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Best Practices in Case Management:
Transcript of Best Practices in Case Management:
Fostering Change in Ourselves, Our Co-Workers, and the People We Serve
Amanda J. Harris, LICSW, MPP
Pathways to Housing DC and t3
Intro and Learning Objectives
Why are you a Case Manager?
Identify the core values and strengths you bring to this work.
Explore the issue of poverty, homelessness, and mental health and the history of case management in the United States.
Name the principles of case management/ACT and understand the underlying spirit or philosophy of each
Move from illness-centered words and phrases to the language of recovery.
Understand the basic elements of Motivational Interviewing
Demonstrate proficiency in recovery planning.
Consider change and how it effects both the people we serve and ourselves.
Best Practices in Homeless Services
Before we look forward
We must look back
History of Homelessness in the US
Mid 1600s: homelessness was deemed a "character flaw" as most communities believed God would take care of the deserving. Homeless individuals needed to prove thier worthiness
The IndustrialRevolution: Many left small farming communities in search of jobs but found little. This led to huge spikes in homelessness in urban settings. At this time, panhandling laws were established and jails became defacto shelters.
Mid 1800s- first reports of homeless youth cast off by parents who could not afford them.
1870- 90s: Morphine became prevalent as many war amputees used this a a painkiller. Many veterans suffered from what is now know as PTSD. The terms "hobo", "tramp", and "bum" were first coined.
1920 - 30s: Many natural diasters such as the Great Chicago Fire, San Fransisco earthquake, and floods in Mississippi displaced more than 1.3 million.
1948- the UN declared housing as the basic human right. 155 countries moved to adopt. The US did not.
1960-70s: Changes in psychiatric care led to de-institutionalization, leaving many severly mentally ill people without a home or proper care.
1980s: Major HUD cuts led to the closing of many public housing units.
Homelessness is and has always been about ...
War, Natural Diaster, and Poverty
have been consistent causes of homelessness.
Promising Trends to Ending Homelessness
What's happening in your community?
Overview of Case Management
What it is and What it isn't
History of Case Management
During the Industrial Revolution, many American cities saw a huge influx of people seeking a better life, be it immigrants from Europe or Asia or poor folks from farming communities. Unfortunately many did not fair well in the new industrialized world and faced poverty, starvation, and often cultural barriers. During the late nineteenth and early twentieth century, settlement houses began to sprout up. These were large homes where immigrants and others could learn skills, receive basic neccessities and the like.
The US saw another insurgent of case management during the mid 1900s, as de-institutionalization forced many out into communities with little to no skills.
Today case management is used in all kinds of setting from healthcare ot homelessness.
Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.
You want to make a difference in the world. You are seeking a position as a case manager. Two job postings catch your eye.
#1 Wanted: Case Manager to engage people experiencing homelessness. Provide hygiene and survival supplies. Build trusting relationships. Assess short and long-term needs. Help to access shelter, treatment services. Assist with obtaining transitional housing to demonstrate stability and readiness to live indepedently in the future.
#2 Wanted: Case Manager to engage people experiencing homelessness with housing-focused approach. Offer permanent, affordable housing up front. Help individuals choose and move into housing as quickly as possible. Ensure linkage with support team to assit with maintaining housing and improving quality of life.
CM is not...
Focused on what people want or desire
Emphasizes what is right with a person
Accepts each person as an individual
Allows people to make their own choices
Highlights personal responsibility
Includes active participants
Focused on mental health symptoms or addiction
Focused on what is wrong with a person
Grouping people into catergories like schizophrenics or addicts
From a belief that professional know best
A life free of responsibility
Inclusive of passive participants
Partnering v. Directing
I give my best advice, but they won't listen.
I educate and give options, what else can I do?
She resists everything I suggest.
Some folks just don't want to be helped.
He's in total denial about his problems.
People just need a good talking to.
The Power of Language
Your task is to try as hard as you can to convince and persuade the speaker to make the change he or she is considering.
(Note: This is not a best practice! This is merely an exercise to better understand what the people we work with go through. )
Specifically, once you find out what the change is that the person is considering, do these 5 things:
1. Explain why the person should make the change.
2. Give at least 3 specific benefits that would result from making the change.
3. Tell the person how they could make the change.
4. Emphasize how important it is for them to make the change.
This might include the negative consequences of not doing it.
5. Tell/persuade the person to do it.
If you encounter resistance, repeat the above, perhaps more emphatically.
Principles of Case Management
Gives priority to the self-identified needs, preferences, and goals of the individual. The helping relationship is collaborative, with the care navigator acting as a guide.
Emphasis on ending homelessness by providing permanent housing upfront, and then providing services as needed. Treatment is not a condition of obtaining housing.
Homelessness is not a choice
Kindness and clean socks are not enough
Everybody deserves housing…first
Housing-focused approach based on the following principles
Recognizes impact of trauma, past and present, on people’s lives. A “trauma lens” helps promote empathic understanding and recognition of adaptive behaviors developed in response to traumatic experiences.
Recognizes that recovery is possible, and that it is a self-directed, ongoing process unique to each individual. A recovery orientation fosters hope.
Understands that everyone needs a “circle of care,” including formal supports and natural networks. Actively helps individuals make and strengthen these connections.
Emphasis on strengths over deficits. Focusing on strengths helps to build confidence in ability to achieve goals.
Who Needs to Change? We Do!
Relationship Building and Engagement
The Language of Wellness and Recovery
See the Person First
People are much more than their labels or diagnoses.
See the individual holistically, as a unique whole person in a particular life context
See the person in their full humanity - not merely as "chronically homeless" or a "mental patient" or and "addict"
You're doing well.
I'm here for you.
How can I help you?
We can work through this together.
It's OK to feel like that.
I accept you and appreciate you the way you are.
What do you need at this time?
You've come a long way.
You're a strong person.
I admire your courage in dealing with this pain.
I encourage you.
Don't give up.
I can't promise, but I'll do my best to help.
I don't understand. Please tell me what you mean.
Tell me how you feel
What if we thought and spoke in terms of...
"intensity" vs. "crisis"
"big feelings" vs. "symptoms"
"justifiably angry" vs. "borderline features"
"filled with grief" vs. "depressed"
"feeling far away/numb" vs. "dissociated"
"having a bad hair day" vs. "decompensating"
"person I work with" vs. "my consumer/client"
"negotiated risk" vs. "safety, safety, safety"
"different opinion" vs. "non-compliant"
Assertive Outreach and Engagement
Express and model respect, treat the person with dignity
Focus on the positive potential of the person and situation
Continuously promote personal choice in small and large ways
Teach the the skills the person says he or she wants to learn
Expand the resources base. Open new horizons by describing possibilities and exposing people to opportunities and recovery role models
Support the person as he or she moves forward
Focus on the potential for a “real life” in the community, rather than the continual need for formal services and a life bounded by the formal service system
Stay in relationship– Stick with the person through hard times, setbacks and relapses
Relationship Building: Engage in Hope-Instilling Practice
Helping relationship can either hinder or promote recovery
Helpers who hinder recovery:
Hold low-expectations and thus kill the person’s hopes
Focus on the person’s problems and deficits; constantly judge the person and find them lacking
Make decisions for the person, jump in to fix people, and do things for them they could learn to do for themselves
Segregate people in entrapping niches where everyone has a labeled identity, and deny everyday freedoms such as the right to come and go as they wish
Treat basic supports (e.g. housing) as commodities that the person must earn and can lose at any time based on the judgment of the worker
Relationship Building: Avoid Helping Relationship that Hurt/Hinder
Get to know the person, encounter him or her directly, person to person, without formalities, assessments, questionnaires
Be genuine and nonjudgmental
Continue to connect and offer assistance repeatedly, over time
Don’t give up on the person, even if they make decisions that don’t pan out, get into trouble, lose their apartment, or if they do not immediately warm up to you
Read and discuss the case study of Doug
Relationship Building: Assertive Outreach (continued)
The worker actively or assertively engages the person
Take your time; it takes time to build a healthy relationship
People may not trust or open up right away, it is highly likely they have experienced trauma and have been violated in various ways, and may actively fear formal helpers
Do not be invasive or overly intrusive—allow people to maintain their territory and set the pace; respect people’s privacy
Offer practical assistance in a matter-of-fact manner
Be impeccable and reliable—follow through on all commitments (continued)
Engagement and Relationship Building: Some Skills of Assertive Outreach
Strong and positive helping/peer relationships are the basis of PHF work and are the main foundation of recovery
The work is a partnership between the team and the person
Team members consistently demonstrate genuine caring
The worker is warm, concerned, empathic, active, interested, curious, informal, friendly, rather than formal, business-like or detached
The relationship is purposeful versus reactive—PHF assists the person to recover and rebuild the life they want, rather than just reacting to unmet needs or crises
The relationship is empowering rather than an artificially one-way one up one down
Both the worker and the participants are whole people. Mutual trust and caring is stressed above professional distancing, neutrality or enforcement of stiff artificial boundaries.
Building the Helping Relationship:
The Stance of the Worker
Pat Deegan on Recovery:
Patricia Deegan PhD is a psychologist and researcher. She was diagnosed with schizophrenia as a teenager. For years, Patricia has worked with people with mental disorders in various ways, to help them get better and lead rewarding lives. This film features a lexture by Patricia Deegan on the subject of her own rout to recovery.
Skills for Assessing Strengths
generous, compassionate, curious, intelligent, perseverant, love of animals, good at math, friendly, flexible, kind, artistic, musical, athletic, open minded, hope, humor, courage
Add your own…
Strengths come in Endless Variety: Some Inner Strengths
First: Take a few minutes to think about your own strengths. Make a mental list, or jot down a few inner strengths in terms of your personality traits, skills, talents, knowledge and wisdom, values, strong motivations, as well as your outer assets or strengths that you can draw on from your family or culture, community, or surroundings
Second: Break into dyads, take 5 minute for each person to tell your partner:
About one inner strength that you have that you believe will help you do your work well, and
About one external strength/asset that comes from your family of origin, cultural background or local community that you think will support you in your work
Exploring Strengths Exercises
Strengths assessment is not done like conducting a questionnaire but rather questions are asked in natural conversation as part of getting to know and serve the person
Handout: Strengths oriented questions
We can also assess strengths by noting things the person says, does, or has in his or her environment, and checking our observations out with the person
Case study: Read and briefly discuss the case study of Pete
Strength Assessment: Asking Questions that Identify Strengths
Inner strengths arise from:
The qualities or traits of the person
Their skills (what they know how to do well and enjoy doing)
Their special talents or gifts
Their knowledge and wisdom
Their interests—what they are curious about
Their aspirations and hopes for the future
What they are already doing that helps them manage their condition
Outer strengths come through the person’s surroundings, family or cultural background, and exiting community assets
Strengths Assessment: Exploring Sources of Strengths
In PHF major emphasis is placed upon assisting the person to identify their
strengths and supporting them to express their strengths in their home and
community. A clear understanding of each person’s strengths is needed to set
goals and create strength based personal plans.
To conduct a strength assessment we:
Find a mutually chosen place to meet (often the person’s apartment)
Engage in informal activities (e.g. such as having coffee together)
Use a conversational manner
Ask open-ended questions and follow-ups to deeply understand the person
Explore strengths from different angles
Listen deeply and express empathy
Encourage the person, notice and appreciate their strengths
Show we really heard the person, by working to help them develop and use their strengths.
Strength Practice: Assessing for Strengths
Recovery Plans and Goal Setting:
Connecting the Dots
Self Care: How to Prevent Burnout
Using the case examples and notes from the role play
1) Identify one individual recovery goal
2) Develop at least 2 associated objectives and
3) Develop at least 2 case management services that will support each objective
Creating Goals, Objectives, and Services
Please take a few minutes to read over the case scenarios. Each situation requires a discussion of, amendment to, or creation of an individual recovery plan.
Choose one person in the group to act as the case manager and another to act as the person receiving services. Engage in a role play for about 10-15 min.
Discuss in your group what went well and what could have gone better.
Be prepared to represent your findings to the larger group.
“Think about it. Whether you have a mental illness or not, you have undoubtedly been a Hope Giver and a Hope Receiver yourself at some time in your life. Perhaps, like me you also have noticed that there are people around you who play the role of Hope Stealers. Hope Stealers fail to see an individual’s full potential and tell others that they can’t, or that they are not qualified to achieve a goal. In order for my recovery to move forward, I had to get pretty savvy about identifying such people and learning how to ignore those “Hope Stealer” influences. I gained courage, confidence and strength by setting out to prove that my Hope Stealers were wrong.”
*Sherri Rushman, licensed Social Worker and Peer Specialist
Our Role as Hope Givers
I met with Johnnie at the library to provide a social skills building service. Johnnie has identified wanting a partner as a recovery goal. I modeled for Johnnie how to initiate a conversation with the librarian about books. Afterwards Johnnie talked about the importance of maintaining eye contact and smiling. He admits he struggles with finding the right balance of eye contact and not just staring at the person. Next week we will return to the library and I will observe Johnnie initiate a conversation with library staff.
Progress Note Example
The Case Manager will model for Johnnie how to initiate a conversation at least once over the next month.
The Case Manager will meet weekly with Johnnie to role-play or practice conversations.
Examples of Services
The service is what the case manager will do to help the person complete the objectives.
Identifying what the CM will do helps to keep us on track and focused on the goals wants and desires of the person
The services should be as clear and precise as the objectives.
It may take multiple types of services or interventions to help someone accomplish a particular objective.
Step 4: Identifying the Services
Objectives are the action steps necessary to achieve goals. They describe the specific steps a person will take.
S – Specific
M – Measurable
A – Achievable
R – Realistic
T – Time- oriented
Step 3: Developing Objectives
“I want a partner to share my life with.”
“I want to my own place to live”
“I want to see my kids again.”
“I want a job so I can make more money.”
Examples of Goals
A goal is something personal the person wants or desires such as a relationship, job, home, friends, and family
Goals are the “big picture” and often long-term
Goals should be written and described using the person’s voice
Ideally goals should be limited to only a few with many smaller “steps” to get there.
Step 2: Identifying Goals
Assessment questions should cover various life domains such as…
Employment and Education
Family and Social Relationships
Health and Mental Health
Drug and Alcohol Use
Finances and Money Management
Initial and On-Going Assessments
A plan allows us to break down the goal into manageable pieces
Provides a road map and keeps us focused on what is important to the person
As case managers, our job is to facilitate recovery not merely “check-in”.
We are able to share in the successes.
Having a clear plan helps keep the person in control of their life and recovery process.
Why do we need a Recovery Plan?
What do people want?
Goals should be written in the person’s voice
Objectives are the action steps the person will take in order to achieve his/her goal
Services tell the person what you as the case manager will do to support him/her with accomplishing the objective
Things to Remember
Let the people we serve be the authors of their own recovery plans.
Use the recovery plan as a guide to the services you provide
Recovery is possible- if we partner instead of direct, folks will acquire the necessary skills to live without us.
The Recovery Plan is a living, breathing document – not just a piece of paper.
Case Managers should constantly be assessing how well the plan is working and if it is still relevant.
If it’s something is not working, don’t keep trying the same thing, do something different!!
On-Going Assessment and Planning
All services provided should be documented in a progress note. These progress notes should always be linked to a recovery goal. Notes must also include detailed descriptions of the following:
Plan for Follow-up
Step 5: Documenting the Work
In the next 3 months, Johnnie will initiate at least 3 different conversations with his neighbors.
Tamara will make a list of the “must-haves” in an apartment in the next month.
In the next 90 days, Barbara will identify at least 2 resources in the community for developing parenting skills.
Examples of Objectives
What’s getting in the way?
What has gotten in the way in the past?
What does the person do well?
What has s/he does well in the past?
Step 1: Identify the Strengths and Challenges
The case manager
Other service providers
Who should be involved in the Recovery Plan Process?
Case Managers as Facilitators of Recovery
Assessments, Planning, and Progress Notes
A place to call home.
Some money in their pocket.
A date on Saturday night!
Move with the Cheese!