Section I. Introduction
This paper describes the case management process in providing Health Care for the Homeless (HCH). Brief introduction to homelessness in the United States and the implication of case management strategy in HCH are presented. Then, each step of case management processes will be applied to HCH to address special issues related to the homeless population. Lastly the concept of community health worker (CHW) and its relevance to HCH will be discussed.
Poverty and shortage of affordable rental housing are two major reasons for homelessness in the Unites States. When limited resources have to cover housing, food, childcare, health care, and education, often it is payment for housing that must be dropped. With unexpected illness, accident, or job loss, it is easy for a poor person to end up on the streets. Eroding employment opportunities and the declining value and availability of public assistance are two factors that account for increasing poverty. Between 1970 and 1995, the gap between the number of low-income renters and the amount of affordable housing units has increased from zero to a shortage of 4.4 million housing units. A recent strong economy has caused soaring rents but the income of low-income households has never caught up with the rising rents (NCH Fact Sheet #1, 2007).
Other factors of homelessness include lack of affordable health care, domestic violence, mental illness, and addiction disorders. A poor individual with serious illness or disability might lose a job, deplete the savings to pay for care, and finally get evicted from the housing. Battered women who are poor often choose homelessness rather than abusive relationships. About 16% of the single adult homeless population suffers from either severe or persistent mental illness. Many patients were released from mental hospitals in the 1950s and 1960s to the community, but dramatic increase in homelessness did not happen until the 1980s, when mentally ill poor people could no longer afford supportive housing and/or other treatment services. For these mentally ill homeless people, case management, housing, and mental treatment are the most needed services. People who are poor and addicted have high risk of homelessness. Once on the streets, addicts without appropriate treatment lose their chances of getting housing. At least 30% of the single adult homeless population is believed to have addictive disorders. Ending homelessness requires a concerted effort to provide jobs with a living wage, adequate support for those who cannot work, affordable housing, and access to health care. (NCH Fact Sheet #1, 2007).
Many mainstream health care services are primarily medical and not organized to deal with the issues that are part of being homeless. Being treated for the "presenting problems" only, without addressing the underlying cause, the person is often discharged back to the environment that contributed to creating the situation in the first place. Given the complexity of problems that face homelessness, it is apparent that no one agency can satisfy all the needs of a homeless person. A fragmented health care system is one of the barriers to provide HCH. Homeless persons face tremendous barriers to treatment services and recovery support, because of lack of health insurance, lack of documentation, waiting lists, scheduling difficulties, daily contact requirements, lack of transportation, ineffective treatment methods, lack of supportive services, fear or distrust of large institutions, and cultural insensitivity. Case management is an answer to overcoming these obstacles. Case management coordinates linkage between and with other organizations, advocates for key services, and provides direct support, in the HCH projects and the community at large, to ensure necessary care for clients who are homeless (McMurray-Avila, 1997).
Compared to other health care services, case management addresses the well-being and quality of life of the client as that person defines it, not as defined by diagnostic categories chosen by health care providers. Case management is more than coordinating comprehensive services. It shapes the nature of health care systems so that they become more responsive and relevant. Case managers create continuum of care, in which no barriers in moving between agencies or discontinuities over time in receiving services exist. Case management brings the health care system to a client, rather than asking a client to find it. Moreover, case management can become a source of human support for those who have none. It is not about mastery and control; it is about assistance and advocacy. Case managers are ready to help but not to treat, to care but to not cure, and to maintain rather than to improve (McMurray-Avila, 1997).
The case management process includes identifying cases, identifying problems, planning and projecting outcome, implementation, evaluation, and documentation (Utz & Kulbok, 2001).
Section II. Case Management Process
1) Case finding, screening, and needs assessment
The first step in case management involves selecting cases by identifying the health needs of clients. The screening process determines the level of care that is needed for each individual. A case is selected when a client has complex needs and is believed to receive the most benefit by the case management service. Target clients who are most likely to need case managers would be those who have frequent hospital admissions, are elderly, have a medical diagnosis that needs elevated attention, are substance abusers, have complex chronic illnesses, are not adherent to medical regimen, or who have suffered major life-changing health events. This step also includes comprehensive and focused assessment of health status and factors affecting health and self-care. Early identification of all relevant problems is important to develop a plan that encompasses care that addresses both the presenting problems and the underlying causes, and prevents future complications and problems (Utz & Kulbok, 2001).
Larson (2002) described a screening tool that can be used to measure the health of homeless persons. Short-Form 12-item survey (SF-12), which as derived from the more extended SF-36, was applied to a day shelter and proved to be valuable to assess and monitor health status among homeless persons. The SF-12 survey form contained yes/no questions that assess limitations in role functioning as a result of physical and emotional health, a three-point response scale that assesses limitations in physical activity and physical role functioning, a five-point response scale that assesses pain and overall health, and a six-point scale that assesses mental health, vitality, and social functioning. Out of 145 homeless persons who participated in the survey, 65 % reported to have high blood pressure, 27% asthma/bronchitis/emphysema, 20% arthritis, 17% heart trouble, and 9% sugar diabetes. The results demonstrated that their health needs are great, as evidenced by the high percentage that reported the presence of various symptoms and conditions, in addition to the low physical and mental health scores.
2) Interdisciplinary diagnosis
The second step involves a dialogue with a client to determine strengths and limitations of a client, to identify problems, and to discuss potential approaches to obtain the specific care. This process requires interdisciplinary efforts to incorporate the perspectives of physicians, nurses, therapists, social service experts, the payers, and others. Building a foundation of understanding about what the client agrees about the problem, what the client expects and finds acceptable, would be important component in this step to make sure the subsequent plans to be complete and useful (Utz & Kulbok, 2001).
3) Planning and outcome projection
This step is to prioritize objectives based on assessments and, in consensus with the client and the interdisciplinary team, and to devise an individualized care plan with flexible and realistic goals. Projecting outcomes in this step is one of the most important case management processes. For a homeless population, quality of life and ability to function are important outcome parameters. Outcomes can be defined at the individual clinical level (e.g., client's functional level increased in a specific time frame), at the group level (e.g., more people contacted service providers), or at the system level (e.g., decreased hospital admissions).
Johnson et. al. (1999) compared different types of case management models that were applied to persons who are homeless and mentally ill. These models have resulted in slightly different outcomes in the different levels. Exploring these models might be a good idea for planners of HCH to decide which model would be appropriate for a specific local situation. The Assertive Community Treatment (ACT) model has been used as an intervention for persons with serious mental illness. The characteristics of this model are assertive treatment in the community, direct sustained support 24 hours a day by the ACT team, assistance with symptom management, and facilitation of supportive social and family environment. At the system level, the ACT has been associated with reduced hospital inpatient days. The Continuous Treatment Team (CTT) model takes continuous, year-long responsibility for providing and soliciting the treatment, rehabilitation, and essential services for a designated number of clients. The Strengths Model features assessment procedures focused on strengths rather than deficits, the training program employed, and a high degree of responsibility given to the client in directing and influencing the intervention. These models had client-to-staff ratios varied between 10:1 to 15:1. There were no significant differences in overall outcomes among ACT, CTT, and Strengths models. All of the models provided outreach, advocacy, medical evaluation, planning, medication maintenance, as well as assistance with housing, entitlements, and budgeting. Other services included counseling, employment assistance, and psychosocial services. A large number of persons in the projects had substance abuse needs as well as mental illness. Also employment and addiction emerged as increasingly important problems to deal with.
The process of case management described does not necessarily happen linearly in HCH. Even though early assessment is crucial to define care plans
and interventions, even before being able to perform an assessment, a case manager may spend weeks or months or even years engaging the client and building trust. This is especially true with the homeless who are mentally ill or who have been on the streets for many years. To build the trust, a case manager might offer a desired service or referral even before knowing the client's full situation (McMurray-Avila, 1997).
Whether case managers should provide counseling is an important element to clarify in the case manager's job description from the beginning. Because homeless people often have issues that could best be addressed by therapy or counseling, and because case managers provide support and advice regularly, the case managers may once in a while function as counselors. This should be advised based on the qualifications of the case manager, the availability of other counseling services, and both the case manager's and client's comfort level (McMurray-Avila, 1997).
If case management does not include counseling that requires professional training, non-degreed case managers may be employed. It is sometimes helpful to hire former clients as case management assistants or client advocates who can assist their peers with some of the basic case management tasks. They can also function as informal peer counselor to encourage the homeless individual in overcoming personal difficulties. These "street-savvy" community health workers can be valuable part of HCH.
CHWs are promoted as a mechanism to increase community involvement in health promotion efforts. Swider (2002) reviewed outcome effectiveness of CHWs. Even though CHWs are believed to increase access to care, especially in underserved populations, she found only small number of studies that document outcomes in the areas of increased health knowledge, improved health status outcomes, and behavioral changes, with inconclusive results.
Dower et. al. (2006), however, paint a brighter picture in utilizing CHWs. They support CHW as a vital missing link that could provide an improved health care system and suggest detailed sustainable financing schemes. They argue that CHWs can be effective and valuable individuals working to improve the health of people and their communities. CHWs may be members of health care teams or may work within communities and autonomously from the health care system. CHWs perform tasks such as - information and referral, education, informal counseling and emotional support, advocacy, and cultural brokerage between providers and recipients. It is with these functions that CHW could be a valuable member of the interdisciplinary health care team, providing case management to homeless clients. Economically, formalization of CHWs into the health care system by sustainable financing could be a source of lifting up the communities of underserved population, as well as contributing to the health care cost saving.
4) Implementation, service provision, and resource allocation
In this step, case managers set up linkages to coordinate, facilitate, and at times provide comprehensive services in conjunction with the plan. A wide array of community resources across the continuum of care must be analyzed with regard to access, affordability, and availability. The dimensions of access include direct factors, such as the client's financial screening, and indirect factors, such as availability of transportation and schedule conflicts. Subjective beliefs and prior experiences of clients, discrimination by race, gender, socioeconomic status, age, or mental status can also indirectly affect access to care. Monitoring the care and the interim outcomes during implementation is another component of the case manager's role, in order to evaluate progress and quality of linkages (Utz & Kulbok, 2001).
Resource allocation includes how to get funds for the uninsured or clinics with outreach programs.
5) Evaluation and follow-up
In this step, case managers compare projected outcomes with actual outcomes of care, to determine if or when changes in the plan are necessary. This process is essential to enhance both quality and cost-effectiveness of the service provided. As the outcomes were projected at the planning stage at the different levels, i.e., individual, group, and system, these outcomes now can be evaluated and scored. For a homeless population, quality of life and ability to function are the most important individual outcome parameters to evaluate. Specific definition of outcomes might be necessary to score the outcome parameters, such as number of sober days or learned skill sets.
Finally, documentation is needed to communicate the plan of care as well as provide a record of events and a legal document. This is necessary to organize individual care and also for system-level reports that would be required to provide the continuum of care. Also documentation for evaluation, cost-benefit, and outreach efforts would be valuable record to keep.
Section III. Conclusion.
Case management model includes many facets of HCH. It navigates and links across and through horizontal and vertical layers of care needs, services, and in between. The difficulties of caring for the homeless is that they require long time commitment, beyond simple follow-ups, to make sure the pre-defined outcomes have been obtained. Because many homeless individuals significantly lack normal cognitive functions and living skills, it challenges the people and system that have been set up to help them. The seriousness of the situation and state of the homeless population will test the level of dedication and sustainability of the HCH program.
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Worker Practice and Utilization: The Focus on Financing. San Francisco, CA:
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Johnson, M., Samberg, L., Calsyn, R., Blasinsky, M., Landow, W., & Goldman, H. (1999). Case Management Models for Persons Who Are Homeless and Mentally Ill: The ACCESS Demonstration Project. Community Mental Health Journal, 35:4, 325-346.
Larson, C. O. (2002). Use of the SF-12 Instrument for Measuring the Health of Homeless Persons. Health Services Research, 37:3, 733-750.
McMurray-Avila, M. (1997). Organizing Health Services for Homeless People: A Practical Guide. Nashville, TN: National Health Care for the Homeless Council.
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