Transformative Change in Community Mental Health Interest Group

Edited by Geoffrey Nelson, Wilfred Laurier University
(gnelson@wlu.ca)

Pathways to Independence: A Transformative Case Management Model for Individuals Experiencing Chronic Homelessness

Written by Molly Brown (mbrown59@depaul.edu) and Martina Mihelicova, DePaul University

Individuals experiencing chronic homelessness face numerous barriers to recovery and housing including lack of affordable housing, no or insufficient income, low educational attainment, job market instability, difficulty navigating complex service systems, and chronic and untreated medical, mental health, and substance use issues (Caton, Wilkins, & Anderson, 2007). In recent years, a promising shift toward evidence-based, transformative housing interventions, such as Housing First, has occurred in the U.S. and internationally to address systems-level causes of homelessness and promote recovery on the individual level (Goering & Tsemberis, 2014). Yet, due to demand, Housing First and other subsidized permanent supportive housing interventions are not readily available to everyone in need, and individuals often remain homeless with access to case management while on housing waiting lists. The quality of traditional case management services may be limited when caseloads are high (Rapp, 1998). Further, generalist case managers may not have the capacity to support individuals in identifying and achieving alternative channels out of homelessness. In order to address the limitations of traditional case management, the Substance Abuse Mental Health Services Administration (SAMHSA)-funded Pathways to Independence (PTI) program was designed as a specialized, team-based service model emphasizing economic independence, thereby expand housing choices and promoting person-centered goal attainment.

The three-year PTI program was initiated in 2011, based at a large homeless service agency in New Haven, Connecticut, and served 275 individuals who met the federal criteria for chronic homelessness, defined as an individual with a disabling condition who has experienced homelessness on the street or in shelters for one year, or who has cycled in and out of homelessness at least four times in the previous three year period. PTI addressed fragmentation of services through co-location of staff specialists in three primary areas: employment; SAMHSA’s SSI/SSDI Outreach, Access, and Recovery (SOAR) initiative to facilitate disability benefit awards; and housing. One way that PTI promoted shared power was through employing a peer educator to emphasize knowledge and capacity of individuals with lived experience. The program also focused on wellness by staffing liaisons from community mental health and community health centers on the PTI team who engaged interested program participants on-site. Upon enrollment to PTI, program participants engaged in an assessment of their personal goals, and the intake coordinator facilitated referrals to the appropriate PTI specialists.

Following a transformative change in community mental health framework (Nelson, Kloos, & Ornelas, 2014), PTI emphasized income and housing attainment over behavioral management and prescribed treatment. The message that participants had the right to employment, disability benefits, and housing was front and center. Moreover, integrated, mainstream housing and employment opportunities were prioritized, reflective of the strengths-based view of participants as individuals capable of recovery. A PTI participant conveyed the following during a focus group, “I didn’t feel confident I was going to be able to do what they wanted for rent – I’m not going to be able to afford it. [The PTI employment specialist] called me and gave me a pep talk. It was a vote of confidence, and without it I would have stayed negative. I took advice. They motivated me to be independent.” PTI staff members encouraged individuals to be active participants in the community in ways that were meaningful to them.

Notably, the composition of the team as specialists further promoted the model’s transformative nature. In contrast to a generalist case management model, the employment, SOAR, and housing specialists were solely responsible for facilitating participant goals in their particular area, allowing the specialists to gain a depth of knowledge and resources. PTI staff described satisfaction with the leeway afforded to them in defining their roles and the ability to think creatively to solve problems (Ponce, Brown, & Rowe, 2016).

The PTI staff specialists were able to overcome community-level factors impeding participant capabilities by bringing community stakeholders to the table. For example, the employment specialist not only provided individual-level employment education and coaching to assist individuals in obtaining and remaining in competitive employment, he also identified and cultivated employment opportunities for participants by building relationships with prospective employers. Gaining buy-in from employers not only increased employment opportunities for PTI participants, it also provided a benefit to employers. One employer shared the following sentiment in a focus group, “If I put a help wanted sign on the building, it takes a long time to hire. But if I call [the PTI employment specialist], he’ll have 10 people that day.” (Ponce et al., 2016). Transactions such as this promoted transformation at the community level by challenging employers’ beliefs about the employability of individuals with lived experience of homelessness.

The PTI program did not have dedicated permanent supportive housing vouchers for program participants, although the housing specialist assisted participants in signing up on housing waiting lists. On average, participants’ monthly income was less than the cost of fair market rent for a one-bedroom apartment. As such, another community-level barrier to overcome using creative solutions was increasing access to affordable housing among those who had an income through employment and/or federal disability benefits. The PTI housing specialist developed a network of landlords with whom he negotiated rent prices and utility costs to reduce the cost burden on tenants. Participants were educated about tenant rights and were encouraged to engage in self-advocacy when landlord issues arose. For those who were unable to afford independent living but were interested in unsubsidized housing, the housing specialist worked with groups of PTI participants on roommate living situations. Nearly 30% of those housed were housed on their own income without a subsidy (Brown, Rowe, & Ponce, 2015).

PTI participants reported a high level of satisfaction with the program, particularly on indicators of recovery-oriented care. For example, average satisfaction ratings on a 1 to 5 scale were greater than 4 on items such as, “Staff here believe that I can grow, change, and recover,” “I was given information about my rights,” and “Staff encouraged me to take responsibility for how I live my life.” On a measure assessing citizenship—the extent to which an individual accesses the rights, roles, and responsibilities afforded in a society (Rowe, Kloos, Chinman, Davidson, & Cross, 2001)—PTI participants reported a significant increase from program entry to 6-month follow-up (Brown et al., 2015). Although promising, the PTI outcomes were measured in an uncontrolled evaluation. Future research is needed to examine the impact of PTI-like models on outcomes important within a transformative community mental health system.

Programs rooted in a transformative change framework are particularly applicable in supporting individuals experiencing chronic homelessness due to systematic issues of fragmentation of services and barriers to housing and income. PTI reflected a transformative change framework by promoting individuals’ capacities to engage in their community, addressing systems-level barriers to basic necessities through integrated services, and defining case management roles through specialty areas. The program’s transformative change values were mirrored in participant experiences. Future iterations of programs like PTI may consider implications for staff growth and work-related self-efficacy, in light of the potential for burnout in human services work. Further, parsing out unique characteristics of transformative case management models will enhance the evidence base for implementation.

References

Brown, M., Rowe, M., & Ponce, A. N. (2015). Increasing economic and housing independence through a comprehensive SAMHSA homeless service program. Manuscript submitted for publication.

Caton, C. L. M., Wilkins, C., & Anderson, J. (2007, September). People who experience long-term homelessness: Characteristics and interventions. In Toward Understanding Homelessness: The 2007 National Symposium on Homelessness Research. Retrieved from https://aspe.hhs.gov/sites/default/files/pdf/125246/report_20.pdf

Goering, P., & Tsemberis, S. (2014). Housing First and system/community transformation. In G. Nelson, B. Kloos, & J. Ornelas (Eds.), Community psychology and community mental health: Towards transformative change (pp. 278-291). New York, NY: Oxford University Press.

Nelson, G., Kloos, B., & Ornelas, J. (2014). Transformative change in community mental health: A community psychology framework. In G. Nelson, B. Kloos, & J. Ornelas (Eds.), Community psychology and community mental health: Towards transformative change (pp. 3-20). New York, NY: Oxford University Press.

Ponce, A., Brown, M., & Rowe, M. (2016). Pathways to Independence: Integrated services for people who are chronically homeless revisited. Manuscript submitted for publication.

Rapp, C. A. (1998). The active ingredients of effective case management: A research synthesis. Community Mental Health Journal, 34, 363-380. doi:10.1023/A:1018783906741

Rowe, M., Kloos, B., Chinman, M., Davidson, L., & Cross, A. B. (2001). Homelessness, mental illness and citizenship. Social Policy & Administration, 35, 14-31. doi:10.1111/1467-9515.00217