5.13 Critical Time Intervention in Action: Serving Homeless Families (Morris)


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This session offers more advanced content on the Critical Time Intervention model and how it applies to families. Speakers will discuss the practical application of the model for families with varying barriers to housing and services. Participants will walk away from this session with an in-depth understanding of how the model can improve outcomes for families in their community.

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  • Our story begins here at the Fort Washington Armory in upper Manhattan in the early 1990s. This large men’s shelter was among many that opened around this time, as New York City was struggling under the weight of the homelessness crisis. Up to 1000 men would sleep on cots on drill floor, many with SMI and substance abuse, untreated medical problems including HIV and TB. After a while, onsite MH and case management services were added to provide outreach, treatment and stabilization----and NY/NY led to placement into housing for many.
  • What we found, unfortunately, was that many became homeless again despite strong discharge plans and referrals to community services So why didn’t their tenure in housing last? One reason is that transitions are especially challenging for mentally ill individuals, especially those who have a combination of the risk factors – these who are poor, lack social support and struggle with other disabilities such as substance abuse and physical health problems Further compounding this was the loss of supportive relationships they had in the shelter and neighborhood, one more set of losses for people who have experienced many throughout their lives Moreover, the community services that existed for this population were fragmented, poorly integrated, difficult to access and not always welcoming of these individuals. These factors combined to result in discontinuity of care and support.
  • We developed CTI as a way to augment our services so that support and continuity of care would be enhanced during the critical time of transition from shelter to community housing. We thought that a time-limited intervention might have a durable impact if it helped to strengthen a network of community support. CTI emphasizes maintaining continuity of care while gradually passing primary responsibility to supports in the community.
  • CTI is a time-limited model delivered by a case manager who has existing relationship with the service recipient. It was designed to provide emotional & practical support during a period of transition for the client, for instance, during the transition from living in a shelter to placement in housing in the community. It is highly focused on a small number of service areas that place the individual at risk of becoming homeless again. Thus, it is very individualized. Gradually, the case manager begins to transfer responsibility to community caregivers over a nine-month period that is divided into three specific phases. The case manager’s primary role is to strengthen ties to services, family, friends, creating a community network that will continue to provide support to the client long after the CTI intervention is over.
  • During the Transition phase, the CTI worker has a high level of contact with clients. He escorts them to their new residence and visits them regularly to evaluate their adjustment to community living. He also accompanies clients to the first community mental health appointment to help smooth this experience. Mediate conflicts between client and prospective network of support (formal and informal) The CTI worker also works with clients to strengthen their ability to advocate for themselves. Continuing assessment of needs in community
  • By the time the Try-Out phase begins, the basics should be in place. The CTI specialist steps back a bit and observes how study the new community linkages are. He encourages the client and members of the support network to handle more on their own. If the system seems to be operating smoothly, the CTI worker can become less active. Most likely, however, problems arise which will require continued mediation, advocacy and sometimes development of new support arrangements
  • During Phase 3, the CTI specialist, the client and community linkages hold a meeting to discuss transfer of care and go over long-term goals. Ideally, this discussion should take place 1-2 months before the end of CTI to allow time to work through any snags. Key issue at this phase is dealing with the end of the CTI relationship. The client and CTI worker need to review and reflect on the work they have done together – where the client was at the beginning, where he moved during the intervention and what possibilities lie ahead. The two should discuss the client’s strengths, new skills, vulnerabilities and “safety net” that is in place should the client need it. A celebration is a nice way to mark the end of the CTI relationship.
  • 5.13 Critical Time Intervention in Action: Serving Homeless Families (Morris)

    1. 1. Background, Description and Evidence
    2. 2. Fort Washington Armory Men’s Shelter, 1990s
    3. 3. Transitions can result in discontinuity of support multiple complex needs loss of supportive relationships fragmented community services
    4. 4. CTI aims to solidify supports as it spans the period of transition CTI
    5. 5. CTI differs from traditional case management Time limited Three phases Focused
    6. 6. Implement transition plan while providing emotional support Phase One: Transition Pre-discharge connection
    7. 7. <ul><li>Home visits </li></ul><ul><li>“ Introduce” clients to providers </li></ul><ul><li>Meet with caregivers </li></ul><ul><li>Substitute for caregivers </li></ul><ul><li>Help negotiate ground-rules for relationships </li></ul><ul><li>Mediate conflicts </li></ul><ul><li>Assess potential of support system </li></ul>
    8. 8. Phase Two: Try-Out Facilitate and test client’s problem-solving skills and capacity of the support system
    9. 9. <ul><li>Monitor effectiveness of support system </li></ul><ul><li>Modify as necessary </li></ul><ul><li>Less frequent meetings </li></ul><ul><li>Crisis intervention and troubleshooting </li></ul>
    10. 10. Phase 1 Phase Three: Transfer of Care Terminate CTI services with support network safely in place
    11. 11. <ul><li>Consultation but little direct service </li></ul><ul><li>Ensure key caretakers meet and agree on long-term support system </li></ul><ul><li>Formally recognize end of intervention and relationship </li></ul>
    12. 12. Focus areas <ul><li>Psychiatric treatment and medication management </li></ul><ul><li>Money management </li></ul><ul><li>Housing crisis management </li></ul><ul><li>Substance abuse </li></ul><ul><li>Family psychoeducation </li></ul>
    13. 13. <ul><li>Design </li></ul><ul><li>randomized trial </li></ul><ul><li>100 men with SMI following discharge </li></ul><ul><li>9-month intervention/ 18-month follow-up </li></ul><ul><li>Results </li></ul><ul><li>3-fold reduction in risk of homelessness </li></ul><ul><li>Effect persisted beyond 9 months </li></ul>Fort Washington Armory Susser, Valencia, et. al. 1997
    14. 14. <ul><li>Design </li></ul><ul><li>“ effectiveness” trial </li></ul><ul><li>non-randomized pre-post design </li></ul><ul><li>men & women with SMI following hospital discharge </li></ul><ul><li>multiple sites nationally </li></ul><ul><li>N=484 </li></ul><ul><li>Results </li></ul><ul><li>19% more days housed over one year </li></ul><ul><li>lower drug, alcohol and psychiatric problem scores </li></ul>
    15. 15. <ul><li>Design </li></ul><ul><li>randomized trial </li></ul><ul><li>150 men & women with SMI following discharge </li></ul><ul><li>9-month intervention / 18-month follow-up </li></ul>CTI in the Transition from Hospital to Community NIMH R01-MH59716
    16. 16. Percent of subjects who were homeless over follow-up period (ITT) 18 months 9 months
    17. 17. Percent of subjects who were homeless over follow-up period (as treated)
    18. 18. adapting the model?
    19. 20. Dan Herman <ul><li>Columbia University & New York State Psychiatric Institute </li></ul><ul><li>[email_address] </li></ul><ul><li>www.criticaltime.org </li></ul>
    20. 22. Critical Time Intervention Montgomery County, PA
    21. 23. Critical Time Intervention in Montgomery County, PA <ul><li>Developed to enhance case management and housing support services for individuals with mental illness who are residents of the only singles adult shelter in the county </li></ul><ul><li>Served the first person in February of 2008 </li></ul>
    22. 24. Development Structure <ul><li>Utilized Re-investment funding for start up (2008) </li></ul><ul><li>Certified program under Intensive Case Management/Blended Case Management Model </li></ul><ul><li>Enhanced educational requirements of supervisor and team members </li></ul><ul><li>Added regular consultation time with psychiatrist </li></ul><ul><li>Rolled into HealthChoices funding (2008) </li></ul><ul><li>Added County Funding (FY 09/10) </li></ul><ul><li>Included Pre-CTI phase </li></ul><ul><li>Tweaked Phase III: Transfer of Care </li></ul><ul><li>Parallel development of Housing Resources </li></ul>
    23. 25. Implementation Characteristics <ul><li>Agency selection – Connection with Shelter </li></ul><ul><li>Monthly/Quarterly Stakeholder Workgroup </li></ul><ul><ul><li>Quarterly reporting </li></ul></ul><ul><ul><li>Discussion/work between meetings </li></ul></ul><ul><li>Partnership with CUCS </li></ul><ul><ul><li>Trainings </li></ul></ul><ul><ul><li>Ongoing supervision with Team and Team Leader </li></ul></ul><ul><ul><li>Fidelity review </li></ul></ul><ul><li>Learning day with Camden CTI team hosted by University of Pennsylvania </li></ul>
    24. 26. Start Up Characteristics <ul><li>Availability of Housing: Average Number in Pre-CTI is 118 Days (Highest 487, Lowest 10) </li></ul><ul><li>CTI Specialist provides ‘Housing Case Management’ </li></ul><ul><li>Develops person-centered plan focusing on three out of six treatment areas at a time </li></ul><ul><li>Replicate positive shelter experiences </li></ul>
    25. 27. Participants in CTI Phases
    26. 28. Challenges <ul><li>Affordable and adequate housing (transitional and permanent) </li></ul><ul><li>Developing relationships </li></ul><ul><li>Staff turnover </li></ul><ul><li>Effects of extended Pre-CTI phase </li></ul><ul><li>Providing service within a fee-for-service model </li></ul><ul><li>Productivity-billing </li></ul><ul><li>Transfer of Care (length and activities) </li></ul><ul><li>Balancing caseloads </li></ul><ul><li>Jail engagement </li></ul>
    27. 29. Successes <ul><li>Total Number of Clients Served: 83 </li></ul><ul><li>Total Number of Clients Successfully Discharged: 26 </li></ul><ul><li>Types of Housing Subsidies Received: </li></ul><ul><ul><li>Housing Choice Voucher (HUD) </li></ul></ul><ul><ul><li>Tenant Based Rental Assistance (CHIPPs/HOME) </li></ul></ul><ul><ul><li>Halfway There (HUD Transitional Shelter) </li></ul></ul><ul><ul><li>Permanent Solutions (HUD SHP-Chronically Homeless) </li></ul></ul><ul><ul><li>Shelter Liaison (HUP SHP) </li></ul></ul><ul><ul><li>Starting Point Housing (County Funded Program) </li></ul></ul><ul><ul><li>Self (SSDI Income) </li></ul></ul>
    28. 30. Outcomes <ul><li>Funding </li></ul><ul><ul><li>Fee for Service Structure (Payer Source) </li></ul></ul><ul><li>Stable Housing </li></ul><ul><ul><li>Nights in Shelter (Pre-CTI) </li></ul></ul><ul><ul><li>Nights NFHH (Average 41 this year) </li></ul></ul><ul><li>Treatment Engagement </li></ul><ul><ul><li>Percent of MH, SA, Dual Inpatient Services (1.5%) </li></ul></ul><ul><ul><li>Average Percent of Members Admitted to IP Care (1.96%/4.4%) </li></ul></ul><ul><ul><li>Percent Seen 31-60 Prior to Admission (75%/90.80%) </li></ul></ul><ul><ul><li>Percent Seen within 7 Days of Discharge (100%/74-84%) </li></ul></ul>
    29. 31. Outcomes <ul><li>Transfer of Care </li></ul><ul><ul><li>Number of Readmissions within 30 days (1/37) </li></ul></ul><ul><ul><li>Number eligible and receiving CM during last 30 days of CTI service (86%/67%) </li></ul></ul><ul><ul><li>Number of Cases continuing Outpatient Service for 90 days post discharge from CTI (67%) </li></ul></ul>
    30. 32. Next Steps <ul><li>Creativity with reunification </li></ul><ul><li>Flexibility with referrals </li></ul><ul><li>Continued interest in jail diversion </li></ul><ul><li>Team growth </li></ul><ul><li>Trainings/partnerships </li></ul>
    31. 33. Laura Morris, LSW <ul><li>Resources for Human Development </li></ul><ul><li>[email_address] </li></ul><ul><li>www.rhd.org </li></ul>