Initiating proactive interventions

Case managers needed time to initiate proactive interventions for the clients. The first level was to see the client as a whole being with physical, emotional, spiritual, social and environmental needs. The second level was to acknowledge that one area e.g. environmental concern, in particular non-payment of rent, could dramatically influence another area for the client, for example, loss of tenancy. This loss may in turn affect the whole person by generating losses in other areas such as loss of self-esteem and social contact. To achieve these levels of understanding, the case

142 managers needed to be continually involved and persistent with the client and to address each need as it was identified.

From the perspective of case managers, the inability to initiate proactive interventions resulted in consequences for the client. One such consequence was that the client could be evicted. Once evicted the client would need to wait for many years before they could be rehoused. Another consequence of eviction was that there was an acute lack of short-term emergency accommodation with the result that the client could easily become homeless again. One case manager describes the likely consequence of non-intervention:

... if there had been somebody that could have worked with her and intervened in the earlier stages, because the trouble is that once you get evicted from housing, you can’t reapply for a period of time. I think it’s seven and a half years. So it has consequences, and all of the emergency accommodation, you can only stay there for three months, so there are consequences. (CM1)

One case manager depicts how those working in the HSP are becoming much more proactive in implementing interventions to support clients:

We're doing it more now… trying to be a lot more proactive. The housing support program is an example that, trying to be more proactive as opposed to other programs… If we get in early… it's better to be proactive with a client as opposed to waiting for something to happen. (CM3)

143 For the case managers, initiating proactive interventions is similar to the nursing process. The essential core aspect of case management is assessment. Case managers discussed how their first assessment was undertaken. Assessment included appraisal of the whole person, including their demographics, health background including how the client became homeless. Detailed histories provided case managers with information on the physical and mental health of clients as well as how clients managed their condition/s up to this point. Information gathered during assessment also provided case managers with directions covering the feasibility of recovery or maintenance for the client. These facets would later provide the basis for planning a sustainable future for clients.

We look at the person and everything to do with the person; their age; how they got into the situation in the first place; their health. They’ve often have undiagnosed illnesses, undiagnosed age-related illnesses or poorly managed mental health issues. We are looking at the person’s history, the viability of retrieving the situation, and then sustaining it afterwards. (CM3)

From the viewpoint of the housing support professionals who refer clients to the HSP, the initiative shown by the case managers in undertaking a detailed assessment was very important. They felt confident that the clients’ issues would be addressed by the HSP. Two focus group participants commented:

… undiagnosed mental health [issues]... failed tenancies, nuisance noise, harassing neighbours, the housing support program is one of

144 those starting points and they’ll actually go through the movements of trying to get them [the clients] assessed… (FG2)

Case managers discussed how the notion of early assessment of issues/problems and exploring the reasons why clients were homeless would move quickly into developing appropriate planning strategies that could be implemented there and then with the clients. Whilst tenancy remained the main issue of concern for the clients, one case manager discussed how challenging it was to get the client to the point where they could begin planning. Another case manager stressed the importance of including education during the planning phase.

That’s a challenge, getting people to the point where you can actually start to... make a bit of a plan about things for and with the client. (CM1)

... helping him and teaching him all of those things, and making sure that the place doesn’t get into disarray. Helping him plan things, how to get to appointments and how are we going to go about doing that? (CM1)

The importance of proactive relationships included being an advocate for the client including establishing relationships with the client and one case manager reported this.

… what they [the clients] need is an advocate, somebody to develop a relationship with them, to help and support them, to learn what they’re really like, because they’re mostly people that have been very isolated and it takes a long while to really get a good picture of them,

145 because they’re used to being quite reclusive and quite secretive. (CM3)

Implementing and evaluating activities of daily living for clients allowed case managers to engage and interact with clients in their environment. During this phase, case managers often saw positive outcomes as the behaviour of clients slowly began to change. Implementation was more than just being concerned with the outcome of having a clean living environment in the house. The process involved working through all the necessary day-to-day living skills that would lead to independence.

You start off with small steps... it’s not a cleaning up process… it’s working through issues such as ensuring that they are eating properly, getting the kitchen tidy, looking at their living skills and budgeting. (CM2)

One client described how the case manager helped them with daily hygiene requirements, while at the same time taking into account their limited mobility. Another client commented on how the meals that were available from the HSP were supplemented from other agencies. Often clients placed a low priority on daily activities of living such as bathing and dressing. One case manager described how any implementation of a plan needed to address a range of living skills:

... working with the client through living skills. A lot of people who have been homeless it’s not important to them to groom themselves. (CM2)

146 After the implementation of any plan to improve quality of care, case managers needed to monitor quality indicators to ensure success of their plans. The main objective change that could be demonstrated for clients in the HSP was that they were in secure tenancy. Maintaining tenancy was, however, reliant on improvement in many other areas such as basic living skills. Once improvements were made in these areas clients were able to engage in higher order skills such as self-expression. The main positive outcome for clients was that they were able to change their identity from homeless to a new identity, which expressed their new life – a tenant.