Can anyone view the recordings in the CTI toolkit?
Yes, anyone can visit and utilize the CTI toolkit for recordings and written materials. Can anyone join the live CTI trainings?
Live trainings are accessible to GPD case management programs in the current training cohort (Wave 3) of Housing Transitions QUERI. What if I have questions between training sessions?
You are welcome to contact the Housing Transitions QUERI team anytime by email at [email protected]. When are the Community of Practice sessions?
Community of Practice sessions for the current training cohort (Wave 3) are held the 1st and 3rd Wednesday of month. Is there a way to get advice about a Veteran on my caseload?
If you are in the current training cohort of Housing Transitions QUERI, you can request a virtual case consultation anytime or join a drop-in hour session held on the 4th Wednesday of each month. As a supervisor, how can I support my case managers to use CTI with Veterans?
The CTI model recommends team supervision on a weekly basis, using tools like the Supervision Form to facilitate discussions of Veteran caseloads. Supervisors in the current training cohort of Housing Transitions QUERI are also encouraged to engage in Community of Practice and Drop-in Hour sessions to learn more about ways they can support their teams’ ongoing use of CTI. If we are already using forms similar to the ones on the CTI website, can we continue to use those forms?
If forms are similar and reflect the core components of CTI, you may continue using your organization’s documentation. If you would like to integrate our provided CTI forms with your existing ones, a CTI Documentation Roadmap is available to help navigate integration, or you may use the CTI forms available on the Tools and Resources page without alteration. For those who are part of the current training cohort of Housing Transitions QUERI and plan to use your organization’s forms, we encourage you to attend a Drop-In Hour or schedule a Case Consultation for assistance in making sure your forms follow the CTI structure. Who can we talk to if we are having problems recruiting Veterans into our GPD case management program?
You can reach out to your VA GPD case management liaison to identify possible VA programs from which you can recruit Veterans. If you are part of the current training cohort of Housing Transitions QUERI, you are welcome to discuss these challenges during a Community of Practice session or Drop-In Hour, or request a Case Consultation with our CTI experts. |
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CTI Topics
During each phase of CTI, do all Veteran visits need to be face-to-face or in a Veteran’s home?
In Phase 1, visits should be face-to-face (in person or via video technology) whenever possible and are generally in the field. While we would expect that some of these visits would be in a Veteran’s home, they do not all have to be. After Phase 1, telephone contacts can take the place of some face-to-face visits.
What are the guidelines for how many supports should be set up in each phase?
There are no specific guidelines for the number of linkages and/or supports, as they will vary by Veteran. The test of whether the linkages/supports are adequate is whether the Veteran is achieving his/her goals.
What is the best method for identifying goals for the Phase Plan?
The goals in each phase should be directly related to increasing the likelihood for long-term housing stability for the Veteran. First, thoroughly explore what caused the Veteran to lose their housing and develop goals that directly address these issues. For example, if a Veteran lost a job due to symptoms of depression, an appropriate goal for Phase 1 would be to connect the person to mental health services. If a Veteran lost their housing due to intimate partner violence, appropriate Phase 1 goals would be family counseling, linkages to social supports and legal assistance. If the Veteran has already been connected to these supports, a good Phase 1 goal may be ensuring these supports are maintained throughout the transition to their new community.
The main purpose of CTI in the GPD case management program is to link Veterans to a support network that will reduce his/her likelihood of housing loss. What if a Veteran doesn’t want to be linked to other services, or isn’t comfortable with case managers contacting their existing or potential supports? Do we discharge after six months, or should we request an extension in their duration of case management?
Yes, discharge at six months is indicated. This is not a case in which extending the GPD case management time frame is likely to be appropriate. However, before deciding to discharge, the case manager should explore the Veteran’s reasons for declining connections to services and take steps to address their concerns and ensure the Veteran’s needs are met.
If a Veteran loses his/her housing while in the GPD case management program but still needs services, does he/she have to re-enter GPD or another VA residential program and connect with other case management? Would we continue to work with him/her until something else is found, or until the 6 months is up?
The answer to this question differs depending on the referral processes in your agency. If the Veteran becomes homeless again and your agency allows for such, it makes sense to try and rapidly re-house him/her with the support of the GPD case management team that knows the Veteran.
Veterans in our program may receive financial assistance of variable duration (to help with housing and other needs), but the GPD case management program is only for 6 months. How do we proceed with Veterans who are still receiving financial assistance, but no longer receiving CTI?
Remember, the six-month time frame does not begin until the Veteran is housed. If your time working with the Veteran in the GPD case management program ends, but financial assistance is continuing, VA and community linkages created and/or strengthened during case management should be the source of support for the Veteran. For this reason, establishing strong linkages to VA and community resources while the Veteran is enrolled in GPD case management is critical and a core component of CTI.
What if there is a lack of supportive services in the area to help Veterans achieve their goals? Do we still discharge the Veteran after 6 months? Should or can the time frame be extended?
Yes, you should discharge the Veteran, unless a critical resource is forthcoming that indicates an extension is vital (e.g., after a waiting period, childcare will become available). A lack of resources for Veterans should be noted and shared with your agency and GPD case management liaison, so that they can work with the VA and local community leaders to add critical services.
A Veteran disengages with the case manager for a significant amount of time due to relapse, incarceration, hospitalization, residential treatment, or other reasons. Later, this Veteran re-engages. Can the clock for the 6-month CTI timeframe be extended by holding them in their current phase during the disengagement, or should they be re-started at Phase 1?
Dependent on the Veteran’s circumstances, it is acceptable to resume where the Veteran left off or to re-start. Re-start would be indicated if the Veteran’s situation has changed significantly so that essentially a “new” transition process is underway (e.g., lengthy hospital admission, incarceration, etc.)
A Veteran contacts a case manager after discharge from the GPD case management program requesting help dealing with a crisis or other reason. Do we refer them back to their supports and linkages or do we provide help and support?
Some limited advice and contact are acceptable, but Veterans should be re-directed to their new supports and sources of help. The case manager should not assume the role of a primary, long- term contact for crisis intervention.
How can we best collaborate with community partner agencies that are not familiar with CTI and its structure?
GPD programs implementing CTI can reach out to community partner agencies to discuss CTI’s 6-month structure and role in the transition and hand-off to community partner agencies, as well as to discuss potential concerns and conflicts.
Supervising case managers in a new case management practice can be challenging. Some case managers are not open to changing the way they work with Veterans. Reactions from case managers about CTI may include: “CTI doesn’t work, this Veteran needs permanent case management”; “This client is not appropriate for CTI. He needs a higher level of care.”; “This household is waiting for HUD-VASH, so why bother with CTI?” How can we support case managers during a change from traditional case management to CTI?
For some, implementing CTI requires a shift in thinking, which can be supported through additional training and supervision. CTI is not meant to be a substitute for long-term case management if that is what the Veteran needs; the GPD case management program employs CTI to transition Veterans to appropriate community supports, including permanent case management (through the VA or community agencies) when indicated and available.
If a Veteran has completely disengaged from CTI case management on their own (e.g., after multiple attempted visits to their home, phone calls, texts, emails, letters, collateral contacts, etc.), at what point can we discharge them early from the program and still maintain CTI fidelity? These disengaged Veterans hold valuable spots in a CTI caseload when other Veterans could be served.
If Veterans make clear after multiple attempts at engagement that they are not interested in receiving GPD case management services (with adequate documentation), discharge may be appropriate if this plan is approved by your supervisor and GPD case management liaison.
A Veteran is doing very well and does not require additional services, but has not yet reached the 6- month end of CTI. Can we discharge the Veteran early to make more space in the caseload for Veterans who need the services and just do a brief monthly check in?
You can do a brief monthly check in, but there is no need to discharge the Veteran early from your caseload. Monthly visits are simply “Phase 3.” By using the weighted caseload tracker, you will be able to add more Veterans to your caseload because Veterans in Phase 3 require less of your time.