Unit 4 DB: Client Questions

Chapter 6: Assessment Phase of Case Management

Chapter Introduction

· Chapter Six addresses Social Work Case Management Standard 5, Assessment and Social Work, and Standard 10, Recordkeeping.

· Chapter Six addresses Human Service–Certified Board Practitioner Competency 8, Assessment/Treatment Planning.

When I got a new admission, I actually completed all of the assessments. The first assessment was basically a psychosocial assessment. It usually meant spending about an hour or an hour and a half with the child or adolescent and gathering some preliminary information about mental health and school, family, peers.

—Permission granted from Sara Bergeron, 2012, text from unpublished interview

This chapter explores the assessment stage of case management: the initial contact with an applicant for assistance, the interview as a critical component in data gathering, and the case record documentation that is required during this phase. The assessment phase concludes with the evaluation of the application for services. For each section of the chapter, you should be able to accomplish the following objectives.

Application for Services

· List the ways in which potential clients learn about available services.

· Compare the roles of the case manager and the applicant in the interview process.

· Define interview.

· Describe a strengths assessment.

· Distinguish between structured and unstructured interviews.

· State the general guidelines for confidentiality.

· Define the case manager’s role in evaluating the application.

· List the two questions that guide assessment of the collected information.

Case Assignment

· Compare the three scenarios of case assignment.

Documentation and Report Writing

· Distinguish between process recording and summary recording.

· List the content areas of an intake summary.

· State the reasons for case or staff notes.

· 6-1Introduction

· Before we discuss each of these issues in more detail, read what case managers have to say about their work related to assessment and the case management process.

· The first time I encounter the client is when I receive the referral. Next, I prepare the groundwork for screening the family to see if their needs match our program. I schedule a home visit; other times, the family visits with me in my office and then I go to their home. My first job is to certify the HIV/AIDS status. I get this information from one of their medical providers. I then conduct a needs assessment and strengths assessment of the family and determine which needs are being met and which are not. I follow through to make sure all needs are met.

· —Case manager, family service center, New York, NY

· The first time we hear from a potential client is by phone. Kids call and tell us about themselves; what they tell is all that we know … we don’t have a way to check out the information, to know if it is true or not … once they come to our shelter, we get their permission to talk with their parents, school officials, and other helpers to verify their story and their situation. Using the phone as a first source of screening and getting to know the client, especially since he or she is a child, is difficult for us. We try to find out if they need our shelter and our services and also if they are a danger to self or others.

· —Hotline case manager, youth services, St. Louis, MO

· In our facility we have an emergency shelter for men. Clients can come in the evening and get a change of clothes and take a shower. We combine this service with our chapel time. We tell the men that they can change and we try to provide a message of hope. We also get men coming for our services through referrals from other local agencies and some who are self-referred. We allow persons to enter the program who want to change, for whatever reason. To stay in the program they must commit to change. For 1 week they can stay and learn about the program. We conduct an initial assessment, but with limited results. When men are using drugs or alcohol, it is difficult to talk with them about their issues and current status.

· —Caseworker, rescue mission, Miami, FL

· Assessment means appraisal or evaluation of a situation, the person(s) involved, or both. As the initial stage in case management, assessment generally focuses on identifying the problem and the resources needed to resolve it. Focusing on the people who are involved includes attention to client strengths, and that can be a valuable resource for encouraging client participation and facilitating problem solving. Specifically, the case manager identifies the initial presenting problem and makes an eligibility determination. As the three opening quotations show, data are gathered and assessed at this phase to show the applicant’s problem in relation to the agency’s priorities. Identifying possible actions and services and determining who will handle the case are also part of the assessment phase. These activities occur differently at each agency. The case manager at the family service center does a preliminary screening after she has received a referral. At the rescue mission, the initial contact is a pre-application or intake interview. At youth services, the initial contact is a hotline call.

· In  Application for Services , we consider how clients enter the case management process by applying for services.

6-1aApplication for Services

Potential clients or  applicants  learn about available services in a number of ways. Frequently, they apply for services only after trying other options. People with problems usually try informal help first; it is human nature to ask for help from family, friends, parents, and children. Some people even feel comfortable sharing their problems with strangers waiting in line with them or sitting beside them. A familiar physician or pastor might also be consulted on an informal basis. However, some people avoid seeking informal help because of embarrassment or fear of disappointment. At times, the decision to seek help or view help in a positive way is rooted in cultural expectations and values.

Previous experiences with helping agencies and organizations also influence the individual’s decision to seek help. Many clients have had positive experiences with human service agencies, resulting in improved living conditions, increased self-confidence, acquisition of new skills, and resolution of interpersonal difficulties. Others have had experiences that were not so positive; some have encountered helpers who had different expectations of the helping process, delivered unwanted advice, lacked the skills needed to assist them, were inaccessible, or never understood their problems. Increasingly, clients may also encounter local, state, and national policies that may make it difficult to get services. An individual’s prior experiences also play a role in the decision regarding whether to seek help. Finally, there may be a financial cost of help that the individual or family cannot afford.

An individual who does decide that help is desirable can find information about available services from a number of sources. Informal networks are probably the best sources of information. Family, friends, neighbors, acquaintances, and fellow employees who have had similar problems (or who know someone who has) are people we trust to tell us the truth about seeking help. Natural helpers such as barbers, hairdressers, and bartenders may also refer. Other sources of information are professionals with whom the individual is already working, the media (posters, public service announcements, and advertisements), the social service booklet, or Web-based sources. As the use of the Internet continues to grow, more individuals will find available services online. Once people locate a service that seems right, they generally get in touch on their own (self-referral).

Other individuals may be referred by a human service professional if they are already involved with a human service organization but need services of another kind. They may be working with a professional, such as a physician or minister, who also makes referrals. These applicants may come willingly and may be motivated to do something about their situation, or they may come involuntarily because they have been told to do so or are required to do so. The most common referral sources for mandated services are courts, schools, prisons, protective services, marriage counselors, and the juvenile justice system. These individuals may appear at the agency but ask for nothing, or they may even deny that a problem exists.

The words of case managers at four different locations illustrate the various ways referral can happen. The first case manager works at a community-based agency.

Creswell Center receives referrals every day of the week all year long. One of the services we provide is outreach. We use vans and bicycles and some outreach workers walk on the streets; counselors make contact with people who are homeless, offering them assistance and services. We may see more than 200 clients per day for services. The length of stay to receive services might be a month or even a year, but usually not longer than a year. We know the length of time they stay in our program, some stay a month or so … sometimes as long as a year.

Case manager (outreach), Creswell Center, urban area, Missouri

The second quote is from a caseworker at an institution that serves the elderly in a large metropolitan city.

Our referrals come from everywhere; some clients hear about us through word of mouth, and others are referred by other professionals who know about our work in the community. We have a large network of professionals in the community involved in discharge planning; we get referrals from them. Most of our clients are referred from the Services for the Blind. The good news in this city is that, by law, if a client needs services related to disabilities, then agencies must refer to appropriate agencies. This helps us gain clients who can benefit from our services.

Director and case manager, home for the aged, New York, NY

The third case manager works at a community mental health center that coordinates services for clients with chronic mental illness. At this agency, client records are available at the time of referral. These provide important information about the client and previous services.

Once I receive a referral, I begin my research about the client. The first test is if the client, on paper, meets the criteria for our agency. Then, if the answer to this question is “yes,” we go to see the client. Usually the client is in the hospital. The hospital visits are really important because we can talk with professional staff, medical social workers, the client, and often the family. All of the sources we need are in one place. Also, it is a good place to meet the clients for the first time. When we see them in the community after their release, we already have begun to establish a relationship with them. They are reluctant to talk with us once they leave the hospital.

Case manager, intensive case management, Los Angeles, CA

The final example is from a program for the homeless in Brooklyn, New York.

We provide housing to homeless individuals. We offer our housing to them once they leave the shelter. To screen individuals for our program and housing, we go to the homeless shelters. We also hope that workers at the shelters will make a referral. We see ourselves as providing bridge services between a shelter, employment, and permanent housing.

Social worker case manager, shelter to home Program, Brooklyn, NY

These examples illustrate the different ways in which a referral occurs. In an institutional setting, referrals are made by other professionals and departments in the institution. In other settings, referrals can also occur in-house or come from other agencies or institutions. Sometimes the referral procedure may include an initial screening by phone (see  Figure 6.1) or on the Internet, a committee deliberation, an individual interview, or the perusal of existing records or reports or both. Usually, the individual who receives the referral makes sure that the necessary paperwork is included.

Figure 6.1Example of Intake Interview Form

Not all applicants who seek help or are referred for services become clients of the agency.  Clients  are those who meet eligibility criteria to be accepted for services. An intake interview is the first step in determining eligibility and appropriateness.

The Interview

An  interview  is usually the first contact between a helper and an applicant for services, although some initial contacts are by telephone, letter, or Internet. The first helper who an applicant talks with may be an intake worker who only conducts the initial meeting, or he or she may, in fact, be the case manager or service provider. If the first contact is an intake worker, then the applicant (if accepted for services) will be assigned to a case manager who will coordinate whatever services are provided. In this text, we will assume that the intake interviewer is the case manager.

The initial meeting with an applicant takes place as soon as possible after the referral. The interview is an opportunity for the case manager and applicant to get to know one another, define the person’s need or problem, and give some structure to the helping relationship. These activities provide information that becomes a starting point for service delivery, so it is important for the case manager to be a skillful listener, interpreter, and questioner (skills that you will read about in  Chapter Seven). First, we explore what an interview is, the flow of the interview process, and two ways to think about interviews that you may conduct as part of the intake process.

Interviewing is a critical tool for communicating with clients, collecting information, determining eligibility, and developing and implementing service plans—in all, a key part of the case management process. Primary objectives of interviewing are to help people explore their situation, to increase their understanding of it, and to identify client resources and strengths. The roles of the applicant and the case manager during this initial encounter reflect these objectives. The applicant learns about the agency, its purposes and services, and how they relate to his or her situation. The case manager obtains the applicant’s statement of the problem and explains the agency and its services. Once there is an understanding of the problem and the services the agency offers, the case manager confirms the applicant’s desire for services. The case manager is also responsible for recording information, identifying the next steps in the case management process, informing the applicant about eligibility requirements, and clarifying what the agency can legally provide a client. There are several desirable outcomes of the initial interview: establish a rapport to enable an atmosphere of understanding and comfort; make the applicant feel understood and accepted; and allow the applicant the opportunity to talk about concerns and goals. Of course, cultural considerations guide preparation for and conducting of this interview.

Exactly What Is an Interview?

In case management, an interview is usually a face-to-face meeting or phone meeting between the case manager and the applicant; it may have a number of purposes, including getting or giving information, resolving a disagreement, or considering a joint undertaking.

An interview may also be an assessment procedure. It can be a testing tool in areas such as counseling, school psychology, social work, legal matters, or employment applications. One example of this is testing an applicant’s mental status. We can also think of the interview as an assessment procedure in which one of the first tasks is to determine why the person is seeking help. An assessment helps define the problem, and the resulting definition then becomes the focus for intervention.

Another way to think about defining the interview is to consider its content and process (Iarussi, et al., 2014). The content of the interview is what is said, and the process is how it is said. Analyzing an interview in these terms provides a systematic way of organizing the information that is revealed in the interaction between the case manager and the applicant. It also facilitates an understanding of the overall picture of the individual. This is particularly relevant in case management because many clients have multiple problems. You will read more about process and content in  Effective Intake Interviewing Skills.

Ivey, Ivey, and Zalaquett (2016) caution that although the terms counseling and interviewing are sometimes used interchangeably, interviewing is considered the more basic process for information gathering, problem solving, and giving information or advice. An interview may be conducted by almost anyone—business people, medical staff, guidance personnel, or employment counselors. Counseling is a more intensive and personal process that is often associated with professional fields such as social work, guidance, psychology, and pastoral counseling. Interviewing is a responsibility assumed by most case managers, whereas counseling is not always the job of the case manager.

How Long Is an Interview?

An interview may occur once or repeatedly, over long or short periods of time. However, some helpers limit the use of the word interview to the first meeting, calling subsequent meetings sessions. In fact, the actual length of time of the initial meeting depends on a number of factors, including the structure of the agency, the comprehensiveness of the services, the number of people applying for services (an individual or a family), and the amount of information needed to determine eligibility or appropriateness for agency services.

A case manager from a community action agency recalled that she had conducted an intake interview in 15 minutes.

In school, I would read books about helping and it seemed to me I would need about an hour and a half for my first interviews. I thought I would have all of the time I needed. Boy was I wrong! When I was in school reading textbooks, I thought I would always have an hour and a half for every interview. And we would just ask questions to get all the information about this person. Not true!

Case manager, family health program, Knoxville, TN

Where Does the Interview Take Place?

Interviews generally take place in an office at an agency, school, hospital, or other institution. Sometimes, however, they are held in an applicant’s home. In such cases, the case manager has the distinct advantage of observing the applicant in the home, which gives information about the applicant that may not be available in an office setting. An informal location, such as a park, a restaurant, or even the street, can also serve as the scene of an interview. Whatever the setting, it is an important influence on the course of the interview.

What Do All Helping Interviews Have in Common?

There are commonalities to all interviews in human services that should occur in any initial interview. First, there must be shared or mutual interaction. Communication between the two participants is established, and both share information. The case manager may be sharing information about the agency and its services, and the applicant may be describing the problem. No matter what the subject of their conversation is, the two participants are clearly engaged as they develop a relationship.

A second factor is that the participants in the interview are interdependent and influence each other. Each comes to the interaction with attitudes, values, beliefs, and experiences. The case manager also brings the knowledge and skills of helping, and the person seeking help brings the problem that is causing distress. As the relationship develops, whatever one participant says or feels triggers a response in the other participant, who then shares that response. This type of exchange builds the relationship through the sharing of information, feelings, and reactions.

The third factor is the interviewing skill of the case manager. He or she remains in control of the interaction and clearly sets the tone for what is taking place. The knowledge and expertise of the case management process distinguishes the case manager from the applicant and from any informal helpers who have previously been consulted. Because the helping relationship develops for a specific purpose and often has time constraints, it is important for the case manager to bring these characteristics to the interaction, in addition to providing information about the agency, its services, the eligibility criteria, community resources, and so forth.

6-1bThe Interview Process

The interview’s structure refers to the arrangement of its three parts: the beginning, the middle, and the end. The beginning is a time to establish a common understanding between the case manager and the applicant. The middle phase continues this process through sharing and considering feelings, behaviors, events, and strengths. At the end, a summary provides closure by describing what has taken place during the interview and identifying what will follow. Let us examine each of these parts in more detail.

The Beginning

Several important activities occur at the beginning of the interview: greeting the client, establishing the focus by discussing the purpose, clarifying roles, and exploring the problem that has precipitated the application for services. The beginning is also an opportunity to respond to any questions that the applicant may have about the agency and its services and policies. Clients raise several questions during the initial interview. Most of these questions relate to how the service is provided.

· How often do you want me to come to see you?

· Will you come to my home?

· What happens if I have a question or need you and the office is closed?

· If I have an appointment and cannot make it, what do I do?

· Tell me again about confidentiality, please.

· What if I have an emergency?

· When do we complete our work?

· What will I be charged for services?

· Do I need insurance?

Answering these questions can lead to a discussion of the applicant’s role and his or her expectations for case management.

The Middle

The next phase of the interview is devoted to developing the focus of the relationship between the case manager and the applicant. As we discussed in detail in  Chapter Five, in this initial interview, the case manage introduces the culture of the interviewer and the client and notes the ways that culture can be considered in the case management process. Assessment, planning, and implementation also take place at this time. Assessment occurs as the problem is defined in accordance with the guidelines of the agency. Often assessment tends to be problem-focused, but a discussion that focuses only on the client’s needs or weaknesses, or both, can be depressing and discouraging. Spending some of the interview identifying strengths can be energizing and can result in a feeling of control. Assessment also includes consideration of the applicant’s eligibility for services in light of the information that is collected. All these activities lead to initial planning and implementation of subsequent steps, which may include additional data gathering or a follow-up appointment.

The End

At the close, the case manager and the applicant have an opportunity to summarize what has occurred during the initial meeting. The summary of the interview brings this first contact to closure. Closure may take various forms, including the following scenarios:

· (1)

the applicant may choose not to continue with the application for services;

· (2)

the problem and the services provided by the agency are compatible, the applicant desires services, and the case manager moves forward with the next steps; and

· (3)

the fit between the agency and the applicant is not clear, so it is necessary to gather additional information before the applicant is accepted as a client.

A technique that some case managers find successful as an end to the initial interview is a homework assignment that once again turns the applicant’s attention to strengths. Individuals may be asked to complete a self-assessment instrument such as the Strengths Self-Assessment Questionnaire, a 40-question self-report instrument designed to involve the client and significant others in identifying strengths (McQuaide & Ehrenreich, 1997). Ingram et al. (2015) suggested assessment of strengths and problem areas together when working with families and children at risk for abuse and neglect. Using their model, an assessment would include exploring alcohol/drug abuse issues, how children or supervised or disciplined, and the relationships between parents and children. In addition, the assessment of strengths and stressors include the home environment, the knowledge and skills of parenting that caregivers demonstrate, the social support the family has, the nature of family communication, the status of the safety of each of the family members, and the apparent well-being of the children. With the knowledge of strengths and stressors, Ingram et al. (2015) believe that helpers such as case managers are able to target their treatment planning and interventions to address family needs and build that treatment on strengths. In addition, helpers are able to address deficits and successfully improve the family lives of the children they served.

Although these types of strengths or strengths/stressor questionnaires can be administered at any time in the case management process, the value in such a technique at this time is the movement that might occur from problem-oriented vulnerability to problem-solving resilience. It may also solidify the client’s intent to return and promote his or her involvement in the case.

Another type of strengths assessment developed by Carla Berg (2009) assesses strengths and ultimately offer hope to the client. She promotes a balanced assessment that allows clients to see both “assets” and “weaknesses” (Berg, 2009, p. 10). She believes that using this approach provides the case manager and the client with a realistic approach of what the client faces. Berg uses a four-part assessment: client assets, client weaknesses, environment assets, and environment weaknesses (see  Figure 6.2).

Figure 6.2Strengths Assessment Embedded in Hope

In addition to proposing this four-part approach to assessment, Berg integrates hope theory (Snyder, 1994) into her work with clients. There are three aspects of hope theory that are useful for work with clients during the case management process. Those are listed and defined here.

· Using goals with clients: humans like setting goals. These goals provide for directing daily life and planning thoughts and actions.

· Developing pathways: thinking about and drawing routes to meeting goals is energizing for the client and can help structure the case management work.

· Motivation: this provides the push for the client to try to meet his or her goals and to follow the pathway established to meet these goals (Snyder, 2004).

Using Berg’s model that integrates assets and weaknesses of the client and the client’s environment and embedding it in the theory of hope fits well in the case management process. The assessment work that we discuss in this chapter is related to the assessment of assets and weaknesses. Later in the text, we demonstrate how the psychology of hope fits into setting goals and planning interventions.

My Story

Sharon Bello, Entry 6.1

I like this idea of looking at my strengths and my weaknesses. Looking at the environment is a new idea for me. Or maybe it is a different way of thinking. Before I applied for vocational rehabilitation, I got to thinking that there was no way out for me and I was not going to get back on my feet. It was my friend Juanita who got me the services that I have now. I definitely think that we could call her a strength. And when I looked at the hope, well, I had lost hope. Completely lost hope. But I was always good at planning and sticking to my plan and working as hard as I could to make things happen. Now, I have someone who is asking questions and figuring out if I can get the help I need. Still, with all that … the idea of hope, now that sticks with me.

6-1cStructured and Unstructured Interviews

Interviews may be classified as structured or unstructured. A brief overview of these two types of interviews is given here;  Effective Intake Interviewing Skills provides more in-depth information about the structured interview in connection with the discussion of skills for intake interviewing.

Structured interviews  are directed and focused, with a form or a set of questions that elicit specific information usually guiding them. The purpose is to develop a brief overview of the problem and the context in which it is occurring. It can range from a simple list of questions to solicitation of an entire case history.

Agencies often have application forms that applicants complete before the interview. If the forms are completed with the help of the case manager during the interview, then the interaction is classified as a structured one. Of course, this is a good way to establish rapport and to identify strengths, but case managers must be cautious. The interview can easily become a mere question-and-answer session if it is structured exclusively around a questionnaire. Asking yes/no questions and strictly factual questions limits the applicant’s input and hinders rapport.

Voices from the Field

Strengths Assessment

Ragan and Sekar (2006) provide a model of strengths-based assessment and intervention that supports positive interventions and goals for the client and family. As discussed in  Chapter One, the strengths perspective is a necessary aspect of client empowerment and the move to self-sufficiency. Using this approach solidifies the sense of collaboration and partnership the client has with the case manager. Strengths assessment provides an opportunity for clients and families and friends to tell the client’s stories. Content from these stories provides the focus for the case manager activities to follow. Dennis Saleebey (2002), an expert in strengths-based assessment and intervention, outlines questions that guide the case manager. He presents survival questions, support questions, exception questions, and esteem questions. Case managers may find this guide helpful as they think about the initial interview.

Examples of Dennis Saleebey’s Five Types of Questions to Assess Strengths

Survival Questions

· How have you managed to survive (or thrive) thus far, given all the challenges you have had to contend with?

· How have you been able to rise to the challenges put before you?

· What was your mindset as you faced these difficulties?

· Which of these difficulties have given you special strength, insight, or skill?

· What are the special qualities on which you can rely?

Support Questions

· What people have given you special understanding, support, and guidance?

· Who are the special people on whom you can depend?

· How did you find them or how did they come to you?

· What did they respond to in you?

· What associations, organizations, or groups have been especially helpful to you in the past?

Exception Questions

· When things were going well in life, what was different?

· What parts of your world and your being would you like to recapture, reinvent, or relive?

· What moments or incidents in your life have given you special understanding, resilience, and guidance?

Possibility Questions

· What do you want out of life now?

· What are your hopes, visions, and aspirations?

· How far along are you toward achieving these?

· What do you like to do?

· What are your special talents and abilities?

· What fantasies and dreams have given you special hope and guidance?

· How can I help you achieve your goals or recover those special abilities?

Esteem Questions

· When people say good things about you, what are they likely to say?

· What is it about your life, yourself, and your accomplishments that give you real pride?

· How will you know when things are going well in your life?

· What gives you genuine pleasure in life?

· When was it that you began to believe that you might achieve some of the things you wanted in life?

· What people, events, and ideas were involved?

Perspective Questions

· What are your ideas or theories about your current situation?

· How do you understand or what kind of sense do you make of your recent experiences and struggles?

· How would you explain these to yourself, to me, or anyone else?

Change Questions

· What are your ideas about how things—thoughts, feelings, behavior, relationships—might change?

· What has worked in the past to bring about a better life for yourself?

· What do you think you should or could do to improve your status and your affairs?

· How can I help you?

Meaning Questions

· What are those things that you utterly believe in and value above all?

· What are those beliefs that give you a sense of purpose beyond the self?

· Where do they come from? Your experience? The culture? Some cosmic source?

· What part do they play in your everyday life?

From Saleebey, D. (2009). The strengths approach to practice: Beginnings. In D. Saleebey (Ed.), The strengths perspective in social work practice (4 th ed., pp. 93–107). New York: Pearson/Allyn & Bacon.

Class Discussion

Developing a Plan to Assess Client Strengths

Assessing strengths helps clients begin the assessment phase of the case management process with hope and a new understanding of themselves. Take a few moments as a class, in small groups, or as an individual and develop a description of a client who is entering your agency for the first time. Develop a short 1-hour interview outline. Include assessing for strengths. Next, conduct a short interview with one of your classmates. Be sure to include the strengths assessment. After conducting the interview, discuss with your classmates your experience of the interview. How was the strengths assessment received by your classmate? What were the positive outcomes of this discussion? Talk about any difficulties you encountered with your classmates.

The intake interview and the mental status examination are two types of structured interviews, each of which has standard procedures. Generally, an agency’s  intake interview  is guided by a set of questions, usually in the form of an application. The  mental status examination  (which typically takes place in psychiatric settings) consists of questions designed to evaluate the person’s current mental status by considering factors such as appearance, behavior, and general intellectual processes. In both situations, the case manager has responsibility for the direction and course of the interview, even though the areas to be covered are predetermined. A further look at the mental status examination illustrates the structured interview process.

A mental status examination is a simple test that assesses a number of factors related to mental functioning. Sometimes agencies will use a predetermined list of questions. Others may use a test such as the Mini Mental Status Examination (MMSE). Both modalities structure the interview. Whatever the method, generally the focus is on four main components that may vary slightly in their organization: appearance and behavior, mood and affect (emotion), thought disturbances, and cognition (orientation, memory, and intellectual functioning). Some of these components may be assessed by observing the client, whereas others require asking specific questions and listening closely to responses. For example, appearance and behavior are observable and may target dress, hygiene, eye contact, motor movements or tics, rhythm and pace of speech, and facial expressions. However, thought disturbances are based on what a client tells the examiner and his or her perception of things: “Do your thoughts go faster than you can say them?”, “Do you hear voices that others cannot hear?”, and “Have you ever seen anything strange you could not explain?” A final word to the examiner: when testing a client, be sure to take into consideration factors such as a person’s country of origin, language skills, and educational level. Terms like “high school” and tasks like naming former US presidents may not be appropriate for all examinees.

As you read the following report, determine the results of the assessment of the four components of a mental status examination.

“Pops” Bellini arrived for his appointment on time. He was dressed in slacks and a shirt but appeared disheveled, with wrinkled clothing and uncombed hair. He stated that he has been homeless for 6 months and has not bathed in 4 days. He wants to work. He rocked forward when answering a question and tightly clasped his hands in his lap. He reports that he is on no medication at the present time, although he has taken “something” in the past for “nerves.” His mood was anxious and tense, and he wondered if he would be able to find some work. Speech was slow, clear, and deliberate. Initially, he responded with a wide-eyed stare. Mr. Bellini often asked for a question to be repeated; upon repetition, he provided responses that were relevant to the question. Cognition seemed logical and rational, although slow. Mr. Bellini is aware of the need to find work to support himself, but he is concerned about his ability to perform at a job. He seems most worried about “pressures” that cause him to “freeze.”

In contrast to the structured interview, the  unstructured interview  consists of a sequence of questions that follow from what has been said. This type of interview can be described as broad and unrestricted. The applicant determines the direction of the interaction, and the case manager focuses on giving reflective responses that encourage the eliciting of information. Helpers who use the unstructured interview are primarily concerned with establishing rapport during the initial conversation. Reflection, paraphrasing, and other responses discussed in  Chapter Seven will facilitate this.

Assessing the Interview

We suggest that it is helpful for the case manager to conduct an informal self-assessment of his or her own competence at the beginning and the conclusion of each interview. It is also important for case managers to conduct formal assessments of their skills development. The Strengths-Based Restorative Justice Assessment Tools for Youth (2004) manual provides ideas about evaluating interviews with clients. The following evaluation questions focus on cultural competence, justice, and strengths-based work. We inserted the term “case manager” to replace “counselor/probation officer” in the questions.

Related to cultural competence and justice, ask feedback from your client.

· Was your case manager helpful?

· How fair do you feel the case manager was?

· How sensitive was the case manager to your family’s background or to experiences you have had because of your race, ethnicity, gender, sexual orientation?” (Strengths-Based Restorative Justice Assessment Tools for Youth, 2004, p. 34).

Related to strengths assessment, how did you do the following

· Ask about strengths

· Point out positives

· Use strengths

· Encourage youth/family involvement

· Move toward a positive plan

· Focus on the future

· Use individualized planning

· Encourage community connection

· Encourage development of youth’s healthy identity (Strengths-Based Restorative Justice Assessment Tools for Youth, 2004, p. 40–41).

6-1dSocial History

During an intake interview, the interviewer may conduct a social history. The purpose of the social history is to help helping professionals; in this case, case managers gain a holistic view of clients. A social history might include information about birth, country of origin, and race, ethnic, and cultural status. It might also include information about the family, educational and career history, and current living situation. During an intake interview, the interviewer may begin to learn about the client and start to write a social history. Because the social history, over time, becomes an in-depth record of the client and his or her life, we discuss more about the social history in  Chapter Nine.

6-1eConfidentiality

Our discussion of the initial meeting would be incomplete if we did not address the issue of  confidentiality. Human service agencies have procedures for handling the records of applicants and clients and for maintaining confidentiality; all case managers should be familiar with them. An all-important consideration is access to information.

All communication during an interview should be confidential to encourage the trust that is necessary for the sharing of information. Generally, human services agencies allow the sharing of information with supervisors, consultants, and other staff who are working with the applicant. The client’s signed consent is needed if information is to be shared with staff employed by other organizations. The exception to these general guidelines is that information may be shared without consent in cases of emergency, such as suicide, homicide, or other life-threatening situations.

Applicants are frequently concerned about who has access to their records. In fact, they may wonder whether they themselves do. Legally, an individual does have access to his or her records; the Federal Privacy Act of 1974 established principles to safeguard clients’ rights. In addition to the right to see their records, clients have the right to correct or amend the records.

There are two potential problem areas related to confidentiality. First, it is sometimes difficult in large agencies to limit access of information to authorized staff. Support staff, visitors, and delivery people come and go, making it essential for records to be secure and conversations to be confidential. If this assessment is conducted over the Internet or over the phone, then additional issues of confidentiality emerge. We discussed many of these issues in  Chapter Four. It is critical for an agency and case managers to make every effort to protect client information and to provide clients with details about how they intend to keep their information confidential.

The second problem has to do with  privileged communication , a legal concept whereby certain communications between clients and professionals may not be used in court without client consent (Corey, Corey, & Callanan, 2011). State laws determine which professionals’ communications are privileged; in most states, human service workers are not usually included, but therapists are. Thus, the helper may be compelled to present in court any communication from the applicant or client. Sometimes it can be a challenge for the case manager to explain this limitation to an applicant while trying to gather essential information. It can also be perplexing to the applicant.

6-1fEvaluating the Application for Services

During this phase, the case manager’s role is to gather and assess information. In fact, this process may actually start before the initial meeting with the applicant, when the first report or telephone call is received, and continue through and beyond the initial meeting. The initial focus on information gathering and assessment then narrows to problem identification and determination of eligibility for services. Guidelines and parameters established by the agency or by federal or state legislation influence this process to some extent. At this point in the process, the case manager must pause to review the information gathered for assessment purposes.

Part of the assessment of available information is responding to the following questions:

· Is the client eligible for services?

· What problems are identified?

· Are services or resources available that relate to the problems identified?

· Will the agency’s involvement help the client reach the objectives and goals that have been established?

· What types of services might be needed to meet unique issues presented by the client, family, or circumstances?

· How will the agency and the case manager provide for the culture of the client and the client’s family?

Reviewing these questions helps the case manager determine the next steps. To answer the questions and evaluate the application for services, the case manager engages in two activities: a review of information gathering and an assessment of the information.

Review of Information Gathering

Usually the individual who applies for services is the primary source of information. During the initial meeting, the case manager forms impressions of the applicant. The problem is defined and judgments are made about its seriousness—its intensity, frequency, and duration. As the case manager reviews the case, he or she considers these impressions in conjunction with the application for services, the case notes summarizing the initial contact with the client, and any case notes that report subsequent contacts. The case manager learns more about the applicant’s reasons for applying for services; his or her background, strengths, and weaknesses; the problem that is causing difficulty; and what the applicant wants to have happen as a result of service delivery. The case manager also uses information and impressions from other contacts. Other information in the file that may contribute to an understanding of the applicant’s situation comes from secondary sources, such as the referral source, the client’s family, school officials, or an employer. Information from secondary sources that can be part of the case file might be medical reports, school records, social history, or a record of services that have previously been provided to the client.

An important part of the review of information gathering is to ascertain that all necessary forms, including releases, have been completed and signatures have been obtained when needed. It is also a good idea at this point to make sure that all necessary supervisor and agency reviews have occurred and are documented.

Assessing Information

Once the case manager has reviewed all the information that has been gathered, the information is assessed. Many case managers have likened this part of case management to a puzzle. Each piece of information is part of the puzzle; as each piece is revealed and placed in the file, the picture of the applicant and the problem becomes more complete.

A case manager working in New York City described it as “lots of information that comes in many forms from many individuals, professional and otherwise, that you have to go through and figure out, ‘What seem to be the salient issues and challenges? What facts do we know?’.” This case manager added that helpers “need the special skills of collecting lots of information, making sense of it, reducing it to a manageable size, and then do[ing] something with it.” As a social worker case manager in Houston, Texas, suggests:

· One way that the case manager understands information is through how it feels, what is happening beyond the details. When you deal with multiple cultures—here there are covens and witchcraft, African Americans, immigrants, and the like—there are different cultures and different needs. I think you become part of the community and part of the culture. It is important that you are aware of what is happening in the community and in the various cultures. Take alternative religious perspectives: some would think a person who believes in shamans and spells suffers from mental illness. Sometimes the client needs a better spell. Frankly, I have seen voices cleared by a shaman.

After learning what information is in the file, the case manager’s task shifts to assessing the information. Two questions guide this activity. Is there sufficient information to establish eligibility? Is additional information necessary? In addition to answering these questions, the case manager also evaluates the information in the file, looking for inconsistencies, incompleteness, and unanswered questions that have arisen as a result of the review.

Is There Sufficient Information to Establish Eligibility?

To answer the question of sufficient information, the case manager must examine the available data to determine what is relevant to the determination of eligibility. The quantity of data gathered is less important than its relevance. Human service organizations usually have specific criteria that must be met to find an applicant eligible. The data must correspond to these criteria if the applicant is to be accepted for services.

The criteria for acceptance as a client for vocational rehabilitation services are a good example. Vocational rehabilitation is a state and federal program with the mission of providing services to people with disabilities to enable them to become productive, contributing members of society. Essentially, the criteria for acceptance for services are the following: the individual must have a documented physical or mental disability that is a substantial handicap to employment and there must be a reasonable expectation that vocational rehabilitation services will render the applicant fit for gainful employment.

During the assessment phase, a vocational rehabilitation counselor assesses the information gathered to determine whether the applicant has a documented disability. The next step is to document that the disability is a handicap to employment. Does the disability prevent the applicant from returning to work? Or, if the person has not been employed, does the disability prevent him or her from getting or keeping a job? If the answers are yes, then the counselor’s final task is to find support for a reasonable expectation that, as a result of receiving services, the applicant can be gainfully employed. This brings us to the second main question in the information assessment activity.

Is Additional Information Necessary to Determine Eligibility for Services?

If the answer is no, then the case manager and the client are ready to move to the next phase of case management. If the answer is yes—that is, additional information is necessary to establish eligibility—then a decision must be made about what is needed and how to obtain it. In the vocational rehabilitation example, the counselor examines the file for the documentation of a disability. Specifically, the counselor is looking for a medical report from a physician or specialist that will establish a physical disability or a psychological or psychiatric evaluation that will establish a mental disability. If the needed information is not in the file, then the helper must make arrangements to obtain the necessary reports.

Establishment of eligibility criteria is not the sole purpose of this phase. Data gathered at this time may prove helpful in the formulation of a service plan. Certainly, the case manager does not want to discard any information at this point; neither does he or she want to leave unresolved any conflicts or inconsistencies. Relevant, accurate information is an important part of the development of a plan. Ensuring relevance and accuracy at this point in the process saves time and effort and allows the helper and the client to move forward without delay.

In  Chapters One and  Two we learned about how Sharon Bello entered the agency. As indicated in this chapter, she engaged in an assessment of her needs. She had a case manager who coordinated that assessment; the information about Sharon came from a variety of professionals. Once the initial assessment was complete, the agency determined that Sharon was eligible for services and she was assigned a case manager to coordinate her services. Throughout her service delivery, Sharon had four case managers, Tom Chapman, Susan Fields, Luis Romano, and Alma Grady. These case managers helped her through the rehabilitation case management process.

Class Discussion

Describe How Sharon Bello Was Evaluated for Services

Let us return to the case of Sharon Bello. Based on the following description of the process for reviewing an application for services, take a few moments as a class, in small groups, or as an individual to develop a description of how Sharon was evaluated. In what ways did the agency follow the process described in this section? In what ways did the process differ? Can you make a case for Sharon’s eligibility for services? List five reasons why she might be eligible. List two reasons why you question her eligibility.

Share this information with your classmates.

6-1gCase Assignment

Once eligibility has been established and the applicant has been accepted for services, there are three possible scenarios, depending on the particular agency. In all three, the applicant becomes a client who is assigned a case manager to coordinate services.

In many instances, the case manager is the same person who handled the intake interview and determination of eligibility. In some agencies, however, there are staff members whose primary responsibility is conducting the intake interview. After a review, the case is assigned to a case manager—the helping professional who assumes primary responsibility for the case and is accountable for the services given to the client, whether provided personally, by other professionals at the agency, or by helpers at a different agency.

A second scenario involves the specialized worker, a term that may refer to either level specialization or task specialization. Level specialization has to do with the overall complexity and orientation of the client and the presenting problem. Is the case under consideration simple or complex? Is it a case of simply providing requested information, or is it a multiproblem situation? Task specialization focuses on the functions needed to facilitate problem resolution. Does the case require highly skilled counseling, or is coordination sufficient?

The third scenario occurs most often in institutions where a team of professionals is responsible for a number of clients. For example, in a facility for children who are developmentally disabled, clients interact daily with staff, including a teacher, a nurse, an activity coordinator, a cottage parent, and a social worker. These professionals work together as a team to provide services to each client.

6-1hDocumentation and Report Writing

Documentation and report writing play critical roles in the assessment phase of service coordination. The main responsibilities facing the case manager in this phase are identifying the problem or problems and determining the applicant’s eligibility for services. Documentation of these two responsibilities takes the form of  intake summaries  and  staff notes . Most agencies have guidelines for the documentation of information gathered and decisions made. In this section, we discuss the forms of documentation, their purposes, and how to prepare them. Before we discuss intake summaries and staff notes, let us distinguish between process recording and summary recording.

6-1iProcess Recording and Summary Recording

A  process recording  is a narrative telling of an interaction with another individual. In the assessment phase of case management, a process recording shows what each participant has said by an accurate account of the verbal exchange, a factual description of any action or nonverbal behavior, and the interviewer’s analysis and observations. The person making the recording should imagine that a tape recorder and a camera are taking in everything that is heard or seen. Of course, because records are required to be brief and goal-oriented, the helper would not attempt an exhaustive description; however, this approach helps focus the recorder’s attention on accuracy and impartiality.

Process recording is a useful tool for helping professionals in training, especially those who are learning to be case managers. Digital audio recorders and video cameras are readily available today, but many agencies and organizations do not have them, and case managers may not have the time or the authorization to use the equipment. Process recording is still an effective way to hone one’s skills of direct observation.

Process recording is most often used with one-on-one interviews. It includes the following elements.

· Identifying information: Names, date, location, client’s case number or identifying number, and the purpose of the interview.

Paulette Maloney saw the client, Rosa Knight, for the first time on Monday, November 5, at the agency. Ms. Knight is applying for services, and the purpose of the interview was to complete the application form and inform her of the agency’s services.

· Observations: Description of physical and emotional climate, any activity occurring during the interaction, and the client’s nonverbal behavior.

Ms. Knight appeared in my office on time, dressed neatly in a navy dress. I asked Ms. Knight to come in, introduced myself, shook her hand, and asked her to sit down. Although there was little eye contact, she smiled shyly with her head lowered. In a soft voice, she asked me to call her Rosa. Then, she waited for me to speak.

· Content: An account of what was said by each participant. Quotes are helpful here, to the extent that they can be remembered.

I explained to Rosa that the agency provides services to mothers who are single parents, have no job skills, and have children who are under the age of 6. She replied, “I am a single parent with two sons who are 18 months old and 3 years old. I have worked briefly as a domestic.” I asked her how long she had worked and where. She replied that she worked approximately 5 months for a woman a neighbor knew. She quit “because the woman was always canceling at the last minute.” She related that one time when she went to work, the house was locked up and the family was out of town. During this exchange, Rosa clasped her hands in her lap and looked up.

· Recorder’s feelings and reactions: Sometimes this is called a self-interview, meaning that the recorder writes down feelings about and reactions to what is taking place in the interview.

I was angry about the way Rosa had been treated in her work situation. She appears to be a well-mannered, motivated young woman who genuinely wants a job so that she can be self-supporting. Her shyness may prevent her from asserting herself when she needs to. Her goal is to get out of the housing project. I wonder if my impressions are right.

· Impressions: Here, the recorder gives personal impressions of the client, the problem, the interview, and so forth. It may also be appropriate to make a comment about the next step in the process.

Rosa Knight is a 23-year-old single mother of two sons, ages 18 months and 3 years. She has worked previously as a domestic (housekeeper). Particular strengths seem to be motivation and reliability. Her goal is to receive secretarial training so that she can be self-supporting and move away from the projects. Based on the information she has provided during this interview, she is eligible for services. I will present her case at the next staff meeting to review her eligibility.

The other style of recording,  summary recording , is preferred in most human service agencies. It is a report of what happened condensed into an organized presentation of facts. It may take the form of an intake summary or staff notes (both discussed later in this section). Summary recording is also used for other types of reports and documentation. For example, a diagnostic summary presents case information, assesses what is known about the client, and makes recommendations. A second example is problem-oriented recording, which identifies problems and treatment goals. This type of recording is common in an interdisciplinary setting or one with a team structure.

Summary recording differs from process recording in several ways. First, a summary recording gives a concise presentation of the interview content rather than an extensive account of what was said. The focus remains on the client, excluding the case manager’s feelings about what transpired. Summary recordings usually contain a summary section, which is the appropriate place for the writer’s own analysis. Finally, summary recording is organized by topic rather than chronologically. The case manager must decide what to include and omit under the following various headings: Identifying Information, Presenting Problem, Interview Content, Summary, and Diagnostic Impressions.

Summary recording is preferred because it is less time-consuming to write and easier to read. It also uses less paper, thereby reducing storage problems. When computerized information systems are used, a standard format makes information easy to store, retrieve, and share with others. However, a reminder is in order. Agencies often have their own formats and guidelines for report writing and documentation. Generally speaking, however, the basic information presented here applies across agency settings.

6-1jIntake Summaries

An intake summary is written at some point during the assessment phase. It is usually prepared following an agency’s first contact with an applicant, but it may also be written at the close of the assessment phase. For purposes of illustration, assume that it is written after the intake interview. After the case manager conducts the intake interview, he or she assesses what was learned and observed about the applicant. This assessment takes into account the information provided by the applicant, the mental status examination, if appropriate, forms that were completed, and any available information about the presenting problem. Client strengths are also identified at this point. The case manager also considers any inconsistencies or missing information. While integrating the information, the case manager also considers the questions that are presented in the previous section. Is the applicant eligible for services? What problems are identified? Are services or resources available that relate to the problems identified? Will the agency’s involvement improve the situation for the applicant?

This information is organized into an intake summary, which usually includes the following data.

· Worker’s name, date of contact, date of summary

· Applicant’s demographic data—name, address, phone number, agency applicant number

· Sources of information during the intake interview

· Presenting problem

· Summary of background and social history related to the problem

· Previous contact with the agency

· Diagnostic summary statement

· Treatment recommendations

In  Chapter One,  Figure 1.2, Application for Services Vocation Rehabilitation, Tom Chapman shares with us his intake efforts with Sharon Bello. We provide an additional example of a sample intake summary from a treatment program for adult women who are chemically dependent in  Figure 6.3. To qualify for the residential program, applicants must have a child who is 3 years of age or younger and has been exposed to drugs. The day program is available to mothers who have a child older than 3 years. The applicant whose intake is summarized in  Figure 6.3 is applying to the residential program, which lasts 1 year. During this time, children live with their parent in one of 10 agency apartments. To graduate from the program, the client must be employed or enrolled in school and be free of substance abuse. Some individuals enter the program voluntarily, and others are ordered to come as part of their probation. On admission, a staff member conducts a 30-minute interview, which is written up and placed in the client’s file within 2 days. The client then receives an orientation to the program and is assigned a care coordinator in charge of that case. The care coordinator and the client then have a more extensive interview, which lasts approximately 90 minutes.

Figure 6.3Intake Summary

Want More Information?

WestBridge Organization offers services to those suffering from mental illness. On their web site, they describe their availability and philosophy of the intake interview.

A Fresh Style of Intake Interview

Did you know that WestBridge will travel anywhere in the country to complete an intake interview? In our ongoing effort to live our mission of flexibility, mobility, and responsiveness, WestBridge will go to a home, hospital, or otherwise convenient location to meet with potential participants and their family, introduce ourselves, and determine if WestBridge is the right fit.

It is no secret that relationships are the foundations of our lives. They are also the cornerstone of long-term recovery from mental illness and substance use. In that spirit, WestBridge believes in beginning the relationship process by sending our staff (admissions counselors and/or clinical staff members) to meet with potential participants and their family. This enables the potential participant to meet some of our staff, hear about our program, and get a feel for the work we do. This service aids our admission process by our being able to have face-to-face conversations with potential participants and families. Our objective is to determine goals and strengths, and to determine if WestBridge offers what is needed. Often this process helps build trust and clinical rapport that can ease the transition to treatment and can be the catalyst of a strong recovery process.

If the participant and his or her family are interested in pursuing an admission, and if WestBridge decides that our programming fits the needs of the participant and family, then there are many ways to facilitate the admission from this point.

SOURCE: http://www.westbridge.org/TheBridgeNewsletter/fall_07_Newsletter.pdf. Reprinted by permission.

6-1kStaff Notes

Staff notes, sometimes called case notes, are written at the time of each visit, contact, or interaction that any helping professional has with a client. Staff notes usually appear in a client’s file in chronological order. They are important for a number of reasons.

· Confirming a specific service. The helper wrote, “John missed work 10 of 15 days this month. He reported that he could not get out of bed. I referred him to our agency physician for a medication review.”

· Connecting a service to a key issue. The helper may write, “I observed the client’s interactions with peers during lunch” or “I questioned the client about his role in the fight this morning.”

· Recording the client’s response. “Mrs. Jones avoided eye contact when asked about her relationship with her family,” “Janis enthusiastically received the staff’s recommendation for job training,” or “Joe resisted the suggestion that perhaps he could make a difference.”

· Describing client status. Case notes that describe client status use adjectives and observable behaviors: “Jim worked at the sorting task for 15 minutes without talking” and “Joe’s parents were on time for the appointment and openly expressed their feelings about his latest arrest by saying they were angry.”

· Providing direction for ongoing treatment. Documenting what has occurred or how a client has reacted to something can give direction to any treatment. “During our session today, Mrs. Jones said she felt angry and guilty about her husband’s illness, in addition to the feelings of sadness she expressed at our last meeting. These feelings will be the focus of our next meeting.”

The format of case notes depends on the particular agency, but they are always important. For instance, one substance abuse treatment facility uses a copy of its form for each client every day. A worker on each of the three shifts checks the behavior observed and makes chronological case notes on the other side. These notes allow the case manager and others working with a client to stay up to date on treatment and progress and provide the means of monitoring the case.

There are a number of other case notes models, such as data, assessment, and plan (DAT), functional outcomes reporting (FOR), and individual educational programs (Cameron & Turtle-song, 2002). These are all variations of the original  SOAP  format, originally developed by Weed (1964). SOAP is an acronym for subjective, objective, assessment, and plan. Developed to improve the quality and continuity of client services by enhancing communication among professionals, SOAP supports the identification, prioritization, and tracking of client problems so they can receive attention in a timely fashion.

Data collection is subjective and objective. Subjective refers to information about the problem from the client’s perspective or that of other people: “reports difficulty getting along with her coworkers” or “mother complains about client losing control and striking younger sister.” The helper’s observations and external written materials comprise the objective component, which is written in quantifiable terms: “client seemed nervous as evidenced by repeatedly shifting in chair, chewing nails, rocking, and looking down.” The assessment section combines the previous sections for interpretation or a summarization of the counselor’s clinical thinking regarding the problem. This is often stated as a psychiatric diagnosis based on the DSM-5 (see  Chapter Nine). The last section of the SOAP notes is the plan that generally includes both action and prognosis: “next appointment is 5/25/05 @ 10 pm; prognosis is good due to motivation and interest in changing anger behavior. Also, referred to anger management group for weekly meetings.” An example of SOAP notes follows that reflect Tom Chapman’s initial work with Sharon Bello.

My Story

Tom Chapman, Sharon Bello’s Case Manager, Entry 6.2

Tom Chapman’s SOAP notes from his initial interview are provided in  Table 6.1.

Table 6.1

An Example of Soap Notes: Tom Chapman’s Soap Notes Related to Sharon Bello

SOAP NOTES: Sharon Bello Intake

Subjective Data: Client reported that she didn’t want to live any more. She tells the case manager in the intake: “Everyday when I get up, I think, ‘I don’t know how I am going to get through this day’.” Sharon says that she has felt this way since her son Sean was killed in a drive-by shooting. She also reported, “I don’t know how I am going to support myself and my two children. I hurt so badly and I can’t do the work that I used to do.”

Objective Data: During our intake interview, I observed that Sharon lowered her eyes during the interview and she slowed her speech when she talked about Sean’s death. I also observed that Sharon wrung her hands and closed her eyes and then cried when she talked about not being about to work to support her children. I also heard Sharon express a willingness to help herself when she looked me in the eye and expressed a willing to help herself if I could point the way. Sharon was able to tell her story in an organized way. She expressed an ability to establish a goal and follow through.

Assessment: Sharon continues to deal with the death of Sean, who was murdered in a drive-by shooting. She is also depressed by her inability to continue her work with elderly clients. Sharon’s strengths are her desire to find gainful employment, her commitment to her two children to care for them, and her drive to be self-sufficient.

Plan: Sharon will participate in a broad assessment, in all probability will be accepted for services, and work with a case manager to choose a vocational path and pursue a vocational goal that aligns with her skills and physical abilities/disabilities.

Another example of case notes is from a residential treatment facility for emotionally disturbed adolescents; this example illustrates another format for case notes. These notes are in the file of a 15-year-old female client who has been diagnosed with borderline personality disorder. At this facility, a staff person from each shift is required to make a chart entry; the abbreviations DTC, ETC, and NTC refer to day, evening, and night treatment counselors. Any other staff member who has contact with the client during the day (such as the therapist, teacher, nurse, or recreation specialist) also writes a staff note. The word Level refers to the number of privileges that a client (Ct.) has. For example, a client at Level 1 has a bedtime of 9 pm; a client at Level 3 would go to bed at 10 pm.

1/22/05, 8:15  am DTC: Ct. awoke on time this morning. She was showered, dressed, and ready for school on time. She had positive interactions with her peers this morning. Ct. received one cue for being loud. Ct. completed her chores in a timely manner and responded appropriately to all staff requests. Ct. remains on Level 2 and under constant supervision.Jan Allen

1/22/05, 2:45  pm TEACHER: Ct. completed all of her classroom assignments in a timely manner. She received one consequence (C) for cursing. She accepted the C appropriately and maintained a good attitude. Ct. had positive interaction with peers throughout the day. She had a slight confrontation with one peer, but the two of them worked it out in a positive manner. Ct. has been very talkative and cheerful today. Ct. responded appropriately to all staff requests. Ct. remains on Level 2 and under constant supervision.Carlos Chaney

1/22/05 4:30  pm THERAPIST: Ct. requested and received her Level 3 today. She appeared very excited and stated that she has worked very hard for this and feels that she deserves it. We discussed the fact that being on Level 3 requires displaying Level 3 behavior. Ct. was receptive to this and seems to want to make the effort to do so. We also mutually decided that her new goal will be to take responsibility for her own actions and not blame other people. She understands that this is essential to her treatment and was receptive to doing so.Kim Stuck

1/22/05 9:30  pm ETC: Ct. participated appropriately in all group activities this evening. Went outside for structured activity time and participated appropriately. Interacted positively with her peers. Ct. participated actively and appropriately in group. Discussed her new goal and how much she desires to achieve it. Gave positive and appropriate feedback in group. Ct. completed her chore in a timely manner without being prompted by staff. She discussed with staff how much she wants to go home and how she wants to work through the program as quickly as possible so that she can go home. She seemed a little quieter than usual this evening. Ct. required no cues for the evening and responded appropriately to all staff requests. Ct. remains on Level 3 and under constant supervision.B. Greer

1/23/05 5:00  am NTC: Ct. slept through the night with no problems and was present for each 15-minute bed check.Phil Thress

This residential treatment facility gives its staff members strict guidelines for charting and consistent abbreviations: Ct. means client, cue means a warning, and C means a consequence. Also, there must be no blank lines or spaces in a case note, so the recorder puts in the line and signature at the end of each entry. Note also that no names of other clients or staff members appear in any entry. The case manager routinely reviews notes such as these.

You will also note that the word appropriate appears often. In this facility, it is an important word because clients with borderline personality disorder often behave and interact inappropriately. It is common for them to act out sexually, exhibit interpersonal difficulties, and rebel against any rules or authority figures.

Class Discussion

Insights about Assessment

In the following case study, the case manager faces many challenges, especially during the assessment phase of case manager. Take a few moments as a class, in small groups, or as an individual and read the case study. Answer the questions posed at the conclusion of the case study. Share your responses with your classmates. Be sure to note your insights about assessment in case management and any questions that still remain.

Deepening Your Knowledge: Case Study

Lonnie and Dorothy live in the southern part of town in a low-income area. Lonnie, age 68, works at a nursing home as a janitor and Dorothy, age 66, does not work due to health problems (although she has worked as a nurse in the past). They have been married for 39 but do not get along very well. They basically coexist together without much substantial interaction.

Lonnie’s job is rough on him because he works 7-day shifts and then has 3 days off. He drives 45 minutes to work in his 1999 pickup (which he still makes payments on). He spends all day on his feet and is exhausted when he gets home. He has talked of finding better work but, because they live from paycheck to paycheck, they cannot afford for him to take any kind of pay cut, even temporarily. Lonnie spends most of his spare time in front of the television.

This is hard on Dorothy. Due to heart problems, she is on disability and rarely gets away from the house, often spending days alone. If she does get away, it is only to go to the grocery store or the pharmacy. She also has a tendency to be paranoid. For instance, if her disability check does not come on the exact day it did last month, she spends the afternoon on the phone talking to the disability office and the post office, positive that someone has “made a mistake” or has “taken her check.” Last month, Lonnie started to have some medical problems himself and has had to go the doctor more frequently than usual.

After receiving information during her disability appointment about financial planning and counseling services from a local nonprofit agency, Dorothy and Lonnie decide to make an appointment. They arrive at the office and meet with Sandra, a case manager who handles between 15 and 20 cases at any given point in time. Sandra welcomes Dorothy and Lonnie and describes the first steps in the case management process. She asks Dorothy and Lonnie if they would be willing to take a mental status exam after a discussion of their situation and needs. Although Lonnie expresses reluctance, both agree to the examination and discussion. Sandra also asked Lonnie and Dorothy to describe their strengths and weaknesses before concluding with a discussion of confidentiality and the scheduling of a follow-up appointment.

· Morgan, C. (2012). Unpublished manuscript, Knoxville, Tennessee. Used with permission.

Discussion Questions

1. Did Lonnie and Dorothy’s case manager conduct a formal interview, informal interview, or both? What would be the purposes of these interviews as they relate to Lonnie and Dorothy?

2. After the initial meeting, Sandra sits down to assess the case of Lonnie and Dorothy. What are some of the key questions she should ask in this process?

3. When they left the interview, Lonnie and Dorothy discussed their thoughts and feelings about the interaction with Sandra. What could Sandra have done to help this discussion take place with all three participants present so that she could understand their opinions more clearly?

4. What are ethical issues that might arise when working with Lonnie and Dorothy? How will you address them?

5. What are potential multicultural issues that might arise when working with Lonnie and Dorothy? How will you address them?

Author Note: We think that it is important for you to review the chapter you just read. We suggest the following.

· First, re-read the class discussion questions in the text and answer these as comprehensively as possible.

· Second, once you complete the discussion questions, review the  Chapter Summary, define the  Key Terms, and answer the questions in  Reviewing the Chapter.

· Third, make notes of what stands out for you during your review. Also, record any questions that you might have.

· Finally, take time to discuss the Questions for Discussion with another class member, either face-to-face or online. Answering these questions with a peer will help you solidify the understanding you have of the contents of the chapter.

Readings and Resources

Articles, Websites, and Videos:

This article focuses on two special interviewee groups: the involuntary adult client and the sexually abused child.

· Problematic interviews. (2013). In Kadushin, A., & Kadushin, G., The Social Work Interview. Columbia University Press.

Explore how nonverbal communication enables you to see what the client is saying.

· Nonverbal communication. (2012). In Kadushin, G., The Social Work Interview: A Guide for Human Service Professionals. Columbia University Press.

This chapter provides an overview of working with clients including the file review, interviewing, and observations.

· Jone's family case study: Writing self-assessment. (2018). In Weisman, D., & Zornado, J. L., Professional writing for social work practice, Second Edition (Vol. Second edition). Springer Publishing Company.

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