or even lost on the campus.

Not long ago I had the chance to learn about the early stages of planning, development and operations of a large and somewhat infamous campus. A psychosocial-rehabilitation model seems pervasive in many campuses, and this one was no exception. It became clear to me in the discussion that there were probably more ideas that didn’t work than did work. Problems that they were assured would be solved in the community through the campus were not solved, just relocated (and with that came some new issues) There has been a huge evolution in programming there, and I have been so proud to play a small part in it, helping them move more towards support and housing people quicker through assessment.

To be clear, not every campus has the issues noted above. Some seem to work, though I would argue, not because of the campus, but despite the campus. And I think there are some opportunities to improve existing campuses further to make them more amenable to ending homelessness.

When there are multiple service providers on one campus, I think a campus has the opportunity to do better work if there is a single pot of funding that goes to the campus rather than providers on the campus. There should be mutual performance metrics associated to what the campus achieves with this funding as a whole. For this to be successful, more centralized oversight is critical related to funding and performance.

Overcoming the overwhelming concentration on a campus can be improved through better diversion to keep as many people out of the campus as possible when there is a safe and appropriate alternative. A robust front door that does problem solving prior to entry into programs is critical (whether in person or over the phone). This must be resourced properly for this to be successful because of the sheer volume of people that can arrive at a campus in any given day. Satellite intake points may be worthy of consideration.

Again when there is more than one service provider on the campus, if each campus has a czar to make decisions and provider leadership, there is a greater likelihood of success. However, leadership only comes with followers. This only works if there is agreement to follow a centralized leader. Nonetheless, it seems critical to me that a highly accountable governance structure is put in place, with an administrator empowered to make decisions on behalf of the entire campus and to provide direction to providers on the campus that must be followed.

Consolidating housing resources becomes possible in a campus environment to truly prioritize and leverage the strengths of different programs on campus. There is the ability to get people housed quicker when there is rapid assessment and assignment to a housing resource. This should ensure that the most chronic people get out of homelessness and into housing – without a return to homelessness – as quickly as possible. I would argue for a more centralized approach to assessment and prioritization on the campus.

Campuses could be an excellent example of co-located services if they were designed to be person-centered. The campus as a whole has to share this vision and approach, and not be a case where individual programs or service providers on the campus consider people to be “my clients”. This likely requires a shared vision of what each campus is attempting to achieve.

And for campuses to ever succeed there has to be loads of education to elected officials, business and community leaders prior to embarking on the process. People that are homeless may end up in places other than the campus…including the downtown, public parks, open space, and civic areas. A campus is not automatically less costly. And if there is one final take-away for those parties, an important reminder that a campus does not end homeless – housing does!

Drop Ins and Day Shelters in the Era of Coordinated Entry

Much discussion in communities has been focused on shelters, street outreach, and the match to support and housing options as communities have focused on implementing coordinated entry. Where drop-ins, day shelters, and other types of programming during daytime hours fits in is worthy of exploration.

One of the challenges to figuring out the role for the likes of drop-ins and feeding programs is that they often serve both homeless and precariously housed households. This is a challenge because with the former group we should be able to figure out intentional engagement and assessment strategies, whereas with the latter group the focus is going to be on maintaining housing stability through various strategies. One way (though rarely feasible or preferred by service providers) is to separate population groups: some drop-ins and feeding programs only serve people experiencing homelessness, while others only serve people that are precariously housed. Another way is to try and deliberately determine through staff/volunteer engagement within the environment which guests are experiencing homelessness and which ones are not. In this situation, there should then be follow-up with people experiencing homelessness to assess and determine how best to support and house them.

Day shelters have different challenges. For example, while homelessness is almost always a given in these environments, patrons of day shelters have often engaged with other homeless service facilities like a nighttime shelter or street outreach service. Therefore, one of the biggest challenges is avoiding duplication of engagement and assessment.

Drop-ins, day shelters and other daytime programs present opportunities as well when it comes to coordinated entry. Let us explore those:

1. They are terrific locations to find and engage with people that have already been assessed as a follow-through to housing.

Given the mobility of persons experiencing homelessness on a day to day basis from one service to another, the more communities integrate the sharing of knowledge across service providers (with participant consent) the better. It makes it easier to locate people when there is space available in a housing program.

2. They are another engagement and assessment site for people not previously assessed.

There is always a risk that people will “fall through the cracks” as they move from one location to another in a community while experiencing homelessness. In other words, they are using various services, but at no particular service have they been engaged and assessed for housing. When this has not occurred through a night shelter or outreach or other type of program, any daytime service can provide another vehicle for making sure people are assessed.

3. Maintaining momentum in the housing process can be active rather than passive.

While sometimes day shelters, drop-ins and other daytime services like feeding programs can be passive locations with minimal staff/volunteer engagement, I would argue that they provide an incredible opportunity to maintain momentum in the housing process in a very active manner. This can range from support in getting identification, information on securing government benefits, assistance in getting diagnosis or accessing other health supports, and the like (all of which are dependent on resources being available) to purposeful engagement by staff to reassure a program participant of their choice to move towards achieving housing.

4. Social contact and support.

Day shelters and drop-ins can be the living rooms of people experiencing homelessness. They can be a place of positive fellowship and connectivity to others. When framed towards social contact and support in the process of being housed (and not just contact and support in homelessness), then there is excellent alignment towards the intention of ending homelessness in a community.

5. Continued support in meeting basic needs. 

Until such time as each person has housing and can meet their needs with greater independence, there will be a need to meet basic needs in community. Daytime programs are often critical to meeting these needs. But this is not the only purpose they should serve. They are programs that support people achieve housing while meeting basic needs programs; not just basic need programs.

The Difference Between Commitment & Interest

If you are committed to achieving something:

• you have steadfast fixity of purpose (nothing gets in your way or detracts you from getting results)

• you have a solution-focus to barriers/problems (there is not a culture of excuse making)

• the good results are fuel to keep working and poor results are welcome as data on what needs to be improved (data drives refinement and improvement)

• you invest in gaining the knowledge to know how to be successful (you don’t assume you know how to be successful or do all of the practices that will be required, you learn how to be successful and implement various practices)

• you innovate as necessary (in the absence of a known solution you experiment to create approaches that may work until you find one that does)

• you have informed, meaningful performance targets that reasonably challenge and stretch people engaged with the work (“some” is not a number and “soon” is not a time – there is analysis that goes into goal setting, not wish lists or dreams)

• you spend time fixing problems instead of wishing others would (you don’t have a laundry list of hollow advocacy wishing some other organization, program or government did something differently)

If you are interested (but not committed) to achieving something:

• you will achieve success if the stars align properly (luck plays a role)

• you are quick to point out all that could/will go wrong or that there are a bunch of things outside your control that will influence your ability to success (you do not accept full responsibility)

• you may report out data, but will be quick to frame it as you want it interpreted not how it is (and are likely to make excuses for why certain results are not favourable)

• you will engage as a passing moment in your career (this task is something you do as a job, not something that you are called to achieve)

• you may make assumptions that you know things you do not know or that certain knowledge does not apply to you or will not work where you live (and sometimes this results in “Made In [insert name of city]” approaches that have no merit of fact)

• you will spend a lot of time advocating for others to make change (a lot of “If they did ‘x’ then we could achieve ‘y’ statements are made)

Another way of looking at this is bacon an eggs. Bacon is a lifetime commitment for a pig. Eggs are a passing interest for a chicken. Ask yourself: are you a pig or a chicken?