Abstract
The Maricopa County Intensive Case Manager serves as a unique position within the Senior and Adult Independent Living (SAIL) program. The County’s use of this new position addresses a critical and growing gap in SAIL services to the highest-need and most intensive cases that were previously underserved. This position has proven a worthwhile investment and for Maricopa County by providing services to people with the high needs level that has resulted in the ability of our staff to improve outcomes for these individuals, while at the same time improving the overall efficiency and effectiveness of the County’s 32 case managers. The need for the Intensive Case Manager position is not unique to Maricopa County. The model that has been developed could be adopted by other jurisdictions providing similar services, as evidenced by the very positive results realized by clients and staff.
Problem or Need for the Program
Maricopa County’s Senior and Adult Services Division (SASD) serves a unique and vulnerable population of seniors (age 60+ years) and adults with disabilities (age 18-59 years) using a Home- and Community-Based Services (HCBS) model of case management through its SAIL program. The Division currently provides services to approximately 3500 individuals across all of Maricopa County and has a case management staff of 32. The current staff to client ratio is 1 case manager per 100 clients. The vast majority (75%) of the population served through these programs lives in poverty at 150% or below the Federal Poverty Level. Nearly 75% of the clientele we serve in this area live alone and each clients has significant medical, physical and/or chronic health conditions impacting their ability remain independent and safe in their homes.
To help clients remain in their homes for as long as possible, SASD case managers provide comprehensive and holistic case management services addressing all areas of a client’s life. At intake and annually thereafter, case managers complete a thorough review of each client’s home environment, medical conditions, recent hospitalizations or falls, income and expenses, behavioral health concerns and other safety concerns that is documented in a 16-page report. Once assessed, clients are authorized for services such as home-delivered meals, personal care (bathing assistance), housekeeping, bath-safety checks to reduce fall risks in the bathroom, and other supportive services.
In addition to authorizing the core set of services provided through the program, case managers make innumerable referrals to community-based resources (housing, utility and rent assistance, hospice organizations, etc.), complete Adult Protective Service (APS) reports when abuse or neglect is suspected, conduct welfare checks when a client cannot be located, assist with Arizona Long Term Care System applications and so much more. These are standard and expected elements of any comprehensive case management program.
Over the last three to five years, SASD case managers (particularly its long-serving case managers with more than 20 years of experience) noticed a shift in the needs of their clients. They observed a consistent trend in client needs escalating into an active crisis for health and safety issues. These situations have included dilapidated homes with infestations of insects, rodents and other pests as well as an accumulation of surfaces covered with trash, feces, and urine. Many homes are below minimal acceptable standards for health and safety conditions. For those clients in rental situations (even some subsidized units), the rent has become unaffordable or is projected to soon be out of reach of their limited income. Many clients are turning to room-for-rent options which leaves some clients living in garages not intended for sleeping quarters or other highly unstable and sometimes dangerous situations. Other clients are finding themselves in emergency shelters and some on the streets without access to permanent safe and affordable housing. The risk of homelessness and the inevitability of homelessness has become a daily report to case management staff among this population of people managing age and/or health and other financial concerns.
The pandemic also highlighted and exacerbated the mental health needs and cognitive status of SASD clients. As clients become increasingly isolated in their homes, mental health crises arose. Case management staff have noticed that clients with dementia experienced a decline that may have gone unnoticed during the periods of isolation during the pandemic. Calls to the behavioral health crisis line increased and case managers frequently turn to Adult Protective Services to assist with cases of extreme self-neglect. Case managers carry full caseloads of approximately 100 clients per month which leaves very little time to fully address client crises, especially when they are frequent and of high magnitude/complexity/difficulty.
Description of the Program
To address the increasing rise of acute and ongoing client crises, SASD began recruitment for an Intensive Case Management (ICM) position in the summer of 2020. This was a new position for the Division and one that was difficult to fill. Ultimately, the recruitment team opted to promote a highly seasoned and well-respected SASD case manager into the ICM role under a special work assignment (SWA). This staff member began in this new role in September 2021.
This ICM staff conducts a variety of specialized assignments. For example, this staff person:
- Works a condensed caseload of highly complex and high-priority clients (Approximately 9 cases).
- Serves as the initial case manager for some clients referred by the Area Agency on Aging (AAA) APS unit. These clients are typically in high need and require a significant level of assistance to become stable before they can be transferred to a regular case manager.
- Assists with complex biohazard cleaning to ameliorate environmental hazards in client homes. This includes ongoing communication with AAA’s APS program, landlords, cities, clients, and the ongoing case manager throughout the biohazard clean process.
- Leads a pilot program for specialized housing vouchers, Tenant-Based Rental Assistance (TBRA), a collaboration with Maricopa County’s Human Services Department and the Housing Authority of Maricopa County.
- Provides ongoing guidance and consultation to regular case managers on client crises – particularly housing crises.
- Provides training to new case managers on APS and Mandated Reporter requirements.
Of all the tasks the ICM has undertaken, working on housing crises and the TBRA voucher program has been the most intensive part of the role.
Almost daily, the ICM is contacted by a case manager requesting guidance on a housing crisis. The ICM provides information about tenant rights, Community Legal Aid, emergency shelter options, and other supports dictated by the circumstances. At times, the cause of the housing crisis has been a housing condition (trash, pest issue, etc.) which prompted the landlord to issue a 5-day notice or non-renewal of lease. The ICM has provided guidance to case managers to help avert an eviction to keep the client housed.
Cases that qualify for the TBRA voucher program are referred to the ICM to lead through the process of obtaining this specialized housing voucher. The goal is to help a total of 20 SASD clients obtain a voucher providing them with long-term stable, subsidized housing. The ICM is working on 5 clients at a time due to the level of work required per client. The process to obtain a voucher is arduous and requires assistance by ICM through each step. Once a client obtains the voucher, it is up to them to find a unit that will accept the voucher. On average, it takes approximately 22 hours to help each client complete the application process.
Responding to Economic Downturn
The economic downturn has exacerbated many socio-economic problems throughout Maricopa County and this has resulted in an increasing number of seniors and adults with disabilities needing high-intensity case management services. Although staff has observed the trend of complex cases increasing for several years, the economic downturn has appeared to spike the number of these cases and intensify the conditions associated with each case. More specifically, internal reports/communications within the SASD indicate an increasing number of clients require a much greater level of care and assistance by case managers than in years before the pandemic. COVID-19 isolation protocols lead to many additional health and economic issues for seniors and adults with disabilities because their access to support services and helpers was severely limited or severed. These issues worsened their living and health conditions causing their cases to become more complex; requiring a more focused case management model to address their issues.
Advancing Diversity, Equity, and Inclusion
Maricopa County’s Human Services Department always strives to advance diversity, equity, and inclusion in all of its programs with SASD case management being no exception. The ICM model allows SASD to focus on equity by providing more focused services to complex, high-need, and very vulnerable clients. The specialized services that are provided by the ICM help restore conditions that contribute to increased safety of these clients and reduce homelessness. With the more intense focus that the ICM can offer clients with more complex needs, their outcomes have improved. They can receive the specialized services they need allowing more equitable outcomes so they can achieve the same or a better level of independent living as clients with more straightforward needs.
The Cost of the Program
The cost of the program for the County is one (1) Full Time Employee (FTE) along with travel costs and other expenses. Due to the intensive nature of this position and advanced skills/responsibilities that this position requires, other localities may choose to pay this position a higher wage/salary commensurate with their experience, skills required, and workload. Maricopa County has discovered through the implementation of the ICM position that investing in a position to provide a more focused, specialized level of care has helped reduce costs in other areas. For example, assisting these vulnerable persons obtain affordable/supportive housing reduces costs on other systems such as hospitals and medical centers, which can cost significantly more to serve those persons compared to supportive housing.
Results/Success of the Program
The ICM has been invaluable to the SASD team in that this person has been able to manage the most time-intensive clients with complex needs. This has resulted in positive outcomes for staff and clients in that the demands on case managers are reduced while the specialized needs of these particular clients are addresses in a more focused way. SASD continues to realize benefits from having this position/program including the following:
- Time Savings for Regular Case Managers: Since September 2021, the ICM has completed more than 300 hours of intensive case management duties that would have otherwise been required by a regular case manager. Additionally, these hours allow for continuous assistance and attention to these clients allowing for a greater likelihood of improvement of their situation compared to the more fragmented assistance regular case managers would have to provide based on their already high caseload of approximately 100 clients per month.
- Homelessness Prevention: The ICM is leading the effort to obtain TBRA vouchers for clients which has proven to be a very time-intensive task that would otherwise monopolize the time of regular case managers, potentially pulling them away from their typical duties. The ICM works the TBRA process to secure stable, permanent, and affordable housing for SASD clients facing homelessness. The ability to focus intensively on the voucher process allows the regular case manager to go back into service in their rotation while at the same time, pursuing housing options for this special-needs population that would face extreme hardship by a lack of resources should they become homeless.
- Home Environment Improvement: The ICM has been instrumental in facilitating multiple complicated biohazard cleanings. These cleanings required significantly greater coordination, communication and interaction with the clients and partners to facilitate these cleanings. This work, in addition to greatly improving outcomes for the clients (averting client evictions), further enhanced the quality of life for these clients by restoring an environment that promotes health and safety. An added benefit of utilizing the ICM position is that shifting this work from the regular case managers allows them more time to devote to their caseload. In essence, the regular clients also realize a benefit from having more time with their case manager that might have been otherwise required to handle a complex home cleanup.
- Demand for this position has been increasing: SASD client crises have not abated and continue to rise County-wide. Internal reports and communication for several years indicate that the complexity of the SASD client population is expected to grow. These trends in increasing need and the successes realized to date through implementation of the ICM position are indicators that Maricopa County expects the need for this position will grow annually.
Supplemental Materials