By Jeni Miller
As of 2020, more than half a million people were homeless in the United States.1 When a case manager cares for a patient who has no home or permanent place of residence, the plan can change quickly.
While the general outline of the case management process might stay the same when serving a homeless individual, there are additional items to consider, says Fred Dyer, PhD, CADC, executive director of administration for the Hope Recovery Center in Minneapolis.
“From my experience, anywhere from 50% to 75% of individuals present with a co-occurring psychiatric or substance use disorder, which often can lead to homelessness,” Dyer shares. “I’ve observed anywhere from 40% to 60% of people with those disorders who come into the hospital as being homeless and in need of case management.”
As case managers carry out their role, they may run into roadblocks if the patient presents with substance use or mental health issues. “Often, [the patient’s] mental illness — together with the stigma of homelessness, mental illness, and substance use — can impact the patient’s acceptance and/or refusal of services,” Dyer explains. “The stigma and shame with all of this is something that the case manager can help the patient work through to be more effective in the case management role.”
Linking with Services
One thing that makes case managers more effective than nearly anyone else on the hospital staff is their vast collection of resources and networks.
“Case management is about linkage. [Homeless] individuals lack linkage, access, collaboration, the ability to connect, and an awareness of services,” Dyer says. “In terms of someone connecting them or linking them — not just handing them a piece of paper with an agency name, but rather the willingness to walk alongside them or have a supportive adult to go with them — the case manager is that connection point.”
Dyer calls this “strength-based case management,” which takes place when the case manager “promotes the use of informal helping networks.” Homeless individuals benefit from these networks, as well as “assertive community involvement by a case manager,” he adds. “A strength-based case manager knows their patient, their needs, and knows the patient like they know the back of their hand. It’s all about the relationship between the patient and the case manager, and connecting the patient with the informal helping networks as part of that relationship.”
According to Dyer, case managers should ask these questions: “What’s already available that this family or patient might not know about? What haven’t they accessed yet? Are there other services that they or their family members have not yet considered? Besides addressing their illnesses, what does this individual need right now?”
As the answers to these questions become clearer, the case management process can take on a more typical shape. “As always, discharge planning begins the day the patient is admitted. That’s standard,” Dyer explains. “Everything starts with an assessment. As the case manager assesses in multiple areas, they should be thinking in terms of what does this patient need, and what is going on right now? They’re homeless. Can we get them linked to something?”
Case managers also can ask these questions:
- What is the patient’s financial situation?
- Can we help the patient access entitlement services?
- Does the patient need help accessing a medical card?
Since the patient may only be in the hospital for a few days or a couple of weeks, it is important to complete a thorough assessment as early as possible, “even working to bring family members into play,” Dyer adds.
Self-Care When Helping the Homeless
When working with this population, case managers might need to proactively take care of themselves to avoid burnout and compassion fatigue.
“Self-care is crucial,” Dyer explains. “Knowing when to back away or say no, having some boundaries, and remembering to take a break before you break — this is all extremely important. Even if you have to say to a discharged patient, ‘At some juncture, I’m going to leave you instructions, and in an emergency you can call 911 or go to the nearest hospital. Those boundaries are crucial.”
According to Dyer, some case managers have reported their hospital allows a patient to contact them “after hours,” even at home. To avoid at-home calls, he emphasizes case managers should “reassure patients, face to face, of the plan and where they can go for help.”
Other self-care for case managers include staying in close contact with supervisors throughout the process of caring for homeless individuals, especially those with substance use issues or mental illness. Some of the responsibility for this is on the supervisors.
“Whoever the supervisor is, the case manager needs to know that their door is always open,” Dyer recommends. “Supervisors should conduct midweek check-ins with every case manager, asking, ‘Is there anything I can do to help right now?’ Case managers need to know that it’s OK to ask for help, and they should receive the supervision and direction they need. Sometimes, case managers are reluctant to say ‘no’ for fear of losing their job, and oftentimes have persuaded themselves that they can handle more than what’s possible. They set themselves up for burnout.”
Dyer suggests case managers — who often are overloaded — ask if they can take on an assistant or carry a smaller caseload when they are working with homeless individuals who may need more care than other patients.
Another self-care consideration is managing the task of working to understand the issues surrounding homelessness and poverty, and the trauma that often is present both for the homeless individual and anyone serving as his or her caregiver. Research and reading certainly hold a place in gaining understanding, but so does talking with patients to better understand their situations.
However, Dyer shares a word of caution for case managers who diligently listen to their patients: “As they listen to how and why [the patient] became homeless, case managers can experience a sort of secondary compassion fatigue. Hearing all the stories, they may feel like they never get a chance to breathe. They need to remember to take a deep breath, exhale, process, and discuss how this impacts them; otherwise, they can develop secondary traumatic symptoms.”
Clarity of Purpose
Dyer reiterates hospital case management is not for everyone. Encountering homelessness and helping the patient out of his or her vulnerable situation carries much responsibility. Many nurses, social workers, and others entered case management to help people, but that mission can too easily become lost in the shuffle. In some situations, the overwhelming caseload or weight of the issues that plague their patients can feel like too much.
“Sometimes, the case manager may say to themselves, ‘I didn’t sign up for this … I have an MSW, I’m a therapist, I’m a nurse. I didn’t sign up to see if someone has a bus card or if they have Meals on Wheels,’” Dyer says.
He notes case managers should truly consider their mission and “be really clear in terms of their purpose in being a case manager.”
“What’s driving them?” he suggests asking. “Are they just going to a job, providing services? Or is there something that intrinsically happens to them as they see people getting better, or observing them moving on and getting their needs met or getting back to normal? Case managers should ask whether they are still intrinsically motivated or if they’ve allowed external forces to dull their star.”
A patient population like homeless adults can require more mental and emotional energy than other patients, and especially call for more introspection on the part of the case manager. For this reason, Dyer says, it is even more important for case managers to be “aligned with their mission and purpose in life, because if they’re not aligned with that, then they won’t be able to give it their all. When this happens, it’s to the detriment of the patient.”
Speaking with a mentor or trusted supervisor regularly can help keep the case manager aligned with his or her mission and purpose to better serve homeless patients and others in their care.
- Statista. Estimated number of homeless people in the United States from 2007 to 2020. March 23, 2021. https://www.statista.com/statistics/555795/estimated-number-of-homeless-people-in-the-us/