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This workshop explores the ground-breaking expansion of the use of feedback to case management services. Based on her eight years of experience in extending the use of outcome management to settings other than traditional therapy, Mary will address the unique benefits and challenges of incorporating client feedback in community-based work with adults.

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  1. 1. 2/28/2011 OUTCOME MANAGEMENT IN CASE MANAGEMENT SERVICES: Takin’ It To The Streets Mary Susan Haynes, Ph.D. Clinical Director Community Health and Counseling Services Bangor, Maine CHCS • Multi-service community mental health center and home health agency • Mental health services to both adults and children • Services provided in homes, in the community and in the office • Twelve office locations • Cover a large geographic, rural area 1
  2. 2. 2/28/2011 Our Clients • Serve about 5300 clients per year in mental health services • Most adult clients meet criteria for “SPMI” • 99% have publicly-funded health insurance • 95% receive Medicaid Case Management • About 1500 clients seen per year in case management services • 95% either SSI or SSDI • 100% partially or fully covered by Medicaid or state grant funds 2
  3. 3. 2/28/2011 Case Management Services • Core service for adults • Array of services – Community Integration – Homeless Outreach – ACT – Community Rehabilitation Services – Specialized Groups Case Management • 99% of CM services delivered in home, homeless shelters or in community • CHCS does clinical case management, not broker CM – Provide “problem-solving supports” – Skill teaching – Linkage – Advocacy 3
  4. 4. 2/28/2011 Why CDOI in Case Management? • 90% of CM clients in more than one CHCS service • Staff across programs needed common approach to multiple- service clients • Staff stakeholder group selected CDOI from several options • CHCS first agency to extend CDOI to CM CDOI In Case Management • Implemented in January 2003 • Four days of required training for all staff – Direct service – Support staff – Security staff 4
  5. 5. 2/28/2011 The CDOI Challenge to Staff • Staff were taught basic CDOI principles • How to use the measures • Challenged staff to apply the ideas in their work settings • Some CM staff fully embraced the ideas, and helped craft CM protocols! Shift Happens! • CDOI is our roadmap to promote client recovery 5
  6. 6. 2/28/2011 CDOI Cultural Change Then vs. Now • Goal was to • Goal is making be in service desired changes • Quality • Quality measure is measure was progress toward access to client-defined services recovery • “Doing For” • Skill coaching • Giving advice • Asking permission before giving advice Then vs. Now • Steering • Accepting client client goals goals • Dismissing • Eliciting client’s client ideas theory of change • Believing in • Believing in the our wisdom client’s wisdom • Speaking for • Coaching clients clients to speak for • Fixing things themselves for clients • Letting clients fix things 6
  7. 7. 2/28/2011 Then vs Now • Communicating • Communicating need for an expectation maintenance for change • Allowing clients • Doing something to remain different if no stagnant change • Providing • Providing services as long services as client wants according to them benefit • Being powerful • Helping clients advocates for know their own clients advocacy power Staff Beliefs • We don’t need all this training. We’re already doing it (i.e., strengths-based work). • This is only good for therapy - it won’t work in CM • Our clients can’t fill out the measures - they’re too ___ (sick, unaware, damaged, etc.) • We won’t have enough clients if people get better 7
  8. 8. 2/28/2011 Staff Beliefs • These forms will take too much time. Case managers have places to go, things to do with clients • This is just more paperwork, and we certainly don’t need that! • Our clients won’t want to do the forms • Clients will lie on the forms Community Concerns • Seriously mentally ill people can’t be trusted to make good decisions for themselves • “These people” are ill. They need someone to take care of them, not someone to ask them their ideas • Clients will lie on these forms. You can’t trust the information • These clients cannot recover. They will need services forever 8
  9. 9. 2/28/2011 Our CM Results • Pre-Post CDOI implementation – Reduced LOS in CM by 72% – Reduced % of clients open longer than a year by 49% – Reduced % of clients open two or more years by 41% – Reduced client complaints and grievances to 0 Use of CDOI Measures • “Sessions” are different in CM than therapy • Measures required only once per month • Staff/clients can use more frequently if desired • Best to use measures when agenda oriented around problem- solving, less around structured activities 9
  10. 10. 2/28/2011 Measures • When multiple services, coordinate use of measures with other staff • CM may not do ORS at all if CHCS therapist is doing weekly • But SRS must still be done monthly Implementation Requirements • Supervisors are key - need to be well-trained, competent and confident in CDOI skills • Data management system • Use of data in individual and group supervision sessions • Inclusion of CDOI expectations in job descriptions and evaluations 10
  11. 11. 2/28/2011 Implementation Requirements • Availability of paper forms, graphs and rulers for field staff • Staff training on change strategies • Client record documentation forms must be consistent with expectations of CDOI practice • Training in utilizing CDOI practice with clients but client record documentation in medical necessity language Why Implementation is Harder in CM Services • Meetings are in-home, in-shelter or in-community. Setting is not as predictable as office-based • Meetings often organized around completion of everyday, practical tasks • Progress tends to be slower in CM than in therapy • CM’s have many stakeholders to please 11
  12. 12. 2/28/2011 Why Implementation is Easier in CM Services • Dx unimportant to case managers • CM’s training doesn’t emphasize learning model and techniques • Role of CM’s allows for greater latitude in informal relational style • Practical aspect of CM function fosters alliance through getting needed resources Implementing CDOI in CM:Things to Consider • Need to be flexible and creative to use CDOI outside of therapy setting • Stick to the values and principles of CDOI • Be visionary in thinking, yet concrete in application 12
  13. 13. 2/28/2011 CM Implementation: Systems Considerations • Educating community stakeholders is crucial • Clients not likely to immediately embrace empowerment aspect • But, clients likely to do forms for the sake of relationship w/CM System Considerations: A Final Comment • Entitlement program requirements are inconsistent with a recovery philosophy and practice • Recovery more “feel good” than actual expectation at this time • It takes courage for both clients and case managers to move around the barriers 13
  14. 14. 2/28/2011 THE END Thanks! 14