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Though not directly responsible for the clients on the CMTM's caseload, you as an intern will still find many opportunities to directly engage with and for those clients. Of these tasks, I think you will most frequently be asked to outreach to those clients who may be lost to follow-up. Essentially, this means contacting or trying to get into contact with those clients the CMTM haven't seen in a while. When you outreach to clients, you sort of act as a broker between the client and the CMTM, linking the two together. It's very likely for a Housing Works client to not have a reachable phone number and also for him/her to be homeless, and thus, many clients can be hard to contact and meet. This may not be the case for many other clients, but as there can be many other reasons why the CMTM may not have been able to see the client in a month, outreaching is an important duty, and one that is required rather frequently. As with all follow-up responsibilities, outreaching starts not with the action of outreaching itself, but with some basic understanding of the client you're going to be outreaching. Try to learn as much as you can about the client before dialing that phone number and definitely before going out of the office to knock on the door of his/her residence. As mentioned before, take advantage of the CMTM meetings and the client charts, starting with the basic information such as the client's phone number and address and going so far as to become familiar with what has occurred between the client and the CMTM thus far. Do this to be prepared but do NOT make any assumptions based on what you read and/or hear about the client. Information is a resource to help you work effectively, but they do not supersede the client's personal input. Outreaching is much easier when you can contact them on the phone. It's an effective way to learn what's been going on, what the client currently needs assistance with, what day and time the client would like to meet with the CMTM, and then pass this info onto the CMTM. Still, since you're still invisible to the client on the phone, you must make sure to audibly demonstrate your respect and empathy. Introduce yourself honestly and be clear in representing the CMTM. Like I stated before, you act as a broker; you are not the case manager. If the client wishes to discuss something that is beyond your role as an intern, it would be best for both you and the client for you to hand the phone over to the CMTM member the client would like to speak with. If the CM or the CMT happen to be out of the office and not available to talk on the phone at the moment, have the client know that he/she can discuss it with the CMTM the next time they meet or talk with each other. If the client really desires to talk to you about an issue, I personally don't think you need to be so clear-cut in your role as an intern to cut the conversation off and tell them to just wait until the next time they talk to the CM or the CMT. However, I have learned from my time as an intern that being clear about your role as a sort of a mediator is very important, especially on the phone. Thus, the client should be made aware that the issues they bring up during the phone conversation will ultimately be resolved not by you, but by the CMTM members communication and working as a team, with each member having clearly-defined roles and duties. Remember that your role as an intern in this phone conversation is to schedule a time for the client to meet and talk with a CMTM member. This purpose should be expressed professionally and clearly. Try to schedule exactly with who, when and where the client would like to meet. Just for good measure, you may also want to have the client repeat scheduling information. The client should also know to call the CMTM if it turns out that the client will not be able to make the appointment. This encourages the client to set a specific time to meet the CMTM, and it also helps the CMTM prioritize their duties. Many times, outreaching is not so quick and easy as having a phone conversation with the client. After all, one reason you may have been asked to outreach is because the client has been unreachable for so long. You'll find that often times, the client doesn't pick up the phone. Some clients won't answer the call unless you leave a message on their answering machine. This is why you should always leave a voice message when you call. One thing to mindful of when leaving voice messages is that many Housing Works clients are concerned about their HIV/AIDS status being disclosed. There's a chance that someone other than the client may be able to listen to the messages left on the answering machine. Perhaps that someone doesn't know that the client is living with HIV. Moreover, it's possible that person knows what Housing Works as an agency does and so will be able to figure out that the client is living with HIV if he/she learns from the answering machine that Housing Works has contacted the client. For these dangerous possibilities, you do not want to leave a voice message stating that you're calling from Housing Works. It's better instead to introduce yourself as a representative of the case manager and the case management technician. When I left voice messages on a client's answering machine, I usually said something like, "Hi, my name is David Kwon, and I'm calling on behalf of Ms. H____ [the CM]. We haven't talked to you in a while and was wondering what was going on. Please call her when you hear this message. As always, you can contact her at (212)966-0466 ext. #___. Again, that's (212)966-0466 ext. #____. Thank you and we hope you're doing well." Of course, all this is assuming that the client has a functioning answering machine. Well, this is also assuming that the client has a phone number at which he/she can be reached. Unfortunately, for a good amount of clients that haven't been seen by the CMTM in a while, these assumptions will not be correct. When this is the case, you will have to try other ways to contact the client, which include phone call to the client's primary care physician, e-mail, snail mail, home visit, visiting the client's methadone clinic, etc. The next best thing to a phone call is e-mail. When I was an intern in Housing Works, neither the pre-screening form nor the intake form asked for the prospective client's e-mail address, but when I conducted these two procedures, I always made sure to ask of it. It is very possible for a person to not have a phone number or a place of residence, and have e-mail as the only means of contact. For some clients, you don't necessarily have to go out of the office to outreach to a client that can't be reached on the phone; you can simply send them an e-mail their way. One of the advantages of this kind of communication is that unlike leaving voice messages on the answering machines, you don't have to hide your association with Housing Works. E-mail is a private form of communication and a user's internet inbox is accessible only to that individual. In that sense, it can perhaps be more comfortable way to contact the client. The downside however is that it may take some time for the client to respond. There's also the possibility that the client may never respond back via e-mail. So even when you send a message to the client's e-mail address, you will most likely still have to outreach in other ways. Just as outreaching is easy if you know the client's phone number, it is likewise easy when you know where the client can be reached. If you know that the client is currently in a transitional housing unit in Bowery for example, then you can go there and meet the client at his/her residence. This can be a really awkward experience especially if you and the client have never seen each other before. Some clients may not be very receptive to you. Still, meeting these clients is still very helpful to the CMTM and ultimately to the client, because your actions will link the client to the CMTM. Just as with any interaction you'll have with a client, introduce yourself honestly and respectfully, representing the CMTM in a professional manner. Be concise and straightforward. Be willing to listen if the client wishes to talk. As with the phone conversation however, your role in outreaching is very definite - to schedule a time and location for the client to meet with the CMTM. Remember that the appointment doesn't always have to be at the Housing Works office, but at the client's residence if the client so wishes. You want to leave knowing for certain that the client knows the appointment time and that the client knows how to contact the CMTM. For this you may want to write that information down and hand it to the client. Sometimes, the client won't be home when you get there, but again, at least you know where the client is staying and can therefore leave some kind of mark to let the client know that you were there, that the CMTM is expecting to meet with the client. This mark is usually the outreach letter you can take with you and leave in the client's mailbox or underneath the door of the client's residence. The outreach letter is a very basic document that addresses the client that the CMTM has been trying to reach and is desiring to talk and meet with him/her. But of course, what if you have no way of contacting the client and also don't know where the client is currently staying at? This can pose a rather frustrating challenge, but outreaching is still not impossible. First, check the client's HIPAA consent form .This important document records the people and the organizations the client has allowed the CMTM to contact and share information with. These can include the client's HASA worker, the client's social worker, the client's primary care physician, the client's brother-in-law, etc. Most, if not all the people listed in that form will not be willing to disclose information about the client nor even their association with the client unless they're ensured that they're listed on the HIPAA form. That's why you'll most likely need to meet them in person and show them the copy of the HIPAA form. Once that necessary formality is out of the way, you will want to find out if they know anything about the client's whereabouts and/or status. If it turns out that the client has regular contact with them, you should ask that they let the client know that Housing Works is wanting to meet with the client. Try to leave some kind of physical mark behind to the person, like an outreach letter to the client. It's also a good idea to hand your contact info to the person you talked with. After all, even after all this there's still a chance that the client will not contact the CMTM so try to establish a good professional relationship with the person that was approved of in the client's HIPAA consent form so that you can contact them regularly. This way, when they meet with the client, they can update you and the CMTM of the client's current status. You'll want to try whatever you can to link the client to the CMTM but the one final possibility is that outreaching may ultimately may not be successful. I can personally recount the times when the client was finally deemed to be "lost to follow-up " after the CFW and I visited the client's methadone clinic several times and being unable to locate her. I was able to collaborate frequently with one of the case managers at the clinic that saw the client, but because the client's visits to the clinic was so infrequent and random that the CMTM ultimately wasn't able to meet with her and the client's case had to be closed. For clients without a telephone or an e-mail address, it definitely can be hard for the CMTM to follow-up with them regularly and it is definitely possible for a client's case to be closed because the CMTM couldn't contact the client. It can be a frustrating experience but since those former clients can always come back and reopen their cases (as long as they're eligible for the services), it's not the end of the world for the case to be closed. Outreaching is a simple task in which you'll be clear of exactly what your role is but it's nonetheless a very important one, as you'll be acting as a brokering force between the client and the CMTM, linking the two together. It can sort of force you into awkward situations, particularly when the client has never spoken to you before, but as with pre-screening, this duty gives you the opportunity to introduce yourself to the client and come to learn about them and their situations directly. The act of outreaching itself is also a great learning experience, as it requires you to effectively apply and utilize the limited information you have about the client. More than that, it may also require you to collaborate your efforts with other people or organizations that may know the client's whereabouts and/or status. Like outreaching, your other duties to the client also has you acting as a sort of a broker for the client. When you outreach those clients nearly lost to follow-up, you are essentially linking the client to the CMTM. In a similar manner, when you escort the client, you are linking that client to the person(s) the client will be meeting with, such as the client's HASA worker, the representative at the Medicaid office, the physician in Housing Works Medical, etc. The client most likely will be visiting these places and meeting with the people there for the first time. If not, maybe the client feels that your presence as a Housing Works representative would really support them. Or perhaps the CMTM feels that the client will be more motivated to meet the appointment if you went to that appointment with the client. Whatever the case may be, there will be times when you will be escorting your client to where he/she needs to go. As with everything, preparation is important, particularly so if you have personally have never been to the place where you will be escorting your client to. Before heading out of the office, you must know with absolute certainty exactly where you'll be going to. Use an Internet-enabled computer in the office to determine which subway train or bus you'll be taking to get to your location and the exact walking directions to your destination. Write these directions down, or print them out. You shouldn't rely on your memory for this information. It's always better to be safe than to be sorry. The resources I'd recommend for path-finding are Google Map (maps.google.com) and Hop Stop (hoptstop.com). Often times, you won't be able to predict when you'll be asked to escort a client. A client may come into the office to meet the CMTM, and the client consequentially being referred to the client's HASA worker. You may then be asked the client to go with the client to the HASA office, given that you don't have something more urgent to do at that time. In these abrupt instances, if you choose to agree to escort the client, first meet with the client (and introduce yourself if this is the first time meeting the client), explain where the client will be going and for what purpose, and then communicate to the client that you will need a short moment to prepare for the trip. Politely ask the client to wait in the waiting room for a few moments and then you can take some time to make sure you get acquainted with the client's situation and issues (look through the client's charts, or through the cheat sheet summary if you formulated one regarding this client) and to figure out how to get to where you'll be going. There are of course times when your escorting of a client is planned from the beginning. In this case, you can make all the necessary preparations before the date and time that you have scheduled for escorting the client. I would advise you to outreach to the client a few days before the appointed date so that the client is aware of the scheduled date and does not forget about the appointment. This of course may be difficult if the client doesn't have a reachable phone number. or an e-mail address. In that case, you just may not be able to outreach to the client. However, if you have the time, it might be a good idea to go and visit the client to remind him/her of the appointment. The starting point of escorting is usually the Housing Works office. Some times though, you may find it beneficial for the client to start the journey at his/her residence. The more uncertain you are of the client's willingness and/or ability to get to his/her appointment on his/her own, the wiser it is to schedule your meeting at the client's residence. On the appointment day, get to the meeting location ten minutes early just in case. As stated before, preparation is important so make sure to be knowledgeable about where the client is going and what the client should expect. By escorting the client, you act as a support to the client, as the client's representative, as the client's guide to the planned destination. You don't necessarily need to do any specific duty while escorting the client. You don't need to conduct an assessment interview or anything of the sort. There is no detailed script to follow, nor a clearly defined role to assume in this stage. All that is expected of you during the train ride to the destination is to provide reassuring and optimistic support to the client, genuinely listening to any concern the client may have, and engaging in an empathic conversation. You will likely end up learning a great deal about the client and even gain the client's confidence. That's what makes escorting such a great opportunity for you as a social work intern. However, make it your goal to not be confused with your role here; you are not the client's friend, but a representative of the client's CMTM. Do not ever forget that role distinction. When you and your client arrive at the destination, you will assume a slightly altered role - that of a client's advocate, representing the client's interests. You become the client's professional voice, a guide should the client not know how to explain why he/she is there, and an empowering force should the third party involved doesn't take the client seriously. In a way, you are an agent of the client's will and by that same token, you are the client's translator. You enforce onto the third party what it is that the client wishes from them and then you explain empathically to the client the third party's response. The biggest struggle to overcome during this process is your own bias. From the time you started on your escorting journey to the second you arrived at the destination, your knowledge of the client's issues was based on the conversation you had with the client. Up to this point, you only know the client's perspective of the story. Do not be surprised to be find that the third party you come to meet has a different version of the story than the one the client has told you. For example, I once escorted a client to his HASA caseworker. The client wished to be transferred to a different SRO because he felt very unsafe in his current placement in a hotel room. In fact, for the past two weeks, he had chosen to sleep on the streets and live as a homeless person because he felt that the streets were safer for him than the hotel. He believed that there was a man who followed him around, occasionally entering his hotel room to disturb him in the bathroom. When I relayed all this to the client's HASA worker, the HASA worker said he wished to speak to me privately. The HASA worker showed me a report made by the client's social worker, which stated that the client had a history of cocaine use. The HASA worker then told me that the client was delusional and suffering from the effects of illicit drugs, and thus would suffer the same issues if he were to be placed in a new SRO. The HASA worker's statements were very different from the client's telling of his issues. He had after all adamantly told me that he had only done cocaine when he was very young and that he had only met his social worker once in his life for a psychiatric evaluation. I was personally biased for the client and against the HASA worker. Dislike of the agency known as HASA was an undesired side-effect of being an intern in Housing Works. This bias made me want to investigate deeper into this discrepancy between the social worker's report and the client's account. But I made sure not to do this when I remembered that my reason for coming to the HASA office was to escort the client here and to act as the client's advocate. I was not a journalist, not a muckraker. Thus, after listening to what the HASA worker had to say, I relayed this back to the client and asked how the client would like to proceed. The client still wished to transfer to a different SRO so I went back to the HASA worker and asked what it would take for the client to be considered for a transfer. The HASA caseworker persistently advised against doing such a thing, but ultimately told me that the client will have to apply to close his current placement and come back to the HASA office after that closure. If I had acted on my bias, I most likely would have started a dispute between the HASA caseworker and the client. Perhaps it could be argued that such a dispute would have been necessary to clear up the miscommunication between the client and the worker, and while I see that argument as potentially valid, I felt it wiser to be more practical about the matter, and to stay true more to my role as a social work intern than to my emotions. After thus advocating for the client, you should ask the client if he/she wishes to be escorted back. The client may want to go back to the Housing Works office or may need to go back home. In the case of the client needing/wanting to go back to the office, escorting the client back is a rather natural thing to do. In the other case of the client wanting/needing to go somewhere else, you can simply offer if he/she would like to be escorted back. If you feel assured that the client will safely be able to go back, it'll be easy for you to agree should the client decide that he/she doesn't need your assistance with the return trip. If you feel strongly that the client needs your escorting back, you can politely insist that you go with them. Once you return to the office from having escorted the client, document the event in the form of a Progress Note. You may also want to jot down some of the important things that happened just so that you don't forget to communicate it later to the CMTM. If some things that happened trouble you - such as your bias towards/against client affecting your advocacy for the client - you'll also want to talk it over with your supervisor during your supervision session. In regards to the example I gave about the discrepancy between the story of the client wanting an SRO transfer and the report of the client's social worker, I talked with the CMTM in detail about it and then talked about it with my supervisor during the supervisory session with her. Talking with the CMTM let the CMTM know of the client's situation while talking with my supervisor helped me better understand my role as a social work intern. In many other situations, you will be referring the client to an appropriate resource or a service provider. Principally, you are still acting as a broker for the client. When you were outreaching, you were actually linking the client to his/her case management team. In the same vein, by providing referrals, you are linking the client to an appropriate resource. Some examples of providing referrals are: -helping to allow the client to use Housing Works clothing voucher -handing out to the client an informative list of free HIV clinics located around the client's place of residence -connecting the client to a mental health counselor More so than outreaching, escorting, or advocating, preparation is the biggest and the most important component of referring. To provide appropriate choice of referrals to a client, you must inevitably spend a good amount of time and effort in researching the best resources for the client. You would no longer be just representing the CMTM or the client, but aiding the client to choose other resources and service providers that would best serve the client. For certain referrals you can make sure to always be prepared. When I was an intern, I was able to create a big folder in which I kept all my research on resources the clients could use. This included an informative list of food pantries and clothing drives, categorized by which borough of the city they were located in. The lists contained information such as the name of the organization providing the housing pantry/clothing drive, the eligibility criteria, the exact address of the event, the kind of services provided, and contact information (phone number and/or e-mail address). Contained also in my blue folder were: lists of free HIV clinics in all boroughs of NYC, lists of housing programs for the formerly incarcerated, lists of COBRA case management programs in NYC, lists of job training centers, lists of MediCaid centers, and lists of the different departments of Housing Works. Preparing all this might sound like too much work and be too time-consuming, but most of these lists are already compiled by government websites and by non-profit organizations. If you use the right key words in search engines like Google, you'll find large lists available for download and print. For list of food pantries, type in "food sources" along with a NYC borough like "Manhattan" and "Queens" and the first search result will usually be a .pdf file formulated by nyc.gov. For example, type in "manhattan food sources" and you'll be able to find this link: http://www.nyc.gov/html/dhs/downloads/pdf/crh_food_ny.pdf. You could find similar lists for "clothing sources" and "free clinics health services." There are many other sources to turn to for such helpful lists, such as nycfoodbank.org and NYC AIDS Housing Network. Searching these files individually and printing them out might end up somewhat tedious but it shouldn't end up to be too time-consuming. When you give these lists to interested clients, give out a copy (utilize the copy machines in the office if you don't have any more extra copies), not the original version. Having access to all the resources you have compiled so far at any time will allow you to be more efficient. Though it may be a hassle to always have to use the copy machine every time you find a client that is interested in one of your referral lists, that hassle is comparatively less time-consuming than having to look up that resource and print it out once again for future use. The great thing about the lists of resources is that they offer the clients with lots of options to choose from. They are not forced to choose one service provider, granting the clients the right to self-determination. Granting this right to the clients makes you the clients' empowering advocate, not their boss. At the same time, this right can be too burdensome for many of the clients. That's why referring is never as simple as handing clients a stack of informative papers. It may begin with such a simple action, but the right kind of referral is all about guidance and follow-up. It's wrong to tell the client what to choose, and instead you want to educate the clients about what resources would be great to consider and also to support however you can to link the clients to whatever resource they have chosen to utilize. This is why research for appropriate referrals is ongoing. Take the time to learn more about the resources listed in the agencies. If you have time, call some of them and ask about how they provide services and what they do. You can even visit them to learn more. Do this especially for resources that the clients are hesitant but curious about. Knowing more about your referral sources makes you better able to educate and support the clients. After the clients choose which service provider they would like to seek aid from, follow-up with them on what happened. You want to be asking if they found what they were looking for when they got there. Even a referral that seemed perfect for the clients may end up unsatisfactory, but that's okay because what matters is that you continue to help the client get linked to a service provider that is the right fit for them. This principle - respectful, empowering guidance and ongoing follow-up to referrals - is all the more crucial when referring the clients to service providers that would be beyond your general lists of resources. The referrals in those lists mostly showcase providers that satisfy immediate and short-term needs, such as ones that hand out winter clothes or clinics that offer free HIV testing. It's easy to research lists of such providers but then there are cases such as when a client may need to be referred to a program that helps people with substance abuse issues. In another case a client may want to be linked to a mental health counselor. To develop a similar list for these kinds of resources will most likely take more time and effort. This is why when you are tasked with providing such referrals, you probably will not have a ready-made list to hand to a client. In most cases, this lack of preparation is actually not a bad thing. Clients needing long-term referrals often have a very good idea of which service provider they want to be linked with. They will most likely be much more informed than you about the resources they want to be linked to. These referrals aren't about formulating the most perfect lists, but about guidance, brokering, and constant follow-up. Find out how to link the client to provider you want to refer the client to. Utilize all the tools at your disposal (Internet, staff, your supervisor) to research the referral. You should also contact the provider (phone is probably the best way, though you can try e-mailing as well) and really learn all the steps necessary to refer to client to there. You may need to escort the client to the provider's site and advocate on behalf of the client. Finally, after the client has been referred to a provider, try your best to follow up on that referral. Try to determine how satisfactory the referral ended up for the client, and if not, you'll need to start this process from the beginning, researching more appropriate referrals, linking the client to that referral, and continuing to follow up on that, until you can deem that the referral ended out to be satisfactory. In order to be great at referring, you really need to become great also at the three duties (you can consider them as skills as well) I mentioned previously - outreaching, escorting, and advocating. It's a challenging task that really requires for the whole case management team to be on the same page. Communication is crucial. Always keep the CMTM on the loop of what you're doing and how you're doing to make this referral happen. On that same line of thought, also always try to be in the loop of what the CMTM is doing and thinking about the referral. Try your best to keep the clients aware of what you and the CMTM are doing to help, which will keep the clients on the same page as you and the CMTM. Keep a good rapport with the referral source so that you can easily conduct follow-up activities after the client has been referred. Lastly, seek the assistance of the program director when serious challenges come up with a referral(and trust me, they will). While this guide tells you what you generally need to do in order to be great at referring clients to other service providers, it's the program director that can offer you practical advice in particular situations. Written like this on paper, I get the feeling that these duties sound complex and hard, but I can promise you that you will really begin to get a good feel for these duties the more you do them. The staff members and the clients themselves will help you immensely along the way. Just as you are an advocate for the clients, so they will also end up to being a great support network and sources of knowledge for you. Many of the staff members are used to doing the exact same tasks that you will be learning to do so even if you forget a lot of what you just read in this section, you will constantly be surrounded by living, breathing guides whom you can follow and be supported by. |
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