Reading A

Case management is one of the primary places in human service systems where the whole person is taken into account. Unlike specific services, case management does not focus on just one problem but rather on the many strengths, needs, and personal concerns a person brings.

For example, an elderly person may be referred to Help Ministries for a voucher for fuel oil because it has been unusually cold and the elderly person has been unable to pay for the additional oil needed to warm his home adequately. In this case, Help Ministries is concerned with his fuel oil need and the warmth he will need to stay in his home during the winter. That is their only concern with regard to this man.

The case manager, on the other hand, is concerned with the person's need for fuel oil, with his desire to move into public housing for the elderly in the spring, with what resources he has among his children, with his recent slurred speech indicating a possible stroke, and with his need for meals-on-wheels. The case manager is aware that there is a neighbor who can look in on him daily, that the man has ties to a church, and that he receives Social Security but little other income. She knows he has a sense of humor, goes to bingo once a month, and should be fitted for a cane.

Case management is a process for assessing the individual's total situation and addressing the needs and problems found in that assessment. As a part of this process, the person's strengths and interests are used to improve the overall situation wherever possible. The primary purpose for case management is to improve the quality of life for your client. This might mean more comfortable or safer living arrangements, or it might require psychiatric care or medication for diabetes. Another major purpose of this activity is to prevent problems from growing worse and costing more to remedy in the future.

In the situation of the elderly man just described, we find that the meals-on-wheels program will deliver a certain standard of good nutrition, preventing malnutrition and costly medical bills in the future. By getting the man a cane, we may be preventing falls that would shorten his life and cost much more in medical bills to repair his injuries. If we enlist the neighbor to look in on our client every day, we have provided a link between the man and his neighborhood. In addition, the neighbor can alert us to small problems that require our attention. In this way we have foreseen possible difficulties and taken steps to prevent them.

In the late 1800s, a formal attempt was made to organize the delivery of services to people in need. Initially the Charity Organization Society took control of this approach, making the collecting of information and the delivery of services more systematic. In the course of its work, the society developed casework as a useful method for tracking needs, progress, and changes in each case. As people had more needs and problems beyond poverty, the need to coordinate these services became important to prevent duplication. Casework also was employed as a means of tracking and using scarce resources to the best advantage.

In the 1960s, the process of deinstitutionalization meant that individuals once housed in institutions were now placed in communities where they needed considerable support to live more independent lives; as a result, casework became ever more important for a larger number of people.

In the 1980s, the term caseworker evolved into the term case manager, and these managers took on greater responsibility for managing resources, finding innovative supports, and coordinating services. Agencies began to use case management as a procedure to assess needs, to find ways to meet those needs, and to follow people as they used those services. In addition to keeping an eye on how scarce resources were spent, case managers were charged with taking a more holistic approach to their clients, looking at all their needs rather than addressing only those that brought the person in for assistance. As part of this charge came the directive to develop individualized plans, plans constructed specifically for that person and not a cookie-cutter approach to supplying services.

Today case managers are seen as a significant service in almost all social service settings and are viewed as the most important way to prevent relapse, track clients' needs, and support progress toward good health.

Language in the social services is a funny thing. After a word is adopted to describe people who use a service, that word becomes pejorative over time and a new word meaning the same thing is sought. In social services, we have gone from labeling people patient (which implied people seeking services were all sick in some way) to client and finally to consumer.

Client was meant to denote that the person was being served by a case manager in a relationship much like a lawyer-client relationship. This originally conferred an obligation on the part of the case manager to give good service to someone paying, in some manner, for that service. However, as with all words describing people who use social services, the word client developed a negative connotation and the word consumer was increasingly used instead. Consumer also implied the person was paying for good services from the case manager.

With the Recovery Model (Appendix A) developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the emphasis on partnerships between case managers and the people seeking services, those words are no longer considered appropriate. The concern is that these words denote a difference in status between case manager and those they serve. Thus, in recent years, the terms client and consumer have given way to person or individual, and in many cases no term is used but rather the person's name is used instead.

In this textbook, we subscribe to the idea that case managers and the people they serve are in a partnership to which each brings a certain degree of expertise. In your work, we strongly encourage you to drop the use of the words consumer and client and adopt what is seen as the more respectful terms of individual and person.

However, having said that, there are places in this textbook where using person and individual alters the meaning of the sentence and the point that is being made. For that reason, in this textbook, we need to use client to denote a person seeking professional services from a professional case manager in order for the point to make sense. This is in no way meant to diminish the person who does seek service, but rather to make our points more coherent.

Case management serves two purposes:

1. First, it is a method for determining an individualized service plan for each person and monitoring that plan to be sure it is effective.
2. Second, it is a process used to ensure that the money being spent for the person's services is being spent wisely and in the most efficient manner.

The money you oversee in consumer care may be public money, such as the money that comes from the state to a county to administer mental health services or substance abuse treatment. It may be money that is provided by insurance companies for services to a policyholder. It may be money provided directly to an agency from either of these sources for the care of a client. Sometimes organizations, such as United Way, divide the money they have raised among various community agencies. These organizations then employ case managers to make certain the most effective use is made of that money. It is therefore the case manager who determines what is needed and how to prevent needs and problems from escalating. It is the case manager who, in collaboration with the consumer, determines what services should be authorized with the existing money. It is the case manager who then follows the consumer and the consumer's services and treatment to keep the plan on track.

Case management is more than looking out for another entity's money. It is also the most efficient way to make certain a person receives the most individualized plan for service and treatment possible. To ensure that this will be done, case management responsibilities have been broken into four basic categories of service: assessment, planning, linking, and monitoring. These four activities constitute the case management process. Let's look at these categories in the order in which they are usually accomplished when working with a person.

Assessment

The first case management task is assessment. A good assessment is the foundation for understanding the problem and informing and guiding the treatment and services. Therefore, it must be done with care. This is an initial assessment, meant to be comprehensive and thorough. For that reason, it covers many different aspects of the person's life in an attempt to develop an accurate profile of the individual and the individual's problem.

There are several kinds of assessments. In some cases you will be asked to do a social history (see Chapter 16). Here you ask a series of questions, and as the person answers, you construct a written narrative. Social histories usually have a number of elements that you are to assess, and each is given a subheading within the narrative. For example, current medical condition, living arrangements, relationships, and work experience are all important. In another kind of assessment, you may be given an intake assessment form that lists all the questions you are to ask and gives you a place to note the answer. Each of these assessment procedures attempts to be comprehensive. Each seeks to assemble a considerable amount of material about the person and his or her problem.

The first thing the case manager does is assess the initial or presenting problem. Why did this person come into the agency, and what is the person asking for? Here case managers look at the extent to which problems have interfered with clients' abilities to function and care for themselves. Does this problem interfere with work or with relationships? It is especially important to note the background of the problem, how long it has gone on, and how it started. In addition, the reasons the person is seeking help now are important.

Case managers include an opinion about what possible problems might arise for this person in the future and what plan might be put into effect with the person to prevent these problems. Your opinions about potential future problems are formed as you listen to consumers describe their situations. Will the individual be likely to be around people who encourage him to drink? Does she have a medical problem that needs attention because it exacerbates her depression?

A discussion of the problem uncovers the person's needs and how he or she views those needs. Case managers look at the overall situation and consider what that person needs to bring stability and resolution to his or her life and problem. Are there needs that can be addressed that will relieve the problem, or at least alleviate it to some extent?

In every assessment with an individual, you will begin to learn what strengths the person has that you and he may draw upon to resolve the current problem. Does your client have an advanced degree, a particularly supportive family, a number of friends, a sympathetic boss, a particular skill? An assessment should never be just about the person's problems, but should also include the strengths the person brings to the problems and the strengths you see in the person's environment.

As you take the information from the consumer, you are, through your observations, also evaluating the person's ability to think clearly and to understand options, and the person's general mood. You are seeking to understand the extent to which the person understands the origin of their problems. Chapter 18 discusses in more detail something called the mental status examination. This is not a series of questions but rather your astute observations of the individual during the interview.

At the end of your assessment document, you will be asked to express your assessment and recommendations. Here you will summarize briefly the problem and the person's ability to handle the problem, noting the person's strengths and needs. Then you will give your own recommendations for service or treatment. Recommendations are generally worked out with the consumer as you learn what it is the person is seeking and share with that person what you have to offer.

To summarize, in an assessment you are exploring and evaluating the following:

1. The initial problem and the background to that problem
2. The person's current situation
3. The person's background in areas such as education, relationships, work history, legal history
4. What the person needs to make life more stable and to resolve the current problem
5. The strengths, including those the person brings to the problem and those in the person's environment that would be useful in resolving the situation
6. Observations about how well the person functions cognitively and any seeming mental problems you have noted
7. Recommendations for a service or treatment plan for the person

A good assessment is the foundation for the development of an individual plan for service or treatment. It delineates what essential services should be provided for individualized treatment. The assessment also establishes a baseline detailing where the person was when he or she entered services and against which you can measure progress.

Planning

After the assessment, you will be expected to develop an initial plan with the client that is comprehensive and addresses all the issues raised in your assessment. This plan should show incremental steps toward improvement and expected outcomes.

As a case manager, you cannot plan well with the person unless you are thoroughly aware of the services, social activities, and resources in your community.

Formal Agencies

Every community has social service agencies that serve specific needs. The best case managers seem to know all the good places to send people for the services those people need. Some communities and counties have more services than others, but in most locations, agencies are serving children and their families, older adults, individuals with substance abuse problems, individuals on probation, women in abusive or rape situations, and individuals with mental illness or intellectual disabilities. Generally, case managers need to learn about other services as well, and the information and phone numbers for these services should be readily available to you when you practice. You will want to gradually develop contacts in these places so that your referrals are smooth and problems are quickly handled.

Begin by knowing what formal agencies are out there to help with a particular issue. For instance, if your client has a mental health problem, you might refer him to an agency that specializes in mental health treatment. The staff at that agency is familiar with medications, diagnoses, and treatment alternatives for mental health problems. Another individual may be elderly and in need of protective services because you suspect she is being physically abused by her family. You would refer her to a specific agency that offers protective services to older people. A third person may have intermittent problems with substance abuse and need services from an office where there is an intensive outpatient treatment program in the evenings. Knowing the agencies in your community and the formal services they offer is a good foundation.

Generic Resources

Good planning is not limited to formal agencies, however. Learn about resources that are available for common problems we all have. Not every problem a person with an intellectual disability has will need to be treated by agencies set up exclusively for individuals with intellectual disabilities. For example, a woman with an intellectual disability, grieving the death of her mother, was welcomed into a grief support group at the local church and given much support. In another example, a child with academic problems in school was referred to the free tutoring at a local church. An older person who needs more social contacts might be referred to a senior center where many older people go for social and recreational opportunities. In the previous examples, the older person suffering abuse may also need the services of your local district attorney, and the person with a substance abuse issue might need medical care from a general practitioner and a public defender for pending charges of disorderly conduct. These are all services anyone can use. Knowing how to access them for your clients is important.

Support Groups and Educational Seminars

Other resources often overlooked are support groups and educational seminars. For example, you may have referred the family of a child you are working with to formal family therapy sessions. In addition, you would look at support groups where parents dealing with similar problems can get together to support each other. Further, you might find a workshop on parenting skills that would greatly benefit this family, and you would tell them about the workshop and strongly encourage them to attend. A man on probation might benefit from a workshop for job readiness or a support group for ex-offenders attempting to make significant life changes. A woman who is struggling with years of sexual and physical abuse might benefit from a support group of other women facing similar issues.

These resources augment your own efforts and those of formal services and give consumers additional support and information. Often they are free or at very little cost. What your clients gain from their experiences in such groups reinforces the other services you are arranging.

Peer Support

A relatively recent trend is to use peer support wherein a former client who is doing well is hired by an agency to support others on the road to recovery and life changes. It might be individuals who were able to turn their lives around after a period in juvenile detention and now are supporting others coming out of juvenile detention to do the same thing. It might be someone who has had a mental illness and is now helping others who are recovering from their own mental illness. And, of course, in substance abuse, Alcoholics Anonymous (AA) has always used that model of one person in AA helping another. The idea is based on the fact that not all professionals know what it is like to experience some problems firsthand. The peer support person is able to say he has been there and can show another how to resolve the issues with firsthand practical information.

Individuals whose functioning is impaired might benefit from a peer support person who can help them function better educationally, socially, or vocationally and may even become involved in helping them with issues of self-care. Much like case management, the peer support person ascertains that the consumer will accept peer support and then works with that person to set realistic and meaningful goals the two can approach together. Good peer support helps people formulate the small action steps needed to move toward the goals the two have identified together, and the peer support person can be there with advice and ideas if the action step doesn't work very well. As a case manager, you will use peer support when a person needs more sustained time than you can give, and the support will significantly help the person move toward recovery.

Informal Resources and Social Support Systems

You will also want to be aware of social activities your clients might enjoy that would keep them involved in their communities. Perhaps one person likes to work on models and could become a member of the model railroaders club. Perhaps another genuinely likes people and enjoys being with them. This person might do well as a member of the Jaycees.

People do better living in a community in which they have healthy social support systems. A social support system refers to the kinds of supports most of us have in our communities such as Lions Club, a church, or volunteering on specific community projects. All of us need to feel we are a part of the place where we live, but many people do not have the skills to interact with others and find useful activities on their own. As a case manager, it is your responsibility to integrate your consumer into the community if this is a need. Find social clubs, churches, and groups that pursue similar interests, and help your client make contact with those people. The more contacts the person has and the more useful activities the person engages in, the more support the community can give. A particularly touching example of the use of informal social supports occurred in a small town in which the firehouse was located just around the corner from a group home for five older men with mental health problems. They had been institutionalized for most of their lives, spent years on medication, and had the common long-term side effects that can develop. One of the men, Nick, wanted to be a fireman, so the case manager connected this man to the fire company around the corner. The men at the firehouse made Nick a part of their everyday routine. Nick helped roll hoses, swept floors, and took his meals with the men. Nick was included in meetings and made decisions about the dinner menu. He became such a part of the fire company that when he died suddenly of cardiac complications the men were deeply saddened. As a tribute to Nick on the day of his funeral, the procession from the funeral home to the cemetery was led by a number of fire trucks, beginning with the trucks from Nick's home station and including some from neighboring communities. This was an excellent example of using social supports to give a person a valued place in his community and a sense of doing something worthwhile.

Case managers often fail to use these valuable informal resources for several reasons. They may feel that their client cannot handle being with ordinary people in ordinary settings. This is often based on the case manager's attitude about the person's disability and is often quite erroneous. Having consumers in small numbers in social activities or organizations that give them an opportunity to practice strengths is an invaluable experience for everyone concerned. Another reason a case manager might be reluctant to place a consumer in a community social group might stem from the case manager's perception that people in such groups do not want to be bothered with people who have disabilities.

In some cases, this assessment is correct, but in others it is quite the opposite. Many organizations are set up to provide service and perceive this as an opportunity to grow and serve the community.

Doing your homework pays off. You cannot rely on suppositions and speculations. Know what is available in your community and have places in mind that would serve your consumers as the need arises. Meet people and talk to them about what you would like to have available for your clients. Gradually, you will develop a list of people and places that welcome your clients and provide the specific experiences and support you are seeking. Your task is to have many resources you can use at your fingertips when developing plans for your clients and to continually be developing new ones in your community.

Creating an Individualized Plan

After you have worked with people to determine where the problems are and what areas need attention, you will also know about the supports and other resources people have in the community and among their family members and friends. You will know what they do well and what interests them most. Each person will be different. As you go about designing the plan with the person, you will place in that plan elements that take advantage of the client's strengths and supports. In addition, you will address those problems most outstanding or immediate for that client. Each person has a different set of strengths, life circumstances, immediate problems, and personal goals. No two people view their situations in exactly the same way, so no two plans will be exactly alike. Each plan will be developed specifically for that individual client.

At one time, a small program for homeless women employed a part-time case manager for the children. Homeless women were given 2 years' residence in apartments belonging to the program to work hard on getting an education or training, and a stable source of income. Many of them were distracted from this by concerns about their children. Still others had little time to think about what their children needed as they went about restructuring their lives. The county social services department gave the shelter a small stipend to hire a children's case manager. The shelter hired a young woman who had just graduated from college. This seemed like an ideal choice. She was energetic, related well to the children, and was genuinely concerned about each of them. In the next year, the program monitor from the county noticed two things. First, there seemed to be very little material on the children in any records. No individual plans could be found, and no assessments on each child appeared to have been done. Second, the children were all following much the same plan. All the girls attended gymnastics; all the boys were enrolled in Little League. On certain weekends, all the children, regardless of their age or interests, went to the zoo or to the circus.

After receiving repeated requests for individualized plans for each child and some guidance about how to create them, the case manager quit. She said, on departing, that she did not have time to sit and write up records, that the children had been "having fun," and that the county was unreasonable. The county became more involved in hiring the second case manager, and this person was well aware of the importance of individualized planning.

In the first 6 months, two children began to get orthodontic work done, one received a scholarship to a private school, four boys went to Little League, one took violin lessons, and a third joined the swim team at the YMCA. Most of the younger children went to the circus and to the zoo. Most of the older children went on a bus trip to Washington, D.C., and half of them went to two symphony orchestra performances that winter. No child's plan was the same as that of another child. Each child's needs had been documented and addressed in some way, and each child's strengths and interests were brought into play as the plans were developed.

In developing these plans, the case manager called all her contacts in the community. She asked two dentists to donate their time. She prevailed upon the symphony to give her the tickets for two performances. She went to a private school and talked to them about this particularly gifted child until a plan for financing the child's education was worked out. She found a violin teacher and asked for 15 free lessons as a gift to the shelter. In churches, mosques, and synagogues, she got people enthused about helping the children whose mothers were working so hard to put a stable life together for their families. She looked at scout troops, church youth groups, and organized sports for possible answers to the children's needs. In any number of cases, the plan simply involved the case manager helping an older child choose from among school activities and arranging transportation.

This is what is meant by individualized planning. When it is done well and done creatively, your clients can grow and thrive.

Continued Assessment and Continued Planning

In continued assessment and planning, as you follow the case, you will take into account changes the person may face. An example will illustrate this kind of planning, which you may be called upon to provide. Mary Beth has an intellectual disability and was assigned to you when she left a state-run institution for individuals with intellectual disabilities. When you did the intake assessment and planning, you determined that she would do better initially in a sheltered living arrangement for about a year. Because the goal is for her to move to an apartment of her own at the end of the year, your planning should start well in advance of this move. This planning makes the transition easier for her and for you. There are no shocks and sudden surprises that might necessitate her need for hospitalization or a regression back to greater dependence on the agency.

You might begin by setting up services and activities with Mary Beth that involve her in her community. Mary Beth told you when you first talked to her of her interest in singing. The people at the institution said she loved music and sang well, although she could not read music. At the time Mary Beth came out of the institution, you could not find a good place for her to use her musical interests, but you noted this as a strength and kept your eyes open for an appropriate link. Now you have found a choir director at a small church who is willing to have Mary Beth sing with her choir. The church has numerous activities, and there are members who see to it that Mary Beth is included. In this way, you begin to prepare her for a move to more independent living. You seek and find a place for her to live not too far from the church, and you work with interested members to ensure that Mary Beth will have their continued help with transportation and inclusion in church activities.

You may think it best that Mary Beth has other social ties to her community as well. There is the Aurora Club, created by professionals just for people with some intellectual disabilities. This club is a place to go and meet others; and the club takes trips, goes bowling, and goes out to dinner together. You could refer her there; however, you might decide that Mary Beth's mild disability does not warrant her being limited to social activities only for individuals with intellectual disabilities. Instead, you might develop a relationship with a local women's club, getting them to take Mary Beth as a member. As Mary Beth makes an adjustment to being outside the institution, you look for a job placement. You make a referral to Goodwill, where she is able to develop her social skills, and soon she is hired by a local Wal-Mart as a greeter. All the while Mary Beth is away from the institution, you are meeting with her, assessing her progress toward independence, and planning for her to take a little more personal responsibility.

By the time Mary Beth moves into an apartment of her own, she has gained new confidence and many friends who connect her to the community. Her success is due in large measure to both your wise initial plan and your modifications of the plan as Mary Beth grew more independent.

Linking

Linking is the general term we use to mean connecting clients to people or agencies where they will receive the help or service they need. Once the plan is drawn up, the case manager links the person to the service, activity, organization or club, or people who will carry out the plan. When we connect the person to a formal agency we make a referral (see chapter 22) but, as noted before, we will link people to more than just formal agencies. Linking a client to a specific service requires care and skill on your part. You need to know the best service that will meet the individual issues and needs of your client.

Linking your client to a social service agency that provides a specific service—such as day treatment, drug rehabilitation, or groups for victims of violent crime—will require a written referral. You will state why you are making the referral, indicating the problem for which the referral is being made, and the goal that you expect as a result of your client's contact with the agency. The referral will also indicate the amount of time you estimate it will take for the agency to reach this goal. The time limit is very important. It keeps treatment from becoming endless and unstructured. With a goal and a set amount of time in which to attain that goal, both the agency and the client are more likely to make the most of their time together.

Sometimes people can take advantage of services on their own. You might tell a client about the Aurora Club, for example, and the next week he may take a bus there and begin going to the club regularly, participating in activities and social events. At other times, you may have clients who are unable to take the first step and who will need you to accompany them or to arrange transportation for them.

In a formal social service agency, personnel at that agency will be able to support your clients in their programs and implement the goals and work on the issues you and your clients have identified as important. Some agencies with very fine programs or specialized services are small, which may require you to give more support to your client. For example, at New Start, a staff of three focuses on second-stage groups for victims of rape and domestic violence, and much of the work is done by volunteers. The success rate is excellent, and clients report a high degree of satisfaction with the agency. However, the small staff is not equipped to handle other problems that might develop while your client is in their group. If you refer a client to a group at New Start and your client has landlord problems between group sessions, the staff at New Start may not be aware of it in time to prevent an eviction notice. Even if they become aware of the notice, they will need to refer the client to you to resolve the matter because of the limited staff time available to clients. On the other hand, at Riverview, a day-treatment program, nurses are aware of medication problems, social workers monitor progress toward goals, and staff can work to prevent eviction of a client, if that appears imminent.

On occasion you may find a service for your client at an agency that does not seem interested in serving her. Perhaps they are reluctant because your client has been ill recently or because the agency is not interested in her type of problem. The agency may accept the client into service with them to fill all their slots and draw down payment for services, but in reality they may give poor or no services. In such instances, linking becomes advocacy as you advocate for your client or on behalf of your client. In a situation like this, advocacy means you will attempt to seek the best services for your client, and you will insist that your client be treated fairly and with respect.

Beyond the formal agencies, however, we might choose generic services that require no formal referral or we might make connections with community social supports where it is often completely unnecessary for the people there to be aware of your client's status with your case management unit. Linking is about choosing all the best options that will support your client toward her goals and the stability she is seeking.

Monitoring

After the plan has been made and implemented (meaning the referrals and links indicated in your plan have been accomplished), it becomes your responsibility to monitor the services given to your client. When a formal agency is holding a planning or treatment conference about one of your clients, you should be invited to attend. You should also receive written reports about your client's progress and about the services given to him or her. If you do not receive reports at specified intervals from the agency, you need to contact them yourself on a regular basis.

Talking with another agency about the service they are giving your client is done for two reasons:

1. To be certain that the treatment or service you authorized for this person is in fact the treatment or service that is being given
2. To keep track of your client's progress toward the goals you developed with the client and be aware of times when modifications and revisions in either the goals or the plan need to take place. Again, your assessment is on-going.

Less formal groups or institutions that are part of your plan should get a call or visit from you occasionally to monitor how the plan is working. Suppose that the neighbor offers to take your client, Bill, to church with her family every Sunday. In August, the family goes away for a month and does not make arrangements with anyone else to take him to church. He begins to feel lonely, and one day he goes to another church closer to his apartment. There he is extremely friendly to everyone, which seems to bother the minister and several members of the church. They decide he is "inappropriate" and call crisis intervention, whose team gets tied up going to the church and sorting out what happened. All of this could have been avoided if you had been able to have regular contact with the family who took your client to church. In that case, you would have known of the vacation and could have requested that they find a substitute or could have found a substitute yourself.

If you have linked your client to a choir, the Lions club, or courses at the community college it would not be appropriate to check in with these entities, but it would be appropriate for you to check in with your client to see how these connections are working out.

Figure 1.1 outlines the knowledge base and skills needed for case management and offers some useful guidelines for you to follow in practicing case management.

FIGURE 1.1 Knowledge base, skills, and guidelines for case management

Knowledge Base for Case Management In order to do case management, you need knowledge of the following: Individual and family dynamics (which you find in courses such as Human Development, Introduction to Psychology, Marriage and the Family, and Abnormal Psychology) The relationship between and among social, psychological, physiological, and economic factors (as found in the ecological model, a theoretical basis for evaluating a person's situation and needs) The focus and policies of your agency State and federal laws and regulations that affect your agency's delivery of service The vast array of community services and resources where you practice Skills You Need to Be an Effective Case Manager To be an effective case manager, you need the ability to: Work effectively with people to promote their growth Work collaboratively with people of various professions, paraprofessionals, the public, and clients and their families Identify what your client needs Keep accurate and well-organized records Allow the client to take leadership in planning services Develop creative resources within your community to meet client needs Guidelines for Case Management Here are some useful guidelines in practicing case management: Plan ahead. Plan before there is a crisis. Develop a plan that will prevent crises based upon what you learned about your clients in their assessments and what you can foresee happening in their situations if the issues are not addressed. Alleviate crisis-provoking situations. Be accountable to your client and to the community. Do what you say you will do. Do it promptly. And carefully document what you have done. Be optimistic about your client. Expect improvement and some degree of independence, and that is what you are most likely to get. Reinforce success, and never miss an opportunity to give positive feedback. Set up situations in which your client is likely to succeed rather than situations that are complex and tricky. Involve your clients in all phases of planning. Let your people decide what issues and problems in their lives take priority. Get their opinions and feedback about services and about their plans. Go where your clients are. Do not stay shut up in your office. Go out and see where your clients are interacting with others, and teach your clients new skills in the field where they will need them. Promote independence. Show pride in the independence your clients demonstrate regardless of how small it is. Model independence, encourage independence, and teach as often as it takes the skills to maintain independence. Develop a large number of resources and know how to find good ones for your clients. Know what formal agencies exist in your community and their focus. Look for and develop good social support systems on which you can rely. As you move about the community, look for new resources you can add to your list.

Nearly everything you do in relation to your client is a form of advocacy. When you plan with your clients, you advocate for their voices and opinions to be heard. When you link your clients to specific services or activities, you advocate for the best placements and treatments for your clients. When you monitor your cases, you advocate for the goals you and your client have determined should be met.

There are other instances where you need to be able to stand up for your client or find the leverage in your community where clients' rights or best interests will be supported. For example, suppose that your client has just left a drug rehab facility and is living on her own for the first time. She is in a small public housing apartment and is told she is being evicted along with a number of other clients because the building has been deemed unsafe. However, the city seems unable or reluctant to find other housing and your client can only afford subsidized housing. If you have met with your client to look at the options, and if you have met with your client and the public housing officials and find them unwilling or disinterested in relocating your client, you may need to go with your client to see her state representative.

True advocacy in this case might involve your accompanying your client to a hearing, testifying on her behalf at a hearing, insisting that she receive a fair hearing, assembling the facts and putting them before a particular board, going to meetings with others whose clients will be affected, and even seeking legal aid.

In the chapters on communication, you will learn ways to communicate your concerns so that you do not come across as petulant and demanding. Nevertheless, many clients are not able to organize on their own behalf, defend themselves effectively, or know when they are being exploited or abused. Case managers have an obligation to monitor when their clients are at an extreme disadvantage and to advocate for these people in whatever way is appropriate.

Service coordination refers to working with other agencies or systems in a person's life. Many of your clients will be involved in other programs and systems, and each of these programs or systems may have a different plan for the person. Each of these plans may be headed more or less toward the same broad general goal, but their specifics for the person are all different. Often the major and most significant role for the case manager is to bring representatives of these different systems together, forming a team that collaborates with one another in supporting the client's goal.

This is not as easy as it sounds. Communities and counties have numerous services, such as the school and other educational systems, mental health and the intellectual disabilities systems, the criminal justice system, a substance abuse system, and health care systems. These organizations often operate as though they are the only program with which the client is involved. Case managers who attempt to get everyone to work together are sometimes not welcome, and the program may be closed to outside input and collaboration with other agencies. However, coordinating the different services can enhance clients' movement toward their goals. When coordination is not possible, a person's goals can be impeded tremendously.

For example, Norita was a student at a community college and also a mother on welfare with one child. Because of her mental health problems in the past, her case manager at the mental health unit had facilitated Norita's receiving welfare to support herself while in school, and the case manager had worked with Norita to get her into school where she was an excellent student. Then the welfare worker insisted that Norita drop out of school and take a job readiness course as all single mothers on welfare were required to do. This demand came in the middle of a semester, and time and money would have been wasted if Norita was forced to drop out of school. The case manager worked with both the school and the welfare office to form a team working to support Norita in her movement toward financial independence.

At first, the welfare worker was not happy about working with the case manager. She was curt and unpleasant and stipulated that the rules for remaining on welfare meant that Norita would have to drop out of school and take a 7-week job readiness course. The case manager made an appointment to meet and brought an academic counselor from the college to the meeting. In this face-to-face context, the welfare worker began to soften and see advantages to Norita's current plan. Norita was only one semester away from graduation after she completed the current semester. The college counselor stated that the counseling department was available to help with resumes and job searches. In fact, it was likely that Norita would be hired from her internship as she was going into a field with a high demand for workers.

Gradually, a team was formed, and collaboration around helping Norita become independent took place. In the end, each party felt the outcome was beneficial to its system. This last element is crucial when coordinating with other agencies and systems. To support the overall plan, each party has to feel that what is being agreed to will have a satisfactory outcome for the system he or she represents. In this case, both the welfare worker and the case manager met the goal for Norita to become independent and self-supporting. In addition, the case manager avoided duplication of services. If the college was showing Norita how to get a job and the welfare system was as well, there would have been duplication of services. What could have been competing systems and ill will became, instead, complementary services integrated around a specific goal and working together on Norita's behalf.

You will not always be coordinating with other social services agencies. In one instance Meredith's client, Phillip, believed he was employed by the Fresh 'N Save grocery store near his home. This was a delusion Phillip had held consistently for over a year. Phillip had gone to the store on numerous occasions, rearranging things on the shelves, helping shoppers with their bags and carts, and generally impeding some of the daily tasks at the store. On a number of occasions, Phillip was arrested for defiant trespass, and often he was escorted off the property by the local police. In one instance he was given a short jail sentence, but 6 hours after his release from jail he was back at the Fresh 'N Save. The case manager pulled together a team of people who previously had been working on their own to try to solve this problem. Present at the first meeting was the probation officer, the county mental health representative, a person from the police department, and the manager of the Fresh 'N Save. The question before the team was, "What resources do we need to resolve this problem and move Phillip to more constructive activities?"

Everyone on the team recognized that there was no treatment in the jail for Phillip, so the team looked at what other resources would be needed. It was agreed Phillip needed some level of supervision. A commitment to a partial hospitalization program would be obtained. Phillip would go there 5 days a week. In addition, supervised housing was arranged for Phillip. In this way, someone would know where Phillip was or should be at all times. The police and the store manager agreed to call the partial hospitalization program or the supervised housing unit if Phillip returned to the store. The case manager agreed to work with Phillip and staff in the partial hospitalization unit to seek other goals Phillip might have for himself. The county mental health representative agreed that the crisis intervention team would intervene when necessary if the case manager was off on a weekend or in the evenings. In this way individuals representing a number of different systems or agencies went from feeling frustrated and exasperated to leaving with a plan and some assurance that Phillip would get the assistance he truly needed.