IV. Model Description

​CTI GPD-CM is a care management model composed of a Pre-CTI period of varying duration that ends at the point of transition to stable housing, followed by three distinct phases; each approximately two months long. The amount of contact between the CTI worker and Veterans should decrease as Veterans move through the phases of CTI GPD-CM, promoting a gradual transition to community supports.

Core Principles

While CTI GPD-CM shares a number of characteristics with traditional case management, the following core principles distinguish it from many other similar interventions:

• The intervention is focused on a transition period — CTI GPD-CM is aimed at assisting individuals to adjust to a difficult transition in their lives. This transition can be a physical shift (e.g., the transition from a shelter to housing in the community) or a lifestyle transition (e.g., the transition from a sobriety model to a harm reduction approach to addressing substance use). Often, but not always, the transitions are into community housing from an institutional setting, such as a residential treatment program, transitional housing program, hospital, shelter, or jail.
• It is divided into four phases -- Pre-CTI takes place before the transition period, and Phases 1-3, which are of equal duration, take place during the first six months of the transition period.
• It is time limited -- Once Phase 1 begins, the intervention lasts no longer than six months.
• The number of CTI worker contacts decrease over time — The CTI worker has fewer face-to-face meetings, phone calls and other types of interaction with Veterans and resources as the intervention progresses.
• It is highly focused -- One to three priority areas are selected for each phase from the program’s list of CTI GPD-CM focus areas. The focus areas selected depend on the type of long-term support the Veteran needs from providers, friends, family and/or other resources in order to maintain stability. We recognize that the Veterans served by CTI GPD-CM programs have many unmet needs and priorities. However, in contrast to 7 CTI IN VA GPD-CM • traditional case managers, CTI GPD-CM workers are not responsible for helping Veterans achieve their ‘treatment goals’. Instead, CTI workers use information about Veterans’ needs, strengths and aspirations to assist in identifying appropriate community services and informal resources that will continue to help them achieve long-term stability and continuity of care. 
• Modest caseload size is essential — All caseloads are limited to 20 “weighted cases” (in CTI, Veterans are assigned a different weight depending on which phase they are in, since the amount of work required is typically greater in early phases).
• The work is community-based -- Assessments and interventions with Veterans and their resource network ideally take place in the home and community where the Veteran lives.
• Supervision is done in team meetings — CTI GPD-CM team members attend weekly team supervision meetings. Some programs also provide individual supervision, but this is not required.

Core Values

​A set of core values guides the approach taken by CTI GPD-CM teams: 

• Strengths-Based
​The approach is grounded in a strengths-based assessment of the person in their environment, and CTI workers leverage these inner resources to connect Veterans to external resources that support long-term stability.

Example:
​A 50-year-old Veteran with chronic mental illness no longer interacts with his parents, who are supportive of him, but only when he takes his medication. He has started taking his medication but it has been years since he has spoken to his parents and he fears the relationship is beyond repair. The CTI worker points out the strengths inherent in his former relationship, and his continued sense of hope to reconcile. Because the CTI worker explored the strengths of the former relationship and praised the Veteran’s eagerness to repair it, the focus turned to creating a solution. The Veteran agreed to work on a plan to reunite with his parents. 

​• Shared Decision Making
​The CTI worker and Veteran take a collaborative approach to ensure that plans are aligned with Veteran preferences, honoring the Veteran’s right to self-determination.

Example:
​During a discussion about the Phase I plan with a Veteran who struggles with addiction, the CTI worker learns that he is already connected to VA and community resources that provide him with enough support for this problem. Therefore, the CTI worker and the Veteran turn their attention to other focus areas. The CTI worker did not automatically assume that the “substance use treatment” area should be a focus area simply because the Veteran is still using substances. 

• Individualized
CTI is not prescriptive, rather it responds to the diverse needs of each individual Veteran. Their strengths and needs vary across a broad continuum and change over time. Similarly, the availability of resources for providing needed support is different for each Veteran.

Example:
​A Veteran wants to return to work, but does not know how to search for a job. In the beginning, the CTI worker helps her to address this barrier. However, when the Veteran’s psychiatrist switches her medication, it becomes apparent that it is making it hard for the Veteran to get up in the morning. The CTI worker and Veteran must now address this new concern.

• Recovery-Oriented
We assume that Veterans have the capacity to progress toward greater stability and social integration, and to obtain enhanced meaning in their lives. Some Veterans need help rebuilding a sense of hope that will enable them to continue to grow and to reconstruct a stable sense of themselves. In a recovery-oriented approach, CTI workers must also believe in their own ability to influence the Veteran’s recovery. They should go at the CTI IN VA GPD-CM •Shared Decision Making The CTI worker and Veteran take a collaborative approach to ensure that plans are aligned with Veteran preferences, honoring the Veteran’s right to self-determination. 10 •Veteran’s pace, taking a harm-reduction approach to encouraging positive behavioral change. This approach includes helping Veterans to:

     • Take on life roles (e.g., being a good neighbor, or a responsible tenant) that will contribute to a sense of self, in which illness is only one aspect
     • Draw on their current coping strategies and develop new ones
     • Develop links to self-help and peer support groups
     • Identify things they enjoy doing and ways they can keep themselves healthy

Example: 
A Veteran says he painted his walls, adding that while painting used to give his life meaning, he hasn’t painted in the past few years while he has been struggling with depression. The CTI worker takes a recovery-oriented approach that goes beyond his illness, by encouraging him to take up painting again as a means of improving the quality of his life as a whole. 

​• ​Culturally Sensitive
CTI workers should respect the different worldviews and beliefs that Veterans might hold and be aware that the Veteran’s experiences and views will inform their decisions. To the extent possible, CTI workers should strive to balance the goal of supporting stability and continuity of care while respecting that the choices Veterans make are based on their personal values and priorities.

Example: ​
​Experiences with landlords who discriminate based on race have had a negative impact on a Veteran’s belief that he will be able to secure a safe and stable home. When his CTI worker tells him about an apartment for rent, he hesitates to submit the application because he believes he will be subject to discrimination in this area of town. Aware of the Veteran’s experiences and concerns, the CTI worker is able to discuss with the Veteran how race-based discrimination might or might not affect the opportunity, and how to address it.

​• Transparent
Veterans have the right to get accurate information about the nature, aims and limits of the CTI intervention and the CTI worker’s role. When the CTI worker introduces themselves to the Veteran, the description of the intervention and worker role should be clear. Transparency maximizes the likelihood of developing an open and productive relationship with the Veteran and can encourage them to share important information. Transparency about a Veteran’s strengths and needs is also important in their communications with their family, providers and other potential sources of support

Example:
​A CTI worker has a Veteran who rarely shows up for scheduled meetings and does not share much about himself when they do meet. During one meeting, the Veteran explains that in previous experiences with caseworkers, decisions were forced on him and many were unhelpful. The CTI worker realizes that the Veteran does not understand the purpose of CTI. Once the worker explains that CTI is time-limited and that they will collaborate on connecting him to resources that will ensure his long-term stability, the Veteran begins to engage more.

​• Trauma Informed
The vulnerable individuals served by CTI programs have often been exposed to one or more severe traumatic stressors during childhood, adulthood or both. For Veterans, the trauma may be service related (e.g., combat exposure or military sexual trauma), or may have occurred outside their service role. For example, many people in the shelter system struggle with mental illness and/or addiction; for some this was what initially led to their housing loss. CTI takes place during a major transition, which could in itself trigger earlier life trauma. Trauma-informed care reflects an understanding of trauma by emphasizing emotional and physical safety, establishing trust, and promoting opportunities for Veterans to rebuild a sense of control and empowerment. It encourages the development of positive relationships in their social network, which promotes successful navigation through transition. Trauma-informed care therefore minimizes the chances that Veterans will be re traumatized and limits their exposure to further trauma.

Example:
A Veteran has transitioned from a shelter to a supportive apartment, far from the healthcare providers at the VA facility where he has received care from trusted providers for years. However, as he refuses to take the bus, he has not used these critical resources since moving out of the shelter. The CTI worker, taking a trauma informed approach, does not assume the Veteran is simply being “resistant” by refusing to take the bus, but rather opens a conversation with him. After learning that the Veteran has a fear of buses due to previous traumatic experiences while waiting at bus stops, the CTI worker discusses alternative options with him, including telehealth, accessibility rides, or trying out new providers closer to home.