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

18. Further information

• Report available for download:

• http://www.ahuri.edu.au/publications/download/90437_fr

• 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)