training curriculum: ethics in case management practice
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February 11, 2010
Kristina Hals and Marie HerbTechnical Assistance Collaborative, Inc.
1
“A system of moral principles”
“That branch of philosophy dealing with values
relating to human conduct”
2
Source: dictionary.com
“The skill, competence, or standards expected
of a member of a profession.”
3
Source: dictionary.com
“When an individual or organization involved
in multiple interests, one of which could
possibly corrupt the motivation for an act in
the other.”
4
Source: dictionary.com
1. Fundamental to our work
2. Not just what we do to help but how we do it
3. Most of our residents have histories with injustices
Inequality
Discrimination
Lack of opportunity
4. Protect us against conflict of interest
5
“Agree or Disagree? Providing case management in supportive housing for people who are homeless sometimes gives rise to ethical dilemmas?”
90% Agree
6
“Agree or Disagree? Providing case management in supportive housing for people who are homeless
sometimes brings up questions as to how case managers can act professionally in every
situation?”
90% Agree
7
1. Recognize the inherent P and E challenges in our field
2. Caution ourselves about conflicts of interest in our field
3. Learn national best practices and standards in our field
4. Understand how to foster a culture of P and E in PSH
5. Share our collective expertise on the topic
6. Know where to find national guidance about our field
8
1. Identifying Ethics & Professionalism Challenges
2. Improving Case Management Professional Practice
3. Bettering Case Management Planning and Structure*
4. Using National Standards and Tools
9
* Most popular in the Pre-work Survey Monkey
Identifying Ethics/Professionalism Challenges
10
1. Sources of the Challenge
2. Examples of the Quandaries
3. Discussion
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Identifying Ethics/Professionalism Challenges
12
1. Each PSH has a signature approach
2. The field of PSH has evolved
3. Best practices and principles are unevenly applied
4. Research is not widely shared
5. National training does not reach most PSH
6. PSH work is demanding and stressful
13
1. Staff are primarily paraprofessionals – on the job training
2. Staff are typically mobile and independent
3. Supervision varies and is limited by staff mobility
4. Staff operating “from their wits”
14
1. Challenge of retaining staff when salaries are low
2. Clinical staff (nurses, psych) = first cut from budgets
15
Common Tenant Characteristics
1. Under stress – economic, emotional, health issues (100%)
2. Have poor problem solving skills –prone to conflict (100%)
3. At-risk – can feel like life and death (89%)
4. Have symptoms impacting cognition/personality (89%)
5. Undiagnosed or inconsistently treated mental illness (78%)
6. Have symptoms producing confusing behaviors (78%)
7. Have serious illness HIV/AID, prematurely aged (67%)
16
1. Demanding jobs
2. Stress - encountering life and death situations
3. Feelings of helplessness, burn out, frustration
17
1. Hard to find middle ground between hoping residents stay clean and sober and regulating it (89%)
2. The fine line between “housing” and “program” (78%)
3. The vaguery as to whether services are voluntary or required (56%)
18
1. Small towns
2. Landlords have histories with staff and tenants
3. Lack of highly professional property owners/ managers
4. Staff time expended on travel
5. Wide geographic catchment area = staff spread out
6. Smaller organization = informality to CM practice
19
Identifying Ethics/Professionalism Challenges
20
1. Confused perceptions held by tenants of role of staff (100%)
2. Residents’ misinterpretations of aspects of the program (100%)
3. Inconsistent philosophical practice from one staff to next (78%)
4. Residents not making enough personal choices (68%)
5. Overstepping by staff stemming from unclear boundaries (68%)
6. Conflicts with tenants that become “personal” (56%)
7. Misunderstandings stemming from cultural differences (56%)
8. Staff have difficulty holding back in helping relationship (45%)
21
1. Ensuring confidentiality with property management (78%)
2. Property management played against case management (78%)
3. Knowing all arrangements with community partners are proper and do not create conflict of interest (68%)
4. Following directives of the funder (45%)
5. Avoiding public relations problems stemming from staff communications (34%)
6. Making sure record keeping meets standards (23%)
22
Guide for Peer to Peer Discussion of Identifying Challenges
As a group, review slides 21 and 22 together.
Answer these questions:
1.Which difficulties listed in the slides have we experienced most?
2.What are specific real examples of the kinds of difficulties listed on
the slides?
3.Which of these problems pose the greatest risk to our work?
4.Which of these problems do we need new tools to solve?
23
Improving Case Management Professional Practice
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1. Elevating Supervision Quality
2. Promoting Best Practice/Principles in Case Management
3. Improving Staff Training
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Improving Professional Practice
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1. PSH housing is demanding work
2. Paraprofessionals carry out much of the CM work
3. Many staff have no academic/professional preparation
4. Staff negotiate their supportive/advocacy role with each new tenant
5. Staff makes judgment calls all day long.
6. Complex diagnosis are common in tenants:
Substance abuse
HIV
Mental illness
Cognitive impairments
Head injury
Co-occurring diagnosis
Trauma
Reasons:
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Norms of the Field
1. One supervisor per six staff
2. Clinical skills, degrees, certifications desired
3. Management experience desired
4. Strong supervision in helping professions background
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Categories
A. Support
B. Education
C. Accountability
Source: Corporation for Supportive Housing, Toolkit for Developing and Operating Supportive Housing, New York,
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Tips
1. Meet weekly with staff
2. Use individual and group modalities
3. Provide clinical insight and the big picture
4. Coach staff to be effective with tenants
5. Support staff in sustaining morale, managing stress
6. Offer concrete resource information
7. Keep open door policy for staff
8. Be available and highly accessible to staff
Source: Kaduchin, A., Supervision in Social Work, Columbia University Press, 2002
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Tips
Train and orient new staff thoroughly
Use case conferences as teachable moments
Conduct scheduled trainings on special topics
Offer in-service trainings by outside specialists
Teach principles and best practices of PSH
31
CM Performance Review
Effectiveness with tenants
Effectiveness with colleagues on the team
Job satisfaction and self-care
Meeting of the program goals
Source: CUCS, New York, NY www.cucus.org
32
Improving Professional Practice
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Features
1. Work with housing retention itself as primary objective
2. Think of “Housing as Healthcare”
3. Know that more complex cases do not correlate with poorer housing outcomes
Coming from street
Coming from incarceration
Co-occurring diagnosis
4. Engage the most mentally ill or most complex
34
Sources: Burt and Anderson, Program Experiences in Housing Homeless People with Serious Mental Illness
Features
1. Case Managers give tenants freedom in choice making
2. Tenants allowed to make bad choices
3. Choices considered the path to self-direction and learning, recovery
4. Derived from national Mental Health consumer movement
35
Source: Barrow, Soto, and Cordova; Final Report on the Evaluation of the Closer to Home Initiative
Reasons
1. Can be interpreted as voluntary services
2. Research demonstrates better outcomes
3. Frees CM staff of burden of service compliance
4. Residents participate at higher rates
5. Assures you are serving those most in need
6. Gets your program out of the “gray area”
7. Normalizes housing arrangements
36
Source: Barrow, Soto, and Cordova; Final Report on the Evaluation of the Closer to Home Initiative
Tips
1. Put aside personal judgments and biases
2. Respect residents’ different value systems than those of staff
3. Use “nonjudgmental” as compass to guides CM work
4. The practice of cultural competence
Sources: CSH and CUCS, Case Management Services Curriculum; Supportive Housing Series; U.S. Department of HUD
Sponsored
37
CM Skills
1. How to help set goals resident wants
2. How to partner rather that direct the resident
3. How to help define small steps leading to larger goal
4. How to see the progress in failures
Source: CSH and CUCS, Case Management Services Curriculum; Supportive Housing Series; U.S. Department of HUD
Sponsored
38
What the Theory Teaches Us
1. Contemplation – Preparation – Action - Maintenance
2. Early period = great loss and sense of vulnerability
3. Many feel constantly at risk to relapse - AA for decades
4. What helps in PSH
Altering daily routines
Finding new social groups
New activities
Sources: Encyclopedia of Homelessness
39
Elements of the Approach
1. Build trust over time
2. Know the person
3. Assist in cognitive restructuring
4. Teach visualization
5. Provide support
6. Establish an agreement
Sources: CSH and CUCS, Case Management Services Curriculum; Supportive Housing Series; U.S. Department of HUD
Sponsored
40
The Basics
1. Know the need for boundaries in helping professions
2. Develop Transference Awareness
3. Set guidelines for boundaries between staff – residents
4. Discuss impropriety of overstepping relationship
5. Maintain focus on resident
6. Limit CM staff from sharing personal information
LUNCH BREAK
41
Improving Professional Practice
42
Tips
1. Have new CM staff shadow experienced staff
2. Offer weekly case conferences – peer to peer learning
3. Have CM learn some skills and practices on the job
43
1. Case management overview
2. Basic counseling skills
3. Cognitive behavioral strategies
4. Cultural competence
5. Motivational interviewing
6. Reducing job-related stress
7. Stages of Change model of recovery
8. Trauma and its aftermath
9. Conflict resolution
10. From incarceration to community
11. Helping tenants develop skills for independent living
12. Understanding chronically homeless people
13. Creating a culture of moving on
14. The 1st year in supportive housing
Recommended Topics
Source: Center for Urban Community Services, PSH training series topics; www.cucs.org
44
Recommended Topics
1. Overview of psychiatric disorders
2. Psychosis
3. Understanding Borderline Personality Disorder
4. Psych Crisis and Suicide Prevention
5. Mental Health Treatments
6. Dual diagnosis
7. Recovery Process
8. Recovery
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To Know
1. Expectations for behavior (bad stuff stemming from SA)
2. Focusing on behavior (noise, visitors that violate lease etc.)
3. Relapse (time of opportunity – engage, identify trigger)
4. Rule Violations (help understand mistake, plan future)
5. Address Drug Dealing (monitor – brings on other crimes)
6. Stages of Change Principles (Protroshaka, DiClemente, Norcrosse)
46
Sources: CSH, Substance Use Services and Supportive Housing
Guide for Peer to Peer Discussion of Professional Practice
As a group, review the topics of Segment Two (slides 26-46):1.Elevating Supervision Quality2.Promoting Best Practice Case Management3.Improving Staff Training
Answer these questions:
•In which of the segment topics does my organization excel?
•In which of these areas do we most need growth or improvement?
•What are the needed first steps to foster needed growth in these
areas?
47
Bettering Organizational Planning and Structure
48
1. Dividing CM from Property Management
2. Establishing Staff Roles and Structure
3. Establishing Resident Involvement and Community
49
Bettering Organizational Planning and Structure
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Reasons
1. Two different roles performed by different people
2. Residents should see the roles as separate and distinct
51
Tips
1. Define role distinctions in Job Descriptions
2. Practice confidentiality in communications
3. Schedule cross-trainings between parties
4. Use Releases of Information between the parties
5. Use Communications Logs
6. Have method for Incident Review
52
Bettering Organizational Planning and Structure
53
Tips
1. Ratio of CM to residents = 1:10 to 1:25
2. Use General Case Managers for foundation
3. Include Specialist Case Managers as compliments
Public Benefits Specialist
Employment Specialist
54
Options
1. Supervisor/ Director
2. Case Managers
3. ACT team (assertive community treatment)
4. Peer specialist
5. Substance Abuse Counselor
6. Resident Aides
7. ADL (Act of Daily Living) Specialists
8. HIV Specialists
9. Benefits Specialists
55
Tips
1. Frequency of CM contacts – 1-2 contacts/week
2. More frequent contacts to newer residents
3. More frequent contacts for at risk residents
4. By 3rd month, plan gradual reduction in service
5. Anticipate spikes in need for services
6. Plan for residents “stepping down” from services
56
Skills Needed
1. Showing empathy
2. Being trustworthy
3. Being respectful
4. Demonstrating flexibility
5. Active listening
6. Effective communication
Source: CUCS, New York, NY; www.cucus.org
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Bettering Organizational Planning and Structure
58
Reasons
1. Counteracts power imbalances of the PSH model
2. Skill building for residents
3. Reframes residents as contributors not takers
59
Techniques
1. Resident Advisory Board
2. Resident Peer Mentors (may be paid/certified)
3. Resident as Employees
4. Speakers’ Bureau of Residents as public relations
Source: Corporation for Supportive Housing, Toolkit for Developing and Operating Supportive Housing, New York
60
Events
1. Community meetings
2. Social events –outings, holiday parties etc.
3. Staff-tenant team building activities
4. Coffee hours, entertainment, guest speakers
61
Guide for Peer to Peer Discussion of
Organizational Planning & Structure
As a group, review the topics of Segment Three (slides 49-61):1.Dividing CM from Property Management2.Establishing Staff Roles and Structure3.Establishing Resident Involvement and Community
Answer these questions:
•In which of the segment topics does my organization excel?
•In which of these areas do we most need growth or improvement?
•What are the needed first steps to foster needed growth in these
areas?
62
Using National Standards and Tools
63
1. Improving Policies and Procedures
2. Properly Protecting Confidentiality
3. Practicing Needed Record Keeping
4. Ensuring Propriety in Resident Admissions
64
Using Standards and Tools
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Tips
1. Create a Policies and Procedures Manual
2. Train new staff in Policies and Procedures
3. Update manual regularly
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1. Eligibility determination procedures
2. Tenant selection process
3. Intake and lease-up procedures
4. Supervision procedures
5. Case management procedures
6. Record keeping procedures
7. Confidentiality procedures
8. Emergency procedures
9. Grievance procedures
10. Incident procedure
11. Staff impropriety procedures
12. Property management functions and procedures
13. HUD funding compliance information
Contents
Source: AIDS Housing Corporation, The Program Director’s Workbook: Tools for Implementing Supportive Housing
67
Using Standards and Tools
68
Rules to Develop
1. To whom CM can share information about residants
2. What can and cannot be shared outside PSH program
3. Role of the Release of Information
4. Confidentiality standards in resident groups
5. Protocol for a breach of confidentiality
69
Standards
1. Never left in public space or view
2. Maintained in secured location or record system
3. Reviewed in privacy
4. Not transmitted electronically without protections
70
Contents
1. Tenant’s full name, signature, date
2. Entity to whom disclosure is authorized
3. Type of information being disclosed
4. Time period during which release is effective
5. Statement of voluntary nature of release
6. Statement that release can be revoked anytime
7. Staff signature and date
Source: AIDS Housing Corporation, The Program Director’s Workbook: Tools for Implementing Supportive Housing
71
Using Standards and Tools
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Standards
1. Fulfills all funders’ requirements
2. Use social work voice – nonbiased reporting style
3. Includes verifications of eligibility and case progress record
4. Clinical mental health records maintained separately by licensed provider
5. Objective language - accounts of fact and behavior
6. Use of a universal language common to all entries
Source: AIDS Housing Corporation, Achieving Excellence
73
1. Income Verification
2. Homelessness Status Documentation
3. Intake Documentation
4. Individualized Service Plan
5. Emergency Contacts
6. Individualized Crisis Plan
6. Provider Contacts
7. Signed Release of Information Forms
8. Signed Grievance Procedure
9. Signed Residents’ Rights
Contents
Source: AIDS Housing Corporation, Achieving Excellence
74
Using Standards and Tools
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Definition
A person is considered homeless only when he/she resides in one of the three places described below. For new and renewal Permanent Housing projects, persons assisted must be homeless and come from:
Living in a place not meant for human habitation, such as cars, parks, sidewalks, and abandoned buildings;
An emergency shelter; or
Transitional housing for persons and who originally came from streets or shelter.
Source: HUD HRE website. Frequently Asked Questions, November, 2009.
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Caveats
If a person is in one of the three categories listed above, but most recently spent less than 90* days in a jail or institution, he/she continues to qualify as coming from one of these categories. (2009 NOFA)
In addition to coming from the above three categories, projects providing Transitional Housing, Safe Havens, or Supportive Services Only may also serve populations experiencing the following circumstances:
Eviction within a week from a private dwelling unit and no subsequent residence has been identified and the person lacks the resources and support networks needed to obtain housing; or
Discharge within a week from an institution in which the person has been a tenant for 30 or more consecutive days and no subsequent residence has been identified and he/she lacks the resources and support networks needed to obtain housing.
Note:For Permanent Housing projects renewed after 2005, the stricter screening criteria applies to units as they become vacant.
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Recommendations
1. All persons that may be eligible can apply
2. Clear, written tenant selection criteria
3. Selection distinct different step from intake
4. Tenant Selection limited to:
Fits eligibility as defined by funding source
Is able to comply with the lease agreement and obligations as tenant
Source: AIDS Housing Corporation, Achieving Excellence: Standards of Care and Best Practices in Supportive Housing,
Boston
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Recommendations
Denials limited to:
Does not fit eligibility as defined by the funder
Not suitable for upholding the lease agreement
Scrutiny to ability to uphold the lease applied consistently
If you run CORI, do so on all applicants
If you check references, do so on all applicants
Source: AIDS Housing Corporation, Achieving Excellence: Standards of Care and Best Practices in Supportive Housing,
Boston
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Recommendations for Notice
1. Explains the reason applicant is denied
2. Includes contact name and phone for an appeal
3. Contains a contact information for local Fair Housing
4. Contains HUD Fair Housing Discrimination Line
5. Conveys that Reasonable Accommodations are offered
Source: AIDS Housing Corporation, Achieving Excellence: Standards of Care and Best Practices in Supportive Housing,
Boston
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1. Develop fair practice for waiting lists
Chronological
Lottery at periodic intervals
2. Avoid sobriety as a requirement for admissions
3. Have tenant selection method reviewed by housing law attorney
3. Know that in assessing ability to uphold a lease, may request
Previous landlords
Credit companies
Employers
Probation officers
Social workers
Past residential programs (if and when there is question of ability to uphold lease)
Source: AIDS Housing Corporation, The Program Director’s Workbook: Tools for Implementing Supportive Housing
Recommendations
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Guidelines
1. Illegal to ask about nature/severity of a disability during tenant selection.
2. Illegal to make decisions about eligibility based on the nature/severity of a disability.
3. The Reasonable Accommodation law applies
4. Local and national fair housing laws apply
Source: AIDS Housing Corporation, Achieving Excellence: Standards of Care and Best Practices in Supportive Housing,
Boston
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Guide for Peer to Peer Discussion of Professional Practice
Review the topics related to Standards and Tools (slides 66-
83):1.Improving Policies and Procedures2.Properly Protecting Confidentiality3.Practicing Needed Record Keeping4.Ensuring Propriety in Tenant Admissions
Answer these questions:
•In which of the segment topics does my organization excel?
•In which of these areas do we most need growth or improvement?
•What are the needed first steps to foster needed growth in these
areas?
83
84
AIDS Housing Corporation, Achieving Excellence: Standards of Care and Best Practices in Supportive Housing, Boston, www.aidshousing.org
AIDS Housing Corporation, The Program Director’s Workbook: Tools for Implementing Supportive Housing, www.aidshousing.org
Corporation for Supportive Housing, Toolkit for Developing and Operating Supportive Housing, New York, www.csh.org/publications
Corporation for Supportive Housing, Developing the Supportive Services Program. New York, www.csh.org/publications
CUCS, Supportive Housing Workbook for Mental Health Program Leaders, New York, www.cucs.org
National Center for Family Homelessness; What about You? A Workbook for Those who Work with Others, Newton, MA, www.familyhomelessness.org
85
HUD Homeless Resource Exchange website: www.hud.hre.gov
Corporation for Supportive Housing website: www.csh.org/publications
CUCS, New York website: www.cucs.org
AIDS Housing Corporation website: www.ahc.org
National Center for Family Homelessness: www.familyhomelessness.org
Building Changes: www.buildingchanges.org
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1. Do Voluntary Case Management Services Work?
Final Report on the Education of the Closer to Home Initiative
Program Experiences in Housing Homeless People with Serious Mental Illness
California’s Supportive Housing Initiative Act Program Evaluation Report
2. How can we Case Managers help SA PSH residents who are not complying with treatment?:
Substance Use Services and Supportive Housing
Developing the Support in Supportive Housing
3. How do we separate Case Management from Property Management roles?
Coordination of Property Management and Supportive Services in Permanent Supportive Housing
87
Annual End Homelessness Conference: July every year. www.endhomelessness.org
Annual End Family Homelessness Conference: March www.endhomelessness.org
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Center for Urban and Community Services, New York, NY
Technical Assistance Collaborative, Boston, MA
National Center for Family Homelessness, Newton, MA
Corporation for Supportive Housing, New York, NY
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