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On-Site Case Management

“Homelessness is an incredibly stressful experience that exacerbates underlying health problems and fuels a cycle of depression and hopelessness. Securing housing is the most important step in improving our clients’ health.”


-Connie Wynne, Commonwealth Land Trust Clinical Director 





CLT provides the on-site medical case management necessary for our residents to address their medical and social challenges, maintain their housing, and rebuild their lives. Once clients are housed, case managers ensure that their basic needs are met. Residents are provided with a furnished room, consisting of a bed, dresser, microwave, refrigerator, sink, and nightstand, as well as access to an on-site food pantry.


Within two weeks of move in, residents meet with their case manager and complete a thorough Individual Service Plan. Case managers assess clients’ current health care and level of medication adherence. Those clients not linked with primary care physicians are assisted in selecting appropriate medical care. Medical case managers encourage clients to create a health care team that includes primary care physicians, mental health care and substance abuse treatment professionals, as well as other necessary providers.


The overarching objective of our on-site medical case management model is to provide residents with the support necessary to manage their health, increase their self-sufficiency, and live independently. Case managers provide mental health and addictions counseling, medication adherence support, basic life skills, and financial literacy training. In addition, they coordinate with other providers to keep clients engaged in care outside the building. Commonwealth Land Trust utilizes a motivational interviewing approach to counseling, helping clients to channel their intrinsic motivation and realize long-term goals.





An overview of our on-site medical case managers’ responsibilities include:


  • Meet with prospective residents and conduct initial needs assessment
  • Design individual service plan tailored to clients’ unique challenges and goals
  • Provide mental health, addictions, relapse, and medication adherence counseling
  • Collaborate with outside providers to ensure delivery of needed services
  • Make referrals and link residents with community resources pertaining to their medical, social, and financial needs, including:
    • Mental health/psychiatric services
    • Substance abuse/detoxification services
    • Health insurance and affordable prescription drugs
    • Affordable groceries and prepared meals
    • Workforce readiness programs
    • Volunteer opportunities
    • Education opportunities
    • Community engagement activities
    • Financial planning and budgeting resources
    • Donated goods like linens, housewares, winter coats, and personal care items
  • Collaborate with supportive housing, overnight/weekend coverage, and maintenance staff to preserve tenancy of residents
  • Assist the transition of thriving clients to independent housing
  • Plan and facilitate in-house events and activities as well as group outings
  • Record case notes and maintain client files according to funder requirements
  • Prepare a quarterly newsletter and post notifications to bulletin boards to inform residents of building activities and community resources





Case management services are provided along a continuum of intensity, which varies depending on the needs of the client. Residents who are in a state of crisis, or who have a history of high-risk behaviors, receive services on a weekly basis, whereas residents who have attained a higher level of self-sufficiency receive services on a bi-monthly basis.





In addition to direct case management services, clients’ interpersonal skills are improved with in-house activities and planned outings, such as movie nights, book clubs, support groups, holiday celebrations, and volunteer trips. These activities provide a venue for clients to support one another and foster a sense of community that is particularly beneficial for clients who lack close social networks. CLT also hosts quarterly Resident Advisory Board meetings where clients meet with our case management and supportive housing teams. Clients provide feedback, offer suggestions, and take an active role in shaping the housing and supportive services they receive.





CLT’s on-site medical managers, like all of our staff members, form a network of support for formerly homeless clients. Many case managers have decades of experience in the areas of counseling, mental health care, and HIV/AIDS service provision. Click here to learn more about our case management team.