Testimony on the Public Oversight Hearing on Integrated Case Management in the District of Columbia
The Committee on Human Services, DC City Council
Councilmember Tommy Wells, Chair
Friday, June 22, 2007 -- 10:00 A.M.

Presenter: Joel Kanter, MSW, LCSW-C on behalf of the
Greater Washington Society for Clinical Social Work


Good morning, Councilman Wells. I appreciate this opportunity to testify before the Human Services Committee of the D. C. City Council on behalf of the Greater Washington Society for Clinical Social Work. The Society represents over 600 clinical social workers in the Metropolitan DC area, many of whom are licensed and practice in the District. Our members are licensed graduate social workers who practice in a variety of settings including mental health clinics, family agencies, psychiatric hospitals, medical facilities and private practice. Although our practice settings may be diverse, we all are social workers in direct practice who are intimately involved in the lives of our clients.

As such, my remarks at this hearing will reflect some comments from the trenches of the nitty-gritty work of case management--from my thirty plus years of experience as a case manager. My written testimony includes reprints of several scholarly articles and a bibliography that address more abstract issues of case management practice which can be reviewed at a later time.

The first point I'd like to emphasize is very simply that case management is difficult work. When clients or consumers need case management services, it is because there is severe social dysfunction that makes it difficult to maintain themselves in their community. This dysfunction may result from severe mental illness, drug or alcohol abuse, developmental disabilities, chronic medical illness, poverty, unemployment, inadequate education, encounters with the criminal justice system, or social network breakdown. However, in a majority of situations, at least three of these factors are involved. This, in turn, often requires the involvement of several social
agencies, each of which has their own agenda and bureaucracy. And when clients have difficulty negotiating these bureaucracies, social breakdown is exacerbated.

A recent example: Last month I helped a client initiate an application for Social Security Disability. This woman has advantages that most clients don't have. She is extremely intelligent and has an Ivy League education. However, she has a severe bipolar illness with frequent episodes of suicidal ideation, a deteriorating spinal column that requires surgery, and is a breast cancer survivor. Unfortunately, her family has largely abandoned her and she has few
sources of social support. Completing the initial application online in my office took nearly three hours. While we had the mundane task of looking up the addresses and phone numbers of dozens of doctors and hospitals, I also had to constantly address the despair that resulted as her frustration with this task mounted.

Then, a month later, we had to spend over two hours completing Social Security's functional assessment questionnaire, answering dozens of stressful questions about her illnesses and disability. The psychiatric illness that is a major cause of her disability had to be continuously addressed in the process of applying for these government benefits.

This leads to my second point: that an integrated approach to case management requires more than just interagency meetings and artistically-crafted service plans. Effective case management requires case managers who themselves can develop an integrated understanding of the client's difficulties and needs on all levels: biological, psychological and environmental. This is both a major personal and intellectual challenge for the worker. The relationship with the client is frequently stressful and, invariably, there are challenges in collaborating with other agencies and social supports. If the helping process isn't messy and chaotic - perhaps like legislating—then one can suspect that little is being accomplished.

In one of the articles (Clinical Case Management: Definition, Principles, Components) accompanying my written testimony, I identify 13 activities of case management:

1. Engagement
2. Assessment
3. Planning
4. Linking with resources
5. Consultation with families and other caregivers
6. Developing social networks
7. Collaboration with physicians and hospitals
8. Intermittent individual psychotherapy
9. Teaching independent living skills
10. Patient psychoeducation
11. Crisis intervention
12. Advocacy
13. Monitoring

These diverse professional activities require considerable professional competency. In regards to this, I will only mention the challenges involved in one of these activities: crisis intervention.

For better or worse, the case manager is often the front line worker when crises develop: psychiatric relapse, eviction, drug overdose, incarceration, premature hospital discharge and so on.

Third, effective case management requires intricate teamwork. The case manager cannot sit on the sidelines and send in the plays. The case manager, like a point guard in basketball, has to be on the court, leading by example with unselfish play, identifying and mobilizing the strengths of all of his or her teammates: the client, the family, the community, social agencies, government bureaucracies and assorted professionals. Cultural competence is required in the broadest sense. On one hand, this requires sensitivity to the client and community. On the other, the case manager must be able to communicate effectively with physicians, attorneys, policemen, social
workers, and government bureaucracies. And, importantly, be able to translate concerns of the various parties to one another. To be effectively integrative, the case manager must be "multilingual" in all these respects.

Too many case management programs overlook these concerns and hire poorly-paid case managers with minimal training or experience. Unable to cope effectively with these challenges, workers burnout and clients experience a "revolving door" of case managers who never develop the requisite skills.

For all of these reasons, our Society encourages the Council to develop case management services comprised of dedicated, highly skilled professionals who can effectively assist our most impaired citizens.

Presenter Bio: Joel Kanter, MSW, LCSW-C is Vice-President of the Greater Washington Society of Clinical Social Work and is currently in the private practice of psychotherapy and case management. Previously, he has worked for the DC Institute of Mental Hygiene, Fairfax County Mental Health Services, Family Services of Prince Georges County and was the clinical consultant to Montgomery County’s case management programs. He has taught and lectured on community care of the mentally ill - with a special focus on case management---across the United States, Europe and Australia and has conducted numerous trainings for mental health personnel under the auspices of District of Columbia’s Department of Mental Health. His publications include over 30 articles and chapters on community care of children and the mentally ill, Coping Strategies for Relatives of the Mentally Ill (NAMI, 1984), Clinical Studies in Case Management (Jossey-Bass, 1995), and Face to Face with Children: The Life and Work of Clare Winnicott (Karnac, 2004).

Selected Publications by Joel Kanter on Case Management:

• Residential Care with Evacuated Children: Lessons from Clare Winnicott. CYC-Online, 80, September 2005.
   
• Beyond Psychotherapy: Therapeutic Relationships in Community Care. Smith College Studies in Social Work. 70(3), 397-426, June 2000.
   
• Clinical Issues in Delivering Home-Based Psychiatric Services. In Psychiatric Home Care, Alan Menikoff (Ed.), New York, Academic Press, 1999
   
• Engaging Significant Others: The Tom Sawyer Approach to Case Management. Psychiatric Services, 47(8), 799-801, August 1996.
   
• Managed Care and Case Management: Investing in Recovery. Psychiatric Services, 47(7): 699-701, 1996.
   
• Depression, Diabetes and Despair: Clinical Case Management in a Managed Care Context. Smith College Studies in Social Work, 66(3): 358-369, June 1996.
   
• Case Management with Longterm Patients: A Comprehensive Approach. In Handbook for the Treatment of the Seriously Mentally Ill. Stephen Soreff (Ed), Seattle: Hogrefe and Huber, 1996.
   
• Editor, Clinical Studies in Case Management (New Directions in Mental Health Services, No. 65), San Francisco: Jossey-Bass, 1995.
   
• Integrating Case Management and Psychiatric Hospitalization. Health and Social Work, 16(1):34-42, 1991.
   
• Clinical Case Management: Definition, Principles, Components. Hospital and Community Psychiatry, 40(4):361-368, April 1989.
   
• Clinical Issues in the Case Management Relationship. In Clinical Case Management (New Directions for Mental Health Services, 40:15-27), San Francisco: Jossey-Bass, 1988.
   
• Mental Health Case Management: A Professional Domain? Social Work, 32(4): 461-462, 1987.
   
• Clinical Issues in Treating the Chronic Mentally Ill (New Directions in Mental Health Services, Vol. 27). San Francisco: Jossey-Bass, 1985.
   

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