How to do Case Management in a Housing First programme

Se Mudando

Se Mudando is an institute that, since 2021, has used the Housing First methodology to have lasting impact on the lives of people with a street history.

Starting from the idea that housing is a basic right that should be denied to no one, “Opening Doors” was created as a programme to provide immediate access to housing, financial assistance and support services. The service is individualised and led by the person being supported, with a focus on social and community integration. In this way we aim to provide the conditions and services people need to keep their home independently.

Introduction

Internally, we divide each case into three stages: opening the case, managing the case, and closing the case. The first steps of opening a case involve listening to the person’s life story, explaining the methodology we base our work on and how the programme works, and finally, finding housing.

Case management begins as soon as the person is in their new home. By that point we have already completed their registration, the signing of the programme’s terms, a check for outstanding legal matters, and their first impact assessment.

Case Management

The first meetings are essential to build a relationship of trust. Bear in mind that the person has just moved into a new home, so the first visit should be about setting the home up. For grocery shopping, at first we go along with the person to help them work out how much money they have and how to spend it, choosing priorities.

This is also the moment when we share the Institute’s view on addiction, harm reduction and the Housing First methodology. That strengthens our agreements and improves the bond with the person, setting our way of working apart from the traditional approach. It is also important to remind them that we are there to help, but every decision and all progress in the programme depends entirely on them.

That is how we start the continuous case management process. It consists of periodic visits in which we apply the case management tools and set goals together with the person. Those goals become action plans followed up at each visit. We also follow up on the search for stable income and on managing expenses. In the first months we visit weekly, though as the case progresses we may agree on a different frequency.

Documentation

Writing a report after every visit is essential to document how the case is progressing. We use that document as the basis for case discussions, filled in using the following template:

We also use two case management tools. The first is the Vulnerability Chart, to identify the person’s risk and protective factors. The second is the Eco-map, to map their social support network.

These tools let us identify the possible barriers to keeping the home, along with the person’s strengths, which can be built on to break those barriers down. Goals are then set, always together with the person, based on this information. We can then break the goals down into action plans for the person themselves and for the team, which is made up of the case worker and the case manager.

In practice, many of the action plans involve connecting the person to information and services in the municipal social care and health network, such as CAPS AD (the psychosocial care centre for alcohol and other drugs) and CRAS (the social assistance reference centre). That is why we maintain a survey of the initiatives available in the municipality where we work.

The survey covers legislation, rights, benefits, the network of public services, and private or voluntary initiatives. We consult and update it with each case.

The team’s main role is to receive the person’s needs, support them, and create the conditions they need to face the issues identified as barriers to keeping their home.

What is the ultimate goal?

It is worth remembering that in Housing First programmes it is essential not to work with deadlines and the frustrating logic of repeatedly renewing them. Knowing that the programme is permanent and that people can count on that home indefinitely has an immediate psychological effect of security.

Case management is a continuous process, and moments of crisis will recur. The team therefore needs to build its own strength, with time for discussion, in-depth study of the cases, and (re)designing strategies. Always keep the person’s own will in view, along with a clear process for agreeing commitments.

We count it as success when a person feels ready to return to work, make new friends, and rebuild family relationships. But above all, we count as success every day the person chooses to stay in their home.

Closing a case depends on the person feeling ready. We begin that process by analysing several indicators, such as income, social support network, and their relationship with substance use.