CHAPTER ONE Introduction to Case Management
Surviving and Thriving as a Case Manager
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· —Permission granted from Ellen Carruth, 2012, text from unpublished interview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 managementand 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.
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