Discover the Essential Functions of a Case Manager

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs register@allce.com counselortoolbox you well hi ho there everybody. Today we are going to start talking about case management. In this presentation, which might end up being a little bit long, we're going to look at the definitions and functions of case management. We'll explore the most prominent models of case management with substance abusers as defined by the Substance Abuse and Mental Health Services Administration. We'll explore case management principles, case management in the community context, looking at the interagency perspective because a lot of times when we're doing case management with our clients, our services or our agency doesn't provide everything. So we're having to work with other agencies and we're going to talk about what that looks like and what some challenges may be. And then we're going to finish up talking about case management for clients with special needs. So what is case management? There's a lot of debate out there. Do counselors do case management? Do case managers only do case management? Do case managers do counseling? Well, the answer is yes to all of the above. And you'll find out as we talk that there are certain models of case management where the case manager does provide therapeutic services and there are certain models of case management where it's just case management or brokering and not any therapeutic services. So it really depends on the model that your agency has chosen to use. But what is case management? It's a process of assisting the patient in re establishing an awareness of internal resources such as intelligence, competence and problem solving abilities. Well, that sounds a lot like counseling. We're looking at strengths based stuff. But case managers are there to help empower and support people. Is a process of assisting the patient in establishing and negotiating lines of operation and communication between the patient and external resources. So this is one area where case management comes in where we really don't do a lot as you know, traditional counsel in traditional counseling. So case managers are going to say, okay Jim Bob, you need vocational services. How do you find those? Let's see what you know and let me see what I can teach you about what resources are available, how to access them and how to call up and get set up for services. Because many clients are not familiar with, quote the system. So it can be very intimidating and very cumbersome to negotiate. So case managers are really there as the tour guide basically and case managers advocate with those external resources in order to enhance the Continuity, accessibility, accountability, and efficiency of those resources. I'll give you an example. When I was working in Florida, our clients, when they were getting ready for discharge, needed vocational services because a lot of them hadn't been employed for a while or were underemployed. So we would refer down to workforce innovation and they would get screened and everything. And a lot of times they were not getting good jobs because of their substance abuse history. And it was incumbent upon me to advocate for them under the ADA because the clients were not currently using and they can't be discriminated against based on prior use. So up to me to advocate for them and say, you know what? These people are protected and they can't be discriminated against in employment. It was also up to me to educate the facility at that time about the fact that there were federal bonding programs that were available for hard to place employees, which a lot of our clients fell into that category. So, you know, a lot of times it's just educating and sometimes advocating going, you know what? This really needs to happen, and then negotiating. They may say, you know, there's only so much I can do, so you may have to come back with, well, how can I help? What can I do to advocate for this person and open a line of communication instead of saying, well, it's your job, you need to do it. Try to understand why they're not able to do it or why they're not willing to do it at that point in time, and then address it from that point to dispel those myths and overcome those barriers. So what's the difference between treatment and case management? Well, treatment helps clients recognize their problems, acquire motivation and tools to stay abstinent and live a healthy lifestyle and use those acquired tools. I mean, you can have all the tools in the world. I have a lot of tools down in my tool shed that I rarely use, and you know, that doesn't do any good. So you need to have tools that not only you know how to use, but you're willing to use. Case management supports clients and helps them move through the recovery continuum and reinforces treatment goals. So the case managers are out there to be the cheerleaders. They're out there to be, again, the tour guides, the people that say, okay, you developed all these skills and tools in treatment, now let's apply them in the real world. Let's make this happen. So you get your biological needs met, so you get your social needs met, so you get your physical needs met, etc. So we're going to Talk real brief. Well, not real briefly. We're going to talk some about some of the models of case management. Now the first one we're going to talk about is sort of the most sparse or the most case management oriented, if you will. And this is more of a broker or a generalist. And broker case managers are just that. They are people who sit there and go, okay, Jim Bob needs medical services. Jim Bob needs access to prescription drugs. Jim Bob needs food stamps. Jim Bob needs housing. Jim Bob needs vocational services. All right, so this is what Jim Bob needs. Let me start making phone calls and helping to connect the person with those resources. But that broker is not going to do any of the services. Brokers often don't conduct outreach or do case finding. Brokers are there and people are sent to them. So it's one of those things. They just kind of sit in their office and agencies know that they do exist. So they can refer people to the brokers who will say, all right, I will help your people with all their case management needs. Sometimes it's done on, it's reimbursable by insurance. Many times it has to be a fee for service thing. So sometimes agencies will say, we'll put you on retainer, you handle all of our clients for X number of dollars per. Other times the individual themselves has to pay out of pocket for the case management services. But it significantly shortens the process. It's like going, if you go to an attorney for a consultation to help you navigate the legal landscape of, you know, buying a house or getting a divorce or adopting a child or something. If you had to do it on your own, it would take you forever. Yes, it costs money and a bunch of money to go talk to an attorney. But if you go to an attorney, they're going to cut down the time and the frustration and make sure you actually achieve the goals that you set out. For brokers or generalists, this is what they do. Their goal is to make sure that you are able to access all of the services and resources you need to get your needs met. They provide assessment and reassessment specific to resource acquisition for current needs. So they're, they've got a checklist. It's not going to be talking about feelings and needs and, you know, all this other stuff. We're going to talk about the nitty gritty from a biopsychosocial perspective, thinking, you know, Maslow's hierarchy. What does this person need in order to be happy, healthy and independent? Goal planning is brief and related to acquiring resources. It's not going to be this in depth, three month sort of thing. It's going to be okay. You need housing. So I will refer you over to HUD and this is how you get on the Section 8 waiting list. And you know, so I want you to go ahead and make the appointment and accomplish that within the week. That's the goal. It's very simple, very straightforward. Referrals may be case management or client initiated. So sometimes the clients are not up to calling the agency and going I need an appointment, yada yada yada, for whatever reason because of cognitive abilities, because of social anxiety, because they've never done it before. So sometimes the case manager will call and say I have this client who needs to come in and get an appointment and they make a warm referral. The intermediate there, which is what I usually use, is the client will make the call, will rehearse it in the office and the client will make the call in my office to whatever agency. So I'm there to coach them and prompt them should they start to get overwhelmed. Brokers and generalists do make follow up checks to see, you know, did you go to your appointment and get on the Section 8 waiting list? Did you go and get signed up for food stamps? They're going to make sure the client follows through, but that's kind of about it. It's here's a task, did you accomplish it? They make referrals as needed for services outside the scope of case management, which is pretty much, you know, everything. So if a person needs counseling, they're going to refer to a therapist or a clinic. If the person needs medical services, obviously the case manager isn't a physician. So the case manager is going to refer to the local health department or something. They respond to crises with related resources. The broker or generalist is not a crisis interventionist. If there's a crisis of some sort, the broker is going to find the resources necessary. They'll hook the person up with a shelter. If for some reason they lose their housing. They'll hook them up with churches if maybe their food stamps ran out and they still need week of food to get through the month. If it's a mental health crisis, they'll hook them up with the local crisis intervention hotline and or crisis stabilization unit. So they're not providing the services, they're making the connection, they're making the linkage between the client and the services. So the strengths based perspective of case management is a lot more touchy feely if you will. They may do outreach and case Finding and when strengths based case managers do assessments, they're looking for individual strengths rather than pathology to serve as the focus for work. So if they're working with somebody who's depressed, for example, or using substances, they're going to say, all right, what have you done in the past that has helped you not use or help you feel happy? What have you done in the past that is helped you have the quality of life that you want? Let's work on those strengths now. You know, maybe going to counseling has been part of it so they can deal with their stuff. The strengths based case manager does not provide counseling, but they help the client see the strengths or the tools that they've already acquired in their toolbox and use them more effectively to address their current situation. The strengths perspective is client driven teaching goal setting for achieving life's goals. So we're going to sit down and we're going to say, what does a rich and meaningful life look like to you? Where do you want to be six months from now? All right, how do you make that happen? And generally with a strengths based perspective, depending on the client's cognitive levels, you're going to use Socratic questioning to help guide them into setting their own goals. You're going to guide them into setting their own objectives. So you say, all right, this is your end goal. So what's the first thing you need to do? All right, what next? All right, what next? And if they choose something for the what next that seems a little bit out in left field, then the case manager can suggest, you know, that's, that's one way you can do it, but that might be too much for the next step. What do you think about doing this, that or the other thing? So case managers are there to teach goal setting, not to set goals for the clients. Strengths based perspectives support what's called the dignity of risk, which assumes that we all, regardless of our ability or disability status, have the right to try, to fail, to succeed and to experience. So the strengths based case manager isn't going to protect and shield from everything. You know, they may say, why don't you go try doing that and see how it works out. And if you have problems, then let's talk about it. You know, come back and you know, in our next session we'll talk about how to do it differently. But we're encouraging people to become self efficacious so they feel like they have control, they feel like they can do the tasks necessary for life. Referrals may be client or case manager initiated again Depending on the client's cognitive and emotional status, there's close monitoring of referrals in the strengths perspective. So this person is a little bit more involved than the broker. They provide education about strengths identification and how to access resources. So we're going to talk about, you know, how do you figure out what a strength is? You know, when a problem comes up, how do you even begin to think about how to solve it? Well, the first step is to look how you've solved it in the past. And if you haven't solved it in the past, how have you solved similar things in the past? And if you haven't solved similar things in the past, how has someone you know solved this or similar things in the past? So looking for the knowledge that they already have, because knowledge is a tool, knowledge is a strength, then developing it from there and encouraging clients to look at not their deficits, but their strengths. What skills and tools and abilities and characteristics do they have that have helped them get to where they are right now? Let's build on those. Instead of trying to do something completely different. It helps develop informal resources such as neighbors, church, family, support systems. So the strengths perspective not only looks at the individual strengths, but it looks at the individual's biopsychosocial strengths. And we say, all right, what do you have going for you in your support system? Who can you rely on? What resources do you have that you can tap into to help you with your kids, to help you get transportation to your appointments, to help you find a job? You know, some. Sometimes finding a job is about knowing somebody. So how can you start using your support system in a way that's helpful? Not using them maliciously, but you know, how can you tap into your support system and how can you strengthen that support system? Because it's not all about take, take, take. You got to give, give, give some strengths perspective, responds to crises related to both resource needs and mental health concerns and is active in stabilization and then referral. So the strengths based case manager is decent at crisis intervention. They're not going to provide counseling. They're going to help the client get stabilized and then make the referral to counseling or wherever. Remember, crises aren't always mental health. They can be substance abuse. If the person slips and uses, the case manager will help get them stabilized, figure out if they need detox, and then make referrals from there on. If the client is triggered and starts feeling like they're going to slip or relapse again, the case manager may be able to help them see relapse warning signs and make referrals as necessary in order to help the client get stabilized. They're not providing the treatment, but they're helping the client identify needs and access resources. Strengths perspective provides services crucial to preparing the client for resource acquisition, such as role playing and accompanying clients to interviews. So they are the cheerleaders, even more so than the broker. The strengths based case manager is community based. They're going to role play, you know, making appointments, they're going to role play job interviews, they're going to role play, you know, whatever types of things that the client has to achieve or client has to do in order to acquire their resources. They're probably going to role play that. Some of our clients where I used to work had never ridden the bus before. So the case managers would teach them how to read the bus schedule, how to go out, get on the bus and get to where you were supposed to be, because that was really overwhelming for a lot of our clients. But they would accompany them the first time and then the second time. The client usually had it down and it was no big deal, but it was just getting over that anxiety of doing something they'd never done. The strengths perspective, to reiterate, is just like it sounds. We're going to build on the strengths and creativity that has helped the client survive and grow until now. Instead of focusing on their pathology and deficits, we're going to make referrals so they can access counseling, for example, to help them with substance abuse or mental health issues. But the case manager is going to say, all right, you're seeking treatment, that's great. Let's look at the rest of your life and how can we make that even more awesome while you're over here working with a counselor too? The clinical or rehabilitation model is obviously much more clinical in nature. They often engage in case finding. Assessment for clinical is broad and biopsychosocial. You know, this is more like counseling. Comprehensive goals may include any life areas from communication to relationships to vocational to mental health to physical health. You know, the whole range. Housing anything's fair game if it is going to help the person achieve a high quality of life. Referrals to resources are integrated into a package of case management services. So the rehabilitation model says, all right, these are all the services that we can offer you. There's close involvement in ongoing client resource relationships. So we want to make sure that, you know, there's a certain person at this particular agency or there's a certain person in your particular agency that you refer to. It's not just this faceless department. Provision of therapeutic activities is central to the model. So we want to make sure that the client is receiving therapy for their substance abuse or their mental health or their cognitive issues. There's an emphasis on family and self help support via therapeutic activities. So we want to get families involved. We want to make sure that the person isn't an island unto themselves. I remember one client I worked with, wonderful, wonderful older lady, probably, I can't remember, early 60s, wicked crack problem, you know, and she was really trying to get it under control. But she also had comorbid schizophrenia. So she struggled to, you know, manage her medication and stay clean and all that kind of stuff. And one of the things, she didn't have family, she lived by herself. So encouraging her to reach out and find support systems and interact with people in self help groups so she had somebody she could call. Because you can't call the case manager 247365 or the therapist. You need to have resources in the community so when you're feeling depressed, when you're feeling like you're going to relapse, you have someone to reach out to. So the clinical rehabilitation model really looks at biopsychosocial rehabilitation. It responds to crises related both to resource needs such as housing, food, medication and mental illness. It's active in stabilization and further therapeutic intervention. So the clinical case managers don't just stabilize and refer, they stabilize and counsel. There's more therapeutic intervention there. They use assertive advocacy and will pursue multiple administrative levels within an agency if needed. So they tend to be the kind of the bulldogs. And this is the model obviously that I came from. So if you go to that first level person and they say this is just not a client we can work with, we can't help them. And you know in your heart that there is something the client can get out of it. This client can be gainfully employed or this client. Another example, I had one psychiatrist I worked with who insisted that clients were not going to get any mental health medications, psychotropic medications, until they'd been clean for six months. And I kept scratching my head and I'm like, okay doc, you got somebody who's clean and sober and clinically depressed or having panic attacks every single day, multiple times a day. They ain't going to stay clean and sober for six months. They're never going to meet that goal. So you know, this was a. Before the co occurring philosophy became much more prominent and he was an older psychiatrist. So I had to advocate for my clients not only with him, but with the medical director in order to try to get my clients stabilized on non addictive medications. But the ones who needed it, like for depression or for anxiety, you can use SSRIs and some other medications that are non addictive for anxiety and depression. And a lot of my clients really benefited from a short course, not all of them, but from a short course of antidepressant medications to help them through that period where their brain was rebalancing. So advocacy is really important. And it was important for me to go back to the client who felt like they'd been shut down and told that they were med seeking and, you know, pathologized to go back and work with them and advocate with them and help them understand that, you know, not everybody is on the bandwagon. So sometimes you have to advocate for yourself. And then we would role play what that advocacy would look like henceforth. Another thing in clinical rehabilitation, I worked in an agency that provided comprehensive services, so it was a lot easier. But when my clients were having medication side effects, I would encourage them to talk to their doctors. Most of the time that wouldn't happen. They'd go in, they'd say yes or no to anything the doctor asked them, which was usually very little, and out the door 10 minutes or under. If the client was having side effects, we would make a list of all the side effects the client was having that were bothersome. And I would say, you need to take this and give it to the doctor so he can see what's going on and put it in your chart. And I would encourage them, when they went to other physicians for other problems, you know, write down their symptoms so they don't forget to tell them something or they don't get kind of tongue tied, hand it to the doctor and say, this is what's going on, Doc. Help me out. So helping clients not only by advocating for them and going to higher levels if necessary, but also teaching them how to advocate for themselves and not take it personally if one service provider tells them no or is sometimes unfortunately unpleasant. Assertive community treatment is another wonderful program that we had where I was, and they may engage in case finding. The assessment, again, is broad and psychosocial, and it's targeted to clients who are high resource utilizers. These are clients who are generally severely and persistently mentally ill and or sometimes severely and persistently relapsing in terms of their substance abuse. So we want to look at some of these clients who really struggle. You know, they may do well in residential, and as soon as they get out, they've got a month of clean time and then they're back and they've been through treatment. I had one client that went, went through treatment or went through detox 14 times in a year. And we want to stop that cycle. So assertive community treatment comes in really helpful. The comprehensive goals again can include any life area and it's provided by a multidisciplinary team with low client staff ratio. So that's usually 10 to 1. Why? Because the case manager is making contact with each client at least three or four times a week, if not every single day during the week to make sure they're taking their meds, make sure that they're bathing, yada yada. As the program goes on, you know, those meetings are weaned down, so it's only down to once a week and then, you know, maybe once every other week and then they're discharged from the assertive community treatment program into more of an aftercare program or a lower intensity case management program. But the ACT program, wonderful at making sure clients transition from residential to, you know, some form of outpatient without having a hiccup, because that's a pretty significant change, whether it's residential mental health or residential substance abuse. You're in a safe, controlled environment and then all of a sudden you're not. Even if the person is in intensive outpatient where they're in treatment three hours a day, five days a week, you still have the other 21 hours a day that they need to be able to stay clean, sober and relatively happy. So assertive community treatment helps maintain that most services are provided in the community and often in the client's homes rather than in the office. And it can be done on a 24 hour basis. So assertive community treatment is going to have somebody on call in case a client destabilizes at 2am Most services are provided by the team rather than brokered out. So instead of saying, we've got a doctor here and a counselor over at this agency and yada yada, it's all going to be within the same organization and everybody's literally on the same team. You have the team meetings, you staff the clients on a weekly basis. Intensive case management and assertive community treatment was developed to meet the needs of high users and referrals to resources are integrated into a broad package of case management services, including, you know, having that case manager go out and check in on the clients and do a home safety survey. And, you know, there the things that the case manager can do are Pretty much limitless if they are linked to, to the goals set by the client and the treatment team for improving their quality of life. There is a close involvement in the ongoing client resource relationship in assertive community treatment. You know, you're not going to have Jim Bob go to an agency where he sees a different psychiatrist every single month. You know, it's going to be the same psychiatrist which is on your team, because then we can see small changes and intervene early before there is a necessary problem. Provides many therapeutic services beyond resource acquisition with a unified package of treatment services. This can include drop in centers, clubhouses, shelters. You know, there are a variety of things that can be included. Response to crises related to both resource needs and mental health concerns. And is active in stabilization. But then refers to, you know, the appropriate agency. Assertive advocacy will pursue multiple administrative levels within an agency. So again, just like in the clinical rehabilitation model, the advocacy is even more assertive in the assertive community treatment model. Making sure that we are getting other agencies and all the resources needed in the community on board. Because you can't provide everything through your agency. I mean, your agency is not going to provide housing, but you need to have a delegate from Housing and Urban Development maybe on the team. Key features of assertive community treatment is making contact with clients in their homes and natural settings. Focusing on the practical problems of daily living. Assertive advocacy, manageable caseloads, frequent contact between the case manager and client. A team approach with shared caseloads. So the counselor that's on the team is going to be seeing the same 10 clients as the case manager on the team, as is the psychiatrist on the team. And long term commitment to clients. Clients who qualify for assertive community treatment are not six week clients. These are clients who are typically going to be in assertive community treatment for a year, 18 months or more. So you have all these different models and your agency is going to choose, number one, what works for them, number two, what they can bill for. Because if you provide, you know, outpatient services or even intensive outpatient services, you're probably not going to need assertive community treatment for your clients. You're probably going to be able to do with either a clinical rehabilitation model or a strengths based model, or even a brokerage model. If you just provide individual outpatient services, then a brokerage model is probably fine. Where you refer out, you say, you know, it sounds like you've got a bunch of needs you need to get met. Here's, you know, the case manager that we use, go talk to them and they will help you get linked with resources. So anyway, your agency determines the model it's going to use, and then we need to look at how do you expand the network of services. Like I said, even with act, you're not going to be provide. Your agency is not going to be providing housing. Most likely, every once in a while you get a grant, but that's a whole different story. So you say, how can I get somebody on this team that can help clients get to housing? Well, you need a delegate from housing and Urban development, You need a delegate from the health department. You need a delegate from any of those other resources that your agency doesn't actually provide. You need to get them on the team. In a single agency model, the case manager establishes a series of distinctive relationships that are based and used on an as needed basis. So you're going to have these relationships with these other agencies and people. And as appropriate, for each individual case, you may call them. In the informal partnership model, staff members from several agencies work as a collaborative team. So you may have somebody over at Housing and urban development or social services that identifies that this person really needs case management intervention. And they'll refer to your case management team and you all work together. But it's informal. There's not any contracts or anything. You just have really good relationships. The formal consortium binds case managers and service providers with formal written agreements called memorandums of understanding. And basically those say this agency agrees to do X, Y and z, and if they don't, these are the consequences. And everybody signs their memorandums of understanding. So you understand what each agency can and will provide and is responsible for providing. And if it doesn't happen, then you can advocate and follow up. Case management principles. Case management offers a client a single point of contact within the health and social service systems. So think about clients that you've worked with. And you know, we didn't have case managers where I was, where I worked as a therapist. So we were often referring clients out and it became somewhat cumbersome for them. You know, I'd have clients coming in and telling me they had an appointment here, an appointment here, an appointment here, their social service appointment. They were getting appointments from every provider and nothing was coordinated. The case manager or the case management philosophy says, okay, there's one single point of contact that helps identify the resource needs and refers out. And referral sources report back to that one single point of contact. And then everybody can communicate with that single point of contact to figure out how Jim Bob's doing. Case management is driven by clients and their needs and involves advocacy. It's community based, it's practical. You know, it doesn't set lofty goals. It says, what do you need right now to have the highest quality of life? It can be childcare, it can be respite services, it can be transportation. You know, again, it's limitless. We want to look at what does this person need to have a high quality of life. It's anticipatory. So we don't wait until the person's insurance gets canceled and then they need a medication refill. We say, you know what, you're on these particular medications and when you get discharged from this facility, you know, we're not going to be providing those meds anymore. So you're going to need to have some sort of prescription drug coverage. So let's look at that to make sure that when you move to your next step, you have the resources necessary. It can be anticipatory in terms of saying you just got out of detox or residential. And this is a really high risk time for relapse. So what can you do to prevent relapse? And let's make a plan for what resources can you use to help you stay clean, safe and sober. It's flexible, sometimes the best laid plans. So case management can drop back and punt. If the client's doing really well and then they relapse or they have a death in the family, or they have a, you know, depressive or psychotic episode or whatever, the plan is not going to go forward as it was supposed to, so to speak. So the case manager says, alright, let's drop back and punt. Let's see why this happened, tune up our plan and prevent it from happening again, and then pick right back up and go. So it's not just written in stone that this is the way it has to be. It flexes like any good treatment plan, it flexes with the clients and their needs and adapts in order to grow with the clients. And it's culturally sensitive. Not every client is going to embrace the 12 steps. Not every client is going to be okay with religion. Not every client is going to be okay with taking meds. Some clients will want their family really involved. Other clients are much more independent. So we need to be sensitive to the client's culture as they define it. Just because someone is African American or Asian or Hispanic doesn't mean necessarily that they embrace all those cultural ideals of that culture. So we want to see, you know, in general, we know what this, the principles are of this culture. We want to See where this person's at in terms of their embracing that culture. Maybe they don't embrace it at all. Maybe they are completely immersed in it. So we want to see what works for that client. Do you want your family involved? Who makes decisions about your treatment? You know, all those things that we need to consider. The referral function in case management establishes and maintains relations with civic groups, agencies, other professionals, governmental entities like social services and Department of Children and Families and the community at large. So the churches, the libraries, to ensure appropriate referrals, identify service gaps, expand community resources, and help address unmet needs. You know, where I'm at right now is different than where I came from, where we had one central food pantry that was, you know, people could go to to get food once a month. Here, it's based much more out of the different churches because there was a gap in that service. You know, the people who were involved, the movers and shakers in this community, so to speak, said this is a service gap. Let's work with the churches or, you know, who is willing to maintain a food pantry and, you know, what are the requirements? You have to set requirements for who can get food and what they can get and all that kind of stuff. So they worked together to determine what the service gaps were, brainstorm ways to fill that service gap. Again, where I came from was a university town where we had interns coming out of our ears, so volunteer hours were, you know, a dime a dozen. So when we had a service gap, especially like a case management service gap, it was easy to create a program where students could get training and get credit for volunteer hours or even for class hours for participating in the program and serving as a case manager or something. So you need to be creative. You want to continuously assess and evaluate referral resources to determine their appropriateness. Sometimes they're going to just not be meeting up to what your clients need. And if there's no memorandum of understanding, you know, you can't enforce it. Whatever, you know, sometimes you may need to find another referral source. Sometimes it's the only thing on the block, and then you need to do some advocacy. So if you're having challenges in your referral functions, for example with social services and food stamps, you know, you want to find out what those challenges are and try to brainstorm ways to make that more effective. Because you can't refer people somewhere else to get food stamps. There's just one place to go. You want to differentiate between situations in which it's more appropriate for the client to self Refer to a resource than those in which a counselor referral is required. So making an appointment for food stamps, making an appointment for a physical, making an appointment to go to detox, whatever. Well, for detox, it depends on how inebriated they are. But sometimes and whenever possible, the client should be the one to make their own appointments because that inspires commitment, that inspires motivation, and it inspires a sense of confidence. Like, hey, I did that. That wasn't so scary. Because many clients have issues with authority and the system, and it's scary. So we want to help them navigate it themselves and kind of serve as a cheerleader. But we're also there to help should they need assistance. A counselor referral may be required. You know, if the client needs medication, for example, it's much easier to do the handoff to the psychiatrist if we can, you know, send over certain records and let the psychiatrist know. This is why I'm making the referral. So when Jane gets there, she doesn't have to reiterate everything because that's painful in and of itself. So think about, is this something that I have information that would be helpful and facilitate the process, or is this something where the client really already has all the information and they can do themselves? They may just need some encouragement. You want to arrange referrals to other professionals, agencies, community programs, or other appropriate resources to meet client needs. Explain in clear and specific language the necessity for and process of referral to increase the client likelihood of understanding and follow through. So why am I sending you to this particular provider? Why am I sending you to vocational resources? Because, you know, you need to get a job in order to fulfill your requirements of your probation or whatever, you know, why are you making the referral? Why is it important the person follows through in order to in a way that's going to help them meet their goals? So if they want to get off papers or if they want to stay clean and sober, or if they want to move to, you know, a better housing situation, how is this referral going to help them meet their goals? You know, you're making this referral. What's in it for them? Exchange relevant information with the agency or professional to whom the referral is being made in a manner consistent with confidentiality, regulations and professional standards of care. So in terms of case coordination, we have a little bit of wiggle room. In hipaa, it's best always if you can get a signed release of information. But once a client is a client for you, and maybe a client at a doctor's office, you know, the psychiatrist's office, then you have more ability to communicate with them without having to have a release of information signed under case coordination. Check with your legal office about how they want those handled. And even once you make referrals, another important thing is to evaluate the outcome of the referral. So if the client doesn't go, why not? If they went and they sat there for 45 minutes and left because they were never attended to, you know, that's important information. If they went and felt like they didn't get anywhere, that's important information. If they went and it was successful, that's important information. So that'll help you not only help the client, but also determine how useful that resource is going to be in the future for other clients. Service coordination, you want to initiate collaboration with the referral source. Review and interpret all relevant assessment and initial treatment plan information. So you're going to get that information and you're going to look at it and go, is this a client I can help? Is this a client that qualifies for services here? And what is it that I think I can do to help this client? You'll confirm the client's eligibility for admission and readiness for treatment, Complete necessary administrative procedures for admission to treatment. So like when clients were admitting to my residential program before they could come in and they had to have a physical done, they had to have a TB test done and they had to have a drug screening done, and we needed to make sure that they had no drugs in their system and if they did, they had to go to detox and they had those other two health requirements marked. They also needed to have a 30 day supply of any medications that they were already on. And there were a couple other things. So a case manager would help the client make sure they had all their proverbial ducks in a row. So when it was time for admission into my treatment facility, the client was good to go. Service coordination establishes realistic treatment and recovery expectations with the client and involves significant others, including, but not limited to, program goals. So clients are enrolled in this program. I am not guaranteeing they're going to stay clean. I am not guaranteeing they're not going to have another psychotic episode. What I am guaranteeing is that we're going to look at all their needs and try to help them get access to as many resources as possible. Everybody, the client and the family members, the supporters that are involved in the program, need to know program procedures, rules regarding client conduct, the schedule of treatment activities, costs of treatment, factors affecting the duration of care, client rights and responsibilities, and coordinate all treatment activities with services provided to the client by other resources. So basically the case manager is saying, doing the orientation, if you will, this is what's going on. If you sign up for this program, this is what you're looking at. This is how you have to behave. This is what you can expect, this is what the cost is. These are your rights and responsibilities. You know, making sure the client is giving truly informed consent and that the receiving program has someone coming in who has their eyes wide open. The consulting function of case managers in a consulting role, we summarize the client's personal and cultural background, treatment plan, recovery progress and problems inhibiting progress for the purposes of ensuring quality care, gaining feedback and planning changes in the course of treatment. So the case manager may come in and get everybody that's involved in this client's care together on a conference call or in the same room and say, you know what guys, this client seems to be stuck or relapsing or maybe ready for discharge, whatever. And here's all the information about the client. What are your feelings? What do you think needs to happen? The case manager needs to understand the terminology, procedures and roles of other disciplines related to the treatment of substance abuse and mental health disorders. So if they're talking about intensive outpatient versus partial hospitalization or a level four recovery home versus a level two recovery home, the case manager needs to understand what that means. And by the way, the levels of recovery home, if you go to nar, the national association of Recovery Residences, you can find a nice little chart that delineates what's available at each level of recovery residents. And as a little bit of an aside, if you don't know, Level 3 and Level 4 recovery residences in some cases with some private insurances can be reimbursed so you can have a client there where the insurance company is paying for them to be in a recovery residence as opposed to residential care. Anyhow, the consultant contributes as part of a multidisciplinary treatment team, applies confidentiality regulations appropriately, and demonstrates respect and non judgmental attitudes towards clients in all contacts with community professionals and agencies. So it's important you know, when you're working with clients, you're going to have some that are your favorites. You know, you're not supposed to, but it happens. Let's just be realistic. And you're going to have some clients that really are frustrating for whatever reason. And you can imagine that if you're frustrated with them, they're probably frustrated with you and, or the process. So you want to be empathetic as much as possible, but you want to make sure that you present a nonjudgmental attitude about this client to each referral source. Instead of going, oh, you're going to have your hands full when you get this one. No, that's not appropriate. So you want to be objective in the information that you provide, the referral sources, the advocacy function. So it's not just linkages. You know, you consult, you advocate, you coordinate services. Advocacy can be precipitated by any one of a number of events, such as a client being refused resources because of discrimination, whether discrimination is based on some intrinsic aspect of the client, such as gender or ethnicity, or the nature of the client's problems, such as addiction. Another example, the facility I used to work for, we had a crisis stabilization unit where people went for involuntary commitment or voluntary commitment if they were suicidal or homicidal. And we had a detox unit where clients went when they were under the influence. Well, it's not unusual to get a client who is suicidal and stoned out of his mind. So which facility would take them? And the client became a proverbial hot potato because the detox nurses would say, we can't handle, you know, aggressive behavior, or if the client gets suicidal, we can't handle that. And the nurses over at CSU would say, we can't handle detoxification symptoms. So ultimately, through advocacy, we had to work out a set procedure. So if we had a client who, you know, was more suicidal than they were drunk or high, they went over to csu. But this detox nurse went over and evaluated the client once every four hours. So there are ways to work around it, but advocacy is important. Another instance of discrimination. Some treatment programs will not accept clients that have certain diagnoses, such as borderline personality disorder, or are on certain medications like benzodiazepines. So it's important to be aware what the rules and regulations are. Sometimes it's because the agency is not equipped to handle it, and other times it's more of an arbitrary policy that may need to be reassessed. Clients being refused services despite meeting eligibility requirements also may require advocacy. I had a client one time who'd been in our program seven times, left on his own volition six times against medical advice, and was back for an eighth time wanting admission. And the general sense at that point was, no, this person needed to be referred somewhere else, but he met eligibility requirements, so we had to admit him. And he discharged, you know, four days later because, you know, he was Ready a client being discharged from services for reasons outside the rules or guidelines of that service. So if you have a client who seems to be discharged arbitrarily, it's going to be important to go back and make sure there's documentation to make sure they weren't discharged. For some unknown reason. A client may be refused services because they were previously accessed but not utilized. So again, like the client that I was referring to that left against medical advice multiple times. The decision was, you know, let's let somebody take this slot who's going to stay through the entire treatment program. But you know, we weren't able to do that. So we needed to let him in and give him a shot. The case managers believe that a service can be broadened to include the client's needs without compromising the basic nature of the service. Again, perfect example, when we opened our unit that allowed or that housed veterans, a lot of the veterans were on benzodiazepines. And up until then we had been a benzo free facility. But once they came, the VA was prescribing them benzos. And so we had to adapt our policies in order to be able to accommodate that. We weren't prescribing them, they weren't quote, addicted to them, they were taking them as prescribed, which was typically something we had not allowed in our facility before. So, you know, we needed to broaden our services. Case management functions during treatment during primary treatment, the case manager must motivate the client to remain engaged and progress in treatment. It's the cheerleader, they're the person that's going to go, okay, I know you're tired of going to these groups. You're tired of doing chores, you're tired of whatever. Let's look at why you're here. Let's look at the progress you've made and use those decisional balance exercises and motivational interviewing techniques. The case manager organizes the timing and application of services to facilitate client success. So again, you know, I'm not a case manager, but we had another program where we had clients who were allowed early release from jail, extended limits of confinement for their last 60 days in order to get treatment services. So they were basically serving their time while they were in treatment. We arranged the timing of that. But sometimes clients had other pending charges or jail sentence in another county. And it didn't make any sense to have them complete, finish their sentence in our county, go through treatment and then go back to jail. Because we know jail undoes a lot of treatment benefits. So we would work with the other county to try to facilitate, you know, them getting either time served or whatever. So when they eventually did come to our program, they weren't going back to jail when they finished, but they were going out into the community. You want to provide support during transitions. One of the things that's important if you're going to reduce intensity. For example, you have a client who's on probation and they're getting drug tested on probation, and they've got to go so many times a week, and they're in residential, all right, so now we're getting ready to discharge them from residential. We don't want probation to also reduce the intensity of services. At the same time, we want that to stay high. So we're only having a gradual change the amount of structure in their day. Then once they're stabilized with being, you know, in outpatient services, then probation can reduce the amount of times that they're observing or whatever. Probation, when the person leaves to go to outpatient, may actually increase the number, the frequency of reporting in order to help monitor the client better. So you want to work with the timing of services, develop external support structures to facilitate sustained community integration. So how can we help this person get a job? How can we help this person get to their job? You know, when you think about a job, people need training, they need job skills, they need a job, and they need transportation to and from the job, and they need clothing to wear at the job. A lot of jobs require, you know, khakis and a button up or require a suit or, you know, people who are coming out of substance abuse treatment may not, or mental health treatment may not have money to buy a specific uniform. So we want to be able to make sure that they can access somehow their uniform so they can get a job and be integrated. We want to reduce the client's internal barriers, such as depression, anxiety, low motivation anger, as well as external barriers which may impede progress. So looking at external barriers, if they've got pending criminal charges, if they've got a chaotic, domestically violent relationship, if they've got a child who is chronically ill for some reason, you know, we want to look at all these barriers that could add stress or impede progress and help them figure out how to deal with those, enhance and maintain motivation and again, ensure that supervision activities in the criminal justice system don't go down at the same time that intensity of clinical services goes down, because that's just too loosey goosey. Disengagement and aftercare is the final place. And you want to summarize the client's progress, assist in generalizing skills. You know, how do you problem solve if you start having a problem with your boss again, how might you handle it if you have problems with other people? How can you use what you know about from this situation to handle disagreements with other people? Ensure supports and resources are in place, Assist the client in anticipating future needs that can include medical care, housing, food, you know, the whole works and effectively close the relationship so you're not just, you know, there one day and not there the next. You're saying, all right, you know, this is a summary. You've done a great job. It's been a pleasure knowing you. If you need anything else, you know, here's how to get in touch with me, or here's how you get back into the process. Forging linkages is another thing case managers do. They find linkages to make with public health departments, the United Way and county governments and other social welfare, housing, vocational and other services offered in the community. So you're going to figure out what your clients need. Then you're going to go out and say, hey, my clients need your service. What are your qualifications, you know, in order to accept them? What services do you provide and how can we make this a mutually beneficial relationship? You don't want to just be referring people out to drain other services, you know, without being able to take some on. Ideally, you want to create a balanced relationship with these linkages. Like I said, if you use a formal structure, you use what's called a memorandum of understanding that ensures continuity of services during staff turnover. So if you work at a clinic where there's 15 counselors and this agency is regularly referring to your counseling staff, and you have three counselors, quit. Well, you can't say, well, I can't see your people right now because we have a staff shortage. You know, you have to be able to ensure continuity of services for the people who were being seen by those three counselors, as well as anybody else who needs services. You want to clarify lines of authority and control over various aspects of the case management process. Who's doing what, who's responsible for managing the service plan, who's responsible for billing for this service or whatever. You want to record commitments for providing or funding case management resources, such as, you know, you may provide staffing for the for that service. You may provide operating funds to a department or to an agency to fund the case management process. So like I said, if you have your agency refers to agency B over here, you may provide them, you know, $2,000 a month to provide case management services to your clients. And how do you provide client referrals? You want to ensure that you provide a formal record of agencies agreements and responsibilities. And MOUs help you hold other agencies accountable. So if they start slacking, not seeing your clients, you know, I wish it didn't happen, but it does. Sometimes when there's, you know, turnover or when there's not enough communication, or, you know, when there's adversity, sometimes linkages can get a little bit unlinked. So it's important to hold agencies accountable, but also to figure out how to work through your disagreements. Factors impacting agency ability to partner social services agencies, number type, historic responsiveness to clients with substance abuse problems, their openness to case management and their relationships with each other. If there's only one social service agency providing these services in your, you know, area, then they may pretty much have to be the one that you partner with. But there may be like where I came from, there were four that provided relatively similar services. Slightly different niches, but relatively similar services. And so figuring out, you know, who do we partner with or who's willing to partner with us and how can we forge a beneficial relationship. Sometimes it came down to we share clients that have similar payors, similar insurance, community leader support for or neglect of substance abuse treatment and their response to case management concepts. If community leaders are on board, then you can get a lot more community funding. You can get a lot more agency buy in from community agencies. If the community leaders are going, we need to band together and create this recovery oriented support net the economic situation in the community. Sometimes each agency is already stretched to its absolute maximum and they can't see how they can do one more thing ethically and effectively. The social climate may or may not support partnering. Geographical considerations, you know, if you have a large community, you may, you know, not be able to partner and refer people to a particular agency because the travel distance is just too far. The agency that I worked for, we encompassed a 13 county area which went from the Florida border all the way down to Ocala and east and west in between, we covered all of that. But our main services and our psychiatrists were based in Gainesville. So when we referred clients, you know, somebody who was up in Jasper, which is up near the border, that would have been a two hour drive for them to go down and see the psychiatrist in Gainesville. That's not practical. So we need to find other agencies in the Jasper area that can partner and provide services. Legal and ethical issues, you know, what's going to be best for this client. And you want to make sure you're not engaging in patient brokering. Most states are starting to create state statutes that forbid patient brokering. Florida has the, I believe they were the first one to write the law against patient brokering. So you can use that as a model funding for programs, startup and continuation. Again, if the agency doesn't have any money and they don't have any resources, then they can't do it. So how can you find funding for this? A lot of times grants from private foundations can be used on a shoestring budget to work, to train volunteers to do some case management activities. You know, that's a low budget way of doing it, but there are some ways. But if there's no funding, you know, agencies just can't do it out of the goodness of their heart and keep their doors open. And there needs to be incentives for entering into an interagency agreement. Again, you can't create an agreement where you go, you know, I have all these clients that are really high service utilizers, so I want to give them to you. Well, you know, if they can bill for every single one of those services, that might be great for them. But if they can't, you know, there's going to be some quid pro quo, you know, so, all right, we take your case management services, but we also, you know, our clients need counseling and so can we refer our clients to your services and create a, you know, a give and take so everybody benefits and the clients to boot. Culturally competent case management requires the ability to be self aware, the ability to identify differences as an issue, and not just ethnicity, but religion, sexual orientation, religious beliefs, the whole gamut. You want to recognize that you are different from every single person that walks in your office. The ability to accept others as they are, to see clients as individuals and not just as members of a group. Because remember, it's stereotyping. If you say that all people who are Hispanic behave this way and believe this way, it is a generalization. If you say the Hispanic culture typically behaves this way and believes this way about this particular thing. Now you as an individual, what do you think? Because everyone's an individual. So knowing your cultural dynamics is important to give you a launch pad to kind of know what issues might come up. But that doesn't guarantee they're going to come up with any individual. Culturally competent case managers are willing to advocate for people and have the ability to understand culturally specific responses to problems. So some cultures may tend to somaticize more they may tend to have more physical complaints than mental health complaints because mental health complaints are seen as greatly shameful. So understanding when they have problems and how they respond to different things. Case Management with clients who are HIV positive There are certain challenges when dealing with clients who have HIV or aids. Providers and other clients often still fear contracting hiv. So education is paramount. There's the dual stigma of being a person with both drug abuse problems and HIV because both are often looked down on in society. So we need to advocate and destigmatize what's going on. Both HIV and substance abuse, but HIV is progressive and debilitating. So, you know, as clients progress from HIV to full blown aids, they're going to have some changes in their cognitive status, in their mental health, mental health status, in their physical health status that need to be dealt with. They often have a complex array of medical, especially pharmacological interventions that are being used. And the side effects of some of those medications are doozies. Sometimes it makes them exhausted, sometimes it makes them gain weight, sometimes it makes them, you know, a variety nauseous, that's another one. So being aware of the side effects and helping the client manage those side effects so they can remain treatment compliant. The onerous financial consequences of the disease and of treatment, you know, it gets expensive for clients to take care of themselves and afford their medications. And as their disease progresses, they're probably not going to be earning as much because they're not able to. So they have reduced income and increased medical bills. So the case manager needs to help them balance that out. And there's hopelessness and a lack of motivation for treatment among the terminally illness. So we need to make sure that we address some of that. Now, whether it's the case manager or referring out to a clinician or a spiritual advisor who can help them deal with that, we do need to be aware of the hopelessness which can sometimes present as a lack of motivation or resistance. A team approach is particularly useful in combating the feelings of frustration, abandonment, grief over identification with the client. You know, this is a really challenging population to work with because you know that they are going to at some point pass away. So you have some grief. You may see this person who is just awesome and be devastated at the fact that their life may be cut shorter than it probably could have been. Now people with HIV are living much longer lives now. There's a sense of abandonment sometimes that the case manager or even the clinician is kind of out there on their own with the client and they can't seem to get help from anywhere. So it's important to work as a team approach to figure out how to advocate. Sometimes you feel like you're constantly advocating and nobody's on your side. So this team approach is really helpful to keeping things in perspective and, and diffusing some of the stress and obligations to avoid staff burnout. Providers should avoid designating the same individual as a case manager for all clients with AIDS and hiv. So if you have a client, you know, each person should be skilled at working with clients with HIV and aids. However, you don't want one person to handle all those cases. And ideally you want people to have a break so they have somebody who is somebody or somebody's on their caseload who are HIV positive. When those clients move off of their caseload, other clients are put back on their caseload that are not HIV positive to give them a respite, give them a break. Some people just love working with this population. So you need to work and identify the specific characteristics of that particular case manager. But sometimes, you know, the supervisor has to advocate and say, you know what, you have been going gangbusters for three years on these cases. Let's, you know, at least cut your caseload in half so only half your clients have HIV and so you have a little bit more breathing room. Issues in mental health treatment programs can often include bias against substance abusers. Mental health treatment programs say, we're for mental health, we don't treat substance abuse even though all the research says that they are co occurring and they need to be treated simultaneously. Some mental health services just aren't prepared and don't have the training. So we need to make sure that clients can get the mental health services they need in conjunction with the substance abuse services they need and that they're not denied services. Some agencies will say, well, their depression is caused because it's post acute withdrawal from cocaine. It may be, but most clients that I've worked with, every client that I can think of has also had a lot of other grief and depression and other issues that they need to work through when they start to sober up. Many inpatient facilities establish an arbitrary minimum number of days of sobriety for their clients. So again, like I said, with our hot potato between CSU and detox, it's important that inpatient facilities recognize that once the clients get there, you know, if they're clean and sober, they're theoretically not going to use on the unit. So letting them in is, you know, really important so they can get the mental health services they need so they don't relapse. And some service providers will not accept clients who are on medication, including methadone. So this is another area where we need to destigmatize and we're not. Methadone is not just a legal way of getting high. You know, methadone is a way of keeping people from relapsing. It's often a titrated dose. Most places. If you want to keep somebody on methadone more than two years in most states, you have to present a really compelling reason to the DEA order to continue to do that. So methadone is not meant to be just a forever, you know, dosing thing. It's meant to help people stay cleaner, clean from illicit substances and not getting high while they are developing the skills and tools they need to deal with life on life's terms. Issues in substance abuse treatment programs that might be counterproductive to mental health treatment include treatment approaches that rely on insight and introspection that some mental health clients are just not capable of achieving. If you've got clients with cognitive deficits or who are having a manic episode or who are psychotic, they're not going to be able to actively engage in insight oriented stuff. The approach used in substance abuse treatment may be too confrontational for people. And we've switched gears a lot. We really look at motivational enhancement instead of confrontation. But there is still some old school confrontation that does happen. So it's important if you have a client with very weak ego strength or borderline personality disorder or something, that they are provided safe treatment and that if they're enrolled in a substance abuse program, clinicians are aware of any particular mental health issues that may need to be special attention and treatment programs and other clients may reject clients taking psychotropic medication. And this is true not only in treatment programs, but also in some many self help groups. So it's important to understand that there are programs out there like Dual Recovery and double trouble, both 12 step based programs that accept clients that have concurrent mental health issues. But some of the traditional na, AA and some of the other self help groups may discourage or even outright criticize people who take psychotropic medication. So it is important to make sure that people are aware. Case management with homeless clients Clients need suitable short and long term housing, screening for treatment of mental disorders, food, access to treatment for health problems secondary to their lifestyle, which include tb, HIV and AIDS and hepatitis, and potentially employment, job skills and clothing. So homeless clients, I mean think about it, if they want to get a job so they can have housing. You know, it's going to be kind of hard if they're sleeping on 7th street to get up, get showered, and get to the job in the morning and, you know, be presented in a way that's appropriate for the workplace. If they have TB or hepatitis or malnutrition, you know, they're not going to be functioning optimally. So we need to look at that base level of Maslow's hierarchy, make sure they're getting their biological needs met, make sure they've got their safety needs met, and help them access the services that they need. It's important to remember that many homeless clients, their support system, their family, are those people on the streets. A lot of times they travel kind of in groups. You know, they may not travel in groups down the street, but everybody from this particular area may convene down in Gainesville, Florida during the winter, and then they may go up to Algonak, Michigan during the summer. So they know people wherever they're going, they know people along their destination. They trust the people in their community. So it's important to recognize that there's a sense of belonging and a sense of safety and trust for many of these clients in their street communities. They may not want to go into public housing. They may not want to get into the system where the government is involved, not because necessarily they've got mental health issues. They may not have paranoid delusions. They may have had really bad experiences with the government and just be like, you know, screw it, I don't want to mess with that. And that is their right to assume that every homeless client wants a roof over their head and to pay taxes and a job is not culturally sensitive. With homeless clients, work on the issues that clients feel are most pressing. The need for stable shelter may not be at the top of the client's list. We just talked about that. While this setting is hardly ideal, it may be one in which the client can function well enough to benefit from treatment. So if they've got co occurring mental health or substance abuse issues, we can help them deal with that. Even if they're living on the street, you know, we don't want to preclude them just because they don't have a house. That doesn't make any sense. Because it could be that their mental health issues are the reason they don't have a house. So, you know, if they're functioning effectively, they feel safe, they are content for the moment. We need to still ensure that they link with as many services as possible. Some programs claim they can't help homeless individuals until other life problems are solved, which requires the case manager to advocate on the client's behalf and go, you know, what does having a house, a roof over your head mean? Terms of accessing mental health treatment. They're not going to be any better or worse necessarily if they're sleeping in a shelter than they are where they're sleeping now, where they feel safe and loved and accepted. Peer case managers are really helpful in developing rapport with persons who are homeless because, you know, that's somebody who's been on the streets, who is now part of the system, who can help them, you know, navigate it and not feel so overwhelmed or intruded upon. Homeless clients are usually turned out of shelters from 9am until 4pm so one thing you can do with homeless clients is provide a day room with snacks and a television where they can stay during the day or even work out. Some sort of day work where clients can earn a few dollars. You know, supported employment is great. With women, a mother's decision to enter treatment means the case manager must either identify a program that will take both the woman and her children, which is there aren't a lot of them, or assist the woman in finding appropriate childcare potentially for 30, 60, or 90 days, which can be really overwhelming for a lot of families who. Or a lot of people with substance abuse issues who have detached from their family of origin. Mothers may avoid treatment out of guilt and shame for the activities in which they've engaged to acquire drugs and the situations in which they've placed their children. So we don't want to stigmatize people and go, you know, I can't believe you did that. You know, whatever they did, it's water under the bridge. They're trying to change and they're trying to do what's best for them and their child. They may have fear that authorities will take their children away. You know, if they hear that I'm in treatment, then DCF will get involved. You know, just because somebody enters treatment in most states is not necessarily a DCF report. You know, that's the mother saying, I need help. It's not. There isn't necessarily any neglect. Women who have children are more often extensively involved with community resources, including the school system, pediatric physicians, child protective services. If their substance abuse has resulted in neglect or abuse. So if they do have a history of neglect or abuse, then you're going to have other agencies that you're probably going to come in contact with that you may need to case manage and advocate for the client. With a criminal justice involved client, we want to look at case management in terms of, you know, within the criminal justice system, either probation and parole or the jails, A broad base of support within the justice system with a protocol for continued and effective communication so you can effectively communicate. When I worked at Probation and parole, I was the liaison there, and I was regularly talking to the probation officers about how their people were doing, and they were regularly telling me what the urine screens were coming up or if somebody ended up, you know, reoffending or. There were a couple times where a client got violated their probation. And I went and I advocated for the client with the judge. It was rare, and it wasn't an adversarial thing between me and the probation officer. It was just me doing what was right for my client and the probation officer doing what they had to do. And it was, you know, it was what it was. An independent task unit with a designated administrator can be really helpful to ensure that treatment begins in the jail and continues once people get out of jail and assist them into making that transition. Policies and procedures must be in place for staff so they understand who needs to do what. You know, if the program's being offered in the jail, who qualifies for the program, when do the people have to go? What are the rules? And there needs to be a data collection system for program management and evaluation. So you can see that you're reducing recidivism. You can see that you're reducing relapse rates. You can see and you can show this to the powers that be that provide funding and say, see how effective this is. Most task programs are wildly effective at reducing recidivism and relapse rates. Operational elements of criminal justice programs there have to be agreed upon offender eligibility criteria. So even if the jail is not providing the service, they may contract in with an agency to come in and provide the services. But we need to figure out who's going to qualify for this. You know, every Jim Bob in jail is not going to qualify. There need to be procedures for the identification of eligible offenders that stress early justice and treatment intervention. Ideally, we want to get our first offenders. We want to get our people who are on diversion. We want to get our people who haven't become inculturated into the jail culture. We want to have documented procedures for assessment and referral, random urinalysis and other physical tests and procedures for monitoring offenders, including criteria for success and failure, required frequency of contact for counseling, you know, while they're in jail. How many times do they have to come. How many groups do they have to go to when they get out of jail? When, when they're released and they're on papers, probation or parole, how often do they have to see the counselor? You know, the program I was in, it was once a week for two hours. The schedule of reporting and notification of termination to the justice system. So the counselor, case manager and probation officer all have to know when Jim Bob is going to be reporting. So you can coordinate services. And everybody's on the same page. And Jim Bob doesn't just fall through the cracks. And you say, well, I thought he was going to get drug tested with you. No, I thought he was getting drug tested with you. So everybody needs to be on the same page. Integration of alcohol and other drug treatment services can help if it starts in the justice system, whether it's in, while the client's in jail, it can be extended limits of confinement like we had, or it can be when the person gets out and they're on probation. And completion of a treatment program is a requirement for the completion of probation. So if you can get your community leaders on board, then you can often make treatment a required component in order to increase motivation, prosecution and defense counsel's promotion of public safety while protecting participants due process rights using a non adversarial approach. So we need the attorneys to be on board. We don't want to force somebody into treatment who doesn't need it, but we want to help them, you know, provide tokens, provide incentives. If you go through this treatment program, maybe we can knock off six months off your sentence or something. There are a variety of different ways to do it. Eligible participants are identified early and promptly. Access to a continuum of treatment and rehabilitation services is available regardless of the setting. There's frequent alcohol and drug testing even if the client is incarcerated. Coordination strategy governing responses to participants, compliance. So if Jim Bob is coming to group but sleeping through it, what consequences can we give if Jim Bob is not coming to group, you know, etc. Ongoing judicial interaction with each participant. So the judge needs to be there to kind of be the bite in your bark, so to speak, that says, you know, if you don't do this, then I'm going to take away this privilege. Measurement through monitoring and evaluation, the achievement of program goals in order to gauge effectiveness. So we want to see, are they getting a job, are they staying employed, are they recidivating, you know, what's the outcome of this program? Three months, six months, one year, and if you can, two years. And forging partnerships among drug courts, public agencies, community based organizations, and just generating local support for helping people who've made a bad choice kind of turn their lives around. So where does this funding come from? These are great services, but how do you get paid for them? Block grants from federal agencies like SAMHSA are available and agencies have to apply for those. Medicaid through the Medicaid rehabilitation option will sometimes pay for it, especially for clients who are severely and persistently mentally ill. Medicare and Social Security, Supplemental income for disabled clients, Migrant health funds, private foundations and funds such as the United Way or certain foundations like, I don't know what Caterpillar funds, but some of the big employers, some of the big organizations in our country have private foundations where they fund, you know, they have a nonprofit wing, so to speak, where they fund certain types of activities. And you can go to, you can go online and find out who funds what types of services. Sometimes you have to apply for multiple, you know, three $5,000 grants. Other times you can get a bigger grant to get started. State and local tax dollars can be used to fund services if you can get everybody on board. Private insurance fee for service clients, so that's out of pocket. Private payers such as corporate employee assistant programs or grant funding can also give you money. So if you have an employee assistance program that says, you know, we know that our client, our employees often have challenges with certain things. So we'll pay a case manager, you know, $2 per employee per month in order to provide services that can help volunteer and local sources. Tap into the churches, tap into the people in your community who want to volunteer. Tap into the universities who have students who need to volunteer, but also have students who need to do independent study activities. This is a great, you know, self study, whatever your university calls it, course for someone who wants to get into social services to do a semester as a case manager. Courts and criminal justice funding and social service providers such as child welfare may have some carve outs for case management treatment. Professionals using case management will provide the client a single point of contact for multiple health and social service systems so they don't have to navigate that maze by themselves. It advocates for the clients. They're flexible, community based and client oriented. So the clients are not coming to you. You're usually going to them, being flexible about what kinds of services you refer them to and your approach. And you assist the client with needs generally thought to be outside the realm of substance abuse or mental health treatment, such as housing, food stamps, vocational stuff, etc. To provide optimal services for Clients. A treatment professional should possess particular knowledge, skills and attitudes, including understanding various models and theories of addiction and other problems related to substance abuse. Once you understand what those problems are, you can start seeing what some of the solutions might be to help clients identify strengths that they have that can help them achieve their solutions and the ability to describe the philosophies, practices, policies and outcomes. The most generally accepted and scientifically supported models of treatment recovery, relapse prevention and continuing care for addiction, substance abuse and mental health problems. So you know, if you're going to refer clients to treatment, you got to know what's out there, how it works, and what the right fit might be for your client. So you have to know a little bit about counseling even if you don't do it in order to make effective referrals. You have to know a little bit about mental health and substance abuse in order to identify what might help the client in order to make effective referrals. To provide optimal services for clients. A treatment professional should also have the ability to recognize the importance of family social networks, community systems and self help groups in the recovery process. They need a network that's bigger than one person. They need a network in the community that's available 24 7. Understanding the variety of insurance and health maintenance options available and and the importance of helping clients access these benefits is another thing that case managers need to do. You know, how can this client pay for this service? Or how might this client be able to get this service paid for? It's important that the case manager understands diverse cultures and incorporates the relevant needs of culturally diverse clients as well as people with disabilities into clinical practice. So if you have a client who is hearing impaired, you know, they may need certain interpreter services. Suggesting that they look at cochlear implants is extremely rude. And because many people who are deaf embrace their deaf community and love their deaf community and don't want to hear. That's just like saying somebody's homeless, of course wants a home. Not necessarily. So we want to incorporate the individual's needs and desires into treatment and understand the value of an interdisciplinary approach to addiction and mental health treatment instead of just providing counseling. What else do they need in order to, you know, be successful? You know, again, look at Maslow's hierarchy. Thank you for paying attention today or being part of this webcast and I will see you in the next installment. I've got one, maybe two more case management presentations coming up. Depending on how long the next one runs, I may break it into two presentations. Have a great day. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. 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