What is CORE Case Management

Introduction

CORE Case Management at Piphus is designed to provide structured, ongoing support that goes beyond reactive care. We focus on consistent monitoring, proactive coordination, and long-term relationship-building. The goal: improved outcomes, reduced crises, and a real path to stability.

The CORE model represents Continuity, Outreach, Responsiveness, and Engagement — four pillars that ensure clients don't just start services, but stay connected, supported, and empowered.

The Problem: Gaps in Follow-Through Create Gaps in Care

Many individuals receiving behavioral health services engage in episodic, fragmented care. This is especially true for clients navigating co-occurring disorders, housing instability, or system involvement. According to research from the National Alliance on Mental Illness (NAMI), over 50% of adults with serious mental illness receive no treatment in a given year. This isn't a failure of awareness — it's a failure of sustained engagement.

Missed appointments, lack of follow-up, and high caseloads lead to drop-offs in care. Without someone checking in and adjusting support plans, clients are left to navigate complexity alone. And complexity, without support, turns into crisis.

Our Approach: Structured, Consistent, Person-Driven

Piphus Case Management addresses this challenge through the CORE approach:

1. Continuity

We build long-term, trusting relationships with clients and remain consistently involved. Our team maintains contact even when services stall, barriers arise, or motivation fluctuates.

• Regular check-ins (in-person, phone, and virtual)
• Monitoring of medication compliance, goal progress, and symptom changes
• Re-engagement strategies when clients disconnect from care

2. Outreach

We don’t wait for clients to come to us — we meet them where they are. This includes in-home visits, field-based services, and collaboration with community partners.

• Assertive outreach for high-risk individuals
• Coordination with shelters, probation officers, schools, and hospitals
• Mobile case management for clients with transportation or accessibility issues

3. Responsiveness

We act quickly when needs arise. Whether it's a housing crisis, benefits issue, or relapse, our team intervenes early to prevent escalation.

• Real-time communication with therapists and providers
• Emergency housing support and benefits reinstatement assistance
• Crisis planning and de-escalation strategies

4. Engagement

Our services are built around what matters most to the client — not just clinical checklists. We build motivation, support ambivalence, and center the client's goals in every care plan.

• Use of motivational interviewing and trauma-informed engagement
• Individualized service plans updated quarterly
• Connection to meaningful activities, peer support, and skill-building opportunities

Evidence Base: Why CORE Matters

Research supports the CORE principles as essential for effective case management. In a longitudinal study by Mueser et al. (1998), individuals with sustained case management involvement were significantly more likely to remain housed, avoid hospitalization, and report improvements in life satisfaction. Another study by Solomon (2000) confirmed that ongoing, proactive contact is a predictor of treatment adherence and positive clinical outcomes.

CORE isn't just good practice — it's evidence-based care.

Outcomes We Target:

• Reduction in ER visits and psychiatric hospitalizations
• Improved housing retention and stability
• Increased follow-through with therapy, medication, and treatment goals
• Greater client-reported satisfaction and engagement
• Sustained recovery from co-occurring mental health and substance use disorders

CORE in Action: A Real-World Snapshot

One of our clients, a 42-year-old man with bipolar disorder and substance use history, had been in and out of shelters and emergency rooms for years. Within three months of CORE case management, he secured housing, reconnected with a therapist, and began job training. Why? Because someone checked in, stayed consistent, and never gave up — even when he did.

This is the power of CORE. It’s not just a model. It’s a relationship. It’s a strategy. It’s a commitment.

Conclusion

CORE Case Management redefines what support can look like. At Piphus, we combine clinical insight with human presence — showing up when it’s hard, following up when it’s quiet, and sticking around until it works. Because healing isn’t linear — but with CORE, it becomes possible.

“People don’t fall through the cracks here. We stay with them — until the path is clear.”