Case Managers Coaxing Families Toward Change
BRATTLEBORO, VT.--As a home visitor who helps link troubled families with young children to support services, Kathy Emerson has learned a sobering lesson: Meaningful change takes time.
Of the eight families she has worked with for two years, she says, some have made "huge strides'' toward change; others have taken small, tentative steps. In a couple of cases, she says, "I haven't seen much change at all.''
"Some families tend to be more chaotic and more imbedded in certain kinds of behaviors that it seems much harder to nudge them out of,'' she says. "There have been little bits of progress here and there, but a lot of backsliding.''
In helping families beat the odds, Ms. Emerson admits that she sometimes feels she is "banging my head against a stone wall.''
The challenge, she says, is to persevere--and be patient.
"I've long ago given up predicting when and what change is going to happen and even what change is,'' she says.
Ms. Emerson works for a program administered by the Brattleboro, Vt., schools under a federal grant designed to help needy families bolster the school readiness of their children. (See related story, page 28.)
But the triumphs and frustrations Ms. Emerson describes are echoed by workers in school-linked projects nationwide that are tapping an approach to at-risk families that emanates from social services: case management.
The strategy provides an opportunity to families to have an ongoing relationship with a person who lends emotional support and assists them in setting goals and gaining access to services to help meet those goals.
"This approach to service delivery has become increasingly prominent across many disciplines and practice settings,'' says a document recently released by the National Association of Social Workers.
The reason, according to the document, which sets out new standards for social-work case management, is that the approach "is believed to be an efficient and cost-effective method for managing the delivery of multiple labor-intensive services to targeted populations.''
A Range of Applications
The case-management approach is being used in a variety of programs designed to address a range of social and family ills. They include:
- Programs designed to comply with special-education laws that mandate that eligible infants and toddlers be provided with a key person to insure services are provided in a "family centered'' and coordinated way.
- Efforts, such as the North Dakota Child Welfare Reform Initiative, aimed at stemming the numbers of children in foster care by offering intensive help to troubled families.
- Projects that seek to move welfare recipients toward self-sufficiency, such as Iowa's Family Development and Self-Sufficiency Demonstration and Grant Program; prevent child abuse, such as Hawaii's Healthy Start program; and provide support to teenage parents to help reduce infant mortality, such as the "resource mothers'' program in South Carolina. (See Education Week, April 1, 1992.)
- Programs designed to help prepare children for school, as in the Brattleboro project; improve student performance and reduce dropout rates, as in the Annie E. Casey Foundation's New Futures initiative; and steer at-risk youths to college, as in the I Have a Dream Foundation launched by the New York City businessman Eugene M. Lang. (See Education Week, April 8, 1992.)
Case management is also a key ingredient of the family-resource centers being established by many communities and states and of school-based centers launched under such initiatives as the Kentucky Education Reform Act. (See Education Week, Sept. 23, 1992.)
Proponents see case management as a way to address family concerns in a more caring and coherent way than is possible with traditional human-services institutions, which they say are fragmented, impersonal, and hard to negotiate.
Case management is a promising approach, says James P. Brennan, who headed the panel that drafted the standards for the social workers' association, because it addresses the child as a whole person and recognizes "how stresses in the family'' affect a child's development.
In addition to making it difficult to address family issues comprehensively, a guide to family-support programs from the Children's Defense Fund concludes, "our social-service system typically offers families nowhere to turn for help until family problems have gotten out of hand and a crisis develops.''
Unlike "traditional social services that wait for the client to come to them,'' adds Howard Blonsky, a former school social worker who served on the standards panel, "case management has a great potential for reaching out to people in need.''
Like Ms. Emerson of Brattleboro, many case managers are buoyed by the progress they see in families that could have fallen through the cracks. But they also wrestle with how to gauge success and overcome barriers posed by agency and school bureaucracies, seemingly intractable social ills, and entrenched family behaviors.
The case-management piece of the Comprehensive Child Development Projects--the federal program that sponsors the Brattleboro program--is "constantly evolving and changing,'' says Judith Jerald, the executive director of the Windham County Family Support Program. "All the directors are looking at it very differently than we did three years ago.''
Some experts worry that case management is not well defined in some projects, and warn that, to have a long-term impact, it must be coupled with deeper changes in human-services agencies.
Case management is "vital if we are going to pull things together for the families we have allowed to get to such a serious point that they need multiple, intensive services,'' says Janet Levy, a program director at the Danforth Foundation.
At the same time, she adds, "we need to be thinking about how to support children and families at much earlier stages ... so that the crises that necessitate case management may never develop.''
Says Peter Forsythe, the former director of children's programs for the Edna McConnell Clark Foundation, "I worry that [case management] is both loosely defined and inappropriately believed to be a panacea.''
The social workers' association issued its new standards as a result of concern that the definition of case management had blurred in recent years.
The standards, geared for use in education, welfare, health, and mental-health settings, define case management as a method of assessing the needs of clients and their families and helping to coordinate, monitor, evaluate, and advocate for services to meet those needs.
Besides offering a "therapeutic relationship with the client,'' the document says, case managers should be in a position to spur policy reform.
That might mean lobbying for more funds or insuring that program requirements are reasonable and clients are well informed, says Mr. Brennan, a senior staff specialist for health and mental health at the social workers' association.
While stressing the need for collaboration across sectors, the standards say clients should have a "single, identifiable case manager throughout the continuum of service delivery.''
But care must be taken, Mr. Forsythe cautions, to insure that case management is not interpreted as "a new layer of coordinators'' who have no personal contact with families but only "convene the meetings'' to assess their needs.
The term, in fact, is being de-emphasized by some because of its negative connotations. In special-education law, for example, case management has been retermed "service coordination'' in response to families who frowned on being viewed as cases to be managed.
Responding to such concerns, the new standards emphasize that "the individual is primary,'' Mr. Brennan notes. "One of the things we try to be clear on is that the client is not the case; the case is the package of services.''
While some view case management as "just making phone calls and linking people'' to services, the new standards stress that the case manager-client relationship is "the glue that holds everything together,'' says Mr. Blonsky, who coordinates a training project for school-based social-service efforts.
While schools are often among the referral sources for participants in case-management efforts, many believe they could play a more prominent role in advancing the concept.
A 1989-90 study of about 200 San Francisco students "who had a foot out the door'' showed that those who received case-management services were more likely to stay in school, notes Mr. Blonsky, who headed the study as part of a federal dropout-prevention program.
The Walbridge Caring Communities program in St. Louis offers case management as one among many intervention services aimed at keeping children at Walbridge Elementary School in school, in their homes rather than in out-of-home care, and out of the juvenile-justice system.
The project--which involves state agencies concerned with health, social services, and education; the St. Louis schools; and the Danforth Foundation--has demonstrated improvements in student academic performance, attendance, and behavior.
No History in Schools
A 1991 study of Homebuilders, a "family preservation'' program based in Washington State that uses intensive case-management techniques, also documented improvements among participating families on several measures, including children's school performance and cooperative behaviors.
The ã.ä.æ. study on family-support efforts, "Helping Children by Strengthening Families,'' also cites evidence that home-visitation programs--which often involve case management--have had a positive impact on children's health and development.
But such research offers few guideposts for schools.
"There isn't a history of how to use case management in education-related settings,'' notes Robert St. Pierre, a vice president of Abt Associates, a Cambridge, Mass., consulting firm.
In the New Futures initiative, a multi-year effort funded by the Annie E. Casey Foundation to improve student outcomes through interagency initiatives in several cities, difficulties in defining the role of case managers initially caused confusion and tension for school and social-services workers. (See Education Week, Sept. 25, 1991.)
New Beginnings, an interagency effort aimed at reconfiguring services for children and families in San Diego, has also encountered problems in determining how best to deploy personnel to serve large numbers of families at the pilot school site. (See Education Week, Jan. 23, 1991.)
Workers there have been "inventing their positions as they are going along,'' says Irma Castro, the coordinator of the center at Hamilton Elementary School. "It's going to take some time to refine.''
'By the Hand'
The key to success in case management, experts say, is being able to respond to family needs quickly and effectively.
Khatib Waheed, the director of Walbridge Caring Communities, says its case-management component centers around "advocacy through referral'' to address needs as diverse as getting families emergency food or arranging for tutoring or counseling.
A case manager will also call and wake the client or "take them by the hand if they can't get where they need to go,'' Mr. Blonsky says. "It's a willingness to be flexible enough to do whatever's necessary.''
Case managers interviewed for this story say they routinely help families arrange for food, housing, utilities, transportation, child care, education or job training, health care, or substance-abuse treatment.
They also recounted helping a family get a vaccuum cleaner, enrolling a child in a sports club, and accompanying a pregnant teenager to the doctor for a sonogram.
Mark Davenport, a project coordinator for the I Have a Dream project in Washington, says he often takes teenagers to college campuses, basketball games, or plays--"anything culturally enriching.''
Projects best equipped to serve families, notes Frank Farrow, the director of children's-services policy at the Center for the Study of Social Policy in Washington, have access to resources beyond those of typical social workers.
The Windham County project has flexible funds that can be tapped--with school district approval--for purposes ranging from helping with rent and utilities to sending a child to camp.
The Prince George's County (Md.) Commission for Families, which runs a family-preservation program as part of a state child-welfare-reform initiative, has used discretionary dollars for such items as food coupons or assessments to hasten a child's special-education placement.
'I Can Only Do So Much'
The person acting as a case manager, experts say, should help coach families toward their goals, direct them to sources of assistance, and accompany them on missions to arrange for such necessities as welfare payments or housing. But the goal, they stress, is to spur self-sufficiency.
An example, says Mr. Forsythe, who recently retired from the Edna McConnell Clark Foundation, would be walking a mother through the steps to reinstate a child suspended from school.
"Otherwise,'' he says, "you are simply creating a dependency not only on a set of services but on having somebody to manage them for you.''
Carolyn Billingsley, the clinical director of the Prince George's County families commission, says its family-preservation program works "to get families to set their own agenda'' and teaches them skills to help resolve family problems, such as role playing to improve communications.
"A family may have six or seven outstanding issues, so you have to try to prioritize and mutually agree with the client where to start and where they want to go,'' says L.D. Ross, who functions as a case manager for the Maryland program.
When families take the lead in goal-setting, Ms. Castro of San Diego's New Beginnings program says, it boosts their "capacity to see themselves as people who have strengths.''
The challenge, Alma Grimes, a case manager and therapist for Walbridge Caring Communities, says, is to lend assistance while setting limits.
"Once a parent knows they have you there to assist them, they kind of take you for granted,'' she says. "My job is to let them know I can only do so much.''
The new standards developed by the social workers' association specify that case managers should have an undergraduate or graduate degree from a social-work program accredited by the Council on Social Work Education and possess appropriate knowledge, skills, and experience.
But some experts say specific kinds of degrees or work backgrounds are less critical than such attributes as sensitivity and familiarity with the community.
While some skills require specific training, says Ms. Levy of the Danforth Foundation, "the essence of case management is being able to work the system effectively and helping people learn how to work the system to get what they need.''
"You need somebody the client likes, who is respectful and can hear and listen and value their priorities, and who can respond to various cultures and learning styles,'' Mr. Forsythe says.
In addition, he says, case managers should focus on family strengths rather than deficits.
"We look for people who want to learn, who are nonjudgmental, have some understanding of poverty,'' and have strong community ties, says Ms. Jerald of the Windham County project, which employs several people who are working toward their bachelor's degrees. The program itself provides training and consultation with professionals.
While a number of projects tap high school graduates, parents, teachers, or paraprofessionals, some argue that trained social workers are better equipped to assess families and link them to services.
Although the New Futures program in Dayton, Ohio, provided substantial training in case management to its "community associates,'' notes Jewell K. Garrison, the associate executive director of the program there, "those with backgrounds in social work seemed to adapt quicker.''
Debate on Requirements
The New Haven (Conn.) Family Alliance, first launched under an Annie E. Casey Foundation effort to spearhead child-welfare reform in Connecticut, favors case managers who have degrees and "have been in the trenches a number of years,'' says Ray Hall, the alliance's superviser of case management. "These are people who are not going to be blown away by these families.''
Caring Communities also requires its case managers to have an undergraduate degree in education, social services, or counseling and at least two years' experience in a related field.
In projects that tap paraprofessionals, Mr. Brennan of the social workers' association argues, professionals should still be involved in assessments and consultation so that case managers are not "out there on their own.''
Others cite a need for more "cross training'' of workers from different sectors.
The Schools Partnership Training Institute, a project coordinated by Mr. Blonsky, offers cross-disciplinary training to "bridge the gap'' between educators and social-service and health personnel involved in school-based efforts. It is sponsored by the Jewish Family and Children's Services in San Francisco and the Children's Health Council of Palo Alto, Calif.
'Keep Knocking on Doors'
Beyond helping families solve everyday problems and obtain services, case managers and proponents say, case management's true potential lies in giving families an advocate who refuses to give up.
A key to successful family-preservation efforts, Mr. Forsythe of the McConnell Clark Foundation says, is having workers be "simply unwilling to write families off because they don't respond in a conventionally acceptable way.''
"You just have to hang in there and eventually something hooks them,'' Ms. Jerald of the Windham County project says.
"It just may be harder or take longer with some than with others,'' Alma Grimes of Walbridge Caring Communities says.
Such perseverance, these workers say, involves not only an emotional commitment but also the willingness to pursue options relentlessly.
"If one door is shut,'' says Gregoria Feliciano, a project coordinator for the I Have a Dream project in New York City, "you just keep knocking on doors and using every single bit of resource available to you ... to find the best possible solution.''
"You go home every night saying, 'I don't know what I'm going to do that will work, but I know I can't give up,''' says Anthony E. DiLucci, the administrator for special projects for the Cortland, N.Y., city school district, which funds youth-intervention teams and other preventive programs jointly with the Cortland County social-services department.
Those kinds of attitudes, says Ms. Garrison of New Futures in Dayton, are critical to developing a level of trust with families that is generally not fostered by traditional approaches.
"One of the things that is really important is that families see that there is someone who is really going to stick with them,'' she says.
In an upcoming resource brief on the role of "family-development specialists'' from the National Center for Integrated Services, Charles Bruner, the director of the Child and Family Policy Center in Des Moines, cites several examples of workers who were "tested'' by families but who won them over through persistence.
"My greatest satisfaction is working with families everybody had given up on,'' observes Mr. Ross of the family-preservation program in Prince George's County.
Bogged Down by Barriers
These workers admit, however, that the obstacles can be daunting.
Ms. Emerson of the Brattleboro project says she sometimes feels overwhelmed by the "inequities'' she sees and her awareness of how "not having what you need ... impacts on all aspects of your life.''
While recognizing that families in distress are not likely to change course overnight, she says it is frustrating when change does not happen "fast enough to be all right for the children'' who are in jeopardy.
Ms. Grimes of Caring Communities also describes the difficulty of working with families with severe and multiple problems who "may have lived in that situation so long that it's a way of life.''
Others voice frustrations about their inability--and the lack of adequate resources--to address such issues as drug abuse or substandard housing.
Another set of challenges, notes Mr. Waheed of Walbridge Caring Communities, involves removing "psychological and environmental barriers that would cause families to be somewhat hesitant to invest themselves fully in the process.''
That task, he adds, requires "continually building understanding'' between program and school staffs.
Barriers posed by child-welfare systems may include insensitivity in dealing with personal issues, while obstacles in schools may include attitudes that alienate or do not meaningfully engage parents, experts say.
'Success Takes Years'
Case managers say they have seen families take major steps toward such goals as continuing their education, finding better housing or employment, or becoming more involved in their children's schooling.
"I feel that my involvement with these families really makes a difference,'' Ms. Emerson of Brattleboro says.
But she and others in similar roles say they have also learned to measure progress on a small scale.
"Sometimes, success takes years,'' Mr. Davenport of the I Have a Dream project says.
While the ultimate aim is to steer students toward college, success may also mean "getting a kid out of high school and keeping him out of jail,'' he says. "Anything I can do to help him get out of school and become a good citizen would be a success.''
Among the families his project has targeted who have substance-abuse problems, says Mr. Hall of the New Haven Family Alliance, "About 25 percent [show] immense and enormous change literally overnight. With 50 percent, I've seen some real change over a year.''
Another 25 percent "quite frankly are just not ready and motivated to deal with their situation,'' he says. "Denial is too pervasive.''
In her two years with the Caring Communities program, Ms. Grimes says, "there has been at least 80 percent progress'' in the families she works with.
"If a child was at risk of being retained in the classroom, we have brought them up to grade level,'' she says. And if a parent "didn't do anything but come to school for a parent-teacher conference or to pick up a report card or talk to teacher, that's a plus.''
Ms. Garrison of New Futures cautions, however, that case managers must remain vigilant to insure that such successes are not short-lived.
"Our experience is that people have learned to say what they think we want to hear, so you have to have resilience,'' she says.
Experts also emphasize that case management should be part of a broad strategy to restructure services for children and families.
In Walbridge Caring Communities, "this is just one of many services we provide,'' Mr. Waheed says. "If the perception is that case management alone is making it work and folks go out and do it and it doesn't, they will say case management doesn't work.''
While touting case management's effectiveness in assisting foundering families, Ms. Levy says such efforts should not detract from pushes to refocus the system.
Otherwise, she says, "We'll continue to see the same amount of stress, disadvantage, and failure even if we are doing an outstanding job of case management.''
Mr. Farrow of the Center for the Study of Social Policy says case managers should help identify resource gaps as well as agency policies or school regulations "that are blocking things.''
The standards developed by the social workers' association, Mr. Brennan points out, stress that case managers "can't just look at that client; they have an ethical responsibility to look at the system as well.''
When that function is carried out, he adds, case management is a "good mechanism for change.''