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Hosted by: Center for Advocacy and Leadership Training A project of Time for Change Foundation Strengths-Based Case Management Presented by Dr. Richard.

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Presentation on theme: "Hosted by: Center for Advocacy and Leadership Training A project of Time for Change Foundation Strengths-Based Case Management Presented by Dr. Richard."— Presentation transcript:

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

2 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 Persons who have substance abuse problems & are HIV positive 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 System Location Rural providers Affordability Eligibility criteria Inflexible hours Admission process Cultural competence Impersonal Intimidating Staff skills Waiting lists Substance abuse treatment & medical care

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 Barriers to Treatment Persons who have substance abuse problems & are HIV positive Substance abuse treatment & medical care 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 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 ITARC Center for Interventions Treatment & Addictions Research Case Management + Strengths Focus Case Management Assessment Planning Linking Coordinating Advocacy Strengths Perspective Focus on strengths Client driven Primary relationship Assertive outreach Creative use of resources

21 Focus on Client Strengths Client Driven Emphasize Relationship Assertive Outreach Use of Informal Resources Assessment Planning Linking Monitoring Advocacy STRENGTHS-BASED CASE MANAGEMENT Linkage with Care Retention in Care Improved Functioning Tangible Support Transportation Childcare Planning Advocacy 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 Strengths Perspective 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 Strengths Perspective 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 a Outpatient28.7 c c 41.2 b Methadone a,b Total38.7 d 44.7 e 55.0 d,e Percentages with same superscript are significantly different. a, e p <.05; c p <.01; b, d p < 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 033 (76.7)10 (23.3)43 (19.4) 125 (48.1)27 (51.9)52 (23.4) 211 (45.8)13 (54.2)24 (10.8) 312 (33.3)24 (66.7)36 (16.2) 411 (36.7)19 (63.3)30 (13.5) 57 (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 Unemployed Fewer Arrests Case Manager Less Drug Use Lower Drug Severity (Six Months) More Weeks in Aftercare Treatment (Baseline) Less Depression Less Use of Crack Cocaine Fewer Treatments

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

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 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 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 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 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 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 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 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 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 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 Goals: –“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


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