Matching supports to client needs

Overview

This module is an overview of how to think about matching support services to client need within Housing First programs. It is organized into three sections: (i) Key Messages, (ii) Key Questions, and (iii) Appendices and Resources.  The Key Messages section gives a summary of how one can think about matching support services to client need for people being provided support services by a Housing First program that is operated with a high level of program fidelity.  The Key Questions section is organized into a serious of general questions about common challenges that program staff and agencies operating Housing First programs often face. Finally, the Features section contains additional information about matching support services to client need in Housing First programs that includes external links to additional resources.

Key Messages

• Providing support and treatment services is critical to the safety, health, well-being, and successful retention of housing for Housing First tenants. Providers must deliver the right kind of services (i.e. they must adequately address the expressed needs of the client) in the right way (i.e. person-centered). 
• Ongoing communication and assessment is key to understanding client needs and should be done using a framework of shared decision making between clients and providers. This way the client is better able to determine the priority of services needed as well as the sequence and intensity.   
• Housing First staff must provide services in a comprehensive and holistic manner. Services need to adapt to a wide range of factors that can influence tenant need and receptivity to services including age, race/ethnicity, gender, sexual orientation, health status, social networks, and past experiences with service engagement.
• The type of services needed by Housing First clients are often beyond the scope of traditional mental health or addiction treatment and include a host of needs that require staff to be creative and flexible and have a “whatever it takes” approach to providing services and support. Accompanying clients to doctors, grocery stores, AA meetings, or a walk around the neighborhood, supporting clients to make a difficult call to reconnect with a family member, helping with household chores, and taking a client to the emergency room at 3AM are just some of the services needs that are part and parcel of the Housing First case manager toolkit. 
• Hiring peer specialist is an excellent way to help inform team practice about the supports needed that are beyond the description of the traditional mental health and addiction specialties.   
• While many teams use an individual case management model to provide support services, programs have more success when using a team approach to services. Models of support services have been differentiated between higher-need tenants (who receive Assertive Community Treatment, or ACT or ACT-like team) and lower-need tenants (who receive Intensive Case Management, or ICM).
• In all models of support available in Housing First (ACT or ICM teams or in individual case management) there is always a need to provide services that are beyond the skill-set or resources of the team. Clients need medical care, dental, ophthalmology, other medical specialties, or they need legal assistance to resolve outstanding legal issues. They may want to join a place of worship or go to a sweat lodge, find a job, develop a new relationship, or numerous other things that are beyond the direct resources of the Housing First program. 
• It is the responsibility of the Housing First program to help the clients address all their needs either by supporting and encouraging the client or by offering support and assistance to meet these needs.
• It is useful for Housing First programs to have formal or informal collaborative relationships with other services providers in their community.
• Referrals to related agencies to meet client needs must be handled in a way that is directed by the client. The client determines the level of effort and level of participation of the staff.  This ranges from staff providing encouragement and support to staff urging the client to consider the needed services, make the call, and accompany the client to the appointment. 
• When a need emerges that is shared by most of the Housing First client population, it is useful to consider modifications of the support services staffing to meet that need. For example, if most participants have multiple chronic health conditions, the support services team should consider hiring a part time physician or nurse practitioner to provide integrated physical and behavioral healthcare. The table below shows the four-quadrant model for healthcare needs based on whether a program has clients with high or low behavioral health (BH) or physical health needs (PH).

When Services Are Not Client Directed

• This principle of matching client needs with services also applies when clients are experiencing a crisis. In most cases, the frequency and intensity of visits is determined by the client.  However, when a client has relapsed, their apartment is overrun with unwanted guests, or the client has withdrawn into an isolated and paranoid state the intensity of services provided is determined by the team.  In rare instances clients may be involuntarily hospitalized.  Again, the responsibility to accurately match the intensity of the services with client needs is the responsibility of the Housing First program. 
• This high intensity intrusive intervention by the team must be used only when necessary and all other methods to engage the client on his or her own terms have been exhausted. It is especially important to be clear and honest in all communication with the client during a crisis intervention.  Even if the client does not agree or is angry with the team or team member it is important to explain your rationale for taking this step. 
• This intrusiveness must be very carefully balanced against losing the potential the valuable lesson that can be learned. There are two questions that must be addressed during a crisis:  1) how to effectively address the crisis?   and 2) what is the best way to address the crisis so that the client can learn and benefit from the experience?  One of the most valuable lessons clients can learn is how to solve their own problems.  Housing First’s harm reduction and client directed philosophy allows for clients to make mistakes and not fear negative consequences such a punishment or discharge from the program.  The real-life consequences of relapse or the consequences of making poor choices are misery and pain enough.  The support services team must remain firmly committed to an empathic, supportive, and possibly educational role during a crisis because that is the best way for clients to learn from their mistakes and stop repeating negative patterns.  Patricia Deegan, a champion consumer advocate puts it this way, “if we don’t allow clients the dignity of failure they will never taste experience the sweet taste of success.”

*Taken from Weinstein, L.C., Henwood, B.F., Cody, J., Jordan, M., & Lelar, R. (2011). Transforming Assertive Community Treatment into an Integrated Care System: The Role of Nursing and Primary Care Partnerships. Journal of the American Psychiatric Nurses Association, 17(1), 64-71.

Key Questions

Why is it important to match support services to client need?

• Key to the success of Housing First is that it provides people experiencing homelessness what they need and want most – a place to live. Support services must similarly be matched to client need to maintain engagement and support successful tenancies.
• Ongoing assessment of client need and negotiation about what services are offered and what services are available is part of an evidence-based approach. If supports do not match client need, tenants are more likely to disengage and develop problems that may result in loss of the housing, poor health, and lower quality of life outcomes.

What if our program cannot provide the type of support services that clients need?  

• Housing First programs may provide holistic, comprehensive care, yet should also work with other health and social services that provide additional services as needed. Referrals to other support services could be for a range of needs (e.g. job development, medication assisted therapies, hospice care). Housing First programs are encouraged to develop written agreements with community partners. 
• Care coordination is critical even after referrals to other support services occur to ensure clients are receiving the support they need. The assumption is that the Housing First team will take primary responsibility unless another agency steps up to clearly and directly take this responsibility.   
• Clients should receive in-patient care as needed (e.g. medical, psychiatric, substance abuse treatment) and then return home through collaborative discharge planning with Housing First support services. Housing First should be involved during admission, discharge, and follow up.
• Ongoing program development based on client needs can consider expanding the range of supports being offered. This should be done in collaboration with a tenant advisory group.
• Peer support should be considered and encouraged.

Are there formal assessment tools that we can use to match support services with client need?

• Assessment can be both formal (e.g. intake assessment, service planning) and informal assessment (observation of environmental context during a home visit) and is ongoing. Engaging tenants in services that match their need should be a collaborative process.