Community case managers working with a behavioral health population are continually on the lookout for a brewing crisis. A missed appointment, a shift in behavior, or a sudden change in housing, job, or family situation can signal a potential crisis.

“If a crisis is brewing a change in behavior or suicidal ideation, it’s time to drop everything and get the person in front of a clinician,” says David Wilkinson, BSW, director of case management services at Central Behavioral Health in Norristown, PA.

Crises occur because of clients’ poverty, mental health challenges, past trauma, homelessness, and other issues. And it is up to case managers to help clients maintain their health and avoid problems.

“Our case managers work with caseloads of 24 people, and they have the opportunity to get to know each person,” Wilkinson says. “They develop a rapport with the person and are aware of what’s going on; they have good listening skills and a level of support.”

Case managers are part of a model called assertive community treatment (ACT), which is all-inclusive, he says.

ACT is an evidence-based practice that includes treatment, rehabilitation, and support services for people diagnosed with serious mental illness. (For more information, visit: https://on.ny.gov/2T6GBC9.)

Case managers help people find stable housing, handle their money and finances, and take their medication as prescribed.

“We use the term ‘recovery coach,’ for our case managers, and many times recovery coaches help support people with their psychiatric appointment and help facilitate communication,” Wilkinson says.

“In Pennsylvania, we work under the regulations called ‘blended case management,’ and across the state, there are different types of blended case management,” Wilkinson explains.

The state has moved the recovery philosophy forward, and part of that was enhancing the intensive case management model to include recovery coaches, he says.

Through brief interventions with patients, case managers/recovery coaches prevent crises of housing, food, medical, and other issues.

“The prevention aspect is for recovery coaches to be in tune to some of their behavior changes and give them support before they end up hospitalized,” Wilkinson says.

The ACT process works in the following ways:

• Identify clients. A generic example would be of a middle-aged homeless woman with schizophrenia and substance use issues. In the woman’s county, there is a 211 number she can call to find shelter, he explains.

“That shelter is familiar with the local mental health center and case management support,” he adds. “The woman would be referred to the intake department of the agency to get an assessment.”

The psychiatric assessment would include a referral to case management support. Within seven days, Central Behavioral Health would explain the organization’s services and how it could provide case management support. Once the woman agrees to receiving help, case managers can get started, he says.

• First meeting with case managers. A case manager might meet the woman at a coffee shop, the homeless shelter, or at the agency. If homelessness is her most urgent problem, then case managers will work with homeless outreach workers and the shelter system to help her find a home, Wilkinson says.

The first meeting is an introduction and an opportunity to build rapport. “If the person is not in the mood for a long conversation, then it could be the case manager saying, ‘Hey, I’m Dave, I’d like to talk to you about our case management services and how we can support you, but today looks like a bad day, so could we speak tomorrow?’” Wilkinson says. “If the person is ready, we start with five different documents from goal planning to strength assessment.”

Case managers assess the person on domains from housing to employability to social connections, looking at things they have done in the past but maybe have not done in a while, he says.

The goal is to have an appointment scheduled before the first meeting ends. The case manager might offer to help the person with transportation services or to attend a medical appointment with the client.

“Typically, it’s a good idea to see the person more frequently to develop that relationship and rapport,” Wilkinson says. “We educate our staff, saying, ‘If the person is at risk, a good practice is to have multiple contacts with the person each week, even if they’re not related to a specific appointment, but just to say, ‘How are you doing, and what’s going on?’”

• Second meeting. The next meeting will focus on the client’s priorities, Wilkinson says. “If there’s an urgent need to get connected to a particular medical or psychiatric appointment, then we talk about that.”

In the first few meetings, the goal is to make sure clients get to their healthcare appointments. This might require the case manager to connect the person with a transportation service.

“The goal is to be hands-on with how the person gets there,” he says.

The case manager also will help homeless and marginally housed clients learn about available housing options.

“A big thing in community case management is connection to community activities,” Wilkinson says. “Does the person have an interest in going to the library? Is that something we can support and help with registration?”

If new crises emerge related to a utility shut-off or medication obstacle, case managers investigate the causes. For instance, a person might not have been opening utility company or payer benefit mail out of fear caused by their mental illness.

“Our support is to say, ‘Let’s look at the mail together,’” Wilkinson says.

• Follow-up support. Every six months, case managers conduct a housing check, asking basic questions about how clients feel about their living situation, he says.

One item on the checklist is, “Do you open your mail and need support looking through it?”

Follow-up appointments vary according to how much a particular person needs case management support. Some people will be in case management for six to 10 months and meet all of their goals. Then they are able to maintain stability and independence. Other people can be in case management for years, often because they do not have family support and are not confident that they could manage without a regular visit, Wilkinson says.

“If they’re stable, we may see them every few weeks to see how they’re doing,” he adds.

Case management support includes helping clients obtain phones, IDs, health insurance cards, and sign up for utility programs for the winter months. Senior clients may be eligible for subsidized housing resources, and a case manager will help with the application process.

“We do a lot of basic things related to food, food cupboards, soup kitchens, and education and help people to be aware of community resources and connect with them,” Wilkinson says.

Case managers also help clients obtain job skills and find peer support. A career center professional identifies employers in the community that would be a good resource, he adds.

• End case management. The end could be driven by the client, the case management organization, or both.

“If everything is going smoothly, some people will say, ‘I’m not interested in these frequent contacts,’” Wilkinson says. “A lot of time, it’s ended because of a mutual understanding that things are going well.”

There might be a warm handoff from the case manager/recovery coach to an in-house case manager who is available for walk-ins and community calls, he notes.

“If a person is stabilized and we’re moving toward closure of intensive case management, we’d introduce the person to the in-house case manager if there is a resource question,” he explains. “This reassures the person that if something happens and you need more intensive support, we can work with you.”