Week 2 - Frankel and Gelman - Case Management - An Introduction to Concepts and Skills.pdf

Part 1 Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. CASE MANAGEMENT PRACTICE Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com...

Part 1 Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. CASE MANAGEMENT PRACTICE Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. CHAPTER 1 The Evolution of Case Management Practice Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. What Is Case Management? Case management as a way of helping people has a long and rich history. At the very beginnings of social work, in the settlement house days in New York and Chicago, social workers guided families needing help into existing private and public support networks, meager though they might have been. When resources were not readily available, social workers helped mobilize their communities for social action. They effectively lobbied for new and innovative ways to support the poor, the infirm, immigrants, families, and children. Today we may talk about generalist or foundation practice, the systems approach, methods of casework, groupwork, community organization, and various practice theories, but a rose by any other name is still a rose. The history of social work is filled with practitioners who worked with their clients using the same case management methods used today—​they just didn’t call it case management. Over the last 40 years, the term “case management” has been widely applied to describe a process or method of service delivery and a set of roles assumed by service providers. Case management approaches have been utilized in medical or healthcare facilities, with elderly clients, substance abusers, the chronically mentally ill, the developmentally disabled, AIDS patients, inmates released from prisons, child welfare cases, employment training and employee assistance programs, and at-​risk populations, including victims of human trafficking. Case management, which is sometimes referred to as “clinical case management,” “service coordination,” or “comprehensive psychosocial enhancement,” has two essential and often conflicting purposes: (a) improving the quality of care to vulnerable populations and (b) controlling the costs of such care. While the focus of case management is linking a client to needed services, other elements involve advocacy and social action (Ballew & Mink, 1997). Case management 3 Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. 4   Case Management can also serve as a means of assuring the accountability of service providers and systems (Gibelman & Gelman, 2005). Historically, there have been many definitions of case management. Generically, it is a way of helping people identify the areas where they need help and connecting them to the personal and community resources that will help them (Rubin, 1992a). It is a systematic problem-​solving process that enables and facilitates individuals in their interaction with their environment. According to the National Association of Social Workers (1984; NASW), “Case management is a mechanism for ensuring a comprehensive program that will meet an individual’s need for care by coordinating and linking components of a service delivery system.” According to Dinerman (1992), “It is a function designed to arrange for, and to sequence, needed services of different sorts by various providers on behalf of a client or client family.” Case management involves the engagement of a client in a system of services by an accountable professional. According to the American Association on Mental Retardation (1994)—​now the American Association of Intellectual and Developmental Disabilities—​ “Service coordination (case management) is an ongoing process that consists of the assessment of wants and needs, planning, locating and securing supports and services, monitoring and follow-​along” (see also Summers, 2008; Woodside & McClam, 2005). The individual or family is the defining force of the service coordination process.” In the words of the National Conference on Social Welfare (1981), “Case management is a growing, evolving process which is shaped by forces in the environment in which it exists.” NASW (1992) views case management as the link between the client and the service delivery system. Social work case management practice is built on a bio-​psycho-​social model that addresses strengths and challenges in systems impacting various populations (NASW, 2016). One can see from these definitions that case management is the glue that binds a fragmented array of services to the unique and changing needs of clients. Case managers become experts on community resources that might help their clients, including government entitlements, charities, job openings, education, child care, legal aid, housing, transportation, and recreational opportunities. Case managers know the procedures clients need to follow in applying for and receiving help. Sometimes, when necessary services are not available, case managers initiate strategies to help communities develop new resources and systems for their clients. Effective case management requires that a comprehensive and coordinated array of appropriate services be available and accessible within a realistic and appropriate time frame. Without such a system, case management is only an administrative tool that manages clients’ access to services. Case management is not just a linking mechanism but also a principle that guides the provision of a full range of needed services. Unfortunately, service networks rarely meet this Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. The Evolution of Case Management Practice   5 level of expectation. While case management is conceived as one component of a comprehensive care system, it is not seen as a way to fix an inadequate or incomplete system of care. As Moore (1992) notes, “The notion that case management is a mechanism for the coordination of services is a myth that has been used to rationalize the current state of fragmentation . . . and becomes a mechanism for rationing services.” Case management is an effective tool but not a panacea for spanning organizational boundaries ( Jansson, 2003). If the goal is service access and coordination, the case manager’s efforts are designed to alleviate or counter the fragmentation of services and the natural tendency of bureaucratic organizations toward disorganization. For the case manager to achieve this goal, the following elements or conditions must be present: Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. • An accurate assessment and ongoing evaluation of client needs • The ability to link clients to resources appropriate to their needs • The power to ensure that appropriate and needed services are actually delivered • The capacity to see that services are utilized • A commitment to evaluating the impacts and outcomes of interventions If the goal of case management is seen only as cost containment, or a “least change” alternative, then the focal point of intervention becomes one of the systematic management and processing of individuals rather than one of engaging clients in a process. There is a difference between case management practice that contributes to the implementation of a service plan and case management systems that represent the administrative structure and interagency networks in which the case manager functions. One must also distinguish between case management models that are client-​driven and those that are provider-​driven. The former, based on a strengths perspective closely linked to an empowerment model, include active client engagement (see Rapp, 1997; Saleeby, 1992, 1997; Tice & Perkins, 1998). The latter are more clerical and bureaucratic, with a focus on documentation. Managed Care versus Case Management Managed care, unlike case management, is a practice or method of financing and delivering services to a range of populations. Although it involves some of the concepts and activities of case management, the two approaches have different objectives. Activities associated with managed care are designed to reduce costs by discouraging unnecessary or expensive services. Case management, with Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. 6   Case Management Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. its focus on linking clients to services, tries to obtain the most appropriate and cost-​effective help for them. Managed care programs review and intervene in decisions about what services are provided, influence or limit who the provider will be, and predetermine the payment for the provider. Managed care systems, which include health maintenance organizations, point-​of-​service plans, and preferred provider arrangements, have come to dominate the delivery of healthcare in this country. They are also the primary method of financing mental health and substance abuse services and are rapidly becoming the way public agencies contract with private organizations that provide specialized services for children and the elderly. Managed care plans are characterized by a preauthorization requirement to qualify for a particular serv­ ice, precertification for a given type or amount of service, concurrent review of the service and the client’s response, utilization review and discharge planning procedures, prospective pricing, service bundling, network development, peer review, and a capitation system of payment (Reynolds, 2000). While case managers need to be aware of the all-​enveloping managed care environment, it is not the authors’ intent to focus on managed care in this volume. For those interested in expanding their knowledge and skill in this area, we suggest the following resources: Birenbaum (1997), Cohen (2003), Corcoran and Vandiver (1996), Dziegielewski (1998), Edinburg and Cottler (1995), Franklin (2002), Franklin and Lagana-​Riordan (2009), Gibelman (2002), Jackson (1995), Mizrahi (1993), NASW (1993), Perloff (1996), Schamess and Lightburn (1998), Shera (1996), Strom-​Gottfried (1996), Vandiver (2008), Winegar (1996), and Zabora (2009). Who Does Case Management and in What Settings? Most social workers who specialize in direct practice do case management. Generalist practitioners, caseworkers, and groupworkers work with clients in the structured ways associated with their respective modalities, usually in weekly sessions over a number of weeks or months, directly trying to help using the theoretical practice model of their choice. However, to be of maximum help in either a casework or groupwork context, most social workers look beyond their offices into the social and community context in which their clients live. In other words, they help clients understand their problems as part of a broader systems approach and help them intervene accordingly. The major differences among generalist or foundation practice, the specialized methods of social work practice, and case management are those of degree. All involve conducting extensive assessments (psycho-​socials), all develop goals and intervention plans, and all work toward termination when clients reach Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. The Evolution of Case Management Practice   7 Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. their goals. Case managers tend to emphasize the use of community resources to help clients meet their needs. Intervention is viewed in terms of facilitation, connecting clients to the agencies, social service organizations, governmental entities, educational institutions, community organizations, and key people who can help them. It is common for one of these referrals to be an agency that offers specialized casework or groupwork services. Ongoing case management contacts with clients usually revolve around making sure that the service plan and the community connections are functioning and augmenting them if necessary. Unfortunately, agency-​based caseworkers and groupworkers often lack the time to perform necessary case management services with their clients. They rely on professional case managers who have much more time and expertise, working in tandem with them to connect clients to services in the community. Although it is clear that social work is heavily involved in case management training and services, the profession does not own the field. The need for professionals who can identify and manage the vast array of services is widespread. For example, case managers in the medical profession may include nurses, occupational therapists, medical assistants, and nutritionists (Cesta & Tahan, 2003; Lippman, 2004). Professionals may also act as case managers in the legal profession, especially legal aid. In fact, any agency that uses psychiatry, psychology, or marriage or family counseling may employ nonsocial work staff to act as case managers. According to the Case Management Society of America (2011), “Case managers are recognized experts and vital participants in the case coordination team who empower people to understand and access quality, and efficient health care.” Where Does Case Management Training Occur? Professional social workers receive their case management training in bachelor and master of social work programs in schools of social work. Case management training also takes place in nursing schools, other schools connected with the medical profession, junior college associate degree programs in social work, and services involving welfare, foster care, criminal justice, drug treatment, mental illness, and the elderly. Thousands of social service workers who perform case management functions are trained through ongoing supervision, workshops, and continuing education programs. According to the NASW (1992), the social work case manager shall: 1. Have a baccalaureate or graduate degree from a social work program accredited by the Council on Social Work Education and shall possess the Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. 8   Case Management 2. 3. 4. 5. 6. 7. 8. 9. Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. 10. knowledge, skill, and experience necessary to competently perform case management activities. Use his or her professional skills and competence to serve the client whose interests are of primary concern. Ensure that clients are involved in all phases of case management practice to the greatest extent possible. Ensure the client’s right to privacy and ensure appropriate confidentiality when information about the client is released to others. Intervene at the client level to provide and/​or coordinate the delivery of direct services to clients and their families. Intervene at the service systems level to support existing case management services and to expand the supply of and improve access to needed services. Be knowledgeable about resource availability, service costs, and budgetary parameters and be fiscally responsible in carrying out all case management functions and activities. Participate in evaluative and quality assurance activities designed to monitor the appropriateness and effectiveness of both the service delivery system in which case management operates as well as the case manager’s own case management services, and to otherwise ensure full professional accountability. Carry a reasonable caseload that allows the case manager to effectively plan, provide, and evaluate case management tasks related to client and system interventions. Treat colleagues with courtesy and respect and strive to enhance interprofessional, intraprofessional, and interagency cooperation on behalf of the client. The National Association of Case Management was founded in 1990. Its purpose is to provide case managers and other community support professionals with opportunities for professional growth. The organization accomplishes its goals through educational meetings, symposia, and the dissemination of materials relating to the case management process. The National Academy of Certified Case Managers, which has a heavy nursing orientation, was created to assure competence in the performance of case management functions through a validated standardized examination. The American Case Management Association, an association of nurses and social workers, advocates for case management practice in hospitals and the health system. Its National Board for Case Management offers the accredited case manager credential through an extensive examination designed to assess candidates knowledge of healthcare delivery, screening and assessment, planning, care coordination, interventions, and outcome evaluation. The Case Management Society of America issued standards for Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. The Evolution of Case Management Practice   9 case managers in 1995 with revisions in 2002 and 2010, with additional revisions in process. These are voluntary guidelines that can be used by those from various disciplines functioning as case managers. NASW participated in the development of the 2010 revisions, which are designed to minimize fragmentation in healthcare systems, incorporate the use of evidence-​based assessments, navigate transitions in care across and between systems and settings, expand interdisciplinary collaboration in care planning, and improve client safety. Case management serves to connect an often fragmented set of services and to assure quality, cost-​effective, and accountable services. The Center for Case Management has a certification and credentialing program for case management administrators. A certificate of case management is offered by the Commission for Case Management Certification (CCMC), and the NASW offers certification at two levels: the certified social work case manager and the certified advanced social work case manager. In 2016, CCMC and NASW announced an expanded collaboration to meet the growing demand for case management practitioners in the healthcare arena. Under the expanded collaboration, social workers who qualify for the NASW case management credential will prequalify for taking the CCMC certification exam (NASW, 2016). There are approximately 4,000 individuals who hold the accredited case manager credential while the certificate of case management has been granted to more than 40,000 individuals. The Journal of Case Management and the Case Management Journal are quarterly publications that offer professional forums for presentations on case management issues and practices. Some universities also offer certificates in case management for individuals preparing to work in various state-​funded programs that have a mandated case management component. These programs are available to individuals who have a bachelor’s or an advanced degrees in social work, nursing, or other health or human service professions. A master’s degree in case management is even available online via distance-​learning courses and experiential learning. The American Case Management Association, the University of Southern California School of Social Work/​Cedar-​Sinai Medical Center, and New York University’s Silver School of Social Work/​Langone Medical Center have recently announced new fellowships in social work case management. Kaplan Continuing Education offers a case management certificate for those in the healthcare field. Case Management Client Populations Every client population group can profit from case management services. In fact, current social work theory suggests that almost every client would benefit if the case management method were part of his or her service intervention plan. Be Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. 10   Case Management that as it may, case management is a major focus of service delivery systems in many areas, while in others it is integrated with other service methods. Children’s services and public welfare are two major domains for case management practice. Every state maintains departments that use case management including early intervention programs, foster care, child protective services, welfare, child care, housing, food distribution, employment, and job training. Many case managers are involved with the chronic mentally ill, the addicted, and veterans. The criminal justice system utilizes case management in prisons, halfway houses, and programs that offer prevention and alternatives to incarceration. Mental health settings, both in institutions and in the community, have case management staff to augment other types of direct services, such as clinical casework and psychiatry. Programs dealing with individuals who are developmentally disabled or autistic make heavy use of case management, as do programs for the aged. Another large domain for case management is in medical settings, such as hospitals and community health agencies (Cesta & Tahan, 2003; Snowden, 2003). Even agencies that do not identify case managers as such often assume that workers will integrate case management into their practice. This is particularly true in the fields of community mental health and family service, which employ clinical social workers to offer case management services in the private sector. For example, one can find social workers specializing in geriatric work being privately employed by families to find housing and other support services for their elderly relatives or workers in the area of developmental disabilities hired to search for appropriate and affordable housing for children or young adults who need to be placed out of their homes. The opportunities for case management practice in the newly emerging managed care marketplace are also significantly increasing for social work professionals. Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. CHAPTER 2 Overview of Case Management Practice Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. Systems Theory While there are some differences between case management and other methods of social work, there is one overriding theoretical theme that unifies case management with the rest of social work—​systems theory. The basic idea behind systems theory is quite simple: People’s behavior and attitudes are affected by everything and everyone around them. They are affected by their families, friends, and relatives; their jobs; educational experience and educational opportunities; and how much money they have and how they spend it. Age, gender, race, religion, ethnic identity, sexual preference, and political ideology affect people, as do the house and community in which they live, their health and access to health services, the government under which they live, and the recreational and community services available to them. Any problem an individual faces is not a factor only of his or her unique psychological make-​up. It is a combination of many forces working on a person that has brought her or him to the point of voluntarily seeking or being mandated to receive help. Thus, the solution to anyone’s problems, including our own, must be seen in the context of many different levels of intervention. To pull yourself up by the bootstraps, you need more than the motivation to reach for your shoes. You may need help finding a decent pair of shoes, learning how to put them on, learning how to walk, or having some place meaningful to walk to. You may find that some people are hoarding shoes, making it harder for you to find them. Maybe the only shoes available are cheap ones that fall apart. Maybe you find that shoe stores are closed to you, perhaps because of your schooling, your race, or your sex. Case managers use the concept of systems theory in very practical ways. We divide up potential assessment areas into three levels (Table 2.1): personal/​ 11 Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. 12   Case Management Table 2.1 Intervention Focus Areas in Case Management Practice Direct interventions Micro Mezzo Macro With clients With clients With clients Outreach interventions On behalf of clients On behalf of clients On behalf of clients Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. interpersonal areas, called the micro level; institutional/​organizational/​community issues, called the mezzo level; and social policy/​governmental/​cultural issues, called the macro level. Interventions also take into account each of these three levels; a systems approach to case management assumes that worker behav­ ior combines interventions in all three domains. Additionally, interventions in each of these areas could be directly with clients—​direct interventions—​or with others on behalf of clients—​indirect or outreach interventions. Thus, there is a two-​by-​three practice case management systems matrix covering the practice of every case management program (Frankel & LaPorte, 1998). For example, a worker in the micro domain could provide short-​term crisis intervention services (direct) and make a referral to an agency for therapy (outreach). In the mezzo area, a worker might help clients form a community support group (direct) and make a contract with a new agency for client referrals (outreach). In the macro domain, a worker could organize clients to help with voter registration (direct) and work with an National Association of Social Workers committee to lobby for changes in the welfare law (outreach). It is rare for a case management program to focus on all three of these possible practice domains; most programs focus on one or two. We will be looking at these issues more intensively as we move into the practice of case management. Case Management Functions To function effectively as a case manager, you should have an understanding of general case management functions, models, and tasks. Rose and Moore (1995) have identified the following case management functions: (a) outreach to or identification of clients, (b) assessment of needs, (c) service or treatment planning, (d) linking or referring clients to appropriate resources, and (e) monitoring cases to ensure that services are delivered and used. An expanded and more detailed set of case management functions is provided by Moore (1990): • To assess the individual’s ability to meet environmental challenges • To assess the caring capability of the individual’s family and primary group • To assess the resources within the formal system of care Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. Overview of Case Management Practice   13 • To enable individuals to use their personal resources in meeting environmental challenges • To enable families and primary groups to expand their caretaking capacity • To facilitate effective negotiation by individuals for resources from families or primary groups and formal service providers • To facilitate effective interchanges between families or primary groups and the formal system of care • To evaluate the ongoing needs of the individual • To evaluate the extent to which the individual is adequately supported by both the family or primary group and the formal system of care • To evaluate the extent to which the efforts of the family or primary group are integrated with those of the formal care system A slightly different list of case management functions is provided by Roberts-​DeGennaro (2008) in the twentieth edition of the Encyclopedia of Social Work: Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. • • • • • • • • • Developing a resource network Assessing the client’s needs and strengths Developing the care plan Establishing a written contract Implementing the care plan Monitoring the services Evaluation Closing the case Follow-​up For these functions to be performed effectively, the case manager must possess knowledge and expertise relating to both social systems and the etiology, needs, and functioning of the client/​consumer. The case manager also needs the interpersonal skills not only to assess the needs and circumstances of the client accurately but also to engage him or her in the process so that both can agree on what is to be done. Although the case manager might be able only to mitigate insufficiencies in the service network, he or she must have sufficient power and authority to make things happen (Rubin, 1992). Workers must also have caseloads of a reasonable size, lest they become processors rather than facilitators or enablers. And, most important, they must maintain accurate and complete records of their activities and the rationale for their actions. Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. 14   Case Management Case Management Models Several models of case management have been identified by various authors; Levine and Fleming (1985) have developed the following classification scheme for case management models: • • • • • • • Generalist Specialist Therapist Family Psychosocial rehabilitation Supportive Volunteer More recently, Bachrach (1989), Bond, Miller, Krumwied, and Ward (1988), Bush, Langford, Rosen, and Gott (1990), and Kanter (1989, 1991) have used the following terms to describe case management models: Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. • • • • • • Assertive Intensive Rehabilitation-​oriented Development/​acquisition Strengths Clinical Eggert, Friedman, and Zimmer (1990) have identified three intensive case management models: the home healthcare team, the neighborhood team, and a centralized individual model. These models differ in terms of the nature of client assessment and reassessment involved, the kind of direct services provided, and whether crisis intervention is available or utilized. Rothman (1991, 1994, 2009) proposes another model of case management that contains 15 sequentially linked functions (see p. 18). Rothman (2002) categorizes the first 11 of these functions as sequential and the last 4 as intermittent. The type of case management model used and the degree, level, and extent of case management activities required will vary depending on the needs and level of functioning of the individual. Authors like Gilson (1998), Rapp (1997), Saleeby (1992, 1997), and Tice and Perkens (1998) stress the need to develop models that recognize and build on client strengths. The model is also dependent on the overall case management goal and the level of skills of the manager. Some individuals will require intensive and ongoing attention. Others will Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. Overview of Case Management Practice   15 require ongoing but less intensive involvement. Some will need only limited or short-​term assistance, while others will require minimal monitoring. Your goal is to balance the client’s needs and capabilities with a range of formal and informal supports and resources. Case Management Tasks Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. Probably the most comprehensive listing of tasks required of and performed by case managers was developed by Bertsche and Horejsi (1980). The 13 basic tasks provide a clear and concise description of case management responsibilities: 1. Complete the initial interviews with the client and his or her family to assess the client’s eligibility for services. 2. Gather relevant and useful data from the client, family, and other agencies to formulate a psychosocial assessment of the client and his or her family. 3. Assemble and guide group discussions and decision-​ making sessions among relevant professionals and program representatives, the client and his or her family and significant others to formulate goals and design an integrated intervention plan. 4. Monitor adherence to the plan and manage the flow of accurate information within the action system to maintain a goal orientation and coordination momentum. 5. Provide follow-​along to the client and his or her family to speed identification of unexpected problems in service delivery and to serve as a general troubleshooter on behalf of the client. 6. Provide counseling and information to help the client and his or her family in situations of crisis and conflict with service providers. 7. Provide ongoing emotional support to the client and his or her family so they can cope better with problems and utilize professionals and complex services. 8. Complete the necessary paperwork to maintain documentation of client progress and adherence to the plan by all concerned. 9. Act as a liaison between the client and his or her family and all relevant professionals, programs, and informal resources involved in the overall intervention plan to help the client make his or her preferences known and secure the services needed. 10. Act as a liaison between programs, providing services to the client to ensure the smooth flow of information and minimize the conflict between the subsystems. Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. 16   Case Management 11. Establish and maintain credibility and good public relations with significant formal and informal resource systems to mobilize resources for current and future clients. 12. Perform effectively and as a “good bureaucrat” within the organization to be in a position to develop and modify policies and procedures affecting clients and the effectiveness of the service delivery system. 13. Secure and maintain the respect and support of those in positions of authority so their influence can be enlisted on behalf of the client and used, when necessary, to encourage other individuals and agencies to participate in the coordination effort. (Bertsche & Horejsi, 1980) Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. Rothman (2009) provides a different organizational arrangement in describing case management by dividing functions into two categories: sequential and intermittent. Sequential functions include: • • • • • • • • • • • Access to the agency Intake Assessment Goal setting Intervention planning Resource identification and indexing Formal linkage to agencies and programs Formal linkage to families and social networks Monitoring Reassessment Outcome evaluation (Rothman, 2009) Included as intermittent functions are: • • • • Interagency coordination Counseling Therapy Advocacy (Rothman, 2009) For other listings of case management tasks, see Grube and Cheenesky (2001), Mather and Hull, 2002, 2009), and Vourlekis and Green (1992). Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. Overview of Case Management Practice   17 Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. Confidentiality Issues Before going any further, we need to deal with the very basic ethical and legal issue of confidentiality. There are very clear guidelines in social work and other helping professions about what information case managers can share about their clients. Using the Social Work Code of Ethics as an example, the guidelines insist that clients have a right to know who will have access to their records and the information in them. No information about a client is supposed to be shared outside the worker–​client relationship without the express—​usually written—​ consent of the client (National Association of Social Workers, 1996). The issues of privacy and confidentiality have taken on added importance as the provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 took effect in April 2003. In the first contact with clients, issues relating to agency policies and the agency policy concerning confidentiality need to be discussed. Further work with clients cannot proceed unless they consent in writing to these policies or at least show that they understand what the policies will be. In this way, clients can make informed decisions about what they will share with the worker. When there is a legal mandate to share information with other professionals and agencies without clients’ consent, they need to be told that this will occur. When clients are unable to understand policies concerning confidentiality—​ children or citizens with intellectual disabilities, for example—​confidentiality is still to be respected and permission for release or sharing of information must be obtained from an authorized third party. Case managers have always had a special problem when it comes to confidentiality, which is now further complicated when health information is involved (HIPAA Privacy Rule). By the very nature of the case management roles, they will be sharing information about clients with other agencies and professionals in the referral and advocacy process (Davidson & Davidson, 1996; Watkins, 1989). Case managers often receive personal information during meetings with clients, much the same as do caseworkers and therapists. Case management records, however, may also contain information collected from a wide variety of sources. What makes confidentiality a potential problem for case management is that some of this information may have to be shared with a broad spectrum of agencies and professionals in seeking out and making appropriate referrals. Caseworkers and other therapists who do individual counseling may also face these same issues but not to the degree of a case manager, whose job is defined as the professional responsible for galvanizing the community on behalf of clients. Case managers have many more opportunities to share information about clients outside of their Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. 18   Case Management agency boundaries and thus must be extremely vigilant to maintain confidentiality. Given the growing use of computerized record-​keeping systems and HIPAA requirements, proactive safeguards must be utilized to limit access and to assure client confidentiality (Brannigan, 1992; Lawrence, 1994; Mills-​Groninger, 2003). You must always remember to get permission from your clients in making contacts on their behalf if anything about them will be discussed, even if you only mention their names. If referral communications are mandated by law, clients still have the right to know under what conditions their names and case information will be shared (Kagel, 1993). An important case management goal is to empower clients to case manage their own problems, to learn to “work the system” on their own behalf. When clients are initiating agency and professional contacts at a case manager’s behest, they need to learn what their rights are when asked for potentially sensitive information about their lives. For example, clients are not required to acknowledge whether they are HIV-​positive when applying to an agency for job training, employment, or housing. Similarly, people’s sexual orientation is of no concern to any agency personnel if clients are requesting access to casework or groupwork services. Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. The Process of Case Management The goals of case management are basically twofold. First, we need to help people connect to the personal, interpersonal, and community resources that will help them resolve their problems. Second, and just as important, we want to teach them how to become their own case managers—​to be able to identify their needs and solve their problems independently. While this second goal may not always be achievable, it is a value for case managers to strive toward. Social work in general, and case management in particular, follows a systematic process of working with people regardless of the types of clients or their problems. This process cuts across generalist, casework, groupwork, administration, and community organization methods, with workers using similar skills no matter what their practice orientation (see Ballew & Mink, 1997). This process does not always flow sequentially. It may proceed in cycles, returning to the beginning as the worker learns more about the client. The longer you work with clients, the more opportunity you have to identify additional problem areas or define problems in different contexts. As that happens, you will need to return to the problem-​definition phase and continue through the case management process, adding depth and breadth to the assessment as time goes on. Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. Overview of Case Management Practice   19 Steps in the Case Management Process • • • • • • • • Defining the problem Determining the severity of the problem Developing hypotheses concerning why client problems are occurring Establishing goals Developing and implementing a service intervention plan Evaluating the success of service interventions Termination Follow-​up Each of these steps raises different issues and carries with it the need for specialized skills. Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. DEFINING THE PROBLEM The case management process starts with an information-​gathering procedure called the psycho-​social. Relatively systematic, it requires the worker to find out everything about a client and his or her life that could be relevant to problem-​ solving. It covers questions that relate to micro, mezzo, and macro levels. Many agencies have standard forms to help case managers conduct psycho-​social; we will spend some time on this issue later in this handbook. One of the essential pieces of information the case manager needs to establish is the problems that brought the client to the agency. Sometimes the problems are initially defined by the agency itself. For example, if you work in a child abuse agency, most of your clients will have abuse as a defined problem. Many agencies focus on particular areas that define clients’ presenting problems before they are accepted for service. However, since we know that every problem in life is connected to other problems and issues—​part of the systems approach—​it is likely that presenting problems are the proverbial tip of the iceberg. Frequently, clients with multiple problems end up at one particular agency simply by chance. Thus, to assume that presenting problems automatically define goals and serv­ ice intervention plans is often unwarranted. For example, a homeless, chronically mentally ill, drug-​addicted man who steals purses to support his habit could end up in any number of agencies—​a homeless shelter, a mental health clinic, a psychiatric outpatient or inpatient hospital, a drug treatment program, or a forensic treatment program in jail. Clients also have their own sense of why they need help. This is often true of those who arrive at an agency voluntarily, on their own, or through professional Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. 20   Case Management referrals. Other clients are mandated to seek help, usually through the courts; their problems will be initially defined by where their “client career” started. The important thing to remember is that whatever the presenting problem may be, it is up to you, through the process of the psycho-​social, to discover the entire gamut of possible problems in your clients’ lives. D ET E R M I N I N G T H E S E V E R I T Y O F T H E P R O B L E M During the process of the psycho-​social, the case manager becomes aware of a series of possible client problems; many, of course, are interconnected. It is important to determine how severe each of them is; the severity of a problem is a direct indication of how immediately it needs to be addressed. In determining problem severity, case managers must take into consideration the opinions of their clients. Respect for clients’ sense of themselves and their assessment of their own lives is at the center of social work’s value system and should not be taken lightly. A worker cannot help anyone effectively unless there is agreement about what problems need to be addressed. If there is disagreement, the issues need to be addressed and overcome, if possible, before moving on to the next step in the case management process. Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. D E V E L O P I N G H Y P OT H E S E S CO N CE R N I N G W H Y CL I E N T P R O B L E M S A R E O CCU R R I N G Determining why a client has problems is one of the most difficult tasks facing the case manager. This task is sometimes called the “assessment of controlling conditions,” or “assessment,” for short. Various theories that can aid you in this task include the behavioral approach, psychodynamic theories, organizational theory, community psychology theory, social psychology, and economic and political theory. As you become more sophisticated in case management, you may wish to study what some of these theories have to say about social ills in American society. However, the basic underlying theory that will guide your assessment of controlling conditions is systems theory. You will be trying to understand how the interplay of forces from micro to macro is affecting your client. At the micro level, what role does the family play? What attempts have the client and family made to resolve the problem? What are the client and family strengths that can be drawn on to help? At the mezzo level, what agency, organizational, and community resources have been involved in trying to help? What blocks, if any, have been put in the client’s way? What additional resources are available, and why haven’t they been used? At the macro level, what are the governmental policies Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. Overview of Case Management Practice   21 and regulations that govern support for your client? How do ethnic, racial, and cultural factors play into the maintenance of client problems? A good assessment should lead you and your clients into making hypotheses about what is causing their problems, further indicating the direction of service interventions. Assessment is useless unless it points to concrete solutions. In addition, assessments that lead to stereotypical “plug and chug” solutions should be avoided because they minimize individual differences. For example, if case management assessment always leads to suggesting therapy, why bother doing a psycho-​social? While there are obviously times when therapy is necessary and appropriate, other interventions might do more to lift a person’s spirit and sense of hope. Similarly, a client who is in need of mental health services but has not been successful in satisfying basic needs for food, shelter, or medical care may not benefit from mental health services until the other needs are met. Each client offers a unique opportunity to assess controlling conditions leading to helpful interventions. Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. E STA B L I S H I N G G OA L S The development of clear goals is a very important phase of the case management process. A goal is a statement defining the expected outcome for each client by the time case management services are terminated. Goal statements should include a time frame and a date by which the goal will be reached. A goal without a date opens the possibility for an endless service delivery process. Within a given time frame, case management goals are stated in terms of one or more of the following areas: (a) What are the behavior changes expected of the client? (b) What community agency social services is the client expected to be utilizing? (c) What economic, medical, or educational support services is the client expected to use? (d) What community/​neighborhood support systems is the client likely to be a part of? (e) What self-​initiated problem-​solving skills are expected of the client? A note of caution: case managers should be careful not to set goals that are unrealistic or unachievable or that do not call for clients to accept responsibility. Setting such goals may expose both the organization and the case manager to accusations that they have not delivered on promises and may result in legal liability. Whenever possible, goals for case management services should be established with, not for, each client. In most situations, clients need to be involved in the work of figuring out where they want to be at a given time. Of course, the worker is an important resource in this process, suggesting options, offering opinions, discussing what might be reasonable and possible given the known resources, helping people focus, and, when appropriate, supporting clients who Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. 22   Case Management Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. want to explore the development of new resources as one of their goals. Case management works much more effectively when clients are intensively involved in all stages of the process to the extent possible. Consumer involvement cannot be emphasized enough. People tend to work toward goals in which they feel they have had involvement; no one likes to have goals imposed on them without their cooperation and agreement. The client’s investment in the process is critical. Even in case management programs where clients are mandated to receive serv­ ice, such as child abuse or forensic programs, it is important that they subscribe to the goals and plans set with them. If this does not happen, a client’s motivation to participate and complete service plans will be greatly weakened and the goals far less likely of attainment. A case manager cannot collaborate in setting goals with all clients. Some will not cooperate, especially those who have been mandated for services against their will. Others cannot engage in goal setting because of age, developmental disabilities, or mental impairment. In these cases, the case manager may have to impose goals, drawing from options expected by the family, the agency in which he or she works, the courts, the community, and sometimes just plain common sense. Still, the worker should try to involve the client, regardless of the diagnosis or the severity of the problem, before imposing goals. The case manager should never assume that a client lacks the capacity to participate meaningfully in the process without first assessing the person. Another more general role for the case manager in the goal-​setting process is lending a positive vision and a sense of hope to clients and their families, no matter how difficult the situation or how slight the cooperation. While at times this may seem to be difficult or even impossible, it is always one of your goals with every client you see. D E V E L O P I N G A N D I M P L E M E N T I N G A S E RV I CE I N T E RV E N T I O N P L A N By the time you have completed the first four steps in the case management process, the types of intervention you and the client will develop should be relatively clear. Following systems theory, you will direct intervention according to what you have learned from assessment. Case management interventions are often initially focused on the micro and mezzo levels. First, you will often do direct interventions, working with your client—​crisis intervention, focused short-​term casework, making referrals, advocacy for services, coordinating serv­ ice delivery, or tracking service utilization and goal attainment. Second, you may be able to help the agency in which you work be more responsive to your Frankel, Arthur J., et al. Case Management : An Introduction to Concepts and Skills, Oxford University Press, Incorporated, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/humber/detail.action?docID=5602452. Created from humber on 2024-01-04 19:46:40. Overview of Case Management Practice   23 clients. This might be done through training, reworking agency policies to make services more accessible, or involving clients as peer workers with new clients. Third, you may work at the community intervention level to pave the way for support services for your clients, enhance existing resources at agencies, or develop resources where none exist. This type of intervention is often called community action, or community development. In many, if not most, cases, clients can be involved in this intervention process. Possible interventions at this level include forming coalitions between agencies to coordinate services, forming and/​or working with community groups around issues important to clients, engaging in voter registration drives, participating in programs that publicize community problems, and supporting fundraising efforts for relevant causes. Interventions at this level do not have to be seen as controversial or “hell-​raising.” They are simply planned social work interventions at a community level, carried out with clear and focused goals in cooperation with fellow professionals and members of a community. Copyright © 2019. Oxford University Press, Incorporated. All rights reserved. E VA LUAT I O N One of the most overlooked aspects of case management is evaluation. It is clear at this juncture of the social work profession and America’s social problems that the very act of service delivery is not a sufficient indicator of success in the worker–​client relationship or in the eyes of the community. We need to do more than show that we delivered case management services; how well did this joint process work? Fortunately, there is a way to answer this question. Technically, it is called determining goal attainment. In determining the degree of goal attainment, the case manager asks questions like these: Was the drug problem alleviated, and is the client in a drug treatment program? Did the client find a mental health center for his parent–​child problem, and are he and his son going consistently? Is the abused child now stabilized, and is her mother attending therapy sessions? Has housing been found, and has the client moved in? Is money for a family’s food now available, and is it being used to improve nutrition? Has the client found a job and stayed in it? Evaluation of this sort raises several issues. The first is the clarity of goals. Goals dictate the evaluation questions, and the more behaviorally specific, the better. For example, if the goal is to decrease drug abuse and attend outpatient drug treatment, the simplest answer could be a simple “yes” to both parts of the first question. However, this is not as specific as a goal stating that drug abuse should decrease from daily usage to zero, with attendance at an outpat