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Engaging Complex Clients in the Case Management Process

Engaging Complex Clients in the Case Management Process. Jenny Thompson Clinical Nurse Consultant ADAHPT. Objectives. Overview of case management ADAHPT model of case management Discuss the ‘Engagement’ process Look at the obstacles to engagement Case study. ADAHPT. Established 1997

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Engaging Complex Clients in the Case Management Process

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  1. Engaging Complex Clients in the Case Management Process Jenny Thompson Clinical Nurse Consultant ADAHPT

  2. Objectives • Overview of case management • ADAHPT model of case management • Discuss the ‘Engagement’ process • Look at the obstacles to engagement • Case study

  3. ADAHPT • Established 1997 • NSW state-wide service • Aids Dementia Complex &/or a HIV Psychiatric condition • Expanded to complex needs • Multidisciplinary approach • Co-case management model

  4. Other Service Providers Negotiation Client Partnership ADAHPT Co-case Manager Case Manager

  5. Case Management • Concept of ‘case management’ varies across services • Five basic functions (Intagliata, 1982) • Assessment, planning, linking, monitoring & evaluation (or review) • Definition: ‘Case management is a process for ensuring clients are provided with whatever service/s they require in a co-coordinated, effective and efficient manner’(Case Management Society)

  6. Crisis intervention Review Citizenship Focus on strengths Support Advocacy Monitoring Home visit/face to face meeting Respect Engagement Planning/Linking Background Information Assessment Consultation with others Referral Steps of Case Management

  7. Referral • Referrer involvement • Clear picture of client • Referral is appropriate • Initial plan • Address safety issues

  8. Engagement • Critically important to case management • Respectful, friendly and tactful • Clients needs • Focus on strengths • Citizenship • Crisis intervention • Support and advocacy • Frequent home visits

  9. Assessment • Formal process • History • Health information • Accommodation • Finances

  10. Crisis intervention Review Citizenship Focus on strengths Support Advocacy Monitoring Home visit/face to face meeting Respect Engagement Planning/Linking Background Information Assessment Consultation with others Referral Steps of Case Management

  11. ADAHPT C/Mgt and the Client • Variety of skills • Assessing • Evaluating • Depth of knowledge • Ongoing engagement • Awareness of changes

  12. Successful Engagement Client • Familiarity • Independence Case Manager • Partnership • Support

  13. Obstacles to Engagement • Legal difficulties: possible incarceration • Housing difficulties: transience • Violence • Alcohol and other drugs • Highly functional

  14. Case Study: Ann 45 year woman HIV positive Hepatitis C positive AIDS Dementia Complex Diagnosed with Schizophrenia Substance use issues Reluctant adherence to medication Sex worker History of self harm

  15. Initial Stages • Difficult to engage • Fierce independence • Refuses service • Psychiatric condition • Local services give up • Referral to ADAHPT

  16. The Process of Engagement • Appropriate medication • Practical assistance • Acceptance of case manager • Case manager gets to know client • Contact with family • Occasional set backs • Re-engagement

  17. Successful Engagement • Trust • More accepting of services • Continues to live independently • Health improved • Mental state stable • Family supported • Timely and appropriate intervention

  18. Setbacks • Driving • Mental Health: Community Treatment Order • Public Health

  19. Current Supports • Family • Immunology clinic • Reluctantly accepting mental health services • Methadone prescribed and supplied • General Practitioner • Ankali • Community Support Network • ADAHPT Case Management

  20. Questions? ADAHPTA state-wide tertiary outreach team for people with HIV and complex needs Tel: +61 (2) 8382 1810 Fax: +61 (2) 9360-2247 E-mail: adahpt@sesahs.nsw.gov.au www.sesahs.nsw.gov.au/adahps

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