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Providing an exit from case management

May 01, 2009

Have you ever noticed that most case management programs don't provide a way for people to leave or graduate because they have become so much better as a result of the services they received? Once a person is in case management there seems to be no planned way to exit. We think this is a carryover from the days before we knew about recovery. We didn't expect people to recover, so we more or less planned on them being with us forever. Many ACT programs were built on the premise that case management teams had an open-ended responsibility for achieving and sustaining progress.

Before the concept of recovery started to take hold we described people as being “chronically mentally ill” and saw them as having “poor prognoses.” The only way case-managed participants could escape was to drop out in a way that was not part of our plan. They had to leave town with no forwarding address or find other ways to avoid us until we closed their cases with “unable to locate” entered into the notes. In other words, people had to “fail” at least from our point of view in order to leave.

This approach caused both the staff and participant to forfeit the satisfaction of celebrating a graduation into a life characterized by self-determination and self-efficacy. Case managers often felt like they had failed, and they usually felt that participants had failed, too. These are the experiences that lead to staff feeling hopeless and helpless, which contributes to the high burnout rate we often see in these programs.

Furthermore, participants returned to the program with a contrite sense of obligation, possibly embarrassment, more or less admitting to failure and that their lives had become unmanageable. This reinforced for both staff and the participants that they could not be self-determining and that they needed to be taken care of and managed.

As a result of California's Mental Health Services Act, many counties are innovating with recovery in mind. So when we learned about a case management program that has an exit strategy that plans for successful community living, we wanted to share it with you. This program is about to take flight in Alameda County. The project was developed and is being implemented by staff at Alameda County Behavioral Health Care Services, and it includes county-operated and -contracted programs, some of which are “consumer” operated. This promising program is about to move out of the planning phase and into the implementation phase. It easily could be replicated and modified to work in other parts of the country. While the specific details still are being worked out, here is the program's purpose:

People who would otherwise not progress off of treatment teams will design their own “exit strategy” moving from higher levels of services and/or institutional living to lives of greater independence in which they develop and manage their own supports to live, work and play in the community of their choice.

To make this a successful experience for both staff and participants, the county has included the following elements in its implementation plan:

  • Staff volunteering for this project will receive initial and ongoing training in recovery principles and practices to provide services that build resiliency, self-determination, and self-sufficiency.

  • The project will work sequentially with groups of 150 to 230 participants who receive case management services from these “exit” treatment teams and volunteer to enroll in the new program.

  • Peer staff (recovery coaches) will join the exit teams and will provide hope and encouragement by sharing their personal stories and knowledge of the recovery process. They also will facilitate the exit process and be the glue that connects the program's various services, which will include recovery education centers, employment services, housing resources, and others.

  • Two recovery education centers will serve as regional hubs for staff and participant training on self-managing medication, successful community living skills, employment and education opportunities, Wellness Recovery Action Plan (WRAP) classes, critical thinking skills, wellness practices for maintaining physical and mental health, and so on.

  • Existing vocational and housing resources will be augmented and redirected to participants to ensure they have a chance at being successful in their new levels of freedom and self-determination.

  • These resources will be offered as “scholarships.” Scholarships generally offer resources to deserving people with the potential to give back and make a positive contribution to their community-precisely the concept that the Alameda County staff wanted to convey about this project. A participant will apply for a scholarship that includes an agreement signed by him/herself and the various staff involved. All will agree to honor their commitments to have a successful outcome. This is different from a treatment plan as it is based on the premise that the person eventually will outgrow the need for case management services and continually will improve his/her self-sufficiency.

  • Participants and staff will attend a daylong retreat at which the project's terms will be clearly defined. Recovery principles and practices will be described so they can learn together how to work as partners in recovery. The retreat will culminate with participants completing the plan and signing their agreements.

The county staff are aware of the importance of role modeling the program's values as they roll it out. They believe that using recovery principles and practices can transform people, organizations, and systems of care by infusing hope, high expectations, and opportunities to focus on what's strong instead of what's wrong. They know that this will require a strong partnership with participants based on mutual respect for each other's strengths and abilities.

As participants move out of the case management program, space will open up for others, allowing for a fluid flow through the program instead of a static capacity that has no planned movement. Also, people who have rotated out of case management will be able to come back at any time to share their success stories-the best antidote for staff burnout. They also will be able to receive more help to stay as self-sufficient as possible. Needing assistance will not be viewed as a failure. It won't be seen as a mud slide but just as a bump in the road.

We congratulate Alameda County for developing such an innovative and creative way to update system-wide case management services in ways that reflect recovery values. Case management can become tired, worn-out, and outdated unless revamped in ways that help people recover. More innovations like this need to be tried in all of our “core” services if they are to keep pace with our best thinking about what staff and participants need to live contributing and meaningful lives.

Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc., in Phoenix. She is also a member of Behavioral Healthcare's Editorial Board.
William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University.

For more information, e-mail

Behavioral Healthcare 2009 May;29(5):10-11
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