Engaging Complex Clients in the Case Management Process Jenny Thompson Clinical Nurse Consultant ADAHPT

Objectives Overview of case management ADAHPT model of case management Discuss the ‘Engagement’ process Look at the obstacles to engagement Case study Today I would like discuss the process of engaging with clients who have complex needs, in the context of the service I work for ADAHPT. The ADAHPT principle of client care is underpinned by our case management model and so I will be looking at engaging with clients via the case management process. I will look at some of the obstacles to case management. Finally I will present a case study to highlight the points I have made.

ADAHPT Established 1997 NSW state-wide service Aids Dementia Complex &/or a HIV Psychiatric condition Expanded to complex needs Multidisciplinary approach Co-case management model For those of you who may not have heard Craig's presentation yesterday I will give a brief over view of ADAHPT. ADAHPT a NSW state-wide service, was established in 1997 to assist in meeting the complex needs and issues related to AIDS dementia complex and/or a HIV psychiatric condition. In 2002 we expanded our referral criteria to include people who are HIV positive with complex needs. ADAHPT is a multidisciplinary team working on the philosophy that with sufficient support, clients with complex needs can be managed in the community by local services. We have therefore adopted a co-case management model which allows us to offer support to local services in the management of clients with HIV and complex needs.

ADAHPT Co-case Manager Other Service Providers Client Negotiation Partnership The diagram highlights the collaborative approach between all parties, with the client central to all decision making. In addition, the diagram represents the supportive role, provided by ADAHPT to all stakeholders via the case manager. In the ADAHPT co-case management approach it is preferred that clients attend all care meetings that discuss their care plan regardless of their level of impairment.

Case Management Concept of ‘case management’ varies across services Five basic functions (Intagliata, 1982) Assessment, planning, linking, monitoring & evaluation (or review) Definition: ‘Case management is a process for ensuring clients are provided with whatever service/s they require in a co-coordinated, effective and efficient manner’ (Case Management Society) The concept of case management tends to vary across services. The model ADAHPT has adopted is based upon the five basic functions described by Intagliata in 1982 assessment, planning, linking, monitoring and evaluation. We have adopted the case management societies’ definition of case management ‘a process for ensuring clients are provided with whatever services they require in a coordinated, effective and efficient manner’.

Steps of Case Management Assessment Planning/Linking Monitoring Review Citizenship Crisis intervention Focus on strengths Support Advocacy Home visit/face to face meeting Respect Engagement Consultation with others Referral Background Information This diagram shows what we believe to be the intricacies of this process. Some of the steps to successful case management are:

Referral Referrer involvement Clear picture of client Referral is appropriate Initial plan Address safety issues The ADAHPT case management process starts with referral to the service. At this point the referrer provides background information regarding the client enabling the intake officer to assess the persons suitability to the service. It is important that this information is as in depth as possible. With the client’s permission we then consult with other service providers who may have had contact with the client in order to confirm the depth of their involvement ,this enables us to get a clearer picture of the client and ensure that the referral is appropriate for this service. Good background information will enhance the engagement process by highlighting the clients situation, needs and preferences. Using this information an initial plan is formulated. At this stage it is also important to address any safety issues.

Engagement Critically important to case management Respectful, friendly and tactful Clients needs Focus on strengths Citizenship Crisis intervention Support and advocacy Frequent home visits Engagement is perhaps one of the most important aspects of the case management process and begins next. Engagement is an ongoing process beginning at the first contact, often best done in the clients own environment by meeting them in their home. Many people may not have previously found themselves in such a dependent situation and be quite sensitive about requiring assistance. Often clients referred to our team have considerable disability and may have little insight into their situation and see no need for involvement. A respectful, friendly and tactful approach is essential particularly in these initial stages. Having gathered as much background information as possible the prospective new case manager should approach this first meeting armed with some idea of the client’s needs most particularly needs that are not being met. Thus the meeting with the client can be made with an offer to assist the client in some way that they see as important. Often this may require some creativity and imagination. The client’s view of need may not be the same as that of the case manager, for the purpose of engagement it may be necessary to satisfy the clients perceived need first, within reason. For example a client may view their current housing situation as their only problem, the case manager can start by offering to advocate on their behalf for a housing transfer first, moving on to other issues later. What matters at this stage is developing positive rapport. One should not to become too carried away, making promises that cannot be met. This early rapport is often the key to engaging meaningfully with our clients. No matter how disabled the client may be, it is important to focus upon their strengths, find out what they are good at, what their interests are, complement them on something. We all respond to positive regard. Identifying a persons strengths and competencies is a good place to start both the relationship with the client and the subsequent management plan. This is also the time to establish some ground rules; precedents occurring at this stage cannot later be undone. We are all citizens with rights and obligations to the society in which we live thus our clients should be treated as a citizens and therefore subject to all the rights, expectations and responsibilities that go with citizenship. Often a referral is made at a point of crisis. Crisis should be seen as an opportunity, the client will have some clearly defined and pressing needs and more than likely an openness to accept assistance, which may not normally exist. This can fast track the process and a relationship will have begun. Engagement is an ongoing process occurring throughout the client/case manger relationship. After the initial meeting the process is nurtured through continued support and advocacy. Generally speaking it is essential that the case manager be able to make regular home visits.

Assessment Formal process History Health information Accommodation Finances While one is commencing the engagement process, at the first meeting with the client a more formal process is also going on, that of assessment. Initially the case manager will be seeking more detail about the client’s history, information about their physical and mental health status, what their living arrangements are, do they have social supports, their financial situation etc. A skilled case manager will also be using a broad range of skills to evaluate the veracity of what they are told. It is not uncommon for example for someone to state that they are completely able to live on their own and manage their own finances when there is little evidence to support this.

Steps of Case Management Assessment Planning/Linking Monitoring Review Citizenship Crisis intervention Focus on strengths Support Advocacy Home visit/face to face meeting Respect Engagement Consultation with others Referral Background Information Going back to the diagram of the steps to case management, planning, linking, monitoring and review come next as in most case management models, however with our clients we need more. This makes those elements of the processes shown in the middle of the diagram the mortar that holds the steps together.

ADAHPT C/Mgt and the Client Variety of skills Assessing Evaluating Depth of knowledge Ongoing engagement Awareness of changes Frequently case management is a poorly understood process, it is perceived as a routine function that requires little planning, all too often reduced to a task orientated process. Unfortunately viewed as the task itself and no more. Once the task is complete the job is done. The task oriented approach all to often gives little credit to the real abilities of the case manager, which encompasses a depth of knowledge and a variety of skills, neither does it facilitate engagement. The task can be useful, in that it gives a reason to be there, however, the value of each visit goes beyond the task, during each contact with the client a number of processes are occurring. The case manager is always assessing the client, evaluating the plan, reinforcing engagement and maintaining rapport. As time goes by the case manager will develop a deeper knowledge of the client and greater level of engagement. Ongoing engagement with the client allows the case manger to become increasing aware of changes in the clients physical, mental and social well being. Often, none of this comes from a textbook and very little of it can be quantified however it it can the crux of effective and worthwhile case management.

Successful Engagement Client Familiarity Independence Case Manager Partnership Support Engagement can be considered to have been successful when there is a sense of familiarity between the client and the case manager. At this point the client generally manages as independently as possible knowing the case manager is available when needed. The case manager knows the client and their circumstances well and has established a working partnership with the client, their carers and other service providers, thus being able to provide appropriate support in a timely fashion.

Obstacles to Engagement Legal difficulties: possible incarceration Housing difficulties: transience Violence Alcohol and other drugs Highly functional As a consequence of the complexity of clients referred to our service the case manager may encounter a number of obstacles to the engagement process. While most of these are self explanatory perhaps I need to explain why a ‘highly functional’ client may be difficult to engage. Such a client may not have the significant deficits, they may be employed, have there own accommodation and not appear to require support services thus the usual strategies we use in engagement are not applicable. This may occur in the case of a client who is perceived as a public health problem, whereby services are required to intervene. As a result of these obstacles the client may not be involved with any service provider as they have been difficult to engage or services have refused to be involved with them.

Case Study: Ann 45 year woman HIV positive Hepatitis C positive AIDS Dementia Complex Diagnosed with Schizophrenia Substance use issues Reluctant adherence to medication Sex worker History of self harm

Initial Stages Difficult to engage Fierce independence Refuses service Psychiatric condition Local services give up Referral to ADAHPT Over the years a number of services had attempted to engage with Ann with little success. Ann was fiercely independent and had always refused to be involved with support services. This was compounded by the fact she had a psychiatric condition. As a result the local services eventually gave up trying and referred her to ADAHPT

The Process of Engagement Appropriate medication Practical assistance Acceptance of case manager Case manager gets to know client Contact with family Occasional set backs Re-engagement Ann complained to her GP about a being infected with mites, he prescribed an antipsychotic medication which Ann found cured her of mites and as a result she was happy to take this medication for some time. Ann’s mental state improved and she was somewhat more open to offers of support, thus the engagement process could commence. The case manager was able to offer Ann practical assistance such as help with the department of housing and referral to a free methadone clinic all of which further consolidated the relationship and the client acceptance of the case management role. Over time the case manager also got to know Ann well enabling an awareness of subtle changes in her presentation. At the same time the case manager gradually got to know Ann’s family. Occasional setbacks occurred from time to time threatening the case manager’s engagement with Ann. However, as Ann had become accustomed to calling upon the case manager when she needed support she re-engaged in the case management process when she needed the case manager to advocate with other services on her behalf.

Successful Engagement Trust More accepting of services Continues to live independently Health improved Mental state stable Family supported Timely and appropriate intervention After a time Ann began to trust her case manager and accepted the assistance of number of other services. She was able to continue to live independently. Her health improved and her mental state was much more stable. In addition the case manager established a good working alliance with Ann’s family and they felt supported. Ann did however continue to present challenges, but this is perhaps when one reaps the rewards of successful engagement in that one is able to intervene in a timely and appropriate manner in times of crisis.

Setbacks Driving Mental Health: Community Treatment Order Public Health The role of case manager carries with it some responsibilities which go beyond the therapeutic relationship and which can threaten the relationship with the client, in this case a number of issues have come up that have destabilised engagement with Ann. Ann continues to drive her own motor vehicle, which has presented an ethical dilemma in that she suffers with AIDS Dementia Complex and should not drive when she is not adherent to her HARRT. On one occasion she was reported by her doctor to the RTA who informed her she was not to drive. Ann was quite upset about this and quite rightly surmised that the case manager had somehow been involved. As a result she refused to see her case manager for several months but continued to drive. During this period the case manager continued to make contact with Ann regularly. On another occasion Ann was admitted to hospital under the mental health Act and subsequently discharged on a Community Treatment Order she once again assumed her case manager had been involved. Again, Ann distanced herself from her case manager for several months. As stated earlier, because Ann works in the sex industry, issues related to public health may have to be considered. There is some concern that Ann may be undertaking unsafe sex without informing partners of her HIV status. This has caused considerable difficulty for the case manager and the case management process. Even with encouragement, support, education and counselling Ann appears not to understand her legal obligations in this matter. This matter continues to cause concern but close case management/intensive engagement may yet solve this concern.

Current Supports Family Immunology clinic Reluctantly accepting mental health services Methadone prescribed and supplied General Practitioner Ankali Community Support Network ADAHPT Case Management Currently Ann’s supports include

Questions? ADAHPT A state-wide tertiary outreach team for people with HIV and complex needs Tel: +61 (2) 8382 1810 Fax: +61 (2) 9360-2247 E-mail: adahpt@sesahs.nsw.gov.au www.sesahs.nsw.gov.au/adahps Thank you for attending my presentation. Are there any questions?