1. Strengths-Based Case Management
Presented by Dr. Richard Rapp
June 12th & 13th , 2014
Hosted by: Center for Advocacy and Leadership Training A project of Time for Change Foundation

2. Wright State University Boonshoft School of Medicine
Richard C. Rapp, M.S.W., Ph.D.
Wright State University
Boonshoft School of Medicine

3. Objectives
Understand principles and practice activities important in Strengths-Based Case Management
Engage in practice scenarios & role plays
Discuss adaptation and implementation issues for your setting

4. Terms Strengths-based Case Management (SBCM)
Treatment Linkage Case Management (TLCM)
Persons with substance abuse problems
ARTAS Linkage Case Management (ALCM)
Persons newly diagnosed with HIV
Emergency Department SBCM (ED-SBCM)
Opiod addicts being treated in emergency departments
“Linkage”; “Care Coordination”

5. Case Management & Substance Abuse
Prior to 1990 case management used almost exclusively with mental health populations
1990 – four case management studies proposed as part of a National Institute on Drug Abuse initiative to improve treatment retention and outcomes

6. Case Management & Substance Abuse
Models adapted from mental health field
Strengths-based: Wright State University; University of Iowa
Assertive Community Treatment: University of Delaware
Generalist: UCLA
Since 1990, mostly generalist case management

7. Case Management

8. Barriers to Treatment Personal Practical Transportation Financial
Childcare
Lifestyle
Substance abuse & mental health
High risk behaviors
Homeless
Incarceration
Internal
Fear of discovery
Stigma
Denial
Fatalism
Lack of trust
Physical
Side effects
Substance abuse treatment & medical care
Persons who have substance abuse problems & are HIV positive
System
Location
Rural providers
Affordability
Eligibility criteria
Inflexible hours
Admission process
Cultural competence
Impersonal
Intimidating
Staff skills
Waiting lists

9. Case Management Functions
Assesses – Identifies service(s) the client needs
Arranges – Makes plans to get service(s)
Coordinates – Makes sure that service(s) are received
Monitors – Follows the progress of client – service(s) interactions

10. Case Management Functions
Evaluates – Makes sure that client gets services as intended
Advocates – Intervenes to assure that client gets the services they needed

11. Duration of Case Management
On-going support of clients over a protracted period of time; long-term support of mental health clients reintegrated into community
AND/OR
Support in achieving specific, short-term goals; assisting clients to link with services

12. Strengths Perspective

13. STRENGTHS PERSPECTIVE
Barriers to Treatment
Personal
Practical
Transportation
Financial
Childcare
Lifestyle
Substance abuse & mental health
High risk behaviors
Homeless
Incarceration
Internal
Fear of discovery
Stigma
Denial
Fatalism
Embarrassment
Lack of trust
Persons who have substance abuse problems & are HIV positive
Substance abuse treatment & medical care
System
Location
Rural providers
Affordability
Eligibility criteria
Inflexible hours
Admission process
Cultural competence
Impersonal
Intimidating
Staff skills
Waiting lists
CASE MANAGEMENT
STRENGTHS PERSPECTIVE

14. Principle I: Focus on Client Strengths
Emphasize client strengths, positives, assets, skills, abilities, etc.
De-emphasize client recounting of what they’ve done wrong
Recognize motivation and personal efforts
Base goal-setting on past assets

15. Principle II: Client Driven
Establish client as responsible for identifying own goals and path to accomplish those goals
Increase client investment in goals
Promote self-determination
Reduces resistance and denial

16. Principle III: Case Manager as Primary Relationship
Development of working alliance, relationship is critical
Provides the short-term foundation for client taking risks
Primary, but not exclusive relationship

17. Principle IV: Community as a Resource
Selective use of formal, informal, and created resources
Formal – specialized, entitlements
Informal – day to day functioning and community involvement
Created – Expand personal interests, skills

18. Principle V: Assertive Outreach
Encourages understanding of client’s life
Helps case manager to help client formulate plans
Promotes relationship between client and case manager

19. Combining Case Management & Strengths Perspective

20. Case Management + Strengths Focus
Assessment
Planning
Linking
Coordinating
Advocacy
Strengths Perspective
Focus on strengths
Client driven
Primary relationship
Assertive outreach
Creative use of resources
ITAR C
Center for Interventions
Treatment & Addictions
Research

21. STRENGTHS-BASED CASE MANAGEMENT
Tangible Support
Transportation
Childcare
Planning
Advocacy
Assessment
Planning
Linking
Monitoring
Advocacy
Linkage
with Care
Retention
in Care
Improved
Functioning
Focus on Client Strengths
Client Driven
Emphasize Relationship
Assertive Outreach
Use of Informal Resources
Emotional Support
Increase Hopefulness
Increase Self-Efficacy
Decreased Resistance

22. Strengths-Based Case Management
A value-added intervention in that:
Case management provides concrete support in getting resources
Strengths perspective provides emotional support in identifying abilities

23. Strengths Perspective and Medical Model
Basic position is to find strengths, assets, and abilities
Diagnosis and labeling is avoided
Full discussion of client’s story is encouraged
Medical/Disease Model
Basic position is to find sickness, problems, disease & pathology
Diagnosis is required; labeling is frequent
Client/patient usually seen as less capable, needs to be helped/fixed

24. Strengths Perspective and Medical Model
Individual is asked about needs
Individual seen as “able” and necessary participant in addressing needs
Active involvement encouraged
Goals are (almost) always supported
Medical/Disease Model
Worker supports “party line” and agency role
Client/patient goes to services
Solutions usually involve formal resources
Doctor-patient relationship

25. Activity #1
Scenario A & Scenario B

26. Outcomes
Linkage & Retention

27. Percent linkage by intervention and modality
Treatment Modality
Standard of Care
Motivational Interviewing
Strengths-Based Case Management
(n=222)
Total
Residential
39.0
43.9
56.2
46.3 a
Outpatient
28.7 c
43.4
52.3 c
41.2 b
Methadone
68.4
48.9
60.0
58.4 a,b
38.7 d
44.7 e
55.0 d,e
46.0
Percentages with same superscript are significantly different. a, e p < .05; c p < .01; b, d p <.001 ++
When substance abusers who attended no case management are removed the total linkage rate was 63.1%.

28. Substance abusers’ linkage by number of CM contacts
Number of SBCM contacts
No linkage with treatment at 3 months
Linkage with treatment at 3 months
Total number of substance abusers
33 (76.7)
10 (23.3)
43 (19.4) 1
25 (48.1)
27 (51.9)
52 (23.4) 2
11 (45.8)
13 (54.2)
24 (10.8) 3
12 (33.3)
24 (66.7)
36 (16.2) 4
11 (36.7)
19 (63.3)
30 (13.5) 5
7 (18.9)
30 (81.1)
37 (16.7)
99 (44.6)
123 (55.4)
222

29. Path Model of Significant Factors on Post-Treatment Contact and Drug Severity
(Baseline)
.251
.122
.165
.129
.136
.399
Unemployed
Fewer Arrests
Less Depression
Lower Drug Severity
(Six Months)
Less Drug Use
Less Use of Crack Cocaine
Fewer Treatments
More Weeks in Aftercare Treatment
Case Manager

30. Path Model of Significant Factors on Post-Treatment Contact and Legal Severity
(Baseline)
.251
.242
.104
.425
Unemployed
Lower Legal Severity
Readiness for Treatment
Lower Legal Severity
(Twelve Months)
Case Manager
.112
More Weeks in Aftercare Treatment

31. Practice of SBCM

32. A Word About Motivational Interviewing
Some of basic skills of MI can be very useful as part of SBCM
Reflective comments vs. open and closed questions
Recognizing stage of change
Rolling with resistance; empathy
Using discrepancy

33. Strengths-Based Case Management
Preparation – Getting ready
Engagement – First impressions are everything
Strengths Assessment – Changing the discussion
Case Management Planning – Following the client
Disengagement – Letting go

34. Preparation (System)
Learn about & make a directory of both formal and informal resources
Examine structure of own agency, what interferes with linkage
Visit all resources where you might refer clients
Shadow program staff; Be the client
Establish informal relationships with staff
Encourage your agency to develop MOUs with other programs

35. Preparation (Clients)
Have a strengths “attitude”
Have knowledge necessary to assist clients
Understand situation of your potential clients
Interview clients who have been successful
Have basic support/counseling skills
Stay open to learning new ways of helping people

36. Note on Preparation
If you aren’t prepared, you put clients’ ability to be successful at risk
Especially true when it comes to:
“Strengths attitude”
Fully knowing the resources where you refer clients

37. Engagement Find out about client; Talk, don’t interview
Ask about their reaction to their situation
Don’t worry about apparent motivation
Recognize and state strengths as soon as possible
Provide a summary of what you can and can’t do for client
Be cautious about self-disclosure too early

38. Example of Strengths-Related Assessment Tools

39. Case Finder Training - ARTAS Model
March 17-18, 2005
Strengths Assessment
Benefits
Help client identify strengths, abilities, assets, skills, dreams, interests
Provide improved sense of self-efficacy and hopefulness
Use strengths, etc. in planning
Develop relationship
Reduce client resistance

40. Case Finder Training - ARTAS Model
March 17-18, 2005
Strengths Assessment
Provides constructive challenge
Can’t do “autopilot” on reciting pathology
Encourages thoughts about, and practice of, strengths (rather than practicing pathology)
Inoculates case manager against hopelessness and skepticism

41. Case Finder Training - ARTAS Model
March 17-18, 2005
Strengths Assessment
Initially may be difficult for both worker and client
Usually unstructured; may have a list of strengths to prompt client’s thinking
Always dynamic and interactive
On-going throughout the relationship

42. Strengths Assessment
Summarize and write strengths down, give to clients
Help client take credit for things going well
Continually connect client strengths and current challenges they face

43. Strengths Assessment Questions
What are your strengths/positives/good points/abilities?
When have you faced challenges successfully?
When were things going well and what were you doing to make them go well?

44. Strengths Assessment - Relationships
Case Finder Training - ARTAS Model
March 17-18, 2005
Strengths Assessment - Relationships
Who do you trust? What is it about them?
What has been the most successful relationship you’ve had, successful for both parties? What made it successful?
When have you been able to just give to others without expecting anything in return?

45. Strengths Assessment - Internal Resources
Case Finder Training - ARTAS Model
March 17-18, 2005
Strengths Assessment - Internal Resources
What was an example of your solving a problem effectively?
When did you successfully identify and complete a goal? What helped you complete that goal?
When did you feel most in control of your own life? What were you doing to make that happen?

46. Strengths Assessment - Recovery
Case Finder Training - ARTAS Model
March 17-18, 2005
Strengths Assessment - Recovery
When was a time that you stayed sober? What were you doing that helped you stay sober?
When was a time that you controlled your drug use? What were you doing that helped you stay in control?
What have you done to try and deal with your drug use?

47. Non-Strengths Information
Suicidal ideation or attempts
Risk to do harm to others
Physical problems associated with drug use, HIV status, general health concerns
Intrinsic limitations such as learning difficulties, not reading well

48. Activity #2
Conducting strengths-based assessments

49. Example of a Goal-Setting Tool

50. Goal Setting/Treatment Planning
Case Finder Training - ARTAS Model
March 17-18, 2005
Goal Setting/Treatment Planning
Benefits
When client identifies own goals (objectives, strategies) they are more likely to accomplish them
Places responsibility for action on client
Enhances client investment in own care
Teaches a process that can be used in the future

51. Goal Setting/Treatment Planning
Case Finder Training - ARTAS Model
March 17-18, 2005
Goal Setting/Treatment Planning
Provides a constructive challenge
Can’t do “autopilot”, expecting someone else to do for them
Minimizes chances of not being successful
Worker only helps shape the process and asks the right questions
Builds in accountability for client (and worker)

52. Goal Setting/Treatment Planning
Case Finder Training - ARTAS Model
March 17-18, 2005
Goal Setting/Treatment Planning
Initially may be difficult for both worker and client
Plan based on demonstrated successes whenever possible
Engages clients who function at various reading and cognitive levels

53. Goal Setting/Treatment Planning
Process includes:
Identifying Goals, Objectives, Strategies
Target dates
Review of plan at every meeting

54. Goal Setting/Treatment Planning
“What do you need/want to accomplish?”
Broad statement in client’s own words
Not for case manager to decide
CM will work on any goal, unless its illegal or hurtful to self or other

55. Goal Setting/Treatment Planning
Objectives
Specific, measurable actions; no doubt if it has been accomplished or not
Allows client to see success in tangible terms, or if not successful make specific alternative plans
Case manager may provide feedback, help client consider pros/cons, put objectives in best order, etc.

56. Goal Setting/Treatment Planning
Strategies
Specific, measurable actions
The action or “baby steps” for accomplishing an objective and thereby a goal
Allows client to see success in tangible terms, or if not successful make specific alternative plans
Case manager may provide feedback, help client consider pros/cons, put objectives in best order, etc.

57. Goal Setting/Treatment Planning
Target Dates
Help client to identify realistic time frame for accomplishing objectives and strategies
Use to discourage procrastination or overly eager expectations
Regular Review
Encourages follow-through
Provides prompt assistance if needed

58. Activity #3
Developing a Personal Roadmap

59. One Example of SBCM
Structured 5 Contacts

60. #1: Building the Relationship
Describe the goals and objectives of SBCM
Review incident that led to ED treatment
Introduce the concept of strengths, abilities, and skills and begin strengths assessment
Encourage linkage with substance abuse treatment or identification of goals that are important to the individual
Identify barriers to linkage or accomplishing goals of importance
Summarize the session
Accomplish tasks on behalf of individual

61. #2: Assessing Personal Strengths
Discuss issues from last session; follow-up on task since previous session
Continue strengths assessment
Encourage linkage with treatment or identifying personal goals
Identify barriers to linkage and personal goals
Summarize the session
Accomplish tasks on behalf of individual

62. #3: Learning to Make Contact
Discuss issues from last session; follow-up on any plans
Continue to emphasize strengths
Encourage linkage with treatment and personal goals
Identify barriers to linkage & personal goals
Begin disengagement process
Summarize the session
Accomplish tasks on behalf of individual

63. #4: Reviewing Progress
Discuss issues from last session; follow-up on any plans
Engage in a summary of strengths & accomplishments
Emphasize disengagement
Identify remaining barriers to linkage & personal goals
Summarize the session
Accomplish tasks on behalf of individual

64. #5: Completing the Work
Discuss issues from last session; follow-up on any plans
Finalize disengagement process
Encourage client’s independent contact with treatment and other resources
Summarize the relationship

65. Activity #4
Staffing cases ala strengths-based case management

66. Implementing SBCM your organization
First 5 Questions to Answer

67. Question #1 How completely do you want to implement SBCM?
Individual staff
Agency-wide
Agency-wide for certain population(s)
Community-wide

68. Question #2
If agency-wide for certain populations, which population(s)?
Consider strategically
Define precisely

69. Question #3 Do you want SBCM to be:
Brief, to help individuals with a specific objective(s)? Or
Long-term with on-going support?
Based on selected population
Based on agency and community services
Very different structures

70. Question #4
Having answered questions #1 through #3, what objectives would you assign to each case management contact?

71. Question #5
What current policies and procedures of your organization will interfere with implementing SBCM?
That’s not how we do it here
The intake process
Lack of clinical supervision focused on SBCM
Others

72. Steps in the Staffing Process
Few facts – name, age, living situation, medical conditions
Strengths, assets, skills, positives, etc.
Goals, Objectives, Strategies
Barriers to Objectives and Strategies
Inherent limitations