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Fifth edition
Fundamentals of
Case
Management
Practice
Skills for the Human Services
Nancy Summers
Harrisburg Area Community College
Australia ? Brazil ? Mexico ? Singapore ? United Kingdom ? United States
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Fundamentals of Case Management
Practice: Skills for the Human Services,
Fifth edition
Nancy Summers
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To my parents, whose humor and wisdom about people and relationships formed the
foundation for my work with others
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Contents
Preface xiii
Section 1
oundations for Best Practice
F
in Case Management
Chapter 1
Case Management: Definition and Responsibilities 1
Introduction 1
A History of Case Management 2
Language in Social Services 2
Why We Use Case Management 3
Case Management as a Process 4
Advocacy 13
Service Coordination 13
Levels of Case Management 16
Separating Case Management from Therapy 19
Case Management in Provider Agencies 19
Managed Care and Case Management 21
Caseloads 25
Generic Case Management 26
Summary 26
Exercises I: Case Management 27
Exercises II: Decide on the Best Course of Action 30
Chapter 2 Ethics and Other Professional Responsibilities
for Human Service Workers 33
Introduction 33
The Broader Ethical Concept 34
Dual Relationships 35
Boundaries 40
Value Conflicts 40
The Rights of Individuals Receiving Services 44
Confidentiality 47
Privacy 51
Health Insurance Portability and Accountability Act 52
Social Networking 55
Privileged Communication 56
When You Can Give Information 56
Diagnostic Labeling 59
iv
Contents
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Involuntary Commitment 60
Ethical Responsibilities 61
Protecting a Person?s Self-Esteem 62
Stealing from Clients 64
Competence 65
Responsibility to Your Colleagues and the Profession 65
Professional Responsibility 67
Summary 68
Exercises I: Ethics 69
Exercises II: Ethically, What Went Wrong? 71
Exercises III: Decide on the Best Course of Action 76
Exercises IV: What is Wrong Here? 76
Chapter 3 Applying the Ecological Model: A Theoretical Foundation
for Human Services 77
Introduction 77
The Three Levels of the Ecological Model 79
The Micro Level: Looking at What the Person Brings 80
Looking at What the Context Brings 80
Why Context Is Important 81
Seeking a Balanced View of the Client 82
Developmental Transitions 86
Developing the Interventions 87
Working with the Generalist Approach 88
Macro Level Interventions Are Advocacy 88
Summary 90
Exercises I: Looking at Florence?s Problem on Three Levels 90
Exercises II: Designing Three Levels of Intervention 91
Section 2
Useful Clarifications and Attitudes
Chapter 4
Cultural Competence 95
Introduction 95
Culture and Communication 95
Your Ethical Responsibility 96
Where Are the Differences? 96
Strangers 98
Anxiety and Uncertainty 99
Thoughtless versus Thoughtful Communication 100
Dimensions of Culture 104
Obstacles to Understanding 109
Competence 111
Summary 112
Exercises I: Testing Your Cultural Competence 113
Chapter 5
Attitudes and Boundaries 117
Introduction 117
Understanding Attitudes 117
Basic Helping Attitudes 118
Contents
v
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Reality Check 123
How Clients Are Discouraged 124
A Further Understanding of Boundaries 127
Seeing Yourself and the Client as Completely Separate Individuals 127
Erecting Detrimental Boundaries 129
Transference and Countertransference 129
Summary 130
Exercises I: Demonstrating Warmth, Genuineness, and Empathy 131
Exercises II: Recognizing the Difference?Encouragement
or Discouragement 136
Exercises III: Blurred Boundaries 136
Chapter 6
Clarifying Who Owns the Problem 139
Introduction 139
Boundaries and Power 140
If the Client Owns the Problem 141
If You Own the Problem 143
If You Both Own the Problem 144
Summary 145
Exercises I: Who Owns the Problem? 145
Exercises II: Making the Strategic Decision 147
Section 3
Effective Communication
Chapter 7
Identifying Good Responses and Poor Responses 149
Introduction 149
Communication Is a Process 150
Twelve Roadblocks to Communication 151
Useful Responses 156
Summary 164
Exercises: Identifying Roadblocks 165
Chapter 8
Listening and Responding 169
Introduction 169
Defining Reflective Listening 170
Responding to Feelings 170
Responding to Content 174
Positive Reasons for Reflective Listening 176
Points to Remember 177
Summary 178
Exercises I: How Many Feelings Can You Name? 179
Exercises II: Finding the Right Feeling 179
Exercises III: Reflective Listening 180
Chapter 9
Asking Questions 187
Introduction 187
When Questions Are Important 187
Closed Questions 188
Open Questions 189
vi
Contents
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Questions That Make the Other Person Feel
Uncomfortable 190
A Formula for Asking Open Questions 192
Summary 195
Exercises I: What Is Wrong with These Questions? 195
Exercises II: Which Question Is Better? 197
Exercises III: Opening Closed Questions 198
Exercises IV: Try Asking Questions 200
Chapter 10 Bringing Up Difficult Issues 203
Introduction 203
Confrontation 203
Exchanging Views 204
When to Initiate an Exchange of Views 204
Using I-Messages to Initiate an Exchange of Views 207
Asking Permission to Share Ideas 213
Advocacy: Confronting Collaterals 214
On Not Becoming Overbearing 215
Follow-up 217
Summary 217
Exercises I: What Is Wrong Here? 217
Exercise II: Constructing a Better Response 219
Exercises III: Expressing Your Concern 219
Exercises IV: Expressing a Stronger Message 222
Chapter 11 Addressing and Disarming Anger 225
Introduction 225
Common Reasons for Anger 225
Why Disarming Anger Is Important 226
Avoiding the Number-One Mistake 227
Erroneous Expectations for Perfect Communication:
Another Reality Check 228
The Four-Step Process 229
What You Do Not Want to Do 231
Look for Useful Information 233
Safety in the Workplace 233
The Importance of Staff Behavior 234
Summary 235
Exercises I: Initial Responses to Anger 235
Exercises II: Practicing Disarming 236
Chapter 12 Collaborating with People for Change 239
Introduction 239
What Is Change? 239
Stages of Change 240
Understanding Ambivalence and Resistance 244
Encouragement 247
Recovery Tools 250
Communication Skills That Facilitate Change 252
Contents
vii
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Trapping the Client 258
From Adversarial to Collaborative 258
Summary 262
Exercises: Helping People Change 263
Chapter 13 Case Management Principles: Optional Review 265
Introduction 265
Combining Skills and Attitudes 265
Practice 267
Exercise I 267
Exercise II 268
Exercise III 271
Exercise IV 273
Exercise V 274
Section 4 Meeting Clients and Assessing
Their Strengths and Needs
Chapter 14 Documenting Initial Inquiries 277
Introduction 277
Walk-ins 278
Guidelines for Filling Out Forms 278
Steps for Filling Out the New Referral
or Inquiry Form 278
Evaluating the Client?s Motivation
and Mood 282
Steps for Preparing the Verification of Appointment Form 282
Summary 284
Exercises I: Intake of a Middle-Aged Adult 284
Exercises II: Intake of a Child 284
Exercises III: Intake of an Infirm, Older Person 285
Chapter 15 The First Interview 287
Introduction 287
Your Role 288
The Client?s Understanding 288
Preparing for the First Interview 288
Your Office 290
Meeting the Client 290
Summary 295
Chapter 16 Social Histories and Assessment Forms 297
Introduction 297
What Is a Social History? 298
Layout of the Social History 298
How to Ask What You Need to Know 299
Who Took the Social History 306
Social Histories in Other Settings 310
Writing Brief Social Histories 311
viii
Contents
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Using an Assessment Form 314
Taking Social Histories on a Computer 316
Taking Social Histories in the Home 316
The Next Step 317
Summary 317
Exercises I: Practice with Social Histories 318
Exercises II: Assessment of a Middle-Aged Adult 318
Exercises III: Assessment of a Child 319
Exercises IV: Assessment of an Infirm, Older Person 320
Exercises V: Creating a File 320
Chapter 17 Using the DSM 321
Introduction 321
Is DSM Only a Mental Health Tool? 322
Cautions 322
Who Makes the Diagnosis? 323
Background Information 323
The DSM-IV-TR 327
DSM 5, the Current Diagnostic Manual 328
Making the Code Using DSM 5 330
Multiple Diagnoses 331
Other Conditions That May Be a Focus
of Clinical Attention 332
When the Diagnosis Does Not Quite Fit 332
When There Is No Number 333
Summary 333
Exercises: Using the DSM 5 334
Chapter 18 The Mental Status Examination 337
Introduction 337
Observing the Client 338
Mental Status Examination Outline 339
Summary 356
Exercises: Using the MSE Vocabulary 356
Chapter 19 Receiving and Releasing Information 359
Introduction 359
Sending for Information 359
If You Release Information 359
Directions for Using Release Forms 360
Examples of the Release Forms 362
When the Client Wants You to Release Information 363
When the Material Is Received 363
Other Issues Related to Releasing Information 365
Summary 365
Exercises I: Send for Information Related to a
Middle-Aged Adult 366
Exercises II: Send for Information Related to a Child 366
Exercises III: Send for Information Related to a Frail,
Older Person 366
Exercises IV: Maintaining Your Charts 366
Contents
ix
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Section 5
Developing a Plan with the Client
Chapter 20 Developing a Service Plan at the Case Management Unit 367
Introduction 367
Involving the Client and the Family 368
Using the Assessment 369
Creating the Treatment or Service Plan 372
How to Identify the Client?s Strengths 373
Individualized Planning 374
Understanding Barriers 375
Sample Goal Plan 375
Summary 376
Exercises: Broad General Goal Planning 377
Exercise I: Planning for a Middle-Aged Adult 377
Exercise II: Planning for a Child 377
Exercise III: Planning for an Infirm, Older Person 377
Exercise IV: Maintaining Your Charts 377
Exercise V: Checking Services 378
Chapter 21 Preparing for a Service Planning Conference or
Disposition Planning Meeting 379
Introduction 379
What You Will Need to Bring to the Meeting 380
Goals for the Meeting 380
Benefits of Conference Planning 381
Collaboration 382
Preparing to Present Your Case 383
Making the Presentation 383
Sample Presentation 384
Follow-Up to Meeting 385
Summary 385
Exercises: Planning 386
Exercise I: Developing a Service Directory 386
Exercise II: A Simulated Planning Meeting 386
Chapter 22 Making the Referral and Assembling the Record 387
Introduction 387
Determining Dates 388
Sample Referral Notification Form 389
The Face Sheet 390
Summary 392
Exercises: Assembling the Record 393
Chapter 23 Documentation and Recording 395
Introduction 395
The Importance of Documentation 396
Writing Contact Notes 396
Labeling the Contact 398
Documenting Service Monitoring 398
Documentation: Best Practice 399
Government Requirements 402
Do Not Be Judgmental 402
x
Contents
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Distinguish Between Facts and Impressions 403
Give a Balanced Picture of the Person 404
Provide Evidence of Agreement 404
Making Changes to the Plan 404
Summary 404
Exercises: Recording Your Meeting with the Client 405
Exercise I: Recording Client Contacts 405
Exercise II: Using Government Guidelines to Correct Errors 411
Exercise III: Spotting Recording Errors 411
Section 6
Monitoring Services and Following the Client
Chapter 24 Monitoring the Services or Treatment 413
Introduction 413
What Is Monitoring? 414
The Financial Purpose of Monitoring 414
Follow-Up 416
Collaboration with Other Agencies 416
Advocating 417
Leave the Office 418
Responding to a Crisis 419
Summary 420
Chapter 25 Developing Goals and Objectives at
the Provider Agency 421
Introduction 421
Client Participation/Collaboration 422
Make Objectives Manageable 423
Expect Positive Outcomes 423
Objectives 425
Combining Goals and Treatment Objectives 426
Finishing Touches 428
Review Dates 429
Vocabulary 430
Summary 432
Exercises: Developing Goals and Objectives 432
Exercise I 432
Exercise II 433
Exercise III 434
Exercise IV 436
Exercise V 437
Chapter 26 Terminating the Case 439
Introduction 439
A Successful Termination 440
The Discharge Summary 443
Examples 444
Summary 447
Exercises I: Termination of a Middle-Aged Adult 448
Exercises II: Termination of a Child 448
Exercises III: Termination of a Frail, Older Person 448
Exercises IV: Organizing the Record 448
Contents
xi
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Appendix A Ten Fundamental Components of Recovery 449
Appendix B Vocabulary of Emotions 451
Appendix C Wildwood Case Management Unit Forms 454
Appendix D Prochaska and DiClemente?s Stages of Change Model 487
Appendix E Work Samples 490
Appendix F Grading the Final Files 496
Appendix G Information for Understanding DSM IV TR Diagnoses 499
Appendix H Case Manager?s Toolbox 506
References 515
Index 518
xii
Contents
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Preface
In a small nonprofit agency handling cases of domestic violence, a woman answers the
phone. She assesses the caller?s concerns, accurately notes the caller?s ambivalence on
the inquiry record, and readily connects the caller to the person most able to assist.
In a mental health case management unit a new worker listens with interest to
the other case managers, the psychologist, and the psychiatrist discuss the possible
diagnosis for a new client of the agency. The worker is able to understand the conversation as the group talks about the DSM IV TR diagnosis and the new DSM 5 diagnosis.
Down the street a young man acting as a case manager in a substance abuse
detox center handles intake calls from physicians? offices. He competently notes the
main concerns for incoming patients and asks the questions he knows will give him
information that doctors and therapists will need later as they work with these new
admissions. His notes are clear and useful.
How long did it take these people to acquire these skills? Did they acquire this
ability well after being hired in a social service agency, or did they arrive able to handle
case management tasks competently?
Purpose
For me and for students, the issue has been how we can teach the social services skills
that will promote their walking from the classroom into the social service setting with
confidence. How can we be assured that students, often steeped in sound theoretical
knowledge, will be able to fill out an inquiry form or make a referral effectively?
It is important to teach these practical skills. In addition, it is important to equip
students with the vocabulary and methods used by more advanced professionals in the
human service field so that upon entering the field students are prepared to engage in
meaningful discussions around client issues. Although entry-level individuals would
not usually give a DSM diagnosis, it is useful for individuals entering the field to be
knowledgeable about what such a diagnosis is and what is meant by an Axis I or Axis II
diagnosis or how diagnoses are given using DSM 5. In this way, conversations among
professionals will not be misunderstood.
Today individuals with a sparse education or with recent college degrees are finding themselves thrust immediately into roles for which they have had little formal
training. It is crucial, therefore, to find a method for teaching the actual human service
experience at the entry level. Fundamentals of Case Management Practice: Skills for the
Human Services, fifth edition, seeks to provide that experience in a thorough, step-bystep process that leads the reader from intake through monitoring to termination.
Preface
xiii
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New in the Fifth Edition
New material has been added to this fifth edition to bring the textbook up to date.
Added to this edition:
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Current terms are used throughout
Information on the DSM 5 and how entry level individuals can use this
Recent changes to HIPAA
Expanded Appendices to include material helpful in completing exercises in the
text, a safety planning tool and a case manager?s tool box with information to
assist in assessment and disposition.
A clear look at case management as a process
A discussion of how the size of a caseload affects service
Ethical considerations for those working in the field of substance abuse
A discussion of the differences among moral, ethical, and legal behavior and how
violations are addressed
More information on the importance of mandated reporting
Expanded treatment of the ecological model
Broader section on empathy and more recent findings on empathy
An extensive feelings list in the appendix for use in various exercises
Differences between confrontation and an exchange of points of view
Enhanced discussion of motivational interviewing and why this is useful
More detail on the significance of the first interview
There are fewer chapters as some material has been combined in single chapters
In addition, a considerable number of smaller items and changes specifically requested by our reviewers were added to the textbook.
Fundamentals for Practice with High Risk Populations (Summers, 2002) has been
published as an adjunct to this text, giving students information and scenarios on
?populations in which they are interested or with whom they intend to work. Chapters
cover topics such as case management with children and their families, survivors of
rape and violence, older people, issues with drug and alcohol dependence, and mental illness and developmental disabilities. Each chapter features information about
?specific populations and provides exercises and intake forms. This textbook also contains a set of forms that can be copied (see Appendix C). These forms can be found
on CengageBrain. Taken from actual social service settings, they give the reader an
opportunity to practice accuracy and skill in handling social service forms and records
and in organizing information.
If you do not wish to cover all of the populations discussed in the text on high-risk
populations and instead want to focus on specific populations, you can order individual
chapters from Fundamentals for Practice with High Risk Populations (Summers, 2002). Please
visit http://www.textchoice2.com/ to view chapters online and to build your custom text.
You can pick chapters about specific populations and create individualized booklets that
you can bundle with this text. If you would like more information about custom options,
please contact your local customer service representative. You can locate your representative by using our rep finder at http://custom.cengage.com/.
xiv
Preface
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Format
For each chapter in the textbook, basic information is laid out, followed in most chapters by many exercises that prompt the reader to handle real issues and practice real
skills. Each of the chapters on case management describes one of the case management responsibilities followed by exercises to practice applying the information. As
readers progress through the text, they gradually assemble files on specific cases. Students can create and monitor believable fictional clients using one of the high-risk
populations discussed in Fundamentals for Practice with High Risk Populations (Summers, 2002). Classroom discussions about these cases and the best disposition for each
of them are not unlike the discussions that occur every day in a variety of social service settings.
Organization of the Textbook
The organization of the textbook follows a logical progression, beginning with the
most basic foundation for good practice, moving to discussions on attitudes, followed
by how the student will talk to others effectively. The second half of the book follows a similar process, beginning with the person?s first contact with the agency and
the assessment and planning process through all the case management procedures to
termination.
In Part One, ?Foundations for Best Practice in Case Management,? readers are
introduced to important foundation pieces for this field. A definition of case management and how it is central to social services, ethics and ethical issues, and the importance of the ecological model in assessment and planning give readers an introduction
to professional basics.
In Part Two, ?Useful Clarifications and Attitudes,? readers are invited to examine what in their thinking will impede effective helping in the social service setting.
Beginning with issues of cultural diversity and moving to the role of personal attitudes
and boundaries, this part concludes with information and exercises related to determining who owns the problem. Each chapter in this part contains exercises encouraging readers to examine realistically their own attitudes and judgments.
Part Three, ?Effective Communication,? begins by introducing the reader to
good and poor responses, with exercises that help students see the c? onsequences
of poor communication. Chapters on listening and responding, asking questions,
bringing up difficult issues, responding to emotions, confronting problematic
?
?behavior, and disarming anger are included. Included is a chapter that gives an
?expanded examination of some of the techniques and ideas related to motivational
interviewing. The section ends with a chapter on the effective application of what
students have just learned and exercises designed to have students practice all the
communication skills in order to smooth out the communication and allow it to b
? ecome
natural and responsive.
In Part Four, ?Meeting Clients and Assessing Their Strengths and Needs,?
readers begin to take inquiries for services. Forms are provided that ask for basic
Preface
xv
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