Understanding service disengagement from the perspective of case managers

Objective: Disengagement from services by persons experiencing homelessness and co-occurring disorders challenges the mental health system and the frontline providers who build clinical relationships that end prematurely. This qualitative study explored how case managers understand and respond to disengagement. Methods: This study was conducted at four programs serving persons with co-occurring disorders experiencing homelessness. The qualitative design used a case study approach based on in-depth interviews with 18 case managers about 29 cases of disengagement. The study compared their accounts with predisengagement interviews when available and the postdepar- ture residential status of consumers. Themes were derived by independent coding and consensus. Results: Case managers attributed disengagement primarily to substance relapse and a preference for alternative living arrangements. The following themes emerged: seeing disengagement as part of their work, believing disengagement to be poor decision making on the part of the consumer, and coping with the revolving-door syndrome. The majority of consumers experienced home- lessness after disengagement. Conclusion: The study illustrated the challenge of building hope-instilling relationships with consumers when faced with the reality of frequent disengagement. In an era of recovery- oriented services and consumer choice, case managers need support when faced with consumer decisions to leave treatment settings. Greater program flexibility may also help to reduce disengagement.