Is it possible to have too much information about a client? Why or why not? In response to your peers, discuss situations that support or are counter to their answers. Challenge yoursel

The Case File

· Describe the reasons why the case file is important.

Medical Information

· Tell how medical information contributes to a case.

· Decode medical terms.

Psychological Evaluation

· List the reasons for a psychological evaluation.

· Make an appropriate referral.

· Identify the components of a psychological report.

· Review two psychological reports.

· Describe the type of information provided by the DSM-5.

Social History

· State the advantages and limitations of a social history.

· Name the topics included in a social history.

· List the ways social information may appear in the case file.

Other Types of Information

· List the types of educational information that may be gathered.

· Define a vocational evaluation.

· 9-1Introduction

· —Case manager, services for children and families, New York, New York

· Our shelter provides mid-term shelter. A few shelters only provide lodging and services for 4 nights. We allow our clients to remain with us for up to 30 days. Other shelters’ clients have to commit to a year of residence. For our month, we provide clients with a wide range of services. We try to meet all of their needs. Comprehensive assessment is key, and we provide an on-staff psychologist, group counseling, and individual and family work.

· —Director, emergency shelter, St. Louis, Missouri

· When a child is referred to our agency, we immediately seek more information. For example, the first thing a case manager does is contact the school and ask for records. Of course we have a release from the parents to get the records…. We need the school records even if the child is referred for a medical issue.

· —Care manager, high school, Los Angeles, California

· The chapter-opening quotations illustrate the kinds of information that a case manager may need from other professionals to develop a plan or to provide services. The medical information, histories, or exams these three helpers mention are part of the case files of clients who have medical problems. The case manager providing services for children and families speaks of the advantages of being familiar with medical terms and medical references when trying to decipher medical reports. Physical assessments and psychological assessments offer important information to the emergency shelter staff as they work with homeless and runaway female teens. Professional staff at the high school in Los Angeles gather much information about the students from other schools.

9-1aThe Purpose of the Case File

Finally, agencies are committed to provide quality care to their clients. Part of that quality of care includes effective responses in times of crises and efficient transition of services as practicing case mangers leave the organization and new staff assume the responsibilities of those leaving. An in-depth case file allows new case managers to establish rapport with and understand their clients and where they are in the case management process.

In summary, the case file directly addresses the critical nature of two facets of case management, that of working with the whole person and that of providing documentation and maintaining good records. This helps in the process of service coordination. Careful attention while building the case file is important for several reasons, including legal accountability, financial and outcome accountability, and effective client services.

The purpose of building a case file shifts during the case management process. For example, when an individual is applying for services, the case manager begins to build a case file to determine if the individual applicant is eligible for services. Once eligibility has been established, the information previously gathered becomes the foundation and provides the initial data for that file. During the case management process, additions are made to the file. These additions may include:

· a)

further assessments;

· b)

the case management plan;

· c)

case manager written case notes;

· d)

periodic assessments of the case management plan and process; and

· e)

revisions of the case management plan.

At the end of the case management process, added to the case file are:

· a)

reasons for ending client services;

· b)

final outcomes;

· c)

plans for client aftercare;

· d)

plans for follow-up;

· e)

client evaluation of services; and

· f)

case manager evaluation of services.

Agencies approach medical information in different ways. Some require documentation of a mental or physical disability or condition when determining eligibility for services. Others use a medical examination as part of their assessment procedures. In certain situations, medical information is not gathered unless there is some indication or symptom of a disease, condition, or poor health that would affect service delivery.

Medical knowledge is particularly crucial when working with people who have disabilities. A general medical examination and specialists’ reports help determine the person’s functional limitations and potential for rehabilitation. It is important to set objectives that are realistic in light of the client’s physical, intellectual, and emotional capacities. When a medical report covers a disability in functional terms:

[I]t addresses the following factors [and] the description can read like the following: strength, climbing, balancing, stooping, kneeling, crouching, crawling, reaching, handling, fingering, feeling, talking, hearing, tasting, and smelling, near acuity, far acuity, depth perception, visual accommodation, color vision, and field of vision. (Debates, Rondinelli, & Cook, 2000, p. 81)

Each medical evaluation includes recommendations relating to the individual’s physical, emotional, and intellectual capacities. What follows is a sample medical recommendation.

The individual has a diagnosis of obsessive-compulsive disorder and has limited strength, balancing, hearing, and near-acuity functionality. This person needs work with supervision, few stressors, and limited lifting.

Often, however, the form for a general medical examination allows only a small space for the diagnosis, so the case manager reads a phrase such as “chronic back pain,” “normal exam,” or “emotional problems.” Not very helpful, is it? Remember that the client is an important source of information; he or she can tell you about any problems. You may then need to decide whether or not a specialist’s evaluation would be helpful.

It is important when referring a client for a medical exam that the case manager prepares the client for that experience. This is especially critical from the multicultural perspective. For many individuals, the medical establishment represents a place where they have little knowledge, no power or authority, or have had previous difficult experiences. Many case managers find that the best resource for culturally sensitive physicians is the client himself or herself. When you follow-up on a medical referral, you can ask clients about their experiences.

Voices from the Field

Conducting Culturally Sensitive Medical Exams

An approach to medicine that is client-centered is important. The University of Washington (2009) uses guidelines to educate and train their medical students regarding how to conduct an interview. The guidelines that follow provide case managers with specific ways they may assess the sensitivity of the physicians conducting the medical exam.

· “Appreciating the ethno-cultural, spiritual, and religious perspectives of patients, families, and communities. … The term cultural humility, coined by Tervalon and Murray-Garcia (1998), expands this to include the recognition of power dynamics in health care and the community at large and encourages physician advocacy to address imbalances” (p. 77).

Goals of culturally sensitive medical interviewing and their responsibilities related to each follow.

· Demonstrate contextual sensitivity and use cultural sensitivity. Be aware of family, cultural, and religious values and the influences of gender, age, socioeconomic status, and education level.

· Gather information regarding patient and family perspectives on, and use of, traditional and/or complementary healing strategies.

· Exploring and understanding the approaches patients have used in treating their illness is very important.

· Eliciting this type of information may be challenging. Historically, some patients and family members have been misjudged and even chastised by healthcare professionals for admitting use of alternative or traditional remedies.

· Be cautious and sensitive when trying to elicit this important information.

· Be attentive to any verbal or nonverbal cues that the patient may be uncomfortable discussing alternative healthcare practices (i.e., silence, eye deviation, a shift in their seated position, crossing their arms, etc.).

· Questions such as the following may be helpful to ask:

· Have you seen anyone else about this problem besides a physician?

· Who do you think gives you good health advice?

· Who else do you trust?

· Have you participated in any healing practices or ceremonies to treat your problem?

· Have you used nonmedical remedies or alternative or traditional treatments for your problem?

· What role do they serve in your care?

· Who in your family or community advises you about this condition?

· How common is this condition in your family and/or community?

· What is done commonly to heal this illness?

The University of Washington suggests a model to guide the cultural sensitivity of the physician during the medical exam.

· Beliefs about health (What caused your illness/problem?)

· Explanation (Why did it happen at this time?)

· Learn (Help me to understand your belief/opinion.)

· Impact (How is this illness/problem impacting your life?)

· Empathy (This must be very difficult for you.)

· Feelings (How are you feeling about it?)

9-1cMedical Exams

Class Discussion

Using Culturally Sensitive Guidelines for Exams and Reports

Sharon Bello, Entry 9.1

I feel like I have been involved with doctors for such a long time. Between my dad dying, having kids, losing two sons, having my car accident, having two surgeries to try to fix my back after my accident at the senior center, and now needing more medical information to receive rehabilitation services, all of this doctoring and reports, well, it just seems like a lot. For my case management services, if you remember, Tom Chapman asked me to get a letter from Dr. Alderman about my surgery. And I had a long appointment with Dr. Brown for my physical exam. Tom prepared me well for that exam. I knew why I was going and I also knew what to expect.

This is the first time that I have ever read an actual doctor’s report. I contacted Dr. Brown’s office 2 weeks ago to let him know that reading it was important for a project I was involved in. Dr. Brown thought reading the report would be a good idea.

The written report looks different from just participating in the examination and answering questions. I remember, at first, I was afraid that something during the exam would happen and then I would not be able to receive the services. But that didn’t happen. Still, when I read the report, there are a lot of words that I didn’t know and didn’t understand.

What it does look like is that I am fairly healthy. It is just the state of my back that is giving me trouble but, well, that pain when I move is enough for me. Honestly, how my back is, it influences me every day. I guess when the doctor said that I am limited in all ways of moving, he was telling Tom how bad some of my life is for me. And when he said that there was no way to improve my back beyond what has been done, that pretty much sums up what I know and explains why I sometimes feel like giving up.

I also saw that Dr. Brown indicated that I was showing ways that I am depressed. Dr. Brown told me that he sees depression differently than most other doctors. I am not sure that I understand what he meant. He says I could have trouble getting out of bed in the morning and cry several times per day when I think about my boys. He says those signs might be just a normal reaction to very difficult experiences. And that might be different than actually having a diagnosis. He thinks a psychologist or psychiatrist might have to figure out if I have depression.

9-1dMedical Terminology