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A Review of Case Management for People Who Are Homeless: Implications for Practice, Policy, and Research

Abstract
Case management programs for homeless people have proliferated since the 1980s but some have questioned the meaning and clarity of the term case management while others have questioned its effectiveness for serving clients. This paper first attends to conceptual issues, identifying primary functions and process variables for understanding and describing case management services. The paper next describes models and approaches to case management for various client subgroups and specialty areas.

The paper also reviews the empirical literature on homelessness and case management, especially as it relates to treatment effectiveness and critical factors. Several conclusions are postulated, including that some case management approaches, especially assertive community treatment (ACT), are effective for helping people who are homeless with severe mental illness; frequent service contact is a critical ingredient leading to positive treatment retention and housing outcomes; case management is more effective with some clients than others. A number of gaps in our knowledge of case management are also identified.

The final section of the paper presents recommendations on exemplary practices. These include recommendations related to critical staff skills and abilities, service principles, case management models, and organizational practices.

Lessons for Practitioners, Policy Makers, and Researchers
Recommendations for homeless case management practitioners include focusing service delivery efforts upon:

Conducting assertive, community-based outreach;
Nurturing trusting, caring relationships with clients;
Respecting client autonomy;
Prioritizing client self-determined needs;
Providing clients with active assistance to obtain needed resources;
Maintaining small case loads; and
Implementing ACT approaches.
The federal government is also encouraged to promote exemplary practices through knowledge dissemination, advocacy, and financing actions and to promote new research and knowledge on case management services for people who are homeless.

Introduction
Within the past two decades, case management has functioned as a cornerstone of efforts to serve people who are homeless. During that period, providers and researchers have recommended case management services for homeless people, policy makers have facilitated the development of case management programs through grant announcements, and Congress has encouraged States to provide case management through legislative initiatives (McKinney Act, PATH, mental health block grants). Program developers have adapted case management services for a variety of subgroups of homeless people, including those with severe mental illness, substance abuse disorders, people with dual diagnoses, pregnant women, and homeless families. Case management services need to be considered within a broad perspective that recognizes the multiple and serious needs of people who are homeless, the varying subgroups, the need for multiple interventions at various levels of society, and the crucial importance of adequate housing resources (Dennis et al., 1991; Federal Task Force on Homelessness and Severe Mental Illness, 1992; Morse, 1992). Undoubtedly, however, case management has become in practice one of the most common services to people who are homeless.

Why have case management services been recommended and implemented so frequently in the area of homelessness? In part, there is a general zeitgeist of case management within human services. More specifically, however, the initial development of case management services has resulted in part from several interrelated, key assumptions about the problems, causes, and solutions of homelessness:

People who are homeless have serious and multiple problems and unmet service needs and problems (Ball & Havassy, 1984; Morse & Calsyn, 1986).
The services and resources necessary to met these human needs are contained within a fragmented system of disparate service organizations (Rog, 1988).
Additionally, the service system is often structured and operated in such a manner that it poses a number of obstacles and barriers for clients in need; clients, therefore, often have difficulty accessing needed services and resources (Goldfinger & Chavatz, 1984; Rog et al., 1987).
Case managers are thought to be necessary to “facilitate access,” “coordinate,” “negotiate,” and ensure services for client needs (e.g., Francis & Goldfinger 1984; Levine & Fleming; 1986; Oakley & Dennis, 1996; Rog et al., 1987).
Note the service system function inherent in these assumptions. As Hopper, Mauch, and Morse (1989), framed it, case managers perform “microsurgery on the service system.” Not surprisingly, some have considered case management to be one intervention strategy for changing and improving the entire service system as well as improving individual client outcomes (Mechanic, 1991; Raif & Shore, 1993; Surles, Blanch, Shern, & Donahue, 1992).

An additional set of beliefs about people who are homeless also facilitated the development of case management programs. Specifically, homeless people have often been described as markedly mistrustful and suspicious of service providers, and to highly value their autonomy (e.g., Francis & Goldfinger, 1986). Case managers have been conceptualized as workers whose first task is to engage people who are homeless, developing and nurturing trust and a working alliance (Francis & Goldfinger, 1986).

While compelling arguments have been for case management services, significant questions and concerns have also arisen. Confusion about exactly what constitutes case management has been common. Others have questioned the effectiveness of case management.

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