Better Outcomes Through Outreach and Case Management

Targeted outreach and intensive case management for people experiencing chronic homelessness leads to improvement in housing, mental health, and other outcomes.

The Chronic Homeless Services and Housing (CHSH) project, a program of The Road Home, in Salt Lake City, Utah, is funded through SAMHSA’s Cooperative Agreement to Benefit Homeless Individuals (CABHI) program. The Road Home was awarded a three-year grant in September 2011. The goal of the CHSH project is to use a Housing First approach to stably house people experiencing chronic homelessness who have been the most challenging to engage. This includes people with a history of mental and/or substance use disorders, and who have been unsuccessful in accessing existing permanent supportive housing. Additional goals include enrolling clients in Medicaid and providing recovery services.

Program objectives include identifying project participants using a focused targeting outreach plan. The plan incorporates input from frontline service providers who are familiar with the diverse clientele and their levels of need. The Road Home designed the CHSH project with its community partner agencies to fill existing gaps by providing resources and building relationships at the point of client contact. The project uses an interdisciplinary and multiagency outreach team to deliver services, and stays close to the client at every point during the housing process.

The CHSH project, based on a Housing First philosophy, is implemented in the form of a modified Assertive Community Treatment (ACT) Team.

This interdisciplinary service delivery model is intended to provide long-term, comprehensive medical, social, and mental health recovery support to clients with severe mental illness to keep them housed and in the community.

The CHSH project’s preliminary results demonstrate that people enrolled in the project show marked improvement in a wide range of outcomes, including housing, financial resources, mental health, substance use, and social integration. For example:

  • At intake, 59% of CHSH clients reported living primarily in an emergency shelter and 76% had been homeless for more than one year. After six months in the program, 71% of CHSH clients were living in their home.
  • Six months after enrollment, CHSH clients’ average monthly income increased from just under $500 to almost $600, stemming largely from enrollment in public benefits programs, such as Supplemental Security Income/Social Security Disability Insurance (SSI/SSDI) and Supplemental Nutrition Assistance Program (SNAP).
  • A majority—74%—of CHSH clients receive ongoing recovery services related to mental illness, compared to only 15% of clients two years prior to enrollment. Fewer clients reported experiencing serious anxiety or using alcohol after six months in the program. Illegal drug use and combined alcohol and drug use decreased as well.
  • Recent contact with family or friends increased from 50% to 63% after six months in the program. There was a marked increase—from 13% to 30%—in clients who felt that they could rely on family members for support. The percentage of clients who reported that they had no one to turn to decreased from 35% to 11%. These numbers suggest that clients’ social isolation decreases while participating in the program, in accord with the CHSH program’s focus on social connectedness and support systems.
  • In the two years prior to CHSH involvement, almost half of the clients had at least two trips to local emergency rooms (ER). After enrollment, ER visits dropped to 10% and the sum total of visits made by the group dropped from 60 to 15.

While this data is preliminary (and reflects nonequivalent time periods), these numbers suggest that the CSHC’s intensive case management is a promising means for helping clients obtain appropriate types of health care.

Similarly, many CHSH clients had a history of criminal justice involvement, with 56% reporting jail bookings and 79% reporting involvement with court cases in the past two years. These events represent an immense and expensive burden on the criminal justice system. After CHSH involvement, less than 20% of clients were booked in jail on a new charge and 47% had a court case filed (for nonequivalent time periods).

These significant results are testimony to the hard work by the staff and the collaborations with key partners in the project. Partners include Fourth Street Clinic, Valley Mental Health, and Volunteers of America-Utah. These partnerships allow each entity to their respective area of expertise to the project, from housing case management, outreach, substance misuse and mental health treatment, to medical care. Collaborative efforts create the safety net and interventions needed to help people experiencing homelessness remain in housing.

Learn more about Housing First at the National Alliance to End Homelessness.

Access more behavioral health and homelessness resources, including resources about case management.

Publication Year

Connie Campos
Last Updated: 04/19/2016