Case Management
Step Three
Chapter Ten
Urgent and Timely Provision of
Concrete Services
Step Three of the Decision Tree
Urgent and Timely Need
Step three of the decision tree addresses the
provision of urgent (hours/days) or timely
(week/month) concrete services to highly
vulnerable client populations through case
management.
Definition of Case Management
• Case management is a direct practice model that
denotes the timely provision of resources to meet
the basic needs of highly vulnerable populations.
• Highly vulnerable client populations often require
multiple services involving professionals from
several different disciplines.
• Case managers locate, refer, broker, coordinate,
monitor, expedite, and coordinate fragmented
services offered by professionals from different
disciplines.
.
Characteristics
Client Population
• Client populations that benefit from case
management are characterized as highly
vulnerable individuals who require a complex
array of services from multiple helpers from
diverse disciplines on an ongoing basis.
• The needs and impairments of this client
population are often outside the individual’s
volition for cause or solution.
• Clients are frequently thrust into a position of
dependency.
Characteristics
Continued
• Many conditions are permanent and
irreversible; some conditions are
progressive.
• The conditions often create long term
barriers to social functioning.
• Many case management clients enter
service in the absence of available family
support.
Who Benefits from Case
Management?
• Populations that benefit from case management
are the: (1) de-institutionalized chronically
mentally ill; (2) developmentally disabled children
and adults; (3) those with physical conditions in
need of rehabilitation; (4) those who are HIV
positive or who have AIDS; (5) impoverished
children and families; (6) children and adults in
need of protective services; (7) delinquents and
the drug addicted; and the (8) homeless.
Strength-Based Assessment
Case Management
• It is especially important to document strengths
when working with individuals who have primary
conditions that are long term, permanent or
progressive.
• A strength focus helps clients retain and build
upon existing strengths so that they can function in
a manner that allows them to maintain a
reasonable quality of life in a community setting.
• Environmental accommodations optimize a
client’s quality of life.
Environmental Accommodations
Social Milieu
• Highly vulnerable client populations benefit from
interventions that target the environment to make
it more supportive.
• Such interventions consist of: supervised
independent living, half way or quarter houses,
group homes, assisted living facilities, residential
nursing homes, residential treatment centers,
structured day programs, recreational activities,
sheltered workshops, club houses, meals on
wheels, foster or kinship care, TANF, Medicare
and Medicaid.
Client’s Point of Entry
Help Seeking Behavior
• Involuntary clients are those referred by others in
authority (e.g. child and adult protective services)
• Mandated clients are wards of the state such as
the chronically mentally ill or those who are court
ordered such as the delinquent or drug addicted.
• Homeless clients often refuse formalized care.
They visit soup kitchens, accept sandwiches from
mobile food distribution centers, accept blankets
in the cold weather and occasionally accept shelter
overnight and receive health care from medical
clinics.
Help Seeking Behavior
The Homeless
• The homeless require outreach as their point
of entry.
• Repeated non-intrusive contact where
concrete goods ( meals, blankets, health
care and shelter) are provided lead to trust
overtime.
Worker-Client Relationship
Case Management
• In those cases where the State has assumed
guardianship, the State acts as the client’s locus in
parentis.
• Clients who need life long services, experience a
series of social work case managers overtime.
• Some clients readily form new relationships and
orient new workers and student interns to their
specific setting.
Worker-Client Relationship
Case Management
• Other clients react negatively to the high
rate of turnover among the helping
professionals in their lives.
• More effort is required to establish,
maintain and terminate a relationship with
this group.
Role Conflict
Case Management
• The case manger has two functions which can
cause role conflict.
• The case manager has a social control function.
The worker is charged with determining client
eligibility for services and with the avoidance of
duplication of services.
• The case manager, consistent with empowerment
theory and advocacy, is charged with helping
clients lead lives of freedom and dignity in the
community.
Contracting
Case Management
• Respect for client self determination is a value in
case management.
• Contracting is constrained both by the type and
degree of impairing condition as well as the
mandated parameters within which service or
treatment occurs.
• Consistent with authentic contracting, case
managers cannot promise resources they do not
have or resources to which the client is not
entitled.
Case Management
Contracting Constraints
• Social work case managers are often faced
with ethical dilemmas.
• The worker’s fiduciary responsibility to act
in the best interest of the client often
conflicts with the client’s right to selfdetermination.
• Workers must balance their legal authority
with the rights of the client.
Contracting Constraints
Continued
• Reasonable goals must be agreed upon through
mutual goal setting.
• There must be a match between what it takes to
achieve a desired goal and the potential a client
has to offer.
• Case plans tend to be individualized (IP’s) and are
reviewed quarterly, bi-quarterly, or annually.
• Case reviews determine what is working, what is
not working and what needs to be changed.
Case Management
Desired Outcomes
1. Environmental accommodations to allow
highly vulnerable client populations to
remain in the community under least
restrictive conditions
2. Skill acquisition through skill training
3. Normalization
4. Quality of life.
Types of Case Management
Systems Driven
•
•
There are two basic types of case management
models: (1) systems-driven and (2) consumer–
driven.
System-driven case management has roots in
structure-functional theory and organizational
and management theory.
(1) It is concerned with maintaining agency
or organizational integrity
System-Driven Case
Management
(2) It runs programs that have pre-determined
client needs and for which client’s must
establish their eligibility; client’s must conform
to established procedures and routines.
(3) It has a stake in maintaining its own integrity.
It often operates to meet the needs of funding
sources and the professionals who staff the
agency; sometimes at the expense of meeting
client needs.
4 Subtypes of Consumer-Driven
Case Management
(1) Single one-time only service i.e. paying an
energy bill
(2) Bureaucratic task-specific division of labor
related to a complex service such as child
child protection services e.g. workers perform
a single task or function within the service such
as investigation of alleged abuse and neglect
reports, recruitment of foster parents, family
preservation, reunification etc.
4 Sub-Types of System Driven
Case Management
(3) Comprehensive Case Management
Includes delivery of concrete services, case
advocacy, day programs and residential living
(4) Street level – case managers have discretionary
power. They can advocate for structural changes
and obtain resources while being part of a
bureaucracy.
Consumer-Driven
Case Management
• This model is based on critical theory and post
modern principles. Critical theory challenges the
legitimacy of system-driven models.
• Coupled with empowerment theory, this model
provides clients with an active voice in asserting
their needs and in determining how their needs
will be met.
• The worker becomes an ally of the client
• Skills training and vocational rehabilitation further
empower client independence.
Declarative Knowledge
• Case Managers must be knowledgeable about each
client’s primary condition; its hypothesized causes
and treatment options.
• Case managers must be knowledgeable about
resource availability.
• Case managers frequently use ecomaps to
visualize a client’s personal environment.
Included are: (1) familial and social networks;
(2) formal agencies and the interdisciplinary
professionals involved in the client’s care.
Declarative Knowledge
Continued
• Case managers must have knowledge of
biological, medical, psychological, social
and spiritual needs secondary to the client’s
primary condition.
• Client needs may be normative, perceived,
expressed or relative.
• There are nine common needs frequently
found among this client population.
Declarative Knowledge
Nine Common Client Needs
1. Need for resources: Case managers locate,
manage, and access resources. Networking and
interpersonal skills are used to secure resources
in a timely manner.
2. Need for skills: Case managers provide skill
training to maximize client independence. Lack
of skills may be secondary to a client’s primary
condition or may be related to their care.
3. Need for information: Case managers help
clients understand their primary condition and
the resources available to treat it. Knowledge
informs and empowers.
Declarative Knowledge
Nine Common Client Needs
4. Sexual Needs: Most clients are sexually
active. Finding suitable partners or an
appropriate outlet to met the sexual needs of
this client population is difficult.
5. Managing Flare-ups: The cumulative
stress of daily life may produce a crisis that
necessitates short-term hospitalization to
stabilize the client’s primary condition.
Declarative Knowledge
Nine Common Client Needs
6. Self-Medicating Behavior: Clients often
attempt to ameliorate their primary
condition and feel better through the use of
alcohol and drugs.
7. Need for Compliance: Clients often go off
or forget to take their medications. Some are
“dismissed” from care for noncompliance with a
program’s rules and regulations.
Declarative Knowledge
Nine Common Client Needs
8. Need for continuity and stability of care:
Changes in client care may trigger a client crisis
i.e. changes in eligibility requirements, in
personnel, in policies related to daily operations,
or changes associated with the termination of a
program or service.
9. Need for safety: Disruptive or violent behavior
(between clients or between clients and staff)
may occur. Safety protocols include knowledge
of how to avoid or deflect conflict.
Student Safety
• As part of their orientation to field placement,
student interns must be educated in agencyspecific safety protocols.
• Students need to be taught:
(1) the safety risks unique to each setting
(2) how to avoid or deflect conflict
(3) how to signal for help
(4) how to position self for safety in a room
(5) how to recognize physiological or motoric
cues that signal loss of control or rising anger
Student Safety
Off-Site
1. Students should go with a supervisor, another
worker or another intern; if warranted a police
officer should accompany them.
2. Students should sign in and sign out. They
should indicate their destination and estimated
time of return.
3. Students should use transportation that enhances
their travel safety.
4. Students should carry a cell phone.
5. Students should be given explicit permission to
protect themselves.
The Helping Relationship
Structure-Functional Theory
• The goal of case management is service not
therapy.
• At a minimum, rapport begins with belief in the
helping relationship and an authentic contract.
• Both worker and client bond in the belief that
mutually agreed upon activities will bring about
changes that will benefit the client and enhance
the client’s self worth in the process.
• Though not therapy, all interactions are intended
to benefit the client and are therefore therapeutic.
The Helping Relationship
Post Modern Principles
• Post Modern principles offer an alternative to
structure-functional theory.
• Unger uses 2 P’s and 3 R’s to describe the
application of this theory to case management.
• The first P stands for power: How one uses
language to construct the delivery of service to
highly vulnerable clients is an exercise in power. It
reflects the program policies and administrative
agendas of those in power rather than the agenda
of those at-risk.
The Helping Relationship
Post Modern Principles
• The second P stands for position: in the workerclient dialogue, the worker’s discourse is
privileged (assigned more power) than the
discourse of the client.
• The first “R” refers to the worker’s obligation to
resist decisions and processes that are not in the
best interest of those being served.
• The second “R” refers to the co-construction of
reality. The worker empowers and validates the
client’s narrative.
The Helping Relationship
Post Modern Principles
• The third “R” refers to reflection in action.
It requires the practitioner to be aware of his/her
privileged location within a structure.
• Critique: Unger asks what should happen when
the worker’s narrative says the situation is not safe
for the child but the parents’ narrative says it is?
What if there is no agreed upon co-construction of
reality between worker and client?
Case Management
Strengths Perspective
• This model focuses on resiliency.
• For each identified need, the worker and client
identify a strength. See Saleebey’s Diagnostic
Strengths Manual(2001).
• Goals, not deficits, drive treatment. Past coping is
emphasized.
• Critique: It is said that the model appears to give a
‘Pass’ to inadequate formal services and does not
address the social causes of scarce resources and
unequal access to them.
Case Management
Task and Role Performance
• Consistent with Structure-functional theory,
individuals are expected to perform certain roles
and tasks in society.
• When individuals are unable to perform the tasks
and roles for which they are responsible ( work,
child care, self care), social work exercises it
fiduciary and humanitarian responsibility.
• Workers use their authority to provide, withdraw,
or withhold services based on client compliance
with assigned tasks.
Case Management
Environmental Modification
• Social treatment includes modification of the
environment within which a client lives.
• Social treatment includes as array of policy and
program-based services such as residential living
day programs, club houses, sheltered workshops,
assurances of non-discrimination in housing and
work situations, financial support, access to
transportation, housing, education.
Case Management
Traditional Talk Therapies
• Traditional talk therapy models will not “cure” the
client’s primary condition nor provide the client
with the concrete resources he/she may need.
• Traditional talk therapy models may augment case
management services and ameliorate problems
secondary to the client’s primary condition or
circumstance of care.
• Talk therapy models may be relevant in teaching
clients basic self care skills and helping them
become compliant with medication and residential
rules and regulations.
Case Management
Talk Therapy
• Some models address issues associated with
self image and identity.
• Some models teach interpersonal skills
and/or resolve interpersonal conflict.
• Some models help clients deal with loss or
personal suffering.
Case Management
Evidence
There is no evidence that one model of case
management is better than another (Shera,
2002).
Cases, Decision Schemas,
Process Recording
• Two cases illustrate the content of this chapter: (1)
Linda and Mrs. Garrity illustrate services to a
developmentally disabled adult woman. (2) “J”
illustrates services to a juvenile in the juvenile
justice system. A process recording of Linda and
Mrs. Garrity is also provided.
• Case management decision schemas are presented
at the end of the chapter.