Critical Time Intervention for Rapid Rehousing Programs CTI

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Critical Time Intervention for Rapid Re-housing Programs (CTI 4 RRH) October 22, 2018 Andrea

Critical Time Intervention for Rapid Re-housing Programs (CTI 4 RRH) October 22, 2018 Andrea White awhite@housinginnovations. us

Project Partners National Alliance to End Homelessness Connecticut Coalition to End Homelessness Housing Innovations

Project Partners National Alliance to End Homelessness Connecticut Coalition to End Homelessness Housing Innovations State of Connecticut Department of Housing The Melville Charitable Trust (funder)

Agenda Overview of Fidelity Review Core Practices RRH - CTI Tools Applying the Practice

Agenda Overview of Fidelity Review Core Practices RRH - CTI Tools Applying the Practice 3

Introductions §Introduce yourself and your agency §How long have you been working in RRH

Introductions §Introduce yourself and your agency §How long have you been working in RRH programs? §How long have you been providing CTI in RRH? §What is the one thing that you would tell a new staff member about implementing CTI in RRH? 4

CTI RRH Pilot Study Fidelity Review Summary of Results

CTI RRH Pilot Study Fidelity Review Summary of Results

Overview of Fidelity Process • Preparations began 6 months prior with Self Assessment tool

Overview of Fidelity Process • Preparations began 6 months prior with Self Assessment tool • Site Visits with worker focus groups and supervisor interviews, document review • Four agencies reviewed- Three completed • one agency did not have sufficient data for full review

Results Across Sites • Average Score on Fidelity Rating Scale = 70, or a

Results Across Sites • Average Score on Fidelity Rating Scale = 70, or a 4 (well implemented) • Strong scores apparent in: • Intake and Early Engagement • Small caseloads • Quality of worker’s role, phase plans, and progress notes • Use of a phased intervention

More Challenging Areas…. • • Community based meetings Meetings that included supports Ending at

More Challenging Areas…. • • Community based meetings Meetings that included supports Ending at 6 months Regular, well documented supervision • This may have been due to agencies using Community of Practice and consult calls as supervision

Implications for Future Implementation • • Areas have been Identified to Emphasize in Training

Implications for Future Implementation • • Areas have been Identified to Emphasize in Training Increase/Improve Supervision Training Importance of Pre-CTI More assistance transitioning existing caseloads More time before fidelity review (1 year post implementation) Ensure agencies have capacity to meet the guidelines for staffing and supervision Staff turnover- CTI training should be prioritized in onboarding for Workers and Supervisors

Core Practices: Early Engagement 10

Core Practices: Early Engagement 10

Expectations During Pre-CTI: CTI workers contact client (meetings or calls) at least twice a

Expectations During Pre-CTI: CTI workers contact client (meetings or calls) at least twice a month to build trust as early as possible. • CTI workers assess basic resource needs to establish where early linkages should be made. • CTI workers act quickly to begin securing early linkages. • CTI workers attend lease signing and establish connection with the landlord. 11

Pre-CTI Phase Duration varies Objective: Housing Location and Assistance; Begin Relationship with case manager

Pre-CTI Phase Duration varies Objective: Housing Location and Assistance; Begin Relationship with case manager (define roles going forward) CM begins assessment process, collaborates with Housing Specialist on Housing Plan and begins to develop Phase I Specific Plan; Goal setting and planning for housing stabilization based on housing and homeless history Connection to resources begins in this phase

Tasks for Pre-CTI Planning • Educate on Options and Expectations of Each • Identify

Tasks for Pre-CTI Planning • Educate on Options and Expectations of Each • Identify Housing Goals and Preferences • Assess Community Living History both homeless and housed • Assist to Connect to Benefits and Employment • Gather Documents for the Application Process • Connect to Resources that Support Housing Stabilization – Formal and Supports • Develop a Housing Stabilization Plan 13

Transition from Pre-CTI to Phase 1 • Ideally, the CM has been involved in

Transition from Pre-CTI to Phase 1 • Ideally, the CM has been involved in the Pre-CTI Phase • Importance of communication between Housing Specialists and CM throughout with warm handoff • CM should attend lease signing and/or move-in • A face to face meeting with person, CM and housing specialist to review work on Pre-CTI Phase, clarify the CM role going into Phase I • Phase 1 - at least once a week direct contact; assessment, completion of Phase Specific Plan and connection to resources • Re - assessment related to housing barriers, strengths and challenges • One to three focus areas chosen from a “menu” of domains

Using the Pre-CTI Assessment The collaboration with Shelter and Outreach was highlighted during the

Using the Pre-CTI Assessment The collaboration with Shelter and Outreach was highlighted during the pilot Understanding the role and skills of participants before entering CTI is key Assisting tenants to continue these roles allows for structure and purpose when in housing Workers began to address the issues that had led to homelessness and developed skills for stabilization Connections were developed during Pre-CTI to enable each participant to move forward. 15

Building Skills • • Educating on rights and responsibilities Modeling for each person/family to

Building Skills • • Educating on rights and responsibilities Modeling for each person/family to negotiate for services Trying it out and debrief Establishing regular check-ins to see if it is working Review cost and benefits – critical thinking Recognizing strong partners and good skills Renegotiate the relationship as necessary

Sharing Resources Team Meetings and communities of Practices are excellent ways to share resources

Sharing Resources Team Meetings and communities of Practices are excellent ways to share resources Tenants themselves often have good information and leads Sharing resources through secure jobs and housing location is firmly established Identifying short term job development strategies such as home health aides and childcare were shared. Looking at the combination of benefits and earnings, school resources for children and strategies to secure childcare were a focus. Developing ways to share these resources will be a priority going forward. 17

Caseload Maximum of 20 SCE cases per worker SCE give different weight to cases

Caseload Maximum of 20 SCE cases per worker SCE give different weight to cases depending on phase Accounts for differing intensity of work during each phase Pre-CTI 1. 5 Phase 1 2 Phase 2 1 Phase 3 0. 5

Each FTE CTI worker has no more than 20 weighted cases (using the Weighted

Each FTE CTI worker has no more than 20 weighted cases (using the Weighted Caseload Tracker). Expectations What about the pressure to rent up and get all the tenants at once? Questions What about teams with mixed case loads? What about families: do they require lower case loads Case Load Questions and Expectations 19

Pre-CTI Phase 1: Transition Phase 2: Try- Out Phase 3: Transfer Time frame/Intensity of

Pre-CTI Phase 1: Transition Phase 2: Try- Out Phase 3: Transfer Time frame/Intensity of Contact Flexible 2 Months/Intense Weekly 2 Months Moderate Bi-weekly 2 Months/Low Monthly Objective Housing Location/Move in; Begin CM Assessment and Housing Plan Complete Housing Plan; Identify Resources and connect client Monitor resource impact and client access Complete transfer of services to the community Action Steps Negotiate Lease Educate/Advocate Relationship Building Accompany client to appointments, follow up to ensure connection Make adjustments to plan in collaboration with client Meet with new service providers or others in the support system; reflect on work with client Potential Barriers Housing placement may be delayed due to multiple challenges Lack of resources; Client hesitant to engage Client may not be ready to assume rent; resources may be inadequate Both client and worker may have difficulty ending, especially if goals aren’t met. Strategies Take opportunities to teach/model housing location process; present services as a resource, not an obligation Do advance work of creating resource networks Empower client to do what they can on their own; create alternative plans if necessary Reduce involvement gradually and inform client early on about the length and nature of CM support

Phase 3 - Transfer Beginning the transfer to a network of care needs to

Phase 3 - Transfer Beginning the transfer to a network of care needs to begin as early as possible tien l c f g o ship n i d n l en latio a e m r For CM F com inal ph res prim pletin ase res pons ary c g th focus o ib as e e - te urces ility t e ma trans s on rm tha o t nag fer sup t w he c em of po ill p om ent rt t ro mu o t vid nit he e lo y clie ng nt

Phase 3 Tasks • Meeting together with key people in the support network •

Phase 3 Tasks • Meeting together with key people in the support network • Reviewing the work, reflecting on what was accomplished, what is ahead • Review plan for client if challenges to housing stability arise in the future • Avoid temptation to end services too early if client appears to be doing well!

Ending at 6 Months There are two main possibilities People are not financially prepared

Ending at 6 Months There are two main possibilities People are not financially prepared People are not ready to leave case management and are financially unprepared Use an example of each by phase and discuss possible interventions based on your experience. What could have begun earlier? What are the other options for this tenant? 23

Community Resource Development • • Develop a person focused resource list Identify resources by

Community Resource Development • • Develop a person focused resource list Identify resources by focus areas and tasks Review resources in current use Add resources developed through work with other people Identify needed connections Income, benefits AND services HANDOUT: Resource Directory 24

Using Resources • Housing: landlord/housing provider, emergency assistance, ongoing support for tenancy • Financial:

Using Resources • Housing: landlord/housing provider, emergency assistance, ongoing support for tenancy • Financial: benefits and employment • Health: treatment and support • Mental Health/Substance use: treatment and support • Family and relationships: support structure • Life skills: services for assistance/support • Education: opportunities and needs 25

Linking to Resources Be knowledgeable • • Introduce yourself and your service • Identify

Linking to Resources Be knowledgeable • • Introduce yourself and your service • Identify how you can help them meet their goals • Explain your role and what they can expect • Gather and share history (with consent) Accompany each tenant to assist with engagement Know full range Visit programs Ask users for feedback Know goals of the service and what they provide • Maintain regular contact to see how things are going • Keep your promises 26

Expectations and Resources CTI workers gather client information to enable a best fit between

Expectations and Resources CTI workers gather client information to enable a best fit between client and community resources (e. g. , client’s interests, skills, strengths, vulnerabilities, aspirations; and client’s history, such as education, jobs, housing, treatment). • CTI workers explore neighborhood with client in order to foster new community-based relationships and skills. • During Phase 1: CTI workers have at least one weekly contact (meeting or call) with the client. • Building on work done during Pre-CTI, CTI workers continue to connect client to community supports where needed and to strengthen relationships with existing supports. • During Phase Two: CTI workers contact client once every two weeks (meeting or call). • CTI workers mediate between a client and his/her support network, including informal supports such as family, friends and spiritual communities. • CTI workers assess the strength of linkages by observing and recording client’s interaction with providers and other supports. • During Phase 3: CTI workers contact client once a month (meeting or call). • CTI workers ensure direct communication between different members of a client’s support network (e. g. , a family member and a provider, as well as between client and his/her providers and informal supports) In Phase 3, before a case is closed: • CTI workers have a transfer-of-care meeting or call with those providers and informal supports with whom it is necessary to meet. (e. g. , maybe not with daycare provider) • CTI workers have a final meeting with each client. (They discuss client’s experience with CTI and relationship with CTI worker; client’s expectations for the future; long-term support network’s contact information. ) 27

Discussion One of the biggest obstacles is that resources don’t call back Using the

Discussion One of the biggest obstacles is that resources don’t call back Using the CTI sheet explain to two resources the benefits of the program and ask them for help Why wouldn’t people tell you about resources? 28

Support for the Practice Joint Resource Development and Educations of Resources Allowing Time to

Support for the Practice Joint Resource Development and Educations of Resources Allowing Time to Accompany Tenants Into the Community Peer support and supervision: one program had case manager meeting, going over phase tracking and sharing strategies and supports Using the Fidelity Self Assessment as a Team: prioritizing areas of practice Using the handoff techniques in phase three to transfer between workers or develop a shared case load model 29

Supervisors

Supervisors

Reflections on Morning Training 31

Reflections on Morning Training 31

Critical Elements to Supervision Administrative: Educational: Supportive • To ensure organizational, program, and tenant

Critical Elements to Supervision Administrative: Educational: Supportive • To ensure organizational, program, and tenant goals are achieved through administrative oversight of tasks • To provide education and information to staff that builds their skills and knowledge to perform their jobs more effectively and to develop professional • To support staff as they encounter obstacles and experience setbacks in their work, and assist them in setting goals for future performance and professional development • Kadushin Model 32

Supervisor and Team Leader Roles Coordinating staff activities Mentoring Provide staff orientation and training

Supervisor and Team Leader Roles Coordinating staff activities Mentoring Provide staff orientation and training Chair team/staff meetings Review documentation – sign off on notes and service plans Manage staff assignments and case loads Advocate for resources with agency administration 33

Supervisor and Team Leader Roles - 2 Develop relationships with community resources Provide or

Supervisor and Team Leader Roles - 2 Develop relationships with community resources Provide or arrange for clinical consultation Program policies and procedures Program monitoring and evaluation Chart audits to ensure documentation is timely and complete Assist with time management and moving from crisis Staff evaluations Others? 34

Expectations Weekly team supervision meetings • Supervision takes place as a team, consisting of

Expectations Weekly team supervision meetings • Supervision takes place as a team, consisting of the supervisor and more than one CTI worker. For agencies with only one CTI worker, supervision is between the supervisor and CTI worker. • Team supervision meetings are led by the supervisor, who is a clinician and has been trained in CTI • Team supervision meetings take place weekly. The team uses supervision to reinforce practices that are consistent with the CTI model and to correct practices that are not. • CTI workers give a case presentation at the supervision meeting for each new client. • Team continuously updates community resource list and shares latest information during supervision meetings. SUPERVISOR ROLE • Some (~6 -8) high priority clients are selected prior to each supervision meeting for in-depth discussion by the team. • Supervisor monitors CTI workers’ documentation regularly to ensure high quality and timeliness. • Supervisor identifies community resource deficits to inform advocacy efforts at the system lev 35

Discussion of Challenges to Supervision • No time for worker or supervisor • Reluctance

Discussion of Challenges to Supervision • No time for worker or supervisor • Reluctance to participate • Control of caseloads and intake • Expectations from Funders and/or Agency • Others? 36

Motivating Change Keep focus moving forward Common Understanding Recognize success Several possible directions What

Motivating Change Keep focus moving forward Common Understanding Recognize success Several possible directions What are the costs/benefits? 37

Caseloads Assigning caseloads can be a complicated process Matching people to staff with specific

Caseloads Assigning caseloads can be a complicated process Matching people to staff with specific expertise First 2 months tends to be the most intensive o. Balancing caseloads between new arrivals and longer term participants Some tenants will have chronic, serious conditions that will present complicated challenges o. Balancing caseloads between the more complicated conditions and tenants with lower needs or who are connected to treatment and support Balanced case loads can provide staff with opportunities to see more immediate success as well as grapple with more complicated needs 38

Complicated Clinical Pictures Tenants may present with complicated clinical pictures Making consultation and training

Complicated Clinical Pictures Tenants may present with complicated clinical pictures Making consultation and training available to the workers cuts down on frustration and allows everyone to move forward Using resources from psychiatry, medical and substance use, trauma specialties to provide input will assist with the intervention and also make these specialties aware of the work of the program. This build networks of care and allows worker to define the role of case management support • Provide input into assessments and plans • Can see tenants individually when another assessment is needed or may be their regular treatment provider • Assist with coordination of care 39

Effective CTI Teams Strong Team Leader with good clinical skills Interdisciplinary practitioners, including Peer

Effective CTI Teams Strong Team Leader with good clinical skills Interdisciplinary practitioners, including Peer Support and Housing Specialists Experience with hands-on, community-based services Committed to the model ◦ Monitor fidelity to prevent practice drift Use outcome data to evaluate services and identify adjustments to improve service quality 40

Advocating for Resources Resource development happens at all levels Funders have made resources available

Advocating for Resources Resource development happens at all levels Funders have made resources available for housing location, job development and child care advocacy. In some case agency resources and education has been effective such as the programs co-located with shelters or agencies with housing and clinical resources Systems advocacy for child care, housing subsidies, and with community based resources ( from legal to treatment) are needed. ◦ Identify patterns of need and advocate/educate community resources 41

Effective Supervision Ensures case manager practice is consistent with phase-specific activities and foci of

Effective Supervision Ensures case manager practice is consistent with phase-specific activities and foci of the CTI model Encourages open communication and demonstrates a willingness to support, as well as instruct, supervisees Carefully monitors workers to ensure that phase transition dates are observed Monitors and manages caseload to ensure there is reasonable time to provide services as intended Ensures that model-specific case planning and recording documents are being completed correctly and are up to date for all workers

Expectations Weekly team supervision meetings • Supervision takes place as a team, consisting of

Expectations Weekly team supervision meetings • Supervision takes place as a team, consisting of the supervisor and more than one CTI worker. For agencies with only one CTI worker, supervision is between the supervisor and CTI worker. • Team supervision meetings are led by the supervisor, who is a clinician and has been trained in CTI • Team supervision meetings take place weekly. The team uses supervision to reinforce practices that are consistent with the CTI model and to correct practices that are not. • CTI workers give a case presentation at the supervision meeting for each new client. • Team continuously updates community resource list and shares latest information during supervision meetings. SUPERVISOR ROLE • Some (~6 -8) high priority clients are selected prior to each supervision meeting for in-depth discussion by the team. • Supervisor monitors CTI workers’ documentation regularly to ensure high quality and timeliness. • Supervisor identifies community resource deficits to inform advocacy efforts at the system lev 43

Documentation and follow up Explain why it is important to discuss this client at

Documentation and follow up Explain why it is important to discuss this client at today’s meeting. Client’s name Worker’s initials Record the reason code in the box. 1=ready to give new case presentation 2=client faced with a crisis or big change 3=cannot be located 4=discuss whether refusal is permanent 5=time to prepare for a new phase 6=time to prepare for end of intervention 7= difficult problem with support network 8= positive occurrence to share with team Place √ mark in box when team discusses client 44