Readings and Resources

Readings and Resources

Articles, Websites, and Videos:

This chapter focuses on special writing within agencies such as transfer/discharge, letters for lobbying advocacy, and client reports to other agencies.

• Agency-based writing – Letters. (2018). In Weisman, D., &Zornado, J. L., Professional writing for social work practice, Second Edition (Vol. Second edition). New York, NY: Springer Publishing Company.

Service Coordination

Chapter 10

Chapter Introduction

• Chapter Ten addresses Social Work Case Management Standard 6, Service Planning, Implementation, and Monitoring, and Standard 8, Interdisciplinary Collaboration.
• Chapter Ten addresses Human Service–Certified Board Practitioner Competency 4, Case Management, which is focused on service coordination.

My company does something a little bit different than case management. It’s case management and then it’s more. We are actually called resource coordinators. My agency is the premier provider for therapeutic foster care in the region … The reason our agency was started was because a man who was working for human services figured out that a lot of these kids who have pretty serious needs aren’t getting their needs met by the department and need specialized, intensive treatment and support.

—Jessica Brothers-Brock, 2012, text from unpublished interview. Used with permission.

This chapter explores service coordination as a critical component of modern case management. We examine the coordination and monitoring of services as well as the skills that will help you perform these roles. After reading the chapter, you should be able to accomplish the following objectives.

Coordinating Services

• Describe a systematic selection process for resources.
• Discuss why networking is important.
• Identity strategies for creating a network of professional colleagues.
• Make an appropriate referral.
• Identify the activities involved in monitoring.
• List ways to achieve more effective communication with other professionals.
• Use technology and social media in coordinating services

Teamwork

• Describe the purpose of a treatment team.
• Define departmental teams, interdisciplinary teams, and teams with family and friends.
• List the benefits of working in and with teams.
• Describe ways to address the challenges that teamwork brings.

Ending Service Provision: Disengagement

• Describe the place of ending services in the case management process.
• List the steps used to end client services.
• Identity why clients may need to be transferred from one professional to another.
• Describe the transfer process.
• Discuss the purpose of a discharge plan.

10-1Introduction

One of the most important roles in case management is service coordination. Rarely can a human services agency or a single professional provide all the services a client needs. Because in-house services are limited by the agency’s mission, resources, and eligibility criteria—as well as by its employees’ roles, functions, and expertise—arrangements must be made to match client needs with outside resources. Case managers must know which community resources are available and how to access them. Case managers also work in partnerships with others as they coordinate services; at times, they work in teams for the benefit of effective and positive client outcomes. And, at the end of the process, for multiple reasons, case managers end the provision of services to their clients.

In the following quotes, case managers talk about the importance of goals and their role in coordinating services.

In my job you have to know about the resources in your community. You can really help your clients get to the right place.

—Director and case manager, intensive case management services, Los Angeles, California

When I worked as a case manager in the downtown hospital, I needed networks in the hospital, in the medical community, and in the human services community. In fact, since I was doing discharge planning, this knowledge was a critical part of my job. I could not meet all of my clients’ needs. And the range of needs was so great, from detox services, to Social Security and government services, to food stamps and housing. I also had to help my families deal with the bureaucracy.

—Case manager, urban hospital, Atlanta, Georgia

It is incredible how important community is to other service providers. In my job I am a broker, and I have to be able to meet people, establish relationships with them, and work well with them. Things have changed since I started my work. Much of my work as a broker is online. And sometimes I use FaceTime or Skype. This inclusion of Internet work requires special attention to professional behavior and to recordkeeping.

—Care coordinator, health system, Pima County, Arizona

The preceding quotations reflect the knowledge and skills that a case manager uses to meet client needs. In the first quote, the case manager works with individuals with serious mental illness. To provide effective care, she expresses a desire to refer clients to the best services. Later in the interview, she talked about an incident when the referral did not go well. This interfered with the client’s care. In the second quote, the case manager was a discharge planner for an urban hospital. The needs of her client (patients) were so varied that she needed knowledge of medical systems and a wide range of social service systems. She shared that it took a long time for her to gain the knowledge of how to refer within these complicated systems. This knowledge served her well from the beginning of the case management process through to her discharge planning. In the third quote, the case manager emphasizes her need to establish networks. These relationships are established over a period of time; the case manager needs both the knowledge of the services available and the ability to establish rapport with fellow professionals. Each of these professionals also needs to know how to negotiate the service delivery system to gain access to those resources for the client. Having networks in place requires knowledge of both the agency and the name of a contact. Perhaps the one indispensable skill in using resources is communication! According to the third case manager who works as care coordinator for health-related services, there is more work conducted over the Internet. This requires a different type of communication and recordkeeping.

Today’s service delivery environment imposes new roles and responsibilities on the case manager. In the past, many services were provided directly by the case manager, but service delivery has become more specialized. Professionals must be careful not to provide direct services in areas in which they are not trained or lack the necessary resources. Case management has thus come to mean providing selected services, coordinating the delivery of other services, and monitoring the delivery of all services. In addition, it includes ending client services. This shift in job definition calls for skills in networking, collaboration, and teamwork. We discuss networking as we talk about coordinating services and making referrals. There is a section that describes working with other professionals, the importance of teamwork and collaboration, and addressing challenges that arise.

10-2Coordinating Services

If a client needs services that an agency does not provide, then it is the case manager’s responsibility to locate such resources in the community, arrange for the client to make use of them, and support the client in using them. These are the three basic activities in coordinating delivery of human services. In coordinating services, the case manager engages in linking, monitoring, and advocating while adding to on the assessment and planning that have taken place in earlier phases of case management. The case manager continues to build on client strengths or emphasize client empowerment within the context of the client’s cultural background and basic values.

Coordinating the services of multiple professionals has several advantages for both the case manager and the client. First, the client gains access to an array of services; no single agency can meet all the needs of all clients. The case manager can concentrate on providing only those services for which he or she is trained while linking the client to the services of other professionals who have different areas of expertise and have the necessary resources. Second, the case manager’s knowledge and skills help the client gain access to needed services. Often, services are available in the community, but clients are unlikely to know what they are or how to get them. The success of service delivery may depend on advocacy by the case manager. Also, service coordination promotes effective and efficient service delivery. In times of shrinking resources, demands for cutbacks in social services, and stringent accountability, service provision must be cost-effective and time-limited. In addition, customer satisfaction is important. Clients have the right to receive the services they need without getting the runaround or encountering frustrating confusion among providers.

Service coordination becomes key once the client and the case manager have agreed on a plan of services and have determined what services will be provided by someone other than the case manager. As case managers begin the coordination of services, they consider several aspects of this work such as reviewing family support, assessing client strengths, insuring quality documentation, reviewing professional contracts, encouraging client participation, and developing plans to monitor services. We discuss each of these.

For services that will be provided by others, a beginning step is to review previous contacts with service providers. This review includes four important questions:

• What services do they provide?
• Is this client eligible for those services?
• Can the services be provided in-house?
• What about the individual’s own resources and those of the family?

A second step is to consider the type of family support available. In fact, family support may be critical for the success of the plan. Third, the client’s own problem-solving skills and strengths may be helpful. This means that the case manager does not ignore the resources of the client, the family, or significant others.

The next step is referral—the connection of a client with a service provider. Equally important is developing a plan to monitor service delivery over time and following-up to make sure the services have been delivered appropriately. These steps may vary somewhat, depending on whether the services are delivered in-house or by an outside agency, but the flow of the process is likely to be the same. Before examining these steps in detail, let us review the documentation and client participation aspects of service coordination.

Documentation is critical in this part of case management. Staff notes must accurately record meetings, services, contacts, barriers, and other important information. During this phase, reports from other professionals are added to the case file. Any progress that occurs in the arrangement of services must be recorded by the case manager.

Client participation is important throughout the service coordination process. This entails more than just keeping the client informed; his or her involvement should be active and ongoing. First, the client participates in determining the problem that calls for assistance. Second, the values, preferences, strengths, cultural perspectives, and interests of the client play a key role in selecting community resources; of course, client participation is critical in following-up on a referral. Clients also have the right to privacy and confidentiality. Without the client’s written consent, the case manager must not involve others in the case or give an outsider any information about it.

Maintaining relationships is a key factor in service coordination. And remembering that meeting client needs is of primary importance is an excellent guideline. Relationships may be between individuals or agencies. Case managers often represent their agencies or organizations during the service coordination effort. At times, relationships among agencies sometimes hinge on the working relationships between individual direct service providers. Often relationships begin with a case manager’s networking with other professionals and continue as case managers consult, refer, or work together with others on teams. In Networking we describe networking, what it is, and its benefits. In this chapter we also present strategies to help case managers develop strong networking systems. Later in this chapter, we describe the case manager’s involvement in teamwork. In addition, we describe the issues and challenges that may occur as case managers work in teams and suggest ways to address these.

Before we continue our discussion of service coordination and discuss the importance of networking, we want you to hear Sharon’s perspective of service coordination.

My Story

Sharon Bello, Entry 10.1

Alma and I talked about who should write this entry. At first she thought that it was her story to write, since she was the case manager involved in the coordination of my care. But, in the end, I convinced her that I had a lot to say about the coordination of care. I just wanted everyone reading this book to know that the client is also affected by all of this interaction with lots of professionals. I have drawn a picture for you of my experiences with the rehabilitation agency. You can see this picture in Figure 10.1. Look at the picture, and then I can explain it to you.

Figure 10.1A Client’s (Sharon Bello) View of the Service Coordination Process

In my agency, my primary contact with the entire service coordination process is Alma. I am not complaining, but you can tell from my description of the case management process that I don’t really know much about how the other professionals work together. So, here is what I think happens:

• I meet with my case manager.
• I have appointments with other professionals who make assessments.
• These professionals provide their reports to one of my case managers (Tom, Susan, Luis, or Alma).
• My case manager at the time describes the results of the assessment to me.
• Sometimes we decide I need another assessment. This just recently happened at my school and I was able to get some financial assistance.
• We make a new plan based on the assessments.
• My case manager’s supervisor approves the plan. She could have asked us to revise it.
• We carry out the plan and I communicate with my case manager periodically. I also call my case manager if I have an emergency.

The process was a little different when I applied for services. At that time a team evaluated my application and accepted me as a client. And I don’t really know much about what happens with Alma when she works with other professionals. That is not part of our discussion when we meet.

One place that I know of where this process is different is at the school where my children attend. I mean where the boys did attend and where the girls attend now. For Sean, especially, we had team meetings to talk about his work and the services he was receiving. We met at least three times during the year. I was invited and I always attended. There were several people who came to the meetings like the school counselor, the social worker, a psychologist, and sometimes the principal attended the meeting. The resource teacher was in charge of the meeting. When Sean was in middle school he came to the meetings, too. In that meeting, I listened mostly to all of the other people talk about my Sean. It was not always a positive experience for me and not for Sean either. Compared to the school experience, meeting with Alma is much more supportive. So, those are my experiences.

Class Discussion

Encouraging Client Participation

Client participation is an important part of service coordination. Sharon Bello shares with us her perspective of service coordination. As an individual, a small group, or a class, discuss what insights you gained from reading her entry. How might her experiences help you coordinate services for your clients?

Share the results of your discussion with your classmates.

Once the process of coordinating services begins, the case manager makes resource selections, refers the client to other professionals, and monitors services. One important aspect of resource selection, locating services for clients, making referrals, and monitoring services is networking.

10-2aNetworking

Networking, an important professional responsibility and skill, is “the exchange of information or services among individuals, groups, or institutions; specifically, the cultivation of productive relationships for employment or business” (Merriam-Webster, n. d.). The purpose of networking, as it relates to case management, supports the complex tasks required to serve clients with multiple needs across a wide range of disciplines. Networking also helps case managers perform several of the roles introduced in Chapter Three, such as advocate, broker, coordinator, consultant, and problem solver. In this chapter, we focus on three of these roles: advocate, broker, and coordinator. In Chapter Twelve, we include the importance of networking as it relates to the role of consultant. Benefits to establishing a strong professional network include providing more effective services to the client, supporting the professional development of the case manager, and building linkages among agencies. Because case managers’ work often extends beyond their own professional expertise (e.g., social work, counseling, human services), networking activities often include settings in which case managers are less familiar. Alma Grady shares a few of her networking experiences.

My Story

Alma Grady, Sharon Bello’s Case Manager, Entry 10.2

To be honest with you, at first networking was very difficult for me. While I was in school, my professors talked about the importance of networking. And during my internship, my site supervisor modeled strong networking skills. I watched her with wonder. You see, I am a shy person, and it looked to me like I would never be able to build networks similar to his. I assumed this would be a weakness that I could never correct.

Once I started my first job, I realized that I could not help my clients without beginning to know what was going on in the community and what services were available. During my first year, every time I needed help, I would ask my supervisor about community services and good contact persons. Every time I picked up the phone or sent an email, I did so with the introduction, “Hi, my name is Alma Grady and I am a counselor/case manager working with rehabilitation clients. I have a client who I believe could use your services.” I kept records of my contacts in my clients’ files. But I also kept a log for myself about the contact, the topic, and the help that I received. Honestly, I thought that I was networking. And, in some ways, I was beginning to develop relationships with professionals in the community.

About 9 months after I started that first job, I was assigned a client who completely surprised me. I was not sure that I could help. But this individual was my client. It seemed that this client represented many of the things that I didn’t know much about. The client was a burn patient, had a diagnosed substance use disorder, was a refugee, and, in his home country, was a victim of torture. I didn’t have any experience with burn patients, little with refugees, and none with victims of torture. I was assigned this client because of my ability to develop rapport. To make things more difficult, the physicians, psychologists, and vocational evaluators I knew had little experience with the issues and challenges this client faced.

To better understand my client and to support the client in the case management process, I had to expand my network of professional help and support quickly. During this time, I found resources with agencies and organizations I knew little about. I did this in two ways. First, I looked up resources in the area—I used the web and I emailed several of my colleagues who work in other agencies and asked for their help. I also talked with several colleagues by phone. I made a list of questions that would help me learn about this specific medical focus, treatment and prognosis for burn patients, and the psychological implications of being a victim of torture.

Since I was in the learning mode, I asked my colleagues about how to introduce myself in a way that professions outside the social services would understand. I thought about how to speak without using our professional jargon, and how to match my client’s needs with another agency’s services. I encountered and then worked with a diverse set of services, including medical specialists, county and state parks and recreation, private foundations, a local mosque, and a support community of refugees. I also found a psychologist in a neighboring county who spoke the client’s native language and was herself a refugee. What I found, for the most part, was that other professionals were willing to help and were interested in helping my client.

Alma and her experiences reflect our belief that building networks is a skill that, with intentional practice, can help case managers build a web of support for their clients and for themselves. In business, networking is a key skill for a successful professional. We present some common practices that may help you develop your own professional network (see Figure 10.2) (Attard, 2016; Greene, 2016; Speisman, 2016). These include personal approaches and professional activities.

Figure 10.2Building a Professional Network

10-2bPersonal Approaches

Be Intentional

A strong professional network does not develop quickly. Develop a strategy for getting to know other professionals and establishing relationships with them (e.g., plan to attend professional meetings, volunteer organizations).

Be Authentic

Professional relationships are built on trust. Be honest about your education, job, and work responsibilities. Integrate your personal self with your professional self. There are multiple ways to “act” professional that might include your sincerity, humor, honesty, and caring.

Be Dependable

Within interactions with other professionals, follow through with what you promise.

10-2cProfessional Activities

Participate in Professional Organizations

Learn about professional organizations and activities in your local area whose goals and focus overlap with your interests and your job. Choose one or two to attend.

Meet Individuals in Attendance

Use an early arrival, session breaks, and a late departure to meet individuals in attendance. Introduce yourself and engage in conversation about the work of the individuals you meet. Share some information about your own work. A common conversation starter might be about the event or meeting you are attending.

Listen and Learn

Part of meeting people is listening to what they have to say. Follow-up with open-ended questions about their work or share something that you see you have in common. Be curious!

Share Business Cards

Business cards are good to exchange during a first meeting. You leave with follow-up contact information and share yours.

Note-Taking

Make sure after each encounter you record who you met, the content of the encounter, what (if any) promising follow-ups were made, and contact information. You may also note how you anticipate the individual or agency that the individual represents might help your client.

Follow-Up

After the meeting, be sure to follow-up this with an email or phone call. If you promised to share information or ideas, be sure to follow-up promptly. Do not be discouraged if you do not get an immediate thank you. You are making the network connection. Be available in ways that meet the other’s needs (e.g., telephone, visit, email).

Extend the Relationship

You may wish to gain additional information about the individual’s work or the purpose of the agency that the individual works for. In either case, make time to read about the agency on the Internet or ask for more information. You may also wish to follow-up with a visit to the agency or a meeting with the individual you met earlier. At this meeting you might exchange information about clients and services and ways you can collaborate.

Class Discussion

Developing Networks

As an individual, within a small group, or as a class, talk about the networks that you have developed over time. A first step would be to review the networks you currently have. We list several types of networks below. Then, describe how you began the relationship, how the individual helps you or can help you in the future, and how you help the individual.

• Personal crisis or decision making
• Educational support
• Career support
• Work-related support

Discuss your responses with your classmates.

10-2dResource Selection

Once client needs and corresponding services have been identified, the client and case manager turn their attention to resource selection—selecting individuals, programs, or agencies that can meet those needs. Paramount in this decision are the client’s values and preferences. The information and referral system that the case manager has developed (see Chapter Eight) is useful in this regard. Let us look at the case of Rube Manning and see how resource selection occurs.

Rube Manning is a 53-year-old White male who is on parole for aggravated rape. He had sexual relations with his 12-year-old niece; she later gave birth to his son. Both parties claim that the intercourse was consensual; the severity of the charge and conviction were due to the girl’s age. The girl and the family seem to harbor no animosity toward Rube, and they even went so far as to write a letter on his behalf to the department of corrections. Rube was sentenced to 3 years in prison and is now eligible for parole. Angela Clemmons is the parole officer assigned to this case. She and Rube must develop a plan of services for him to pursue once he is released. Among the conditions of Rube’s parole are completing a mandatory sex offender program, supporting his son, and finding employment.

As we think about Rube Manning’s case, we realize that there are no options for the mandatory sex offender program; only one program is available in his community. Angela, his case manager, senses that Rube is motivated to do everything in his power to comply with the conditions of parole. Although he does not talk much about his prison experience, he does say that he did not like it. Angela suspects that he was abused by other inmates. Sex offenders are usually on the lower rungs of the prisoner hierarchy unless they are very strong or charismatic; Rube is neither.

Finding employment and supporting the child are tied together. Checking her information and referral computer file, Angela advises Rube that there are three short-term training programs that can provide him with job skills. The first two are at the vocational school and would give him a certificate in either horticulture or industrial maintenance. The third one is on-the-job training in food services, with a modest salary until training is finished. Rube’s preference is horticulture, because he grew up on a farm and thinks he would feel more comfortable outdoors. He knows that industrial maintenance is a fancy term for janitorial work, and he is not interested. The location of the food services training is not on the bus line, and Rube has no transportation of his own, but this option offers a salary immediately. Angela notices that Rube sounds interested—even a little excited—about horticulture, so she checks her addresses and email file for the phone number of her contact (see Figure 10.3.)

Figure 10.3

Entry in Information and Referral File

Service Coordination Agency: Lincoln Vocational Technical School

Address: 30512 Townview Parkway

Contact Persons: Lynda Johnston, Admissions Robert Griffin, Student Services

Phone: 555-1516

Services: Short-term training programs in auto mechanics, cosmetology, horticulture, industrial maintenance, printing, and secretarial services.

Comments: Good student services and advising: Janet Evans 7/1/XX

In this case, resource selection is systematic, which has advantages for both the client and the case manager. The client and the case manager proceed objectively and deliberately, taking into account Rube’s values, beliefs, and desires. The rationale for the choice is articulated, and it reinforces his motivation to follow through with the referral. Rube Manning and his parole officer have chosen the horticulture program. It is on the bus line, it builds on Rube’s previous farming experience, and it is something he wants to pursue.

The selection process can also accommodate many alternatives and can tailor services to the client’s unique circumstances. The conditions of Rube’s parole include work, and he does want the independence, salary, and respect that come with employment. However, he is not willing to do just anything. Being a janitor does not appeal to him, and he does not want to work indoors. If the parole officer ignored his feelings at this point and had decided to steer him toward janitorial work, then Rube would probably not be motivated to do well. At the very worst, he would do nothing, and his parole would be revoked. In addition, the relationship between Angela Clemmons and Rube Manning would not develop as a partnership.

Being aware of the client’s preferences, strengths, and values is critical to the success of the selection step in service coordination. There must be a strong partnership between the participants. In our example that focuses on Rube Manning and his need for work, the decision to try the horticultural program takes into account Rube’s wishes, along with his need for training and employment.

10-2eMaking the Referral

As mentioned, no helper can provide all conceivable services. Therefore, arrangements must often be made to match client needs with resources. This is done by referring the client to another helping professional or agency to obtain the needed services. Referral is the process that puts the client in touch with needed resources. According to a case coordinator working with parents of students at an urban high school, “We know that many of our families and students do not have money to provide the basics of food, housing, clothing, and medical services. We work hard here to help families and students find reliable sources within the community to provide help in these areas …. [I]n this city there are emergency services and long-term services … often we refer to both of these types of services. Churches and local and state government services provide the most support for families. Sometimes we also need shelters—these are available in the community. During the 2008 economic downturn, the needs have more than tripled. And now, 7 years after that, the needs continue.”

A referral connects the client with a resource within the agency structure or at another agency. In no way does referral imply failure on the case manager’s part. Limitations on the services that a case manager can personally provide are imposed by policy, rules, regulations, and structure, and they reflect his or her own expertise and personal values.

The case manager assumes the role of broker at this point in service coordination. The broker knows both the resources available in the community and the policies and procedures of agencies. He or she acts as a go-between for those who seek services and those who provide them. As a broker, the case manager and the client may have access to information about an agency’s mission, goals, and services. Either independently or together, they can read about an agency and discuss that agency’s appropriateness for referral online. If the client has Internet access, then the case manager can encourage the client to explore the agency in more depth. In addition, both case manager and client may have access to client reviews of the agency’s work or client-based comments made on social media.

The case manager will be able to provide additional information about an agency and its services based on previous interaction with its staff or client experiences. Knowledge of how the agency works and help negotiating the bureaucracy remain the responsibilities of the case manager.

Consider the following case with regard to the referral process and the broker role.

Bethany’s first client on Tuesday is Anna, a young woman who has just discovered that she is pregnant. This pregnancy has caused a crisis in Anna’s family. Her parents are first-generation immigrants from El Salvador, they are Catholic, and they are very opposed to both the pregnancy and abortion. Although the agency that employs Bethany specializes in career development services, Anna feels comfortable with Bethany and wishes to discuss her options for the pregnancy with her. However, this is a difficult subject for Bethany, because her sister had an abortion 3 years ago and still feels guilty and upset about her decision. In fact, the whole family is still having difficulty with it, since the sister is living at home. Bethany also knows that her training is in career development, and that she has never worked with anyone dealing with an unwanted pregnancy.

The encounter illustrates a situation that is appropriate for a referral. Bethany has some personal feelings that may impair her objectivity; she recognizes that she has no professional experience with this problem and that her agency’s purpose is career development. For these reasons, she decides it is best to make a referral to someone who can help Anna explore options related to the pregnancy. And she feels fortunate that there are other professionals available who can help Anna. Bethany will continue to support Anna’s career development efforts. In the referral process, Bethany’s role is that of a broker. We consider this a transfer of the client from one professional to the next. This process is discussed later in this chapter.

Making a referral may seem like a fairly uncomplicated process, but it often results in failure. If a case manager believes that all that is necessary is being aware of client needs and making a phone call, then the referral is likely to be unsuccessful. In fact, it is common for clients referred to other community resources to resist making the initial contact. Clients may also fail to follow through after the first interview and drop out before service provision is complete.

A referral can fail for three reasons. The first is insensitivity to client needs on the part of the case manager. Identifying the problem but failing to grasp the client’s feelings about it contributes to an unsuccessful referral. The client may not be ready for referral at this point, feeling only that he or she is being shuffled among workers or agencies. Second, if the case manager lacks knowledge about resources, then the client may be referred to the wrong resource. This makes him or her feel lost in the system, think that it is all a waste of time, and believe (sometimes correctly) that the case manager is incompetent. A third reason for failure is misjudging the client’s capability to follow through with the referral. Suggesting to an involuntary client that she should call to make an appointment for a physical examination may not work, perhaps because she is new in town, is unsure of who to call, does not have a phone, or does not actually want the exam.

How can the case manager make the referral process a successful one? Two areas of focus are assessing client capabilities and understanding the case manager’s role in making the referral. Assessing clients’ capabilities means finding out how much they can do on their own. It is good to encourage independence and self-sufficiency in clients, but some of them will prove unable to identify what they need and take the steps to obtain it. The nature of the problem, the feelings the client has about it, and the energy required for action may all contribute to feelings of being alone, an inability to act, and a lack of motivation to follow through.

In addition to assessing the client’s capabilities, the referring case manager must form a clear idea of what role he or she will play in the referral process. The case manager should be guided by what the client needs and what relationship the case manager has with the other professional or agency. The case manager’s degree of involvement in the referral can fall anywhere on a continuum, from discussing several resources with the client, who then takes responsibility for selecting a resource and following through, to providing concrete assistance with details, such as making the appointment on the client’s behalf and having an agency volunteer accompany him or her to the appointment.

Bethany approached the referral process in the following way. She acknowledged Anna’s concern about her situation and recognized her desire for some help. She also shared with Anna her reservations about being able to assist her, explaining that her training was in career development and she had limited knowledge about options for an unmarried pregnant woman. However, she did know of two agencies that offered just the services Anna was seeking. Anna wanted to know about these, so they discussed the services they provide and their geographic locations. Anna was concerned about the cost of services, and Bethany was unsure about the agencies’ charges. She checked her computer file and found that both agencies charged fees on a sliding scale. Anna didn’t know what that meant, so Bethany explained that such a scale determined the fee in accordance with the individual’s income. Anna was unsure how to get an appointment—who to call, how to explain the problem, and so forth. She also wondered whether she would be able to continue working with Bethany on career development. Bethany discussed all these concerns with Anna. Together, they decided on one of the agencies, and Bethany agreed to make the initial contact. Her previous work with Anna led her to believe that once the initial anxiety of making contact was over, Anna was capable of showing up for the appointment and getting the services she needed.

Bethany:	HELLO. THIS IS BETHANY DOUGLAS AT CAREER DEVELOPMENT. I AM WORKING WITH A CLIENT WHO NEEDS HELP IDENTIFYING HER OPTIONS FOR DEALING WITH AN UNPLANNED PREGNANCY. COULD SOMEONE AT YOUR AGENCY SEE HER?
Receptionist:	WE DO PROVIDE COUNSELING. LET ME CONNECT YOU WITH ONE OF OUR COUNSELORS.
Counselor:	HELLO, THIS IS CAROL FONG. MAY I HELP YOU?
Bethany:	YES, BETHANY DOUGLAS HERE. I AM A CAREER COUNSELOR AT CAREER DEVELOPMENT. MY CLIENT HAS JUST FOUND OUT SHE IS PREGNANT AND WOULD LIKE TO TALK WITH SOMEONE ABOUT HER OPTIONS. SHE IS 19 AND SINGLE. COULD WE SET UP AN APPOINTMENT FOR HER TO COME SEE YOU?
Counselor:	YES, I WOULD BE GLAD TO SEE HER. WOULD MONDAY AT 11:00 O’CLOCK BE OKAY?
Bethany:	(CHECKS WITH ANNA, WHO NODS) YES, THAT WOULD BE FINE. HER NAME IS ANNA RODRIGUEZ. SHE WILL SEE YOU AT 11:00 O’CLOCK MONDAY. THANK YOU.

Bethany used several strategies to ensure that Anna’s referral was a successful one.

1. Discuss with the client the services that are provided by the resource. The discussion should include why the referral is needed, how it will be helpful, how the client feels about it, and what information should be provided. If client information will be shared, then the client or guardiansigns a release form at this time. If client information is shared over the Internet, make sure that the Internet sites are secure.
2. Make the referral. Making a referral may entail just providing the client with a phone number and an address; helping him or her with the initial contact, as Bethany did; or taking the initiative to contact the resource. The interaction may involve scheduling an appointment, telling what the client knows about the resource, and finding out what information the resource needs. Of course, before any information is released, the client’s permission must be obtained. Finally, if there are cultural dimensions to be considered, the case manager should communicate this to the referral source. Any language or cultural barriers should be addressed before the client arrives at the point of referral.
3. The referral does not go as planned. When Bethany made the call, Carol Fong might have responded differently—perhaps she could not see Anna until next month, or her agency did not do that kind of counseling anymore. Bethany would have two options. She could return to her file to locate another agency that provides the services Anna needs. However, suppose that Anna lives in a small town or a rural area where there are not any other agencies to call. Bethany’s second option would be to become a mobilizer—one who works with other community members to get new resources for clients and communities. Bethany could try to mobilize Carol Fong and other professionals so that Anna could gain access to needed services.
4. Share the referral information with the client. He or she needs to know the appointment time, the location, and the name of the person to see on arrival. If needed, provide the client with directions to the site. Also, if the case manager knows, then describe to the client what will occur during this visit. It is also appropriate to find out what support the client might need to follow through with the appointment.
5. Follow-up on the referral. The service coordinator can do this by talking with the client and the helper who received the referral. Did the client show up? What happened? Was the client satisfied with the services? With the worker? Service coordinators with thorough information and referral systems make a habit of noting such information in their files. Information from the worker who saw the client may be conveyed in a phone call, a written report, or not at all.

Bethany followed up on Anna’s referral by talking with her about it the next time they met. She discovered that Anna had no trouble finding the agency, liked the worker immediately, and felt positive about exploring her options with her. Bethany received no official report from the other agency and did not request one.

Class Discussion

Making a Referral

As an individual, in a small group, or as a class, assume that you are a case manager. Create a description of a client you might be asked to serve. Review the information about this client and suggest an additional service the client needs but that you cannot provide. For this assignment, outline how you will make the referral. Include your interaction with the client and the referral agency. Include how you might anticipate barriers and challenges and address them.

Discuss your work with your classmates.

The referral process is a flexible one that can be adapted for use with any client, but client participation is vital to good service coordination. Clients participate in the decision to refer and the choice of where to refer. Their capabilities determine the extent of their involvement in the steps of the referral process, including making an appointment, getting to the agency, and so forth.

The case manager’s role in the referral process varies from little involvement to integral involvement, depending on the client’s capabilities. The case manager’s responsibilities include knowing what resources are available for the client, how to make a referral, and how to assess the client’s capabilities accurately. His or her involvement does not end after the referral; the next step, monitoring services, is also the case manager’s responsibility.

10-2fMonitoring Services

Once the referral is made, monitoring service delivery becomes the focus of case management. Monitoring services is more than following-up on the contact; it may mean offering information, intervening in a crisis, or making another referral. The case manager continues to work in the roles of broker and mobilizer throughout this phase of service coordination. In monitoring services, the case manager reviews the services received by the client, any conditions that may have changed since the planning phase, and the extent of progress toward the goals and objectives stated in the plan. This review can occur as often as once per day or three times per week, or as little as once per month or once per year, depending on the goals of the program, caseload of the helper, and resources available.

Review of Services

Once a case manager has made a referral, delivering the needed service becomes the responsibility of the resource—the agency or professional that has accepted the referral. However, the case manager does not relinquish the case completely. He or she remains in contact with the client to ensure that the services are being delivered, that the client is satisfied with them, and that the agreed-on time frame is maintained. As you remember, all these are specified in the plan of services.

When checking with Rachel Vasquez after her visit to the health clinic, the case manager heard about the generous time a volunteer had spent with Rachel in making a balanced nutrition plan for her diabetic son. Rachel was excited about knowing what to buy, how to prepare it, and why it was a good meal. Most of all, she was impressed by how much time the volunteer spent with her.

If there are problems with service delivery, then the case manager has the ultimate responsibility of intervening. Problems may be caused by the agency, the client, or both. For example, the agency may be unable to see the client for several weeks, or it may neglect to do what the client has been promised. The client, however, may fail to show up for appointments or refuse to cooperate (e.g., be reluctant to give needed information). The case manager must be aware of the situation if he or she is to know that intervention is required. The intervention in such a case involves identifying exactly what the problem is and working with the client and the resources to resolve it.

Sam Miller received a call from the VA Hospital, where 22-year old Raymond Fields (who has a developmental disability) had been placed as an orderly just 2 weeks before. Both the supervisor and Raymond had been pleased with the match. This morning, the supervisor reported that twice in the past 3 days, Raymond had been seen unzipping his pants and playing with his penis in the hallways. Sam hurried over to the hospital to talk with Raymond about the behavior. He told Raymond to keep this pants zipped. There was no more trouble afterward.

Changing Conditions

Often there is a time lag between plan development and the provision of services. During this period, the case manager seeks agency approval, if necessary, and arranges for services either within the agency or at another one. It is also likely that there will be changes in the client’s situation during this time. Living arrangements, relationships, income, and emotions are some of the factors that may change. The presenting problem may show some alteration or additional problems may surface. Any such changes may necessitate review and revision of the plan.

Adalae Justus is raising two granddaughters and one grandson with the help of her son Zack. The mother of the children, Adalae’s daughter, lives in another state with her boyfriend and his two children. Adalae and the children are receiving assistance from a case manager at the local office on aging. Last week, Adalae was placed in the hospital. After extensive testing, it was confirmed that she had had a series of slight strokes. The case manager will work with the family to determine the changing need for services.

The client’s circumstances may also change during service delivery. Part of service monitoring is staying informed of changes that occur in the client’s life. Some changes may occur as a result of service delivery; for example, a client might learn more appropriate ways to express anger than hitting his spouse. Other changes may have nothing to do with service delivery, yet they influence it. For example, a client might decide to marry while halfway through service delivery—an action that could well affect her economic eligibility for services. Again, monitoring of services helps the case manager to stay abreast and to be ready to intervene if necessary.

My Story

Sharon Bello, Entry 10.3

I have experienced the changing conditions that Marianne talks about here. My care changed each time I had a new case manager. I know that I am still with the same agency, but case managers are different and they talk to me in different ways. For instances, it seems to me that each case manager is concerned about a different part of my case. For instance, Tom was focused on my medical reports.

And then with two of my case managers, we have changed my service plan. The first change in my plan was when I decided to change my major at school. I remember when I discovered Interpreting and how excited I was to think that I could use my skills to help others. But I had to get permission to make the change.

Then, Alma and I just recently completely revised my plan. Well, maybe not completely, but we did make some changes. Alma had to get the new plan approved by her supervisor. In some sense, it was like starting all over. But the process of making a new plan was different because I had been receiving services for a while. This recent plan helps me with some different worries that I have now. Thank goodness I was doing well in school, but the financial worries were weighing me down. And I was having times of being really down and worrying about the girls.

Evaluating Progress

Monitoring services also entail continually checking progress toward the goals and objectives set forth in the plan of services. Continual evaluation may lead the case manager to modify the plan to improve its effectiveness or deal with new developments. In monitoring services, the case manager repeatedly asks the following questions:

• Has the identified problem changed?
• Was the referral made correctly?
• Were the desired outcomes achieved?
• Were cultural differences acknowledged and attended to?
• Should the plan be altered?
• Should the case be closed?

Monitoring of services goes most smoothly if close contact is maintained with the client. Outcome measures focus on the client, so he or she is a key source of information regarding service delivery. Did the client use the resource? Was the goal of the referral attained? The case manager’s responsibility continues until the client’s problem is resolved. Follow-up and monitoring are performed to make sure that referrals result in the desired outcomes. Client satisfaction is important in a successful referral.

The following case illustrates how a case manager monitors services by reviewing the services received, considering any changes in conditions, and evaluating progress toward goals and objectives.

It was chilly on February 17, but the Naylors were happy. It was Presidents’ Day weekend, and they were going to have 3 days off. Everyone gathered in the den in front of the fireplace. Jennifer, the younger daughter, was wearing a tank top and shorts to be comfortable because she had just come down with chickenpox. Johanna, the older daughter, went to look for the kitten her grandparents had given her for Christmas. It appeared to be just another quiet evening.

Johanna came in the back door about 6:30 p.m. and said, “Mom, there’s a fire in the garage!” Mrs. Naylor looked out the door that led to the garage and saw flames at least 10 feet high. Calmly she said, “Everybody out,” and headed for the front door. Mrs. Naylor and both daughters made it out safely. As the Naylors stood watching the fire consume their home, they wondered what they were going to do and where they were going to go. Would they be able to salvage anything at all?

The Naylor family lost everything. The burn shelter in their community immediately stepped in to provide the many services that fire victims need. Bettyjean Fleming, a case manager at the local shelter, was assigned to work with the Naylor family. Once notified of the fire, Ms. Fleming went to the site of the fire to help the family members with their immediate needs. Comfort, clothing, a meal, transportation to the hospital, and temporary lodging are among the services the shelter provides. Case managers work with the victims to cope with any losses they may have suffered (including family members, pets, and possessions). Once the immediate needs are met, the counselor and the victims develop a plan to meet long-term needs, which will be met by other agencies. One of the most critical needs was to help the Naylors re-establish contact with the rest of their family and friends. One of the local Internet providers had a temporary service program to help with emergency short-term mobile services. This contact included 24/7 contact with Ms. Fleming.

The Naylors had a number of needs: transportation, housing, clothing, household furnishings, connectivity, and counseling. One of the most serious needs was counseling for the two girls. They lost not only everything they owned but also every picture and memento of their father, who had died a year before. They desperately needed help in coping with the loss of their father, as well as the loss of their home, their possessions, and their pet. Ms. Fleming learned of these circumstances from Mrs. Naylor, and they developed a plan for long-term services. She was supportive of counseling for the girls; together, they discussed several alternatives using the file of community services at the shelter. They decided on counseling services at the local mental health center, which is known particularly for its children’s services. Mrs. Naylor agreed to call for an appointment. Unfortunately, she was told that the earliest appointment was next month; she didn’t see any alternative, so she took that appointment.

The following week, Ms. Fleming called to see whether Mrs. Naylor had received her insurance check. In the course of the conversation, she learned about the delay in getting counseling. Ms. Fleming alerted Mrs. Naylor to the emergency services that were available and volunteered to call and talk with a counselor. Ms. Fleming often worked with staff at the mental health center, so she called one of her contacts, Frances Lane. Ms. Lane told Ms. Fleming that the agency now provided emergency tele-counseling and agreed to see the girls that week. She requested some background information, which was provided. Mrs. Naylor was grateful for the intervention because there had been no improvement in the girls’ mental state.

Ms. Fleming was able to locate a tele-counseling service that could provide counseling for the girls in 2 days. Ms. Fleming worked with the counselor to begin that service. With Ms. Naylor’s permission, Ms. Fleming also contacted the school and the school counselor, so that members of the school community could be sensitive to the family’s needs.

Ms. Naylor and the girls were able to talk with the tele-counselor, and then they met with a staff member at the mental health center. When the girls returned to school, the school counselor met with them to see how they were doing with their return to school and asked if they wanted to participate in a small group with a few of their friends. The group was a lunch-bunch group that would meet every Wednesday for 6 weeks.

At the next meeting with Mrs. Naylor, Ms. Fleming asked about the visit to the mental health center. Were they seen on time? How did the girls feel about Ms. Lane? Were they feeling better? What were the next steps? At the same meeting, Ms. Fleming asked again if the insurance check had arrived, how the apartment was working out, and whether Mrs. Naylor or the girls had other needs. And Ms. Fleming asked the girls how their return to school had been. She was interested in their interaction with their school counselor and their teachers.

In this case, the case manager’s responsibility did not end after the referral. Because she monitored service delivery, Ms. Fleming became aware that there were problems. She was able to intervene using her contacts to expedite service delivery. She also monitored the delivery of the other services, verifying that the identified services were delivered within a reasonable time and by the professionals designated to deliver them. Ms. Fleming also belonged to a network of emergency care providers who met over the web once every month. Several professionals had formed an informal network to support each other and the clients. Ms. Fleming often used this network to help find services for her clients or problem solve when resources were not available.

Of course, keeping contact with the client or families is also important. Sometimes this contact is being available 24/7 or talking three or four times every day. For clients in crisis, the needs are often dynamic. In fact, not keeping abreast of developments in a case can result in delays in needed services (or even nonperformance). Then, clients become frustrated and dissatisfied with both the resource and the case manager.

As you can see in this discussion of coordinating services, working with other professionals is very important. In this chapter we discussed how to establish a network of other professionals. Establishing a network is the beginning of a case manager’s work with others. Successful networking helps the case manager with resource selection, referral, and monitoring of services.

10-2gTechnology and Service Coordination

Technology has changed the way that agencies and organizations are providing services and meeting client needs. For case managers, especially as it relates to service coordination, the use of technology and its many aspects is being integrated into the case management process (Mullahy, 2014). Technology is now a part of resource selection, referral, and the monitoring of services. For example, for a case manager to match client needs with client services, the case manager must search for community resources. As we discussed, the Internet and agency and organization web sites provide readily available information about agency mission and goals and information about how to apply for services. In most instances, there is also a way to contact agency staff when questions arise. Case managers also use professional listservs and chat rooms to ask their colleagues about availability of services, especially when resources are limited. Listservs and professional chat rooms extend the professional network and increase the number of colleagues to help a case manager search for resources. Technology also helps case managers expand their networking capacities. Even though a contact is not face-to-face, technology is now a familiar way to develop relationships and help others support their clients.

Making referrals is also easier when information systems already exist between agencies. Many times there is a secure (confidential) way between agencies to make the referral, schedule a meeting for the client, provide background information about the client, and share this information and exchange with the client. Rather than “play phone tag,” the case manager can send a request for a client appointment and receive a response with a day. Conveying information referrals to clients is also facilitated using technology. Again, with a secure line, case managers may communicate with clients about referrals and provide vital information about purpose of the visit, time and place of meeting, and plans for follow-up.

The use of technology can also enhance the monitoring of the case management process. No longer do clients and their case managers have to wait for a face-to-face meeting to provide updates, ask for information, ask for help, or provide help. A simple email or text to a case manager can smooth out a difficulty or initiate a meeting or a service if addressing a difficult challenge is needed. Monitoring clients also includes recordkeeping and documentation. Technology can assist in this process. Case management software provides a structure that case managers can use to record meetings with colleagues or clients and client progress. In fact, clients may be using technology as a part of their intervention and the outcomes can be automatically recorded.

The case manager should always be aware of three difficulties that may occur with electronic communication. First, the client may not have access to electronic technology—and without access the client also may not understand how to use it. Research indicates a cultural divide to electronic availability and capability; those receiving social services are less likely to have available means to communicate electronically. For instance, those with less access include the elderly, those living in rural areas, those with less education and lower incomes, and members of minority racial and ethnic groups (Belloumini, 2013; Perrin & Duggan, 2015).

A second concern, introduced in Chapter Four, relates to issues of privacy and confidentiality. Whether providing direct services or monitoring services, the interaction with the client must be within a confidential and secure electronic environment. Case managers should ensure that client information is encrypted and that the interface between the client and the case manager and the agency is secure. The case manager has less control over confidentiality at the client’s end of the interaction. For example, if a client is involved in a video chat with a case manager, there may be other family members or friends in the room. If the case manager or other professional is emailing or texting the client, then that client may allow others to read the text or, in some instances, participate in the texting.

A third challenge is how to document the electronic interaction and services. Within a face-to-face communication, the case manager documents an interaction with a client. This documentation is more difficult with texting and emailing and video chats. It is not impossible to track and record interaction such as social media (e.g., Facebook) and a client’s use of apps (e.g., meditation, client-focused homework). Focusing on ethics and confidentiality, although we suggest that technology can assist in documentation and recordkeeping, processes must be reliable and relatively easy to use.

10-2hWorking with Other Professionals

In this section we discuss how to work with other professionals. We highlight one of the ways case managers work with others as they participate in teams. After we describe ways of working in teams, we then discuss issues that may arise and suggest ways of addressing these issues. We then talk about the final process of providing services, that of ending client services.

Clearly, effective service coordination depends, to a certain extent, on the case manager’s relationship with other professionals. Both referrals and service monitoring are more easily achieved when the case manager has a relationship with the resource. Working with other professionals is critical in a case manager’s work with clients, and professional organizations expect it and guide it.

In Chapter Four, we introduced the concept of professional codes of ethics and describe the ways in which they guide professional behavior and practice. Remember that the details of the codes of several professional organizations (e.g., National Association of Social Work; National Organization of Human Services) are located in Appendix A. One area addressed in most professional codes is the responsibility that professionals have to their colleagues. For example, the National Association of Social Workers Code of Ethics, in the section, Social Workers’ Ethical Responsibilities to Colleagues, includes demonstrating respect to others, positive interdisciplinary collaboration, and addressing unethical conduct of colleagues (National Association of Social Workers, 2008). In the Ethical Standards for Human Service Professionals, Standards 19, 20, and 21 relate to responsibility to colleagues. These include finding ways to collaborate with others, seeking to address conflict, and responding to unethical behavior (National Organization of Human Services, 2015).

The professionals on whom a case manager relies have a wide variety of cultural backgrounds, academic achievements, and job descriptions. Often barriers to service coordination appear; they may be rooted in turf issues, competition for clients, or concern about confidentiality. Communication, sometimes a challenge among those with different perspectives, is one way of addressing these barriers.

Good communication skills are critical when working with personnel from other agencies. These skills can be the deciding factor in making effective use of resources on the client’s behalf. Here, we present certain suggestions for enhancing communication with other helpers.

• Avoid stereotyping other professionals. You may have encountered one nurse who was rude, but it is unreasonable to think that all nurses are that way.
• Do not hesitate to ask for clarification or a definition of terminology that you do not understand. It is better to ask than to pretend you know. You can help others learn your own terminology by using it and explaining its meaning.
• Be aware that other professionals may have different styles of communication. For example, a clinical style may be more comfortable for psychiatrists. Other styles that have been identified are legal (equal adversaries), political (unequal adversaries), and pedagogical (teacher–student).

It is important to prepare for any encounters with other professionals, either within your own organization or outside your organization. Here are steps to help you prepare. We present this information in terms of the process of service coordination that includes pre-meeting homework, meeting with others, and post-meeting homework.

10-2iPre-Meeting Homework

Gather any background information you need and research any issues you believe might arise. Learn about the other professionals, their values, their roles, and what their positions might be. You will want to listen and to demonstrate respect. Understand your own role and the context of the specific situation you are in. Think about how you will communicate with others in a way that fits into their organizational culture. Be aware of your strengths and limitations. Do not overcommit without the ability to follow through. Consult often.

Meeting with Others

• Identify commonalities.Use this time to identify mutual concerns and common goals of all parties. Build bridges with others who may support your position and understand your concerns, or be willing to compromise.
• Define the issue.Keep focused on the challenges, concerns, and stated agenda for the work. Do not get sidetracked.
• Approach each conversation or meeting with a listening ear.This is the time to hear the other, make sure the other knows he or she was heard, and state your position in a fair-minded way.
• Be concrete.Do not use jargon. Provide numerous examples.
• Be sure to say, “I don’t know” and “I’ll find out.”When you are unsure of an answer or process, these phrases will help you respond to the client.
• Use your humor to deflect anger. Direct the humor to yourself, not others.
• Expect to compromise.Expect to revisit your position as you learn more about the issue from others.

Post-Meeting HomeWork

• Review the past meeting.Outline what happened, what decisions were made, and what responsibilities you have, and think about how you could have improved the communication and outcomes.
• Follow up.Follow-up with others if need be.
• Make informal contacts.Have conversations or exchange emails with those involved in decision making. Keep the channels of communication open.

Using these guidelines can facilitate your work with other helping professionals. Being a skillful communicator and having good working relationships with other helping professionals enhances the case manager’s role as a client advocate.

10-2jTeamwork

As stated, working with others—teamwork—is a key component of the case management process. Professionals find themselves forming relationships with clients, families and friends of clients, co-workers, other professionals, and other agencies. These relationships include working on teams, counseling families, and forming partnerships with other agencies, businesses, or governmental units and departments.

10-2kTreatment Teams

In meeting the needs of clients who have multiple problems—children, those with developmental disabilities, the elderly, and many other client populations—a coordinated team approach is necessary because several professionals are involved. Sometimes referred to as the treatment team, this group of professionals meets to review client problems, evaluate information, and make recommendations about priorities, goals, and expected outcomes. The director and care coordinator, who works at a shelter for runaway girls, describes the shelter’s staffing procedures.

Every Tuesday the entire staff meets, and we discuss every client. We begin with the newest girls who have entered the residence. There we talk about the initial intake and assessment. For the others, we talk about any new information, how the girls are progressing with their goals, what other services we might provide, and how we might enhance their success; then, we think about changing goals, transition, and perhaps termination.

Using a team to make decisions has numerous advantages. Working as a team, professionals can share responsibility for clients as well as the emotional burdens of working with clients who have difficult problems. When a group of professionals is involved, all the dimensions of the client’s situation are more likely to be considered, and team members can get one another’s viewpoints about the advantages and disadvantages of each decision made. Furthermore, in the team setting, helpers can share their expertise and knowledge as they focus on each client’s unique set of needs and circumstances.

10-2lTypes of Teams

One type of team used in case management is the departmental team, comprising a small number of professionals who have similar job responsibilities and support each other’s work. Colleagues bring their most challenging cases to the team, and their co-workers help identify client problems and generate alternative approaches to treatment. One case manager who works with adults with disabilities talks about her work in the departmental staff meetings:

When we began our services, we were so excited to move clients from the institution to group living and then to independent living…. Honestly, we didn’t think through the process very well and we were optimistic about how well clients would do. We now have a team in charge of the transition. We support our clients better and they are more stable.

Departmental teams are particularly useful when decision making is difficult or when client problems create a stressful situation for case managers. The departmental team shares information, offers opinions, and often makes group decisions about how to work with clients. A case manager who works with children describes the importance of teams:

My team saved my life; it is so important to have relationships and support with other members of your team.

Within the departmental team, the case manager can fill either of two roles: leader or participant. When assuming the leadership role, the case manager presents a case for review. He or she describes the client and the current status and summarizes conclusions and decisions made to date. The material is presented in such a way as to encourage feedback and dialogue with other colleagues. When the case manager is in the participant role, another colleague presents a case and the case manager must listen, study the situation, and provide advice and counsel.

An interdisciplinary team is a different way to work with other professionals to provide services to the client. As the name suggests, this team includes professionals from various disciplines, each representing a service that the client might receive. Often it includes the client or a member of his or her family. Early in the treatment of a client, the interdisciplinary team gathers and shares data, establishes goals and priorities, and develops a plan. In the later stages of treatment, the interdisciplinary team monitors the progress of the client, revises the plan, and often makes decisions about aftercare. The case manager is often the team leader, giving other team members a holistic view of the client, ensuring that the client or a member of the family is heard or representing that individual’s viewpoints, and conducting an assessment of client problems. In addition, the case manager is expected to monitor client progress between meetings, set the agenda for the meeting, give a summary of client progress, discuss next steps and any dilemmas, and help reconcile differences of opinion. At times, the team leader is placed in a difficult situation because each helper at the table has credentials in a specialized area of professional expertise. Many of them are accustomed to managing cases, being leaders, and making assessment and treatment decisions on their own.

One outcome of initial interdisciplinary team meetings is an organized, well-integrated plan designed to meet the goals that have been established to meet client needs. A good example is the Family Service Plan (FSP), which is provided for Carl, Martha, and Redana Young and is presented in Table 10.1. This plan supports Redana, who is developmentally delayed, and her parents. They are involved in the Hope Project, supported by a coalition of providers including a local hospital, an early childhood support program, and the mental health advocacy center. This program involves families as care managers for infants and toddlers with chronic illnesses and developmental disabilities. In this project, infants and toddlers are identified and receive comprehensive services to meet their own needs and the families’ needs. These include the provision of services during hospitalization, assistance in transition from hospital to home, and follow-up when children return home.

Table 10.1

Family Service Plan for Redana Young

	Identified	Plan	Person responsible for positive outcomes
1.	The Youngs will receive developmental assistance before Redana leaves the hospital.	1.     Referral to Jones School. 2.     Give Youngs ideas about how to work with Redana. 3.     Youngs will decide when they need help from team.	a. S. Toutzel b. S. Toutzel c. C. Cho
2.	The Youngs will be given information about resources to help family.	1.     Give the Youngs information about resources. 2.     The principal at Jones Elementary will be contacted by the Youngs.	a. S. Roberts b. The Youngs
3.	The Youngs will look at financial needs and support.	Arrange for consultation with Eleanora Howard.	C. Cho E. Howard
4.	The Youngs will receive information about Redana’s condition.	1.     Educator will discuss interventions and visitation. 2.     The Youngs will read material about how Redana’s condition affects the family.	c. C. Cho d. S. Roberts
5.	Help Redana communicate with others.	Set up ways to play games for young children. See if Redana responds.	The Youngs’ pediatric nursing staff
6.	Help Redana by establishing routines and games.		S. Toutzel E. Howard The Youngs
7.	Reinforce Redana’s development using material provided.	Use interventions provided by staff.	The Youngs

The service coordination functions include coordinating assessments and coordinating the FSP. One component of the plan is the designation of responsibility to the professionals providing each of the services listed. Besides the parents, there is a team of four professionals involved in developing the comprehensive plan. Tasks are clearly stated, and an individual is assigned to oversee or perform each task. Once the treatment plan begins, interdisciplinary team meetings are scheduled to help monitor the client’s progress. Each of the professionals involved presents a progress report, and together they make a decision about how to proceed. The case manager often meets with each of these professionals one-on-one before the meeting. In crisis situations, he or she may have to revise the plan without team approval. Interaction with other professionals can sometimes be difficult if they have not provided the services for which they are responsible or if there is some question about the quality of the service delivered. The case manager is most often not their supervisor, so when such issues arise, he or she must manage by persuasion and collaboration.

Two other benefits of the team are support and challenge. Other team members bring multiple perspectives to each case management situation. These members may support a case manager’s work, but they also may provide critical feedback that allows case managers to see situations in different ways. For example, others may see different goals as a priority, may suggest alternative approaches, and may challenge your assumptions about the clients or families. They may ask for evidence for conclusions, helping you separate facts from intuition or identify biases. The challenge and critical feedback that occur in a supportive and trusting context can enhance case manager skills and improve work with clients.

Successful Teams

The use of interdisciplinary teams is increasing because of the complexity of client and patient issues, the need for a wide range of knowledge and skills to serve client and patient needs, the specialization needed to meet client and patient needs, and the need for a continuum of care for clients and patients (Nancarrow et al., 2013). There are several factors that define the success of disciplinary teams. These factors all contribute to closing a divide that might occur when professionals from different disciplines might try to work together and encourage positive cooperation (Brader & Jaeger, 2014; Nancarrow et al., 2013).

A Clear Mission

If professionals are working together from various disciplines (e.g., social work, nursing, rehabilitation), then a clear mission of their work can help stimulate their interest and direct or guide challenging decisions. A clear mission statement may help each professional describe his or her place or purpose in achieving the mission.

Communicate in a Positive Way

“Compassionate communication” is the term and interaction suggested by Bader and Jaeger (2014) to move beyond simply giving and receiving information. These authors suggest “communicating with empathy in a way that encourages practitioners to develop a willingness to hear another perspective, listen without interrupting, and reach genuine understanding”.

Administrative Recognition of the Importance of Working on Teams

Many practitioners work on teams on a daily or weekly basis, yet there is little recognition that this activity is important. Being a good team member is not considered in performance evaluation, nor is the time spent counted in billing hours worked. Acknowledging the importance of this activity would indicate commitment by others to the value of this work.

Respect for Each Member, Respect for Each Profession

Issues of leadership and structure of the team may contribute to the environment and outcomes of the team. Each member needs to feel valued and heard. At times, there exists a perceived hierarchy of professions and professionals. A title of a paper by Thylefors (2012) strikes at the notion of respect: “All professionals are equal but some professionals are more equal than others.”

Class Discussion

Rewrite the Naylor’s Story: Service Coordination in a Crisis

As an individual, in a small group, or as a class, review the account of the Naylor’s fire and the work that Ms. Fleming and the Naylors did together. The Naylors were in crisis and Ms. Fleming’s responsibility as a case manager was to support them during the time immediately after the fire.

In this assignment, continue the story of the Naylors as if they worked with a team of individuals rather than just Ms. Fleming. Assume Ms. Fleming was in the case manager role, but that you met with at least five other professionals to help you through the crisis. As you re-write the story, address the following questions:

Who are the other five professionals? What are each of their roles? What is it like to work with a team? According to the four factors that describe a successful team, how does the team work together? How does their work influence the Naylors’ crisis intervention?

Share your new story with your classmates.

10-2mTeams with Families and Friends

Because case management is a viable model for serving clients with long-term, complex needs, families and friends are often an important part of the team. When working with clients such as the elderly, people with limited mental capacities, children and youth, the mentally ill, and other populations who depend on family and friends to help make decisions, provide care, or both, the case manager must recognize that the caregivers expect to be involved in the planning for services. There is also a trend to include families in treatment of pregnant teens, single mothers, parolees, immigrants, and others who were traditionally given individual treatment. Input and participation by families and friends are viewed as important at each phase of the case management process.

Working with families and friends can be rewarding and challenging. The benefits include expanding the network of support and care for the client, adding another perspective on the environment and needs of the client, and engaging those in the immediate environment as part of the solution. Not all family and friends facilitate the teamwork process. Family members may not agree with each other, may not support the client’s commitment to change, or may try to sabotage the case management process. Most case managers would rather have family members on the team even if they are not totally supportive.

One example of broad inclusion of family is the Relationships Australia Family Integration project, which provides support to individuals who are members of stepfamilies or are considering joining a stepfamily. Members of families in this situation have multiple needs and, at times, few resources or support. The family is at the center of the service delivery, which includes counseling, group activities, child care services, and other services as needed. Service delivery is based on identified needs of stepfamilies, including adjusting to the breakup of previous families or the death of a family member, supporting members of families as they explore new roles and relationships, helping children in vulnerable situations, and expanding the ways that a new couple can relate to each other (Relationships Australia, 2012).

10-2nBenefits of Teams

Working on a team is an exciting experience for most case managers. They welcome the creative thinking and the support that come from a collaborative effort. However, building an effective team requires the efforts of all the members, especially the case manager. In most interdisciplinary teams, the case manager has the responsibility for leading the team and developing an atmosphere conducive to good collaboration. A positive atmosphere in which a team functions well occurs when there is a common goal. In the case of teams involved with case management, the goal is the successful development and implementation of a plan that meets client needs. Team members must have respect and trust for the others. Respect is important because teams share in decisions that can radically alter clients’ lives. Mutual respect is especially important in interdisciplinary teams because each member is relied on to bring knowledge and skills in a particular area of expertise. In the case of departmental meetings, the participating colleagues continue to work side by side, so it is important to maintain respect for each other.

For the case manager who is involved with teams, several aspects of teamwork can directly improve the services provided and the work environment of the professionals involved. First, the clients receive services from several professionals working together. The greater the sum of expertise, creativity, and problem-solving skill that the team applies, the more effective the planning and delivery of services will be. Each professional can perform his or her responsibilities better because of having participated in the process of setting goals and priorities as well as planning. Because of the team, the professionals also have a better sense of the client as a whole person and a clearer concept of how their own expertise and treatment fit into the larger plan.

Teamwork also enhances members’ skills in making decisions and solving problems creatively. They not only have opportunities to practice those skills but also can learn from the other professionals. The environment fostered by teamwork is valuable to any helping professional, but especially to a case manager who is coordinating services. Good communication skills are developed in a team atmosphere; members learn to listen well and to speak to the group when appropriate. The opportunity to share responsibility—to ask for assistance, to volunteer, to give advice and to receive it—helps all team members by increasing their sense of community and reducing isolation.

At a home for the elderly, one case manager used team meetings to discuss difficulties, and it brought positive results.

In our team meetings we talked about the difficult situations we were facing. It is really difficult to work with some of our clients. Sometimes they are not nice, they scream, yell, complain, and are violent. And often they demand much of the staff. We give each other room to say, “I’ve had it!”

Class Discussion

Exploring Experiences of Teamwork

As an individual, in a small group, or as a class, think about a team that you have worked with during the past year or two and answer the following questions developed by Bader and Jaeger (2014). These questions are designed for you to explore the nature of the team you choose and its strengths and limitations. When the questions do not reflect the purpose or nature of the group, look at the text in parentheses to expand the meaning of the questions.

• Do team members socialize outside of work or do you believe they should?
• In hiring (choosing members), how much attention is given to personality, empathy, values, and communication styles?
• Is there more emphasis on skills and qualifications?
• How is job satisfaction (membership satisfaction) of team members evaluated?
• Do practitioners feel as though they are working toward shared goals for the clients, or is their work compartmentalized?
• Does work have meaning to team members more than simply being just a “job” (responsibility)?
• Do team members have fun and laugh when they are together?
• How much attention is given to status/rank? For instance, is there reserved parking for certain positions? Is everyone on a first name basis? (Is there a status or rank among the members?)
• Do team members spend most of their time following instructions given by others, or do they have the opportunity to exercise their own judgment in deciding what care a client needs (or deciding the task or responsibility of the group)?

Share the results of your responses with your classmates.

10-2oConfronting Team Issues and Challenges

Sometimes service coordination does not go well. We introduce the following problems that may occur during the coordination process. We divide these problems into four categories: areas of disagreement; relationship issues; work performance; and ethical and legal issues. We list several issues that may occur and provide suggestions about how to address these.

Professionals Do Not Agree About the Case Management Process

Both agreement and conflict are part of group work and group decision making. During the case management process, individuals may disagree about that very process. There are several reactions that members of a group may have to challenges and conflicts. Individuals may try to avoid or ignore the conflict, use authority to declare what is correct, or try to address the problem as a group by considering mutual benefits and seeking compromise.

We suggest a process of conflict management that case management teams may use when conflicting opinions arise. We believe it is important to view conflict as an opportunity to generate a diverse set of views about an issue and come to an agreement. Using conflict management helps foster a sense of team process, fairness, positive working relationships, and a sense of respect among team members (Behfar, Peterson, Mannix, & Trochim, 2008). These authors indicated a balance between the task at hand and concern for team member satisfaction during conflict resolution; therefore, there is “a mix of accommodating, collaborating, and compromising” (Behar et al., 2008, p. 182). We note in the discussion of conflict resolution that the ultimate goal is the “good of the client.” Areas of conflict for case management teams might include defining the priorities and goals, clients’ problems and issues, values and culture, agency responsibilities, individual responsibilities, and fiscal responsibility, to name a few.

Conflict resolution on a case management team might look like the following (Department of Veterans Affairs, 2004):

• Set aside a time during a meeting to discuss the issue. This is an acknowledgment that the issue exists and begins a formal process to address it.
• State the issue clearly.
• Allow individuals in the meeting to have their say. Take notes so each person at the meeting can view the position or ideas.
• As each person presents his or her point of view, listen with care. Ask questions to clarify. Repeat the other’s viewpoint and rationale. Be respectful. Help each member of the group to feel heard.
• Generate a list of possible solutions. Look for outside input, encourage individuals as ask “dumb questions,” and ask someone to play the “devil’s advocate.”
• Decide on the criteria the team will use to make the decision.
• Review the decision and determine how to proceed.

We build on a small case presented in this chapter and illustrate two ways that professionals can disagree with the case management process, the services the client should receive, and how to measure outcomes.

Introduction to Rachel When checking with Rachel Vasquez after her visit to the health clinic, the case manager, Ms. Banic, heard about the generous time a volunteer had spent with Rachel in developing a balanced nutrition plan for her diabetic son. Rachel was excited about knowing what to buy, how to prepare it, and why it was a good meal. Most of all, she was impressed by how much time the volunteer spent with her.

Description of Rachel’s staffing meeting at the domestic violence shelter Rachel and her children have been living in a domestic violence shelter for the past 3 months. Rachel has been slow to engage in the case management process. In fact, to remain in the shelter, Rachel has to fulfill several responsibilities; in a sense, she has to “earn her right to be at the shelter.” During weekly staff meetings, several members of the larger case management team keep pushing Rachel’s case manager, Ms. Banic, to be clear with Rachel that she will lose her “home” if she does not use the vocational trainer to look for employment, volunteer at the local school as a way of giving back, perform the daily living tasks that she is assigned at the shelter, and participate in group parenting sessions. The counselor and the assistant director, both members of the team, believe that Rachel needs to be given an ultimatum about her stay at the shelter. They cannot see any progress Rachel has made during the case management process. Ms. Banic is thrilled that Rachel visited the health clinic and seemed to appreciate the services provided; Ms. Banic sees this as hope for Rachel and forward progress.

Question Based on the information about how to handle disagreements among team members, how might you handle this conflict?

Relationships in the Team are Stressed or Strained

It is well documented that positive relationships are a key to effective and efficient teamwork (Lencioni, 2002; Maxwell, 2013). It is equally well established that teams do not always function well; at times, they function so poorly that their results have negative consequences for the team, team outcomes, and team members (Lencioni, 2002). There are several characteristics that effective teams demonstrate (Brown, 2016; Riordan, 2011).

• Establish a clear vision and focus for the team.
• Define a specific outcome for the team.
• Establish rules or norms for positive group interaction (e.g., be respectful of other’s ideas; listen to other members of the team)
• Share with members of the team know what is expected of them.
• Make assignments based on each team member’s strengths.
• As a coordinator, serve both the agency leadership and your team members.
  • Clarify to team members what your agency director expects of you.
  • Ask your team members what they need from you to help them fulfill their responsibilities.
• As a coordinator, demonstrate excellent professional behavior and hard work.
• Provide positive feedback to the team and individual members of the team.
• Directly address issues and challenges of quickly using an established process.

There are also some guidelines that we consider essential if you are going to be a positive contributing member of any group. Many of these reflect your own personal orientation to the work. And these personal characteristics and orientation will serve you well in most aspects of your work as a case manager.

• Be honest and trustworthy in your work. Be clear about your work, your confusions, your questions, your intentions.
• Focus on your responsibility. Accept feedback for your work.
• Understand that communication is challenging and that misunderstandings will occur. Your goal is to improve communication once miscommunication occurs.
• Modify your responses to teamwork as they change. Teamwork requires you to expand your understandings, assume new responsibilities, and give up responsibilities. Working on a team is a dynamic process.
• Be willing to do extra work if it is required or needed.
• Meet your obligations; inform others if you cannot do so.
• Ask for help if you need it.
• Do not talk about the team outside the team meetings.

The characteristics of effective teams and suggestions about the ways you can support positive teamwork will help guide your behavior as a team member. Teams have a critical role to play in the social services and especially in the case management process, where improving clients’ lives is the goal. Each member has a part to play in building a successful team. You can help build healthy teams.

Introduction to Adalae Adalae Justus is raising two granddaughters and one grandson with the help of her son Zack. The mother of the children, Adalae’s daughter, lives in another state with her boyfriend and his two children. Adalae and the children are receiving assistance from a case manager at the local office on aging. Last week, Adalae was placed in the hospital; after extensive testing, it was confirmed that she had had a series of slight strokes. The case manager will work with the family to determine the changing need for services.

Description of Adalae Justus’ treatment team The local office on aging provides services for grandparents caring for grandchildren. The grandparents who participate in the program need a range of care. Some of the grandparents or grandparent, in the case of Adalae Justus, are the primary guardian or caretaker for their grandchildren. Others provide care but are not the primary guardians.

Regarding the office on aging, this program runs on a shoestring. This means that they borrow staff from other programs to serve on case management teams. The office on aging has three such teams—Team A, Team B, and Team C; one of the teams, Team B, is in trouble. The case manager, Mr. Adanir, has only been at the agency for 2 months. This is his first job as a case manager. Previously, he was a corrections officer in a neighboring state. Two team members working with Mr. Adanir resent him. They do not believe that he is qualified for the case management job. And his idea of leadership is very dictatorial. In his defense, he believes he is accountable for the success of the team and positive outcomes for clients. And he is used to being totally in charge of his caseload.

Question Based on the information about how to handle strained relationships among team members, how might you handle this stress?

Poor and Unethical Work Performance

There are two issues that are difficult for case managers to address, especially when case managers coordinate the team and do not supervise the team members. In fact, many of the team members may work from another department or another agency or organization. One issue, work performance, occurs when a member of the group or team does not contribute quality work, meet expected deadlines in a timely manner, and/or fails to communicate or miscommunicates with team members or the team as a whole. Another issue that threatens the quality of the work and may undermine the team and agency occurs when a team member acts unethically. The suggestions we provide to address both of these issues require, we believe, similar approaches (The Fortune Group, 2016; Steere, 2016).

An individual case manager’s specific response may vary depending on his or her leadership responsibilities. For instance, in teams with a designated leader, addressing difficult issues is often viewed as the leader’s responsibility. In more democratic groups, where the responsibility for the group is shared, it remains the group members’ responsibility to address the issues.

As a team, establish ground rules about how to address difficult issues It is helpful if teams have previously developed a set of procedures or agreements to use when issues arise.

Issues receive immediate attention When issues arise, they need to be addressed as quickly as possible or a member of the team may act in an unethical way. The work performance of the team depends on tackling problems. It is best to address work-related issues as quickly as possible.

Discuss issues in private When there is a need to discuss performance with a team member, it is preferably done face-to-face and in private.

Be clear Be clear when discussing poor, unprofessional, or unethical performance and describing observable behaviors and patterns of behaviors or outcomes. These may include behaviors that indicate unhelpful attitudes, a lack of knowledge or skill, or poor or inappropriate work.

Allow feedback Once the team member is clear about the issues, provide an opportunity to explore any misconceptions, misunderstandings, or explanations.

Focus on the future Unless the action is egregious, focus on what supports the team member needs to demonstrate quality work. Identify what behavior is causing the employee to underperform.

Gain commitments from the team member Work with the team member to create a plan of improvement and ask for a commitment to the plan.

Follow-up As with any plan, there needs to be a time when the team member and the supervisor meet to evaluate the team member’s progress.

Unethical Behaviors

Codes of Ethics of the National Association of Social Workers (2008) or the National Organization of Human Services (2015) provide guidelines for addressing issues that involve unethical behaviors. Both of these codes suggest following a process of due process. First, discuss concerns with colleagues. Second, if the concerns are not addressed, then the individual should use appropriate channels to process a complaint or concern. These channels include local, state, and national channels. Appropriate support can include employers (e.g., supervisors), agencies, professional ethics committees, and licensing board. Although an in-depth approach to addressing unethical behavior is beyond the scope of this text, the steps recommended to address poor work performance can serve as guidelines. Ultimately, unethical behavior can jeopardize work with a client, the work of the team, and the work of an agency. It also puts the value of a professional at risk.

Introduction to Sam Sam Miller received a call from the VA Hospital where 22-year old Raymond Fields (who has a developmental disability) had been placed as an orderly just 2 weeks previously. Both the supervisor and Raymond had been pleased with the match. This morning, the supervisor reported that twice in the past 3 days Raymond had been seen unzipping his pants and playing with his penis in the hallways. Sam hurried over to the hospital to talk with Raymond about the behavior. He told Raymond to keep this pants zipped. There was no more trouble afterward.

Description of Sam Miller’s dilemma with the supervisor at the VA Hospital Sam Miller believed that the issue with Raymond and his unzipped pants was a one-time issue. In fact, because Sam had not heard from the supervisor at the VA Hospital, he assumed that things were going well for Raymond at the VA Hospital. He was usually scheduled to visit Raymond once every month, and it had been 3 weeks since he had seen Raymond. He had visited a client out of the county and was driving back to his office. He knew he would drive by the VA Hospital and he was ahead of his schedule, so he decided to stop and see Raymond. It was not unusual for Sam to make impromptu visits with his clients. He liked to check on them more than the scheduled visit once every month. When he entered the VA Hospital, he was told he could not see Raymond because he was in solitude. He was sure that this must be some mistake. The desk staff informed Sam that Raymond had not been out of his room for more than 2 weeks. He was considered a risk to the other patients. Sam met with the supervisor who stated, “Raymond could not keep his pants zipped, so he was being punished for that behavior. He further indicated that Raymond was only being fed one meal as a way to make the point that the behavior would not be tolerated.” The supervisor also told Sam that he made the decision without consulting the team, of which Sam was a part.

Question Based on the information about how to handle unethical behaviors of team members, how might you handle this issue?

Summary

Teamwork is central to performing the case management role of service coordination. Linking clients to services, monitoring client progress, and communicating with other professionals are important components of effective service delivery. And team members can provide support and critical feedback to one another. The team is—or can be—a safe place.

10-3Ending Client Services: Disengagement

For the case manager, work with most clients includes a beginning and a concluding of services. This disengagement means that the case manager and the client will no longer be formally connected to one another. Because much of the case management process is built on the relationship between the case manager and the client, the disengagement should be conducted with care.

The conclusion or ending of services, often called termination, can occur for many reasons. First, clients may meet their goals and be ready to use their newly found knowledge and skills as a foundation for future self-sufficiency. Second, the services may be time-limited with an end in sight regardless of whether the goals have been met. Third, at times, work with a specific case manager may end but services continue with another professional. Case managers refer clients to another professional because they believe another professional can be a more effective service provider. Finally, the client may choose to terminate the case management process before it is completed. The reasons for this can vary from an unwillingness to participate or an inability to participate.

In this section, we present four aspects of the ending of services: termination, transfer, discharge planning, and follow-up. The first three are listed as tasks of disengagement by the National Association of Social Workers description of the core function of social work case management (NASW, n.d.). For each of these aspects, we added follow-up as a fourth task. We describe the process and the care that must be taken during this period of disengagement.

10-3aTermination

As stated, termination represents for the client and the case manager the ending of case management services. The case manager has several ethical obligations related to termination. These include ending services once clients have met their objectives, not ending services when goals and objects have not been met, planning the termination with care, and planning follow-up after termination (National Association for Human Service, 2015; National Association of Social Workers, 2008). With these in mind, we suggest the following guidelines for terminating with clients for whom there is a timeline or there is an expected end to the services (e.g., once goals and objectives are met) (Woodside, 2017).

The initial visit During the application process and before an individual has been accepted as a client, the case manager explains the nature of service to the client and the case management process. Part of this explanation includes the conclusion of service delivery and subsequent follow-up. At the initial meeting after the client has been accepted for services, the case manager again outlines the case management process; this includes concluding services and follow-up.

Two or three weeks (or months) before the conclusion of services There is a time during the case management process when the case manager knows that the service delivery will be coming to an end. This may be because work with clients is time-limited (i.e., six sessions, 6 months, 1 year, etc.). Also, if the services are not limited by time because the case manager and the client review goals and objectives together, then both can see that the work is almost completed.

The case manager has the responsibility of beginning to indicate that services will be coming to an end. At this time, the case manager also needs to be clear that the goals and objectives of the case management process have been met. There also may be an agency team, an interdisciplinary team, or an interorganizational team that advises on the process of termination. This process may be a counting down, and the case manager and the client perform this task together. The counting down activity helps clients remember what occurs between the current session and the time of termination. Engaging in the counting down might be a good close to a case management session. The case manager and the client can include this in a summary of the session and any homework each may have before their next meeting. This means reminding both of them of how many more weeks there are to work together or how many more sessions are scheduled. In the conversation, the case manager might say:

I wanted to let you know that we will begin our final sessions during this next 3 months. Your work with this agency appears to be going well. We will want to review your goals and objectives and determine our last steps. And I want to talk with you about what you need before we end our work. We will need to talk about the planning for this conclusion and the follow-up. And we will talk about this ending each time we meet until our final session.

Sometimes clients are surprised when the case manager brings up concluding the case management process. It is possible that work with the case manager, and perhaps with the case management team, has become a stable part of their lives. Clients might also experience a sense of loss. These emotions underscore the reasons for a discharge or transition plan or follow-up and helps with the sense of continuity of care.

My Story

Sharon Bello, Entry 10.4

I was startled when I read this section about the end of the case management process. I know that I have considerably more time to count on the support, but right now I feel like I can turn to my case managers for help and they are always willing to try to provide me with what I need. I know that the services that they can provide are not unlimited, but my case managers have always had great ideas to help me solve my problems. And we have a real connection. I know that they will help me figure out and get what is best for me. I think that I need to talk with Alma about the end of case management at our next meeting. I don’t think that I want to wait until she brings it up.

The final meeting When case managers meet with their clients for the final time, the agenda is a long one. But the case manager has been working on this meeting for weeks, so hopefully there are few surprises. Case managers are wise to set aside extra time for this final meeting so they are not rushed and have plenty of time for client questions and issues. It is important to be positive about this transition and ensure that the client fully participates. Some guidelines for that final meeting are as follows.

• Focus on the entire case management process, outline the work in this session, and consider the future.
• Review what has been accomplished during the case management process. This can include goals and objectives, but may also include other insights and observations the client may have.
• Summarize client strengths, including values, beliefs, cultural influences, personal traits and characteristics, family and friends, and environmental supports.
• Talk about feelings about the transition.
• Discuss how the client sees the future.
• Discuss any transition or discharge plan (including finding support when needed).

Next, we look at transfer of client services as one aspect of concluding services.

10-3bTransfer

Transfer of services refers to the act of moving a client from one case manager to another and, perhaps, from one agency to another. This transfer of services can occur in a variety of ways. Case managers may refer the client to other professionals because of a lack of knowledge or skills or an ethical challenge or dilemma (e.g., boundary issues, value conflict). In other instances, case managers may be leaving an agency and the transfer is to another case manager within the same agency. Clients may also require more services than the current agency is able to provide and a transfer to another agency (and another case manager) is in the client’s best interest. Clients may need services but also may need to relocate, so they must initiate the transfer. Regardless of the reason for the transfer of services, guidelines for transfer resemble guidelines for a referral and guidelines for termination of services (both are presented in this chapter). In summary, making a referral includes contacting relevant services, arranging the referral, and supporting the transfer process (Community Door, 2013).

Contact relevant services

• Determine if the referral agency can meet client needs.
• Establish if the agency can provide the service.
• Share a summary of client goals and objectives without violating confidentiality.
• Ask for a description of the services provided and how the client enters the agency.
• Discuss how to monitor client outcomes and how information is shared.
• Identify the referral policies of your own agency and the agency to which the referral will be made.
• Obtain client permission to share any confidential information about the client.

Making arrangements

• Be clear with the client about the details of the first visit (e.g., documentation, times of appointment, directions, transportation, cost).
• With client’s consent, send appropriate referral information.
• Confirm the referral.
• Confirm any transition or follow-up work with client.
• Plan, if appropriate, to attend the first meeting if the client has reservations.

Support the client

• With client consent, provide the agency with the previous assessments and plan of service.
• Follow-up with client about participation.
• Encourage the client to discuss progress and any issues with new case manager.
• Encourage the client to build on their strengths.

Class Discussion

Planning a Transition of Services

As an individual, in a group, or as a class, assume the role of Alma Grady. Within this scenario (which is not true), assume Alma is leaving her present position as a case manager. Detail how you would prepare Sharon Bello for the transfer to a new case manager.

Discuss your plan with your classmates.

10-3cDischarge Planning

Discharge planning represents a concrete proposal for the care of clients after they have received services. This type of planning assumes that clients do not automatically move from the need for services to complete self-sufficiency. And it recognizes the existence of a continuum of care for clients as their need for services changes. Clients still need care, and in most instances they need different care. The discharge plan also addresses the ways that clients may re-enter a different environment, whether it be from residential care to community care, from vocational support to full employment, from homelessness to transitional or secure housing, from being incarcerated to being on probation, or from being hospitalized to returning home.

In many situations, the case manager is also the discharge planner; however, in some agencies there is a designated discharge planner who is not involved with the care of the client. Discharge planning is a complex process. It involves knowing how human services and health systems work, having strong relationships with the community and agencies, establishing rapport quickly, working with the client’s families and friends, and prioritizing the most important aspects of a transition care plan (Sims-Gould et al., 2015). The roles in discharge planning include planning, recordkeeping, documentation, counseling, conflict resolution, brokering, and advocacy.

One case manager with primary experience as a discharge planner at a residential mental health facility describes her job:

I meet with clients and establish rapport with them very quickly. I read all of the material in the case file and meet with them to determine what they believe they will need when they leave our residential facility. I work out a process for their medications, outpatient individual counseling, group counseling, housing, and, if possible, a return to employment. I regret that I am not able to follow-up on these clients once they leave. I do have a good set of colleagues in the community and they can let me know if the aftercare is not going well. And, of course, if there is a crisis, then the client may return to our residential program.

There are some guidelines for developing a client-focused discharge plan. The guidelines we present have some of the same components as termination and transfer of services and integrate findings from medical, correctional, children and family, and substance abuse settings (Sims-Gould, 2015; Toi &Mogro-Wilson, 2015). We recognize that discharge planning in case management involves an even broader span of services. And what appears to be unique about the discharge planner role is that the planner may not have been involved in the case management process, provides support on a time-limited basis, must consult with a team, and primary responsibilities are planning and referral. There also may be key factors in the discharge planning for specific populations that predict successful outcomes. For example, in working on a discharge plan for adult inmates with co-occurring mental illness or substance use disorders, research indicates that providing medication support is a strong predictor of positive outcomes (Tio &Mogro-Wilson, 2015).

The following guidelines provide some suggestions for discharge planning.

• Begin the discharge planning with enough time to have supports and services in place for the client.
• Review the case file.
• List the client needs during transition from care.
• Establish a list of possible sources to meet needs.
• Contact possible organizations to consider and arrange support for the client.
• Develop a discharge plan.
• Consult with an interdisciplinary team, if possible, about the needs, support, and possible challenges to the plan.
• Attend to the challenges identified.
• Meet with the client and the family to discuss the discharge plan.
• Address concerns and, perhaps, revise the plan.
• Create a document for the client and family to follow after discharge (includes contact number of support staff if questions arise).
• Contact the client and family after they have left the agency to inquire about how the discharge plan is working and if there are questions or issues they cannot address.

The processes of termination, transfer, and discharge planning lead to the conclusion of working with the client. This leads us to describe the importance of follow-up at the conclusion of services and the barriers to its implementation.

10-3dFollow-Up

Regardless of how the case management process ends, there is an obligation for follow-up of services (e.g., National Association of Social Work; National Organization of Human Services). However, at times, there is limited time and other resources to monitor the progress of the client after the case management process. But participation in follow-up can enhance the case manager’s understanding of the client, the outcomes of case management for the client, and client satisfaction (Malmberg-Heimonen&Tøge, 2016; van Berkel, 2007; Woodside &McClam, 2015). It is a professional expectation in the helping professions that the client, in most instances, will receive service for a period of time and then will receive follow-up support during their aftercare (Nance, 2014).

When thinking about follow-up services, the types of these services may be considered in the continuum of care model. In other words, there is a range of and intensity of services during follow-up. Follow-up extends from making a one-time phone call or home visit to answering questions about the end of services, a transfer of services, or an aftercare plan; making a referral; making an assessment; crisis intervention; and providing services.

Barriers to follow-up we spoke of are limited time and other resources. Case managers and discharge planners may experience so much pressure from their current clients that it is difficult to maintain contacts and documentation about clients they are not directly working with. Follow-up may also not be seen as part of their job responsibility; as much as they would like to follow-up, there is no expectation to do so. The agency may not have a policy or procedure for follow-up contact with clients; a phone call to a client might result in client needs that the case manager cannot meet (Malmberg-Heimonen&Tøge, 2016).

There is also a benefit to the agency in conducting follow-up. As indicated in Chapter Eleven, assessing client outcomes beyond the delivery of services and gaining information about client satisfaction and experience with the case manager and the case management process can support efforts to understand evidence-based practice, program evaluations, and quality improvement efforts.

Now that we have described the end of the case management process, let us read about Karen, a case manager in Phoenix, Arizona. Karen’s experience will help us gain a better understanding of the role of service coordination.

Deepening Your Knowledge: Case Study

Karen is a case manager with a juvenile justice program in Phoenix, Arizona. She works with a wide range of adolescents who have become involved in the juvenile justice system and require additional treatment and service options after they spend time in the mandatory municipal program for first-time offenders. She recently took on case management services for Ashley, who at 15 was placed in the municipal program for grand theft auto, driving under the influence, and drug possession after stealing her neighbor’s car to run away from home with her older boyfriend. Ashley is 10 days from completing the program and has been recommended for a probationary period that includes additional services after her discharge.

In meeting with Ashley, Karen learns that she has experienced repeated physical and sexual abuse from her stepfather. She has a strained relationship with her mother whom, she says, “doesn’t care about me. She always puts him (stepfather) first and if I have to live in that house then I’ll keep running away until I make it or get killed.” When asked about her boyfriend, Ashley states that “he’s a low-life; I’m only with him because he knows how to get pot.” Karen asks Ashley if she has any other options for places to live and informs her of referral options with local teen abuse centers. Ashley reveals that she has wanted to move in with her aunt, but she has not seen her in a few months and she is not sure if it would be a possibility. Karen spends the rest of the interview assessing Ashley’s strengths and weaknesses, documenting her substance abuse history, and listening to Ashley’s thoughts and concerns.

When the interview concludes, Karen informs Ashley that she will have to report the physical and sexual abuse and lets her know that they will meet two more times before her discharge. During those meetings, Karen agrees to update Ashley on her post-discharge expectations and possible follow-up treatment and living options for Ashley after the program. Ashley seems skeptical about Karen’s commitment, although she states that the abuse should be reported. Karen reminds Ashley that she will remain the case manager in charge of monitoring her experiences in future inpatient or outpatient treatment and that she knows of many caring facilities that can assist Ashley in working through these issues.

Discussion Questions

1. Even though Karen works with a court-mandated program, she attempts to include Ashley in the decision-making process. What are some of the ways in which she does this? Why is this important?
2. What steps might Karen take to help this client?
3. How might a treatment team approach affect the course of Ashley’s treatment?
4. How might Karen’s ability to communicate with and make referrals to external resources affect the course of Ashley’s treatment?

Author Note: We think that it is important for you to review the chapter you just read. We suggest the following.

• First, re-read the class discussion questions in the text and answer these as comprehensively as possible.
• Second, once you complete the discussion questions, review the Chapter Summary, define the Key Terms, and answer the questions in Reviewing the Chapter.
• Third, make notes of what stands out for you during your review. Also, record any questions that you might have.
• Finally, take time to discuss the Questions for Discussionwith another class member, either face-to-face or online. Answering these questions with a peer will help you solidify the understanding you have of the contents of the chapter.

Morgan, C. (2012). Unpublished manuscript, Knoxville, TN. Used with permission.