TRANSITION PLANNING IN CASE MANAGEMENT SUCCESSFUL OUTCOMES THROUGH COLLABORATION, EMPOWERMENT AND CLIENT SELF-DETERMINATION
RUTH-ANNE CRAIG, B.A., M.S.W., R.S.W. THERAPIST / CO-OWNER – PROFESSIONAL VOCATIONAL REHABILITATION THERAPIES, WINNIPEG, MANITOBA
PRESENTATION OBJECTIVES 1. DISTINGUISH THE IMPORTANCE OF THE ROLE OF THE TRANSITION PHASE IN THE CASE MANAGEMENT PROCESS 2. UNDERSTAND HOW THE CASE MANAGEMENT PROCESS, STANDARDS OF PRACTICE AND CASE MANAGER’S SKILLS ATTRIBUTE TO A SUCCESSFUL TRANSITION FOR THE CL IENT AND CASE MANAGER 3. IDENTIFY THE IMPORTANCE OF TRANSITION PLANNING FROM THE BEGINNING OF INTERVENTION 4. IDENTIFY THE IMPORTANCE OF KNOWLEDGE OF AND COLLABORATION WITH COMMUNITY SERVICES
PROCESS OF CASE MANAGEMENT 1. ENGAGEMENT / ELIGIBILITY 2. ASSESSMENT 3. PLANNING AND GOAL SETTING 4. INTERVENTION / IMPLEMENTATION 5. MONITORING, EVALUATING AND COORDINATION 6. TRANSITION / TERMINATION
FIRST RULE OF CASE MANAGEMENT… THE PROCESS IS NOT LINEAR.
GUIDING PRINCIPLES OF CASE MANAGEMENT • CASE MANAGEMENT SUPPORTS CLIENT RIGHTS • CASE MANAGEMENT IS PURPOSEFUL • CASE MANAGEMENT IS COLLABORATIVE • CASE MANAGEMENT SUPPORTS ACCOUNTABILITY • CASE MANAGEMENT STRIVES FOR CULTURAL COMPETENCE (NATIONAL CASE MANAGEMENT NETWORK OF CANADA, 2009)
SECOND RULE OF CASE MANAGEMENT… THE PRINCIPLES OF CASE MANAGEMENT ARE FOUNDED ON EMPOWERMENT AND RESILIENCE THEORIES, WHICH ARE STRENGTH-BASED.
CASE MANAGER’S ROLES / FUNCTIONS • WORKING WITH CLIENT TO CONDUCT A COMPREHENSIVE, HOLISTIC ASSESSMENT AND TO DEVELOP A COLLABORATIVE PLAN THAT MAXIMIZES CLIENT’S STRENGTHS , AS WELL AS THE STRENGTHS OF THE CLIENT’S NATURAL SUPPORT NETWORK, FORMAL AND IN FORMAL NETWORKS AND SERVICES • FACILITATING COMMUNICATION AND COORDINATION BETWEEN MEMBERS OF THE HEALTH CARE TEAM, INVOLVING THE CLIENT IN THE DECISION-MAKING PROCESS • EDUCATING THE CLIENT, FAMILY (NATURAL SUPPORT NETWORK) AND MEMBERS OF THE HEALTH CARE DELIVERY TEAM ABOUT TREATMENT OPTIONS, COMMUNITY RESOURCES, BENEFITS, CONCERNS, ETC., SO THAT TIMELY AND INFORMED DECISIONS CAN BE MADE
CASE MANAGER’S ROLES (CONT’D) • EMPOWERING THE CLIENT TO PROBLEM-SOLVE BY EXPLORING OPTIONS OF CARE … AND ALTERNATIVE PLANS, WHEN NECESSARY, TO ACHIEVE DESIRED OUTCOMES • ENCOURAGING THE APPROPRIATE USE OF HEALTH CARE (AND OTHER) SERVI CES… • STRIVING TO PROMOTE CLIENT SELF-ADVOCACY AND SELF-DETERMINATION • ASSISTING THE CLIENT IN THE SAFE TRANSITIONING OF CARE (CASE MANAGEMENT SOCIETY OF AMERICA (CMSA), 2010)
THIRD RULE OF CASE MANAGEMENT… CASE MANAGERS MUST STRIVE TO INCORPORATE THE STRENGTHS PERSPECTIVE IN THEIR WORK WITH CLIENTS BY INCORPORATING THE PHILOSOPHY OF EMPOWERMENT AND RESILIENCE INTO ALL ASPECTS OF THEIR ROLES AND FUNCTIONS.
PRINCIPLES OF STRENGTHS-BASED CASE MANAGEMENT • THE HELPING EFFORT FOCUSES ON THE STRENGTHS, INTERESTS AND ASPIRATIONS OF THE CLIENT. • PEOPLE POSSESS THE INHERENT CAPACITY TO LEARN, GROW, AND CHANGE • THE CLIENT IS THE DIRECTOR OF THE HELPING ENCOUNTER • CLIENT / CASE MANAGER RELATIONSHIP BECOMES AN ESSENTIAL FACTOR IN THE HELPING PROCESS • COMMUNITY IS AN OASIS OF POTENTIAL COLLABORATORS IN THE HELPING PROCESS (SALEEBEY ET AL., 2012)
FUNCTIONS / ACTIVITIES OF THE STRENGTHS MODEL 1. ENGAGEMENT 2. STRENGTHS ASSESSMENT 3. PERSONAL GOAL PLANNING 4. IMPLEMENTATION THROUGH ADVOCACY AND LINKAGE 5. MONITORING 6. GRADUATED DISENGAGEMENT
STRENGTHS-BASED DISENGAGEMENT • GRADUATED DISENGAGEMENT PROMOTES NORMATIVE INTERDEPENDENCE. • INCREASE CLIENT’S ACTIVITIES WITH OTHER PROVIDERS AND NATURAL SU PPORT NETWORKS. • FREQUENCY AND INTENSITY OF CASE MANAGEMENT CONTACT DIMINISH. • FOCUS ON CLIENT EMPOWERMENT, PERSONAL DECISION-MAKING, AND AUTONOMY.
POSITIVE CASE MANAGEMENT CLOSURE 1. SUPPORT PLAN GOALS ARE MET 2. AN AFTERCARE PLAN IS AGREED UPON AND THE CLIENT IS ABLE TO INDEPENDENTLY ACCESS SUPPORTS 3. PLAN FOR FUTURE RE-ENGAGEMENT PLANNED IF NECESSARY (DUBLIN REGION HOMELESS EXECUTIVE, 201
TRANSITIONING TO COMMUNITY SERVICES • THE FOCUS OF ALL WORK WITH CLIENT SHOULD BE GEARED TOWARD A SUCCESSFUL ENDING IN THE CASE MANAGEMENT PARTNERSHIP • PREPARE FOR TRANSITION AND END OF SERVICE FROM THE OUTSET OF THE CASE MANAGEMENT PARTNERSHIP • CASE MANAGER SHOULD BE EXPLICIT IN SPECIFYING THE PROCESS OF CASE MANAGEMENT PARTNERSHIP AND EXPECTATIONS OF CLIENT TO END SERVICE DURING INITIAL MEETING AS WELL AS THROUGHOUT THE CASE MANAGEMENT PROCESS. • END OF THERAPEUTIC PARTNERSHIP SHOULD BE VIEWED AS CLIENT SUCCESS AND ACHIEVEMENT OF GOALS. • TRANSPARENCY REGARDING ALL CASE MANAGEMENT PROCESSES AND INTERVENTIONS IS PARAMOUNT THROUGHOUT THE CASE MANAGEMENT PARTNERSHIP • ONGOING DISCUSSION OF OPTIONS FOR SERVICES IN COMMUNITY DURING CASE MANAGEMENT PARTNERSHIP • ONGOING IDENTIFICATION OF GOAL ACHIEVEMENT • ENSURE THAT CLIENT FULLY UNDERSTANDS WHEN, WHY AND HOW TERMINATION OF SERVICES WILL TAKE PLACE
TRANSITIONING TO COMMUNITY SERVICES, CONT’D • FINAL SESSION (FACE – TO – FACE) FOCUSED ON REVIEWING OVERALL PROGRESS AND ACHIEVEMENTS • SOME ACTIVITIES THAT CAN BE INCORPORATED INTO FINAL SESSION ARE: GOALS ATTAINMENT, STRENGTHS IDENTIFICATION, COPING STRATEGIES, SUPPORTIVE PEOPLE A ND GROUPS IN PERSON’S NETWORK, RESOURCES (FORMAL & INFORMAL), SELF-CARE STRATEGIES, FUTURE GOALS • A LETTER OUTLINING CLIENT’S ACCOMPLISHED GOALS AND PLANS FOR FUT URE • ASSIST WITH REFERRALS IF YOUR PROFESSIONAL CREDENTIALS BENEFIT THE CLIENT (OR IF NECESSARY) • ENSURE THAT CLIENT DOCUMENTS INFORMATION REGARDING POTENTIAL REFERRAL SERVICES
LINKING CLIENTS TO COMMUNITY • ASSIST CLIENT IN IDENTIFYING NEEDED RESOURCES • ASSIST CLIENT IN LOCATING NEEDED RESOURCES • FACILITATE ACCESS TO SUPPORTS AND SERVICES • ASSESS CLIENT’S ABILITY TO PAY FOR SERVICE • NETWORK / ADVOCATE FOR CLIENT • MAXIMIZE CLIENT INDEPENDENCE BY TEACHING AND SUPPORTING SELF-ADVOCACY SKILLS • INFORM RELEVANT STAKEHOLDERS OF TERMINATION OF SERVICE AND CLIEN T’S PLAN • PROVIDE REFERRALS AND APPLICATIONS IF NECESSARY • INVOLVE CLIENT • INVOLVE CLIENT’S FAMILY / SUPPORT NETWORK
ACCESSING COMMUNITY SERVICES IN WINNIPEG AND MANITOBA • MENTAL HEALTH BEST RESOURCE IN TOWN FOR NAVIGATING THE MENTAL HEALTH SYSTEM IS THE MENTAL HEALTH RESOURCE GUIDE PUBLISHED ANNUALLY BY THE CANADIAN MENTAL HEALTH ASSOCIATION, WINNIPEG REGION HTTP://MBWPG.CMHA.CA/RESOURCES/MENTAL-HEALTH-RESOURCE-GUIDE-FOR-WINNIPEG/ • MENTAL HEALTH SELF-HELP AND PEER SUPPORT • FACES, 4 FORT STREET, WINNIPEG, MB (ANXIETIES DISORDERS ASSOCIATION OF MANITOBA, MOOD DISORDERS ASSOCIATION OF MANITOBA, MANITOBA SCHIZOPHRENIA SOCIETY, MENTAL HEALTH EDUCATION AND RESOURCE CENTRE,
MENTAL HEALTH AND ADDICTION RESOURCES, CONT’D FREE AND SLIDING SCALE COUNSELLING • KLINIC COUNSELLING SERVICES • FAMILY CENTRE OF WINNIPEG • AURORA FAMILY THERAPY CENTRE • WRHA COMMUNITY MENTAL HEALTH PROGRAM BRIEF TREATMENT COUNSELLING • MEN’S RESOURCE CENTRE • WOMEN’S HEALTH CLINIC • ADDICTIONS FOUNDATION OF MANITOBA
PHYSICAL AND MEDICAL HEALTH SUPPORTS • 211 MANITOBA – ONLINE INFORMATION ON ACCESSING COMMUNITY SERVICES INCLUDING: HOUSING AND HOMELESSNESS, HEALTH, FOOD AND CLOTHING, EMPLOYMENT AND TRAINING, PERSONS WITH DISABILITIES, LEGAL ISSUES, FINANCIAL, INDIGENOUS PEOPLE, YOUTH, OLDER ADULTS, NEWCOMERS AND REFUGEES, LGBTSQ+, MENTAL HEALTH AND ADDICTIONS, CHILDREN AND PARENTING, ABUSE AND ASSAULT. MB.211.CA/ • SELF-HELP SUPPORT GROUPS (EG. ARTHRITIS SOCIETY OF MANITOBA) • CAREGIVER SUPPORT GROUPS (EG. ALZHEIMER SOCIETY OF MANITOBA) • SELF AND FAMILY MANAGED CARE (WINNIPEG REGIONAL HEALTH AUTHORITY HOME CARE PROGRAM)
CONCLUSION • CASE MANAGERS DO THEIR BEST WORK WHEN THEY LET THEIR CLIENTS DO THEIR BEST WORK • CLIENTS KNOW THEMSELVES BETTER THAN ANYONE ELSE, INCLUDING SERVICE PROVIDERS • BALANCING THE POWER IN THE THERAPEUTIC PLAYING FIELD BY PROVIDING SERVICES BASED ON EMPOWERMENT PRINCIPLES PROVIDES CLIENTS WITH OPPORTUNITIES FOR GROWTH BASED ON SOCIAL JUSTICE AND EQUALITY • THE BEST OUTCOME FOR CASE MANAGERS IS TO BE FIRED BY THEIR CLIENTS – NOT BECAUSE THEY DID A BAD JOB, BUT BECAUSE THEY DID A GREAT JOB AND THEIR CLIENTS ARE NO LONGER DEPENDENT ON THEM.
THANK YOU IF YOU HAVE ANY QUESTIONS OR YOU WOULD LIKE TO CONTACT ME REGARDING THIS PRESENTATION PLEASE FEEL FREE TO CONTACT ME AT PVRTHERAPIES@GMAIL.COM
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