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Integrated Social Services: Reaching the Most Vulnerable. Training package for case managers

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Integrated Social Services: Reaching the Most Vulnerable. Training package for case managers

  1. 1. CASE MANAGEMENT TRAINING PACKAGE Module 4. The Case Management process ... following a concrete case somewhere in the world, and some general situations
  2. 2. The Case Management practical process Once a Case Manager is involved in providing help to a family in a social need situation, taking the case in charge follows a characteristic process, which is very similar, in structure, in almost all the cases. At the beginning, the Case Manager can only count on a small number of people already involved in the case. They can be informal or formal members of the “coping” network. The first task of the Case Manager is to reach a shared and articulated definition of the problem, starting from which he will be able to widen the coping network with other informal members. At this point only, the Case Manager guides the coping network to widen itself with other formal members. It is very important not to change the correct sequence: if a Case Manager tries to involve new formal members before the informal ones, the latter may not be available to be involved any further Case Management – module 4 – slide 2
  3. 3. The Case Management practical process: contents of this module Firstly, the general flow chart of Case Management methodology will be described, step by step. You can see that the passage from one step to another is guided by specific questions that the Case Manager asks to the coping network members. Secondly, a practical application of this process will be described, through the analysis of a real situation, the case of Judith and her family. It is a traditional case for a social protection service, not too difficult, chosen for didactical reasons, because it has shown itself useful for explaining the process to students at the beginning of their training in Case Management. Finally, two specialized processes, related to two very difficult situations, will be shown. Generally, Case Management methodology works with more efficacy than any others, both for the cases which are becoming chronic (whatever the level of difficulty), and for those cases requiring a high social protection level. Case Management – module 4 – slide 3
  4. 4. Case Management methodological process for improving and guiding the coping network First (self) report of a social Is there already a little group of No need people aware of the problem? Yes Is it possible to involve some Do we want to involve these subjects? How, practically, do we gather them people belonging to the informal for improving the situation? network? What operative solution is better for us? Who could we involve? How can we Are we doing what is agreed among us? improve the whole situation? What operative solution is better for us? Are we doing what is agreed among us? Next Yes No Next Is it necessary/appropriate to Is it necessary/appropriate to involve other informal subjects? No involve other formal subjects? Yes No Exit (1) Who could we involve? How can we improve the whole situation? What operative solution is better for Yes What must we face together? us? How can we improve the situation? Are we doing what is agreed among us? What operative solution is better for us? Are we doing what is agreed among us? No Yes Next Yes Are we on the way to reaching (have we already reached) what Is it necessary/possible that Can we share the role of guide? we hoped for? someone else takes the role of How can we realize that? case manager? What organizational way is better for us? Exit (2) Are we doing what is agreed among us? Yes Case Management – module 4 – slide 4
  5. 5. A practical application of Case Management: the Judith case Judith’s parents go to the social protection service (SPS) to meet the social worker who will be their case manager (CM). Their case has been reported to the CM by Dr. Marcus, working as Child Psychiatrist in the local health service: in fact the girl, who is eleven, has been referred to this service for problematic behaviour, lack of attention, hyperactivity, lack of impulse control, aggressive conduct. Her parents have been worried for a long time, but particularly at the moment, about school attendance (the teachers are complaining more and more) and homework, which the girl refuses to do with her mother, the only person who has the time to spend looking after Judith during the day. Judith has had a complex and hard life: she was adopted by her parents when she was six; her biological family was a multi-problematic one, the mother having chronic mental health problems, and the father was unknown. She was separated from her mother when she was three for seriously inadequate parental care, put in a residential care institute, and then adopted after a long and complex legal process. For the problems during her early childhood, the girl was diagnosed with “early attachment reactive syndrome”. After adoption her condition slowly improved, but when she was nine a new child, her little sister, was unexpectedly born in a natural way, and Judith’s psychological condition got worse again. The parents, particularly the mother, are now very stressed and exhausted. Case Management – module 4 – slide 5
  6. 6. The Case Manager arranges and guides the first coping network (1) At the beginning, the CM could describe Judith’s situation in this way: there are some people – her parents and Dr. Marcus – who cannot deal with the task (that has become a problem precisely because they cannot address it) of ensuring that Judith has adequate educational support. They are aware that it is a problem (even if in different degrees and ways) and for that reason they have called the SPS and have held a meeting with the CM. After receiving the report of the problem, the CM also becomes part of the network, because he/she must do something (according to his/her role), and, like the other network members, he/she does not yet know what he/she has to do, and how to improve the situation. In Judith's case it should not be very difficult to reach a (first) shared definition of the problem and make all the network members aware of it: despite the parents asking firstly for help with Judith's homework, the wise CM will be able to recognize that their real need is to ensure support for their parental role, and provide for themselves and for their daughters a family climate less conditioned by the problem of Judith's homework and school behaviour. So, the CM could try to revise the tasks to be addressed, more or less in these terms: "we must (together) try to improve the family relational climate; I think I have understood that the most important thing for this is to provide support for Judith's homework". Note: The CM places the first problem brought by the parents (Judith’s homework) in a wider framework (the family relational climate). Case Management – module 4 – slide 6
  7. 7. The Case Manager arranges and guides the first coping network (2) At this stage the coping network is not able to manage the problem yet: it is poor and weak. Although the Case Manager works from this base to improve the network and its capacity of action. Note: the Case Manager is both a member of the network (he is also not able to help Judith’s family yet), and the guide of the network. This dual role will be maintained for the whole helping process. Case Manager Judith’s Judith’s mother father Taking care of Judith Coordinated Dr Marcus actions Guiding Case Manager Case Management – module 4 – slide 7
  8. 8. The case manager guides the coping network to widen itself with new informal members (1) Let's imagine that Judith's parents have named the parish priest, some of Judith's past teachers, and the headmaster of the school, because they are keen and willing. Involved in the network through the mediation of the CM, these people begin to formulate some proposals. The priest advises asking Monica for help. She lives a bit far from the town, but she knows many boys and girls who are very busy in social activities like volunteering. Further, she is studying psychology and this experience could be important, beyond the usual altruistic reasons. The headmaster proposes contacting a young but very good teacher who works part-time, and could be interested in adding some activities to her spare time. The young teacher says that it will be difficult for him to guarantee a continuing effort, because of his uncertain work situation; while Monica is more available. Judith’s parents prefer the teacher to Monica, because he has a bit of experience; and Monica is doubtful because she has never dealt with children with this kind of problems. Later, Judith’s parents report to the CM the outcomes of their contacts and the CM decides to meet them for a more in-depth discussion. Case Management – module 4 – slide 8
  9. 9. The Case Manager guides the coping network to widen itself with new informal members (2) During this network meeting, a first division of tasks is drafted: Monica will take care of Judith for three afternoons a week, maybe four when the girl has a school test, but she needs more information about the behaviour of the girl and how she can deal with it: Dr Marcus is available to provide this information and to supervise. And on the other days? The CM feels that Judith’s mother is stressed and a bit disappointed; in fact, she is worried, particularly about Saturdays, when she has to look after the other daughter as well. The CM takes note that the proposed help is not yet sufficient, but Monica cannot give more: it is too much work for only one person. Maybe Judith’s aunt, so far forgotten, could get involved - following an idea expressed by Judith’s parents? (everyone had previously thought she was not available). So, Judith’s father proposes to contact her himself. Unexpectedly, she seems very happy to receive the call and she is available to help Judith with her homework on Saturdays. But that is not all: she says that Judith likes swimming very much, so they can go to the swimming pool, or shopping on Saturday after doing the homework: it is important to involve Judith in something enjoyable after the trouble of her homework! More, because Judith’s aunt always goes to the parish recreation centre every Wednesday, she can take her niece there as well, to play with other children in a friendly setting. Now, Judith’s mother seems more relieved: for the other two days, she and her husband can take care of Judith by themselves. Case Management – module 4 – slide 9
  10. 10. The Case Manager guides the coping network to widen itself with new informal members (3) More people (informal members) are involved in the coping network, and the task of the network (taking care of Judith) is better specified in three sub-tasks Case Manager Helping Judith Helping Judith to Judith’s Judith’s to meet new mother father do her homework friends Judith’s Monica aunt Taking care of Judith Coordinated Dr Marcus actions Taking Judith to the swimming pool Guiding Case Manager Case Management – module 4 – slide 10
  11. 11. The Case Manager guides the coping network to widen itself with new formal members The CM has to ask himself: “are we sure that we have explored all the problems of this family? Have we ignored some important questions that can suddenly spring up, and undermine all our work?” It is clear, for example, that the problems with Judith rose partly from her difficult childhood, and partly from the unexpected birth of her sister. Both Judith and her parents will have to be aided, now and then, to face these psychological problems. It seems necessary that a psychologist takes a more active role for this purpose. If this specialized intervention had been made before, at the beginning of the taking in charge, that would have compromised the whole process, because it would have made both Judith and her parents feel guilty: in the case management perspective, the first step is always action-oriented. Since the problem was firstly described as an educational one, and the solution has been built for dealing with it, it seems necessary to provide specific supervision in the educational area: a tutor. The coping network has not faced the school problem yet. Do you remember? The teachers are very upset about Judith’s school behaviour. Maybe it could be useful to provide for Judith a special teacher for some hours a week, at least for a year: the coping network is already sure that when Judith benefits from personalized relationships, she becomes calmer and more open to learning. Case Management – module 4 – slide 11
  12. 12. The Case Manager tries to share the guiding role, involving a member of the coping network Some months have now elapsed, Judith is attending the school with some difficulty, but much better than before the project began; her parents, her aunt, Monica and the tutor help her with her homework; the socialization activities are becoming more and more important, the psychological interventions (both for Judith and for her parents) are producing some results, and the family relational climate has significantly improved. It seems very important that Judith’s mother feels a lesser sense of guilt and can stay close to Judith without anxiety and fear of the behaviour of her adoptive daughter. The CM has met the network at regular intervals, verifying that the coping network is steady, all its members are satisfied with their work for dealing with Judith’s problems, and even when some tension occurs among some of them (Judith is still a problematic child), the network seems to have learnt to regulate itself and solve the tensions without the need for an external intervention. At this point, the CM could say to the network; “Things seem to work quite well and all of you are satisfied about what you are doing for Judith. It is important you meet together from time to time, and whenever it is necessary. I can’t promise to be present all times, so it would be a good idea if someone else takes responsibility for organizing these meetings, or calling the others to listen to the news and to judge if everything is working in a positive way. Of course, I’ll always be available for involvement in your meetings, or to give some advice to my substitute. Is all that possible, in your opinion? How?”. Case Management – module 4 – slide 12
  13. 13. The Case Manager guides the coping network to widen itself with new formal members, and shares the guiding role More practitioners (formal members) are involved in the network. The role of network guide is shared by the Case Manager with another member of the network. Case Manager Judith’s Judith’s mother father Monica Judith’s aunt Special teacher psychologist Taking care of Teacher Dr Marcus Judith Coordinated actions Double guiding Judith’s aunt Case Manager Case Management – module 4 – slide 13
  14. 14. The great importance that a Local Social Plan can have for coping with social cases like Judith’s It is possible to imagine the role which the Local Social Plan, if it exists, can play in this simple situation. In fact, let’s consider the work of the Case Manager described above in the following alternative scenarios: The Social Protection Service where the Case Manager is working has never formalised an agreement of mutual collaboration with the school; besides, it has a conflictive relationship with the Child Neuropsychiatric Service, and the priest and other NGOs in the territory are known by nobody belonging to the Social Protection Service. The Social Protection Service has an agreement with the school for enhancing mutual collaboration, the Case Manager knows almost all the teachers working there, and very often he meets the headmaster and the most relevant teachers for discussing pupils and students who are showing some school and social problem, or for proposing some actions for preventing social risks for young people; the Case Manager and child psychiatrist have worked together on several cases, on the basis of an understanding between the two services; and this understanding belongs firmly within the Local Social Plan. Many agreements between the Social Protection Service and the main NGOs operating in the territory in the social field or having a social relevance for the population have been in place for a long time.... What is the best scenario in which the Case Manager can work? Case Management – module 4 – slide 14
  15. 15. Different models of (co)operative action coordination What I think about the others’ action/work I abide by the I prefer to + We can negotiate an What I think about my action/work others’ authority agreement depend on the others We can try to compromise Only a competition among us - I IV + II III Let me work alone! I work against the others I’d like to stay alone... I try to exploit the others with my depression - I only deal with my “garden” Case Management – module 4 – slide 15
  16. 16. Case Management in very severe social needs situations The concrete case discussed analytically above is not very hard, but it represents a classical one, because most of the cases treated by a Social Protection Service are similar to it, and these cases taken as a whole, on the one hand require the allocation of much work and resources, and on the other have a high risk of becoming chronic and multi-generational. Not only are their human and economic costs very high, but also they block many social resources for generations. Now, two specialized processes will be explained, related to two very difficult situations: a case of child abuse, requiring a high protection project to be provided very quickly; and a case of an institutionalized child which is a difficult situation to face, but not having the feature of emergency like the previous one. These cases are not explained so analytically as the Judith case, and reference is not made to concrete cases, but only to a general situation. Case Management – module 4 – slide 16
  17. 17. Acute protection cases (violence and abuse): the flow chart Report of the case (victim, family, institute, public, hospital) to the Police or other public offices – First emergency care (hospital, separation from the family) if required. Investigation of the Police and reports Identification of a CASE from the hospital MANAGER (TOSS) No Can the case manager follow directly and immediately the case? Yes Outsourcing: the case manager Registration, collection of information, Can delegate to somebody else the involvement of professionals, relatives and case, under his/her responsibility others that can contribute to define a care What is the motivation of plan. Data are collected in the CASE FILE these persons to help? How can we ensure their commitment? Other persons are identified among Is the network of persons identified No professionals and resources of the sufficient to help the child and the family community to improve their situation? Yes A CASE CONFERENCE is organised, with the involvement «States Parties shall take all of the family. The case is presented by the Case manager. appropriate legislative, Decisions are taken by all the participants and documented administrative, social and educational in the Case File measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect The child and the family are referred to the or negligent treatment, appropriate services available to provide them maltreatment or exploitation, with protection and support. The case manager is including sexual abuse, while in the Can the persons involved identify responsible for the monitoring of the case care of parent(s), legal guardian(s) or other services/resources that can help? any other person who has the care of No Are the objectives achieved? the child.» Is the child protected according to CRC, Article 19 her/his best interest? Other case conferences and bilateral meetings are organised, till when the Yes network can autonomously provide The case is closed care and protection to the child
  18. 18. Acute protection cases (violence and abuse): some comments These types of cases are characterized by emergency and great urgency. Unlike the Judith case, in these urgent situations the CM cannot begin the networking process at once, because it is firstly necessary to put the child into a safe setting, or make safe its usual place of life. Because of this initial intervention, the CM could be tempted to be directive even when the emergency is over. Instead, in this case the case management methodology is strategic, in order to avoid further problems for the child, and to build a future for it. For the cases of abuse or violence against children, the rehabilitation and therapeutic processes are very important and usually have to begin as soon as possible, usually before the building of a coping network, rich with informal members. This is also a relevant difference compared to the Judith case, where the involvement of new formal members in the coping network happens only after the involvement of new informal members. For these reasons, the case manager must pay great attention to ensuring that the early involvement of professional people does not compromise the enlargement of the network to new informal members. Case Management – module 4 – slide 18
  19. 19. Children in residential care (including In collaboration with the children’s home manager, a CASE FILE is prepared and the situation detention!): of the family is analyzed After identification of the special needs of the child (psychological support, resolution of the flow chart Clarification with the home manager of the responsibilities of the case in court, health check, education support) the additional professional support the CASE MANAGER (TOSS) required is identified Is the placement in residential Yes institution Actions are agreed with the home the best solution for the child? manager and the family on the additional support provided to the child No A CASE CONFERENCE is organised with the family and other professionals to verify which other solutions are possible for the care of the child Is the family in the condition Yes The child is reunified with the family. to take care Other resources are identified at of the child at home, community level that can support the ensuring the access to health, family education and social services? Are there available families in the No community « 1. In all actions concerning children, whether undertaken That can foster or adopt the child? by public or private social welfare institutions, In cases of abandonment, neglect, abuse, and when it is clear that the family will not be able to take care of the courts of law, administrative authorities or legislative child, alternative care solutions are identified (Foster bodies, families, Adoption) the best interests of the child shall be a primary consideration. Yes 2. States Parties undertake to ensure the child such An order is requested to the Guardianship and protection and care as is necessary for his or her well- No Trusteeship Commission to declare the being, abandonment of the child, and authorize another taking into account the rights and duties of his or her care solution parents, legal guardians, or other individuals legally Initiatives are developed in the responsible for him or her, and, to this end, shall take all community to raise the awareness appropriate legislative and administrative measures.» about the right of the child to live in No Is the new solution responding to CRC, Article 3 a family and identify possible foster the best interest of the child? families «A child temporarily or permanently deprived of his or her family environment, or in whose Yes own best interests cannot be allowed to remain in that environment, shall be entitled to The case continues to be special protection and assistance provided by the State.» monitored until it is closed CRC, Article 20
  20. 20. Children in residential care (including detention!): some comments Unlike the cases involving abuse and violence against children, the cases of de-institutionalization do not present any emergency feature. The institutional condition is not desirable at all, and grievously prejudices the natural rights of people; and, there being no immediate need to intervene, there is a risk of a certain inertia in the appropriate Social Protection Service, which must organize some internal process of assessment for taking into account these cases. Fortunately, these cases permit the CM to organize his work without the urgency of the case applying pressure, and can study very deeply the situation and involve an efficient coping network before the project begins. In any case, for these situations a very articulated Local Social Plan is required, because it is usually necessary to have at the CM’s disposal some specific formal (day care centre, specialized pedagogue, and so on) and informal (foster family, volunteers) services and subjects. Case Management – module 4 – slide 20
  21. 21. Case Management & referral process – an example (1) Steps in procedure Responsibility Timeframe 0. Report of the case – first aid From family, police, hospital, community, Day 0 provided school, social services… 1. Referral of the case to the Social Any service receiving information of the case. Day 1 Services (front desk or officer in Availability on call of the case manager also out of working time charge) 2. Registration The officer of the SS on duty – the Day 1 information is registered in the registration book 3. Emergency response - referral SS or Police in consultation with officer in Day 1-3 to: charge in social services. Police (if required) Police or court will proceed with the Safe place (if required) – NGO? investigation and preparation of documents Foster family? required by their services Magistrate for temporary placement In case of non compliance, the case can be (if required) referred to the supervisor 4. Appointment of the case manager The name of the case manager is registered Day 1-3 – opening of a CASE FILE in the Case File Time limit: 7th day
  22. 22. Case Management & referral process – an example (2) Steps in procedure Responsibility Timeframe 5. Assessment of the child and Case Manager – this task can be partially Day 4-6 family situation – involvement of the delegated to persons whose names are persons who can be part of the included in the Case File, but the overall coping network of the child (including responsibility is with the case manager. In health, education services, and case of non compliance the CM can be relatives/neighbours) referred to his/her supervisor 6. Organisation of the first CASE Case Manager – this task cannot be Day 7-14 – CONFERENCE - identification of the delegated. Time limit: actions to be implemented as part of The family/guardian of the child have to 15th day the care plan participate (Case manager) The decisions taken by common consensus are reported in the Case File 7. Recommendations to the Case Manager – this task cannot be Day 15 Magistrate based on the decisions delegated. Recommendations are reported in taken at the case conference (if the social inquiry form required) 8. Court order (if required) – Magistrate, based on the required reports Day 15 and CHANGE OF LEGAL CUSTODY from case manager, Police following
  23. 23. Case Management & referral process – an example (3) Steps in procedure Responsibility Timeframe 9. FOLLOW UP – monitoring of the Case Manager - this task can be partially Day 15 - situation of the child, on the actions delegated to persons whose names are ongoing implemented, and referral to other included in the Case File, but the overall services if recommended at the case responsibility is with the case manager conference 10. Organisation of the second CASE Case Manager – this task cannot be Day 15-45 – CONFERENCE – monitoring the delegated. The family/guardian of the depending on capacity of the coping network to child have to participate the case protect and care for the child The decisions are reported in the Case File 11. Progress report (social inquiry) Case Manager – this task cannot be Depending on presented to the magistrate (if delegated. the case required) 12. Statistics on caseload and Data input from the Case File to the To be defined recurrent protection issues are shared database (at regional level) – logistics to –every 2 with the regional departments of social be defined - figures are discussed at the months? services social services office meetings 13. Following case conferences - if Case Manager – the case can be closed Depending on required - and closure of the case only when the coping network is strong the case enough to protect the child

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