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.
What Does it Mean when Government Endorses a Housing First Approach?
More and more I am seeing different orders of government – municipalities, states, provinces, federal – slip the words “housing first” or “Housing First” into their documents, policy briefs and contracts. I suspect (because I used to be one in a former life) there is a policy wonk that did some research, found the evidence of this approach to homelessness compelling, and advised political masters it was the bees knees.
But does government know what it is asking/endorsing/requesting? Is what the policy advisor is recommended understood and translated well in the political arena? Do program designers that may have never delivered direct service at any point in their lifetime in this field really know what they are asking for?
My experience suggests this is probably not the case. All of the evidence that pointed to this approach being a good one requires fidelity to practice of a true Housing First model, either through Intensive Case Management or Assertive Community Treatment. You can read my thoughts on this or listen to the podcast here or watch a video about it here.
Truth is government should be demanding fidelity to practice in exchange for investment of resources. And government should be investing in the training to help service providers gain the knowledge necessary to fulfill the requirements of the practice. Not doing so is a gross injustice to homeless people, and will not yield the results (housing stability, cost savings, etc.) that were expected when the community went down the road of this approach to service delivery.
Things that should not be happening that I see far too often in my travels:
Government touting that they have invested in a Housing First approach when they may have invested in a housing program, but not Housing First
Various government entities requiring communities to have a Housing First approach in their local housing/homelessness plans, but not providing any direction or definition of what it is they mean (or worse, asking people to provide an explanation of what “Housing First” will mean/look like in their community…um, that’s like asking a triage nurse in one emergency department to explain a litany of medical tests and screening they do to determine if someone has had a heart attack and the next hospital over interpreting the testing and screening for a heart attack as being able to read Winnie the Pooh, provide the patient a cuddle, and tickle their toes – and considering both to be valid/appropriate!!!)
Service providers bragging that they do Housing First, but conveniently ignoring some of the core concepts or parts of the necessary service orientation (for example, there is no such thing as a Sober-Living Housing First Program, nor is there such a thing as a Compliance Based Transitional Housing First Program…two examples from just the last month of travels)
Slapping the “Housing First” label on previously existing practices and just calling it something else
Reporting that anyone housed in a community was part of a “Housing First” approach, when Housing First is for a very specific type of individual/family
Lack of evaluation of whether what is being done is actually Housing First when it is called that
Service providers and CoCs convincing government reps that somehow they are unique and a true Housing First program will not work in their community, but that they will adapt the Housing First model in a way that works locally (see triage nurse example above)
Government rolling up data across communities to speak of investments in Housing First services, when there is tremendous variation of service delivery, many communities that are not actually doing Housing First, and somehow treating all as being the same
I’ll stop there. I don’t want this to turn into one of my rants.
I don’t want governments to stop promoting, endorsing or requiring Housing First. But, I want it to be done intelligently, with merit, and with expectations of being able to measure fidelity so that they can achieve the results of the investment that they were planning on achieving. Not doing so is simply a waste of our tax dollars. We can and should do and demand better.
When to Let Clients Go
In this blog I want to explore the transition of clients from being part of the active caseload in a time-limited housing support program to the point where they no longer need their housing case manager because they are connected to other community supports and their acuity has decreased. My experience – and through my travels this experience has been validated and shared by others – suggests that some of these thoughts may also be applicable to some individuals and families in Permanent Supportive Housing depending on the nature of the household, their length of time in PSH, and why they were first connected to PSH in the first place.
You’ve worked your butt off to help an individual or family get to a place where their housing is stable in your housing support program. There are still matters in their life they are working on and they go through ups and downs. There are two main reasons why case managers continue to hold on to clients in these situations that I have experienced – a concern/fear that one of the “downs” in the “ups and downs” will de-stabilize their housing in the future; or, the good feeling of having a client in a solid place is so good that we don’t want to let go.
We do not have crystal balls (well, not ones that actually allow us to see the future anyway). We have no way of knowing if someone will experience an adverse situation so intense that it will result in a return to homelessness in the future. We can merely plan and act in our supports to decrease the likelihood of this happening. So when someone says to me, “If I stop supporting them they will lose their housing!” I always ask, “How do you know that?”
I don’t ask the question to be a jerk. I ask the question to see if their assumption is based upon a true assessment of need that has clearly defined components of higher acuity that require support for a specific duration of time. Most often, though, the statement on the part of the case manager is based upon a feeling or hunch – not an holistic assessment of acuity and needs at all.
Life (sh!t) happens. We all have ups and downs. It is how we help support and prepare our clients for these eventualities that matter. It is important that time is spent with clients brainstorming the things they think may go wrong with their tenancy and how they will respond if that occurs. If we don’t do this, we run the risk of “therapeutic incarceration”.
In any time-limited support program, it is incumbent upon the service provider to inform the prospective client before they begin with the program that the supports are time-limited. Important to this, however, (funders and policy wonks please pay special attention here) time-limited supports must ALWAYS be client-centered. For example, we may wish that households in Rapid Re-Housing do not need supports beyond six months, but some will; we may wish that scattered-site time-limited Housing First do not exceed 12-18 months, but in some cases that will be necessary.
The next thing we need to make sure occurs is solid case management that brokers and advocates for connections to other community resources. The housing case manager cannot and should not be the only support in the life of the individual or family. Nay, the case manager should actively be promoting, supporting, introducing, and accompanying clients to connections with other longer-term community supports… a peer support group; an AA meeting; a social club; a mental health therapist; a parenting resource center; a play group; employment training; etc. If these sorts of activities do not occur – directly related to client needs – the likelihood of a dependent relationship increases and the likelihood of the household being prepared to move on without the housing supports in the future decreases.
I recommend looking at some indicators of housing stability as part of the assessment of moving towards exit. Of interest:
Has rent been paid for at least three consecutive months on time and in full?
Have utilities been paid for at least three consecutive months on time and in full?
Are there any outstanding damages to the unit that are likely to result in eviction?
Has their acuity decreased?
Is there any reason to believe the individual/family will need to be imminently re-housed because of a negative situation in their housing?
And we also need to be actively involved in comprehensive exit planning with clients well before the projected exit date from the program. For example, in a six month Rapid Re-Housing Program I would be introducing exit planning at about the three-month mark; with a 12 month Housing First Program I would be introducing exit planning somewhere between the 6-9 month mark. Proactive exit planning allows us to reinforce the notion that preparing for greater independence and community connections without the housing case manager is important. It also allows for earlier identification of the skill development opportunities that need to be paid attention to prior to exit.
So, starting well before the actual project exit date, recommend an Exit Planning tool that starts with a client’s perspective/responses to the following (you can email us for a copy of the tool if you want):
The steps they will take to ensure their rent is paid on time and in full
What they need to pay attention to in order to not get kicked out of their apartment
Why they think they are ready to live with greater independence and without their Housing Support worker
The areas in their life that they are still working on
Signs that their housing is becoming unstable
What they will do if their housing is becoming unstable
Signs that their housing is unstable
What they will do if their housing is unstable
What they will do if the landlord ever asks them to leave the apartment
And the client’s self-assessment of their skill level to:
Clean the apartment
Go grocery shopping
Pay rent
Speak with the landlord
Do laundry
Budget
Pay other bills
Be a responsible tenant
Set goals & take action
Problem solve with a level-head
Keep emotions in check when frustrated/angry
Follow crisis plans when necessary
Make appointments & keep them
Follow doctor instructions
Follow psychiatrist instructions
Take medicine
Refill medicine
Have fun without creating problems
Fill the days with things that make me happy
Invite guests over and know when to ask them to leave
Seek out help when needed
Keep the apartment
By introducing these matters long before the time of exit, we are better supporting and preparing clients for greater independence. We are investing in their interests and needs. We know the areas to work on together to increase the likelihood of success. We are getting set to let go. After all, the reason we provide supports isn’t about us…it’s about them. Do all you can to make the people you serve as successful as possible without needing you anymore – and celebrate that doing so was in part possible because of the great support and preparation that you were part of.
Sobriety is NOT a Precondition for Housing Success – Look at the Facts
Once people hit the age of majority, they are entitled to drink legally. Everyone can have their own opinions about their own consumption. These opinions may be based upon their personal values, religious beliefs, upbringing or whatever. BUT – making sobriety a precondition for assisting a person who is homeless for accessing a housing program is egregiously misguided.
Let us look at 8 facts…
More adults consume alcohol than adults that do not [this Gallup Poll shows 67% of Americans consume alcohol, for example]
Most adults that consume alcohol or other drugs never experience homelessness, even when their use may be considered to be problematic or substance abuse [if you look at Point in Time Count data from HUD, while almost 664,000 people are homeless on any given night, this occurs within a country of 312,000,000; and 23.2 million Americans are considered to have an addiction…so some very simple math – .002 of the population is homeless on any given day, while .07 have an addiction on any given day]
Even for those individuals that choose to access treatment for substance use, there is no universally accepted definition for what constitutes rehabilitation or treatment [and here is a great opinion piece from Time Magazine that discusses that very issue in the article]
It is not well understood why some approaches to addiction treatment work for some people and not for others [the same Time article reference for Fact #3 is relevant here too if you want a layperson’s discussion of the issue]
While many substance treatment programs tout a 30-35% “success rate”, this is a misleading statistic as it accounts only for those that have completed the program [Joseph A. Califano Jr., who founded the National Center on Addiction and Substance Abuse at Columbia claims the therapeutic community boasts a 30% success rate, but points out that 70-80% of participants in programs drop out in three to six months.]
Problematic substance use results in considerable costs amongst homeless individuals that use substances, especially in use of police, paramedic, and ambulance resources and goes down once housed [the Journal of the American Medical Association – no slouch of a journal – shows that costs of substance using homeless persons goes down considerably once housed, in this article; and it is only one of several research pieces that have demonstrated the same thing]
The “enabling hypothesis” (providing housing for individuals that use substances results in increased use) has been debunked [see this article from the Journal of Public Health]
Motivation to change behaviour, including a reduction or cessation of substance use, increases when people have stable housing [see this article from the journal Addictive Behaviors]
Substance use is also no reason to prevent a homeless person from accessing shelter. There can be reasons to prevent people from accessing shelter because of behaviour (depending on the particular shelter), but not solely because a substance was used. Imagine if you were never allowed access to your bed just because you had a drink (the case in many shelters where abstinence is required) or smoked a joint. Why do we expect something different from homeless persons?
But now back to housing programs…
If people’s reduction is likely to decrease or stop once they have housing gets better results than expectations of treatment in order to access housing programs…
AND
If costs to the taxpayer related to police, paramedics and hospital use related to substance use of homeless persons go down considerably once people are housed…
AND
If most people with an addiction to substances are not homeless and will never experience homelessness….
AND
If being housed does not enable people to drink more…
AND
If motivation to change increases once people have secure housing
THEN
Can we please stop using sobriety as a precondition to access housing and support programs? Logically doing so makes no sense, costs a whack more, decreases the likelihood of addressing the substance use and punishes people for having an addiction.
Lessons from my Mother About Ending Homelessness
My mom is not a social worker. She has never worked in a homelessness setting of any sort. About the closest she has come, as I recall, was helping out a community kitchen. But that doesn’t mean she didn’t teach me lots about ending homelessness. Here are 10 pearls of wisdom given to me in my upbringing that I apply to my work trying to end homelessness.
Do your best work. Always.
There’s no “mailing it in” when it comes to ending homelessness. Each and every day the best work possible is important. Over time I have come to realize that doing the best work means taking the time to learn and practice… that being well-intentioned is not the same as being highly effective.
A mess can and should be cleaned up.
While my mom would let my room slide (thanks, mom) there was no tolerance for a mess anywhere else in the house. I have applied this life lesson to the messes that I see in organizations and communities. Messy governance and sloppy funding, as well as ugly service delivery are all things that can and should be fixed.
Focus on the important stuff.
This is a tough one to live and follow when the minutiae can try to rule our lives if we let it. In my pursuit of ending homelessness with communities and organizations, I have come to learn it is futile to try and address every last inconsistency with the vision right from the get go. These things take time. And so, focusing on the important stuff has been the way to go – providing training; aligning funding; gathering political will; motivating people and organizations to change. Thinking everyone will get on board and be supportive and engaged from the start is a fantasy.
You have talents. Use them.
In this work, I twist this one a little bit to “everyone has talents”. Each and every person that is served by a housing and homeless program has strengths. Sometimes the toughest job a support worker/case manager has is helping that person find their strengths again – and use them.
The human spirit is an amazing thing.
People can and do recover. They can recover from the experience of homelessness. They can recover from being dislodged from friends and/or family. They can recover wellness. They can recover from idleness. They can recover from economic poverty. They can recover to have a positive perspective on the future.
Being organized matters.
While this remains a work in progress in my personal life, I have come to appreciate the amazing value of a community and each organization having a plan or framework for what it is they are trying to achieve. That way they don’t get side-tracked by crises or distracted by going through the motions of day to day service.
Don’t burn the candle at both ends.
Don’t tell my mom, but I still suck at this. Her point? Being really busy with too many activities and not taking time for yourself will burn you out. Practically, professionally, what I have applied from this lesson is the critical need to prioritize…activities, new projects, funding, who should be served, etc. Otherwise, everything is a chaotic hot mess all the time.
Trust your intuition.
I believe homelessness can be ended because I trust my intuition. It is the right thing to do. My intuition tells me that housing is the only cure to homelessness. So, all I do is try and help people and communities focus on helping people experiencing homelessness to access and maintain housing.
Treat others the way you want to be treated.
There is no doubt that if I were homeless I would be appreciative of people helping me meet my basic needs – shelter, food and clothing. But if it stopped at that, I’d likely be ticked off, especially if I didn’t know how to find housing or access income benefits or had other complex issues going on in my life. I would want people not to judge me. I would not want sympathy. And I would want people to help me with supports to help ensure I never became homeless again.
Never give up.
My mother in a kind and loving manner did not support quitting. Meet adversity? Take it on. Come up against a barrier? Find a solution. Have a difficult connection with another person? Try a different way of communicating. And so on. Ending homelessness is hard work. It is the hardest (and most rewarding) work that most of us will ever do. Some days I have to remind myself – some days I need to remind others – never give up!
When Clients Die
When working with vulnerable populations, one of the unfortunate realities is that some clients will die. Death is part of life. Even when exercising professional boundaries, there is a bond formed with clients. With death, we need closure – even when a client is palliative and our work with clients was catered to the best possible end of life support. There are also pragmatic steps that must be considered in the event of a death that are best thought about and explained prior to a case manager or other staff member dealing with a client’s death.
Not all deaths have the same response from workers and organizations and we need to acknowledge that. The violent death of a middle age client may stir up different emotions than an older client that has been receiving care for several chronic illnesses. A sudden death through something like a heart attack may have a different reaction than a drug overdose. The death of a child in a family that a case manager is working with may cause different feelings than a suicide. And so on. I am not suggesting that any particular cause of death is better or worse than another. It is just different. Even though a staff member may be professionally objective, personal values and perceptions may still influence how we process any particular death.
Some communities have homeless memorials. There are different approaches to how the matter of death is considered in these memorials. In some communities it is just people that died on the street or in shelter. In others, the memorials only account for people that died when it is seen as a direct result of his/her homelessness. Some communities may consider anyone for the memorial that was homeless at any point in their life, while others only include people that were homeless at the point of their death. Regardless, communities should be acknowledged for taking the time and making the effort to remember those who are no longer with us that were part of the group of homeless people in that community.
Because the people we serve will have a (hopefully small) percentage that will pass away, I’d like to offer some suggestions on:
the emotional impact;
what practitioners need to consider when working with a vulnerable and often medically frail population;
how it can make our practices better; and,
data considerations.
On the emotional impact, we need to consider how the death of any particular client impacts the case worker and support organization, as well as the friends and family of the deceased. Just like each type of death may bring about a different response, so too must we consider that each case manager may have a different perspective on death or dealing with death. Memorials may help bring closure for some, while others may want time to reflect on their practice and not attend a memorial. Some case managers may want to debrief with a professional counselor, while others do not need or see the necessity of doing so. Team Leaders/Supervisors that express empathy are important to providing the right level of support to each case manager based upon the unique circumstances of any particular client death rather than taking a “one size fits all” approach.
And the same goes for the friends and family of the deceased. This brings with it some potential privacy concerns that have to be delicately navigated. Assuming a place of sharing and disclosure, there are instances where friends or family will look to the case manager for comfort or closure to the death, when this is outside the area of expertise or expectation of the worker. Some may look for answers or opportunities for blaming amidst his/her grief. Others may look to the organization or the case manager to arrange all burial or memorial activities, when this may be outside the purview of the case manager or the organization.
When considering emotional impacts, it is very important to draw upon the best possible resources within the community rather than expecting in all instances all of the necessary experience and expertise lies with the case manager or organization. Death in our culture has various interpretations based upon values, principles, spirituality, customs, rights, and religion. Those with training on navigating this milieu of interpretations are more likely to help people deal with loss and grief, hopefully in keeping with the practices and beliefs of the person that passed away. I applaud faith-based service providers that take time to consider that the person that passed away and was receiving services from them may have had a different faith or spiritual beliefs than their own, and go to great lengths to work with other faith groups in the community (even ones that aren’t service providers) to be truly person-centered even in burial and memorial.
There are also some pragmatic issues that must be considered when it comes to death of clients. When support work is occurring with vulnerable populations, I think it is important for support workers to consider that this type of case management work may very well be an investigation waiting to happen when there is a death, whether that is through a coroner or other legal means. If housing case management work is professional work (and I believe it is) then it is essential that each case manager is appropriately documenting each interaction with each client, the case plan, and activities. Information must be up to date (I recommend daily), following professional standards for accuracy and privacy. Should a subpoena ever compel a case manager to turn over their documentation or copies thereof, completeness and accuracy of the notes and demonstrated effectiveness in professional delivery ensure that the support services were beyond reproach. When a death is being investigated is not the time to be coming up with excuses of why there was a lag in entry of case notes or trying to fill in the holes of the narrative of supports up to the point of death.
Ensuring there is an appropriate, clear organizational policy for when a case manager or other staff member encounters a client that has died is also important. Back to the emotional impacts, this can be a remarkably unsettling experience that I am not sure anyone ever gets desensitized to. It has also been my experience that staff tend to never forget the first time they encountered a deceased client, regardless of the circumstances of the death. Nonetheless, regardless of whether the death seems to be of natural or suspicious causes – or any cause for that matter – organizations must train their staff and outline expectations of staff on exactly what it is they should do in what order if someone is found dead. Complicating matters or raising suspicion even in the most unintended way is problematic. Many organizations have taken the step of having a Board approved policy that was informed by a legal or police professional on how exactly these circumstances should be dealt with.
In some communities it is also appropriate for the head of the Continuum of Care of Service Manager to also be informed of a client death. There are legal issues related to privacy in this matter that may also need to be navigated. However, in more than one instance I have seen a client death become a news item for media. When the CoC, Service Manager and/or other appropriate community leaders are not informed, being blind-sided by the news can cast them in an inappropriate, and even uncaring, light.
How can client deaths make service and support practices better, as well as potentially make improvements to the support delivery system? Through appropriately debriefing each death and examining aggregate data from service delivery, each death – regardless of circumstance – can inform future improvements to services for other clients. It may not prevent all future deaths, but it makes sure that there is sensitive value considered to each death. For example, a death from a violent cause may help inform future approaches to risk assessment and safety planning. A death from chronic disease may help improve street outreach efforts to locate the most medically vulnerable, through the likes of the Vulnerability Index. A death from lack of treatment or detection of a chronic ailment may point to the need to better connect with health care resources in the community. A death from improperly treated illness or premature discharge may help inform how the health care community and health and homelessness service community better work together in an integrated fashion while someone is an inpatient, as well as in discharge planning. A death from a suicide may be reason to re-examine crisis planning and the connection between clients and community crisis supports.
And then there is the matter of data. Unfortunately, many data systems and annual reports fail to appropriately account for those clients that passed away. For example, how does a client’s passing impact the overall percentage of people that remain housed? Are they considered permanently housed (unable to lose housing) if they were housed when they die? Is there a separate section in reporting that should account for all of those individuals that passed and the percentage of all people housed in a program that passed away? Under what circumstances may it be appropriate to aggregate the total number of deaths by the types of deaths (e.g., natural causes, etc.) Communities need to take the time to grapple with this data issue. Otherwise, deaths of clients may be inappropriate reflected in reports of how a particular program is performing and/or the disposition of clients after being housed.
Death will happen amongst the clients we serve and support in housing. If this has not yet happened to someone who is a case manager, it likely will in the future. Taking the time to thoughtfully consider how we debrief from the experience, learn from the experience, and provide information on these instances is important for all organizations and workers.