Hosted by: Center for Advocacy and Leadership Training

A project of Time for Change Foundation

Strengths-Based

Case Management

Presented by Dr. Richard Rapp June 12th & 13th , 2014

Richard C. Rapp, M.S.W., Ph.D.

Wright State University

Boonshoft School of Medicine

Objectives• Understand principles and practice

activities important in Strengths-Based Case Management

• Engage in practice scenarios & role plays• Discuss adaptation and implementation

issues for your setting

Terms

• Strengths-based Case Management (SBCM)– Treatment Linkage Case Management (TLCM)

• Persons with substance abuse problems

– ARTAS Linkage Case Management (ALCM)• Persons newly diagnosed with HIV

– Emergency Department SBCM (ED-SBCM)• Opiod addicts being treated in emergency departments

• “Linkage”; “Care Coordination”

Case Management & Substance Abuse

• Prior to 1990 case management used almost exclusively with mental health populations

• 1990 – four case management studies proposed as part of a National Institute on Drug Abuse initiative to improve treatment retention and outcomes

Case Management & Substance Abuse

• Models adapted from mental health field– Strengths-based: Wright State University;

University of Iowa– Assertive Community Treatment: University of

Delaware– Generalist: UCLA

• Since 1990, mostly generalist case management

Case Management

Barriers to Treatment

Persons who have

substance abuse

problems & are HIV positive

Personal

• Practical • Transportation• Financial• Childcare

•Lifestyle• Substance abuse &

mental health• High risk

behaviors• Homeless• Incarceration

•Internal• Fear of discovery• Stigma• Denial• Fatalism• Lack of trust

•Physical• Side effects

System

•Location•Rural providers•Affordability•Eligibility criteria•Inflexible hours•Admission process•Cultural competence•Impersonal•Intimidating•Staff skills•Waiting lists

Substance abuse

treatment & medical care

Case Management Functions

• Assesses – Identifies service(s) the client needs

• Arranges – Makes plans to get service(s)• Coordinates – Makes sure that service(s)

are received• Monitors – Follows the progress of client –

service(s) interactions

Case Management Functions

• Evaluates – Makes sure that client gets services as intended

• Advocates – Intervenes to assure that client gets the services they needed

Duration of Case Management

• On-going support of clients over a protracted period of time; long-term support of mental health clients reintegrated into community

AND/OR• Support in achieving specific, short-term

goals; assisting clients to link with services

Strengths Perspective

Barriers to Treatment

Persons who have

substance abuse

problems & are HIV positive

Substance abuse

treatment & medical care

Personal

• Practical • Transportation• Financial• Childcare

•Lifestyle• Substance abuse &

mental health• High risk

behaviors• Homeless• Incarceration

•Internal• Fear of discovery• Stigma• Denial• Fatalism• Embarrassment• Lack of trust

System

•Location•Rural providers•Affordability•Eligibility criteria•Inflexible hours•Admission process•Cultural competence•Impersonal•Intimidating•Staff skills•Waiting lists

CASE MANAGEMENT

STRENGTHS PERSPECTIVE

Principle I: Focus on Client Strengths

• Emphasize client strengths, positives, assets, skills, abilities, etc.

• De-emphasize client recounting of what they’ve done wrong

• Recognize motivation and personal efforts• Base goal-setting on past assets

Principle II: Client Driven

• Establish client as responsible for identifying own goals and path to accomplish those goals

• Increase client investment in goals• Promote self-determination• Reduces resistance and denial

Principle III: Case Manager as Primary Relationship

• Development of working alliance, relationship is critical

• Provides the short-term foundation for client taking risks

• Primary, but not exclusive relationship

Principle IV: Community as a Resource

• Selective use of formal, informal, and created resources

• Formal – specialized, entitlements• Informal – day to day functioning and

community involvement• Created – Expand personal interests, skills

Principle V: Assertive Outreach

• Encourages understanding of client’s life• Helps case manager to help client formulate

plans• Promotes relationship between client and

case manager

Combining Case Management & Strengths Perspective

ITARC Center for Interventions

Treatment & Addictions Research

Case Management + Strengths Focus

Case Management• Assessment• Planning• Linking• Coordinating• Advocacy

Strengths Perspective• Focus on strengths• Client driven• Primary relationship• Assertive outreach• Creative use of

resources

Focus on Client Strengths

Client Driven

Emphasize Relationship

Assertive Outreach

Use of Informal Resources

Assessment

Planning

Linking

Monitoring

Advocacy

STRENGTHS-BASED CASE MANAGEMENT

Linkage with Care

Retention in Care

Improved Functioning

Tangible Support

TransportationChildcare

PlanningAdvocacy

Emotional Support

Increase HopefulnessIncrease Self-EfficacyDecreased Resistance

Strengths-Based Case Management

• A value-added intervention in that:– Case management provides concrete support in

getting resources– Strengths perspective provides emotional

support in identifying abilities

Strengths Perspective and Medical Model

Strengths Perspective• Basic position is to find strengths, assets,

and abilities• Diagnosis and labeling is avoided• Full discussion of client’s story is

encouraged

Medical/Disease Model

• Basic position is to find sickness, problems, disease & pathology

• Diagnosis is required; labeling is frequent

• Client/patient usually seen as less capable, needs to be helped/fixed

Strengths Perspective and Medical Model

Strengths Perspective

• Individual is asked about needs• Individual seen as “able” and necessary

participant in addressing needs• Active involvement encouraged• Goals are (almost) always supported

Medical/Disease Model

• Worker supports “party line” and agency role

• Client/patient goes to services

• Solutions usually involve formal resources

• Doctor-patient relationship

Activity #1

• Scenario A & Scenario B

Outcomes

Linkage & Retention

Percent linkage by intervention and modality

Treatment Modality

Standard of Care

Motivational Interviewing

Strengths-Based Case

Management(n=222)

Total

Residential 39.0 43.9 56.2 46.3 a

Outpatient 28.7 c 43.4 52.3 c 41.2 b

Methadone 68.4 48.9 60.0 58.4 a,b

Total 38.7 d 44.7 e 55.0 d,e ++ 46.0

Percentages with same superscript are significantly different. a, e p < .05; c p < .01; b, d p <.001

++When substance abusers who attended no case management are removed the total linkage rate was 63.1%.

Substance abusers’ linkage by number of CM contacts

Number of SBCM contacts

No linkage with treatment at 3

months

Linkage with treatment at 3

monthsTotal number of

substance abusers

0 33 (76.7) 10 (23.3) 43 (19.4)

1 25 (48.1) 27 (51.9) 52 (23.4)

2 11 (45.8) 13 (54.2) 24 (10.8)

3 12 (33.3) 24 (66.7) 36 (16.2)

4 11 (36.7) 19 (63.3) 30 (13.5)

5 7 (18.9) 30 (81.1) 37 (16.7)

99 (44.6) 123 (55.4) 222

Path Model of Significant Factors on Post-Treatment Contact and Drug Severity

Unemployed

Fewer Arrests

Case Manager

Less Drug Use

Lower Drug Severity(Six Months)

More Weeks in Aftercare Treatment

.251

.122

.165

.129

.136

.399

.113 .120

(Baseline)

Less Depression

Less Use of Crack

Cocaine

Fewer Treatments

Path Model of Significant Factors on Post-Treatment Contact and Legal Severity

Unemployed

Lower Legal Severity

Case Manager

Readiness for Treatment

Lower Legal Severity

(Twelve Months)

More Weeks in Aftercare Treatment

.251

.242

.104

.425 .112.092 .089

(Baseline)

Practice of SBCM

A Word About Motivational Interviewing

• Some of basic skills of MI can be very useful as part of SBCM– Reflective comments vs. open and closed

questions – Recognizing stage of change – Rolling with resistance; empathy– Using discrepancy

Strengths-Based Case Management

• Preparation – Getting ready• Engagement – First impressions are

everything• Strengths Assessment – Changing the

discussion• Case Management Planning – Following

the client• Disengagement – Letting go

Preparation (System)

• Learn about & make a directory of both formal and informal resources

• Examine structure of own agency, what interferes with linkage

• Visit all resources where you might refer clients• Shadow program staff; Be the client• Establish informal relationships with staff• Encourage your agency to develop MOUs with other

programs

Preparation (Clients)

• Have a strengths “attitude”• Have knowledge necessary to assist clients• Understand situation of your potential clients• Interview clients who have been successful• Have basic support/counseling skills• Stay open to learning new ways of helping

people

Note on Preparation

• If you aren’t prepared, you put clients’ ability to be successful at risk

• Especially true when it comes to:– “Strengths attitude”– Fully knowing the resources where you refer

clients

Engagement

• Find out about client; Talk, don’t interview• Ask about their reaction to their situation• Don’t worry about apparent motivation• Recognize and state strengths as soon as

possible• Provide a summary of what you can and

can’t do for client• Be cautious about self-disclosure too early

Example ofStrengths-Related Assessment Tools

Strengths Assessment

• Benefits– Help client identify strengths, abilities, assets,

skills, dreams, interests– Provide improved sense of self-efficacy and

hopefulness– Use strengths, etc. in planning– Develop relationship– Reduce client resistance

Strengths Assessment

• Provides constructive challenge – Can’t do “autopilot” on reciting pathology– Encourages thoughts about, and practice of,

strengths (rather than practicing pathology)– Inoculates case manager against hopelessness

and skepticism

Strengths Assessment

• Initially may be difficult for both worker and client

• Usually unstructured; may have a list of strengths to prompt client’s thinking

• Always dynamic and interactive • On-going throughout the relationship

Strengths Assessment

• Summarize and write strengths down, give to clients

• Help client take credit for things going well• Continually connect client strengths and

current challenges they face

Strengths Assessment Questions

• What are your strengths/positives/good points/abilities?

• When have you faced challenges successfully?

• When were things going well and what were you doing to make them go well?

Strengths Assessment - Relationships

• Who do you trust? What is it about them?• What has been the most successful

relationship you’ve had, successful for both parties? What made it successful?

• When have you been able to just give to others without expecting anything in return?

Strengths Assessment -Internal Resources

• What was an example of your solving a problem effectively?

• When did you successfully identify and complete a goal? What helped you complete that goal?

• When did you feel most in control of your own life? What were you doing to make that happen?

Strengths Assessment - Recovery

• When was a time that you stayed sober? What were you doing that helped you stay sober?

• When was a time that you controlled your drug use? What were you doing that helped you stay in control?

• What have you done to try and deal with your drug use?

Non-Strengths Information

• Suicidal ideation or attempts• Risk to do harm to others• Physical problems associated with drug use,

HIV status, general health concerns• Intrinsic limitations such as learning

difficulties, not reading well

Activity #2

• Conducting strengths-based assessments

Example of a Goal-Setting Tool

Goal Setting/Treatment Planning

• Benefits– When client identifies own goals (objectives,

strategies) they are more likely to accomplish them

– Places responsibility for action on client– Enhances client investment in own care– Teaches a process that can be used in the future

Goal Setting/Treatment Planning• Provides a constructive challenge

– Can’t do “autopilot”, expecting someone else to do for them

• Minimizes chances of not being successful• Worker only helps shape the process and

asks the right questions• Builds in accountability for client (and

worker)

Goal Setting/Treatment Planning

• Initially may be difficult for both worker and client

• Plan based on demonstrated successes whenever possible

• Engages clients who function at various reading and cognitive levels

Goal Setting/Treatment Planning

• Process includes:– Identifying Goals, Objectives, Strategies– Target dates– Review of plan at every meeting

Goal Setting/Treatment Planning

• Goals: – “What do you need/want to accomplish?”– Broad statement in client’s own words– Not for case manager to decide– CM will work on any goal, unless its illegal or

hurtful to self or other

Goal Setting/Treatment Planning

• Objectives– Specific, measurable actions; no doubt if it has

been accomplished or not– Allows client to see success in tangible terms,

or if not successful make specific alternative plans

– Case manager may provide feedback, help client consider pros/cons, put objectives in best order, etc.

Goal Setting/Treatment Planning

• Strategies– Specific, measurable actions– The action or “baby steps” for accomplishing an

objective and thereby a goal– Allows client to see success in tangible terms, or if not

successful make specific alternative plans– Case manager may provide feedback, help client

consider pros/cons, put objectives in best order, etc.

Goal Setting/Treatment Planning

• Target Dates– Help client to identify realistic time frame for

accomplishing objectives and strategies– Use to discourage procrastination or overly

eager expectations

• Regular Review– Encourages follow-through– Provides prompt assistance if needed

Activity #3

• Developing a Personal Roadmap

One Example of SBCM

Structured 5 Contacts

#1: Building the Relationship• Describe the goals and objectives of SBCM• Review incident that led to ED treatment• Introduce the concept of strengths, abilities, and

skills and begin strengths assessment • Encourage linkage with substance abuse treatment

or identification of goals that are important to the individual

• Identify barriers to linkage or accomplishing goals of importance

• Summarize the session• Accomplish tasks on behalf of individual

#2: Assessing Personal Strengths• Discuss issues from last session; follow-up

on task since previous session• Continue strengths assessment• Encourage linkage with treatment or

identifying personal goals• Identify barriers to linkage and personal

goals• Summarize the session• Accomplish tasks on behalf of individual

#3: Learning to Make Contact• Discuss issues from last session; follow-up

on any plans• Continue to emphasize strengths• Encourage linkage with treatment and

personal goals• Identify barriers to linkage & personal goals• Begin disengagement process• Summarize the session• Accomplish tasks on behalf of individual

#4: Reviewing Progress• Discuss issues from last session; follow-up

on any plans• Engage in a summary of strengths &

accomplishments• Emphasize disengagement• Identify remaining barriers to linkage &

personal goals• Summarize the session• Accomplish tasks on behalf of individual

#5: Completing the Work

• Discuss issues from last session; follow-up on any plans

• Finalize disengagement process• Encourage client’s independent contact with

treatment and other resources• Summarize the relationship

Activity #4

• Staffing cases ala strengths-based case management

Implementing SBCM your organization

First 5 Questions to Answer

Question #1

• How completely do you want to implement SBCM?– Individual staff– Agency-wide– Agency-wide for certain population(s)– Community-wide

Question #2

• If agency-wide for certain populations, which population(s)?– Consider strategically – Define precisely

Question #3

• Do you want SBCM to be:– Brief, to help individuals with a specific

objective(s)? Or – Long-term with on-going support?

– Based on selected population– Based on agency and community services– Very different structures

Question #4

• Having answered questions #1 through #3, what objectives would you assign to each case management contact?

Question #5

• What current policies and procedures of your organization will interfere with implementing SBCM?– That’s not how we do it here– The intake process– Lack of clinical supervision focused on SBCM– Others

Steps in the Staffing Process

• Few facts – name, age, living situation, medical conditions

• Strengths, assets, skills, positives, etc.• Goals, Objectives, Strategies• Barriers to Objectives and Strategies• Inherent limitations