morning for all of you. It is just a little bit before one for me. So I'm in Nashville and it's really, really hot. I'll just say that it's really, really hot. So what we're going to do today, guys, is we're going to go through and take a look at what a critical time intervention actually is and why it might have some value for the work that you're going to do, okay, or that you're currently doing. And before I go on, as you know, I mean, Sarah's here with the Opioid Response Network. And here's what I will just tell you about it since you're already here and you know it. If you have technical assistance needs, call Sarah, email Sarah, or submit online and it'll get to Sarah. And here are the contacts that, you know, if you need them, but you already are in contact and you are in really good hands. So with that, let's jump in here and I'll just, you know, I'll introduce myself a little bit. And I want to get into the meat of this because I think that's really why you're here. So I am a person in long-term recovery and I have, you know, the big five of behavioral health conditions. So I've dealt with homelessness and I've dealt with, I have an opioid use condition and I have a couple of mental health challenges and all of those have affected me, you know, re-entered from prison after a couple of years for a non-violent cannabis drug crimes. And I've got all kinds of childhood trauma. I'm like the, you know, the pretty much, you know, the folks that you engage with and try to find housing with and, you know, come with a, you know, a backpack full of challenges with them. And it's kind of pretty much how a lot of us are, right? So what we'll do today is we're going to define critical time intervention. By the time we're done, you'll be, this is not rocket science. It's just a little bit of science, right? And some, I think, you know, considered steps. Okay. So we'll be able to define it. We should be able to talk about the three phases. We should be able to talk a little bit about the core component, actually a lot of it, and then why we would even consider using that. Okay. All right. And before I really get going, if you have questions, if you need a more clarification, as you're probably going to see one of my, one of my mental health diagnoses is ADHD, severe inattentive type, and they also pay me to talk. So I earned my money. And if you need to stop me and just push in, just do that. Okay. I won't take any offense to that. Excuse me. All right. So what the heck is this CTI or this critical time intervention? Well, it is an evidence-based practice. So first and foremost, I mean, that's a really important piece for the work that we do today, particularly around, you know, data-driven grant funding, for example. And the whole idea of CTI is to really support vulnerable individuals and families as they're going through that, that really tricky transition from homelessness into some sort of housing, whether that's transitional, whether we're talking about housing first, you know, whether we're talking about an Oxford house it's still that transition and return back into the mainstream community life. That's really hard for a lot of us. And it's because there's, you know, there's a bunch of stuff around cultural competency here. We won't dive into it, but what I will tell you is in terms of community, if we move people who have been experiencing homelessness for any real length of time, particularly folks who have lived in camps and we put them in housing, I think all of you know that, you know, without bringing some sort of community along with that, you've basically put somebody in a box and given them a TV and they're not going to stay there. And it's because they missed their community, right? I mean, it's really the whole thing. Does somebody got a question? Okay. Disagreeing with you. Awesome. Awesome. You do your work for sure. So, you know, if we don't have a better community and a sense of community wrapped around them, it's those cultural pieces of homelessness, you know, the need to be, to support a brother or sister, if you have a house or a place to live, they need a shower, you can open your door. And the reason you're normally going to do that is because your housing has likely been tenuous throughout. You have a real strong feeling you're probably going back at some point happens all the time. And the last people you want to tick off are all the people that you hung out with and, you know, took care of each other while you were living in that camp. So it's really hard for us to kind of break away from the pull of that community. And the only way really that we break away is when we're moved as slowly into a community that's stronger, like, like, you know, the recovery community as an example. So as we kind of move through this, you know, the phases, and we'll talk about them in a second, what ends up happening is, and our role is to build some skills, and most importantly, networks of support, right? And, you know, we'll talk about the difference between kind of goal oriented, and what we have as our role in a minute, okay. But as I said, you know, it's around those networks of support, and living successfully in the community, and reduce those returns to homelessness, to institutions, right to recidivism, and back to jail, all those things, community. And, and, you know, we talked about this a lot. And we talked about cultural competence a lot. And we train on it all the time. And I'm not sure how we keep missing these, you know, these really important subcultures, they exist. And they are major barriers to recovery, major barriers to maintaining housing, just major barriers to sort of returning to, you know, some sort of a life without homelessness, without substance misuse, etc. So how they do it is they come at this in phases. And each phase, I don't like the term intervention, it's sort of scary on the street anyway. But it is kind of an intervention. And it's a really detailed assessment. And then how, what is based on that assessment, and most importantly, what you're hearing from the individual, how are we going to support that person, what services in our community are, you know, available to, you know, kind of take on this need. And that's, that's one of the best things about CTI, because it spreads the effort. And it, you know, you can think about it as it takes a village, right? It uses evidence and best practices. And, you know, pretty much, that's all it uses. I mean, there's, you know, it's hard to think about anything that, you know, is done in critical time intervention that doesn't have data to back it up. And it does practice harm reduction. And just a quick word about that, because harm reduction sometimes gets, you know, some folks in our community will raise their eyebrow at it. It's community driven. So what it's harm reduction is whatever the community wants. It's not, you know, a team coming in and forcing a, you know, supervised consumption site on the corner next to the local church, right? It's, it's not that. It's what the community wants. So, you know, a little bit of harm reduction. You know, the wear your seatbelts when you drive to work. You know, it's pretty straightforward harm reduction. It's also person centered, right? Everything that we do revolves around that individual. And that person really tries to help drive what the, you know, what the, what the effort and approach and, you know, the services needed, all those pieces. We want to hear from them. Because when we don't hear from them, you know, we, we move forward. And listen, I know, we all have really good intentions, right? We don't do this work because we're getting rich. Many of us do this work because we've either had to deal with some of this, we have family members who have, you know, we've, we've, we've got, you know, we believe in humanity and dignity and respect of each other. You know, those are the reasons we're here, right? So, for, you know, for us, working with somebody in, you know, kind of around that, that, you know, that, that reality of who they are, and what's going on in their life, brings us really tightly alongside them. And unfortunately, it also brings a lot of our biases and, you know, a lot of our experiences from the past, that, you know, especially when we are engaging with folks who, you know, we're, we're catching really at the, you know, probably one of the worst moments of their lives, right? So, it's kind of hard to base an assumption or make a judgment on that. We do all the time. And then finally, what we want to do, I do want to say a thing about motivational interviewing, really quick before I move on. Am I motivational interviewing? It's awesome. There's no question. But if you're trying to really do clinical motivational interviewing, it's really, really challenging if you're not a clinician, and you don't have controlled environments, and you, it's difficult. It's difficult to maintain the fidelity. It's not difficult to practice the principles. And the principles are what moves you. And there's a version of MI that I promote a lot. And I know they're working on, you know, kind of developing this, but I call it MI light or MI for the streets. And it, it is how I would engage a person with lived experience who's been in those subcultures. It's how I would engage using motivational interviewing techniques that sound like I'm talking in the language of my subcultures. If you can't do that, it's really hard for us to believe that you have any clue about what we, you know, what we're going through, what we endure, what our daily life is. And that's one of the reasons people with that lived experience can make those connections faster than most of us. Right? So we want people who are engaging with our brothers and sisters who are struggling like that, to be able to connect, to be able to help that individual build their own tension about what they know they should be doing versus what they actually are doing. Right? And I mean, that's the, you know, sort of fundamental bottom line of motivational interviewing. It works on the street and in housing first and in CTI really, really well, because the goal is to move people forward, right. And to move them forward back into the community. To do it, we got to make sure our direct service folks really know and have these basic sort of engagement assessment. And I don't like the term counseling either. But I mean, it's, you know, it's going to have to do for here. When I think of counseling, I always think of the real clinical environment. And that's not what they're talking about at all. As you can see, I mentioned utilizing peer workers here with lived experience and a recovery oriented set of knowledge and skills will help support and they'll definitely help improve the engagement you're having with the folks that you're working with in CTI. It is, I mean, to me, yeah, it's strongly encouraged. But if, you know, if you're struggling as a provider, in an environment where, like I said, you really don't know that culture, and it's hard to speak the language, they're not going to believe you. And, you know, honestly, you're just one more voice that they have hundreds of telling them what they can and can't do all day long. You know, they know that. And as soon as you leave, they shut the door. Okay, now, where were we? Right? That's, you know, that's kind of how it is. When you send me in. It's a lot different. Because, excuse me, because I can talk their language. And I can talk in a way that, you know, most people can, yep, it, you know, it gets pretty much down and dirty is, you know, our language on the bricks is, but it's one of the ways I build cred with them, too. Right? If I can speak that language, they know within 30 seconds, whether I'm a poser or not. And as soon as they, they know that I'm for real, then the guard comes down. And it's what happens with most peers, right? peers that are trained, there's a difference between, you know, a trained recovery coach or certified peer specialist, and a person with lived experience. And I'll point that out just briefly, a peer worker is trained, they're certified in almost all states now. And often they'll have several different credentials around, you know, reentry support, or could be, you know, emergency room support, or, you know, there's a there's a number of newer and ever expanding titles for peer workers, because we know that they work, those folks can work one on one with with the folks that you're engaging. If you have a person with lived experience in their training, those folks make fantastic advisory group members, they are great for focus groups, they're great to send surveys to, because they like to fill them out, it's and they get some results from that. Those folks are really good at developing understanding what folks actually need, where your gaps might be, and some of the program, programmatic ways of coming at it to make it a little bit more appealing to folks. There's a lot of value in bringing somebody in with lived experience to help. So just briefly, you know, the CTI started in in the 80s in New York. And I think at that time, for, you know, for a Section 8 voucher, you had like a nine year wait, I'm not exaggerating. I mean, it was nine years. I know here in my community was four years, and I live in Nashville. And that's been a while. I don't think it's getting much better. Because I just saw our recent point in time count, and you know, homelessness here, like every place else just about has increased. So as you can see, it was a response to that crisis. And the best practices came out of what they learned as they did the CTI work. And it is a short term approach. And it helps people adjust in that real critical time of transition. And it is, you know, it's considered an intervention that we can use in other areas. And we use some of this around substance misuse. You know, CTI is, it's working in areas that aren't in my lane. But I know that, you know, CTI has some scalability. So what is it? What's that model? Well, I don't really look at the pre CTI arrow up there. Basically, what that is, is outreach and engagement to somebody who is contemplated, who may be, you know, struggling, who is who is interested, right? And who might say to an outreach worker, yep, you know, I'd like to try some housing. I've spent a lot of time doing street outreach with housing first outreach, I use CTI, I understand the VI Spadat, we ran it here in the Nashville area, we ran it when it was the VI. And then we did another one, the VI Spadat when you know, that was revised. So, you know, I, all that work is pre CTI. That's really how I see it got to find people. And then, you know, they got to be in a position to be able to be housed. I think all of you know, that, you know, okay, I need to get a birth certificate, I need to get some ID. Oh, boy, you've got to, you know, get some unresolved court things, we got to get them out of the way first. Oh, boy, those, man, those arrears you have on that, you know, that rent that, you know, you owed last time you were in public housing, man, it's going to be a barrier. All those things happen to us all the time, right? Oh, I got my birth certificate, my birth certificate is in Oklahoma. Okay, so go ahead and try to get that Oklahoma birth certificate without any ID, just, you know, dropping a line to the county clerk in some place in Oklahoma. It actually worked for me. But I remember the last time I had sent something off to a, you know, to a birth certificate clerk, I got it back, and it said on the envelope on the back, last time, and I don't think I'd ever asked this particular court for anything before. But clearly, folks have been right. So what are you going to do? And you all know that it just, it is what delays us over and over. And while we're delayed, you know, the individual is, I mean, and, you know, in an emergency crisis, right? So we can't expect them to even be thinking rationally. And it's pretty much, you know, trauma activation the whole time you're out there. So CTI is really time limited, too, because what we want to do is, we want to be really intensive, we want to wrap as much support around that individual as we can, that's really targeted. And it needs to be just in that critical period, really the first year, and then we're out. And we're out whether or not they were successful or not. We're out of the CTI model, okay? It is not intended to become a primary source of ongoing support. That's not the role of CTI. And I know that sometimes it's, you'll see, I always struggled with this, but I understood why. It is really compatible with the effort to intervene. And particularly when folks are, you know, really struggling, I see the most success, I'll just be honest, with people who have recently been, you know, pushed into homelessness some way. And man, you give a, you know, CTI opportunity to folks like that, and they usually come flying back. Great. But it's also really good in working with the really chronic brothers and sisters who are out there, been out there for years, some of us for decades, and we don't even know how to live in the mainstream community. It's not our community. It's not at all who we are, what we understand, what we know. We don't know how to survive in that community. Our community, me and you, we are scary to that community. We've harmed them in the past. And, you know, we didn't want to, it's what I said earlier, we're, you know, we're here because we want to help. But we've been sort of, we've been guided by, you know, good, kindly folks who didn't ask the people that they're, you know, that they're trying to provide services for what the heck it is they need. And that was a big mistake for us. That's a big mistake. Because if we can meet immediate need, I think you all already know, people become a little bit more trustworthy. And they become a little bit more inclined to take another step forward. Right? So, so what we're trying to do here is give them the courage, and, you know, sort of the advocacy, and an advocate at their side, when they need them the most, and when it's the most scary for folks. Again, not the primary support for folks. And this one is really important. It is highly focused. And it doesn't try to address all the needs that a vulnerable individual or, you know, and a family might have. And you all know, man, those can be as unique as the folks that come through your door. And this is not CTI's role. It focuses only on the really key areas that put people at risk of future housing instability. We want to keep them in housing. That's the goal. All the other stuff, we're going to refer out into the community. And we're going to let the community do what the community is supposed to do. And if we've got a bunch of these services on site, awesome. You know, we'll refer them right into, you know, our stuff. But honestly, it is pushing these folks into the community. And when I say these folks, I'm sorry. I'm one of these folks. So it's about, you know, pushing them back into the community in ways that build some confidence, aren't terrifying, and are more powerful in a positive way than returning to the community of homelessness. So the core components here, I mentioned before, there's a period of transition. It's time limited and it's phased approach. Phase one, phase two, phase three, we'll go through them in a minute. And as I said, focus. And here's the thing, it decreases in its intensity over time. And basically, you know, what that means is every three months, as you go through the three, three month periods, and we'll talk about some modifications that have come about where they've reduced it to six months instead of nine months, right? But we'll get there. We decrease the intensity of our support and our contact over those phases. And until you know, until we actually hit phase three, and it's minimal, right? That's what we're hoping that it's minimal, where, you know, we're dropping in, hey, did you make that appointment? You know, where are you at with this? Do you need any support? Can I get you to that appointment, right? We just want to make sure that if they're doing what they need to do to, you know, to just return to the community, treat their mental health, if they need to find work, childcare, all those things, they've got the resources to do it. And if they don't, we're going to help find them, right? We don't kick people out of CTI, there's no early discharge. And this is usually the one that's really tough for folks, because we're busy as hell, small caseloads. And I've heard a whole bunch of different sized, you know, caseloads that are acceptable, I think it may even say in the, you know, our little core components, I think it's like 10 to 20. It's a, I mean, it's a small number. For those of us who have ever done case management, I had 120 folks on my, you know, my management roster. That that's, that's insane. I mean, you if you do 60, you know, how do you, you know, yeah, it's insane. So the small caseloads allow a case manager, and a peer, and, you know, anybody else that may need to be involved, a detailed and sort of comprehensive understanding of what is going on and what we might need to do. Throughout this all, we're going to take a harm reduction approach, right? Any way that we can reduce on Wow, man, I am so proud of you, you've gone from a 12 pack to 10 beers a night. That's amazing. It actually is. And anybody who makes an effort, even if it's once a week, and the rest of the time there, you're pounding down at the you know, the 12 pack, it's something to be celebrated, because we kind of need that reinforcement. We know, trust me, we know this stuff is killing us. And we know that we're trapped in this really crappy lifestyle. And we know that it's going to be really, really hard to get out. And it's overwhelming. And then we're treated, you know, like, like pieces of crap, it strips all of our motivation to do anything. And if we don't have any motivation, we really don't have any hope that any of this is going to change for us. I gotta, you know, I gotta be honest, if, if I was to be homeless tomorrow, and I don't think I'd be sober by Friday. And I've been in recovery 24 years. Why? What's the point? And how am I supposed to cope with this incredible anxiety and terror and trauma? And how do I do that? I'm not doing it sober. You know, I don't think I could. And we need to meet weekly. And the reason I know that that's sometimes a struggle. But this is really more of a sort of a peer supervision model. Yes, it's team, but it's, you know, everybody coming together to go over some of the cases, because each one of you brings your own perspective, and your own expertise to that. And that includes the individual themselves. And it includes any peers or people with lived experience that are working alongside that person. Those supervisor meetings are really great, because they can also help you assess where somebody is at in the continuum through eyes that are different than yours. And trust me, when I tell you we all carry bias, all of us, and the more that we're exposed to a sort of, you know, singular image, a stereotype, if you will, of an individual who's coming in for treatment, the harder that bias builds. It's nothing to be ashamed of. It's not anything that you have to worry about in the sense that, you know, you're somehow bad or wrong. I got it. You know, Sarah's got it, you got it, we all got it. The important thing to remember is that we know that when bias is triggered, and it's triggered instantly, as soon as you see the face, and it's triggered unconsciously, it does have, there's, I mean, there's good evidence that impacts the quality of the care that we deliver. So that matters. And just remember, when we come to see you, we've got the same bias, right? Because we've been seeing you guys as the folks who have harmed us, even though, say it again, that's never your intention. But we see it, you took our kids, you sent us to jail, you suspended our license, and then you told us we have to go do all these things that we needed all those things for. What is that? I mean, that's insanity. That's how we see it. And now folks are saying, well, oh, no, listen, and that was the past. Come back. And we'll really help you this time. Yeah, do you know how suspicious folks are? Right? This is why that, you know, that the relationship building, the community building is so important. And it's a marathon, you guys, you know, you've got you see this, it don't happen overnight. And all it takes is a one, you know, violation of somebody's trust, and it's over. Because we've had that happen to us enough. Right? We, you know, we're not taking that. And so, you know, you probably have had some really what you thought were great. I can't wait to see Bob, you know, come back next week or tomorrow with Bob never comes back. That's why. And you can almost count on it. He saw something that happened, heard something could have been a glance at your phone. Right? While he was talking to you. And we would have known right away up this person even hearing us how it is, right. And then in that team super supervision, we need to look at all of our caseloads. So I'm not saying that, you know, you've got 10 CTI case managers, you need a five hour meeting, right. But we do want to take a look at what we're doing in terms of caseload, because there could be trends, there could be patterns that you know, we can look at, and hone how we're coming at this work. A lot of it's community specific. All right. I don't know if this will play. It's about five minutes. And let's let's go through it. If it plays great. Let me make sure my sound and everything's on. Yep. All right. Let's see what we get. CTI is a time limited phased approach to case management that was developed over 20 years ago as a way to prevent men who are living with mental illness and experiencing chronic homelessness from becoming homeless again after leaving shelter and moving into housing. Multiple research studies have supported its effectiveness, leading to its widespread use in the US and elsewhere. The main goal of CTI for rapid rehousing is to improve the client's capacity to remain housed during rapid rehousing and afterward by effectively connecting them with critical community supports and by helping them to attain greater economic stability. Critical time intervention rapid rehousing is aimed at connecting clients to supportive services and improving economic stability as a means to best position the client for ongoing housing stability. In order to achieve this, the intervention focuses on factors that may directly influence housing stability, including obtaining and coordinating applicable financial benefits, accessing health care, child care, employment and education, as well as financial planning and management and connection to social and community supports. Critical time intervention rapid rehousing is not expected to resolve poverty. And in many cases, clients housing may remain precarious, although most are expected not to return to homelessness. Although rapid rehousing programs may use different forms of case management, the National Alliance to End Homelessness recommends that providers use CTI for their case management model. You can see that case management is one of three elements that are engaged to reach the rapid rehousing goal of a quick exit from shelter and a return to permanent housing. The other two elements are rental and move-in assistance, which is also referred to as financial assistance, and housing identification, which includes the work of securing a unit for the client. CTI for rapid rehousing has unique characteristics that set it apart from other case management approaches. It's time limited, meaning it has a definite beginning, middle and end that is dependent on time, not the achievement of goals, and has three distinct phases. We'll touch back on this later. The phases begin with intense contact from the worker. Over time, the intensity of this contact decreases as the needs of the client start to be addressed by the client on their own and by other community resources. In order to provide initial high levels of contact, CTI caseloads are kept relatively small. Weekly team supervision is recommended so that CTI workers can review their cases with peers and a supervisor. Weekly team supervision helps workers to remember to transition clients through phases and is critical in helping make important decisions with clients. The core values of CTI for rapid rehousing include being strengths-based, individualized, culturally sensitive, transparent, and trauma-informed. At all times, the CTI worker operates in partnership with the client and honors the client's right to self-determination. These first two bullet points address the work of creating access to financial resources, both public benefits and employment. They also include connecting clients to critical resources needed to maintain employment and well-being, such as health care, child care, and education or training. Lastly, the CTI worker aims to connect clients to both informal social supports, such as family, neighbors, and friends, as well as community supports, such as faith groups, community centers, and social service providers. The duration of CTI is six months following move-in. The intervention consists of a pre-CTI phase and three subsequent phases. Phases one, two, and three each last two months. The length of pre-CTI will vary depending on how long it takes for the client to obtain housing. Once a client moves into their new housing, phase one begins. It is important to remember that the movement of clients from one phase to another does not depend on the achievement of certain goals in each phase. The phases are intended to guide the worker's activities, not the client's successes. Providers often ask, how can we end CTI services with clients who are still at high risk of losing their housing? It's important for you to remember that a CTI intervention is not designed to provide treatment for mental illness, nor is it aimed at resolving poverty. The purpose of the intervention is to identify the client's needs, locate support for them in the community, and connect clients to them. Your job is to create connections that are deep and long-lasting, and to step away and let those resources take over so that you can go on to work with the next client. So you can see CTI, CTI really is not about what the individual has accomplished. It is, you know, they can set some goals, they may make a couple, they may not. But that's not what CTI and those of us who are, you know, managing those cases are doing. What we're doing each phase is making sure that the things that we know are going to be problematic or challenging for an individual, if they were left, you know, on their own, we need to make sure they're connected to community resources around. And to do that, you know, I know, here, you know, go over to, you know, the mental health co-op and, you know, here's your referral card that, you know, that you have an appointment in two weeks. They're not going. And if they do, you know, it's just by sheer luck, right, that, you know, maybe they were in the area and thought, well, maybe I should stop in. What often happened here in Nashville is that we would set appointments for folks at one o'clock, maybe even two. And they would be miles from where the, you know, food was available on any given day. So if you have to make a decision whether you're going to eat lunch, or you're going to walk all the way over to where this appointment is that those folks never helped me anyway, I think I'm just going to go eat lunch. And if you've given them a bus pass, well, you know, that's, you know, four or $5. It is here in Nashville. So they, you know, they got a couple of dollars in their pocket. I mean, you know, it's how things happen. And I, you know, I know that all of you understand that, right. So, excuse me, our, you know, our goal is just to connect them in the community. And in as many ways as we can, so that the community absorbs all of the challenges and works with the individual to do that. We need to get that person there now, right, not tomorrow, not, you know, next week, I know what I'm asking is a giant lift. And it's, you know, often impossible. But it's something we really need to work for. Because when people are, you know, interested at all, we need to under promise and over deliver to those folks, because we're trying to build trust and confidence that, you know, that we're there for them. And that, you know, we're not here to exploit you or to somehow harm you. Now, they talked a minute about, you know, CTI is two months, two months, two months, it actually started out as three months, three months, three months, that's still a model. And it's really up to the provider, you know, which model they want to use. And I suspect that a six month model moves more people through the program, there's, you know, there's pros and cons for both of them. I think one of the hardest things, at least for me, when I did CTI, was when you knew that somebody just was not going to be on phase three, you know, as soon as they were out, you know, wouldn't be long before they returned to homelessness. And, you know, it happened a lot. And it's tough, because you're, you know, you're really, you have a lot of, you know, a lot of hope, a lot of faith, you work really, really hard. And some folks just, their challenges are big, you know, their challenges are big, I had my own, and they were very difficult to overcome, and I had a lot of support. So I often think about my brothers and sisters out there who are, don't have near the support I did, and what they were able to accomplish. It's sometimes really amazing, and sometimes really, really sad. So what we do in phase one, it's intense, right, we're going to provide as much support as we can. And within the acceptance, that's the best word I can come up with, within the acceptance of the individual we're working with, if we're trying to connect Bob to, you know, the, I don't know, you know, a recovery community organization, and he's like, I need a place to sleep tonight. We, you know, we've mismatched what we're, what Bob needs. And end of the day, what Bob needs is the most important need, not what we want Bob to have, because if we don't meet Bob's need, then Bob ain't coming back, right? And now we'll never meet any of Bob's needs. So that's, that's why it's so important to listen to us. And, you know, you'll often hear things in there, I get it, that a lot of us want to vent, because finally somebody hears us, and we'll try to say everything that we've been saving up for six months, all at once. And, you know, we look animated, some folks think we look aggressive, you know, a lot of passion coming out. And that you hear them is really important, because you may hear the things that you need to focus on for the phases, right? So we're going to make home visits, we're going to pop in, and this is why you need peers, because they're not going to want you knocking on their door as a case manager, and looking in their apartment, I don't care if it's housing first or not. And, you know, they're required to comply with the lease agreement, period. Now, we're not gonna rat them out. But, you know, if you got half a pound of cocaine on the table in there, you know, I think I have a bit of a duty to report. If I see a crack pipe, I'm not saying anything, right? But it's illegal to have those drugs, right? This is housing first, you can do what you want in here, but that's breaking the law. And you can't break the law, I don't care if you're in a house or not, period, right? To do that, it needs to come from us, because they're going to be terrified. And, you know, they're going to think the cops are coming any second. So we need to have those kinds of conversations. And we need to be the ones that just pop in, hey, here's a card, man, listen, just at your door, I just want to share with you, I'm a person in recovery, been right there with you, man, I've just lived there just not too long ago. And I'm always here if you need some help. And I've come by two, three times a week, just check in with you. If you need something great, you can yell through the door, kick rocks, and I will, but I'll be back. Right? And I'll just I'll just keep popping in. That's phase one. And it is intensive. And if we can get them to say, you know what, I'm interested, collaborative assessments. And that's when CTI starts collaborative assessments. We're meeting with who is existing in terms of available support now. And we want to take that individual and start introducing in warm advocacy hands on handoffs, right? We don't want to just send them out with a card, because you all know already, that's, you know, we were lucky if we get, you know, 20% of those folks to go, I didn't, we need to be advocates, right? And we need to introduce them. This was really where I got the most success in the work I've done. When I know somebody at a different provider organization, that is, you know, that provides the services that I need, I want to know that person. And I want to have a conversation with that person. And the reason I do is because when people know you, it's a lot harder for them to just put your case alongside 20,000 other ones and get to it when they can. We want them to act as fast as they can on our people. And the best way to do that is to have a relationship because you don't want to let that person down. I am so sorry, Joe. I, oh my gosh, I got so busy yesterday. I'll get right on it. I've done that where I've had people call and ask me the status. So, get to know the folks that we're referring people to and let them know these are warm handoffs and they'll likely be an advocate with them because it's difficult, right? We also give our support and our advice to both the individual and the folks that are providing additional services. There may be a, honestly goodness, just a food service that Bob is gonna need for three months as he gets back on his feet. Even those folks should be involved in, hey, here's why we're doing this and letting them understand their own role in supporting people in their own community. We do that for about 60 to 90 days. To me, I'm a 90-dayer. It's what I was trained on. So, that's kind of what I go with. And after 90 days, you can imagine that's a pretty strong relationship or the person has said, you know what, I'm out. I don't need this, it's too much. And that happens too. So, then we move to phase two. And what we're looking at in phase two is we've connected Bob. He's been connected out the while. And we can see that Bob is actually probably making some of those appointments. And so, we're monitoring this. And we're coming to Bob about twice a week, maybe once a week now. Bob, how's it going? Hey, listen, I know you're really busy. Is there anything else you could use in order to make sure that what you're doing, you can keep doing? Yeah, I could really use some transportation, just some confidence that I will have the transportation to go do what I need to do. I mean, usually it's pretty simple stuff once we hit here. We still will have, I have to go to court and I'm really worried about, I might get incarcerated. We're gonna deal with those things, I get it. But for the most part, what we're trying to do now is encourage and gently, we're pushing the baby bird out of the nest, right? That's, we're lifting them up and we're letting them look over the edge of our nest so that they get a pretty good idea of what's out there and it's no longer scary. We're gonna be looking at who that support network is around this person. And we're gonna watch for those subcultural involvements. Those are really important, okay? If they're part of a subculture of addiction, if they're working, living with an addiction, if they've ever been incarcerated, particularly in prison, if they've experienced homelessness more than 30 days, trust me, they have those subcultural understandings. And we're gonna need to make sure to the extent that it's possible that we are moving folks away from them. And into things that are just a better option than the community that they are leaving, right? So those things, they really matter. And when that happens, if there are conflicts, we'll deal with them and we'll modify their networks as necessary with them. We're not telling them what to do. We wanna work with them and help them make their own decisions. That's why MI is really powerful here. And as folks go, it is about taking more responsibility. That's a big piece of recovery and returning to mainstream community and living a satisfying and productive life to the fullest potential you can achieve. That's the SAMHSA sort of outline for what recovery is. And we want everybody to reach that. At phase three, it's done, right? We've got these last two or three months, we're gonna start phasing out our services. We know that the network's in place. We're gonna make sure that the supports this person has work independently, they work without us. And then we wanna help set a plan. Basically, I always think of it as an action plan that looks at some of their long-term goals. This is, our noses need to be out of that. Unless they ask, what do you think should be a goal? Let them do it, right? Because when they do it, they're more likely to follow through with it than us telling them. None of us like to be told what to do, right? None of us. We do wanna have a couple of meetings as we near the end. We wanna start breaking it that it's coming to an end. Are you ready? And then we have one last meeting and the person's out, out of the program, okay? This is the tricky part because CDI isn't treatment and it doesn't look at whether or not you have a mental health challenge or a substance use condition. And it doesn't work to resolve poverty. We wanna know what the needs are, where the resources are. And we wanna make sure that when we send them there, they get there and somebody takes them in, right? And starts to work with them. That's the role of CTI in a nutshell. So this is just the continuum. And I wanted to make sure that you saw Housing First projects because CTI is really, really good for Housing First. All right, so there's some challenges here. Is our local COC and our system of care really aligned with Housing First and with the CTI philosophies? Because if they're not, then we're gonna be battling on two different fronts. I suspect you're dealing with this anyway, lack of affordable housing. We all are. I mean, I don't have an answer. The only thing I can say is that, we're gonna walk alongside of you, provide the basic services and emergency services we can until this changes, right? Until we can find some housing. And we all know what that is out here on the street too. We're just as hopeless as the folks are trying to do that. Internally, we need the right people. And that's why I mentioned peers. I mentioned case managers who maybe have a little bit of additional training around trauma-informed care, those kinds of things. We need to be able to do multiple service approaches and they have to be done for each individual, right? We can't, there's no cookie cutter and we cannot pound that square peg into the round hole. We're all unique and we're all gonna have all kinds of things that are gonna throw us for a loop at times, right? And then we're all gonna have a whole bunch of things that we do every day. Get the birth certificate, find the driver's license or state ID, get the VASH, whatever it may be, right? We do them all the time. We will need to manage that flow and we need to be connected to the direct service folks who are doing the work. Because if they've got an issue, we wanna address it as fast as we can. And then, of course, every team needs supervision. We just do. And we need it weekly. And it should be done, really, if you're gonna do supervision for behavioral health, especially in this context, there's a peer supervision model that would be really well-suited here. So what are the benefits? Well, we know it improves the quality of services. We know that they're structured, but individualized. So we hear this person, right? We can better ID who really needs high service levels and who can do a lot of this work on their own if we give them the right tools. We'll feel better that we know how to meet the needs of folks that we're providing services to. Because we're not looking at their successes. We're looking at the goals that we need them to achieve, right? It's not about success here. Well, it is for them, right? For us, did we connect them? Are they out there in the community? Are they getting the services? When we can do that, we know we'll have improved program outcomes because we'll see people discharged into permanent supportive housing or long-term housing. They'll stay there longer. There'll be a better connection to public benefits. I mean, even the SOAR program, right? I mean, this is an opportunity for us to run folks through SOAR. And really, I mean, SOAR benefits are, we've gotten a few folks through SOAR and they change lives. And it also will decrease hospitalization and recidivism. Does it work? Well, there you go. Yeah, it works. And this is just some pretty simple data, but I use this because it's in that 10-year follow-up and I really wanted to see that. There's plenty other data, but when we implement this with Fidelity, the model really works well. So these are some of the questions, right? Do CTI workers fulfill the same responsibilities as case management? No, not meant to be a substitute for comprehensive long-term case management. How often do I meet with a client during phase one? You meet often and it doesn't tell you the exact frequency. That's gonna be something that you guys figure out as you start engaging with people. And remember, you're gonna know right away, man, there's some high needs here. And you're probably gonna also know, you know this person, I mean, if we get them the right supports, I think that's why those weekly meetings are really important. Because you're seeing things that other folks may not and vice versa. And the more minds that come at this, the better, it takes a village, right? So it is kind of, you know, when you want, right? Where do we make these visits? Community based. We need to directly observe folks in their environment in order to make that assessment. And so part of this in phase one, at least four meetings in the community, and we need to be sensitive to what folks are actually gonna prefer. And, you know, what time will work the best for them, speak with them and ask them and don't set an appointment that, you know, they aren't aware of and then tell them, this is a, you know, collaboration. How many and what types of linkages, whatever that individual needs to support themselves in the community without you, that's available in the community. I mean, that's really the bottom line, because most of us need everything, right? Is it effective among chronically homeless? Yes, and randomized trials have gotten tons of evidence. It's effective in reducing recurrent homelessness. And, you know, a lot of the other sort of adverse outcomes that, you know, plague a lot of our brothers and sisters who are out there chronically experiencing homelessness. So if we're talking about the phase durations, right? When may CTI phases be extended? Don't do it, don't do it. A grace period of few weeks permitted to terminate the intervention after the originally planned closing date. But if the client is out of contact for more than 25% of the total duration of that intervention, right? And it may be, you know, six months, it may be nine months, 25%, you can restart at that point when they return. Otherwise, you work along that planned timeline, that's it. Should the period be extended? We should not expect clients to meet their long-term goals within that timeframe. The goal of CTI phases are related to successful linking of those individuals to the supports out there in the community that are gonna take over helping folks meet those long-term goals. Excuse me. And if a client disengages after, I mean, for an extended period of time, and we've made, you know, multiple attempts, when do we discharge? Well, if we make clear multiple attempts, that, you know, excuse me, if we make the multiple attempts and our person just makes clear that they're done with CTI services, discharge is appropriate. Should a CTI worker extend phase three? Each case, you know, has its own stuff, but we still wanna discharge folks at the original planned date. An extension of the phases can be appropriate if we know that services and supports that are needed are likely to come available in the very near future. If they're not, then yep, we end. And if a client loses housing, especially during pre-CTI or phase one, two, or three, should we continue working? Well, ideally they remain in the program until the end of that intervention, or intervention, excuse me. But it may not be permissible because of the way our organizations are regulated. Some of us make up CTI backup plans, and we'll refer those folks to a long-term case manager. Usually it's in a different program, and it may be by their organization, it may not. If a client contacts a CTI worker after they've been out of the program, and they're requesting assistance during a crisis, we should not be the ongoing contact for that crisis intervention. We should remind that client, CTI is over. We can offer a few limited, you know, there's some stuff we can tell you, and then we wanna redirect that client to the services and supports that are gonna help them, and the ones that they actually need. We don't reopen that case unless there is a major life event where CTI might help again with that transition. And if a client is successfully making use of that support network on their own, do we discharge early? No early discharge. That is a core component of this model. We'll give a grace period. It's usually a couple of, you know, two weeks prior to the original plan date. And if by like phase two, the links to supports are already strong, then we may begin to just really limit how much more we get involved. Our job now is just making sure that if, you know, this person needs an additional support, we're there to, you know, to do our best to connect them. And we wanna have a final transfer of care, and that includes the person, some of the supports if we can get them, and we also wanna talk to that person alone before they walk out the door out of that program. Just let them know how things are going and what they need, okay? So in terms of implementing this, some ways of coping with the mismatch between like an agency tradition and the expectations of the CTI model, because there can be some stuff here. And there is, you know, at times conflicts between what the agency expects and then the fidelity to the CTI model. We need to make sure that before we implement CTI, all of our team, all of us are oriented to the model and we understand how it is done. Those core components of the model should always be adapted to the context of the agency, but some of them are just non-negotiable because if we make changes, we've really changed the fidelity of that model. CTI programs can best collaborate and educate their partnering organizations by having some conversations. Do a dog and pony show at the local COC monthly meeting, right? Get people to understand what you're doing and why this program matters for the rest of the folks in that room, because there's an awful lot of referrals that you guys can push out to people who often, even though they've got a full plate, they need those referrals, right? CTI can be implemented in a rural context and we've been doing that already, but one of the big challenges is the large geographic stuff that we need to deal with. And if we're doing that in a rural area, it's just a matter of being really thoughtful about what we're trying to do, okay? So generally speaking, I'll just say this and then I'll wrap it up because I know I've got a hard stop in about four minutes. And why CTI, why I really like CTI is because it shifts the responsibility back onto my brother and sister. And we want that, but it's scary if we don't know what we're doing and we already have shame and guilt. We already have a lot of stigma. We know people think we're stupid. We know that they think we're scumballs. All this stuff is going through our head, right? And we really, I mean, we really want out, but it's really, really hard to do that if we're trying to navigate our own steps and we don't know, you know, we've got a blindfold on. And that's why for us, CTI as providers takes the blindfold off, pushes them out like the baby bird, gives them the necessary resources. We're gonna toss worms until, you know, until our baby bird is, you know, fledged. And then we're gonna, on a wing and a prayer, we're gonna hope that they make it. And if they don't, they'll, you know, they'll likely be back and we'll figure out another way to support them. So that's what I got here about critical time intervention. I'm always happy to respond to other things or other questions, anything about it, anything about housing first. And here I am. So if you ever wanna reach out and yak with me, I'm happy to do that as well. And then I'm gonna pull this one up because this is a slide that Sarah makes sure I send up all the time. And that's all I got, folks. So if you've got any questions, let me know. If you guys could, if you guys could take out your cell phones and take a picture of the QR code and do the survey, it'll take 90 seconds, maybe. There's like two questions. It really helps us do our work and continue to provide these free trainings for everyone. So we'd really appreciate it if you could do that. And as you're doing that, if you do have questions, please feel free to speak up. If you would prefer to send an email, feel free to reach out to Melissa and she will send me an email and we can communicate that way. Sarah, did you mean Monica rather than Melissa? Yes, Monica. I'm so sorry. Because we have a Melissa here and I'm sure she was like, uh, no. No. Yeah, I'm so sorry. It's Monday. Sorry, Monica, Monica. I feel your pain, Sarah, on the Monday thing. You know, wrong presentation, you know. All right, you guys, listen, I'm gonna run and I know you'll get through this. And I think this program is good. I think it's great.

Critical Time Intervention

CTI model

case management

chronic homelessness

mental health

community resources

individualized support

self-determination

affordable housing

positive outcomes