Models of how to organize housing, clinical and complementary supports

Information about the Housing First Service Delivery Models

Intensive Case Management (ICM) and Assertive Community Treatment (ACT) are two case management models under Housing First (HF) that have well-defined standards and a strong evidence base. These models represent the two major ways by which housing, clinical and complementary supports are organized and provided to HF clients. It should be noted that each of these models is intended to be understood on a continuum rather than as absolute standards. It is fully expected that communities would adapt these models to fit their local situation.

In practice, most communities apply ICM and ACT very broadly, organizing housing and clinical and complementary supports provided to homeless HF clients based on the particular community setting and the self-determined needs of the client. For more detail on the wide variance of how HF is organized and delivered in communities, please see case studies.

Intensive Case Management

Intensive Case Management (ICM) is a team model in which case workers, working alone or in teams, link individual clients to mainstream housing, clinical and complementary supports. Case managers provide outreach, develop relationships and coordinate with other services to help people access needed services. ICM teams may include housing and complementary support workers, with a link provided to mainstream clinical services.

Specific characteristics of ICM include:

  • One-on-one case manager to client relationship using a recovery-oriented approach (the team of case managers may include housing and complementary support workers).
  • The case manager brokers access to mainstream services that the client identifies as needed to attain his or her goals.
  • The case manager links clients to health professionals (e.g. family doctor) and other services.
  • The case manager often accompanies clients to meetings and appointments in support of their goals/needs.
  • Case managers are available on a regular schedule; caseloads are often shared to assure coverage of 7 days per week, 12 hours a day.
  • The staff to client ratio is generally 1 case manager per 20 clients.
  • The duration of the service is determined by the needs of the client, with the goal of declining supports and transitioning to mainstream services as soon as possible. In some cases, it may be possible to transition clients within 12 to 16 months.

ICM and the HPS

ICM activities would be considered eligible for funding under the renewed HPS, and communities could use HPS funding to support ICM teams either in part or in full. The HPS approach is to broker service with existing systems of support. This fits the overall approach of the ICM model, which is to link clients to mainstream services. It is expected that most communities will apply some variation of the ICM model for their HF programs.

Assertive Community Treatment

Assertive Community Treatment (ACT) is a recovery-oriented, comprehensive, multi-professional model that usually includes comprehensive clinical supports, such as a psychiatrist, doctor, nurse and substance abuse specialists on a single team, and that team serves all of the client's needs. Housing and complementary supports may also be provided by the team; alternatively, the ACT team may link the client to mainstream housing and complementary supports. An ACT team provides a client-centred, intensive service for people with significant mental health and/or addictions issues. They provide a range of supports directly to individuals who would not be ready for integration into the mainstream for some time (e.g. recovery and wellness services; peer support; integrating mental health and addictions supports).

Characteristics of ACT teams include:

  • A multi-disciplinary team of health professionals that provides wrap-around service directly to the client.
  • The team members are available 24/7 and provide real-time support.
  • The ACT team meets regularly with the client and with each other (could be daily).
  • The team is mobile, often meeting clients in their homes.
  • The staff to client ratio is generally 1 ACT team per 10 clients.
  • The program components are informed by client choice, peer support and a recovery-orientation.
  • Services offered on a time-unlimited basis, with planned transfers to lower-intensity services for stable clients.

ACT and the HPS

The creation of new ACT teams is ineligible for funding under the HPS as health falls within provincial/territorial jurisdiction. The direct provision of ongoing clinical supports (services of a psychiatrist, doctor, nurse and/or substance abuse specialists) is an ineligible activity. Communities currently without ACT teams would therefore be expected to offer an ICM-type model with brokered access to mainstream services.

For those communities with an existing ACT team, the HPS approach is to develop collaborations with existing ACT teams in place in a province or territory.

In all cases, communities are encouraged to work with local partners, health authorities and provinces/territories to provide coordinated services required for clients in a sustainable way that fosters self-sufficiency and that avoids creating any kind of long-term dependency.

It is of note that funding for housing and complementary supports could be used to leverage access to existing teams. Similarly, the HPS could fund a coordinator and/or peer support worker to facilitate access to existing clinical supports or to leverage the creation of a new ACT team which would be funded through non HPS funds.