Health, Housing, and Service Supports for Three Groups of People Experiencing Chronic Homelessness. 3.1. How Care is Delivered


Members of all three groups may receive care and supports in a number of ways. The scope and intensity of supportive services to PSH tenants varies substantially from one provider or community to another, probably almost as much as it varies among members of Groups 1, 2, and 3, although funding limitations make it difficult for PSH programs to offer comprehensive health services if most tenants are uninsured. Some of the most common approaches rely on case managers, often but not always attached to housing locations. Other arrangements involve interdisciplinary teams comprising staff from several parts of a single agency, two or more partner agencies, or even a whole community. Basic arrangements are therefore described here, starting with case management, which can take many forms.

3.1.1. Case Management

Some arrangements rely primarily on case managers. All receive appropriate training and supervision, though they may or may not have professional licenses. At a minimum, case managers in PSH conduct assessments, work with clients to develop a care plan, make referrals, and pursue related activities that help people get needed services. They monitor progress, and follow up to see how things are going. Most PSH case managers go well beyond this minimum, providing some direct services such as coaching, skill-building, and motivational interviewing, as well as linking clients to off-site clinical care and other community supports. PSH service-providers often describe “doing whatever it takes” to establish trusting relationships. They also usually coordinate and advocate for clients to help them access and use the most appropriate health and behavioral health care and link them to social services and income entitlements. Some case managers perform a variety of specialized functions, shown in the text box.

Specialized Case Management Functions

  • Doing “whatever it takes” to establish trust, restore hope, and reduce social isolation.
  • Providing motivational interviewing, crisis intervention and coaching in recovery and relapse prevention.
  • Working with landlords and PSH tenants to resolve issues that might otherwise lead to a loss of housing.
  • Providing “medical case management” to PSH tenants with major medical problems, including help to link to primary care, get van service to get to appointments, manage oxygen tanks, and similar activities. Case managers are often the only staff working regularly with PSH tenants who can bring back information on the results of primary care visits and integrate that information into ongoing tenant supports.
  • Helping PSH tenants build skills for wellness and self-management so they can handle their own appointments and ongoing care.

3.1.2. Supportive Services Teams

Agencies working with chronically homeless people have developed a variety of team structures. Teams are most often interdisciplinary, with team members having different skills. Outreach is often done in teams of two or three, including staff with skills in the areas of mental health, substance use, public benefits, peer support, and emergency medicine. It is also common in all-PSH buildings for case managers and property management staff to work as a team, bringing their unique perspectives and knowledge of clients together to avert housing loss.

Integrated Care--Structures for Serving Any Chronically Homeless Person

Agencies that serve clients with Medicaid are most likely to offer care that integrates health, mental health, and substance use services. As a consequence, persons in Group 3 are the most likely to get integrated care. However, some integrated care structures have been developed that bring together multiple agencies to serve a broad range of homeless people, many of whom do not have Medicaid. One example is the South Middlesex Opportunity Council, described in the text box.

South Middlesex Opportunity Council (SMOC)

  • SMOC is a collaboration involving 19 programs in the southwest Boston suburbs that provides comprehensive services to homeless individuals and families.
  • SMOC formed the Common Ground Resource Center to integrate its rich array of services for individual clients, and began to use a relapse-sensitive, harm reduction-oriented “Housing First” model to end homelessness for individuals.
  • Major components of SMOC’s service response are outreach to people living on the streets and in emergency shelters; assistance to qualify for Medicaid-MassHealth and SSI; primary health and behavioral health care; a continuum of community-based housing options; and employment and/or education services once individuals are housed.
  • SMOC’s Common Ground Resource Center holds regular meetings of up to 20 team members representing different service components, at which clients in every homeless program are reviewed and new cases are assessed and service plans developed. As needed, service plans are adjusted and coordination across participating organizations assured.

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