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Complete all exercises in each chapter. The require forms that is needed for an exercise is located at the end of the book   Chapter 25 Exercises I, II, III, IV, V Chapter 26 Exercises  I, II, III F i F t h e d i t i o n Australia • Brazil • Mexico • Singapore • United Kingdom • United States Fundamentals of Case Management Practice Skills for the Human Services N a N c y S u m m e r S Harrisburg Area Community College Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. This is an electronic version of the print textbook. 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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. © 2016, 2012, 2009 Cengage Learning WCN: 02-200-203 ALL RIGHTS RESERVED. No part of this work covered by the copyright herein may be reproduced, transmitted, stored or used in any form or by any means graphic, electronic, or mechanical, including but not limited to photocopying, recording, scanning, digitizing, taping, Web distribution, information networks, or information storage and retrieval systems, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without the prior written permission of the publisher. 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Purchase any of our products at your local college store or at our preferred online store www.cengagebrain.com Fundamentals of Case Management Practice: Skills for the Human Services, Fifth edition Nancy Summers Product Director: Jon-David Hague Product Manager: Julie Martinez Content Developer: Lori Bradshaw Media Developer: Mary Noel Associate Content Developer: Sean Cronin Product Assistant: Kyra Kane Marketing Manager: Shanna Shelton Art Director: Vernon Boes Production Management, and Composition: Lumina Datamatics, Inc. Manufacturing Planner: Judy Inouye Text Researcher: Kavitha Balasundaram Cover Designer: Norman Baugher Cover Image: © Ajn / Dreamstime.com For product information and technology assistance, contact us at Cengage Learning Customer & Sales Support, 1-800-354-9706 For permission to use material from this text or product, submit all requests online at cengage.com/permissions. Further permissions questions can be emailed to [email protected] Printed in the United States of America Print Number: 02 Print Year: 2015 Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. To my parents, whose humor and wisdom about people and relationships formed the foundation for my work with others Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. iv Contents Preface xiii Section 1 Foundations for Best Practice in Case Management Chapter 1 Case Management: Definition and Responsibilities 1 Introduction 1 A History of Case Management 2 Language in Social Services 2 Why We Use Case Management 3 Case Management as a Process 4 Advocacy 13 Service Coordination 13 Levels of Case Management 16 Separating Case Management from Therapy 19 Case Management in Provider Agencies 19 Managed Care and Case Management 21 Caseloads 25 Generic Case Management 26 Summary 26 Exercises I: Case Management 27 Exercises II: Decide on the Best Course of Action 30 Chapter 2 Ethics and Other Professional Responsibilities for Human Service Workers 33 Introduction 33 The Broader Ethical Concept 34 Dual Relationships 35 Boundaries 40 Value Conflicts 40 The Rights of Individuals Receiving Services 44 Confidentiality 47 Privacy 51 Health Insurance Portability and Accountability Act 52 Social Networking 55 Privileged Communication 56 When You Can Give Information 56 Diagnostic Labeling 59 Contents Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Contents v Involuntary Commitment 60 Ethical Responsibilities 61 Protecting a Person’s Self-Esteem 62 Stealing from Clients 64 Competence 65 Responsibility to Your Colleagues and the Profession 65 Professional Responsibility 67 Summary 68 Exercises I: Ethics 69 Exercises II: Ethically, What Went Wrong? 71 Exercises III: Decide on the Best Course of Action 76 Exercises IV: What is Wrong Here? 76 Chapter 3 Applying the Ecological Model: A Theoretical Foundation for Human Services 77 Introduction 77 The Three Levels of the Ecological Model 79 The Micro Level: Looking at What the Person Brings 80 Looking at What the Context Brings 80 Why Context Is Important 81 Seeking a Balanced View of the Client 82 Developmental Transitions 86 Developing the Interventions 87 Working with the Generalist Approach 88 Macro Level Interventions Are Advocacy 88 Summary 90 Exercises I: Looking at Florence’s Problem on Three Levels 90 Exercises II: Designing Three Levels of Intervention 91 Section 2 Useful Clarifications and Attitudes Chapter 4 Cultural Competence 95 Introduction 95 Culture and Communication 95 Your Ethical Responsibility 96 Where Are the Differences? 96 Strangers 98 Anxiety and Uncertainty 99 Thoughtless versus Thoughtful Communication 100 Dimensions of Culture 104 Obstacles to Understanding 109 Competence 111 Summary 112 Exercises I: Testing Your Cultural Competence 113 Chapter 5 Attitudes and Boundaries 117 Introduction 117 Understanding Attitudes 117 Basic Helping Attitudes 118 Copyright 2016 Cengage Learning. 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Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. vi Contents Reality Check 123 How Clients Are Discouraged 124 A Further Understanding of Boundaries 127 Seeing Yourself and the Client as Completely Separate Individuals 127 Erecting Detrimental Boundaries 129 Transference and Countertransference 129 Summary 130 Exercises I: Demonstrating Warmth, Genuineness, and Empathy 131 Exercises II: Recognizing the Difference—Encouragement or Discouragement 136 Exercises III: Blurred Boundaries 136 Chapter 6 Clarifying Who Owns the Problem 139 Introduction 139 Boundaries and Power 140 If the Client Owns the Problem 141 If You Own the Problem 143 If You Both Own the Problem 144 Summary 145 Exercises I: Who Owns the Problem? 145 Exercises II: Making the Strategic Decision 147 Section 3 Effective Communication Chapter 7 Identifying Good Responses and Poor Responses 149 Introduction 149 Communication Is a Process 150 Twelve Roadblocks to Communication 151 Useful Responses 156 Summary 164 Exercises: Identifying Roadblocks 165 Chapter 8 Listening and Responding 169 Introduction 169 Defining Reflective Listening 170 Responding to Feelings 170 Responding to Content 174 Positive Reasons for Reflective Listening 176 Points to Remember 177 Summary 178 Exercises I: How Many Feelings Can You Name? 179 Exercises II: Finding the Right Feeling 179 Exercises III: Reflective Listening 180 Chapter 9 Asking Questions 187 Introduction 187 When Questions Are Important 187 Closed Questions 188 Open Questions 189 Copyright 2016 Cengage Learning. 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Contents vii Questions That Make the Other Person Feel Uncomfortable 190 A Formula for Asking Open Questions 192 Summary 195 Exercises I: What Is Wrong with These Questions? 195 Exercises II: Which Question Is Better? 197 Exercises III: Opening Closed Questions 198 Exercises IV: Try Asking Questions 200 Chapter 10 Bringing Up Difficult Issues 203 Introduction 203 Confrontation 203 Exchanging Views 204 When to Initiate an Exchange of Views 204 Using I-Messages to Initiate an Exchange of Views 207 Asking Permission to Share Ideas 213 Advocacy: Confronting Collaterals 214 On Not Becoming Overbearing 215 Follow-up 217 Summary 217 Exercises I: What Is Wrong Here? 217 Exercise II: Constructing a Better Response 219 Exercises III: Expressing Your Concern 219 Exercises IV: Expressing a Stronger Message 222 Chapter 11 Addressing and Disarming Anger 225 Introduction 225 Common Reasons for Anger 225 Why Disarming Anger Is Important 226 Avoiding the Number-One Mistake 227 Erroneous Expectations for Perfect Communication: Another Reality Check 228 The Four-Step Process 229 What You Do Not Want to Do 231 Look for Useful Information 233 Safety in the Workplace 233 The Importance of Staff Behavior 234 Summary 235 Exercises I: Initial Responses to Anger 235 Exercises II: Practicing Disarming 236 Chapter 12 Collaborating with People for Change 239 Introduction 239 What Is Change? 239 Stages of Change 240 Understanding Ambivalence and Resistance 244 Encouragement 247 Recovery Tools 250 Communication Skills That Facilitate Change 252 Copyright 2016 Cengage Learning. 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Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. viii Contents Trapping the Client 258 From Adversarial to Collaborative 258 Summary 262 Exercises: Helping People Change 263 Chapter 13 Case Management Principles: Optional Review 265 Introduction 265 Combining Skills and Attitudes 265 Practice 267 Exercise I 267 Exercise II 268 Exercise III 271 Exercise IV 273 Exercise V 274 Section 4 Meeting Clients and Assessing Their Strengths and Needs Chapter 14 Documenting Initial Inquiries 277 Introduction 277 Walk-ins 278 Guidelines for Filling Out Forms 278 Steps for Filling Out the New Referral or Inquiry Form 278 Evaluating the Client’s Motivation and Mood 282 Steps for Preparing the Verification of Appointment Form 282 Summary 284 Exercises I: Intake of a Middle-Aged Adult 284 Exercises II: Intake of a Child 284 Exercises III: Intake of an Infirm, Older Person 285 Chapter 15 The First Interview 287 Introduction 287 Your Role 288 The Client’s Understanding 288 Preparing for the First Interview 288 Your Office 290 Meeting the Client 290 Summary 295 Chapter 16 Social Histories and Assessment Forms 297 Introduction 297 What Is a Social History? 298 Layout of the Social History 298 How to Ask What You Need to Know 299 Who Took the Social History 306 Social Histories in Other Settings 310 Writing Brief Social Histories 311 Copyright 2016 Cengage Learning. 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Contents ix Using an Assessment Form 314 Taking Social Histories on a Computer 316 Taking Social Histories in the Home 316 The Next Step 317 Summary 317 Exercises I: Practice with Social Histories 318 Exercises II: Assessment of a Middle-Aged Adult 318 Exercises III: Assessment of a Child 319 Exercises IV: Assessment of an Infirm, Older Person 320 Exercises V: Creating a File 320 Chapter 17 Using the DSM 321 Introduction 321 Is DSM Only a Mental Health Tool? 322 Cautions 322 Who Makes the Diagnosis? 323 Background Information 323 The DSM-IV-TR 327 DSM 5, the Current Diagnostic Manual 328 Making the Code Using DSM 5 330 Multiple Diagnoses 331 Other Conditions That May Be a Focus of Clinical Attention 332 When the Diagnosis Does Not Quite Fit 332 When There Is No Number 333 Summary 333 Exercises: Using the DSM 5 334 Chapter 18 The Mental Status Examination 337 Introduction 337 Observing the Client 338 Mental Status Examination Outline 339 Summary 356 Exercises: Using the MSE Vocabulary 356 Chapter 19 Receiving and Releasing Information 359 Introduction 359 Sending for Information 359 If You Release Information 359 Directions for Using Release Forms 360 Examples of the Release Forms 362 When the Client Wants You to Release Information 363 When the Material Is Received 363 Other Issues Related to Releasing Information 365 Summary 365 Exercises I: Send for Information Related to a Middle-Aged Adult 366 Exercises II: Send for Information Related to a Child 366 Exercises III: Send for Information Related to a Frail, Older Person 366 Exercises IV: Maintaining Your Charts 366 Copyright 2016 Cengage Learning. 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Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. x Contents Section 5 Developing a Plan with the Client Chapter 20 Developing a Service Plan at the Case Management Unit 367 Introduction 367 Involving the Client and the Family 368 Using the Assessment 369 Creating the Treatment or Service Plan 372 How to Identify the Client’s Strengths 373 Individualized Planning 374 Understanding Barriers 375 Sample Goal Plan 375 Summary 376 Exercises: Broad General Goal Planning 377 Exercise I: Planning for a Middle-Aged Adult 377 Exercise II: Planning for a Child 377 Exercise III: Planning for an Infirm, Older Person 377 Exercise IV: Maintaining Your Charts 377 Exercise V: Checking Services 378 Chapter 21 Preparing for a Service Planning Conference or Disposition Planning Meeting 379 Introduction 379 What You Will Need to Bring to the Meeting 380 Goals for the Meeting 380 Benefits of Conference Planning 381 Collaboration 382 Preparing to Present Your Case 383 Making the Presentation 383 Sample Presentation 384 Follow-Up to Meeting 385 Summary 385 Exercises: Planning 386 Exercise I: Developing a Service Directory 386 Exercise II: A Simulated Planning Meeting 386 Chapter 22 Making the Referral and Assembling the Record 387 Introduction 387 Determining Dates 388 Sample Referral Notification Form 389 The Face Sheet 390 Summary 392 Exercises: Assembling the Record 393 Chapter 23 Documentation and Recording 395 Introduction 395 The Importance of Documentation 396 Writing Contact Notes 396 Labeling the Contact 398 Documenting Service Monitoring 398 Documentation: Best Practice 399 Government Requirements 402 Do Not Be Judgmental 402 Copyright 2016 Cengage Learning. 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Contents xi Distinguish Between Facts and Impressions 403 Give a Balanced Picture of the Person 404 Provide Evidence of Agreement 404 Making Changes to the Plan 404 Summary 404 Exercises: Recording Your Meeting with the Client 405 Exercise I: Recording Client Contacts 405 Exercise II: Using Government Guidelines to Correct Errors 411 Exercise III: Spotting Recording Errors 411 Section 6 Monitoring Services and Following the Client Chapter 24 Monitoring the Services or Treatment 413 Introduction 413 What Is Monitoring? 414 The Financial Purpose of Monitoring 414 Follow-Up 416 Collaboration with Other Agencies 416 Advocating 417 Leave the Office 418 Responding to a Crisis 419 Summary 420 Chapter 25 Developing Goals and Objectives at the Provider Agency 421 Introduction 421 Client Participation/Collaboration 422 Make Objectives Manageable 423 Expect Positive Outcomes 423 Objectives 425 Combining Goals and Treatment Objectives 426 Finishing Touches 428 Review Dates 429 Vocabulary 430 Summary 432 Exercises: Developing Goals and Objectives 432 Exercise I 432 Exercise II 433 Exercise III 434 Exercise IV 436 Exercise V 437 Chapter 26 Terminating the Case 439 Introduction 439 A Successful Termination 440 The Discharge Summary 443 Examples 444 Summary 447 Exercises I: Termination of a Middle-Aged Adult 448 Exercises II: Termination of a Child 448 Exercises III: Termination of a Frail, Older Person 448 Exercises IV: Organizing the Record 448 Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. xii Contents Appendix A Ten Fundamental Components of Recovery 449 Appendix B Vocabulary of Emotions 451 Appendix C Wildwood Case Management Unit Forms 454 Appendix D Prochaska and DiClemente’s Stages of Change Model 487 Appendix E Work Samples 490 Appendix F Grading the Final Files 496 Appendix G Information for Understanding DSM IV TR Diagnoses 499 Appendix H Case Manager’s Toolbox 506 References 515 Index 518 Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. In a small nonprofit agency handling cases of domestic violence, a woman answers the phone. She assesses the caller’s concerns, accurately notes the caller’s ambivalence on the inquiry record, and readily connects the caller to the person most able to assist. In a mental health case management unit a new worker listens with interest to the other case managers, the psychologist, and the psychiatrist discuss the possible diagnosis for a new client of the agency. The worker is able to understand the conver- sation as the group talks about the DSM IV TR diagnosis and the new DSM 5 diagnosis. Down the street a young man acting as a case manager in a substance abuse detox center handles intake calls from physicians’ offices. He competently notes the main concerns for incoming patients and asks the questions he knows will give him information that doctors and therapists will need later as they work with these new admissions. His notes are clear and useful. How long did it take these people to acquire these skills? Did they acquire this ability well after being hired in a social service agency, or did they arrive able to handle case management tasks competently? Purpose For me and for students, the issue has been how we can teach the social services skills that will promote their walking from the classroom into the social service setting with confidence. How can we be assured that students, often steeped in sound theoretical knowledge, will be able to fill out an inquiry form or make a referral effectively? It is important to teach these practical skills. In addition, it is important to equip students with the vocabulary and methods used by more advanced professionals in the human service field so that upon entering the field students are prepared to engage in meaningful discussions around client issues. Although entry-level individuals would not usually give a DSM diagnosis, it is useful for individuals entering the field to be knowledgeable about what such a diagnosis is and what is meant by an Axis I or Axis II diagnosis or how diagnoses are given using DSM 5. In this way, conversations among professionals will not be misunderstood. Today individuals with a sparse education or with recent college degrees are find- ing themselves thrust immediately into roles for which they have had little formal training. It is crucial, therefore, to find a method for teaching the actual human service experience at the entry level. Fundamentals of Case Management Practice: Skills for the Human Services, fifth edition, seeks to provide that experience in a thorough, step-by- step process that leads the reader from intake through monitoring to termination. Preface Preface xiii Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. New in the Fifth Edition New material has been added to this fifth edition to bring the textbook up to date. Added to this edition: • Current terms are used throughout • Information on the DSM 5 and how entry level individuals can use this • Recent changes to HIPAA • Expanded Appendices to include material helpful in completing exercises in the text, a safety planning tool and a case manager’s tool box with information to assist in assessment and disposition. • A clear look at case management as a process • A discussion of how the size of a caseload affects service • Ethical considerations for those working in the field of substance abuse • A discussion of the differences among moral, ethical, and legal behavior and how violations are addressed • More information on the importance of mandated reporting • Expanded treatment of the ecological model • Broader section on empathy and more recent findings on empathy • An extensive feelings list in the appendix for use in various exercises • Differences between confrontation and an exchange of points of view • Enhanced discussion of motivational interviewing and why this is useful • More detail on the significance of the first interview • There are fewer chapters as some material has been combined in single chapters In addition, a considerable number of smaller items and changes specifically request- ed by our reviewers were added to the textbook. Fundamentals for Practice with High Risk Populations (Summers, 2002) has been published as an adjunct to this text, giving students information and scenarios on populations in which they are interested or with whom they intend to work. Chapters cover topics such as case management with children and their families, survivors of rape and violence, older people, issues with drug and alcohol dependence, and men- tal illness and developmental disabilities. Each chapter features information about specific populations and provides exercises and intake forms. This textbook also con- tains a set of forms that can be copied (see Appendix C). These forms can be found on CengageBrain. Taken from actual social service settings, they give the reader an opportunity to practice accuracy and skill in handling social service forms and records and in organizing information. If you do not wish to cover all of the populations discussed in the text on high-risk populations and instead want to focus on specific populations, you can order individual chapters from Fundamentals for Practice with High Risk Populations (Summers, 2002). Please visit http://www.textchoice2.com/ to view chapters online and to build your custom text. You can pick chapters about specific populations and create individualized booklets that you can bundle with this text. If you would like more information about custom options, please contact your local customer service representative. You can locate your representa- tive by using our rep finder at http://custom.cengage.com/. xiv Preface Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Format For each chapter in the textbook, basic information is laid out, followed in most chap- ters by many exercises that prompt the reader to handle real issues and practice real skills. Each of the chapters on case management describes one of the case manage- ment responsibilities followed by exercises to practice applying the information. As readers progress through the text, they gradually assemble files on specific cases. Stu- dents can create and monitor believable fictional clients using one of the high-risk populations discussed in Fundamentals for Practice with High Risk Populations (Sum- mers, 2002). Classroom discussions about these cases and the best disposition for each of them are not unlike the discussions that occur every day in a variety of social ser- vice settings. Organization of the Textbook The organization of the textbook follows a logical progression, beginning with the most basic foundation for good practice, moving to discussions on attitudes, followed by how the student will talk to others effectively. The second half of the book fol- lows a similar process, beginning with the person’s first contact with the agency and the assessment and planning process through all the case …