Housing

 

1. Member will learn and effectively apply skills necessary to avoid homelessness, as evidenced by maintaining stable housing with no episodes of homelessness for at least 6 consecutive months. Baseline: Less than 3 months out of the last 12.

Rehab: CM will provide coaching, modeling, and prompts to help member acquire basic skills necessary for living independently (e.g., housekeeping, maintaining utilities, paying rent, etc.).

CMS: CM and Housing Specialist will facilitate linkage to housing resources and programs such as Continuum of Care, MHSA (Fullerton Heights), and Section 8 to help member obtain stable housing for herself and her children.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of depression and PTSD.

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence as described in CFS 8.

Therapy: Clinician will provide therapeutic interventions such as CBT to help member identify patterns in her decision-making and behavior she might be able to change going forward, to reduce risk of homelessness.

Member will work collaboratively with CM and Housing Specialist to obtain/maintain housing.

2. Member will decrease the number of times he changes residences due to conflict with others, from a baseline of 6 in the last 12 months to a goal of 2 or less, and sustain this change for the duration of the cycle, as measured by collateral and CM observation.

Rehab: CM will provide skill-building by teaching client coping skills such as deep breathing and progressive relaxation to manage feelings of irritability and anger that lead to conflicts with housemates and house managers.

CMS: CM will conduct weekly visits to member’s home to assess functioning, monitor progress, consult with residential manager, and address any issues that could interfere with housing stability.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of depression.

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence.

Therapy: Clinician will provide therapeutic interventions such as CBT, DBT, and RCCS techniques to help member manage symptoms of depression including anger and impulsivity.

Member will practice using the techniques he learns with his CM and work collaboratively with CM and Housing Specialist to obtain/maintain housing.

3. Member will reduce the number of days he spends homeless per month, from a baseline (average) of 14 to a goal of 3 or less, and sustain that change for at least 6 months, as measured by member self-report and CM observation.

Rehab: CM will help member identify patterns in his decision-making and behavior that have led to a loss of housing (for example, choosing to stop taking his medications) that he might be able to change going forward. Will teach communication skills to help member learn to resolve disagreements he has with housemates and house managers.
 
CMS: CM and Housing Specialist will facilitate linkage to housing resources (R&Bs, sober living homes, etc.) and programs such as Continuum of Care and Section 8 to help member obtain stable housing.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of thought disorder and mood lability.

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence (as described in CFS 8).

Group: Group facilitator will conduct COEG (Co-Occurring Education) Group to help participants develop awareness of the connection between substance use and recovery from mental illness.

Member will attend at least one series of COEG group. Will practice using the communication skills he learns, begin applying them to real-life situations, and discuss the results with his CM during their weekly meetings.

4. Member will improve his ability to resolve conflicts with others as evidenced by an increase in the number of months he is able to maintain residence at a single location, from a baseline of 2 to a goal of 6, as measured by member self-report and CM observation.

Rehab: CM will help member search for patterns in his behavior and assist him in identifying precursors to angry outbursts, with the goal of helping him intervene before he loses his temper. Will teach coping skills for managing anger. Will use modeling, role-play, and rehearsal to help member learn to resolve conflicts with housemates and house managers more effectively.
 
CMS: CM will facilitate linkage to housing (R&Bs, room rentals, etc.). Once member is housed, CM will have weekly discussions and/or meetings with member and house managers to monitor member's progress and address any issues that could pose a threat to his housing.
 
Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of thought disorder, mood lability, and depression.

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence as described in CFS 8.

Member will practice using the conflict resolution skills he learns, discuss the results with his CM, and contact his CM immediately if any issues arise that could pose a threat to his housing (e.g., unresolved issues with housemates, conflict with house managers, etc.).

5. Member will increase the number of disagreements with his R&B manager that he is able to resolve without raising his voice, from a baseline of 1/4 to a goal of 3/4, and sustain this change for the remainder of the cycle, as measured by report of R&B manager.

Rehab: CM will provide skill-building to help member develop positive alternatives to maladaptive behaviors (i.e., improved communication skills, anxiety-reduction skills, ability to manage frustration and anger, etc.). Will provide positive reinforcement for progress observed.

CMS: CM will facilitate ongoing linkage to housing by conducting weekly visits to member's R&B to monitor his level of functioning and identify any issues that may pose a threat to his housing (e.g., not following house rules, not doing assigned chores, etc.).

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of A/H and depression.

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence as described in CFS 8.

Group: Group facilitator will conduct RCCS group to help participants improve their ability to manage strong emotions such as anger and anxiety.

Member will attend at least one series of RCCS group and inform his CM immediately if any problems arise that could jeopardize his housing.

6. Member will increase the number of disagreements with housemates that he is able to resolve without shouting or making threats, from a baseline of 1/4 to a goal of 3/4, and sustain this change for the remainder of the cycle, as measured by member self-report and report of R&B manager.

Rehab: CM will provide skill-building to help member develop positive alternatives to maladaptive behaviors (i.e., improved communication skills, anxiety-reduction skills, ability to manage frustration and anger, etc.). Will provide positive reinforcement for progress observed.

CMS: CM will facilitate ongoing linkage to housing by conducting weekly visits to member's R&B to monitor his level of functioning and identify any issues that may pose a threat to his housing (e.g., not following house rules, not doing assigned chores, etc.).

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of A/H and depression.

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence as described in CFS 8.

Group: Group facilitator will conduct RCCS group to help participants improve their ability to manage strong emotions such as anger and anxiety.

Member will attend at least one series of RCCS group and inform his CM immediately if any problems arise that could jeopardize his housing.

7. Member will increase the number of disagreements with his mother that he is able to resolve without shouting or making threats, from a baseline of 1/4 to a goal of 3/4, and sustain this change for the remainder of the cycle, as measured by member self-report and report of mother.

Rehab: CM will use RCCS exercises such as "Exploring My Triggers", "Stop, Breathe and Think", and "My Wise Mind" to help member identify situations in which he is at increased risk of losing his temper, and stay focused and in control if he finds himself in them.  Will teach member anger management techniques via modeling, role-play, practice, and rehearsal.

Collateral: CM will work to increase mother's awareness of communication patterns that trigger member's anger and identify alternative styles of communication that may be more effective.

Therapy: Clinician will use therapeutic interventions such as CBT and DBT to help member more effectively manage feelings of anger and aggression.

Group: Group facilitator will conduct RCCS group to help participants improve their ability to manage strong emotions such as anger and anxiety.

Member will practice using the anger management skills he learns and then begin applying them to real-life situations, and discuss the results with his CM during their weekly meetings.  He will attend at least one series of RCCS group.

8. Member will successfully apply anger management techniques he has learned, as evidenced by having no more than 1 housing-related incident involving the police.  Baseline: During the prior cycle, member was involved in 3 incidents requiring police intervention.

Rehab: CM will help member search for patterns in his behavior and assist him in identifying precursors to angry outbursts, with the goal of helping him intervene before he loses his temper. CM will teach skills for de-escalating and managing anger. Will use modeling, role-play, and rehearsal to help member learn to resolve conflicts and disagreements more effectively.

CMS: CM will facilitate ongoing linkage to housing by conducting regular visits to member's apartment to monitor his level of functioning and identify any issues that could pose a threat to his housing (e.g., disturbing other tenants, not following rules, making threats, etc.).

Collateral: With member's approval, CM will work to increase apartment manager's awareness of communication patterns that trigger member's anger and identify alternative styles of communication that may be more effective.

Member will practice using the anger management skills he learns and then begin applying them to real-life situations, and discuss the results with his CM during their weekly meetings.

9. Member will decrease incidents of damaging or destroying the property of others, from a baseline of 3 incidents in 6 months to a goal of no more than 1 incident, and sustain this change for 6 months, as measured by report of R&B manager, collateral from other sources.

Rehab: CM will provide skill-building by teaching member coping skills such as deep breathing, progressive relaxation, and exercise to manage feelings of frustration and anger. Will also teach member skills for reducing/controlling her symptoms, such as remembering to take her medications in the right amounts, at the right times; and identifying and eliminating unnecessary sources of stress.

CMS: CM will facilitate ongoing linkage to housing by conducting weekly visits to member's R&B to monitor her level of functioning and identify any issues that could pose a threat to her housing (e.g., damaging property, not following R&B rules, fighting with housemates, etc.).

Collateral: With member's approval, CM will work to increase R&B manager's awareness of communication patterns that trigger member's anger and identify alternative styles of communication that may be more effective.

Member will practice using the anger management skills she learns and then begin applying them to real-life situations, and discuss the results with her CM during their weekly meetings.

10. Member will decrease incidents of shouting at housemates, from a baseline of 5 incidents per week to a goal of no more than 1 per week, and sustain this change for at least 3 months, as measured by report of R&B manager.

Rehab: CM will use modeling, role-play, and rehearsal to help member manage feelings of anger and frustration, and help him resolve conflicts without raising his voice and making threats.  Will help member identify precursors to angry outbursts, with the goal of helping him intervene before he loses his temper (e.g., by disengaging from the situation temporarily, focusing on his breathing, taking a walk, journaling, talking to a friend, etc.).

CMS: CM will facilitate ongoing linkage to housing by conducting weekly visits to member's R&B to monitor his level of functioning and identify any issues that could jeopardize his housing (e.g., making threats, not following rules, causing disturbances, shouting at neighbors or housemates, etc.).

Medication:  MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of depression and anger. 

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence (see CFS 8). 

Group: Group facilitator will conduct COEG (Co-Occurring Education Group) to help participants gain a better understanding of the relationship between substance abuse and recovery from mental illness.

Member will attend at least one series of COEG, practice using the de-escalation and conflict resolution skills he learns, and contact his CM immediately if any issues arise that could pose a threat to his housing.

11. Member will decrease the number of instances in which his behavior leads to a warning or threat of eviction, from a baseline of 4 per month to a goal of 0 per month, and sustain this change for at least 6 months, as measured by collateral from manager/ landlord and on-site housing staff.

Rehab: CM/Housing Coordinator will provide skill-building to help member develop positive alternatives to maladaptive behaviors (i.e., more effective communication skills, problem-solving skills, and conflict-resolution skills). Will provide coaching, modeling, and prompts to help member acquire skills necessary for living independently (e.g., following housing rules, being respectful of other tenants, paying rent on time, maintaining his apartment, etc.).
 
CMS: CM/Housing Coordinator will facilitate ongoing linkage to housing by conducting weekly visits to member's apartment to monitor his level of functioning and identify/address any unresolved issues that could pose a threat to his housing. 

Therapy: Clinician will provide therapeutic interventions such as CBT to help member identify patterns in his decision-making and behavior he might be able to change going forward, to reduce risk of eviction and/or loss of housing voucher.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of thought disorder.

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence (see CFS 8).

Member will practice using the positive coping skills he learns and work cooperatively with his apartment manager and treatment team to maintain housing.

12. Member will decrease the number of instances in which his behavior results in his being evicted, from a baseline of 1x/3 months to a goal of 0x/3 months, and sustain this change for at least 6 months, as measured by collateral from manager/landlord.

Rehab:  CM will help member analyze his history of successful and problematic residential situations with the goal of identifying patterns in his decision-making and behavior that he might be able to change going forward (e.g., choosing to stop taking his medications, ignoring warnings by landlord/manager, disturbing neighbors, etc.). Will teach member "5 steps to problem-solving" and work to improve his communication skills.

CMS: CM will facilitate ongoing linkage to housing by conducting weekly visits to member's apartment complex to monitor his level of functioning and identify/address any unresolved issues that could pose a threat to his housing. 

Therapy: Clinician will provide therapeutic interventions such as CBT to help member identify and correct inaccurate beliefs he has about himself and the world around him that may be contributing to feelings of anger.

Group: Group facilitator will conduct COEG (Co-Occurring Education Group) to help participants develop awareness of the connection between substance use and recovery from mental illness.

Member will attend at least one series of COEG group. He will practice using the problem-solving and communication skills he learns and begin applying them to real-life situations.

13. Member will increase the number of nights he spends indoors in a place he feels safe, from a baseline of 0/7 days a week to a goal of 5/7 days a week, and sustain this change for 6 months, as measured by CM observation and member self-report.

Rehab: CM will provide coaching, modeling, and prompts to help member acquire basic skills necessary for maintaining a small living area (i.e., making his bed, picking up after himself, etc.) and cooperating with housemates/roommates/peers. Will teach member coping skills such as deep breathing, progressive relaxation, and exercise to manage feelings of anxiety and irritability.

CMS: CM will facilitate linkage to appropriate housing resources (shelters, R&Bs, B&Cs, etc.). Once member is housed, CM will conduct regular visits to monitor progress, consult with housing managers, and identify/resolve any issues that arise.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of thought disorder. Nurse will assist with medication management to help member overcome impairments related to lack of med adherence.

Member will work cooperatively with treatment team to obtain and maintain housing; will inform team of any barriers he encounters that could interfere with his ability to maintain housing or his willingness to utilize housing resources.

14. Member will have acquired the skills and resources necessary to successfully live on his own, as evidenced by moving from his parents' home into his own place and maintaining stable housing there for at least 3 months. Baseline: Needs to move out of parents' home; has not had his own apartment before.

Rehab: CM will use coaching and prompts to teach member skills for living independently (e.g., housekeeping, shopping, preparing meals, maintaining utilities, paying rent, etc.). Will use modeling and role-play to help member improve communication skills and prepare for situations he is likely to encounter 1) during the application process, and 2) once he has moved in.

CMS: CM and Housing Specialist will facilitate linkage to housing programs (e.g., CoC, Fullerton Heights, Section 8); basic services (e.g., Anaheim Public Utilities, AT&T); and resources (Housing Navigator, utility payment assistance, etc.).

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to reduce symptoms of thought disorder. Nurse will assist with medication management to help member overcome impairments related to lack of med adherence as described in CFS 8.

Member will work collaboratively with CM and Housing Specialist to obtain and maintain housing.

15. Member will have developed independent living skills as evidenced by moving into her own apartment.  Baseline: Used to live independently but declined to current level (i.e., needing assistance in living arrangements) when she became ill.  Now living in R&B.

Rehab: CM will use coaching, modeling, and prompts to help member re-learn skills for living independently (e.g., managing her finances, paying bills, shopping for food, preparing meals, maintaining her apartment, etc.).

CMS: CM and Housing Specialist will facilitate linkage to housing programs and resources (e.g., CoC, Section 8, Housing Navigator, utility payment assistance, etc.). Once member is housed, CM/Housing Coordinator will conduct weekly visits to member’s apartment to monitor her level of functioning and identify/address issues that could interfere with her ability to maintain stable housing.

Medication: MD/NP will provide psychoeducation and prescribe and monitor psychiatric medications to stabilize mood and reduce symptoms of depression.

Medication: Nurse will assist with medication management to help member overcome impairments related to lack of med adherence.

Member will practice the skills she learns and work collaboratively with CM and Housing Specialist to maintain independent housing.

All PHI has been de-identified per HIPAA Privacy Rule