The purpose of treatment team
Readings and Resources
Readings and Resources
Articles, Websites, and Videos:
This chapter focuses on special writing within agencies such as transfer/discharge, letters for lobbying advocacy, and client reports to other agencies.
· Agency-based writing – Letters . (2018). In Weisman, D., & Zornado, J. L., Professional writing for social work practice, Second Edition (Vol. Second edition). New York, NY: Springer Publishing Company.
Service Coordination
Chapter 10
Chapter Introduction
· Chapter Ten addresses Social Work Case Management Standard 6, Service Planning, Implementation, and Monitoring, and Standard 8, Interdisciplinary Collaboration.
· Chapter Ten addresses Human Service–Certified Board Practitioner Competency 4, Case Management, which is focused on service coordination.
My company does something a little bit different than case management. It’s case management and then it’s more. We are actually called resource coordinators. My agency is the premier provider for therapeutic foster care in the region … The reason our agency was started was because a man who was working for human services figured out that a lot of these kids who have pretty serious needs aren’t getting their needs met by the department and need specialized, intensive treatment and support.
—Jessica Brothers-Brock, 2012, text from unpublished interview. Used with permission .
This chapter explores service coordination as a critical component of modern case management. We examine the coordination and monitoring of services as well as the skills that will help you perform these roles. After reading the chapter, you should be able to accomplish the following objectives.
Coordinating Services
· Describe a systematic selection process for resources.
· Discuss why networking is important.
· Identity strategies for creating a network of professional colleagues.
· Make an appropriate referral.
· Identify the activities involved in monitoring.
· List ways to achieve more effective communication with other professionals.
· Use technology and social media in coordinating services
Teamwork
· Describe the purpose of a treatment team.
· Define departmental teams, interdisciplinary teams, and teams with family and friends.
· List the benefits of working in and with teams.
· Describe ways to address the challenges that teamwork brings.
Ending Service Provision: Disengagement
· Describe the place of ending services in the case management process.
· List the steps used to end client services.
· Identity why clients may need to be transferred from one professional to another.
· Describe the transfer process.
· Discuss the purpose of a discharge plan.
10-1 Introduction
One of the most important roles in case management is service coordination. Rarely can a human services agency or a single professional provide all the services a client needs. Because in-house services are limited by the agency’s mission, resources, and eligibility criteria—as well as by its employees’ roles, functions, and expertise—arrangements must be made to match client needs with outside resources. Case managers must know which community resources are available and how to access them. Case managers also work in partnerships with others as they coordinate services; at times, they work in teams for the benefit of effective and positive client outcomes. And, at the end of the process, for multiple reasons, case managers end the provision of services to their clients.
In the following quotes, case managers talk about the importance of goals and their role in coordinating services.
In my job you have to know about the resources in your community. You can really help your clients get to the right place.
—Director and case manager, intensive case management services, Los Angeles, California
When I worked as a case manager in the downtown hospital, I needed networks in the hospital, in the medical community, and in the human services community. In fact, since I was doing discharge planning, this knowledge was a critical part of my job. I could not meet all of my clients’ needs. And the range of needs was so great, from detox services, to Social Security and government services, to food stamps and housing. I also had to help my families deal with the bureaucracy.
—Case manager, urban hospital, Atlanta, Georgia
It is incredible how important community is to other service providers. In my job I am a broker, and I have to be able to meet people, establish relationships with them, and work well with them. Things have changed since I started my work. Much of my work as a broker is online. And sometimes I use FaceTime or Skype. This inclusion of Internet work requires special attention to professional behavior and to recordkeeping.
—Care coordinator, health system, Pima County, Arizona
The preceding quotations reflect the knowledge and skills that a case manager uses to meet client needs. In the first quote, the case manager works with individuals with serious mental illness. To provide effective care, she expresses a desire to refer clients to the best services. Later in the interview, she talked about an incident when the referral did not go well. This interfered with the client’s care. In the second quote, the case manager was a discharge planner for an urban hospital. The needs of her client (patients) were so varied that she needed knowledge of medical systems and a wide range of social service systems. She shared that it took a long time for her to gain the knowledge of how to refer within these complicated systems. This knowledge served her well from the beginning of the case management process through to her discharge planning. In the third quote, the case manager emphasizes her need to establish networks. These relationships are established over a period of time; the case manager needs both the knowledge of the services available and the ability to establish rapport with fellow professionals. Each of these professionals also needs to know how to negotiate the service delivery system to gain access to those resources for the client. Having networks in place requires knowledge of both the agency and the name of a contact. Perhaps the one indispensable skill in using resources is communication! According to the third case manager who works as care coordinator for health-related services, there is more work conducted over the Internet. This requires a different type of communication and recordkeeping.
Today’s service delivery environment imposes new roles and responsibilities on the case manager. In the past, many services were provided directly by the case manager, but service delivery has become more specialized. Professionals must be careful not to provide direct services in areas in which they are not trained or lack the necessary resources. Case management has thus come to mean providing selected services, coordinating the delivery of other services, and monitoring the delivery of all services. In addition, it includes ending client services. This shift in job definition calls for skills in networking , collaboration , and teamwork . We discuss networking as we talk about coordinating services and making referrals. There is a section that describes working with other professionals, the importance of teamwork and collaboration, and addressing challenges that arise.
10-2 Coordinating Services
If a client needs services that an agency does not provide, then it is the case manager’s responsibility to locate such resources in the community, arrange for the client to make use of them, and support the client in using them. These are the three basic activities in coordinating delivery of human services. In coordinating services, the case manager engages in linking, monitoring, and advocating while adding to on the assessment and planning that have taken place in earlier phases of case management. The case manager continues to build on client strengths or emphasize client empowerment within the context of the client’s cultural background and basic values.
Coordinating the services of multiple professionals has several advantages for both the case manager and the client. First, the client gains access to an array of services; no single agency can meet all the needs of all clients. The case manager can concentrate on providing only those services for which he or she is trained while linking the client to the services of other professionals who have different areas of expertise and have the necessary resources. Second, the case manager’s knowledge and skills help the client gain access to needed services. Often, services are available in the community, but clients are unlikely to know what they are or how to get them. The success of service delivery may depend on advocacy by the case manager. Also, service coordination promotes effective and efficient service delivery. In times of shrinking resources, demands for cutbacks in social services, and stringent accountability, service provision must be cost-effective and time-limited. In addition, customer satisfaction is important. Clients have the right to receive the services they need without getting the runaround or encountering frustrating confusion among providers.
Service coordination becomes key once the client and the case manager have agreed on a plan of services and have determined what services will be provided by someone other than the case manager. As case managers begin the coordination of services, they consider several aspects of this work such as reviewing family support, assessing client strengths, insuring quality documentation, reviewing professional contracts, encouraging client participation, and developing plans to monitor services. We discuss each of these.
For services that will be provided by others, a beginning step is to review previous contacts with service providers. This review includes four important questions:
· What services do they provide?
· Is this client eligible for those services?
· Can the services be provided in-house?
· What about the individual’s own resources and those of the family?
A second step is to consider the type of family support available. In fact, family support may be critical for the success of the plan. Third, the client’s own problem-solving skills and strengths may be helpful. This means that the case manager does not ignore the resources of the client, the family, or significant others.
The next step is referral—the connection of a client with a service provider. Equally important is developing a plan to monitor service delivery over time and following-up to make sure the services have been delivered appropriately. These steps may vary somewhat, depending on whether the services are delivered in-house or by an outside agency, but the flow of the process is likely to be the same. Before examining these steps in detail, let us review the documentation and client participation aspects of service coordination.
Documentation is critical in this part of case management. Staff notes must accurately record meetings, services, contacts, barriers, and other important information. During this phase, reports from other professionals are added to the case file. Any progress that occurs in the arrangement of services must be recorded by the case manager.
Client participation is important throughout the service coordination process. This entails more than just keeping the client informed; his or her involvement should be active and ongoing. First, the client participates in determining the problem that calls for assistance. Second, the values, preferences, strengths, cultural perspectives, and interests of the client play a key role in selecting community resources; of course, client participation is critical in following-up on a referral. Clients also have the right to privacy and confidentiality. Without the client’s written consent, the case manager must not involve others in the case or give an outsider any information about it.
Maintaining relationships is a key factor in service coordination. And remembering that meeting client needs is of primary importance is an excellent guideline. Relationships may be between individuals or agencies. Case managers often represent their agencies or organizations during the service coordination effort. At times, relationships among agencies sometimes hinge on the working relationships between individual direct service providers. Often relationships begin with a case manager’s networking with other professionals and continue as case managers consult, refer, or work together with others on teams. In Networking we describe networking, what it is, and its benefits. In this chapter we also present strategies to help case managers develop strong networking systems. Later in this chapter, we describe the case manager’s involvement in teamwork. In addition, we describe the issues and challenges that may occur as case managers work in teams and suggest ways to address these.
Before we continue our discussion of service coordination and discuss the importance of networking, we want you to hear Sharon’s perspective of service coordination.
My Story
Sharon Bello, Entry 10.1
Alma and I talked about who should write this entry. At first she thought that it was her story to write, since she was the case manager involved in the coordination of my care. But, in the end, I convinced her that I had a lot to say about the coordination of care. I just wanted everyone reading this book to know that the client is also affected by all of this interaction with lots of professionals. I have drawn a picture for you of my experiences with the rehabilitation agency. You can see this picture in Figure 10.1. Look at the picture, and then I can explain it to you.
Figure 10.1A Client’s (Sharon Bello) View of the Service Coordination Process
In my agency, my primary contact with the entire service coordination process is Alma. I am not complaining, but you can tell from my description of the case management process that I don’t really know much about how the other professionals work together. So, here is what I think happens:
· I meet with my case manager.
· I have appointments with other professionals who make assessments.
· These professionals provide their reports to one of my case managers (Tom, Susan, Luis, or Alma).
· My case manager at the time describes the results of the assessment to me.
· Sometimes we decide I need another assessment. This just recently happened at my school and I was able to get some financial assistance.
· We make a new plan based on the assessments.
· My case manager’s supervisor approves the plan. She could have asked us to revise it.
· We carry out the plan and I communicate with my case manager periodically. I also call my case manager if I have an emergency.
The process was a little different when I applied for services. At that time a team evaluated my application and accepted me as a client. And I don’t really know much about what happens with Alma when she works with other professionals. That is not part of our discussion when we meet.
One place that I know of where this process is different is at the school where my children attend. I mean where the boys did attend and where the girls attend now. For Sean, especially, we had team meetings to talk about his work and the services he was receiving. We met at least three times during the year. I was invited and I always attended. There were several people who came to the meetings like the school counselor, the social worker, a psychologist, and sometimes the principal attended the meeting. The resource teacher was in charge of the meeting. When Sean was in middle school he came to the meetings, too. In that meeting, I listened mostly to all of the other people talk about my Sean. It was not always a positive experience for me and not for Sean either. Compared to the school experience, meeting with Alma is much more supportive. So, those are my experiences.
Encouraging Client Participation
Client participation is an important part of service coordination. Sharon Bello shares with us her perspective of service coordination. As an individual, a small group, or a class, discuss what insights you gained from reading her entry. How might her experiences help you coordinate services for your clients?
Share the results of your discussion with your classmates.
Once the process of coordinating services begins, the case manager makes resource selections, refers the client to other professionals, and monitors services. One important aspect of resource selection, locating services for clients, making referrals, and monitoring services is networking.
10-2aNetworking
Networking, an important professional responsibility and skill, is “the exchange of information or services among individuals, groups, or institutions; specifically, the cultivation of productive relationships for employment or business” (Merriam-Webster, n. d.). The purpose of networking, as it relates to case management, supports the complex tasks required to serve clients with multiple needs across a wide range of disciplines. Networking also helps case managers perform several of the roles introduced in Chapter Three, such as advocate, broker, coordinator, consultant, and problem solver. In this chapter, we focus on three of these roles: advocate, broker, and coordinator. In Chapter Twelve, we include the importance of networking as it relates to the role of consultant. Benefits to establishing a strong professional network include providing more effective services to the client, supporting the professional development of the case manager, and building linkages among agencies. Because case managers’ work often extends beyond their own professional expertise (e.g., social work, counseling, human services), networking activities often include settings in which case managers are less familiar. Alma Grady shares a few of her networking experiences.
My Story
Alma Grady, Sharon Bello’s Case Manager, Entry 10.2
To be honest with you, at first networking was very difficult for me. While I was in school, my professors talked about the importance of networking. And during my internship, my site supervisor modeled strong networking skills. I watched her with wonder. You see, I am a shy person, and it looked to me like I would never be able to build networks similar to his. I assumed this would be a weakness that I could never correct.
Once I started my first job, I realized that I could not help my clients without beginning to know what was going on in the community and what services were available. During my first year, every time I needed help, I would ask my supervisor about community services and good contact persons. Every time I picked up the phone or sent an email, I did so with the introduction, “Hi, my name is Alma Grady and I am a counselor/case manager working with rehabilitation clients. I have a client who I believe could use your services.” I kept records of my contacts in my clients’ files. But I also kept a log for myself about the contact, the topic, and the help that I received. Honestly, I thought that I was networking. And, in some ways, I was beginning to develop relationships with professionals in the community.
About 9 months after I started that first job, I was assigned a client who completely surprised me. I was not sure that I could help. But this individual was my client. It seemed that this client represented many of the things that I didn’t know much about. The client was a burn patient, had a diagnosed substance use disorder, was a refugee, and, in his home country, was a victim of torture. I didn’t have any experience with burn patients, little with refugees, and none with victims of torture. I was assigned this client because of my ability to develop rapport. To make things more difficult, the physicians, psychologists, and vocational evaluators I knew had little experience with the issues and challenges this client faced.
To better understand my client and to support the client in the case management process, I had to expand my network of professional help and support quickly. During this time, I found resources with agencies and organizations I knew little about. I did this in two ways. First, I looked up resources in the area—I used the web and I emailed several of my colleagues who work in other agencies and asked for their help. I also talked with several colleagues by phone. I made a list of questions that would help me learn about this specific medical focus, treatment and prognosis for burn patients, and the psychological implications of being a victim of torture.
Since I was in the learning mode, I asked my colleagues about how to introduce myself in a way that professions outside the social services would understand. I thought about how to speak without using our professional jargon, and how to match my client’s needs with another agency’s services. I encountered and then worked with a diverse set of services, including medical specialists, county and state parks and recreation, private foundations, a local mosque, and a support community of refugees. I also found a psychologist in a neighboring county who spoke the client’s native language and was herself a refugee. What I found, for the most part, was that other professionals were willing to help and were interested in helping my client.
Alma and her experiences reflect our belief that building networks is a skill that, with intentional practice, can help case managers build a web of support for their clients and for themselves. In business, networking is a key skill for a successful professional. We present some common practices that may help you develop your own professional network (see Figure 10.2) (Attard, 2016; Greene, 2016; Speisman, 2016). These include personal approaches and professional activities.
Figure 10.2Building a Professional Network
10-2bPersonal Approaches
Be Intentional
A strong professional network does not develop quickly. Develop a strategy for getting to know other professionals and establishing relationships with them (e.g., plan to attend professional meetings, volunteer organizations).
Be Authentic
Professional relationships are built on trust. Be honest about your education, job, and work responsibilities. Integrate your personal self with your professional self. There are multiple ways to “act” professional that might include your sincerity, humor, honesty, and caring.
Be Dependable
Within interactions with other professionals, follow through with what you promise.
10-2cProfessional Activities
Participate in Professional Organizations
Learn about professional organizations and activities in your local area whose goals and focus overlap with your interests and your job. Choose one or two to attend.
Meet Individuals in Attendance
Use an early arrival, session breaks, and a late departure to meet individuals in attendance. Introduce yourself and engage in conversation about the work of the individuals you meet. Share some information about your own work. A common conversation starter might be about the event or meeting you are attending.
Listen and Learn
Part of meeting people is listening to what they have to say. Follow-up with open-ended questions about their work or share something that you see you have in common. Be curious!
Share Business Cards
Business cards are good to exchange during a first meeting. You leave with follow-up contact information and share yours.
Note-Taking
Make sure after each encounter you record who you met, the content of the encounter, what (if any) promising follow-ups were made, and contact information. You may also note how you anticipate the individual or agency that the individual represents might help your client.
Follow-Up
After the meeting, be sure to follow-up this with an email or phone call. If you promised to share information or ideas, be sure to follow-up promptly. Do not be discouraged if you do not get an immediate thank you. You are making the network connection. Be available in ways that meet the other’s needs (e.g., telephone, visit, email).
Extend the Relationship
You may wish to gain additional information about the individual’s work or the purpose of the agency that the individual works for. In either case, make time to read about the agency on the Internet or ask for more information. You may also wish to follow-up with a visit to the agency or a meeting with the individual you met earlier. At this meeting you might exchange information about clients and services and ways you can collaborate.
Developing Networks
As an individual, within a small group, or as a class, talk about the networks that you have developed over time. A first step would be to review the networks you currently have. We list several types of networks below. Then, describe how you began the relationship, how the individual helps you or can help you in the future, and how you help the individual.
· Personal crisis or decision making
· Educational support
· Career support
· Work-related support
Discuss your responses with your classmates.
10-2dResource Selection
Once client needs and corresponding services have been identified, the client and case manager turn their attention to resource selection —selecting individuals, programs, or agencies that can meet those needs. Paramount in this decision are the client’s values and preferences. The information and referral system that the case manager has developed (see <a target=”_blank” rel=”nofollow noopener
