Assignment 1: Termination Summary

As helping professionals, employees in the human and social services field want their client to be successful. They try to interview clients to create a social history, set goals, make recommendations, and refer clients. However, things do not always go as planned. As a human and social services professional, it might be necessary to terminate the client relationship for other reasons, such as the client becoming aggressive towards the professional or other situations such as a client no longer wanting services or moving away which makes it no longer possible for him or her to receive services.

To Prepare

• Review your interviews and documentation related to your Final Project.
• Review Chapter 11 of your Summers text regarding addressing and disarming anger.
• Imagine that before you ended your services with the client, the client displayed some inappropriate confrontation, crisis and/or had an angry outburst in front of you.
• Consider how you would document this in a Termination Summary.
• Although your Termination Summary does not need to follow a specific format, refer to pp. 443-447 in your Summers text for ideas.

For this Assignment

Create a 2-page Termination Summary of your work with your interviewee/client from your Final Project interview and document the progress related to the service plan/goals that you created in Week 10. As part of your Termination Summary, document the inappropriate confrontation, crisis and/or angry outburst incident you imagine could happen. Include what your response and the client’s response might be, that might not be the most appropriate (refer to Chapter 11 for ideas). Then, include a plan for managing this type of crisis in the future.

PG439-444

CHAPTER 26: Terminating the Case

Introduction

We have seen how people enter the human service system and how their services and treatment are determined and monitored. There is usually a point at which people leave the system, moving on in their lives. Here are some of the reasons a case may be terminated.

• 1. The individual and the case manager agree the individual is ready to move on. This is the ideal. The service or treatment has been successful and is no longer needed. Many people do leave for this reason, feeling that their original issues and problems are less significant than they once were or that these problems have been resolved.
• 2. The individual dies or moves away. When people die or move to another jurisdiction, their cases are closed. If they formally request that their records be sent to the new jurisdiction, this should be done immediately to facilitate a smooth transition to the new program.
• 3. The funding source will no longer finance services. Managed care has introduced limitations on care that you and the client may find unrealistic. It is important that people know the limitations during the first interview so that they can prepare for termination. When termination is imposed by a funding source before you or the client feel it should, work with the person to find alternatives to your service. Support groups or specialized programs funded by other sources may not give the level of service you have provided, but they may help the person make the adjustment. It is not ethical to drop someone with no plan or referral when the insurance or funding runs out.
• 4. The individual no longer wants the services. People may be dissatisfied with the services being offered and request that their cases be terminated. In situations like this, sit down with the dissatisfied individuals and learn why they are not pleased with the service. This may provide you with valuable information about how you or a provider agency is perceived by people who are served there, and it may facilitate people leaving with the feeling that they can come back if they need to do so. Others decide to leave because they no longer find working with you a priority and simply wish to move on.
• 5. You cannot find the individual. Sometimes people indicate they are not interested in our services by disappearing. It may be a person you feel is really in need of support, medication, or treatment of some sort; but often people feel case management is either intrusive or a nuisance, and just disappear. You may make attempts to find such people, and you may even track some of them down, but they have every right to refuse services. When you encounter this situation, make sure that both your contact notes and the termination summary reflect your attempts to contact the person who has disappeared.

Not all clients will leave case management. A child with autism may need services all his life. A woman with severe developmental disabilities may require case management during her entire lifetime in order for her to live in her community successfully.

A Successful Termination

Cases should not be closed without the person, or the person’s family, if they are involved, knowing that this is about to occur and why. A letter by itself cannot convey warmth and concern for the individual and often comes across as bureaucratic and unfeeling. A phone call is not much better. You might convey warmth, but there is no meaningful exchange or documentation.All clients whose cases are being closed, except those who have moved away or died, should receive two things from the case management unit:

• 1. An opportunity to meet with you to discuss the termination
• 2. Follow-up by letter outlining the main points in your final interview and inviting the person to return if the need arises

Feelings about Termination

Leaving anything can be difficult, and leaving services can be particularly difficult for people who have grown fond of the workers at the agency or who feel uncertain about how they will handle life on their own. Sometimes terminations are milestones. The people have reached a new level of independence, emotional health, or sobriety. But the accomplishment still can be tinged with misgivings.In some cases, people may regress in order not to have to leave your services. Will struck a pose as a very independent person. He came with obvious reluctance to the case management unit after his supervisor demanded he get help for his drinking problem or he would lose his job. Throughout his time with his case manager, Will boasted that he could manage all this on his own and did not need to receive help. He wanted to be sure his case manager knew he had come only to please his boss and to keep his job. Will did well and at one point confided to his case manager that he was surprised at how he had managed to go to AA and “stay off the bottle.” When it was time for Will’s case management services to end, he suddenly began drinking on a Saturday afternoon. When he came in for his final interview he announced that he had been “on a bender” although his wife said he “only had a couple of beers.” The situation was perplexing and Will insisted he had strong urges to drink again and was concerned that he could lose his job if he reverted to his old behavior. His case was not terminated and Will continued to come in and report abstinence, but he wanted the case manager to know “it is a struggle.”Again when termination was about to take place, Will reported drinking again. Contrite and embarrassed, he came into the office on a Monday morning to tell his case manager that he “tied one on at the wedding Saturday.” He reported being extremely intoxicated and said he needed more time in case management to be able to “get a better handle on this.” It was at this point that the case manager and his supervisor sat down with Will and addressed what seemed to be his reluctance to leave case management, even though he had shown remarkable progress most of the time. Will agreed to terminate his case and was told he could certainly return if he had further problems. He seemed cooperative and willing to leave the services. He would continue in AA and he would work with his sponsor. His job was now secure and he appeared to be well prepared to move on. However, 3 weeks following termination while on vacation Will showed up drunk at the case management unit and his case was reopened. This episode, timed to take place on vacation when it could not interfere with his work seemed coincidental. Will reported that he had been having a “whale of a battle, I tell you,” trying to remain sober. Clearly, Will is able to control his drinking and has made progress, but leaving a case manager he has come to lean on for support has been extremely difficult for him.Try to recognize the underlying feelings your client is experiencing in the final interview and respond empathically. Some people resent being terminated. They may have grown accustomed to the support, enjoyed having a person in their lives who cared for them, or they may just be feeling that they are being “shoved out the door,” as one person put it.As the person’s case manager, you may have feelings as well about the termination. Perhaps you and your client have had a particularly good working relationship. Together a lot was accomplished. It is sometimes hard to say goodbye to clients when we are fond of them or have enjoyed our work with them.Terminations work better if clients have a chance to get used to the idea that the relationship will end and can in some ways prepare for that. This is particularly true if you and the person have had a long relationship and been through the ups and downs of the person’s life. Encourage people to talk about their feelings about leaving and respond empathically to what they have to tell you about what the change will mean to them. Acknowledge your own sense that you have worked hard together, if that applies.While this chapter is about the client leaving the services, much of what we have said here applies to times when you are leaving and the client will receive a new worker. Feelings of uncertainty, loss, even grief are not uncommon. Sometimes life intrudes inconveniently and we need to leave our positions with very little notice, but wherever possible plan your leave-taking so that clients have an opportunity to know and prepare for the change.
The Final Interview

Use the interview to summarize the work that has been accomplished and the reasons for the termination. If there are gains, review how far the person has come since first seeking help some time before. For those who have requested termination of their cases themselves, ask them to tell you more about their reasons for making the request and be open to their suggestions for change. Invite questions. People often want to know where they should turn should former problems resurface. Give them information they can use, particularly information that will help them prevent a relapse or regression.There should be a sense of reassurance during the interview that clients are not being cut off or dumped and that they are welcome to return should they need services again. These feelings are especially likely when people have run out of funding or they were funded for only a specific amount of time. They may not tell you all of that explicitly. Nevertheless, people may feel dumped or dropped and be unable to express that to you. Speak to these concerns in the final interview.It is useful to go over in the final interview the gains and accomplishments that the client has attained. Talking about these specifically is a good way to summarize for the person where you and he started, what you have accomplished together, the gains he has made, and where he is now. This is a good time to point out specifically the strengths you have come to see in this person and the specific gains made in reaching goals you set together some time before.In addition to strengths and achievements, talk about areas the person still sees as weaknesses or areas she feels still need to be addressed in her life. This too is part of summarizing for people where they have been, where they are now, and perhaps where they feel they need to go from here. This summary gives people a feeling of tying up the loose ends, relating the tasks and work, and looking positively toward an end to the relationship.Finally, talk about where people will go after the relationship ends. Will they be referred to another service? Will they join community self-help groups? Are there things they can now do on their own to continue their progress and prevent future issues?Many agencies seek an evaluation of their services when clients leave the agency. If your agency does that explain the process to people and prepare them to receive evaluation materials or a call.

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The Letter

The letter is a follow-up to the final interview. It should summarize the main points of the interview, recapping briefly what was discussed. There should be a brief statement about why the termination took place so the person has documentation of it. In addition, questions that seemed particularly important to the person during the interview should be answered again in the letter, especially if the individual needs addresses, names of resources, and other supportive information.

Figure 26.1

provides a sample termination letter. In this letter there is a summary spelling out why Mrs. Warren is leaving the agency, the positive gains she made, and her plans for the future.

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Documentation

Like all contacts with clients, this last contact and letter should be documented in the person’s chart. In the note, the focus of the interview would be the termination of the case. You would note the highlights of the discussion, any follow-up arrangements that were made for the person, and his or her response to the interview.

The Discharge Summary

In most cases, your agency will ask for a termination summary or discharge summary. This is not the same thing as the final case note discussed earlier. Although you include the information from that contact note in the discharge summary, you are actually summarizing the most important information about what took place while the individual was working with you. It is wise to think of your summary as a document that may go to other professionals in other agencies who will see the person in the future. Asking for summaries is common practice when beginning work with a new person who was seen before in another agency. For that reason, your summary functions in part as an indication to other professionals of how thoroughly your agency addresses the needs of clients. This is a major way that other programs and professionals can learn about the quality of the care given in your case management unit. Sloppy summaries containing little useful information or those that indicate little organized effort on the client’s behalf can make your agency look unprofessional.What you include in your summary should be helpful to a new case manager or therapist developing a strategy to help the person. For this reason, your summary should discuss what was tried, what worked, and what was less successful and why.

Figure 26.2

provides a sample discharge or termination summary.

Your agency may have a standard format for discharge summaries that you can use as a guide to writing good discharge summaries. If not, you can use the “Discharge Summary” form provided in

Appendix C

.Here are important items to include in the discharge summary:

• 1. Name, date of birth, date of admission, and date of discharge
• 2. Diagnosis (if there is one)
• 3. Any medication that was prescribed by physicians who were working with the case management unit and whether it has been discontinued. (Make sure to note the name of the medication, the dosage, the frequency, and any adverse reactions.)
• 4. The reason for discharge
• 5. The major presenting problem that brought the person to you
• 6. Your goals and objectives for the individual
• 7. The extent to which the client participated in formulating these goals and objectives
• 8. Progress that was made or goals that were accomplished
• 9. Problems that were identified but were not addressed
• 10. How the individual appeared to be at intake and how the individual appeared to be at termination
• 11. Attempts to locate the person if she has disappeared

Examples

We can look at several cases and how they were terminated. First is Alex, whose insurance stopped payment for services, which stopped Alex from having further contact with the agency. Alex did not want to leave and felt he had gained support he needed to continue to work through his difficulties on his job. The reason for discharge was “insurance no longer available.” The goal for Alex to begin a course that could have led to a promotion was not met. This was noted and the need for further support to obtain this advanced training was noted under problems that had been identified but not addressed. Because Alex seemed as agitated about his work situation when his insurance ran out as he did the day he came in for assistance that too was noted and in fact, the case manager noted that the loss of insurance coverage was contributing to his difficulty. Before discharge the case manager worked with Alex and his minister to give Alex some support for attending the advanced classes. This gave Alex someone to work with before the insurance was reinstated the following year. This was not an ideal solution, but the case manager made sure there was some support system in place before the final termination.