Case Study Shows Positive Results of Intensive Care Coordination
For one client, care coordination assistance through a Transition to Success (TTS) framework helped her go from being homeless to housed within 86 days, says Brooke Churchill, care coordinator supervisor with NEXT Memphis in Tennessee.
“Accessibility and affordability of housing in our area is a major challenge,” Churchill notes. “The waiting list on low-income housing and voucher programs is ridiculous. Having someone with limited income find affordable housing in 86 days is a huge win.”
This particular client had spent 30 days in a hotel with her young children, storing food in a mini fridge and preparing meals under those challenging circumstances. Her job paid less than $8 per hour, Churchill explains.
But the woman persevered and applied for a GED course. She obtained a higher-paying job and found an affordable home for her family.
The client’s story began when she attended a parent meeting at a day care center and told a care coordinator she needed help in different areas of her life, recalls Carla Watson, care coordinator with NEXT Memphis. Once connected with care coordination, the woman described her basic needs, including legal issues.
“We were able to address that legal issue, and by addressing it, she gained trust with me and shared more of her story,” Watson says. “She was very guarded and was worried about sharing too much information.”
The woman continued to meet with the care coordinator. Over time, Watson realized the woman was not safe in her home because of intimate partner violence. She helped the woman create a plan to make herself and her children safer.
Breaking the Cycles
A first step was to connect her with an agency that could help her become financially independent. This was challenging because the woman had not completed her education and needed help understanding various documents.
“She followed all the steps and got her family into a shelter,” Watson adds. “She said it was the first night all of them slept through the night.”
Watson continued to listen to the woman, treating the case as a puzzle she needed to solve. “She gave me pieces, and I was trying to figure out how to put the puzzle together because she wasn’t sharing everything,” she says. “By my allowing her to talk every time she called and wanted to talk, she’d share a piece of her story, and I’d write it down. Eventually, she shared the whole puzzle.”
Part of the puzzle involved adverse childhood experiences. The woman decided those needed to end with her generation, so becoming independent from her extended family was important — even if it meant she would have no family support as she transitioned to independence.
“Taking the initiative to engage with a mental health specialist is important because she does not have a large support network like family because of many relationships that were pretty abusive,” Churchill says. “There was a cycle of abuse she was trying to break.”
Within three months, the woman and her children were able to move into a three-bedroom, two-bathroom apartment in a safe environment, and they are doing well, Watson says.
It was not easy, but Watson supported the woman as she visited apartment complexes, personally assessing their safety for her family. When the client found one place she knew would be a good environment, Watson helped her talk with the leasing office about her financial circumstances and how she had been homeless. They agreed to have her live in their facility, despite some factors that worked against her leasing application.
“She was so excited,” Watson recalls. “Things have changed — it’s wonderful.”
The new and stable housing also has helped the client’s children, the eldest of whom went from poor grades to honor roll.
Supportive Care Coordination
Care coordination also helped the woman gain confidence to improve her working conditions and future job prospects. She spoke with the supervisor at a hotel where she had been staying prior to landing the apartment, and she asked if she could apply for a job there. They hired her at a higher pay rate than she had been making, Watson says.
“She exhibited a lot of resilience while homeless and was engaged with mental health services and a financial coach,” Churchill says. “She learned her situation is temporary. She’s working poor now, but it’s not at the end of the road yet because she’s working on improving outcomes for her family, and she has more tools in her pocket for self-advocacy.”
TTS care coordination helps clients with dream mapping. “When you are trying to meet basic means on a daily basis, you’re not in a position to dream yet,” Churchill notes. “Once the bottom-level needs are met, you’re in a position to begin dreaming.”
It takes supportive care coordination for people to gain confidence in dreams. For instance, Watson used a technique of going back to the client’s care plan and showing her how she had already accomplished some of her goals.
“I told her she was strong and had already done this, so we can keep moving,” Watson says. “She had forgotten a lot of things she had accomplished, so we pushed forward every time.”
Once the woman had obtained safe housing and a job that made the apartment possible, she began focusing on her goals to obtain a GED, improve her professional status, and buy her own home.
“She is looking forward to having a backyard for her children,” Watson adds.
For one client, care coordination assistance through a Transition to Success framework helped her go from being homeless to housed within 86 days.Subscribe Now for Access
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