# Presentation: 148378

## HUD-VASH

- Case Management System

- Paul Smits, MSW  Associate Chief Consultant,
- Roger Casey, PhD  Director, Grant and Per Diem Program

## Establishment of Program Requirements

- Full description of procedures and services codified in VHA Handbook.
- Identifies priorities for services among the chronically homeless.
- Addresses oversight, service, and support responsibilities at each level of the organization.
- Detailed description of referral and assessment process, program design, case management services, program monitoring and evaluation.
- Establishes staffing guidelines and training requirements.

## Principle Sources of Referral

- HCHV Outreach staff
- May make direct referrals from community to HUD-VASH.
- Community education can generate referrals to VA from community providers (i.e. shelters, food kitchens, welfare offices, etc.)
- VA Homeless Programs
- Homeless Residential Treatment
- Grant & Per Diem

## Assessment

- Confirm eligibility
- Assess for suitability
- If not housing ready, possible acceptance pending treatment in residential and/or inpatient setting
- If not appropriate, alternative treatment plan developed
- Determine need for other services to ensure adequate income, skills and support to maintain housing status once placed.
- Multidisciplinary team to make determination on acceptance.

## Entry Into HUD-VASH

- Once accepted, an individualized treatment plan is developed by the case manager and the veteran.
- Treatment plan reflects of the goals of the veteran. Potential strengths and barriers to maintaining housing placement are addressed.
- Establish process to monitor treatment plan including: use of alcohol and drug screening,   frequency of medical and mental health appointments, assistance with employment and income needs, resolution of legal and financial issues.

## Housing Placement

- Alert PHA of referral.
- As needed, assist veteran in completing and assembling required documentation.
- Following PHA guidelines, assist veteran in locating suitable housing.
- Request PHA inspection and approval of selected unit.
- Assist veteran and landlord to complete lease.
- Prepare for the move as needed providing guidance on turning on utilities, obtaining furnishings and supplies, and transportation to complete the move.

## Case Management Goals

- Establish a therapeutic relationship.
- Provide support for long-term recovery by working towards treatment plan goals.
- Reassess needs and goals based on changing conditions. Inability to maintain sobriety does not generally lead to discharge from case management if veteran can maintain housing.
- Foster community integration and independence.
- Maintain veteran in housing.

## Delivery of Services

- Coordinate VA and community interventions, acting as a liaison with critical partners (the landlord and other service providers).
- Make regular home visits to assess veteran’s ability to maintain themselves in a safe environment that promotes sobriety, physical, and mental well being.
- Schedule individual and group meetings. Individual sessions will focus on treatment plan and current needs. Group meetings should foster peer support.
- Provide linkages for child care, medical coverage for family members (ex. Medicaid), family therapy, legal and income assistance programs.

## Discharge from Services

- Agreement between case manager and veteran that goals have been met.
- Permanent loss of rental subsidy.
- Move into more intensive level of care.
- Client refusal of services.
- Loss of contact.
*Every effort will be made to re-engage veterans who are struggling or ultimately discharged from housing.*