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Department of Behavioral Health and Intellectual disAbility Services


Guide to Providing Values-Based Support

Phase 4 kicks in when members receive their housing match, and it lasts until the member has fully transitioned into their new home.

Individuals will react to their housing match in a variety of ways. Some may attempt to emotionally disconnect from staff in preparation for leaving the program. Some may feel confident about their ability to live independently, while others may struggle with anxiety and uncertainty about whether they will be successful on their own. The important thing to keep in mind is that, regardless of a person’s time in the program or their level of comfort with independent living, members transitioning to housing are entering a period of significant vulnerability.

A housing match can sometimes happen quickly, before a member has established a firm foundation for recovery and wellness. Research shows that the risks associated with a transition into housing can be substantially reduced if individuals have adequate support. So our main objective for this phase is to ensure that members have sufficient clinical and nonclinical community-based support in place before they leave the residence. While promoting self-determination and multiple pathways to recovery, we also want to remind members that they can stay in the JOH residence until they feel ready to move to their new residence. If they accept housing, remind them of the program’s commitment to serve them after they leave the residential treatment phase, and ensure they have a plan to stay engaged with the JOH Project during and beyond the transition.

The participant’s peer specialist and case manager will play a large role in delivering the supports that achieve Phase 4 goals.

Why is Phase 4 important?

Phase 4 Goals:

1. Support individuals with selecting among housing options

Whenever members are matched with housing, it’s important to work with them to think critically about whether they should accept the housing offer. Understanding that no housing may be perfect, it may be better for a member to wait until a more suitable housing opportunity arises rather than to leap at the first opportunity that comes along. Ideally, you would have already worked with members to envision the kind of home situation they would like to have and the community that would suit them best. That information can be used to help assess how close the housing match aligns with their needs.  

Goal 1 strategies:
  • Accompany individuals on visits to their housing options and help them to weigh the advantages and disadvantages of each before deciding where to live.
  • Spend time with the member in their new neighborhood to help familiarize them with the area, learn the location of grocery stores and pharmacies, learn about transportation options, and other community resources.
  • Support members in identifying the closest natural recovery supports to their chosen community and schedule visits together to assist them with beginning to build relationships. These might include 12-Step fellowships, faith-based recovery opportunities, recovery centers, and community-based peer-run support groups.
  • Collaboratively identify areas in the community that might present a challenge to the individual’s sustained wellness and support the person in creating strategies for successfully navigating the challenges. For example, if there is a corner where there appears to be a significant amount of drug activity, are there alternate routes that the individual can take to avoid the corner?

2. Ensure that members have the material supplies needed for their home

This goal involves helping JOH members acquire the range of material and practical resources that will help them live independently in their new setting. To get started, members will likely need furniture, household goods, and food.

Goal 2 strategies:
  • Working with the member, create a list of basic items they will need to get started in their new home (furniture, bedding, food, and so on) and work together to identify how the member might obtain these items.
  • Support the member in making phone calls to begin locating needed supplies.
  • Explore ways to get vouchers from local organizations (such as thrift stores) that might be willing to reduce costs or donate items.
  • Visit local resources together, such as thrift shops, recovery centers, places of worship, or other organizations that might assist with providing some of the supplies.

3. Complete a Continuing Support Plan

Although continuing care is not a requirement for receiving housing, it should be strongly encouraged. Work with the member to determine the level and type of support the person wants and needs. Many individuals will assert that they no longer need support, so be ready to use your motivational interviewing skills and the strength of your relationship to help them identify a level of support and continued engagement that would be comfortable for them. For some, it may mean participating in the full JOH program for a week or two. For others, it may mean participating in a couple groups a week, having dinner with the community, or continuing to work with a JOH certified peer specialist. Many people will feel that they do not need to stay connected because they view JOH as only a treatment program. Be prepared to share the benefits of continued engagement. Here’s how:

  1. Acknowledge progress the member has made toward recovery and the skills they have built.
  2. Explore with the individual what excites them about the housing connection.
  3. Ask about concerns that they may have about the future, skills they want to build, or goals they’d like to achieve. Let them know how you could continue to assist them in working toward their goals.
  4. Reiterate that recovery is a journey and that staying connected to supports over a long period of time supports long-term recovery.
  5. Avoid sharing horror stories about people who left JOH before they were viewed as clinically ready and then experienced severe consequences.
  6. Give examples of the ways that continuing support will change and remain relevant to them based on their changing needs.
Goal 3 strategies:
  • Support the member in creating a schedule for the first few weeks of life in their new home. Explore with them what they will do, where they will do it, and who they will do it with. Ask the member to think about the kind and level of support that they would desire to accomplish these tasks.
  • Develop a menu of continuing support options that people can choose from and create a continuing support plan or Mutual Agreement to work together.
  • Based on the individual’s fears, concerns, hopes, vulnerabilities, and the findings from the recovery capital scale, create a continuing support plan that will provide the necessary dose of support to match their level of need.
  • When possible, have people start their next treatment program or support programs before they leave the residential portion of their JOH experience.
  • Collaborate with members to implement their transition support plan.
  • Coordinate with community-based service providers to ensure the member will continue to receive services.
  • Support individuals with engaging in off-site activities that will help with the transition to the community.
  • Learn what skills a member most needs to work on, and document a strategy for gaining those skills in the continuing support plan.
  • Update their contact list.
  • Give, or work with the member to create a resource book with names and contact information for community resources and supports.

4. Engage members using a healing-centered approach

Nine of 10 individual receiving publicly funded behavioral health services report a history of trauma, and chronic homelessness is a trauma in itself. Individuals cope with their trauma in different ways, and many won’t feel the need to disclose their traumatic experience to clinicians, peer staff, or anyone else. It’s a given that trauma-informed approaches must be a part of our engagement with JOH members and others. But our core value of healing-centered engagement aims to go further, to acknowledge not only personal trauma, but also collective trauma, and to address trauma at multiple levels to empower individuals and their communities.

Goal 4 strategies:
  • Provide personalized therapeutic services; healing looks different for everyone.
  • Ensure all staff are trained on how trauma can affect a person’s behavior and expression of emotions.
  • Avoid re-traumatizing or tacitly threatening members. It’s not effective to use threatening language, such as, “This might be your last chance,” or “Don’t blow this opportunity.”
  • Intentionally help members identify strengths, and work with them to explore their assets and potential.
  • Acknowledge the impact of collective trauma and explore healing through activism, volunteerism, education, or other activities.
  • Identify relevant community supports for trauma-specific services. Build relationships with these supports and be prepared to introduce members to them.

5. Increase community-based living skills

Clinical care can help launch recovery, but members sustain their recovery in communities. Developing these skills takes time. So don’t wait until the person is preparing to leave the residential portion of the JOH Project to think about the community-based supports that would serve them. Instead, starting as soon as possible, provide opportunities for members to learn or enhance a range of adult living skills and to practice those skills in real-world settings.

Goal 5 strategies:
  • Find out what community living skills members would like to work on, such as finding a bus route, learning to read, enhancing parental skills, or applying for a job.
  • Encourage peer staff to support people in natural community contexts.
  • Work with the individual to identify and apply for volunteer opportunities that will enhance their desired skill sets.
  • Assist members in exploring new interests and in participating in activities they may not have had an opportunity to do in the past.

6. Strengthen the member's natural or informal support network

Because it’s impossible to predict when a member may receive a housing match, it’s important to start as soon as possible to assess the member’s natural support system and strategically strengthen it.

Goal 5 strategies:
  • Ask members to reflect on how they would like to give and receive support from others.
  • Inventory the person’s existing circle of support.
  • Help the person identify people that they would like to add to their support system.
  • Assist members with developing interpersonal skills that can be helpful in building relationships and expanding their support system (sharing personal information about oneself, taking calculated risks, asking for help, reflective listening, enforcing boundaries, and so on).
  • Help members meet new people by hosting events that include members living in other JOH programs and alumni.
  • Inventory the places in the community that individuals go to or visit.

Phase 4 Resources:


Published 2020

Program Manager: Deanna.Lear@phila.gov

Project Assistant: Tina.Newstead@phila.gov