How To Develop a Plan for Services

Reading and Resources

Articles, Websites, and Videos:

This chapter focuses on building a collaborative client-worker relationship.

· Expanding on collaborative partnerships and goal formation . (2016). In Blundo, R. G., & Simon, J. K.  Solution-focused case management. Springer Publishing Company.

This next chapter expands upon developing the client-worker relationship by addressing future goals and developing steps to realize that future.

· Solution-Focused Planning and Assessment . (2016). In Blundo, R. G., & Simon, J. K.  Solution-focused case management. Springer Publishing Company.

This article discusses the importance of writing your goals down using the SMART Goals strategy.

· Crowell, N. (2016, February 5).  How goal SMARTS will make you a more successful social worker .  Social worker success.

 

Chapter 8:

Service Delivery Planning

Chapter Introduction

· Chapter Eight addresses Social Work Case Management Standard 6, Service Planning, Implementation, and Monitoring.

· Chapter Eight addresses Human Service–Certified Board Practitioner Competency 4, Case Management.

I work with school-age children, and most of these children have behavior problems. During the planning for them, we use a central file for all records. All of our records are electronic, so everything is on the computer. For every visit, we have to do a case management progress note, which is just kind of an outline. It has subjective findings of what you and the client are working on and what comes out of that. It has objective findings where I might record the child’s appearance and affect. There is also an assessment part; I just record my ideas and opinions about what’s going on. In that section I have to talk about our SNAP goals, which refers to the client’s strengths, needs, abilities, and preferences, and that’s in every single assessment.

From Katie Ferrell, 2012, text from unpublished interview. Used with permission .

In this chapter we focus on the planning of service delivery. The needs of the client are complex, and planning provides the foundation for the case management process. For each section of the chapter, you should be able to accomplish the objectives listed here.

Revisiting the Assessment Phase

· List the two areas of concern that are addressed when reviewing the problem.

· Describe the ways in which the continued assessment can change over time.

Developing a Plan for Services

· Identify the parts of a plan.

· Write a plan.

· See first-hand how a plan can change during the case management process.

· See how a client (Sharon Bello) and a case manager (Alma Grady) work together to develop a plan for services.

· Learn how goals and objectives are formulated.

Identifying Services

· Locate available services.

· Create an information and referral system.

Gathering Additional Information

· Compare interviewing and testing as data collection methods.

· Identify the types of interviews.

· Show how sources of error can influence an interview.

· Illustrate the role of testing in case management.

· Define test.

· Categorize a test.

· Identify sources of information about tests and the information that each provides.

· Learn about how to prepare clients for testing.

· Analyze the factors to be considered when selecting, administering, and interpreting a test.

· 8-1Introduction

· At this point in the process, the agency has determined that the applicant meets the eligibility criteria and the services are appropriate, so the person can now receive services. At the family services agency, the applicant becomes a  consumer, but the welfare-to-work program uses the term  client. An agency in South Dakota that serves adults with developmental disabilities calls the service recipients  individuals, explaining that “they are not clients or consumers anymore. They are just people.” Other agencies or organizations use the term  customer. The change in status from applicant to recipient of services marks the move into the second phase of case management: planning service delivery.

· Although some agencies call the individuals they work with “clients,” we use the term “consumers.” We changed our language when we began to evaluate our services. These individuals actually come here for the services we provide. In other words, they actually “buy” our services. They could go elsewhere. Consumers choose agencies for a variety of reasons; we hope they see this agency as a welcoming and friendly place.

· —Case manager, family services, New York, New York

· We use the Millon Adolescent Clinical Inventory for each of our new clients who come to live with us. We call our clients “residents.” This inventory has 160 items. It is a questionnaire that addresses a range of issues, including personality patterns, expressed concerns, and clinical syndromes. First, we score the questionnaire, and then we identify issues of concern from the question and from the resident. Finally, the resident and the case manager together make a treatment plan that addresses the areas of concern.

· —Case and intake worker, emergency shelter, St. Louis, Missouri

· When I first meet clients during the interview, I help them understand what will happen if they join our program. We have some basic criteria, such as having a 9.5 in math and a 10.0 in reading on the TABE test. Plus, they have to be able to type 30 words per minute and have a minimum understanding of computers. If they join the program, they must attend classes on a regular basis. They may only miss 8 days within a 6-month period. That is difficult for some of them.

· —Case manager, welfare-to-work and case management services, Knoxville, Tennessee

· The quotes that introduce this chapter identify some of the activities that occur during this phase. At the emergency shelter in St. Louis, Missouri, client participation is important in planning. In fact, clients determine the goals. Client interests and expectations and use of test data are shared at the welfare-to-work program in Knoxville, Tennessee. One case manager in New York City summarizes this phase of case management: “You just have to read through the information several times and say, ‘What stands out here? What issues should I pay attention to?’ Then you say, ‘Well, if these are the problems my clients and I think are important, what do we do about them?’.”

· A caseworker at a school for the deaf also notes the importance of gathering information to see the big picture.

· One skill that I need in this job is to be able to talk with the different professionals, family, and friends of the children I work with. So many people have to be involved to address such complex problems. I search and search for all of the little pieces. But the job is still not done. I need to step back and see the big picture. This is the key to case management. Without a case manager or someone taking the case management approach, no one has the big picture.

· This chapter explores the planning phase of case management, when the helper and the client together determine the steps necessary to reach the desired goal. The activities involved in this phase include reviewing and continuing to assess the problem, developing a plan, using an information system, and gathering additional information. Running through our discussion in this chapter are two critical components of the case management process—client participation and documentation.

8-1aRevisiting the Assessment Phase

The next phase of case management begins with a review of the problems and strengths identified during the assessment phase. Before moving ahead with the process, the case manager will need to know if the problem has changed, if the same client resources are available, and if any shift in agency priorities has occurred. To complete the review quickly before moving into a planning mode, the case manager and the client examine two aspects of a case.

The first area of concern involves a review of the relevant facts regarding the problem. At this point, the case manager and the client revisit the identification of the problem. The initial question that the helper asks can help determine whether the problem still exists. Working with people requires an element of flexibility; clients’ lives change, just as ours do. Thus, the problem may have changed in some way: the client may have a different perspective on it; the participants may be different; or assistance may no longer be needed, appropriate, or wanted. Once the case manager has confirmed that the problem still exists and has documented any changes that have occurred, the problem itself is revisited. Is the problem an unmet need, such as housing or financial assistance, or is it stress that limits the client’s coping abilities or causes interpersonal difficulties? Is the problem a combination of several factors? This activity is best accomplished by talking with the client and reviewing his or her file. The client is still considered the primary source of information and a critical partner in the case management process. We return to Sharon Bello to illustrate reviewing the previous assessment.

My Story

Sharon Bello, Entry 8.1

I want to provide more information for you about my experience with case management process. What I want to focus on is the fact that the assessment process is never really over. I know that my case is unique. When I first began my work with the agency, I felt overwhelmed by all of the information that I had to provide and I was shocked by all of the visits I had to make with other professionals. I understood that I needed to prove that I was eligible for services. Still, I was not doing very well during that time. Each visit to the doctor seemed like a heavy burden. From my perspective now, it was all worth it. But when I re-read what I wrote in  Chapter One, I can understand why the process was so difficult for me.

But all of that has changed for me. I have been working with my case manager, Alma Grady, for some time. She is able to help me understand more about the planning process. She doesn’t just use the agency forms. She and I are going to share our process with you. We want you to understand the process of planning, what we do with the information we have gathered, how we both manage the information, and then how we locate services. In  What Do I Know About the Source of the Problem?, you will see how Alma and I use this information to formulate a plan together.

Sharon and I are writing this section together about gathering information and using that information in the planning process. When I inherited Sharon’s case, one of the first things that I did was work with Sharon on a form that she and I could both use to review the information that we had about her case. Instead of using an agency form, I had a chart that we used to summarize what she and I knew about her case. My source was her case file and what I had read about her application for services and her receipt of services. She added information about herself. We both used this form to begin to manage the information we had and to review the goals and objectives already established. Here is what the beginning of our review looked like.

A second area of concern in the review of the problem requires an examination of available information to answer the following six questions.

· What do I know about the source of the problem?

· How does culture influence the client and environment?

· What attempts have been made previously (before agency contact) to resolve the problem?

· What are the motivations for the client to solve the problem?

· What are the interests and strengths of the client that will support the helping process?

· What barriers may affect the client’s attempts to resolve the problem?

An important source of information is the client. Talking with the client can reveal what he or she has thought about doing, what has been tried, and some possible solutions. Working with the client to explore his or her motivations, strengths, interests, and cultural considerations indicates that the process of case management continues to be a partnership between the client and the case manager.

8-1bWhat Do I Know About the Source of the Problem?

Sharon Bello

I was able to tell all of my case managers about the sources of my issues. It is interesting that my story about the source of my issues has changed. When I first met with Tom, I was really in need. I was grieving the loss of my sons, feeling depressed, stressing about the lack of employment, and struggling to find work that I could do to support my family. My life was all about loss.

Now that I am in school and am studying a subject that I have experience with, I am less depressed and feel hopeful. I am also grateful for all of the support that I am receiving. I probably would not have realized the change in my situation without working with Alma.

Alma Grady

When I first started working with Sharon, I read through her file several times. Then, when she and I met for the first time, I asked her to tell me about herself. As the conversation continued, I asked her to help me think about my situation. I thought this would be a good way for us to get to know one another and begin our work together. When I read Sharon’s file, I could see her situation when she first came for services. But looking at the later entries, I could also see how her situation changed. When she first applied for services, we needed to verify her financial situation, confirm her physical disabilities, assess her vocational skills and interests, and assess her mental health needs. Everything to date has changed except her physical disabilities. Once she and I outlined a list of her first issues and then considered her status now, we agreed we needed to update her plan.

Joint Summary

I wanted Sharon to describe her current issues (and then we will work on strengths). We constructed this description with Sharon taking the lead:

“I am doing well in school and making progress toward my employment training. I want to stay in school and attend a 4-year college to become a human services professional. My financial situation has improved, although it is still difficult for me to care for my children. I don’t have much extra support and lots of times my children need things for school and athletics. Although I am not so distraught about the death of Sean, I am still depressed. I go to see the psychiatrist to manage my meds for depression. Alma thinks that counseling on a regular basis might help. I also feel lots of stress with school and childcare demands.”

Sharon and I agree that we will:

· a)

Revise her educational goals

· b)

Re-assess her mental health status

· c)

Explore a part-time job at the college

· d)

Explore a paid internship at the college

Other techniques that are helpful in reviewing the problem are observations and documentation. In the course of receiving the application, conducting the intake interview, making a home visit, or all three, the case manager has opportunities to observe the client beyond the office setting. For example, these observations may be richer if they occur in the home or if the client is accompanied to the office by family members or a significant other. Information available from such observations includes the client’s thoughts, feelings, behaviors, and relationships. In the case of Sharon, Sharon and Alma agreed that they would work together to gain new information and reformulate her plan as needed.

Documentation in the case file also provides facts and insights about the client. Case notes, reports from other professionals, and intake forms help the case manager pin down past occurrences and pertinent facts about the present situation. Case managers who have a long history in service delivery may call on knowledge and experience from the past to understand a current case. Sometimes, knowledge comes from a case manager’s own perception, instinct, experience, or street know-how. Many case managers mention rapid insight they sometimes have about a client, the client’s environment, possible difficulties, and creative approaches to the case management process. This insight is treated as just one piece of information and must undergo the same scrutiny as the other information collected.

Once the case manager has revisited the problem, confirmed its existence, documented any changes, and reaffirmed the client’s desire for assistance, the case manager and client move to the next step of the planning phase, which addresses the need to determine the steps necessary to reach the identified goal or goals. This is the plan that will guide service provision.

8-1cDeveloping a Plan for Services

The  plan  is a document, written in advance of service delivery, that sets forth the goals and objectives of service delivery and directs the activities necessary to reach them. The plan also serves as a justification for services by showing that they meet the identified needs and will lead to desired outcomes. More specifically, a plan describes the service to be provided, who will be responsible for its provision, and when service delivery will occur. If there are financial considerations, the plan may also identify who will be responsible for payment. Sometimes financial support is available from outside sources, including the client and the family. Usually, the completed plan is signed by the client and the case manager as the representative of the agency. It may then be approved by someone else in the agency before the authorization to provide services is granted.

Clearly, the plan is a critical document because it identifies needed services and guides their provision. How is it developed? What is included? What are goals and objectives? What factors might present planning challenges? You will learn answers to these questions as you read this section.

Plan development  is a process that includes setting goals, deciding on objectives, and determining specific interventions. The process begins with the synthesis of all the available data. This information is scrutinized carefully to assemble as complete a picture of the case as possible. It is analyzed to identify inconsistencies, desirable outcomes, or both. It is also important to consider the veracity of the available data. For example, if substance abuse is a problem, then how accurate is the client’s report of the amount of alcohol consumed daily or the extent of withdrawal (sleeping disturbances, DTs, blackouts, convulsions, hallucinations, etc.).

For the beginning case manager, the following method uses a step-by-step approach to synthesize data and integrate the information into a workable plan. Using the worksheet displayed in  Table 8.1, the case manager can record his or her analysis.

· Re-read the client file and complete the following categories on the worksheet: sources of information and relevant facts.

· With this snapshot of the contents of the client’s file, assess and record conclusions, contradictions, and missing information.

· Review this assessment with the client and make revisions according to his or her input and other new data gathered; fill in client motivations, strengths, interests, and cultural considerations with client input.

· Discuss desirable outcomes with the client.

Table 8.1

Integrating Client Information

Client Worksheet
Client Name:
Date:
Source of information	Relevant facts	Conclusions	Contradictions	Missing information	Motivations of client	Strengths of client	Interests of client

Class Discussion

Integrating Client Information

Integrating information is an important part of the service planning process. As an individual, in a small group, or as a class, review the information you have about Sharon Bello and her work with her case manager, Alma Grady. Using the information that you have, complete  Table 8.1, integrating client information. Discuss what new information you gained about Sharon Bello. What ideas do you have about any future work with Sharon? What advice would you give Alma Grady?

Share this information with your classmates.

In Sharon Bello’s case in  Chapter One, the information available at the time of plan development was derived from Sharon’s application for services, the intake interview, reports from her orthopedic surgeon, case documentation, a general medical examination report, a psychological evaluation, and a vocational evaluation report. When Sharon and her counselor, Susan Fields, developed the plan of services, they reviewed and considered all this information using the steps listed in  Table 8.1.

During that intake and plan development, Sharon had a back injury and needed assistance finding a job; she also met economic eligibility criteria. Her service plan, presented for the first time in  Chapter One,  Figure 1.8, included a program objective and intermediate objectives. For each objective, a service was identified, as was a method of checking progress toward the achievement of the objective. The form also provided space to describe any other client, family, or agency responsibilities or conditions. Because this agency values client participation, Sharon’s view of the program was also noted. Then, both Sharon and the counselor signed the plan.

Exactly what a plan looks like varies from agency to agency. However, if you are employed by an agency that provides case management or client services, then you can be sure that a plan will guide your work. Let us examine the components of a plan of services. After we review the characteristics of a service plan, we review an updated version of Sharon Bello’s Service Plan (see  Figure 8.2). This new Amended Service Plan includes a revision of the Program Objective (on other plans this is known as the Program Goal) and the Intermediate Objective (on other plans this is known as the Objective).

Figure 8.2Amended Service Plan

Service plans are goal-directed and time-limited, so they should include both long-term and short-term goals. Long-term goals state the situation’s ultimately desired state. Short-term goals aim to help the client through a crisis or some other present need. Whatever the time constraints, goals establish the direction for the plan and provide structure for evaluating it.

Goals  are statements that describe a state, condition, or intent. For clients, a goal is a brief statement of intent concerning where they want to be at the end of the process; for example, “Learn daily living skills in order to live independently,” “Acquire knowledge and skills for a career in business communications,” or “Develop a support network for help in coping with phobias.”

Having written goals helps us focus on what we are trying to accomplish before we take action or provide any services. Action is often easy, but sometimes relating actions to outcomes is not. For accountability reasons, service provision is tied to outcomes. This makes writing goals a critical step in plan development. Remember that these broad statements of intent can be achieved only to the degree that their meaning is understood, so well-stated, reasonable goals are essential for problem resolution.

At one intensive case management program in Los Angeles, California, clients decide on their goals.

When we create a record of the plan, we use the client’s own words. We work hard with the client to list problems, issues, strengths, and barriers to reaching the goal. In other words, we ask the client, ‘What will get in your way to accomplishing this goal?’ Then, we talk about next steps. We break down the steps into little pieces. I have some clients who cannot even make one goal, no matter how small. Sometimes I have to write it down for them and list steps. The next step is to decide who does what. What do I do? What does the client do? What does the client’s family do?

How does one write goals that are well stated and reasonable? Three criteria help us achieve this. First, the goal should be expressed in language that is clear and concise. Second, the goal statement should be unambiguous. Third, the goal must be realistic and achievable. These criteria are illustrated in the following goals, which were established for a 74-year-old woman who will attend the Daily Living Program at the Oakes Senior Citizens Center.

Draft 1 is a goal statement for Ms. Merriweather. Draft 2 improves the statement by making it more clear and concise.

· Draft 1: Ms. Merriweather will participate often in many of the Oakes programs that relate to sports, games, music, communication, exploring other cultures, and other educational programs as they are developed by the creative staff in the activities area.

· Draft 2: Ms. Merriweather will increase her social opportunities by participating in center activities.

A description of the plan is presented in Draft 1. In Draft 2, it is restated less ambiguously by defining who will help with medications and what the help entails.

· Draft 1: They will work with Ms. Merriweather and her numerous family members to help with medications.

· Draft 2: Nursing staff will develop a plan to administer Ms. Merriweather’s medication.

The goal in Draft 1 is to establish general physical goals for Ms. Merriweather. Draft 2 restates these goals in realistic and achievable terms.

· Draft 1: Ms. Merriweather will increase her range of motion, physical strength, and stamina.

· Draft 2: Ms. Merriweather will participate four times per week in an exercise program that includes walking, weight lifting, and stretching.

Thus, goals are an important part of the service plan. They increase the chance of solving the problem by providing direction and focusing attention on well-expressed, reasonable statements. Because formulating goals requires collaboration between the client and the case manager, writing them also highlights the shared responsibility for the case.

Once the client and the case manager have agreed on a broad statement of intent, it is time to identify the activities that will lead to the desired outcomes. This process continues as a cooperative effort between the client and the case manager. Activities are identified as objectives.

An  objective  is an intended result of service provision rather than the service itself. It tells us about the nuts and bolts of the plan—what the person will be able to do, under what conditions the action will occur, and the criteria for acceptable performance—so that we can know whether the objective has been accomplished. Objectives are useful for several reasons. First, they tell us where we are going. Second, they give the client guidance in organizing his or her efforts by stating the intervention or action steps. Third, they state the criteria for acceptable performance or outcome measures, thereby making evaluation possible. Objectives are all-important for the case manager because they provide the standards by which progress is monitored. As progress is made, the case manager adjusts the plan as needed.

Writing clearly defined objectives benefits the client, the case manager, and the agency. The Centers for Disease and Control and Prevention (2013) provide the following five guidelines for writing and evaluating service objectives. These follow the SMART model (specific, measurable, achievable, realistic, and time-phased). We have provided an additional six guidelines (see  Figure 8.1).

Figure 8.1Guidelines for Writing Objectives

Specific

· Objectives should provide the “who” and “what” of program activities.

· Use only one action verb, because objectives with more than one verb imply that more than one activity or behavior is being measured.

· Avoid using verbs that may have vague meanings to describe intended outcomes (e.g., “understand” or “know”), because it may prove difficult to measure them. Instead, use verbs that document action (e.g., “At the end of the session, the students will list three concerns …”).

· Remember, the greater the specificity, the greater the measurability.

Measurable

· Objectives are the basis for monitoring to determine whether objectives have been met, unless they can be measured.

· The objective provides a reference point from which a change in the target population can clearly be measured.

Achievable

· Objectives should be attainable within an implementation of your strategies and progress toward achieving your program goals. Objectives also help set targets for accountability and are a source for program evaluation questions.

Realistic

· Objectives are most useful when they accurately address the scope of the problem and programmatic steps that can be implemented within a specific time frame.

· Objectives that do not directly relate to the program goal will not help achieve the goal.

Time-Phased

· Objectives should provide a time frame indicating when the objective will be measured or a time by which the objective should be achieved.

· Including a time frame in the objectives helps in planning and evaluating the program. (Department of Health and Human Services, Centers for Disease and Control, 2009). Evaluation Briefs, SMART Objectives. Retrieved from http://www.cdc.gov/healthyyouth/evaluation/pdf/brief3b.pdf

Written

Each of us, whether consciously or unconsciously, has a convenient memory. We tend to remember the things that turn out the way we want them to and either forget or modify those things that do not go as we wish. If we did not put objectives in writing, then it would be relatively easy to look on accomplishments as if they were in fact planned objectives. On the other side of the coin, one of the sharpest areas of conflict among case manager, client, and supervisor is illustrated by phrases such as “I thought you were working on something else!” or “That’s not what we agreed to do” or “You didn’t tell me that’s what you expected.” Having objectives in writing will not eliminate all these problems, but it will provide something more tangible for comparison. Furthermore, written objectives serve as a constant reminder and an effective tracking device by which the case manager, the client, and the supervisor can measure progress.

Consistent with Resources

A statement of objective must be consistent with the available or anticipated resources.

Individually Accountable

Ideally, an objective should avoid or minimize dual accountability for achievement when joint effort is required. If dual accountability is needed, then assign specific tasks to each individual.

Consistent with Rules

Objectives must be consistent with basic agency policies and practices.

Voluntary

The client must willingly agree to the objectives without undue pressure or coercion.

Communicated Personally

The setting of an objective must be communicated not only in writing but also in face-to-face discussions with the client and the resource persons or agencies contributing to its attainment.

My Story

Sharon Bello, Entry 8.2

I wanted you to see my revised plan that Alma and I wrote together. Alma and I worked on the Program Goal and Intermediate Objectives together. We made some changes because, right now, we both believe that I need some help. We also need some additional information because my life has changed since I began receiving services from the VR.

The document that we filled out and I signed, well, it is an official document. If you look at the conditions spelled out at the end of the document, then you can see all of the things about the plan that I have to agree to. I remember when I signed the first plan with Susan Fields; I was really scared that I would not be able to fulfill all of these requirements. Now, after I have changed my major and am more familiar with the agency, I still take those promises seriously, but I also know that the agency and especially my case manager are here to help me. I also know that we can change the plan if necessary.

We provide an additional example of the development of goals and objectives (including intervention and outcome measures) with a client who is elderly and needs assistance.

Mary Sue Davis is an 86-year-old white married female. She recently placed her husband in a nursing home facility so that he can receive full-time care. Mrs. Davis has a severe heart condition and has been ordered by her physician to rest every 2 hours and to not travel by herself because of dizzy spells. The nursing home is now receiving her husband’s Social Security income. Mrs. Davis lives in a two-bedroom apartment. They have one son who lives an hour away and also has a heart condition. Mrs. Davis is requesting assistance with transportation to visit her husband on a more regular basis.

An interview with Mrs. Davis at her apartment revealed that her income consists solely of her Social Security checks. She does have Medicare to help with the costs of treatment for her heart condition. She currently uses public transportation (bus) to travel where she needs to go. During the interview, the service coordinator identified additional problems: the affordability of her current apartment, the availability of affordable housing, the need for an escort for travel, and possible grief issues regarding her husband’s condition, and placement in a nursing home.

Mrs. Davis agrees that she cannot afford her apartment and needs to seek more affordable housing. She is willing to apply for Community Action Committee (CAC) transportation that will pick her up at her door. She is very realistic regarding her husband’s condition. Although she wishes he could come home, she has accepted that he will most likely remain at the nursing home. She realizes that she has to take care of her own health, but at the same time she has to get things done, and there is not always somebody around to help.

In this case, the service coordinator identified two main goals for Mrs. Davis: to find affodable housing and to secure transportation that is appropriate. These are set forth in the Client Plan (see  Figure 8.3).

Figure 8.3Ms. Davis’ Client Plan

The first objective toward the housing goal was to complete an application for a rent-controlled apartment with the city housing authority. Due to long waiting lists, this needed to be done within the week. The next step was to determine where she preferred to live (probably close to the nursing home). After the application was completed, the service coordinator arranged for a volunteer to take Mrs. Davis to look at several apartments and to meet with apartment managers to find out about waiting lists. (Mrs. Davis couldn’t afford to wait for long.) The service coordinator found a volunteer to help with this. Once Mrs. Davis decided on an apartment, other volunteers assisted with the move. Her son could afford to rent a moving truck and to drive the truck, although he could not lift or carry due to medical problems. The time allotted for these objectives was workable, and the objectives were met within a month.

The objectives for the goal of transportation were to apply for the K-Trans lift along with CAC vans. Obtaining an assessment from the state office on aging was also an objective; that agency provides escorted transportation for medical appointments and necessary errands for people older than 60. This service would be available until Mrs. Davis was accepted by another agency that provides transportation.

In this case, the plan identified services and then guided the delivery of those services. The goals and objectives in the plan were developed using the guidelines suggested previously. Note that each objective clearly defined the intervention or action steps, stated who would provide the service, and stated a time frame for service delivery. The outcome measures were clear and the plan was implemented successfully.

Often planning is not quite so easy. Suppose Mrs. Davis refuses to rest as prescribed or is insistent that she will continue to ride the bus. Or perhaps there are no transportation services in her community, or agency rules limit services to those who have no other family. As you can see, a number of challenges may appear during plan development. Sources of these challenges include, but are certainly not limited to, clients themselves, family members, funding restrictions, agency policies and procedures, eligibility requirements, or lack of community resources. Barriers can also be more intangible, such as client values, the denial of problems, cultural prohibitions, reluctance, or lack of motivation. All of these possibilities present opportunities for the case manager’s resourcefulness and creativity, such as working with a client to develop a plan that is congruent with client values and desires, understanding cultural norms, mobilizing resources, consulting with colleagues, and networking with other agencies. Many of these challenges must be resolved to move forward with identifying services.

Class Discussion

Learning How to Evaluate Goals and Objectives

As we indicated in the text, writing goals and objectives is rarely simple. One way to learn how to write sound goals and objectives is to assess those written by others. Review the Program Objective and Intermediate Goals written by Alma Grady for Sharon Bello. These are in  Figure 8.2. Evaluate the goals in terms of the following standards:

· Specific:

· Measurable:

· Realistic:

· Time-phased:

· Written:

· Consistent with resources:

· Individually accountable:

· Consistent with rules:

· Voluntary:

· Communicated personally:

As an individual, in a small group, or as a class, discuss how you evaluated each.

Share these with your classmates.

8-1dIdentifying Services

Once the plan is complete and has been agreed on by the client and the case manager, it is time to begin thinking about the delivery of services. A well-developed plan provides information about what the service is, who will provide it, what the time frame is, and who has overall responsibility for service delivery. It is the case manager’s responsibility to implement the plan. What are these responsibilities? How does one begin implementation? These questions are explored next.

Identifying services has been compared to the brokering role. In both situations, the case manager is involved in the legwork and planning that is necessary for implementation. As a broker, the case manager helps clients access existing services and helps other service providers relate better to clients. This linking of clients and services also occurs as the case manager arranges for service delivery. The steps are similar. Before we discuss how case managers develop information and referral systems, let us look at how Alma Grady began to identify the additional professionals that she needed to carry out Sharon’s plan. Alma explains what she does in her own words.

My Story

Alma Grady, Sharon Bello’s Case Manager, Entry 8.3

After Sharon and I developed her new service plan, I had to send the plan to my supervisor. In fact, after each meeting I have with one of my clients, I send a report to my supervisor. I fill out a special review request when a client’s service plan changes. My supervisor will review the requested changes in the plan and then make some suggestions, call me in for a special consultation if needed, and then approve or ask me to make revisions to the amended service plan. Usually I hear from my supervisor in approximately 1 week. Because I review my clients with my supervisor and my colleagues at a weekly staffing meeting, my supervisor is familiar with Sharon and the progress she is making toward meeting her goals.

I received an approval to proceed with the amended service plan. I will introduce how I begin my work with either a new plan or an amended plan, determining what is important. I describe how I make referrals and then coordinate the requests and care of the client. I followed three steps.

Step One

In thinking about Alma and her new plan, my work begins with Sharon. I read through three documents before I begin to plan. First, I refer to the information that Sharon and I put together in  Table 8.1 that gathers additional information about Sharon and her situations. As a reminder, the information in  Table 8.1 represents a meeting that Sharon and I had where we discussed the following questions:

· What do I know about the source of the problem?

· How does culture influence the client and environment?

· What attempts have been made previously (before agency contact) to resolve the problem?

· What are the motivations for the client to solve the problem?

· What are the interests and strengths of the client that will support the helping process?

· What barriers may affect the client’s attempts to resolve the problem?

Sharon responded to these questions, I wrote a response, and then the two of us prepared a response together.

Step Two

My second step was to review the information that you and your classmates prepared for me for one of your class discussions. Remember you reviewed  Table 8.1, integrating client information together. And, finally, in that class discuss, you prepared some recommendations for me about my future work with Sharon.

Step Three

For the third step, I would review the Amended Service plan, approved by my supervisor and detailed in  Figure 8.2. I would use the list of Intermediate Objectives and fill out that information in more detail. I would consider this my action plan. I would consult with Alma as I wrote out the action plan. Although, as a first step, many case managers like to choose a first priority and work on that objective first, I take a different approach. I like to have a broad view of all of the objectives and what each will require to begin, monitor, and end. Usually this summary page takes me about an hour. Once completed, I can prioritize (with Sharon) the work and identify services and service providers.

First, I would write down each of the seven objectives and make a list of the tasks and outline what Sharon and I need to do to complete it. For this amended service plan, there are seven objectives. Once I have written this plan and Alma has revised it, we would target one or two objectives at a time. We might make a 6-month calendar and outline how we would move from one objective to another. In  Table 8.2, Alma and I turn the service plan objectives into an action plan. Because Alma and I are meeting every month, we would review this action plan each time we meet.

Table 8.2

Partial Action Plan: Alma Grady (Case Manager) and Sharon Bellow (Client)

Intermediateobjective	Tasks: Sharon	Checklist: Sharon	Tasks: Alma	Checklist:Alma
Priority One To assess client’s general health	Schedule appointment with primary physician. Take letter from the VR and physical exam form used by from VR.	Call soon and try to make appointment in the next 2 weeks. Next steps depend on the appointment time.	Check to see if Alma is able to schedule an appointment with her primary physician (next monthly meeting). Provide recommendations if Alma does not have a primary physician. Follow-up with primary physician and ask for a report on Sharon’s physical health. Integrate findings from the report in the next monthly meeting.	Put discussion and status of visit and report of primary physician on the agenda for next monthly meeting. In preparation for meeting in 2 months, call primary physician, request report, and discuss results of the report.
Priority Two To determine client opportunities for financial aid	Contact the college officials about the possibility of additional financial aid. Discuss with academic advisor or internship supervision the possibility of a paid internship.	Make notes from meeting with financial aid staff member. Collect the appropriate forms, due dates, and send email with meeting results to Alma Grady. Make an appointment with academic advisor to talk about paid internship. Take notes from the conversations. Share these with Alma by email.	Follow through with Sharon about the possibility of a paid internship at next month’s meeting. Read through Sharon’s emails about her meetings at the college. Follow-through by phone if necessary to make a plan.	Place discussion of financial aid and paid internship on the next month’s meeting agenda.

Note: In a complete plan all priorities from the Amended Service Plan would be included.

For the purpose of illustration, Alma and I share with you our choice of the first two priorities and the tasks and responsibilities that we outline (see  Table 8.2). We also include a timeline. With the timeline, we understand that our work does not always go according to plan. We chose one priority that focused on assessing Sharon’s current physical health assessment. We felt we needed to know if her physical health had changed since her initial assessment. As a second priority, we chose to work with the college regarding help for financial aid (with incurring debt). This can include exploring securing a paid internship in her interpreting program. We thought a paid internship might lessen some of her financial stress.

8-1eInformation and Referral Systems

One of the most helpful tools for a case manager is knowledge of the human services delivery system in the community. Who do you know? What services are available? How does one access the services? Is there a waiting list? One of the challenges facing new case managers is to establish an  information and referral system . For case managers with experience, the challenge consists of continually developing and updating their systems. Knowing what an information and referral system is, how to set up one, and how to use it are valuable skills in case management.

Human services employers believe that the people their agencies will serve in the future will be multiproblem clients, such as people with dual diagnoses, diverse problems, and long-standing problems (Woodside & McClam, 2015). The needs of clients such as these rarely match the services available from a single agency. In these cases, the case manager finds it invaluable to have information about other available services. Many helping professionals have personal service directories to supplement existing community or agency directories.

There are three components to information and referral. One component is the  social ser