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
Richard C. Rapp, M.S.W., Ph.D.
Wright State University
Boonshoft School of Medicine
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
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”
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
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
Case Management
Barriers to Treatment
Personal
Persons who
have
substance
abuse
problems &
are HIV
positive
• 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
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
Case Management Functions
• Evaluates – Makes sure that client gets
services as intended
• Advocates – Intervenes to assure that client
gets the services they needed
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
Strengths Perspective
Barriers to Treatment
Personal
Persons who
have
substance
abuse
problems &
are HIV
positive
• Practical
•Transportation
System
•Financial
•Childcare
CASE MANAGEMENT
•Location
•Lifestyle
•Rural providers
•Substance abuse
•Affordability
& mental health
•Eligibility criteria
•High risk
•Inflexible hours
behaviors
•Admission process
•Homeless
•Cultural competence
•Incarceration
•Impersonal
STRENGTHS PERSPECTIVE
•Internal
•Fear of discovery •Intimidating
•Staff skills
•Stigma
•Waiting lists
•Denial
•Fatalism
•Embarrassment
•Lack of trust
Substance
abuse
treatment &
medical care
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
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
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
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
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
Combining Case Management &
Strengths Perspective
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
C
Center for Interventions
ITAR
Treatment
& Addictions
Research
STRENGTHS-BASED CASE MANAGEMENT
Tangible Support
Assessment
Planning
Linking
Transportation
Childcare
Planning
Advocacy
Monitoring
Advocacy
Linkage
with Care
Focus on Client Strengths
Client Driven
Emphasize Relationship
Assertive Outreach
Use of Informal Resources
Emotional Support
Increase Hopefulness
Increase Self-Efficacy
Decreased Resistance
Retention
in Care
Improved
Functioning
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
Strengths Perspective and
Medical Model
Strengths Perspective
Medical/Disease Model
• Basic position is to
• Basic position is to find
find strengths, assets,
sickness, problems,
and abilities
disease & pathology
• Diagnosis and labeling • Diagnosis is required;
is avoided
labeling is frequent
• Full discussion of
• Client/patient usually
client’s story is
seen as less capable,
encouraged
needs to be helped/fixed
Strengths Perspective and
Medical Model
Strengths Perspective
Medical/Disease Model
• Individual is asked
about needs
• Individual seen as
“able” and necessary
participant in
addressing needs
• Active involvement
encouraged
• Goals are (almost)
always supported
• Worker supports “party
line” and agency role
• Client/patient goes to
services
• Solutions usually
involve formal
resources
• Doctor-patient
relationship
Activity #1
• Scenario A & Scenario B
Outcomes
Linkage & Retention
Percent linkage by
intervention and modality
Treatment
Modality
Standard of
Care
Motivational
Interviewing
StrengthsBased Case
Management
(n=222)
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
Total
38.7 d
44.7 e
55.0 d,e
++
Total
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%.
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
0
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
Path Model of Significant Factors on Post-Treatment
Contact and Drug Severity
(Baseline)
Unemployed
Fewer Arrests
Less
Depression
Less Drug
Use
Less Use of
Crack
Cocaine
Fewer
Treatments
.251
.122
.129
.113
.136
.399
Case Manager
Lower Drug Severity
(Six Months)
.165
.120
More Weeks in
Aftercare Treatment
Path Model of Significant Factors on Post-Treatment
Contact and Legal Severity
(Baseline)
Unemployed
.251
Lower Legal
Severity
.242
Readiness for
Treatment
Lower Legal
Severity
(Twelve Months)
.104
Case
Manager
.425
.092
.089
.112
More Weeks in
Aftercare Treatment
Practice of SBCM
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
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
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
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
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
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
Example of
Strengths-Related
Assessment Tools
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
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
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
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
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?
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?
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?
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?
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
Activity #2
• Conducting strengths-based assessments
Example of a
Goal-Setting Tool
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
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)
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
Goal Setting/Treatment Planning
• Process includes:
– Identifying Goals, Objectives, Strategies
– Target dates
– Review of plan at every meeting
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
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.
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.
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
Activity #3
• Developing a Personal Roadmap
One Example of SBCM
Structured 5 Contacts
#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
#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
#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
#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
#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
Activity #4
• Staffing cases ala strengths-based case
management
Implementing SBCM
your organization
First 5 Questions to Answer
Question #1
• How completely do you want to implement
SBCM?
–
–
–
–
Individual staff
Agency-wide
Agency-wide for certain population(s)
Community-wide
Question #2
• If agency-wide for certain populations,
which population(s)?
– Consider strategically
– Define precisely
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
Question #4
• Having answered questions #1 through #3,
what objectives would you assign to each
case management contact?
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
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