COMMUNITY-BASED CASE MANAGEMENT

POLICY AND PRACTICE


MAY 11, 2007

CSCS’s membership comprises neighborhood-based case management agencies throughout the city and a broad array of other community-based senior services organizations. Member agencies provide services that span the continuum of care which allow older New Yorkers to age in place in their communities as well as supporting family caregivers.

Please go to www.cscs-ny.org to learn about the broad array of advocacy and programs CSCS provides for the community-based aging services network. For further information regarding this report, please contact Bobbie Sackman, Director of Public Policy,
(212) 398-6565 x226 or bsackman@cscs-ny.org


Igal Jellinek, Executive Director
William Dionne, Board President

CASE MANAGEMENT PROGRAMMATIC POLICY
MAY 11, 2007

Given the demographics of NYC and the well-documented growing numbers of minority elderly and older old (those over 85), we are seeing an ever-increasing need for case management services to help these most vulnerable of New Yorkers to remain safely in the community and negotiate the service delivery systems in an efficient and cost-effective manner. With this explosion of the elderly population, we are also seeing increasingly complex situations involving issues around health, poverty, mental health, elder abuse and isolation, among others. With a strong, neighborhood-based case management system in place, we are better prepared to provide a strong safety net for frail, older New Yorkers.

Evidenced-based studies have reported that early intervention is key to better outcomes for seniors requiring supportive services to remain in their community. A 2002 study reported in The Gerontologist, “Effects of a Community-Based Early Intervention Program on the Subjective Well-Being, Institutionalization, and Mortality of Low-Income Elders”, “those elders who received the intervention (case management) had significantly higher subjective well-being and were less likely to be institutionalized or die than those in a comparison group (remained on waiting lists for case management) across the 18-month period.” The study states that the implications of the results is that they “make a strong case for the importance of community-based programs to the well-being of elders. Effective early intervention and prevention has to be targeted and culturally sensitive. Practitioners and policy makers should continue the search for community-based programs that are cost-effective and improve the quality of life for elders.” The EISEP case management program addresses these concerns.

Early intervention includes services while the older adult is home or upon discharge from a hospital. Lack of proper supports upon discharge can result in unnecessary readmission within weeks of returning home. Hospitals are not reimbursed for readmissions soon after discharge. This is one example of how timely case management supports can save government and hospitals millions of dollars. The success of the NORC program, lauded as a national model with its roots in urban NYC, solidifies the programmatic policy that providing services to older adults as neighborhood-based as possible, ie – in the building developments seniors have aged in place in, is another example of a successful model of the value of preventive services. Case management is a core function of NORC programs. Regionalizing and/or centralizing EISEP case management services would move policy and services in a direction away from the NORC model and raise concerns about providing the same level of services for the general community as NORCs do. Neighborhood based case management is the lynchpin to timely, appropriate access to services on a neighborhood level and optimizing opportunities to save health care dollars and improving the quality of life for seniors and caregivers as local solutions are developed and implemented.

For case management services to reach the optimum level of effectiveness, services must be client-focused and easily accessible. Case management must be comprehensive and strengths based, allowing for consumer choice, when feasible. Services need to be neighborhood based and local in order to maximize local resources and access the entire continuum of care, strengthening the ability to forge community partnerships. For a senior or caregiver to have meaningful choice, case management services must be easily accessible. Neighborhood based services allow for accessibility to family members and clients, as well as allowing for optimal outreach constantly shifting populations. The local case management agency needs to be easily identifiable by older community residents and their family caregivers. The presence of EISEP funded case management agencies have become stabilizing factors in communities throughout the city for older residents and caregivers. This is an especially valuable and necessary asset as we see increases in diversity, poverty and longevity in the older adult population in NYC. In responding to state RFI’s on the NY Connects program under discussion, CSCS emphasized the financial benefit the state would realize by replicating the social model of EISEP case management services and include Medicaid eligible clients as well.

We are facing great challenges with the number and complexity of the long term care needs of the City’s elderly. A strong neighborhood-based case management system would greatly enhance the City’s ability to meet these needs in a cost-effective, efficient and humane manner. We also recognize that the State is looking at single access points for long term care for all elderly and disabled, regardless of payment source. We feel that this is the opportune time to strengthen the existing cost-effective social case management model, rather than move to a more costly medical model and/or a centralized or regionalized system. The only way to provide this level of care without causing bottlenecks in timely access to services for the elderly and their family caregivers is to increase the number of local access points. Bottlenecks are avoided by appropriate case coordination and consumer empowerment, ie – helping individuals and their families make decisions regarding care. Additionally, in order to ensure the avoidance of case management service disparities that regionalization could bring, catchment areas must be defined by on a neighborhood basis. Larger service districts could lead to service inequities among diverse ethnic and economic populations across the city.

As is evident from the following paper on the skills set necessary for individual case managers and case management agencies to possess, CSCS believes it is incumbent upon the city to increase capacity to work with individuals on a one to one basis, locally. It is also important to keep in mind that many of the seniors who are clients of case management agencies have no family or caregiver to assist them. The case manager has the responsibility to assess and facilitate access to the gamut of services and resources clients, especially without other supports, need. We share the goal with the Department for the Aging, to increase the capacity of case management agencies to provide comprehensive case management, not just refer individuals to certain government funded services. This will take additional funding and regulatory flexibility. There are currently models of comprehensive case management around the city that should be used as best practices to be replicated. The second part of this paper addresses case management practice that could be used to inform the RFP process.

Coordinating case management services to a vulnerable elderly individual is a delicate, labor intensive balance between appropriate care and a cost-effective service delivery system. The EISEP case management system has a history over two decades of providing case management in a community-based, cost-effective manner. Until recently, case managers labored under average caseloads of 90 or more. Recent state increases have brought welcomed respite lowering the caseloads to about 65. CSCS welcomes the investment into case management services by the administration as seen by the projected Case Management Enhancement funding of $ 2.19 million beginning in FY2009 which will lower caseloads further. CSCS would welcome the opportunity to discuss planning for the future of case management services by working with local communities to retain and strengthen their case management agencies, along with strengthening case management capacity in neighborhoods throughout the city.

CASE MANAGEMENT PRACTICE

According to the National Association of Social Work (NASW) Standards for Social Work Case Management:
“Case management encompasses well-established social work concepts and techniques. As an approach to arranging and coordinating care, it has its origins in the earliest history of social work practice and the social work profession. Social work case management is clearly linked to social casework, a fundamental concept of social work practice. Traditional social caseworkers maintained a dual focus on the client and the environment, working directly with and indirectly on behalf of individual clients and families in need of social services. Case management remains an important professional component of competent social work practice. It is based on the recognition that a trusting and empowering direct relationship between the social worker and the client is essential to expedite the client’s use of services along a continuum of care and to restore or maintain the client’s independent functioning to the fullest extent possible. Case management is believed to be an efficient and cost-effective method for managing the delivery of multiple labor-intensive services to targeted populations.
All aspects of social work case management rest on a body of established social work knowledge, technical expertise, and humanistic values that allows for the provision of a specialized and unique service to designated client groups. The social work case manager must have the capacity to provide assistance in a sensitive and supportive manner to particular client populations based on knowledge of human behavior and well-developed observational and communication skills. With this foundation, a social work case manager establishes helping relationships, assesses complex problems, selects problem-solving interventions, and helps clients to function effectively and, thus, is a therapeutic process.
The conduct of the social work case manager follows the basic social work ethical tenets of the NASW Code of Ethics, including the primacy of the client’s interests, the recognition of the inherent worth and capacity of the individual and the individual’s right to self-determination and confidentiality.
Social work case management is a method of providing services whereby a professional social worker assesses the needs of the client and the client’s family, when appropriate, and arranges, coordinates, monitors., evaluates, and advocates for a package of multiple services to meet the specific client’s complex needs….. Social work case management addresses both the individual client’s biopsychosocial status as well as the state of the social system in which case management operates. Social work case management is both micro and macro in nature: intervention occurs at both the client and system levels. It requires the social worker to develop and maintain a therapeutic relationship with the client, which may include linking the client with systems that provide him or her with needed services, resources, and opportunities.”

Case Management must provide comprehensive case assessment that looks at the client in regards to unmet needs and care planning, not only as an assessment for specific government services. Ongoing comprehensive Case Management services should be available to all seniors residing in New York City regardless of payer. These services provided by agencies utilizing a professional social work model provide cost effective means to assess and handle ongoing case management as well as facilitating referrals to appropriate services. These community based social service agencies are able to utilize their own continuum of care and linkages to other community based agencies to meet the wide array of client needs. This strong, established community system is often the most effective means to meet the needs of our senior consumers. Case Management agencies that provide services along a continuum of care or those agencies that can demonstrate that they have effective linkages to agencies that provide this continuum are essential in providing quality case management services.

Community-Based

Community-based doesn’t just mean “in the community”. To be most effective, a case management agency needs to be involved in the communities it serves and at a minimum:

• Maintains accessible offices in the communities served

• Serve all neighborhoods of the assigned service area and make sure they are well known to all neighborhood factions.

• Participate in community planning groups and service coordination efforts

• Maintain formal and informal linkages with the network of health care, social service and advocacy organizations as well as senior citizen and other community groups.

• Serve as a resource to the community on issues related to and resources available for older persons.

• Provide staff that understands the ethnic backgrounds of the communities they serve and speak the language of clients in their community.

• Identify emerging needs of longstanding older residents and new populations living in the neighborhood. This takes an intimate understanding and participation in the local community.

The four core functions of case management are:

1. Screening, information and referral

2. Assessment

3. Care Planning

4. Service Coordination and follow-up

Screening and Information/referral
Screen each potential client to determine whether the client is appropriate for case management (60+, lives in the service area, and has unmet needs); provide information and referral to those who are ineligible for case management services and need to be referred elsewhere. Since the client and/or family may have made many calls before, this function must be sensitive to the fact that the caller may be in crisis and has had to repeat his/her story to many different people without receipt of the needed help. The screening/intake function must be managed so that knowledgeable staff makes decisions about who should be accepted as a client and who should be referred elsewhere. Staff must have the skill, knowledge and experience to perform triage to identify and prioritize emergency situations.

Assessment
Conduct in-home visits to all clients accepted for case management to provide each client with a comprehensive, individualized assessment that includes all areas needed to create a complete picture of the client and his/her situation. This includes but is not limited to an evaluation of physical health, functional abilities, mental status, nutritional status, social supports, economic status, home environment (e.g. risk for falls), as well as the client’s level of compliance with recommended medical regimens and/or previous care plans. Personal interests (e.g. social cultural, familial, and religious, etc), strengths, and wishes that might impact on care planning must also be evaluated. In cases where the client has no significant others and has some mental or emotional impairment that prevents him/her from making independent decisions, workers must have the skills to assess capacity and risk level and whether the client may be amenable to services, or whether there is risk to self and/or others necessitating involuntary intervention. In cases where the client is judgment-impaired and unable to express consumer choice but not at immediate risk and therefore not appropriate for involuntary intervention, intensive case management may be warranted in order to maintain the client at the present level of functioning and prevent further deterioration.

Care Planning
Work with each client and his/her informal supports to develop a mutually agreed upon care plan that addresses his/her assessed needs and builds on her/his strengths and capacity for independent functioning that respects each client’s wishes, protects his/her right to self-determination, explores impediments to implementing the care plan and educates the client so that he/she may make informed decisions. Again, in more complex situations where the client may be judgment impaired and unable to express choice in care planning and has limited or no informal supports, more intensive involvement on the part of the case manager may be necessary in order to provide a safety net, while respecting the client’s right to the least restrictive environment.

Service Coordination and Follow up
The administrative, clinical, and assessment activities that bring the client together with case management services, community agencies, and other resources to focus on issues and needs identified in the care plan. Service coordination includes case management and client advocacy, and establishes a framework of action for the client to achieve specified goals. It involves collaboration with the client and significant others. Coordination of the care plan and referrals, liaison activities with community resources, client advocacy, and ongoing evaluation of client progress and client needs are all critical components to the coordination of services. Good service coordination and follow-up ensures that each client receives the services indicated in the service plan in a timely manner. Service coordination also requires linking each client to needed resources in the community that best suit her/his needs and wishes, informing each client of his/her rights, ensuring that communication and consultation occurs between the case manager, the client, informal supports and other service providers to ensure the client receives services seamlessly and without duplication. Case consultation between the case manager and other professionals (physicians, mental health workers, attorneys, etc.) when necessary, ensures monitoring of each client’s care plan to determine that it is being implemented as authorized. In addition, the case manager must reassess each client on a regular basis, as well as when there are significant changes in the client’s status impacting his/her ability to function. Case managers must also assist each client with discharge and long-term care planning when the client needs to move to another level of care, or no longer needs the service.

Staff Professionalism:
To provide these core functions of case management, agencies must ensure a minimum level of staff professionalism. To curb expenses by hiring less qualified staff ends up costing more in the long term. Case Management agencies must:

• Require minimum education – MSW preferred, or BSW with related human service experience and training and/or experience in gerontology.

• Provide competitive compensation and benefits

• Provide staff training

• Limit caseload size

• Provide regular professional administrative and clinical supervision.

• Ensure a sufficient number of supervisors for adequate supervision

Essential Knowledge and Skills:
The core functions of case management require a broad base of knowledge and skills. Some skills are necessary to a particular core function, but others are necessary to all four functions. Case Management Agencies must demonstrate both knowledge and skills including:

Assessment Skills

• Interviewing techniques for individuals, groups, and families

• Methods for assessing client's past and present biopsychosocial status

• Soliciting comprehensive and accurate information from numerous sources including the client

• Methods for assessing all systems that may affect the client's progress

• Methods for continuous assessment and modification of the treatment plan

• Knowledge of social, cultural, and family systems

• Methods of assessing and documenting client change over time

• Acquiring, interpreting, prioritizing, and using relevant information received from the client and others

• Assessment of client motivation and ability to initiate and follow through with referral and care plan

• Methods of assessing client's progress toward care plan goals

• How client defenses, abilities, personal preferences, cultural influences, presentation, and appearance effect referral and follow through

• Assessing level and intensity of client care needed

Skills in Comprehensive Care Plan Development

• How care planning and referral relate to the client goals

• Techniques to engage the client in the care plan process

• Involving family and significant others in care planning

• Identifying the role and limitations of significant others in the care plan

• Methods for determining the client's goals, treatment plan, care plan, and motivational level

• Factors to consider when determining the appropriate time to engage client in referral process

• How client defenses, abilities, personal preferences, cultural influences, presentation, and appearance effect care planning and follow through

• How to tailor resources to client care plan needs

• How to define long- and short-term goals of the care plan

• Logistics necessary for client access and follow through with the care plan

• Assessment of client motivation, and ability to initiate and follow through with the care plan

• Educating the client regarding appropriate services and their use

• Methods of assessing client's progress toward care plan goals

• Observing and identifying problems that might impede the care plan

• Soliciting and interpreting feedback related to the care plan

Knowledge and Skill in Managing the Referral Process

• Comprehensive referral information and protocols

• Terminology and structure used in referral settings

• Terminologies appropriate to the referral source

• How to access and transmit information necessary for referral

• Documenting the referral process accurately

• Motivating clients to take responsibility for referral and follow-up

• How to tailor resources to client care plan, needs, referral

Demonstrated Skill and Practice in Ongoing Case Management

• Outreach, follow-up, and aftercare techniques

• Participating in conflict resolution, negotiating, contracting, problem solving, and mediation

• Assisting the client in maintaining motivation

• Advocating for clients

• Using effective communication styles

• Demonstrating clear and concise written and verbal communication

• Using language and terms the client will easily understand

• Demonstrating appropriate written and verbal communication

• Observing, recognizing, assessing, and documenting client progress/change/deterioration

• Eliciting client perspectives on progress/changes

• Recognizing, documenting, and communicating client change

• Applying crisis intervention techniques

• Appropriate sources and techniques for evaluating outcomes

• Maintaining contact with client, referral sources, and significant others

• Using appropriate technology to access, collect, document and forward data

• Interpreting and using evaluation and client feedback data

• Soliciting client satisfaction feedback

• Empowerment techniques

In addition to the knowledge and practice of essential social work skills, agencies must also demonstrate solid practice in these key areas:

Knowledge of the Community

• Understand the needs of the client population served

• Knowledge of community demographics, current and changing

• The community's political and cultural systems

• Existing community resources and services and how to access them

• Service gaps and appropriate ways of advocating for new resources

• Access available funding resources, local, state, federal and private.

• Philosophies, policies, procedures, and admission protocols for community agencies

• Criteria for receiving community services, including fee and funding structures

• How to access community agencies and service providers

• Establish and nurture collaborative relationships with key contacts in community service organizations

• How to access key resource persons in community service provider network

• Using existing community resource directories including computer databases

• Give feedback to community resources regarding their service delivery

• How to access client satisfaction data regarding community service providers

• Establish trust and rapport with colleagues in the community

Knowledge and Practice of Professional Ethics and Standards including

• How to apply regulatory and ethical standards related to confidentiality including documentation and sharing of client information

• Client rights and responsibilities

• Respect for the client's right to self-determination

• Professional concern for the client

• Commitment to professionalism

• Communicating respect and empathy for cultural and lifestyle differences

• Willingness to be flexible

• Establishing appropriate boundaries with client and significant others

Knowledge of Changing Government Programs and Changes in Proposed Service Delivery Systems

• State and Federal legislative mandates and regulations

• Managed care and other systems affecting the client

Expertise and Knowledge of the Aging Population

• Knowledge of chronic ailments and common medications used to treat ailments common to the elderly population

• Knowledge of issues relating to environmental safety and home safety

• Knowledge of Alzheimer’s Disease and related dementias

• Knowledge of mental illness including depression, anxiety

Effective Case Management Agencies also Value

• Roles, responsibilities, and areas of expertise of other team members and disciplines

• Participation in interdisciplinary team building

• Encourage staff in networking and communication

• Encourage staff participation in career development and training

• Participate in field placement programs from accredited Social Work programs

• Provide internships/field placements for students from other professional study programs to enhance services, i.e. OT and Nursing programs.

• Provide innovative programs to enhance case management services.

Never in the history of New York City have New Yorkers lived as long as they are living. According to the Department for the Aging’s 2007-2008 Annual Plan, “For the first time in 60 years, life expectancy for New Yorkers is above the national average by about 7 months.” The fastest growing segment of the city’s population is the 85+ cohort. Longevity engenders complex situations as seen by the fact that people age 85+ have a 50% chance of having dementia. Diversity is increasing rapidly with almost half of the 60+ population belonging to minority groups. The challenges faced by the city are how to assist seniors to age in place in their homes and communities and support their family caregivers. As discussed in this paper, case management on a neighborhood based level is key to providing appropriate and humane services and placing quality of life for older New Yorkers as the priority goal of all our programs.