Targeted Case Management Helps Patients Experiencing Homelessness
By Melinda Young
The lack of affordable housing is a crisis affecting Americans in all age groups, in every city, in every state. Nearly half of Americans say finding affordable housing in their community is a major problem, according to Pew Research.1
In 2023, Los Angeles and New York City declared record levels of homelessness. Advocacy groups and researchers attribute the problem to the decline in affordable housing.2
A case management model in Philadelphia helps a local homeless population by connecting people with the healthcare they need as well as finding them stable housing.
“Everyone has an individual story on how they end up without a home,” says Ethan Jury, MSW, team lead for FaSST/Connections Resources for Human Development in Philadelphia. “They go through individual and family crises. We have a huge addiction problem in Philadelphia that contributes to homelessness, and we have a lack of affordable housing here.” Philadelphia is known nationally for its entrenched poverty, Jury notes.
FaSST/Connections case managers work with Medicaid patients, which helps cover services for this population. City funding also contributes, along with gap funding from the county government that helps with people who lack insurance coverage, says Ann Ryan, program director of FaSST/Connections.
“We work mostly with Medicaid on a fee-for-service model,” Ryan says. Case managers help everyone who is a client, regardless of the funding, she adds.
One of the reasons Medicaid is involved with the homeless population is because many of the people who lack homes also are diagnosed with medical and mental health issues, Jury says. “Our population are people who fall through the cracks,” he explains. “They live with bipolar disorder, schizophrenia, major depression, and other psychiatric disorders.”
People with a mental health diagnosis are overrepresented among the homeless. The organization’s case managers provide services that help link people with these diagnoses to mental healthcare.
“As case managers, we work within the shelter system primarily,” says Traynesha Allen, BSW, an intensive case manager at FaSST/Connections. “Most of our staff are connected with the shelter system. We link them to services, based on their needs. There is an array of needs from substance abuse, mental health, and legal issues, and we connect them to those resources.”
Housing Is Not Always First Step
Case managers refer patients to primary care providers, community social support, and even reconnect them to their families. “We have two levels of care: resource coordinators and intensive case managers,” Allen says. “We all work with the same population of people, but intensive case managers work with individuals who have a little higher need.”
Those could be people with a history of chronic homelessness in Philadelphia as well as a persistent mental health disorder.
While the goal is to house everyone, that is not the first step. “There are so many other factors that go into housing, and we address all of those issues, as well,” Allen says. “We have a very unique approach because our style of case management is we can do things like community-building.”
For example, case managers may identify places their clients can go for healthy activities, such as walking in parks and attending art shows. “Every weekend, we explore the different resources the city has, and we identify what programs and services are appropriate,” Allen says. “If you have diabetes, we want to find you a class to teach you how to eat well, and we want to connect you with your daughter and grandchildren.”
The program’s goal is from shelter to self-sufficiency through targeted case management. “We work from a person’s strength and build from there with a harm reduction model,” Ryan notes. “We work with them in the community.”
When case managers succeed in finding housing for clients, they also teach clients how to be good neighbors. This can help prevent problems such as neighbors with a “not in my backyard” attitude, Ryan notes. “We go to their house and integrate them in the community,” she adds. “We show them how to join faith-based organizations to maintain stability and to have a support network outside the family.”
Mental Health Is a Focus
Working with a holistic perspective that includes a focus on mental health, case managers teach clients how to handle bad days and how to reconnect with services to prevent their landing back into homelessness.
“Our goal is to get them housed,” Allen says. “There are a lot of people who need the services, but there are not enough resources. We see challenges in that.”
For example, Allen helped a client who was in his late 30s and had a history of homelessness, as well as diagnoses of bipolar disorder and schizophrenia. He was struggling with reintegration into the community and had an array of medical needs.
“One thing he loves to do is draw, so we connected him with different programs, including one where he was in an art auction,” Allen says. “He drew pictures, and this program exhibited his pictures where people could see them and maybe buy them.”
This resource gave him small stipends and led him to contribute to a large mural the city was funding. “He got away from the shelter life and the stresses and pressures of living in a shelter, and he made a few dollars doing something he loves to do, which is art,” Allen says. “Now, he paints for people, and we connect him with programs that get him art supplies.” When the client sees his drawings on walls, he feels a sense of accomplishment, and it brings him joy, she adds.
Finding ways to bring meaning and joy to people who have experienced homelessness is not talked about much in the United States. “It’s still a very real thing — just not publicized as much,” Ryan says. “Our goal as case managers and as an agency is to help this person be successful in all areas of their life and to combat what made them homeless to begin with. It can be one catastrophic event, but more often it’s just over time, they became homeless.”
Stigma surrounding homelessness also presents challenges. “If your neighbors are looking at you like you’re a villain, that’s not helpful,” Ryan says.
What helps is for people who have experienced homelessness to live in neighborhoods and communities where they can feel a sense of belonging. This can help if a city enacts policies that promote community integration, such as scattered housing.
“Philadelphia is really good about scattered housing,” Ryan adds. “When they do vouchers for assistance, you can go wherever you want in the city, if the landlord will accept it.”
Some buildings offer housing subsidies and units, creating a mixed residency in a neighborhood. “We help people integrate into the community as much as we can,” Jury says. “We work with them on their goals for maintaining their independence and familiarizing themselves with community resources.”
Case Managers Get Creative
Case managers can be creative. They may show people how to shop at the grocery store and visit the library. If a person wants to go back to school or attend college, case managers can help with that. Some clients want to volunteer, and case managers assist them in finding those opportunities.
“We serve as a liaison between the participant and our services,” Jury says. “If someone is able to move out of homeless to group living, we connect them with peer support to smooth the process and improve engagement in the community.”
Clients may need to know how to visit area food banks and become familiar with public transit systems.
“We have clients who get involved in various day programs and drop-in centers,” Jury says. “We help coordinate transportation to medical appointments.”
Case managers also work with clients on establishing personal goals, including socializing, creating dating profiles, or attending a tai chi class. “We go to lunch in the park and practice exercise,” Jury says. “The individual establishes the goal, and we engage them on those goals in creative ways.”
If a person wants to find a job, their case manager will help them work with a staffing agency.
Another major role for case managers is helping participants find mental health professionals and other providers. “Our people see all kinds of medical providers, therapists, and psychiatrists. We want to help connect them to those services and also monitor those services,” Jury explains.
Case managers work closely with the social work team on psychiatric units, sharing information that will help move the client out of the hospital setting and connected to ongoing support.
“One of our goals is to keep folks out of the [behavioral health] hospital as much as we can because it’s better for them to do things in the community in a less restrictive environment,” Ryan says. “We work diligently with the social worker, and that’s a goal in itself — to make sure they’re not back in the hospital.”
Acute care providers sometimes ask case managers for help. “Last week, one patient was hospitalized, and we played a role in determining which medication is best,” Jury says.
Case managers might offer input on the patient’s next level of care, and they ensure patients’ medical information is linked to various providers to prevent readmissions.
“We meet weekly and bi-weekly, especially for high-needs clients,” Jury says.
Case managers discuss all their clients with the team to keep everyone informed, especially when someone is hospitalized, Jury adds.
- Schaeffer K. A growing share of Americans say affordable housing is a major problem where they live. Pew Research Center. Jan. 18, 2022.
- Ludden J. Why can’t we stop homelessness? 4 reasons why there’s no end in sight. NPR. July 12, 2023.
The lack of affordable housing is a crisis affecting Americans in all age groups, in every city, in every state. Nearly half of Americans say finding affordable housing in their community is a major problem, according to Pew Research. A case management model in Philadelphia helps a local homeless population by connecting people with the healthcare they need as well as finding them stable housing.
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