Presentation on theme: "Strengths-Based Case Management"— Presentation transcript:
1 Strengths-Based Case Management Presented by Dr. Richard RappJune 12th & 13th , 2014Hosted 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 UniversityBoonshoft School of Medicine
3 ObjectivesUnderstand principles and practice activities important in Strengths-Based Case ManagementEngage in practice scenarios & role playsDiscuss adaptation and implementation issues for your setting
4 Terms Strengths-based Case Management (SBCM) Treatment Linkage Case Management (TLCM)Persons with substance abuse problemsARTAS Linkage Case Management (ALCM)Persons newly diagnosed with HIVEmergency 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 populations1990 – 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 fieldStrengths-based: Wright State University; University of IowaAssertive Community Treatment: University of DelawareGeneralist: UCLASince 1990, mostly generalist case management
8 Barriers to Treatment Personal Practical Transportation Financial ChildcareLifestyleSubstance abuse & mental healthHigh risk behaviorsHomelessIncarcerationInternalFear of discoveryStigmaDenialFatalismLack of trustPhysicalSide effectsSubstance abuse treatment & medical carePersons who have substance abuse problems & are HIV positiveSystemLocationRural providersAffordabilityEligibility criteriaInflexible hoursAdmission processCultural competenceImpersonalIntimidatingStaff skillsWaiting lists
9 Case Management Functions Assesses – Identifies service(s) the client needsArranges – Makes plans to get service(s)Coordinates – Makes sure that service(s) are receivedMonitors – Follows the progress of client – service(s) interactions
10 Case Management Functions Evaluates – Makes sure that client gets services as intendedAdvocates – 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 communityAND/ORSupport in achieving specific, short-term goals; assisting clients to link with services
13 STRENGTHS PERSPECTIVE Barriers to TreatmentPersonalPracticalTransportationFinancialChildcareLifestyleSubstance abuse & mental healthHigh risk behaviorsHomelessIncarcerationInternalFear of discoveryStigmaDenialFatalismEmbarrassmentLack of trustPersons who have substance abuse problems & are HIV positiveSubstance abuse treatment & medical careSystemLocationRural providersAffordabilityEligibility criteriaInflexible hoursAdmission processCultural competenceImpersonalIntimidatingStaff skillsWaiting listsCASE MANAGEMENTSTRENGTHS 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 wrongRecognize motivation and personal effortsBase goal-setting on past assets
15 Principle II: Client Driven Establish client as responsible for identifying own goals and path to accomplish those goalsIncrease client investment in goalsPromote self-determinationReduces resistance and denial
16 Principle III: Case Manager as Primary Relationship Development of working alliance, relationship is criticalProvides the short-term foundation for client taking risksPrimary, but not exclusive relationship
17 Principle IV: Community as a Resource Selective use of formal, informal, and created resourcesFormal – specialized, entitlementsInformal – day to day functioning and community involvementCreated – Expand personal interests, skills
18 Principle V: Assertive Outreach Encourages understanding of client’s lifeHelps case manager to help client formulate plansPromotes relationship between client and case manager
19 Combining Case Management & Strengths Perspective
20 Case Management + Strengths Focus AssessmentPlanningLinkingCoordinatingAdvocacyStrengths PerspectiveFocus on strengthsClient drivenPrimary relationshipAssertive outreachCreative use of resourcesITARCCenter for InterventionsTreatment & AddictionsResearch
21 STRENGTHS-BASED CASE MANAGEMENT Tangible SupportTransportationChildcarePlanningAdvocacyAssessmentPlanningLinkingMonitoringAdvocacyLinkagewith CareRetentionin CareImprovedFunctioningFocus on Client StrengthsClient DrivenEmphasize RelationshipAssertive OutreachUse of Informal ResourcesEmotional SupportIncrease HopefulnessIncrease Self-EfficacyDecreased Resistance
22 Strengths-Based Case Management A value-added intervention in that:Case management provides concrete support in getting resourcesStrengths perspective provides emotional support in identifying abilities
23 Strengths Perspective and Medical Model Basic position is to find strengths, assets, and abilitiesDiagnosis and labeling is avoidedFull discussion of client’s story is encouragedMedical/Disease ModelBasic position is to find sickness, problems, disease & pathologyDiagnosis is required; labeling is frequentClient/patient usually seen as less capable, needs to be helped/fixed
24 Strengths Perspective and Medical Model Individual is asked about needsIndividual seen as “able” and necessary participant in addressing needsActive involvement encouragedGoals are (almost) always supportedMedical/Disease ModelWorker supports “party line” and agency roleClient/patient goes to servicesSolutions usually involve formal resourcesDoctor-patient relationship
27 Percent linkage by intervention and modality Treatment ModalityStandard of CareMotivational InterviewingStrengths-Based Case Management(n=222)TotalResidential39.043.956.246.3 aOutpatient28.7 c43.452.3 c41.2 bMethadone68.448.960.058.4 a,b38.7 d44.7 e55.0 d,e46.0Percentages 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 contactsNo linkage with treatment at 3 monthsLinkage with treatment at 3 monthsTotal number of substance abusers33 (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 (Baseline).251.122.165.129.136.399UnemployedFewer ArrestsLess DepressionLower Drug Severity(Six Months)Less Drug UseLess Use of Crack CocaineFewer TreatmentsMore Weeks in Aftercare TreatmentCase Manager
30 Path Model of Significant Factors on Post-Treatment Contact and Legal Severity (Baseline).251.242.104.425UnemployedLower Legal SeverityReadiness for TreatmentLower Legal Severity(Twelve Months)Case Manager.112More Weeks in Aftercare Treatment
32 A Word About Motivational Interviewing Some of basic skills of MI can be very useful as part of SBCMReflective comments vs. open and closed questionsRecognizing stage of changeRolling with resistance; empathyUsing discrepancy
33 Strengths-Based Case Management Preparation – Getting readyEngagement – First impressions are everythingStrengths Assessment – Changing the discussionCase Management Planning – Following the clientDisengagement – Letting go
34 Preparation (System)Learn about & make a directory of both formal and informal resourcesExamine structure of own agency, what interferes with linkageVisit all resources where you might refer clientsShadow program staff; Be the clientEstablish informal relationships with staffEncourage your agency to develop MOUs with other programs
35 Preparation (Clients) Have a strengths “attitude”Have knowledge necessary to assist clientsUnderstand situation of your potential clientsInterview clients who have been successfulHave basic support/counseling skillsStay open to learning new ways of helping people
36 Note on PreparationIf you aren’t prepared, you put clients’ ability to be successful at riskEspecially 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 situationDon’t worry about apparent motivationRecognize and state strengths as soon as possibleProvide a summary of what you can and can’t do for clientBe cautious about self-disclosure too early
39 Case Finder Training - ARTAS Model March 17-18, 2005Strengths AssessmentBenefitsHelp client identify strengths, abilities, assets, skills, dreams, interestsProvide improved sense of self-efficacy and hopefulnessUse strengths, etc. in planningDevelop relationshipReduce client resistance
40 Case Finder Training - ARTAS Model March 17-18, 2005Strengths AssessmentProvides constructive challengeCan’t do “autopilot” on reciting pathologyEncourages 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, 2005Strengths AssessmentInitially may be difficult for both worker and clientUsually unstructured; may have a list of strengths to prompt client’s thinkingAlways dynamic and interactiveOn-going throughout the relationship
42 Strengths AssessmentSummarize and write strengths down, give to clientsHelp client take credit for things going wellContinually 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 ModelMarch 17-18, 2005Strengths Assessment - RelationshipsWho 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 ModelMarch 17-18, 2005Strengths Assessment - Internal ResourcesWhat 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 ModelMarch 17-18, 2005Strengths Assessment - RecoveryWhen 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 attemptsRisk to do harm to othersPhysical problems associated with drug use, HIV status, general health concernsIntrinsic limitations such as learning difficulties, not reading well
50 Goal Setting/Treatment Planning Case Finder Training - ARTAS ModelMarch 17-18, 2005Goal Setting/Treatment PlanningBenefitsWhen client identifies own goals (objectives, strategies) they are more likely to accomplish themPlaces responsibility for action on clientEnhances client investment in own careTeaches a process that can be used in the future
51 Goal Setting/Treatment Planning Case Finder Training - ARTAS ModelMarch 17-18, 2005Goal Setting/Treatment PlanningProvides a constructive challengeCan’t do “autopilot”, expecting someone else to do for themMinimizes chances of not being successfulWorker only helps shape the process and asks the right questionsBuilds in accountability for client (and worker)
52 Goal Setting/Treatment Planning Case Finder Training - ARTAS ModelMarch 17-18, 2005Goal Setting/Treatment PlanningInitially may be difficult for both worker and clientPlan based on demonstrated successes whenever possibleEngages clients who function at various reading and cognitive levels
53 Goal Setting/Treatment Planning Process includes:Identifying Goals, Objectives, StrategiesTarget datesReview of plan at every meeting
54 Goal Setting/Treatment Planning “What do you need/want to accomplish?”Broad statement in client’s own wordsNot for case manager to decideCM will work on any goal, unless its illegal or hurtful to self or other
55 Goal Setting/Treatment Planning ObjectivesSpecific, measurable actions; no doubt if it has been accomplished or notAllows client to see success in tangible terms, or if not successful make specific alternative plansCase manager may provide feedback, help client consider pros/cons, put objectives in best order, etc.
56 Goal Setting/Treatment Planning StrategiesSpecific, measurable actionsThe action or “baby steps” for accomplishing an objective and thereby a goalAllows client to see success in tangible terms, or if not successful make specific alternative plansCase manager may provide feedback, help client consider pros/cons, put objectives in best order, etc.
57 Goal Setting/Treatment Planning Target DatesHelp client to identify realistic time frame for accomplishing objectives and strategiesUse to discourage procrastination or overly eager expectationsRegular ReviewEncourages follow-throughProvides prompt assistance if needed
60 #1: Building the Relationship Describe the goals and objectives of SBCMReview incident that led to ED treatmentIntroduce the concept of strengths, abilities, and skills and begin strengths assessmentEncourage linkage with substance abuse treatment or identification of goals that are important to the individualIdentify barriers to linkage or accomplishing goals of importanceSummarize the sessionAccomplish tasks on behalf of individual
61 #2: Assessing Personal Strengths Discuss issues from last session; follow-up on task since previous sessionContinue strengths assessmentEncourage linkage with treatment or identifying personal goalsIdentify barriers to linkage and personal goalsSummarize the sessionAccomplish tasks on behalf of individual
62 #3: Learning to Make Contact Discuss issues from last session; follow-up on any plansContinue to emphasize strengthsEncourage linkage with treatment and personal goalsIdentify barriers to linkage & personal goalsBegin disengagement processSummarize the sessionAccomplish tasks on behalf of individual
63 #4: Reviewing ProgressDiscuss issues from last session; follow-up on any plansEngage in a summary of strengths & accomplishmentsEmphasize disengagementIdentify remaining barriers to linkage & personal goalsSummarize the sessionAccomplish tasks on behalf of individual
64 #5: Completing the WorkDiscuss issues from last session; follow-up on any plansFinalize disengagement processEncourage client’s independent contact with treatment and other resourcesSummarize the relationship
65 Activity #4Staffing 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 staffAgency-wideAgency-wide for certain population(s)Community-wide
68 Question #2If agency-wide for certain populations, which population(s)?Consider strategicallyDefine precisely
69 Question #3 Do you want SBCM to be: Brief, to help individuals with a specific objective(s)? OrLong-term with on-going support?Based on selected populationBased on agency and community servicesVery different structures
70 Question #4Having answered questions #1 through #3, what objectives would you assign to each case management contact?
71 Question #5What current policies and procedures of your organization will interfere with implementing SBCM?That’s not how we do it hereThe intake processLack of clinical supervision focused on SBCMOthers
72 Steps in the Staffing Process Few facts – name, age, living situation, medical conditionsStrengths, assets, skills, positives, etc.Goals, Objectives, StrategiesBarriers to Objectives and StrategiesInherent limitations