Who are IDPs?

Internally Displaced Persons (IDPs) are people forced to flee their homes because of war, occupation, or disasters but who remain inside their country’s borders. Unlike refugees, IDPs don’t cross an international border—so they often fall through service gaps: documents are missing, access to healthcare and schooling is disrupted, income is gone, and trauma is untreated. For families arriving from temporarily occupied territories in Ukraine, these gaps are multiplied

At Save Ukraine’s “Hope & Healing” Center, we use case management to turn a family’s urgent, overlapping needs into a clear, time-bound plan. Below is the model we’ve found to work—and how we measure it.

What case management means in displacement response

Working definition. A structured, trauma-informed process that accompanies a family from first contact to stability through an individual support plan, coordinated across psychology, law, social services, healthcare, and education.

Objectives

• Stabilize risk quickly: safe shelter, food, basic items.
• Restore rights & access: identity documents, social benefits, healthcare, school re-entry.
• Rebuild agency: realistic plans, routines, and community integration.

The service blueprint: from triage to “soft exit”

1. Intake & triage — the first hour matters. We assess observable stress signals and immediate risks.
2. Crisis block — body first, paper second: food, a safe room, a brief safety orientation (shelters, contacts).
3. Documents & legal — ID card for youth 14+, restoration of Ukrainian documents, legal/advocacy where Russian-issued papers complicate access.
4. Health & mental health — primary screenings; psychology is introduced without trigger words (“let’s talk” vs. “see a psychologist”).
5. Education for children — day center to close learning gaps, group activities, art therapy to re-open communication.
6. Individual plan — concrete steps with deadlines, responsible staff, and checkpoints.
7. Review & adapt — every 2–4 weeks: what worked, what changes.
8. Soft exit (graduation) — typically within ~3 months of intensive support; the family moves to self-reliance with a light, remote check-in option.

Core principles: trauma-informed, do-no-harm, family-centered, dignity-first language.

Roles and why coordination wins

• Case manager — the integrator and first trusted contact; holds the whole picture.
• Psychologists — stabilization, co-regulation, restoring child/parent roles when teens have “become the adult.”
• Lawyers/advocates — documents, court procedures, complex occupancy cases.
• Social workers — navigating public services and local aid.
• Education specialists — rapid return to learning with individualized support.
• Medical partners — screenings and referrals to specialists.

Why it matters: without a coordinator, families must navigate 6–10 parallel processes—often while exhausted and scared. Coordination reduces drop-off and speeds recovery.

Language, trust, and small wins

Trust first. A hot meal, a safe bed, plain-language safety rules—signals that fear can stand down.

Words matter. “Conversation” instead of “assessment,” “meeting” instead of “psych consult.”

Small wins early. Proof that progress is possible (ID application filed, first clinic appointment booked).

Autonomy over dependency. We hand over the fishing rod, not the fish.

Measuring what matters: from outputs to outcomes

Operational KPIs

• Time-to-ID: days from intake to ID issuance for youth 14+.
• Time-to-care: days to first medical/psych appointment.
• Case cycle time: average length of intensive support (target ≲ 90 days).
• Service uptake: % of families accessing healthcare/education/legal aid within set timeframes.

Well-being & integration

• Stability index (0–10): perceived safety/control at entry vs. exit.
• Family functioning snapshot: sleep, appetite, routines, conflict levels (pre/post).
• Education re-entry: % of children back in school within 30 days.
• Client voice: qualitative feedback; repeat contact for planned—not crisis—needs.
• Data practice: minimal-necessary collection, strong privacy, de-identification for analytics.

Common pitfalls (and fixes)

• Paper before people: pushing documents without stabilization → shutdown.
• Trigger language: “mandatory exam,” “psychiatry” → resistance. Use supportive phrasing.
• Endless care: open-ended support breeds dependency. Plan for graduation from day one.
• Siloes: legal/psych/education teams not sharing context → higher burden on the family.

A short composite case (anonymized)

A teen arrives after occupation—mute, not eating or sleeping. The case manager starts with safety cues and routine, introduces a psychologist through a low-pressure “let’s talk,” and adds gentle group sessions. Within weeks: restorative sleep, basic peer interaction, a re-entry plan for school.

Lesson: the quality of the first contact sets the trajectory.

What funders and policymakers can scale

• People: training case managers (trauma-informed practice, active listening, crisis skills), regular supervision to prevent burnout.
• Processes: clear SOPs; a single, shared care plan; scheduled reviews.
• Data: simple dashboards aligned to decisions, not just reporting.
• Partnerships: health systems, schools, municipalities, civil society—so the family’s route is “stitched,” not scattered.

Bottom line

For IDPs, case management is critical infrastructure. It converts fragmented services into a coherent path, and turns a family from a passive recipient into an active agent with plans and options. Investing in people, processes, and data for case management shortens the distance from mere survival to stability and self-reliance—one family at a time.

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The project is implemented with the support of the KSE Foundation, a charitable foundation of the Kyiv School of Economics