NIWL Resource HubNIWL Resource HubCase Management is a participant-centered, goal-oriented, assessment-based process of planning, coordination, and support in partnership with program participants to access services and resources to meet their individual needs, achieve program goals and make strides toward self-sufficiency.
Case Management is participant-centered and comprehensive. Case Management essentially says to an individual, “Who are you, where are you now, where do you want to go, and how will we work together to get you there?”. Initiating the case management process must begin with gaining participant buy-in of the expectations and requirements of the program. Additionally, once an initial assessment has been completed during an intake interview deeming the individual both suitable and eligible for the program, the next step is for the navigator to begin the enrollment process and embarking on a “partnership path” with the participant who has indicated readiness to be a part of the program.
The Case Management process is integrated and coordinated by a designated navigator (a.k.a. case manager). Navigators are assigned to individual participants and are designated as the team lead among internal program staff. They are the central point of contact and nucleus for all case management efforts. Navigators are responsible for service coordination on behalf participants with internal program staff as well as external services providers. They oversee and guide the participants’ process of accessing services and resources, monitor services being provided, and holding them accountable to pursuing their program goals.
The navigator’s priority during the enrollment process is to establish a rapport with the participant. This is vital in achieving an initial connection to the program. It will increase the chances of the participant staying engaged until program completion. Making a personal connection with the participant through a one-on-one conversation is key. Necessary paperwork and required data entry will follow but should not drive the initial meeting. Once the rapport is established, navigators will go on to oversee participant progress in accessing services and resources.
An effective case management process will begin once the partnership has been established between the navigator and participant. Both parties are actively involved in the development and execution of objectives leading to goal achievement. Participants need to acknowledge their responsibility for pursuing their goals and their level of initiative should increase over time as they become more connected to the program. Ultimately, the case management process moves program participants to increasingly believe in themselves to the point where they can execute behaviors and action items necessary to move toward attainment of their ISP goals as well as gain a greater sense of control over their own lives.
Navigators must show empathy and patience as well as demonstrate the organizational skills necessary to walk with participants during their participation in the program. Navigators must be receptive to the participants’ point of view and help to steer them to define what success means for them. Navigators must be multi-taskers and organized, able to handle a caseload of no more than 25-30 participants.
Quality program service delivery is not the sole responsibility of the navigators but a collective effort of the entire program team. It requires the dynamic integration of all the components and providers of service delivery. When a team approach is the norm, participant goals are more realistically developed, supported, and achieved. At the same time, program performance outcomes are attained leading to success for both the participant and the program team/organization.
The primary goals of case management include the following:
Providing a standardized process facilitates an easier transition for service coordination to other staff members, allows for efficiency and fairness, and helps with successful monitoring and evaluation. Helping participants pursue their goals and function more independently is only possible when all parties understand their roles within the context of the program’s service delivery flow.
The flow or sequence of how program services will be delivered must be clearly understood by staff, articulated to participants, and shared with partner organizations. Sharing the service delivery flow with all involved parties helps to ensure a smooth process, consistent messaging, and a collaboration in which everyone is on the same page.
Two helpful tools which illustrate and convey service delivery flow are the Logic Model and Participant Flowchart:
A Logic Model is an organized and visual way to display your understanding of the relationships among the resources you must have to operate your program, the activities you plan, and the changes or results you hope to achieve. Logic models are sometimes referred to as “road maps” for the organization. They help to illustrate how the program is going to work, and what the program will do to achieve the desired results. (see Logic Model example below)
A Participant Flowchart is a visual depiction or illustration of the phases and process for participant programming. It is a helpful tool for program staff, participants, and partner agencies as it maps out the path for services while in the program. The participant flowchart ideally illustrates the beginning, middle and end of the program, from enrollment to program completion. In some cases, it may illustrate a recruitment or pre-enrollment phase prior to official enrollment. The participant flowchart should indicate which phases are offered in-person, virtually or via hybrid programming. Consistent use of the of this tool has implications throughout the program for participant buy-in, appropriate and successful team handoffs, suitable referrals internally and externally, messaging between staff and partners, and necessary data reporting at each phase. (see Participant Flowchart example below)
Effective Case Management begins with the big picture in mind and takes into consideration what happens to a participant from hello to goodbye (e.g., enrollment through program completion). These service delivery flow tools help to ensure that everyone is following the same process for programming, messaging in the community is consistently accurate, and participants are on their path to success. Once the service delivery flow is understood, the service delivery approach and corresponding roles is the next order of business.
Tri-Level Case Management (TL-CM) is a systematic approach to service delivery that develops and implements a strategy for coordinating the provision of services, utilizes a participant-centered, goal-oriented process for assessing strengths and needs, and assists participants to utilize necessary services and take initiative to achieve their programmatic goals.
TL-CM identifies the roles and responsibilities of each member of the internal program team as well as program participants. This dynamic process of service delivery co-manages the helping process from program enrollment to completion and includes the participant in the process. The Tri-Level Approach to case management incorporates three levels of roles:
The Navigator should review participant responsibilities during the program orientation to gain buy-in before initiating the case management process. Program partners are encouraged to implement this approach as it helps to ensure the provision of a standardized process for delivering services, facilitate successful services integration, and optimize participant functioning towards their own success.
Team Lead – Coordinating all case management services from enrollment through program completion and keeping team members and partners abreast of the status, needs and strides being made by the participant
Coach – Meeting frequently with the participant to check-in on how things are going with pursuit of goals as well as providing encouragement and advice necessary for service plan completion
Counselor – Providing a steady presence, being an example via informal mentoring, and helping participant to address problems and explore solutions
Advocate – Intervening when difficulties or issues arise, negotiating for assistance from community partners, and mediating when problems arise with instructors, employers or other service providers
Liaison – Communicating with external service providers oftentimes needed to address the whole individual and family, if applicable
Another significant consideration around service delivery involves the way in which trauma-impacted participants are approached and engaged throughout programming. Trauma-informed/sensitive and healing centered approaches will make all the difference in the lives of participants served and will contribute to them feeling safe, embraced, supported, and empowered while in your program.
“Individual trauma results from an event, a series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”
Definition of Trauma – SAMSHA’s 3 Es
Trauma-Informed Care “acknowledges the need to understand a client’s life experiences in order to deliver effective care and has the potential to improve patient engagement, treatment adherence, health outcomes and provider and staff wellness.” (Substance Abuse and
Mental Health Services Administration (SAMSHA)- www.samhsa.gov
Trauma-Informed Care (TIC) is defined as an approach to helping people who have experienced trauma that:
TIC is more than providing services and support. It is about making an effort to understand where a participant is coming from. It is important to understand that trauma includes overwhelming conditions/events that are difficult to understand resulting in cognitive, social, emotional, and behavioral changes, and include past experiences that may remain present.
Five Principles of Trauma-Informed Care (TIC)
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“A healing centered approach to addressing trauma requires a different question that moves beyond “what happened to you” to “what’s right with you” and views those exposed to trauma as agents in the creation of their own well-being rather than victims of traumatic events. An important ingredient in healing centered engagement is the ability to acknowledge the harm and injury, but not be defined by it…The healing centered approach comes from the idea that people are not harmed in a vacuum, and well-being comes from participating in transforming the root causes of the harm within institutions. HCE is strength based, advances a collective view of healing, and re-centers culture as a central feature in well-being.”
The Future of Healing: Shifting from Trauma Informed Care to Healing Centered Engagement-2018 (Shawn Ginwright Ph.D.)