Strengths-Based Case Management Presented by Dr. Richard Rapp June 12th & 13th , 2014 Hosted by: Center for Advocacy and Leadership Training A project of Time for Change Foundation

Wright State University Boonshoft School of Medicine 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 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 Substance abuse treatment & medical care Persons who have substance abuse problems & are HIV positive System Location Rural providers Affordability Eligibility criteria Inflexible hours Admission process Cultural competence Impersonal Intimidating Staff skills Waiting lists

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

STRENGTHS PERSPECTIVE Barriers to Treatment 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 Persons who have substance abuse problems & are HIV positive Substance abuse treatment & medical care 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

Case Management + Strengths Focus Assessment Planning Linking Coordinating Advocacy Strengths Perspective Focus on strengths Client driven Primary relationship Assertive outreach Creative use of resources ITAR C Center for Interventions Treatment & Addictions Research

STRENGTHS-BASED CASE MANAGEMENT Tangible Support Transportation Childcare Planning Advocacy Assessment Planning Linking Monitoring Advocacy Linkage with Care Retention in Care Improved Functioning Focus on Client Strengths Client Driven Emphasize Relationship Assertive Outreach Use of Informal Resources Emotional Support Increase Hopefulness Increase Self-Efficacy Decreased 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 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 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 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 months Total number of substance abusers 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 (Baseline) .251 .122 .165 .129 .136 .399 Unemployed Fewer Arrests Less Depression Lower Drug Severity (Six Months) Less Drug Use Less Use of Crack Cocaine .113 .120 Fewer Treatments More Weeks in Aftercare Treatment Case Manager

Path Model of Significant Factors on Post-Treatment Contact and Legal Severity (Baseline) .251 .242 .104 .425 Unemployed Lower Legal Severity Readiness for Treatment Lower Legal Severity (Twelve Months) Case Manager .092 .089 .112 More Weeks in Aftercare Treatment

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 of Strengths-Related Assessment Tools

Case Finder Training - ARTAS Model March 17-18, 2005 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

Case Finder Training - ARTAS Model March 17-18, 2005 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

Case Finder Training - ARTAS Model March 17-18, 2005 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 Case Finder Training - ARTAS Model March 17-18, 2005 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 Case Finder Training - ARTAS Model March 17-18, 2005 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 Case Finder Training - ARTAS Model March 17-18, 2005 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 Case Finder Training - ARTAS Model March 17-18, 2005 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 Case Finder Training - ARTAS Model March 17-18, 2005 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 Case Finder Training - ARTAS Model March 17-18, 2005 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 “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