What makes case management work? Bringing together the evidence Dr Hellene Gronda Australian Housing and Urban Research Institute QCOSS Conference “Ending Homelessness: A Vision and a Plan,” Brisbane, 2-3 September 2009
1. What makes c ase management work? Bringing together the
evidence Dr Hellene Gronda Australian Housing and Urban Research
Institute QCOSS Conference Ending Homelessness: A Vision and a
Plan, Brisbane, 2-3 September 2009
2. Evidence informed case management practice for homeless
persons agencies
Partnership between AHURI and Hanover Welfare, independently
funded by the Helen McPherson Smith Trust
Evaluation of international scientific research for the
homelessness practitioner community
Published January 2009
3. Bringing together the evidence
the research literature itself is messy, methodologically
flawed, often dated, inconsistent, and ambiguous (Kirk 1999)
Which case management?
Intensive, Enriched, Clinical, Advanced, Mobile, Brokered,
Critical Time Intervention, Strengths Based, Community Care,
Enhanced, Team, Assertive, Person-centred, Social Network,
Specialised
Asking the how and why questions
4. The evidence base Total empirical sources: 5 3 (26
quantitative/27 qualitative) Year published 1996 - 2000 8 2001 -
2005 17 2006 6 2007 1 2 Geographic spread North America 41 Europe 7
Australia 5 Research focus Case management 3 3 (not exclusive)
Homelessness 2 7 Mental illness 37 Substance use 15 Housing
provision 8
5. What makes case management work? Key findings A persistent
and reliable relationship characterised by intimacy and respect
Service system design and capacity Staff skills and support
Comprehensive, practical support and increased self-care
capacity
6. A developmental outcome Case management on the care
continuum Low High Personal capacity for self-care High Low State
responsibility for care Case management Increasing a persons
self-care capacity Institutional care or restraint Universal
service provision
7. Persistence, reliability and comprehensive practical support
18 month randomised comparison of assertive community treatment
with broker-referral case management (Morse et al 1997, Wolff et al
1997)
Assertive community treatment produced better housing outcomes,
better client satisfaction, reduced symptom severity at no greater
cost
8. Relationship The figures
US demonstration project 15 cities, 3,481 participants at
baseline (Chinman et al 1999, 2000)
Stronger relationship at 3 months predicted better housing
outcomes at 12 months
50% fewer days homeless for people with strongest relationship
compared to none
9. Relationship The words
They may have that skill but they have to bond as well, there
has to be that trust and that relationship
I cant emphasize the time scale of things, theres no rush, you
dont feel as though you are being a burden
Well, esteem, pure esteem thats the feeling we had, that she
cared about us (Beresford et al 2007)
10. Persistence and respect
Even though I didnt want to be seen, theyve seen me... They
approach you slowly, on the level that makes you comfortable, they
dont force you... Even if they say hello to you when you dont
respond, they will leave you... They just leave it be, go on their
way, come back later... I think that means a lot to people (Kirsh
and Tate 2006)
11. Dimensions of intimacy
The most fulfilling thing is the level of relationship you gain
with your client [] going through crisis with clients, and gaining
that relationship how it evolves over time, is absolutely
invaluable
...youre doing the laundry an youre cleanin house with them all
these intimate things. If youre disclosing stuff about yourself you
could cross that line ... And you are doing all these things with
them that you would do with a, your friend (Angell & Mahoney
2007)
12. Being more than a case manager
She was there for me, not for her job or the system, but
because she wanted to be
He sometimes helps me out with a ride when I need it
He takes me to the mall, he gives me rides. He is generous. Hes
a nice person (Buck and Alexander 2006)
13. Assisting developmental change
there are times that case managers need to be the stop
signbeing firm sometimessupporting sometimes, again, means saying
no. (Angell & Mahoney 2007)
W hat service users valued was someone who was prepared to stay
alongside them in their journey; also someone with firmness and the
ability to talk straight (Beresford et al 2007)
14. Feeling like nobody
my case manager is pushing me like, I feel that what Im doing
is not enough for her
She ...act like... she giving it to me out of her pockets,
which she is, which you all are, but she make you feel like you
beneath
I know she gets tired of me calling and not getting any
information. I mean ... if something come through I told her to
grab it, I don't care where it's at right now. You know Im between
a rock and a hard place at this moment. I cant be picky
(Dickson-Gomez 2007)
15. Feeling like somebody
It doesnt seem like [the case manager] sits there and judges
me. He listens to what I have to say and then well talk about what
were going to do or what were going to change. He doesnt tell me,
Well, you need to do this; you need to do that. Just Why dont you
try this? That really makes a difference (Nehls 2001)
16. Respecting strengths
The street, it helped me to be strong. Dont let nobody hurt
you. I used to be really sensitive. I had to get strong because
there are people who try to hurt you out there
someone can go to a university and know a lot of sh-t but they
would come out here and wouldnt know what to do with themselves
people definitely take pride in that (Kidd & Davidson
2007)
17. Policy implications
Service system design and capacity
Timely access to appropriate resources and specialist
supports
Support duration and intensity determined on an individual
basis
Staffing issues
High level assessment and communication skills
Adequate staff supervision, training and recognition
F or project information, contact: [email_address]
19. Additional slides
20. Methodology
Ray Pawson, Evidencebased policy: a realist perspective, Sage
Publications, 2006.
Interventions are fragile creatures (Pawson, 2006)
Realist synthesis: the how and why questions
Social policy interventions are theories
identify and evaluate the theories that underlie families of
interventions
Outcome = Mechanism + Context(s)
21. Timely access to resources
Housing makes a difference (Nelson et al 2007)
Mean effect sizes
Housing and support 0.67
Support alone (ACT) 0.47
Support alone (ICM) 0.28
Specialist housing improves outcomes - especially for men, and
for people with complex mental health and substance use issues
(Clark and Rich 2003, 2005)