Case Management Rooted in Compassion and Care
Case management isn’t about checking boxes or pushing people through systems. It’s about loving people until they can love themselves, and helping them build the foundation for long-term stability and wellness—on their own terms.
“OnPoint NYC’s case management takes a holistic approach to addressing participants needs, often through incremental steps,” explains Martha Ruiz, Associate Director of Low-Threshold Services. “It embraces a harm reduction strategy by meeting participants where they are in their journey.”
For our participants, many of whom are navigating life without an ID, a stable place to sleep, or access to healthcare, applying for benefits, attending a medical appointment, or simply finding food are often overwhelming hurdles. Nearly 75% of our participants are unstably housed, and over 80% report histories of trauma.
In addition to the stigma and isolation our participants face, they are routinely disconnected from the very services that could help them overcome these barriers. Per the National Institutes of Health, of the estimated 2.5 million people in the US with opioid use disorder, only 22% received services.
With so many doors closed to our participants, distrust in the system is understandable. We believe that by introducing low-threshold support services, we not only build trust with our participants, but that it will translate into them spending less time navigating obstacles and more time working toward their own life goals.
Participants Lead Their Own Journeys to Stability
Participants connect with our case managers in a number of ways—through community events, referrals from partner organizations, or even a conversation sparked by our Outreach and Public Safety team. There’s no rigid intake checklist or eligibility barrier. We serve individuals who use drugs or have in the past, sex workers, and those impacted by HIV or HCV.
“Many participants come without an ID and live under bridges, trains, and on the streets, which creates a bigger challenge to receive services,” Martha shares. “Case managers help with gathering all necessary documentation for eligibility of services.” From day one—or day 100—we meet people where they are. Whether someone needs one day to open up or six months to start gathering documents, we work at their pace.
Once a participant is ready, case managers step in as advocates, care coordinators, and support systems—not decision-makers. “OnPoint NYC uses a participant-driven approach,” Martha explains. “This contrasts with traditional treatment organizations, where case managers typically provide services without involving the participants in the planning process.”
At OnPoint NYC, participants co-create their own goals and action plans. One hundred percent of the participants enrolled at our Overdose Prevention Centers (OPCs) have participated in detoxification, long-term treatment, medication-assisted treatment, or attempted self-administered taper, ‘cold turkey’, at least once, if not multiple times. Our case managers walk beside them every step of the way, wherever they are on their journey.
“We Bring the Services to Them.”
Our case managers support participants through a myriad of services, such as obtaining identification, assisting participants in accessing benefits and health insurance, finding and securing housing, connecting participants with recovery resources, medical care, mental health, and holistic services, navigating the legal system, and so much more.
Through our efforts, more than 75% of OPC participants accessed vital wrap-around services, with 1 in 5 referred to stable housing, detox, treatment, primary care, or employment. Furthermore, all of our OPC participants who were seeking recovery or inpatient substance use treatment were connected to outside providers.
What do these services look like in our participants’ lives? Our team worked with a group of participants living in a Single Room Occupancy (SRO) shelter. Many were actively using, disconnected from HIV care, and hesitant to leave their rooms. Through our community-focused case management—offering on-site groups, snacks, and metro cards—participants slowly began to engage. Over time, many visited our centers for more in-depth support. Some now have their own apartments. Others have jobs with us at OnPoint NYC. “We bring the services to them,” Martha says. “That’s what meeting people where they are really means.”
Stability Begins with Love
Looking ahead, our case management services will continue to evolve—driven by participant feedback, community needs, and the lived experience of our staff. We know that the path to stability doesn’t begin with judgment—it begins with love.
And our case managers are there every step of the way, offering participants the space, support, and self-determination they need to reclaim their lives.
