Frequently Asked Questions
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Case Planning
1. CTI GPD-CM training indicated that visits with Veterans should be at least weekly in Phase 1, bi- weekly in Phase 2, monthly in Phase 3 and more as needed in any given phase. Do all of those visits need to be face-to-face visits or visits in their homes?
In Phase 1, visits should be face-to-face (in person or via video technology) whenever possible, but don’t have to be in the Veteran’s home. After Phase 1, telephone contacts can take the place of some face-to-face visits.
2. 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, as they will vary case to case. The test of whether the linkages are adequate is how well the system is operating, and whether or not the Veteran is achieving his/her goals.
3. What is the best method for identifying goals for the Phase Plan?
The purpose of CTI GPD-CM is to connect Veterans to supports and resources that increase the likelihood for long-term housing stability.
Therefore, the goals in each phase should be directly related to this outcome. A good first step is to thoroughly explore what caused the Veteran to lose their housing and to make 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 goals would be family counseling, linkages to social supports and legal assistance. If the Veteran has already been connected to these supports before entering the GPD-CM program, a good Phase 1 goal may be ensuring these supports are maintained throughout their transition to their new community.
Therefore, the goals in each phase should be directly related to this outcome. A good first step is to thoroughly explore what caused the Veteran to lose their housing and to make 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 goals would be family counseling, linkages to social supports and legal assistance. If the Veteran has already been connected to these supports before entering the GPD-CM program, a good Phase 1 goal may be ensuring these supports are maintained throughout their transition to their new community.
4. The main purpose of CTI in the GPD-CM program is to link Veterans to a support network that will reduce his/her likelihood of repeated housing loss. What if your 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 is indicated. This would not be a case where extending the GPD-CM time frame is likely to be appropriate. However, the case manager should explore the Veteran’s reasons for declining the connection to services and take steps to address their concerns.
5. A Veteran loses their housing while in the GPD-CM program but still needs services. Does he/she have to re-enter GPD or another VA residential program and connect with other case management, or should we 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 them again with the support of the GPD-CM team that knows the Veteran.
Extending Beyond GPD-CM Time Frame
6. Veterans in our program may receive financial assistance of variable duration (to help with housing and other needs), but the GPD-CM program is only for 6 months. What do we do 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-CM program ends, and financial assistance continues, VA and community linkages should be providing support to the Veteran. Establishing linkages to these VA and community linkages is a major part of CTI while Veterans are enrolled in GPD-CM.
7. 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 that an extension is vital (after a waiting period, childcare becoming available, for example).
A lack of resources for Veterans should be noted and shared with your agency and GPD-CM liaison, so that they can work with the VA and local community leaders to add critical services.
A lack of resources for Veterans should be noted and shared with your agency and GPD-CM liaison, so that they can work with the VA and local community leaders to add critical services.
8. A Veteran disengages with the CTI Worker 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 time frame be extended in these circumstances by holding them in their current phase during the disengagement, or starting them over fresh in 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 changes significantly so that essentially a “new” transition process is underway (e.g., lengthy hospital stay, incarceration, etc.).
9. A Veteran contacts a CTI worker after discharge from the GPD-CM program requesting help dealing with a crisis or other reason. Do we tell them that we are no longer providing GPD-CM and refer them back to their supports and linkages, or do we help them?
Some limited advice and contact are acceptable, but Veterans should be re-directed to new supports and sources of help. The CTI worker should not assume the role of a primary, long-term contact for crisis intervention.
The CTI Philosophy
10. Some agencies we work with in the community do not embrace the CTI approach and collaborating with them can be difficult. Traditional case management strategies seem to prevail and there is a lot of disagreement about how to work with Veterans. How do we best collaborate with and educate other agencies about CTI and maintain these important partner agency relationships?
CTI agencies should work with their GPD-CM liaison and consider convening meetings with partner agencies to educate them about the model and discuss potential concerns and conflicts.
11. Some agencies that agree to use CTI do not engage in proper utilization of it. Common phrases/concerns from Case Workers: “CTI doesn’t work, this Veteran needs permanent case management.” Or, “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 do we check ourselves with this kind of thinking? How do we prepare our teams to change their way of thinking from traditional case management to CTI?
For some, implementing CTI requires a shift in thinking, which can be supported through additional training and supervision. It may be helpful to meet with other workers who have successfully employed the model with similar clients. CTI is not meant to be a substitute for long-term case management if that is what the Veteran needs; the GPD-CM program employs CTI to transition Veterans to appropriate community supports, including permanent
case management (through the VA or community agencies) when indicated and available.
Many Veterans can exit homelessness with short-term case management and/or financial subsidies; in fact, current nationwide data suggests that rapid-rehousing and other short term models are successful interventions for many people experiencing homelessness.
It is often challenging – if not impossible – to identify which Veterans need HUD-VASH or other permanent supportive housing and which Veterans only need a lighter touch, like CTI implemented in the GPD-CM program. Sometimes Veterans who appear to need HUD-VASH are able to resolve their situations with temporary help and sometimes the opposite is true. Helping staff to recognize and believe in Veterans’ strengths and resilience can be discussed in supervision. In case conferencing, a review of successful CTI examples can also help reinforce this.
case management (through the VA or community agencies) when indicated and available.
Many Veterans can exit homelessness with short-term case management and/or financial subsidies; in fact, current nationwide data suggests that rapid-rehousing and other short term models are successful interventions for many people experiencing homelessness.
It is often challenging – if not impossible – to identify which Veterans need HUD-VASH or other permanent supportive housing and which Veterans only need a lighter touch, like CTI implemented in the GPD-CM program. Sometimes Veterans who appear to need HUD-VASH are able to resolve their situations with temporary help and sometimes the opposite is true. Helping staff to recognize and believe in Veterans’ strengths and resilience can be discussed in supervision. In case conferencing, a review of successful CTI examples can also help reinforce this.
Ending Services
12. If a Veteran has completely disengaged from CTI of their own free will (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-CM services (with adequate documentation), discharge may be appropriate if this plan is approved by your supervisor and/or GPD-CM liaison.
13. A Veteran is doing very well and does not need services but has not reached the 6-month time frame. Can we discharge the Veteran early to make more space in the caseload for Veterans who need the services and just do a brief check in monthly?
Yes, you can do a brief check in monthly. Monthly visits are simply “Phase 3” and there is no need to discharge the Veteran from your caseload. By using the weighted caseload, you will be able to add more Veterans because Veterans in Phase III require less of your time.