Case Management Guidebook

Comprehensive guidance and support to professionals working in homeless and drug services

The future of homeless services: Overview of the Pathway to Home model

The stages referred to previously describe the ‘current system’ of homeless and housing services and act as a guide for the case manager in navigating the current system on behalf of the service user.

It is vitally important to be aware that homeless and housing support-related services will be undergoing very significant changes throughout 2010 based on the implementation of a new homeless and housing system, namely, the Pathway to Home model. These changes are fundamentally necessary in order to achieve the agreed vision of eliminating long-term homelessness and the need to sleep rough in Dublin by the end of 2010.

The following paragraphs refer to the main features of the Pathway to Home model and will give an outline of what services will be developed into the future (see Figure 3. Pathway to Home).

Implementing the many and wide variety of actions to ensure that the vision is achieved will take some time. It is vital that case managers and service providers are kept up to date with changes as they happen, so as to minimise confusion and/or disruption to the service user. Therefore, it is critically important to keep in touch with your line manager as these changes are rolled out. Case managers can also access up-to date information on www.homelessagency.ie. Future print and web editions of this guidebook will be updated so as to ensure that the most accurate and up-to-date account of services is available. Up-to-date information will be logged on www.casemanagementguidebook.ie

1 What is a Pathway to Home?

The main focus of the Pathway to Home model of homeless and housing support services in Dublin is to both prevent homelessness and simplify and speed up the journey out of homelessness for those who experience it. The model provides a series of concrete actions for all stakeholders in the provision of services (both statutory and voluntary) to people who are homeless in Dublin; this series of actions will need to be completed in order to implement changes in how homeless people’s needs can be best addressed.

In essence, this means that homeless services are to be reconfigured so as to ensure that we will be able to increase the number of people who can gain access to long-term housing with supports provided in their own home (as required), and minimise the time that people are staying in an emergency situation without access to appropriate support or housing options.

The structure of the Pathway to Home model has three inter-related and mutually dependent elements, namely:

  • Interventions and services that prevent homelessness.
  • Temporary accommodation and homeless service.
  • Housing with supports.

Central to the Pathway to Home model is a person-centred approach. The significance of this in relation to various elements of the model is as follows.

2 Person-centred outcome for prevention

A person’s risk of homelessness can arise from any number of situations. The Pathway to Home model will ensure that homelessness is prevented by services delivering early interventions, thus diverting the person at risk from experiencing homelessness, or from having to enter temporary accommodation.

3 Person-centred outcome for temporary accommodation

Where prevention does not occur and a person is experiencing homelessness, the Pathway to Home approach will ensure a same-day initial contact assessment of a person’s needs and their placement into an appropriate form of temporary accommo-dation. During their stay in this accommodation, the person will work with their key worker to complete a Holistic Needs Assessment (HNA), and their housing options will be examined and assessed by the local authority. This will result in a person-centred support plan and move-on housing options being agreed. Prior to an allocation being made to appropriate move-on housing, the required housing supports will be confirmed and secured so as to ensure that as seamless as possible a move from temporary accom-modation into housing is made for the person.

4 Person-centred outcome for housing with supports

The housing support service will deliver person-centred housing supports to the person who resides as a tenant in appropriate housing. Housing support will work to help establish, secure and sustain the tenancy; settle the person into their neighbourhood and community; support the person towards independent living and the realisation of their full potential and rights. 

5 Pathway to Home assessment

To attain the sought after person-centred outcomes of a Pathway to Home, it is important that all statutory and voluntary providers agree and utilise the HNA. This should achieve a comprehensive understanding of the multiple care and related needs of the person in a holistic manner, as well as establish the extent of their experience of homelessness, and their housing and housing support needs. This is a challenging and sometimes complicated task and requires time, resources and practices that respect and protect the individual.

Mechanisms such as interagency protocols are being put in place. These will clarify and strengthen roles, relationships and responsibilities among service providers, and are aimed at improving the assessment and support planning process where multiple agencies are involved.

Work is well underway under Core Action 4 of ‘A Key to the Door’, which involves implementing the Holistic Needs Assessment and Care and Case Management Interagency Protocols across the sector.

In order for the Pathway to Home model to work well, certain other key operational components are in place. This includes a common operational criteria for homelessness that ensures a Dublin city and country wide provision of services to all people at risk of rough sleeping and rooflessness.

6 The Pathway to Home model portfolio

The Pathway to Home model is made up of a portfolio of housing and temporary accommodation types and services, which are configured to realise and ensure the sought-after person-centred outcomes described above.

 Table 1: Pathway to Home portfolio of services

A: PREVENTION SERVICES B: TEMPORARY EMERGENCY ACCOMMODATION AND SERVICES C: HOUSING AND HOUSING SUPPORT SERVICES
  • The Local Authority Homeless Helpline: a 24-hour Freefone service providing information, advice and (on an out-of-office hours basis) initial contact and placement into Temporary Emergency Accommodation.
  • The Local Authority Housing
    Service: (across all Dublin local authorities) providing information and advice and referral to prevention services where appropriate.
  • The Community Welfare Service: a statutory service providing income maintenance, early interventions and access to housing options that prevent rooflessness and shorten and truncate an episode of homelessness.
  • The Contact and Outreach Services: delivers early interventions, initial contact and placement into temporary accommodation to prevent rough sleeping and rooflessness.
  • The Homeless Prevention Services: specifically, day services, information, advice and advocacy services, mediation and dispute resolution services and early intervention housing support services that prevent homelessness. In addition, all mainstream public services have a role in preventing homelessness.
  • The Local Authority Housing Service: providing initial contact and placement (based on common criteria in use across all Dublin local authorities) into Temporary Emergency Accommodation.
  • The Local Authority Housing
    Service’s Centralised Placement Service: confirms and monitors access to all Temporary Emergency Accommodation via a bed management function.
  • Supported Temporary Accommodation: (STA), including inreach services provided by the HSE, FÁS, VEC etc and housing support services for persons moving into housing.
  • Temporary Emergency
    Accommodation: (TEA) including housing support services for persons moving into housing.
  • The Local Authority Housing Service: providing the Assessment of Housing Need and delivering priority access to all available housing options8, including specialised housing schemes with on-site housing support services.
  • The Housing Support Service: including visiting housing support services and on-site housing support services that are provided in addition to established mainstream social service provision.

 8 Mainstream Housing Options, including (a) Local authority social rental (b) Approved housing body (housing association) social rental (c) Rental Accommodation Scheme (RAS) social rental (d) SWA rent supplement private rental (e) The new Supported Housing Leasing Arrangement (f) Local authority affordable housing schemes and shared ownership housing. Specialised Housing Options, including (a) Local authority group housing schemes for the elderly (social rental), (b) Approved housing body (housing association) group housing schemes (social rental) (c) the new Supported Housing Leasing Arrangements with on-site support.

Table 2. outlines the step-by-step process of assessment from the first point of contact of a
homeless household with homeless services through to Holistic Needs Assessment and Support Planning and finally to exiting homelessness in the context of a Pathway to Home.

Table 2. Process of Assessment

Action Services Responsible      
Initial Contact and Placement Form
 
Local Authority Housing Service (office hours)
 
Local Authority Helpline Placement (out of hours)
 
Contact and Street Outreach Team (placement through LA Housing
Service/ Helpline)
Temporary Accommodation Provider (self-referrals)
 
Holistic Needs Assessment Temporary Emergency Accommodation
 
Supported Temporary Accommodation
 
Contact and Street Outreach Team (in exceptional circumstances)
Also Housing Support Service (where not already completed)
 
Long-term Supported Accomodation Provider (where not completed already)
 
Assessment of Income and Welfare
 
Community Welfare Service9
 
     
Assessment of Housing Need
 
Local Authority Housing Service in collaboration with housing provider      
Housing Support – supports move into and sustainment of housing Housing Support Service
 
     


9 See p42 of “Pathway to Home”: http://www.homelessagency.ie/getdoc/f1f3f07f-0845-4011-be50-189ffae0cee4/Pathway-to-Home-model.aspx