The case manager's handbook 5th edition

1. Explain the role of the case manager in monitoring and evaluating services.

2. Describe the process for evaluating outcomes and determining future services.

3. Identify the components of a psychological report

4. Examine the role of dynamic factors and static criminal history in case management.

5. Describe the three ways in which a social history may appear in a case file.

6. Why are there times when case managers have to perform multiple roles?

7. Describe complexities of the case with Juan Ruiz. (in chapter)

8. Name the components of a budget.

9. Name the two steps that list.

Generalist Case Management

Woodside and McClam

Use book and two outside sources.

At least 100 words per question

THANKS

CHAPTER ONE Introduction to Case Management Surviving and Thriving as a Case Manager Ellen The agency I work for is located in the northwestern United States. We serve all age ranges. It is a community mental health center. The center has several different campuses across the county. I believe they serve around 18,000 people: children, adults and older adults. And the programs that they offer are quite extensive. They have counseling services, forensic services, housing and rehabilitation, case management, intensive case management, and then different psycho-educational sorts of things they do as a group. I had two positions within the agency. It is not unusual to stay in an agency and assume a new position. At first I worked for a program that provided extended support and we provided intensive case management to adults and older adults who were chronically mentally ill. So I worked with a lot of folks who had psychotic disorders and anxiety and depression that were living mostly in adult family homes in the community, which are small residential facilities. They have twenty-four–hour care within the homes and so my role as a case manager was to go to those homes a few times a week to do just case management things. The case manager's job is to make sure clients are thriving in their environment, and everyone is safe and healthy. I worked in that position for about two years and I carried a caseload of between 20 and 30 people at any given time. We spent a lot of time traveling between houses. And then with the shifts in the budget, I transferred to a different position. I worked in one of the adult community support clinics in the south side of the county. At that particular clinic I was a case manager. Most of our clients would come to us. These clients were more capable of managing public transportation in order to make it to appointments, but they were still very much mentally ill. They had other marginalizing sorts of issues: housing issues, financial issues. —Permission granted from Ellen Carruth, 2012, text from unpublished interview I n this agency we focus on meeting the needs of individuals and their families. The individuals, our clients, have difficult medical diagnoses and our goal is to allow them to live in their homes. In additional, all of our clients have other needs, reflecting social, educational, financial, and other family concerns. Meeting these multiple needs requires service coordination. We provide services that meet the specific needs of each client. And we involve the client and the families in service delivery. Coordination and integration support the management process. Sometimes professionals working in mental health and developmental disabilities do not understand how to work together to serve a single client. We provide the bridge. —Case manager, children's services, New York, NY T he agency I work for helps adolescent females. It would be difficult to describe the average client. Our clients come from various economic circumstances and they present very different issues. For some, they have resided in state custody for a number of years and they need short-term housing. For others, they are in crisis and parents or guardians either asked for help or the court referred them. Some are homeless. The girls can stay at this facility for as long as fourteen to thirty days, depending upon who provides the payment. In this agency we offer an array of services including individual and family therapy, psycho-educational groups, and a mental health assessment. Of course, we give the girls food, shelter, and clothing. —Case manager, youth shelter, St. Louis, MO I ntensive Case Management Program is the name and focus of our program. Our commitment is to meet the long-term needs of the persistently mentally ill. These clients will always need focused help, so when we enroll clients we take the long view. We do everything we can to help these folks. One of our goals is to normalize their experiences; we try to give them a life in the community. We also hope to reduce the stigma in the community. Some of the services we provide include daily living skills training, transportation, health needs, and medications. —Case manager, mental health comprehensive care services, Knoxville, TN The preceding quotations represent the words of case managers involved in the delivery of human services. This chapter introduces you to the subject and presents a model of case management that guides many helping professionals who work in human service delivery. Focus your reading and study on the following objectives. CASE MANAGEMENT DEFINED • Describe the context in which human service delivery occurs today. • Differentiate between traditional case management and case management today. THE PROCESS OF CASE MANAGEMENT • List the three phases of case management. • Identify the two activities of the assessment phase. • Illustrate the role of data gathering in assessment and planning. • Describe the helper's role in service coordination. THREE COMPONENTS OF CASE MANAGEMENT • Define case review and list its benefits. • Describe why there is the need for documentation and report writing in case management. • Trace the client's participation in the three phases of case management. PRINCIPLES AND GOALS OF CASE MANAGEMENT • List the principles and goals that guide the case management process. • Describe how each principle influences the delivery of services. Case Management Defined The world in which case managers function is changing rapidly. Because of client tracking systems, the electronic transfer of records, dual-diagnosis clients, limited resources, and rapid communication capabilities, current service delivery is vastly different from that of a few years ago. One result is that the time between policy development and implementation is much shorter. Another is that many human service agencies and organizations have chosen to limit the services they provide. More and more, case managers need skills in teamwork, networking, referral, and coordination in order to obtain the services clients need. All this takes place in a constellation of service providers that continues to grow and change. Service delivery is affected by the current economic downturn and negative economic climate resulting in an expanding number of individuals, families, and communities needing help and support to meet basic needs. Rising unemployment and underemployment, loss of homes to foreclosures, rising health care costs, and increasing costs of postsecondary education, to name a few, are consequences of the late-2000s financial crisis in the United States (Altman, 2009). In addition, many individuals and communities are dealing with the aftermath of increasing weather-related crises. Changing demographics and multicultural perspectives present additional challenges to delivering case management services to clients in need. A report by Kotkin (2012) for the Smithsonian Institute described significant shifts to youthful and diverse. Accordingly, although there is an increase in the number of those over the age of sixty-five living in the United States, the number of those between fifteen and sixty-four is projected to increase by 42 percent. In addition, by 2050, it is projected that the minority population will increase from 30 percent to 50 percent of the population. The growth of the U.S. minorities reflects an increase in mixed-race individuals, Latinos, Asians, and immigrants from diverse countries and backgrounds. Immigration remains a significant aspect of the changing demographics globally. Experts anticipate that approximately one million people a year will come to the United States (University of Southern California, 2011), and that these immigrants will represent predominantly an educated and skilled workforce contributing to public and private businesses. In addition, the current political climate brings the role of government under close scrutiny, especially with regard to human services. How involved should government be in meeting human needs? What is its role? What is the proper relationship between state and federal governments? As these questions are examined and debated, case managers sometimes find themselves working under a cloud of uncertainty that influences the work they do, their professional identity, and their professional development. The quotations that introduced this chapter share a common theme: All three situations require providing and coordinating services for the individuals and families served. Our first case manager directs an agency that provides intensive case management to children and families with complex medical problems. In this agency, the case management process begins as early as the diagnosis of a medical problem and can be terminated once clients are back home and able to manage their own care. An assessment, planning, and coordination process supports clients. There is a continuous evaluation of both client needs and the effectiveness of the care provided. Because the ultimate goal is for the family to manage its own case, all plans and services focus on and build on family strengths. The services provided by the youth shelter are different. Its primary responsibility is to provide housing, assessment, and counseling for two weeks; the staff then makes appropriate referrals. Although contact is short term, the girls receive intensive physical and psychological care, participate in determining their own treatment plan, and receive shelter and nutritious food. The treatment plan is based on their needs, strengths, and interests. Accountability means developing plans based on the girls' priorities as established on the day they arrive. The third case manager works in an agency that provides long-term managed care for people with mental illness. Rarely do they close a case. People with severe mental illness who reside in the community require service coordination that is long term, closely monitored, and supportive. The agency's commitment to these clients is to assess their needs periodically and adjust plans and provide services accordingly. Often this agency is the only lifeline for these adults. Because the agency maintains a long-term relationship with clients, its staff develops ways to update assessments and service plans. These diverse examples illustrate service delivery today. As you can see, the care varies from agency to agency, from helper to helper, and from client to client. One element each example has in common is the use of case management to coordinate and deliver services, moving an individual through the service delivery process from intake to closure. Traditional Case Management To define case management, it is helpful to look at the ways in which case management was traditionally regarded. In mental health service delivery in the 1970s, case management was a necessary component of service delivery because clients with complex needs required multiple services. Case management was a process linking clients to services that began with assessment and continued through intervention. In the 1980s, there was a shift in the focus of case management. Many professionals and clients objected to the use of the word manage because it connotes control. This language did not seem to reflect a commitment to client involvement or empowerment. Terms such as service coordination and care coordination were considered to indicate more completely these new goals of case management. Many believed that the term service coordination more accurately represented the primary work of the case management process—linking the client to services and monitoring progress. Jackson, Finkler, and Robinson (1992) describe the development of the term care coordination during their work with Project Continuity, which facilitated care for infants and toddlers who required repeated hospitalization and who qualified for intervention under the Education for All Handicapped Children Act (1975) and its 1986 amendment, the Preschool Infant/Toddler Program (PL 99-47; parts B and H). Over the course of this project, the term care coordination evolved from what is popularly described as case management. Staff expressed dissatisfaction with the case management term because they did not feel families should be viewed as cases needing to be managed. Therefore, the project changed the description to care coordinator, which reflects the role as coordinator of care services for the child and family (p. 224). Case Management Today Since the late 1990s and early 2000s, many effective case managers have assumed the dual role of linking and monitoring services and providing direct services. In many instances, this dual role is called intensive case management and reflects the time and financial resources committed to the client. The trend of the dual role continues today. The principles of integration of services, continuity of care, equal access to services and advocacy, quality care, and client empowerment, described later in this chapter, guide the case management service delivery. Today, case management characterizes an accepted way of providing human services to clients and their families. For example, the certification of the Human Services Board-Certified Practitioner includes demonstrated competence in case management, professional practice and ethics as one of the four knowledge and skills assessment components (Center for Credentialing and Education, 2011). In addition, the National Association of Social Workers offers BSW social worker case managers the Certified Social Work Case Manager credential (National Association of Social Workers, 2011). In the area of substance abuse, the Substance Abuse and Mental Health Services Administration (SAMHSA), specifically the Center for Substance Abuse Treatment (CSAT), provides a comprehensive guide for the case manager and case management function (Siegal, 1998). Many states developed their own case management certification on the roles, responsibilities, and competencies and skills outlined in the SAMHSA Treatment Improvement Protocols for addiction-related and other human service professionals (Kansas Association of Addiction Professionals, 2011; Oklahoma Behavioral Health Case Management Certification, 2012). Multicultural concerns are embedded in each of these efforts to professionalize case management. There is an emphasis on understanding multicultural competencies required of case managers and addressing issues of advocacy and social justice. It is interesting to note that the certifications include attention to ethnic and cultural aspects of providing services. We conducted numerous interviews with service providers who are performing the role of case manager, and some indicated a preference for terms other than case management and case manager in describing their jobs and job titles. Three primary objections to these terms surfaced. One is that the practitioners find it objectionable to think of clients as “cases.” A second relates to the resentment clients may feel at being managed. Third, these helpers believe that they do more than case management. Many of the helpers interviewed did refer to themselves as case managers, but not necessarily in the traditional sense of the term. Want More Information? The Internet provides in-depth resources related to the study of case management. Search the terms listed below to read more about how professional organizations and the federal and state government describe case management. • Human Services Board Certified Practitioner • Social Work Case Manager • Commission for Case Management Certification • SAMHSA Treatment Improvement Protocols What has emerged today is a broader perspective on service delivery, one that encompasses traditional case management as well as case management with a broader focus. In some situations, it includes case management with a new focus. Case management is a creative and collaborative process, involving skills in assessment, communication, coordination, consulting, teaching, modeling, and advocacy that aim to enhance the optimum social functioning of the client served and positive outcomes for the agency (Commission for Case Manager Certification, 2009). Note that it includes the dual role of coordinating and providing direct service. The goal of case managers is to help those who need assistance to manage their own lives and to support them when expertise is needed or a crisis occurs. These professionals gather information, make assessments, and monitor services. They find themselves working with other professionals, arranging for services from other agencies, serving as advocates for their clients, and monitoring resource allocation and quality assurance. They also provide direct services. Social justice as a consideration for client rights and equality, as well as respect for the client's culture, guide this work. The evidence is clear that case management is more a part of service delivery than ever before. In fact, case management is defined and mandated through federal legislation, has become part of the services offered by insurance companies, and is now accepted by helping professionals as a way to serve long-term clients who have multiple problems. The diversity of professionals with case management responsibilities is reflected in the many job titles they have: case manager, intensive case manager, service coordinator, counselor, social worker, service provider, care coordinator, caseworker, and liaison worker. In some cases, these professionals provide services themselves; in others, they coordinate services or manage them. Increasingly, they are assuming new responsibilities, such as cost containment and budget management. There is little agreement about what to call those they serve, but most frequently they talk about clients, individuals, or participants. The diversity of job titles, the range of individuals and groups served, and the variety of job responsibilities are all indications that service delivery is changing. This text explores case management as a complex, evolving, and diverse process. As you study this text, you will review traditional case management, learn about the new ways in which case management is being applied, and explore the new roles and responsibilities given to helpers. One of the important ways of learning about case management is through the voices of helping professionals themselves, as in the many concrete examples in this book. As you read, note their different job titles, roles, responsibilities, service delivery methods, and terminology. The examples that illustrate concepts and principles generally use the terminology of the particular setting involved. When a case or example does not define the terminology, the term case management will be used to mean the responsibilities of both service provision (e.g., counseling) and service coordination (e.g., arranging for services from others). The term also refers to the management skills needed to move a case from intake to closure. In referring to the service provider, the term case manager will mean the professional who performs the tasks of case management. The section that follows introduces the process of case management and its three phases. The case of Roy Johnson illustrates each phase. The Process of Case Management The three phases of case management are assessment, planning, and implementation. (See Figure 1.1.) Each phase will be discussed in detail in later chapters. Human service delivery has become increasingly complex in terms of the number of organizations involved, government regulations, policy guidelines, accountability, and clients with multiple problems. Therefore, the case manager needs an extensive repertoire of knowledge, skills, techniques, and strategies. Let's see how these phases occur in three different settings. Steve is a case manager at an agency that works with children and families or guardians of children served by the juvenile court system. He maintains a caseload of young people being sent to correctional facilities. For him, assessment is complex and multifaceted. He describes it this way. First, I try to collect lots of information about the child I am helping. I will call schools, doctors, psychologists, and other professionals who worked with the child. If I think it is needed, I will also request additional testing or examinations. This might include a mental health status exam, psychological exam, intake interview, or environmental scan of the child's home. This I would do in a home visit and I might talk with other family members or neighbors. Maria is a director at a children's services center. She describes the process of planning how her staff will provide services to clients. When I work with clients, I follow certain steps. This is important for me and for the client. Many clients see so much that is wrong with their lives and they want to fix everything all at once. So, from my staff and me the clients hear the same phrase, “one step at a time.” We help clients understand that change is difficult and a long-term process. For many new case managers, this is a difficult concept to put into practice. They want to save the day and make a difference. Their enthusiasm for helping leads to rushing in with grandiose ideas. These high expectations often cannot be met or cannot be met in a short period of time. Figure 1.1 The process of case management Fredrico, a social worker, serves as a case manager in the emergency room of a large metropolitan hospital. He provides frontline assessment and referral for treatment for emergency admissions from various sources. Finding a place for patients to stay represents the implementation phase. So in my job, I see the patient initially. Usually patients come to the emergency room involuntarily; the police bring them in. Once this occurs, I fill out the necessary paperwork for the hospital to accept responsibility for patient commitment. Once the hospital is ready to dismiss the patient, I find the patient a place to stay. That is really challenging, especially when the patient is angry. As you can see, the responsibilities at each phase vary, depending on the setting and the case manager's job description. It is important to understand that the three phases represent the flow of case management rather than rigidly defined steps to successful case closure. An activity that occurs in the first phase (e.g., the information gathering that Steve does) may also appear in the second or third phases, as in Maria's planning and the hospital social worker's (Fredrico's) referral. Other key components in effective case management appear throughout the process, including case review, report writing and documentation, and client participation. Ultimately, the goal of case management, stated earlier, is to empower clients to manage their own lives as well as they are able. The case of Roy Johnson illustrates how this happens. Roy Johnson is a real person, but his name and other identifying information have been changed. The case as presented here is an accurate account of Roy's experience with the human service delivery system and the case management process. His case exemplifies the three phases of case management. The agency that served Roy uses the terms counselor and client. The following background information will help you follow his case through assessment, planning, and implementation. Roy referred himself for services after suffering a back injury at work. He was twenty-nine years old and had been employed for five years as a plumber's assistant; he hurt his back lifting plumbing materials. After back surgery, he wanted help finding work. Although he had received a settlement, he knew that the money would not last long, especially since he had contracted to have a house built. He heard about the agency from a friend who knew someone who had received services there and was now working. The agency helps people with disabilities that limit the kind of work they can do. An important consideration in accepting a person for services at the agency is determining whether services will enable that person to return to work. The agency opened Roy's case; we will follow it to closure. Assessment The assessment phase of case management is the diagnostic study of the client and the client's environment. It involves initial contact with an applicant as well as gathering and assessing information. These two activities focus on evaluating the need or request for services, assessing their appropriateness, and determining eligibility for services. Until eligibility is established, the individual is considered an applicant. When eligibility criteria have been met, the appropriateness of service is determined, and the individual is accepted for service, he or she becomes a client. You will read more about assessment in Chapter 5. THE INITIAL CONTACT The initial contact is the starting point for gathering and assessing information about the applicant to establish eligibility and evaluate the need for services. In most organizations, the data gathered during the initial contact is basic and demographic: age, marital status, educational level, employment information, and the like. Other information may be obtained to provide detail about aspects of the client's life, such as medical evaluations, social histories, educational reports, and references from employers. Roy was self-referred to the agency. He initiated contact by telephoning for an appointment. Fortunately, a counselor was able to see him that week, so he made an appointment for May 24 at 10:30. The agency sent him a brochure about its services and a confirmation of his appointment. When he arrived at the agency, Roy completed an application for services. (See Figure 1.2.) The agency believes the applicant should supply the information in this initial information gathering. He completed it without too much trouble, although he wasn't sure how to answer the question about where he had heard about the agency. He didn't know the name of his friend's friend. The receptionist helpfully told him to write in “self-referral.” She suggested that he leave any questions blank if he wasn't sure about the response. She also asked him not to sign the application until he had met with a counselor. She stated that each counselor liked to explain the paragraph at the end of the application in order to make sure that applicants understood the implications of applying for services and the conditions that apply to the release of any client information. She would later transfer this information to the agency's client database. Roy had brought a copy of a letter prepared by his orthopedic surgeon, Dr. Alderman, for his attorney a year earlier. (See Figure 1.3.) Dr. Alderman had expressed the opinion that Roy would be left 10% disabled as a result of the injury. Dr. Alderman was also careful to clarify that Roy's condition did not reflect a preexisting disability even though he had suffered back problems previously. Tom Chapman, the counselor who saw Roy, made a copy of the letter and returned Roy's copy to him. Figure 1.2 Application for services During the initial contact, the case manager determines who the applicant is, begins to establish a relationship, and takes care of such routine matters as filling out the initial intake form. An important part of getting to know the applicant is learning about the individual's previous experiences with helping professionals, his or her strengths, and his or her perception of the presenting problem; the referral source; and the applicant's expectations. As these matters are discussed, the case manager uses appropriate verbal and nonverbal communication skills to establish rapport with the applicant. (These skills will be discussed in Chapter 6.) The case manager demonstrates sensitivity to cultural considerations that influence applicant strengths, perceptions, and expectations and cultural considerations. (These skills will be discussed in Chapter 3.) Skillful use of interviewing techniques facilitates the gathering of information and puts the applicant at ease. The counselor makes the point at the conference that the client is considered an expert and that self-reported information is very important. By providing information about routine matters, the case manager demystifies the process for the applicant and makes him or her more comfortable in the agency setting. Some of the routine matters addressed during the initial meeting are completing forms, gathering insurance information, outlining the purpose and services of the agency, giving assurances of confidentiality, and obtaining information releases. Of course all of this has to be complete with attention to multicultural aspects of the client's experiences. Documentation records the initial contact. Figure 1.3 Dr. Alderman's letter In the agency Roy went to, case managers fill out a counselor's page (Figure 1.4), which describes the initial meeting, and a client master record (Figure 1.5). The client master record provides basic information about the client, his or her sources of support, and his or her employment. Its format was designed so that data could easily be entered into the computer, thus simplifying the agency's recordkeeping. At this point, Roy was still considered an applicant for services in accordance with agency guidelines. Figure 1.4 Counselor's page Although Dr. Alderman's letter provided helpful information about Roy's presenting problem, agency guidelines stated that all applicants must have a physical examination by a physician on the agency's approved list. Mr. Chapman also felt that a psychological evaluation would provide important information about Roy's mental capabilities. He discussed both of these with Roy, who was eager to get started. As Roy prepared to leave, Mr. Chapman explained that it would take time to process the forms and review his application for services. He would be in touch with Roy very soon, explaining the next steps. (See Figure 1.6.) Figure 1.5 Client Master Record Figure 1.6 Tom Chapman's memo GATHERING AND ASSESSING INFORMATION If the applicant is accepted for services, the client and the case manager will become partners in reaching the goals that are established. Therefore, as they work through the initial information gathering and routine agency matters, it is important that they identify and clarify their respective roles, as well as their expectations for each other and the agency. From the first contact, client participation and service coordination are critical components in the success of the process. The case manager must make clear that the client is to be involved in all phases of the process. A skillful case manager makes sure that client involvement begins during the initial meeting. Client involvement helps support attention to individual client needs and demonstrates respect. In Roy's case, the counselor reviewed the application with him. There were some blanks on the application, and they completed them together. Roy had not been sure how to respond to the questions about primary source of support and members of his household. As Roy elaborated on his family situation, the counselor completed these items. Roy felt positive about his interactions with Tom Chapman because Tom listened to what he said, accepted his explanations, and showed insight, empathy, and good humor In gathering data, the case manager must determine what types of information are needed to establish eligibility and to evaluate the need for services. Once the types of information are identified, the case manager decides on appropriate sources of information and data collection methods. His or her next task is making sense of the information that has been gathered. In these tasks, assessment is involved: The case manager addresses the relevance and validity of data and pieces together information about problem identification, eligibility for services, appropriateness of services, plan development, service provision, and outcomes evaluation. During this process the case manager checks and rechecks the accuracy of the data, continually asking, “Does the data provide a consistent picture of the client?” Client participation continues to play an important role throughout the information-gathering and assessment activities. In many cases, the client is the primary source of information, providing historical data, perceptions about the presenting problem, strengths assessment, cultural considerations, and desired outcomes. The client also participates as an evaluator of information, agreeing with or challenging information from other sources. This participation establishes the atmosphere to foster future client empowerment. The counselor needed other information before a certification of eligibility could be written. In addition to Dr. Alderman's letter, a general medical examination, and a psychological evaluation, the counselor requested a period of vocational evaluation at a regional center that assesses people's vocational capabilities, interests, and aptitudes. Tom Chapman had worked with all these professionals before, so he followed up the written reports he received with further conversations and consultations. Following a two-week period at the vocational center, the evaluators met with Roy and Mr. Chapman to discuss his performance and make recommendations for vocational objectives. After completing the report, Mr. Chapman and Roy met several times to review information, identify possibilities, and discuss the choices available to Roy. Mr. Chapman's knowledge of career counseling served him well as he and Roy discussed the future. Unfortunately, an unforeseen complication occurred, delaying the delivery of services. Tom Chapman changed districts, and another counselor, Susan Fields, assumed his caseload. Meanwhile, Roy moved to another town to attend school. Although he was still in the same state, Roy was now about 200 miles from his counselor. While Roy was attending his first semester at school in January, Ms. Fields completed a certificate of eligibility for him. (See Figure 1.7.) This meant that he was accepted as a client of the agency and could now receive services. In May, his case was transferred to another counselor (his third) in the town where he lived and attended school. Planning The second phase of case management is planning, which is the process of determining future service delivery in an organized way. When planning begins, the agency has usually accepted the applicant for services. The individual has met the eligibility criteria and is now a client of the agency. During this planning process, the counselor and the client turn their attention to developing a service plan and arranging for service delivery. Client participation continues to be important as desired outcomes are identified, services suggested, and the need for additional information determined. The actual plan addresses what services will be provided and how they will be arranged, what outcomes are expected, and how success will be evaluated. More information on planning is in Chapter 7. A plan for services may call for the collection of additional information to round out the agency's knowledge of the client. Some case managers suggest that the service delivery process is like a jigsaw puzzle, with each piece of information providing another clue to the big picture. During this stage, the case manager may realize that a social history, a psychological evaluation, a medical evaluation, or educational information might provide the missing pieces. You will read more about this information in Chapter 8. The plan identifies what services are needed, who will provide them, and when they will be given. The case manager must then make the appropriate arrangements for the services. During the assessment phase, Tom Chapman did a comprehensive job of gathering information about Roy. When Roy was accepted for services, the task facing him and his new counselor was to develop a plan for services. (See Figure 1.8.) Clarity and succinctness characterize the service plan, which the counselor and the client complete together, emphasizing the client's input in the process. The plan lists each objective, the services needed to reach that objective, and the method or methods of checking progress. Suppose that Tom Chapman had believed that a psychological evaluation was unnecessary and had been able to establish eligibility solely on the basis of the medical and vocational evaluations. Susan Fields, the new counselor, might find that a psychological evaluation would be beneficial, especially since the agency was contemplating providing tuition and support for training. One objective of the plan would then be to provide a psychological evaluation of the client. This is an example of continuing to gather data during the planning phase, as well as continuing to assess the reliability and validity of the data. Figure 1.7 Certificate of eligibility Roy's plan indicates that he is eligible for services and meets agency criteria. His program objective, business communications, was established as a result of evaluation services, counseling sessions with Mr. Chapman, and Roy's stated vocational interests. The three stated intermediate objectives would help Roy achieve the program objective. The plan also provides a place to identify the responsibilities of Roy and of the agency in carrying out the plan. Note that this agency takes very seriously the participation of the client in the development of the plan, even asking that the client sign it, as well as the counselor. There is one additional part of the plan to be signed by the client. Because one of Roy's objectives is to acquire training, which involves a significant expenditure on the agency's part, Roy has also signed a Student Letter of Understanding that further describes his responsibilities. In a sense, this letter is a contract between the student and the agency; the counselor signs it as the agency's representative. The letter also states that this agreement is valid as determined by federal and state regulations. Figure 1.8 Service plan Once the plan is completed, the counselor begins to arrange for the provision of services. He or she must review the established network of service providers. Experienced case managers know who provides what services and who does the best work. Nonetheless, they should continue to develop their networks. For beginning helpers, the challenge is to develop their own networks by identifying their own resources and building their own files of contacts, agencies, and services. Chapter 7 provides information about developing, maintaining, and evaluating a network of community resources. Implementation The third phase of case management is implementation, when the service plan is carried out and evaluated. It starts when service delivery begins, and the case manager's task becomes either providing services or overseeing service delivery and assessing the quality of the service delivery. He or she addresses the questions of who provides each service, how to monitor implementation, how to work with other professionals, and how to evaluate outcomes. This phase is discussed further in Chapter 10. In general, the approval of a supervisor may be needed before services can be delivered, particularly when funds will be expended. Many agencies have a cap (a fee limit) for particular services. In addition, a written rationale is often required to justify the service and the funds. As resources become increasingly limited, agencies redouble their efforts to contain the costs of service delivery. In Roy's case, the agency's commitment to pay his training tuition represented a significant expenditure. Susan Fields submitted the plan and a written rationale to the agency's statewide central office for approval. Who provides services to clients? The answer to this question often depends on the nature of the agency. Some are full-service operations that offer a client whatever services are needed in house, as described in Chapter 3. As a rule, however, the client does not receive all services from a single worker or agency. It is usually necessary for him or her to go to other agencies or organizations for needed services. This makes it essential for the case manager to possess referral skills, knowledge of the client's capabilities, and information about community resources. No doubt you remember that Roy's first counselor, Tom Chapman, arranged for a psychological evaluation. Many agencies like Tom's have so many clients needing psychological evaluations that they hire a staff psychologist to do in-house evaluations of applicants and clients. Other agencies simply contract with individuals—in this case, licensed psychological examiners or licensed psychologists—or with other agencies to provide the service. Whatever the situation, the counselor's skills in referral and in framing the evaluation request help determine the quality of the resulting evaluation. Another task of the case manager at this stage is to monitor services as they are delivered. This is important in several respects: for client satisfaction, for the effectiveness of service delivery, and for the development of the case manager's network. Monitoring is doubly important because of the personnel changes that constantly occur in human service agencies. Moreover, there may be a need to revise the plan as problems arise and situations change. Cultural considerations play a part in monitoring services. Clients need to receive services within a culturally sensitive context. They need to feel respected and heard and believe the services represent the values they hold. The implementation phase also involves working closely with other professionals, whether they are employees of the same agency or another organization. A case manager who knows how to work successfully with other professionals is in a better position to make referrals that are beneficial to the client. These skills also contribute to effective communication among professionals about policy limitations and procedures that govern service delivery, the development of new services, and expansion of the service delivery network. Perhaps there is no other point in service delivery at which the need for flexibility is so pronounced. For example, during the implementation stage it often becomes necessary to revise the service plan, which must be regarded as a dynamic document to be changed as necessary to improve service delivery to the client. Changes in the presenting problem or in the client's life circumstances, or the development or discovery of other problems, may make plan modification necessary. Such developments may also call for additional data gathering. In his second semester at school, Roy heard about a course of study that prepared individuals to be interpreters for the deaf. This intrigued him, because he was already proficient in sign language. His mother was severely hearing impaired, and as a child, Roy signed before he talked. He also thought back to the evaluation staff meeting, at which the team discussed the possibility of making interpreter certification a vocational objective for him. Roy liked the interpreting program and the instructors, so he applied to the program. The change in vocational objective made it necessary to modify his plan. His counselor (by now, his fourth) revised the plan at the next annual review to include his new vocational objective of educational interpreting. Three Components of Case Management Case review, report writing and documentation, and client participation appear in all three phases of case management; they are discussed in detail in later chapters. Here we introduce the concepts by examining how each applies to Roy's case. Case review is the periodic examination of a client's case. It may occur in meetings between the case manager and the client, between the case manager and a supervisor, or in an interdisciplinary group of helpers, called a staffing conference or case conference. A case review may occur at any point in the case management process, but it is most common whenever an assessment of the case takes place. Case review is an integral part of the accountability structure of an organization; its objective is to ensure effective service delivery to the client and to maintain standards of quality care and case management. Roy's case was reviewed in several ways. Each time a new counselor assumed the case (unfortunately, this was often), a review was held. There were also reviews on the occasion of the two counselor contacts Roy had per semester. At the end of each semester, his grades were checked—also part of the case review. The staffing related to Roy's vocational evaluation is an example of case review by a team. In this case, the client was an active participant in the case review. Roy also participated in developing the service plan, which involved a review of the information gathered, the eligibility criteria, and the setting of objectives. The agency serving Roy implemented the important component of case review in various ways at different times throughout the process. An important part of case review is the documentation of the case. Documentation is the written record of the work with the client, including the initial intake, assessment of information, planning, implementation, evaluation, and termination of the case. It also includes written reports, forms, letters, and other material that furnishes additional information and evidence about the client. The particular form of documentation used depends on the nature of the agency, the services offered, the length of the program, and the providers. A record is any information relating to a client's case, including history, observations, examinations, diagnoses, consultations, and financial and social information. This also includes agency documents such as application forms, financial assessments, outcome assessments, case review notes, referrals, confidentiality and HIPAA documents, and transition or termination documents. The case manager's professional expertise must include documenting events appropriately and in a timely manner and preparing reports and summaries concisely but comprehensively. Roy's file includes many different types of documentation. In this chapter, the written record includes computer forms, applications for services, counselors' notes, medical evaluations, reports, and letters. Other documentation (not shown here) in Roy's file is a psychological evaluation, a vocational evaluation, specialized medical reports, and medical updates. In Roy's case, all this documentation turned out to be indispensable because he worked with five different counselors. In addition to Roy's documentation, strengths assessment and cultural assessments were included in his file. Both of these assessments help case managers provide Roy with services that reflected his unique individual needs. For continuity of service, good case documentation is essential. Client participation means the client takes an active part in the case management process, thereby making service delivery more responsive to client needs and enhancing its effectiveness. In some cases a partnership is formed between the case manager and the client; an important result of this partnership is client empowerment. One of the many factors involved in forming a partnership with the client is clear communication or two-way communication, bearing in mind cultural dimensions of communication. The case manager must explain to the client the goals, purposes, and roles of the case manager as defined by the agency. The case manager encourages the client to define his or her goals, priorities, interests, strengths, and desired outcomes. At this point the client also commits to assuming responsibility within the case management process. As client participation continues and the partnership develops, it is helpful for the case manager to have knowledge of subcultures, deviant groups, reference groups, and ethnic minorities so as to communicate effectively with the client about roles and responsibilities. Other factors can affect client involvement, including the timing, setting, and structure of the helping process. Minimizing interruptions, inconveniences, and distractions always enhances client participation. Encouraging client participation has identifiable components. The first is the initial contact between the client and the case manager. It is easier to involve clients who initiate the contact for help, as Roy did, because they usually have a clearer idea of what the problem is and are motivated to do something about it. In Roy's case, the clarification of roles and responsibilities occurred at three points in the assessment phase. Roy and his counselor were able to talk about the agency and the services available, and the counselor encouraged Roy to talk about his goals, motivations, strengths, and interests. When Roy completed his application, the counselor reviewed it with him, especially the statement at the bottom of the second page. On signing such a statement, the client voluntarily places himself or herself in the care of the agency. With this agreement come roles and responsibilities for both the client and the counselor, which the counselor reviews at that point. A second opportunity to clarify roles and responsibilities comes with the completion of a service plan. Both the client and the counselor sign the service plan, which designates the responsibility for each task and the time frame for completion of each service. The middle phase of case management is devoted to identifying problem areas, reaffirming client strengths, and developing and implementing a plan of services. It was during this phase that Roy decided to change from business communications to interpreting, which required an amendment to the plan. Roy also needed help paying for a tutor in a science course that was particularly difficult for him. Client participation during this phase ensures that the client's perceptions of the problem and its potential resolution are taken into account. The final phase of client participation comes at the termination of the case. At this time, the client and the case manager together review the problem, the goals, the service plan, the delivery of services, and the outcomes. They may also discuss their roles in the process. Thus, in terms of client participation, termination means more than just closing the case. It is an assessment of the client's progress toward self-sufficiency, the ultimate goal of client empowerment. Self-sufficiency is defined differently for each client. Now that you have some sense of the flow of the process and its component parts, we will review the responsibilities of managing cases in all three phases. This section introduces the principles and goals that guide service delivery and discusses how they influence the work of case management. Principles and Goals of Case Management The guiding principles and goals of case management have emerged through the work of early pioneers in helping, through federal legislation, and through current practice. These include integration of services, continuity of care, equal access to services/advocacy, quality care, client empowerment, self-determination, and evaluation. The subsections that follow discuss these principles and their relevance to case managers. Integration of Services Case managers must be committed to a holistic view of the individual receiving help. This means they recognize that they work with the whole person, acknowledging the many human dimensions that are considered in service delivery: social, psychological, medical, financial, educational, and vocational. Most likely, the client has problems in more than one of these areas. Multiproblem clients are best served by integrating the needed services. This means developing and implementing a plan that brings together a variety of services to help a client. Integrated service delivery means each service enhances and supports the other efforts and is a guiding principle of case management. Many people enter the system with multiple needs or needs that change over a long period.