→ Case Plans and Case Management

The case plan is used to structure activities during the participants’ stay at ROP. Youth must have a primary focus on employment and/or education, or if dealing with mental health or addictions issues may follow an alternative track that looks at dealing with those issues. Additional activities in a case plan could include life skills, health, legal issues, identification, discussion of curfews or chores, personal goals, budgeting and financial issues, volunteering, future housing plans and any other issues that arise that are important to help the youth successfully transition to independent living.

Case management is a collaborative process at ROP. We are client-driven and client-focused while at the same time balancing that it is a residential program that does ask its participants to identify these goals and to commit to themselves and the program how they want to spend their time and what’s important to them. Case management process is about trying to find meaning in how they want to spend their time while they’re at ROP.” — Dillon Dodson, Team Leader, Covenant House Toronto

Youth entering the Rights of Passage program have a referring worker (internal in another Covenant House department or external in the community). They also enter the program with a plan in place that has short and long term goals. This plan is initially discussed and agreed upon by the young person and their referring worker.

The application procedure is quite in-depth and includes a written application with support from the referring worker, an interview and a tour of the facility. During the application process ROP staff are able to delve deeper into a young person’s ideas and intent to help develop the case plan (as well as make sure the program is a good fit).

Both sites have an extensive orientation period to help youth adjust to living at ROP. In Vancouver the intake is conducted by the Youth Support Worker and the orientation period (Step 1) lasts a month. In Toronto a variety of workers take part in the orientation with the intention that the youth will be required to get to know and interact with the majority of staff. This orientation period usually lasts about two weeks.

Vancouver’s Case Plan Reviews Policy says “Youth have aspirations for themselves that do not include living on the streets. Youth made decisions for a variety of reasons that brought them to the streets, but this does not speak to their long-term intentions. They need support and assistance to develop the skills and knowledge to reach their full potential, and to mature and learn from their mistakes in a safe environment.

When a youth seeks help and support voluntarily, it signals that they are ready to begin making positive changes. At this stage, achieving their goals will be much easier. It will be more difficult when a youth is forced or feels forced by external pressures to comply with program goals and objectives that do not match what the youth believes to be their goals and objectives.” 

Both Toronto and Vancouver have a significant focus on education, which differs from most American ROP programs where the focus is employment.

In Vancouver, the majority of the 22 youth (19 out of 22 as of November 2014) are engaged in educational plans. This is supported by the extended stay possibility (a young person could finish high school and complete college/university while residing at ROP) and extensive financial support through scholarships that are made available.  In Toronto, more youth are engaged in employment, however a significant number are also in school.

In developing case plans both locations use the SMART goal concept. This means ensuring that plans are Specific, Measurable, Achievable, Realistic and Timely. This makes it easier to break the plans down into manageable chunks so that the youth can quickly develop a sense of possibility and success. 

CHT: The case plans in Toronto are developed by the Consistent Worker in partnership with the young person. A summary (Case Review Summary form) is prepared by the Consistent Worker and taken to one of the weekly Case Management Team (CMT) meetings; each youth’s file is reviewed every two weeks. The CMT meetings are attended by the Consistent Workers and Team Leaders, as well as the Life Skills Coordinator, Mentor Coordinator and other staff from Covenant House or community partners. At each CMT meeting, the Team Leader completes a Case Management Notes report based upon the input of the Consistent Worker and the other CMT attendees. 

At the 9 month mark planning begins for discharge and involves the youth’s Consistent Worker, Youth in Transition Workers and Housing Workers. This planning includes a very comprehensive assessment that looks at the skills a youth will need to live on their own and where they are in obtaining these skills. This helps determine future housing plans, including whether the youth needs another transitional housing program or is ready for independent living. In some cases, the gaps can be addressed through focused life skills development in the last few months. In others, the Youth in Transition (aftercare) workers may need to address some of these issues with the youth.

CHV: During Steps 1-3 the case plan form is filled out by the Case Manager and is discussed during the youth’s weekly case planning session, which is attended by the youth, Case Manager, and Key Worker. The Life Skills worker attends as needed. 

It is a very collaborative document. In Step 4, the youth begin developing their case plan for review with the Case Manager. By Step 5, youth are writing plans themselves and presenting them during their Case Plan session. In Step 6, the weekly case planning meetings move to bi-weekly and the youth continue to write their plans.

The Case Plan document has multiple components (see example – CHV ROP - Case Plan Sample). It includes basic demographic information, updates in a variety of key areas, notes on new areas/goals/dates and a section for the youth to make their own request of staff.

There is also a Case Management Residential Log, which is a narrative written by the Case Manager each time they meet with a youth or when they need to relay an update to the team (strategies, consultation with the mental health team etc.).

A Program Tracking Sheet forms part of the residential log. This contains steps and progress with program requirements, including curfew, key worker meetings, case plan, community dinners, life skills etc.). This information is formally tracked in Efforts to Outcomes (the evaluation database software) on a weekly basis and becomes one of the metrics used to evaluate the program.  Information from this section may be mentioned in the Case Plan, but is not a requirement as it is monitored by the Key Worker.

Covenant House Vancouver recently transitioned to a new Case Management Model. Under the previous model there was one Case Manager responsible for the 22 youth in the ROP program, as well as the youth in independent living with Hollyburn. Other Case Managers followed youth in the shelter program and through the outreach services. When a youth transitioned between programs they were given a new Case Manager.

Now, youth are assigned a Case Manager when they enter any Covenant House Vancouver program regardless of entry point. That individual will stay with and support the youth through their entire journey with the agency. If/when youth move between stages on the Continuum of Care, the Case Manager continues to work with them and support them in their new area of focus. 

Our goal is to have one youth, one file, and one Case Manager that will work with them up until they’re twenty-five years old. This way they don’t have to repeat their stories over and over again, and it will help them—one of the things we were seeing is we were starting over, every time the youth was coming back into the building. So this way even though that they may leave, they can still come back and we can continue moving forward with them.” — Lisa Ronaldson, Case Manager, Covenant House Vancouver

Homeless Hub Thoughts:

Case plans are excellent for tracking goals and activities. The plans are always youth-driven, which allows a young person to develop planning skills and autonomy even within a transitional housing/congregate living situation.