Case ManagementStep Three

Chapter Ten

Urgent and Timely Provision of Concrete Services

Step Three of the Decision TreeUrgent and Timely Need

Step three of the decision tree addresses the provision of urgent (hours/days) or timely (week/month) concrete services to highly vulnerable client populations through case management.

Definition of Case Management

• Case management is a direct practice model that denotes the timely provision of resources to meet the basic needs of highly vulnerable populations.

• Highly vulnerable client populations often require multiple services involving professionals from several different disciplines.

• Case managers locate, refer, broker, coordinate, monitor, expedite, and coordinate fragmented services offered by professionals from different disciplines.

.

Characteristics Client Population

• Client populations that benefit from case management are characterized as highly vulnerable individuals who require a complex array of services from multiple helpers from diverse disciplines on an ongoing basis.

• The needs and impairments of this client population are often outside the individual’s volition for cause or solution.

• Clients are frequently thrust into a position of dependency.

CharacteristicsContinued

• Many conditions are permanent and irreversible; some conditions are progressive.

• The conditions often create long term barriers to social functioning.

• Many case management clients enter service in the absence of available family support.

Who Benefits from Case Management?

• Populations that benefit from case management are the: (1) de-institutionalized chronically mentally ill; (2) developmentally disabled children and adults; (3) those with physical conditions in need of rehabilitation; (4) those who are HIV positive or who have AIDS; (5) impoverished children and families; (6) children and adults in need of protective services; (7) delinquents and the drug addicted; and the (8) homeless.

Strength-Based AssessmentCase Management

• It is especially important to document strengths when working with individuals who have primary conditions that are long term, permanent or progressive.

• A strength focus helps clients retain and build upon existing strengths so that they can function in a manner that allows them to maintain a reasonable quality of life in a community setting.

• Environmental accommodations optimize a client’s quality of life.

Environmental AccommodationsSocial Milieu

• Highly vulnerable client populations benefit from interventions that target the environment to make it more supportive.

• Such interventions consist of: supervised independent living, half way or quarter houses, group homes, assisted living facilities, residential nursing homes, residential treatment centers, structured day programs, recreational activities, sheltered workshops, club houses, meals on wheels, foster or kinship care, TANF, Medicare and Medicaid.

Client’s Point of EntryHelp Seeking Behavior

• Involuntary clients are those referred by others in authority (e.g. child and adult protective services)

• Mandated clients are wards of the state such as the chronically mentally ill or those who are court ordered such as the delinquent or drug addicted.

• Homeless clients often refuse formalized care. They visit soup kitchens, accept sandwiches from mobile food distribution centers, accept blankets in the cold weather and occasionally accept shelter overnight and receive health care from medical clinics.

Help Seeking BehaviorThe Homeless

• The homeless require outreach as their point of entry.

• Repeated non-intrusive contact where concrete goods ( meals, blankets, health care and shelter) are provided lead to trust overtime.

Worker-Client RelationshipCase Management

• In those cases where the State has assumed guardianship, the State acts as the client’s locus in parentis.

• Clients who need life long services, experience a series of social work case managers overtime.

• Some clients readily form new relationships and orient new workers and student interns to their specific setting.

Worker-Client RelationshipCase Management

• Other clients react negatively to the high rate of turnover among the helping professionals in their lives.

• More effort is required to establish, maintain and terminate a relationship with this group.

Role ConflictCase Management

• The case manger has two functions which can cause role conflict.

• The case manager has a social control function. The worker is charged with determining client eligibility for services and with the avoidance of duplication of services.

• The case manager, consistent with empowerment theory and advocacy, is charged with helping clients lead lives of freedom and dignity in the community.

ContractingCase Management

• Respect for client self determination is a value in case management.

• Contracting is constrained both by the type and degree of impairing condition as well as the mandated parameters within which service or treatment occurs.

• Consistent with authentic contracting, case managers cannot promise resources they do not have or resources to which the client is not entitled.

Case Management Contracting Constraints

• Social work case managers are often faced with ethical dilemmas.

• The worker’s fiduciary responsibility to act in the best interest of the client often conflicts with the client’s right to self-determination.

• Workers must balance their legal authority with the rights of the client.

Contracting ConstraintsContinued

• Reasonable goals must be agreed upon through mutual goal setting.

• There must be a match between what it takes to achieve a desired goal and the potential a client has to offer.

• Case plans tend to be individualized (IP’s) and are reviewed quarterly, bi-quarterly, or annually.

• Case reviews determine what is working, what is not working and what needs to be changed.

Case ManagementDesired Outcomes

1. Environmental accommodations to allow highly vulnerable client populations to remain in the community under least restrictive conditions

2. Skill acquisition through skill training

3. Normalization

4. Quality of life.

Types of Case ManagementSystems Driven

• There are two basic types of case management models: (1) systems-driven and (2) consumer–driven.

• System-driven case management has roots in structure-functional theory and organizational and management theory.(1) It is concerned with maintaining agency

or organizational integrity

System-Driven Case Management

(2) It runs programs that have pre-determined client needs and for which client’s must establish their eligibility; client’s must conform to established procedures and routines.(3) It has a stake in maintaining its own integrity. It often operates to meet the needs of funding sources and the professionals who staff the agency; sometimes at the expense of meeting client needs.

4 Subtypes of Consumer-Driven Case Management

(1) Single one-time only service i.e. paying an energy bill (2) Bureaucratic task-specific division of labor related to a complex service such as child child protection services e.g. workers perform a single task or function within the service such as investigation of alleged abuse and neglect reports, recruitment of foster parents, family preservation, reunification etc.

4 Sub-Types of System DrivenCase Management

(3) Comprehensive Case Management Includes delivery of concrete services, case advocacy, day programs and residential living(4) Street level – case managers have discretionary power. They can advocate for structural changes and obtain resources while being part of a bureaucracy.

Consumer-DrivenCase Management

• This model is based on critical theory and post modern principles. Critical theory challenges the legitimacy of system-driven models.

• Coupled with empowerment theory, this model provides clients with an active voice in asserting their needs and in determining how their needs will be met.

• The worker becomes an ally of the client• Skills training and vocational rehabilitation further

empower client independence.

Declarative Knowledge

• Case Managers must be knowledgeable about each client’s primary condition; its hypothesized causes and treatment options.

• Case managers must be knowledgeable about resource availability.

• Case managers frequently use ecomaps to visualize a client’s personal environment. Included are: (1) familial and social networks; (2) formal agencies and the interdisciplinary

professionals involved in the client’s care.

Declarative KnowledgeContinued

• Case managers must have knowledge of biological, medical, psychological, social and spiritual needs secondary to the client’s primary condition.

• Client needs may be normative, perceived, expressed or relative.

• There are nine common needs frequently found among this client population.

Declarative KnowledgeNine Common Client Needs

1. Need for resources: Case managers locate, manage, and access resources. Networking and interpersonal skills are used to secure resources in a timely manner.

2. Need for skills: Case managers provide skill training to maximize client independence. Lack of skills may be secondary to a client’s primary condition or may be related to their care.

3. Need for information: Case managers help clients understand their primary condition and the resources available to treat it. Knowledge informs and empowers.

Declarative KnowledgeNine Common Client Needs4. Sexual Needs: Most clients are sexually active. Finding suitable partners or an

appropriate outlet to met the sexual needs of

this client population is difficult.

5. Managing Flare-ups: The cumulative

stress of daily life may produce a crisis that

necessitates short-term hospitalization to stabilize the client’s primary condition.

Declarative KnowledgeNine Common Client Needs

6. Self-Medicating Behavior: Clients often attempt to ameliorate their primary condition and feel better through the use of alcohol and drugs.7. Need for Compliance: Clients often go off or forget to take their medications. Some are “dismissed” from care for noncompliance with a program’s rules and regulations.

Declarative KnowledgeNine Common Client Needs

8. Need for continuity and stability of care: Changes in client care may trigger a client crisis i.e. changes in eligibility requirements, in personnel, in policies related to daily operations, or changes associated with the termination of a program or service.

9. Need for safety: Disruptive or violent behavior (between clients or between clients and staff) may occur. Safety protocols include knowledge of how to avoid or deflect conflict.

Student Safety

• As part of their orientation to field placement, student interns must be educated in agency-specific safety protocols.

• Students need to be taught: (1) the safety risks unique to each setting (2) how to avoid or deflect conflict (3) how to signal for help (4) how to position self for safety in a room (5) how to recognize physiological or motoric cues that signal loss of control or rising anger

Student SafetyOff-Site

1. Students should go with a supervisor, another worker or another intern; if warranted a police officer should accompany them.

2. Students should sign in and sign out. They should indicate their destination and estimated time of return.3. Students should use transportation that enhances their

travel safety.4. Students should carry a cell phone. 5. Students should be given explicit permission to protect

themselves.

The Helping Relationship Structure-Functional Theory

• The goal of case management is service not therapy.

• At a minimum, rapport begins with belief in the helping relationship and an authentic contract.

• Both worker and client bond in the belief that mutually agreed upon activities will bring about changes that will benefit the client and enhance the client’s self worth in the process.

• Though not therapy, all interactions are intended to benefit the client and are therefore therapeutic.

The Helping RelationshipPost Modern Principles

• Post Modern principles offer an alternative to structure-functional theory.

• Unger uses 2 P’s and 3 R’s to describe the application of this theory to case management.

• The first P stands for power: How one uses language to construct the delivery of service to highly vulnerable clients is an exercise in power. It reflects the program policies and administrative agendas of those in power rather than the agenda of those at-risk.

The Helping RelationshipPost Modern Principles

• The second P stands for position: in the worker-client dialogue, the worker’s discourse is privileged (assigned more power) than the discourse of the client.

• The first “R” refers to the worker’s obligation to resist decisions and processes that are not in the best interest of those being served.

• The second “R” refers to the co-construction of reality. The worker empowers and validates the client’s narrative.

The Helping RelationshipPost Modern Principles

• The third “R” refers to reflection in action.

It requires the practitioner to be aware of his/her privileged location within a structure.

• Critique: Unger asks what should happen when the worker’s narrative says the situation is not safe for the child but the parents’ narrative says it is? What if there is no agreed upon co-construction of reality between worker and client?

Case ManagementStrengths Perspective

• This model focuses on resiliency. • For each identified need, the worker and client

identify a strength. See Saleebey’s Diagnostic Strengths Manual(2001).

• Goals, not deficits, drive treatment. Past coping is emphasized.

• Critique: It is said that the model appears to give a ‘Pass’ to inadequate formal services and does not address the social causes of scarce resources and unequal access to them.

Case ManagementTask and Role Performance

• Consistent with Structure-functional theory, individuals are expected to perform certain roles and tasks in society.

• When individuals are unable to perform the tasks and roles for which they are responsible ( work, child care, self care), social work exercises it fiduciary and humanitarian responsibility.

• Workers use their authority to provide, withdraw, or withhold services based on client compliance with assigned tasks.

Case ManagementEnvironmental Modification

• Social treatment includes modification of the environment within which a client lives.

• Social treatment includes as array of policy and program-based services such as residential living day programs, club houses, sheltered workshops, assurances of non-discrimination in housing and work situations, financial support, access to transportation, housing, education.

Case ManagementTraditional Talk Therapies

• Traditional talk therapy models will not “cure” the client’s primary condition nor provide the client with the concrete resources he/she may need.

• Traditional talk therapy models may augment case management services and ameliorate problems secondary to the client’s primary condition or circumstance of care.

• Talk therapy models may be relevant in teaching clients basic self care skills and helping them become compliant with medication and residential rules and regulations.

Case ManagementTalk Therapy

• Some models address issues associated with self image and identity.

• Some models teach interpersonal skills and/or resolve interpersonal conflict.

• Some models help clients deal with loss or personal suffering.

Case ManagementEvidence

There is no evidence that one model of case management is better than another (Shera, 2002).

Cases, Decision Schemas, Process Recording

• Two cases illustrate the content of this chapter: (1) Linda and Mrs. Garrity illustrate services to a developmentally disabled adult woman. (2) “J” illustrates services to a juvenile in the juvenile justice system. A process recording of Linda and Mrs. Garrity is also provided.

• Case management decision schemas are presented at the end of the chapter.