Tiered Case Management Model in a Scattered Site Housing Program

1. Tiered Case Management Model in a Scattered Site Housing Program Nancy M. Strohminger, LCSW-C Steven L. Dashiell, M.A.

2. Disclosures • This 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.

3. Disclosures • Nancy M. Strohminger, LCSW-C • Steven L. Dashiell Has no financial interest or relationship to disclose. • CME Staff Disclosures Professional Education Services Group staff have no financial interest or relationship to disclose.

4. Learning Objectives At the conclusion of this activity, the participant will be able to: • Cite the theoretical constructs underlying a tiered case management model for long term care. • Construct realistic (housing) program goals that are based on individual performance and national Ryan White and HUD priorities. • Operate a staff practice that can be trained to effectively and efficiently focus on program goals. • Assess aggregate program data to identify unmet needs in your target population that can build justification for new program initiatives or partnerships.

5. Baltimore vs. Statewide Profile (2010) BALTIMORE-- Population: 620,961 Persons Below Poverty Level: 24.7% Ranked 5th in the nation for newly-diagnosed HIV cases. STATEWIDE-- Population: 5,773,000 Persons Below Poverty Level: 9.9% Baltimore is home to 47% of all Marylanders living with HIV/AIDS.

6. AIRS History and Mission • FOUNDED 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.

7. Permanent Housing Programs • General Adult Population—Singles and Families—CURRENT TOTAL: 231 Households. • Sub-Populations: • Ex-Offender Projects (Transitional and Permanent) • Limited English Proficient (mostly Hispanic) Project • Youth Ages 18-25 • Baltimore County (nearby jurisdiction)

8. Race Profile

9. Gender Profile

10. Family Configuration Profile

11. Level of Stability

12. Program Intervention Model

13. Program Wide Goals • For 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)

14. 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).

15. Federal Funding Priorities • HUD • 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 level • Housing is permanent, but working towards client self-sustainability • Ryan White • Provision 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)

16. Supportive Case Management Model • Completely Individualized Service Planning • Completely Client-Driven • Variability of approach from one Case Manager to another • Only measurement of change was tied to completion % of Goals. • “Successes” described in anecdotal terms only. • Imperfect understanding of client’s barriers around change.

17. Case Management Vision • Unrealistic 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.

18. Deciding on Variables • Must 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.

19. Towards a Targeted Housing Case Management Model • Individual 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.

20. MODEL APPLICATION What We Learned

21. Theoretical Contributions • Tran theoretical Model of Change (DiClemente, Procraska, & Norcross) • AIDS Institute Models of Case Management • Comprehensive • Supportive • Targeted (Triaged) Case Management • HUD National Benchmarks—Supportive Housing Programs • Outcomes Management for Program Effectiveness (R. Pena)

22. Intervention Variables

23. Level I (Basic) Service Elements Services Received Qualitative Goals Individual Service Plan Weekly 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)

24. Level II (Intermediate) Service Elements Services Received Qualitative Goals Individual Service Plan 2/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)

25. Level IIIA (CM FOCUS-FINANCIAL/ HOUSING NEEDS) Service Elements Services Received Qualitative Goals Individual 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 Notice 100% Pass Housing Inspection 100% verified full entitlements

26. Source of Income Profile

27. Level IIIB (CM FOCUS—HEALTH/ FAMILY NEED ) Service Elements Services Received Qualitative Goals Individual 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 insurance 100% verified full entitlements 90% Medical Care Compliance—focus area

28. Co-Morbid Health Conditions

29. Level IIIC (AGE-RESTRICTED) Service Elements Services Received Qualitative Goals Services 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 insurance 100% verified connection to care (medical, mental health, substance abuse recovery) 90% No Late Rent/BGE Turn-off Notice

30. Age Profile

31. Level IV (CASE MANAGEMENT ON-DEMAND) Service Elements Services Received Qualitative Goals Case Management on demand, or problem-focused with time limits 1 contact per month Automatic 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

32. Annual Check Up Comments • Done Annually as a Point-In-Time Snapshot or Update • Changes are noted based on client’s relation to: • Length of Time in the Program • Health 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.

33. Tiered Case Management Profile

34. Training Comments for Staff • Need 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.

35. Training Challenges • Change 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.

36. Effect on Case Management • Case 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.

37. 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.

38. Using Outcome Information to Identify Needed Resources • Annual 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.

39. Contact Information AIRS/ 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

40. Obtaining CME/ CE Credit If you would like to receive continuing education credit for this activity, please visit: http://www.pesgce.com/RyanWhite2012