M4 · Architecture
M4
Slide 7
CONTENT
Principle 1:
Whole-Person Integrated Care
This part continues Principle 1, covering how whole-person care is coordinated and anchored within the wider system. Each tab below explores one service area in depth — read through all three to continue.
7.HOUSING-RELATED SERVICES
8.SUPPORT SERVICES
6. Case Management — The Coordinating Core
Case management is the operational backbone of whole-person care. It is not administrative paperwork — it is structured coordination around the individual's needs, goals, and capacities.
Core Functions include:

Comprehensive assessment across health, housing, income, legal and social domains

Individualised care planning

Service coordination and referral follow-up

Monitoring continuity of care

Advocacy within fragmented systems

Case management reduces service dropout, emergency overuse, and fragmentation while increasing trust and stabilisation.
Models of Case Management in Integrated Care
Case management is delivered at different levels of intensity depending on complexity. Two models are particularly relevant in homelessness services and Housing First: Intensive Case Management (ICM) and Assertive Community Treatment (ACT).
INTENSIVE CASE MANAGEMENT (ICM) — one dedicated case manager (typically 15–25 clients). The case manager:

Coordinates services

Supports housing stability

Monitors engagement

Provides practical and emotional support

Facilitates referrals

Does not directly deliver all clinical services — ensures they are accessed and coordinated. Suitable for individuals with moderate complexity who can engage with structured support.

ASSERTIVE COMMUNITY TREATMENT (ACT) — high-intensity, multidisciplinary team for severe and persistent mental illness. It includes:

A shared team caseload

Small staff-to-client ratios

Direct service delivery in the community

Embedded psychiatric and nursing care

High outreach intensity

Often crisis availability

Unlike ICM, provides many services directly rather than only coordinating them.

ICM and ACT in Housing First
Housing First programs typically use ICM for most participants and ACT for those with the highest needs. The principle is proportionality — support intensity should match clinical and social complexity. In both models:

Housing is not conditional on treatment compliance

Engagement is persistent but non-coercive

Harm reduction principles apply

This tiered approach allows integrated systems to remain both flexible and sustainable.
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