Guide to Housing Works Community Follow-Up Program for Interns (Pt 1)

Hi, my name is David Euddeum Kwon and I was a social work intern in Housing Works Manhattan-1 Community Follow-Up Program (HW Man-1 CFP) from September 2009 to April 2010. Because the full name of the agency is rather lengthy, many people refer to the place simply as "Housing Works" or "Crosby Street." The Manhattan-2 CFP is referred to as "13th Street COBRA."

Still, while it's convenient to use these shorter names, it is important to know the full exact name of the place because there are many branches of Housing Works. For instance, in the exact same building that houses HW Man-1 CFP, near the reception desk is the headquarters of Housing Works Harm Reduction Place (HW HRP). The ultimate aims of all Housing Works branches and services are very similar, but of course, there is a huge difference between HW Man-1 COBRA CFP and HW HRP. This guide is intended for interns in Housing Works CFP, not for those in HW HRP.

As a disclaimer, I would like to point out that this guide is not an official document. It hasn't been certified by any highly credible entity. I, as the writer of this guide, cannot boast to you of any awards or honors. This is simply an informal instruction guide for student interns, written by a former student intern. I hope this guide turns out helpful to you. If in the end this self-titled "guide" turns out to be not so helpful to you, I at least hope that it shows you what another intern's experience in this agency was like.

Secondly, this guide is not the end-all, be-all of all things COBRA case management. Every student intern has different personalities, knowledge bases and approaches, so what worked for me may not work for you. You should read this as a first inside look at what COBRA case management is all about (I'd be honored if that was the case), or as a supplement to all the trainings and information you'll come to accrue over your time as an intern here. COBRA case management can be complex, frustrating, and maybe even ineffective at times, but that's all part of the learning experience. One of the Housing Works staff member I came to admire strongly once told me that it takes a lot of time and research to start getting COBRA right, and I hope that this guide helps to make sure that you don't discover that truth the hard way.

Finally, this guide has a very parochial vision, as it is only intended for those interns placed in one of Housing Works Community Follow-Up Program. It most likely won't be as helpful to interns in other Housing Works departments and interns in other non-Housing Works CFPs, since each CFP is structured differently.

General Overview

COBRA in COBRA case management stands for "Consolidated Omnibus Budget Reconciliation Act of 1985." This refers to how the services provided by this agency are funded. It allows those people living with HIV/AIDS or those people who are at risk for obtaining HIV to receive case management services by having their health coverage (almost always Medicaid) pay for those services.

You'll come to see that when a person first enters the facility to become a client to Housing Works, all the staff members will have a crazy preoccupation with the person's Medicaid or other similar entitlements, and that really is because that's how case management services are funded. This is arguably the most bureaucratic aspect of HW COBRA CFP, but it can't be helped, as it is one of the most fundamental way the organization's services are funded. After all, Housing Works is the largest grassroots organization in the United States (and possibly in the world as well) advocating for and assisting people living with HIV/AIDS, and thus, it'd be logical to assume that the revenue generated from grants and Housing Works thrift stores may not be sufficient.

For more detailed information about what COBRA actually is, check out the United States Department of Labor webpages on the topic, which you can access by going to the following web address: http://www.dol.gov/dol/topic/health-plans/cobra.htm

The more important acronym to be familiar with however is CFP, which stands for Community Follow-Up Program. As defined by the New York State Department of Health, the Community Follow-Up Program "provides intensive, family-centered case management services to HIV-infected and high risk persons, who are identified as having had difficulty accessing medical care and/or other services, and who require frequent personal contacts and/or home visitation to ensure their return for medical care and other needed services."

The case management services provided by Housing Works Community Follow-Up Program are the direct responsibilities and duties of case management teams (CMTMs) composing of three team members: the case manager (CM), the case management technician (CMT), and the community follow-up worker (CFW). The community follow-up program itself is composed of about four or five CMTMs, all of which are instructed and supervised by one program director (PD), who will also probably be your supervisor.

Housing Works as a whole has four community follow-up programs in total: (1) East NY Brooklyn Community Follow-Up Program at 2605-09 Pitkin Ave., Brooklyn, NY 11208; (2) Bronx Community Follow-Up Program at 1255 Rev. James Polite Ave., NY 10459; (3) Manhattan-1 Community Follow-Up Program at 130 Crosby St., 7th Floor, New York, NY 10012; and (4) Manhattan-2 Community Follow-Up Program in West Village Health Center at 320 West 13th St., New York, NY 10014.

Finally, the quality assurance manager (in conjunction with program directors) evaluates how each CMTM has provided services to their clients. The quality assurance manager is also responsible for the monthly COBRA Client Advisory Board (CAB) meetings, which invite clients to give their feedback on COBRA case management services. There are of course more positions (e.g. outreach supervisor) and more departments (e.g. Cylar House Medical) that fit into the structure of CFP but case management at its core refers to the members in the CMTMs and their supervisors and evaluators.

When I was an intern, I directly assisted two CMTMs, the HW Man-1 CMTM1 and HW Man-1 CMTM3. As mentioned, the ideal structure of each CMTM contains three key staff members: the case manager, the case management technician, and the community follow-up worker. I say this is ideal because in my experience, either not enough CFWs were hired - so one CFW was working for two CMTMs - or some event like a CM taking a paid time off (PTO) created a situation in which the CMTM was not operating at its full capacity. But that's the realistic nature of case management. Thus, the strength of a CMTM will depend largely on its flexibility to handle challenging situations and also the CMTM members' ability to communicate effectively with each other.

Now, just in case you may be suffering from information overload at this point, I will take this time to list important abbreviations I will be using. To fully understand the structure of a CFP, you must become familiar with these terms.

HW = Housing Works
CAB - Client Advisory Board
COBRA = Consolidated Omnibus Budget Reconciliation Act of 1985
CFP = Community Follow-Up Program
CM = Case Manager
CMT = Case Management Technician
CFW = Community Follow-Up Worker
CMTM = Case Management Team
PD = Program Director

Assuming you got all that, let's talk about the structure and functions of the CMTM in more detail. Communication and teamwork among the member of the CMTM are crucial particularly because the CM and the CMT share many responsibilities. Both CM and CMT are able to: conduct intakes (which initially assess the needs of prospective clients); formulate and implement service plans, conduct assessments and reassessments (which periodically determine how the needs of the clients are being met), hold case conferences with the client and client's other service provider(s) (e.g. primary care physician, HASA caseworker), and conduct homevisits.

They're both college graduates, with the position of CMT requiring an Associate's degree and the position of CM requiring a Bachelor's degree. They are both required to fulfill specific amount of billable units each week, and most of their responsibilities are billable. Basically, what this means is that the CM and the CMT must do certain kinds of activities on behalf of their clients each day. Most of their job responsibilities are billable, and the longer they do those activities, the more units they can document. Responsibilities such as intake, assessment, case conferencing, face-to-face contact with clients are billable actions and when documented, they all count toward the amount of units the CM and CMT must fulfill. This is how the CM and CMT are obligated to act for their clients, and also to document those actions. The bureaucratic system is there to make sure the CM and CMT are engaging in activities to help their clients, and also to enable QA director and the PD in evaluating the CMTM's ongoing efforts with their clients, but the downside is that the CMTMs can be dragged down by the required paperwork and documentation, which can compromise the resources they need to provide the best possible services to their clients.

If we're comparing a CM to a CMT on the sole basis of what their assigned duties are, you'll find that there really aren't any differences, other than the fact that the CM represents the CMTM. When the PD holds a supervision session for the CMTM, that actually means that the PD is talking with a CM, with the CM representing the entire CMTM. As a leader and representative of the CMTM, the CM holds weekly (realistically, it may not be this frequent) team meetings in which the CMTM decides who will do what for which client.

Working under and assisting the CM and the CMT is the CFW, the community follow-up worker. In my experience as an intern, it was the CFWs that I worked the most closely with (hence I often felt my closest allies in the agency were CFWs I've come to know), and it was the CFWs who taught me the most when it comes to being a good intern in Housing Works. Lot of this has to do with the fact that many of the duties of a student intern mirror that of a CFW, which include: pre-screening (to determine the eligibility of a prospective client); linking clients to entitlements they're eligible for; organizing and filing client charts; researching and providing appropriate resources and/or referrals; outreaching to clients lost to follow-up, and otherwise assisting the CM and CMT. Compare that list to the duties that you as an intern will be responsible for: pre-screening; explaining the structure and purpose of case management to prospective clients; linking clients to entitlements they're eligible for; researching and providing appropriate resources and/or referrals; outreaching to clients lost to follow-up; and otherwise assisting the CM and CMT. The only discrepancy between your duties and the CFW's duties is that you don't organize and file client charts.

In addition to these duties (which I will talk about in more detail later on in this guide), you may also possibly be allowed to co-facilitate (or even actually facilitate as I have done) CAB meetings and conduct intakes, but those aside, the duties of an intern and the duties of a CFW are virtually identical, especially in the beginning of the internship.

When you come across extremely complicated issues and perplexing questions, you'll most likely end up going to your supervisor and to other program directors for answers, but for many many other smaller issues, I believe you'll end up seeking help from your fellow CFWs. They may not be as well-educated and well-qualified as the CM or the CMT since the position of the CFW doesn't require a college degree, but even so, their expertise will prove to be invaluable for you. Most of what you'll be doing are most of what the CFW already does. I hope you'll also find your fellow CFWs to be inspiring and supportive, especially since a good number of CFWs were former Housing Works clients. In turn, I hope you'll be inspiring and supportive to your fellow CFWs as well.

With the CM, CMT, and CFW cooperating with one another to form a single CMTM, case management services are offered on average to about 35 clients per CMTM, give or take about three clients.

Here's how the CMTM works to provide case management services to a client.

When a person comes into the office hoping to become a client to HW CFP, the CFW first meets with the person to conduct a pre-screening, which determines the eligibility of the person. When the pre-screening deems that the person is eligible and so the person is given a Housing Works client ID number, the CM or the CMT conducts an intake to fully assess what the client's needs are. Many people come to HW CFP simply wanting assistance with obtaining independent housing (the agency is titled "Housing Works" after all), but case management services actually means helping those clients with HIV/AIDS or those at risk for obtaining the virus be able live as independently as possible. Because the services HW CFP provides is overseen by the AIDS Institute, CMTMs are particularly focused on a client's medical needs, and thus works to make sure the client is linked to eligible and appropriate primary care physician, and assists in adhering to their medical regimen. CM and CMT forms individualized service plans with clients to address their needs that are medical, mental health related, housing related, post-incarceration, domestic violence related, substance abuse related, HIV/AIDS related, and/or legal. Depending on what the client's needs are, the CMTM works to refer clients to appropriate service providers, making sure that the client is given the opportunity to consent to and choose which referral he/she would like to take, as not to violate the client's right to self-determination.

For example, for a client who is in need of mental health counseling, the CMTM refers the client to appropriate mental health counselor, whether that be the social worker in Housing Works Harm Reduction Place or a therapist in a hospital that the client wishes to go to.

Good case management does not end with a provision of services and/or a referral. That's why the CMTMs are required to follow-up on the clients on their caseload. The members in the CMTM are obligated to fill out various follow-up forms after every action taken on behalf of the clients and also after every evaluation of the clients. As mentioned before, the CM and CMT are billed for most of these follow-up responsibilities, meaning that they count their billable units.

However, the most commonly documented form - the progress note - is one of the the very few follow-up documentation that is not billable for the CM and the CMT. It's also a form that all members of the CMTM are required to do, including you the intern. Whenever your or any other member of the CMTM does some action on behalf of the client, that action must be documented on the progress note. This is a very simple form in which you must write down:

(1) when (from what time to what time) and where the event took place;

(2) what kind of activity it was (e.g. face-to-face contact with client, phone call on behalf of client, case conferencing with client's other service provider);

(3) what the issue was that prompted the action being documented, or in other words, why was this action necessary (e.g. "client not linked to primary care physician," "client hasn't been heard from for over a month");

(4) what the action on behalf of the client was (e.g. "referred client to Housing Works medical department," "contacted the client's emergency contact");

(5) how the action turned out ("e.g. client now linked to a primary care physician in HW medical," "client's emergency contact did not answer the phone so CM left a message on his answering machine");

(6) and finally, what the CMTM will continue to do for the client in the future. (e.g. "CMTM will make sure the client doesn't miss his medical appointment on ____ (a future date)," "CMTM will continue to outreach to the client").

It really shouldn't take too long to document progress notes since it just acts as a summary of what the members of the CMTM did and are continuing to do for the client. A progress note, though not billable, is an important follow-up document because it records not only at which date and time the CMTM acted on behalf of the client, but as more and more progress notes of a client accumulate over time, it displays the progress of the client. It's an official document that must be initialed by the member of the CMTM who wrote the note, and filed in chronological order (with the most recent note on top) in the client chart.

While progress notes are written up after every action taken on behalf of the client, other follow-up obligations are completed periodically. For clients who are HIV positive or for those clients who have AIDS, the CMTM should fill out quarterly forms for them every three months, and these forms document the client's medical status and progress. Face-to-face contact or even phone conversation with the client is not necessary to fill out a quarterly since the information needed to complete the form can be found in the client's most recent medical lab reports.

CM and CMT complete the quarterlies because they're the ones authorized and qualified to do so. Still, since I at one point assisted a CMT with her quarterlies, it is perhaps possible for you to be able to do so as well. Just make sure to talk with your supervisor to see if you would be allowed to assist with filling out quarterlies. Unlike progress notes, filling out quarterlies count toward the CM's and the CMT's required billable units. What this means is that you need permission from the CM and the CMT to be able to fill out quarterly forms. Any form that is billable for the CM/CMT is something you need permission to do.If you learn how to properly fill out quarterlies, I doubt the CMTM will be opposed to you helping them with the quarterlies, especially since they tend to be one of the least favorite forms for the CM/CMT to complete, but just to be safe, always make sure that you're able to do it, and that you know how to do it properly.

There aren't too many follow-up obligations nor forms that you'd be allowed to do, even with enough practice and training. Quarterlies are filled out every three months so you will not have much chance to work on them, and for pretty much everything else, CM and CMT are the only ones qualified to do the follow-up. You may possibly be able to do apartment assessments, in which you visit a client's residence and report the status of the client's living environment, but like quarterlies, apartment assessments don't happen frequently enough for you to be that concerned about. It's important to learn how to fill out all the forms, but be aware that you will not be able to actually fill out most of them.

CM and CMT will most likely especially prioritize Assessments and reassessments, which review the client's needs after a certain period of time. I mentioned before that for someone to become a client to Housing Works, that person has to go through a pre-screening and intake process. The intake form asks the potential client all kinds of personal detail in order to determine the needs of the person, from his/her name and address of residence (if he/she has a place of residence) to his/her medical condition (especially if he/she has HIV and if so, what his/her counts are and what kind of medications he/she takes) and down to their sexual orientation and sexual risk history. The assessment and reassessment basically does what the intake does, but in even more detail and after the person has been a client of Housing Works for a period a time. These follow-up evaluations determine whether the needs that the client has come into Housing Works with has been fulfilled, and to what extent.

You as an intern will not every have to worry about actually doing assessments or reassessments, but it is still very important for you to be aware that assessment/reassessment must be finished before the end of the month. One reason for this is that one of the responsibilities of the CFW is to update this form called the TICKLR, which is a list of deadlines for all the follow-up activities for all clients in the CMTM. You are not required to update the TICKLR nor should you do so (you have so many other things to be doing after all I bet), but if you ever need to assist the CFW with the TICKLR or even just understand what the TICKLR means, you must be familiar with what assessment and reassessment is. Another reason you have to be familiar with the assessment/reassessment process of course is because filling out these forms can very often be very taxing and time-consuming for the CM and the CMT in the CMTM. This being the case, knowing when a CM or CMT has to do intakes, assessments, or reassessments allows you to effectively schedule what kind of case management activities you'll be doing on which day of the week.

There are many other follow-up forms involved in case management, such as case conferences - in which the CM/CMT, the client, and/or the client's other service provider (e.g. client's primary care physician, client's HASA worker) discuss with each other about the client's progress and ongoing needs. Just like how you will not be allowed to complete assessments and reassessments, you also do not and will not have the authority to be in charge of case conferences. However, if you get a chance, try to shadow, or follow a CM/CMT to a case conference. You can learn a lot about the case management process this way, and more importantly, come to know who the clients really are.

Not all follow-up activities are so formal and daunting as a reassessment, and not all follow-up activities require the CMTM member to fill out a form. Simply calling a client or the client's HASA worker to know how the client is doing follow-up. Of course, even such a simple activity must be documented in the form of a progress note, but putting aside all the bureaucratic mandates of follow-up, the best and the most ethical way of thinking of and doing follow-up is to constantly worry about how the client's needs are being met and working most effectively as you can to help client satisfy those needs, all the while taking into consideration the individuality and the unique strengths of each client.

That ends my overview of HW CFP. I have no doubt that it's been a lot to take in, and most likely at this point, you're probably turning the pages to see just how much more I will blabber on, and maybe even to reevaluate if you indeed can handle this internship, but don't fret, because although case management on paper looks so formulaic, tedious, bureaucratic, and lengthy, I hope you'll find - as I have - that the more you get your hands dirty in case management, the more you'll feel confident and the more you'll witness the true power of empathic social work as it works to improves the lives around you.