GUIDED PATHWAYS PROCESS FINAL REPORT ...

The University of British Columbia School of Social Work 2080 West Mall, Vancouver, BC V6T 1Z2 Phone: 604.822.2255 Fax: 604.822.8656 www.socialwork.ubc.ca

GUIDED PATHWAYS PROCESS FINAL REPORT October 21, 2011

Project Team Elizabeth Jones, MSW, RSW Dr. Miu Chung Yan, MSW, Ph.D. Dr. Pilar Riaño-Alcalá, PhD.

ACKNOWLEDGMENTS The researchers worked closely with an Advisory Committee and we would like to thank those members who advised us, created case studies, and kept our work “real”: Jennifer Basu, AMSSA Sherman Chan, MOSAIC Alexandra Charlton, Settlement Orientation Services Connie Hong, OPTIONS Community Services Hilma LaBelle, South Okanagan Immigrant and Community Services Winnie Lee, Inter-Cultural Association of Greater Victoria Tim Welsh, AMSSA Without the willingness of our interviewees and survey respondents to share their ideas and information with us, we would not have had such a rich knowledge base from which to develop the GP process in this report. We would like to express our sincere gratitude to them. We also thank Vicki Chiu, Stefan Virtue, Hartaj Sanghara, Alison Dudley and many others at IIB who supported this work through funding, feedback, and their commitment to newcomers in British Columbia.

UBC School of Social Work: Guided Pathways – Final Report October 21, 2011

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Table of Contents EXECUTIVE SUMMARY……………………………………………………………... 1 A.

INTRODUCTION..................................................................................................2

B.

LITERATURE REVIEW – CASE MANAGEMENT........................................3 1. Case Management Defined..............................................................................3 2. History of Case Management ..........................................................................4 3. Theoretical Perspectives of Case Management .............................................4 4. Case Management Process and Role of the Case Manager .........................5 5. Case Management in Settlement Services .....................................................7 6. Core Values and Best Practices ....................................................................12 7. Conclusions about Case Management from the Literature Review .........14

C.

METHODOLOGY ..............................................................................................14

D.

FINDINGS FROM EXTERNAL CONSULTATIONS WITH OTHER MINISTRIES........................................................................................................14

E.

INFORMATION FROM THE REGIONAL MEETINGS ORGANIZED BY AMSSA..................................................................................................................15

F.

DATA COLLECTED FROM THE SURVEY AND INTERVIEWS .............20 1. Findings from the Survey ..............................................................................20 2. Findings from the Qualitative Interviews ....................................................25

G.

PROPOSED GUIDED PATHWAYS PROCESS .............................................31 1. What can be learned from the findings?......................................................31 2. Guided Pathways Process as a New Service Mode .....................................34 3. Definition ........................................................................................................34 4. Principles ........................................................................................................34 5. GP process ......................................................................................................36 Step 1: Settlement and Integration Service Intake ................................... 39 Step 2: Guided Pathways: Assessment ....................................................... 44 Step 3: Guided Pathways: Service Process ................................................ 49 Step 4: Transition ......................................................................................... 55 Step 5: Evaluation (outcomes and other) and Exit ................................... 57 Step 6: Follow up .......................................................................................... 60

H.

SUMMARY OF RECOMMENDED FORMS ..................................................62 Form 1: General Intake Form ............................................................................62


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Form 2: GP Assessment Form ............................................................................64 Form 3: GP Action Plan ......................................................................................65 Form 4: Quarterly Monitoring ...........................................................................65 Form 5: Exit, Evaluation and Follow Up ...........................................................66 Consent form(s) ....................................................................................................67 Case Management Reference Resources .......................................................................68 References .........................................................................................................................70 APPENDIX .......................................................................................................................72 Regional Meeting Questions................................................................................73 Interview Guide ....................................................................................................74 Survey....................................................................................................................76


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EXECUTIVE SUMMARY

The Ministry of Jobs, Tourism, and Innovation awarded a contract to the University of British Columbia‟s School of Social Work to develop (or acquire and modify appropriately) a case management model and implementation of resources, and identify data management criteria that will support the Guided Pathways approach for settlement and integration services. The main objective of this project was to develop a case management model for the implementation of the Guided Pathways settlement and integration service approach in accordance with the principles set out by the Ministry for the Settlement and Integration Program. Specifically: 1)

Identify guidelines for each sequential function in case management, including client identification, needs assessment, goal setting and pathway planning, linking clients with services, coaching and on-going support, progress and outcome monitoring, transitioning out or disengagement; and

2)

Provide input into a business plan for a data system to support the implementation and evaluation of the Guided Pathways approach for settlement services

This report starts with a literature review on case management, and then describes four sources of data collection which inform the Guided Pathways process: Regional Meetings with the settlement and integration sector; consultation with several staff in the Ministry of Children and Family Development and Ministry of Health; the results of 21 interviews with content experts; and the results of a survey to the sector. Integrating all this information, we then present a six step Guided Pathways process, together with the identification of the sequential factors in each of the steps, and operational guidelines for each step. We identify some ideas for data collection. Finally, we include a recommended training plan and templates for the content of forms recommended to be used in the Guided Pathways process.


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GUIDED PATHWAYS MODEL FINAL REPORT

A. INTRODUCTION The Ministry of Jobs, Tourism, and Innovation (formerly Regional Economic and Skills Development, “the Ministry”) awarded a contract to the University of British Columbia‟s School of Social Work to develop (or acquire and modify appropriately) a case management model and implementation of resources, and identify data management criteria that will support the Guided Pathways approach for settlement and integration services. PROJECT OBJECTIVES The main objective of this project is to develop a case management model for the implementation of the Guided Pathways settlement and integration service approach in accordance with the principles set out by the Ministry for the Settlement and Integration Program. Specifically: 1)

Identify guidelines for each sequential function in case management, including client identification, needs assessment, goal setting and pathway planning, linking clients with services, coaching and on-going support, progress and outcome monitoring, transitioning out or disengagement.

2)

Provide input into a business plan for a data system to support the implementation and evaluation of the Guided Pathways approach for settlement services.

PROJECT DELIVERABLES 1)

2)

3) 4)

A Guided Pathways Guidelines document, including a summary of learning from the environmental scan, key features/sequential functions of a case management model relevant to the Settlement and Integration Program, and suggested guidelines for each function. A summary of data and information that should be documented throughout the Guided Pathways process - this may be a separate document or part of the Guided Pathways Guidelines document. Resource materials, including an intake assessment form and needs assessment matrix to be distributed at future training workshops. A recommended training plan to train Ministry service provider staff in the use of the case management model.

Added to this subsequently were:


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5)

6)

An orientation plan and materials for the introduction of the approved guided pathway model to all Ministry‟s contracted agencies, in order to ensure consistency in program implementation. Delivery of orientation sessions on the guided pathway model as part of the overall program orientation arranged by the Ministry.

The Ministry wanted the contractor to work closely with The Affiliation of Multicultural Societies and Service Agencies of BC (AMSSA), who would act as a broker for any information about the project, distribute data collection instruments, and initiate the development of an Advisory Committee. The Committee was established early on in the project, made up of leaders in the settlement and integration sector, and acted as a „sounding board‟ for the progression of the project. One early recommendation by this Committee was to develop a survey (not conceptualized in the initial proposal) as a way to engage and to obtain information more broadly from the settlement and integration sector about the developing approach. The Committee also took an active part in creating scenarios for use in training the Guided Pathways process and provided feedback on the report before it was circulated to the sector. REPORT OUTLINE This report begins with a literature review of key features that make up case management models within the social services sector generally and the settlement and integration sector specifically. Included here are some practice frameworks, best practices, and trends. We then move to a description of our findings on case management practices identified from the following sources: consultations with several people outside the settlement and integration services sector; consultations at sector Regional Meetings set up by AMSSA; interviews with content experts and surveys from a range of workers in the settlement and integration sector. We then move to the proposed Guided Pathways process, as a schema, and include operational guidelines for the development of Ministry policy at each of the steps. We outline data collection materials, and conclude with a recommended training plan and templates for forms. B. LITERATURE REVIEW – CASE MANAGEMENT 1. Case Management Defined One definition of case management in the human services field is “a client-centred approach led by a team or individual that serves to coordinate a broad range of services and resources that maintains continuity of care and the well-being of people with various needs” (Moxley, 1989, p. 17). A similar definition, with a few more elements, is “a process through which the professional practitioner and his/her service user collaboratively determine, secure, coordinate and monitor an orderly and planned provision of services intended to facilitate a client‟s functioning at as normal a level as possible and as economically as possible” (Weil and Karls, 1985).


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Case management is about working with people or a client system, such as a family. Case management seeks to do three things: to help the client utilize their own skills to access services and supports, to promote the capacity of service agencies in ensuring the wellbeing of their clients, and to work towards efficient and effective service provision (Moxley, 1989, p. 17). In other words, case management is a way of working alongside clients to guide them through a well-planned process of coordinated resources (Yan, n.d.). 2. History of Case Management In brief, case management grew out of the need to deliver human social services in new ways that served to: a) Address the impact of deinstitutionalization which saw community social service practitioners working with individuals with multiple needs. b) Address the impact of decentralization of community services. c) Recognize the importance of social support in the overall well-being of community members. d) Decrease the fragmentation and duplication of human services. e) Improve communication and efficiency between agencies. f) Decrease the cost of providing human services. g) Improve outcomes and client satisfaction (Moxley, 1994, p. 12; Day, 1996, p. 54). 3. Theoretical Perspectives of Case Management There are some overarching theoretical frameworks that guide the work of case management. Using a strengths-based approach individualizes the process and seeks to discover each person‟s unique skills and strengths. A strengths-based approach also ensures a collaborative process between the client and the case manager who then guides the client through the process. The case manager can also incorporate a systems approach to understand how the individual or family is impacted by their environment and how the environment affects the client. An anti-oppressive approach to case management seeks to understand how oppressive conditions such as poverty, illness, and addiction have impacted individuals and families (Heinonen & Spearman, 2010, p. 139). Passing on a case manager‟s awareness of oppression and injustice to the client can help clients avoid self-blame for their difficulties and focuses on strengths instead of limitations (Heinonen & Spearman, 2010, p. 139). Cultural sensitivity considers the values of individuals and families who may not originate from Canada or a western culture. An anti-racist approach means moving beyond cultural sensitivity to one that actively works to address racist attitudes and discrimination towards racial minorities (Heinonen & Spearman, 2010, p. 132). For the case manager, this can mean recognizing personal race location and helping the client


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understand that discrimination can lead to internalized oppression and a negative selfimage (Heinonen & Spearman, 2010, p. 133). Understanding one‟s cultural and racial location means knowing who we are and where we situate ourselves in society. Understanding our own social location is examining what advantages and disadvantages have impacted our life in relation to others and how we have overcome some of life‟s obstacles (Heinonen & Spearman, 2010, p. 132). To work in an anti-racist way means being open to learning from others, appreciating variety across cultures, and building on the strengths of individuals and families (Heinonen & Spearman, 2010, p. 132). 4. Case Management Process and Role of the Case Manager Five case management models were reviewed. We summarize these models below: Moxley, 1989 p. 17-18

Rubin, 1992 Werrbach, 1994, cited in p. 328 Werrbach, 1994 a) Persona) Assessment a) Assessing the centred of strengths strengths, assessment and needs, and weakness goals of families and children b) Goal b) Goal b) Planning and planning planning developing strategies to meet these goals c) Intervention c) Linking c) Advocating client to for services services and and resources resources d) Monitoring d) Monitoring

e) Evaluation

d) Evaluating the achievement of goals

NCMN, 2009

NSSSF, 2003

a) Person-centred a) Client assessment of assessment needs, paying and attention to screening strengths b) Goal planning to meet these needs

b) Service plan development

c) Interventions c) Service that link clients delivery to resources and services d) Monitoring to d) Service plan ensure client monitoring needs are being met e) Evaluating e) Evaluation whether goals and followhave made a up, where positive impact outcomes are on the person measured or family. f) Transition to next services or independence


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As indicated in these models, the case management process unfolds through different stages which are not necessarily in a linear direction. Despite some minor differences among them, we can summarize that the key elements of traditional case management include: a) Person-centred assessment of needs, paying attention to strengths. b) Goal planning to meet these needs. c) Interventions that link clients to resources and services. d) Monitoring to ensure client needs are being met. e) Evaluating whether goals have made a positive impact on the person or family. f) And for one model, and appropriate for our purposes, transitioning client to other services or to exit current services smoothly. In each stage, the workers and case managers will have different roles to play and tasks to accomplish. First, the assessment process sees the case manager working collaboratively with the client to explore areas of need as well as the individual‟s or family‟s own internal strengths. The process involves gathering information and prioritizing it in a standardized way, which remains open to revision as the client‟s needs change (Moxley, 1994, p. 26). Having the needs of the client formalized provides the case manager and client with information that serves as a guide for the planning stage that outlines agreed upon goals. Second, the planning stage, works with the client to ensure the identified needs are laid out in a step-by-step process that accomplishes the goals. Third, the intervention, linking, or advocating stage is an active stage that sees the case manager working directly and indirectly on behalf of the client to coordinate services that will be utilized by the individual or family. Part of the case manager‟s role is to not only link the client with other services and resources, but to help break down the barriers to access these services. Case managers are responsible for guiding their clients through an often confusing array of services and resources, such as housing, employment, health care, education, and social networking. Case management is typically a dynamic practice in that it adapts to the changing needs of the client over time. Fourth, the monitoring stage means reviewing goals with the client to ensure they are being achieved and whether there is a need for revision. The fifth stage is evaluating whether services and resources have made a positive impact on the client and what, if anything, needs revision (Moxley, 1994, p. 17-22). The Canadian Standards of Practice for Case Management suggest a stage of transition to another service or exit in a self-sufficient manner (NCMN, 2009).


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5. Case Management in Settlement Services The stages of case management in the settlement sector closely follow the previously discussed case management stages. The National Settlement Service and Standards Framework (NSSSF) sets out five stages that include: a) Client Assessment and Screening b) Service Plan Development c) Service Delivery d) Service Plan Monitoring e) Evaluation and Follow-up, where outcomes are measured (2003). The NSSSF briefly outlines the first four stages. First, Client Assessment and Screening consists of developing rapport with the client and collects information that will inform goal planning (NSSSF, 2003). Second, the Service Plan Development stage uses the information gained during the assessment to develop the specific actions to achieve the client‟s short-term and long-term goals and requires the counsellor or coach to know what resources are available in the community (NSSSF, 2003). Third, depending on the assessment, the Service Plan Delivery may require crisis intervention, emotional support, mediation, referral to appropriate community resources, workshops, such as employment skills, or interpretation or translations services (NSSSF, 2003). Fourth, the counsellor or coach is then responsible for Service Plan Monitoring which ensures that the resources are available and are being utilized by the client. During this stage the coach may need to motivate the client to participate, to connect with outside resources to make sure they are following through on commitments, and to make sure the resources are suitable to the needs of the client (NSSSF, 2003). The Ontario Council of Agencies Serving Immigrants (OCASI) developed a training guide that outlines standards for the service delivery of an initial assessment that ensures basic needs of clients are met before other settlement tasks are undertaken (2000). These basic needs include: a) Securing adequate housing b) Providing access to food c) Ensuring adequate income is secured d) Reviewing of the health status of client e) Reviewing of client‟s pre-immigration and immigration experience f) Reviewing of any family reunification issues g) Children‟s education, care and safety is ensured h) English language ability is discussed (OCASI, 2000).


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OCASI have also set standards for other areas of service delivery such as, orientation to Canadian society, employment counselling, social, individual and family support services, advocacy, general agency standards, and case coordination standards. The Canadian National Settlement Service Standards Framework (CNSSSF) compiled by the Canadian Council for Refugees (CCR), outlines the services that every immigrant and refugee is entitled to. The CNSSSF (CCR, 2000) state that the following list of services is based on the needs of the immigrant and refugee and it is not the intention that these services be offered by every agency. The purpose is that the services be available on a continuum to provide support over a period of time depending on the needs of the immigrant (CCR, 2000). After information is provided upon entry into the country, the main areas of service provision are as follows: a) Initial intake  Orientation to the services  Assessment of immediate needs (food, shelter, clothing, physical and mental health, safety, language translation/interpretation, income security, immigration status) b) Assessment, Information, Referral, and Follow-up  Identification of other needs (documentation, employment, language, physical and mental health, immigration, education, family issues, housing, income, transportation, social connectedness, legal, life skills)  Prioritization of needs  Development of short-term and long-term plans and implementation strategies  Information and referral  Follow-up and re-assessment of needs  Evaluation of service impacts c) Orientation (individually or in groups)  Practical i. Transportation ii. Emergency services iii. Community and government services iv. Housing and utilities v. Health (promotion, services, nutrition) vi. Legal issues (services, Canadian laws) vii. Education viii. Language resources ix. Finance (including banking, budgeting, tax returns, credit) x. Employment xi. Consumer awareness (e.g. credit cards, contracts) xii. Climate  Cultural and Social Orientation i. Civil rights and responsibilities (e.g. human rights legislation, diversity)


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ii. Community life skills iii. Managing change (e.g. Canadian cultural norms, culture shock, immigration experience, role reversals in the home, intergenerational conflicts) iv. Voluntarism v. Addressing issues of racism d) Facilitating Access to Appropriate Services  Includes advocacy for clients, accompaniment, interpretation/translation, form-filling, support in immigration and other processing, sensitization of mainstream services, family support services, and mediation. e) Volunteer and Peer Support Services  Includes Host Families, Programme de Jumelage, tutoring, conversation circles, and community kitchens. f) Supportive counselling  Includes active listening, reassurance, talking through experiences. g) Specialized services for survivors of torture and trauma  Settlement services delivered in a manner sensitive to the special needs of survivors of torture and trauma. h) Language training  Includes literacy, language acquisition and upgrading, employment-related language. i) Employment counselling and training  Includes employment counselling, labour market orientation, job search skills training, job maintenance. j) Community capacity building  Includes support for new communities developing networks and organizations, leadership skills, facilitating dialogue with government and institutions, facilitating group activities (Canadian Council for Refugees, 2000). Valtonen cautions that the refugee experience is different from those who migrate on a voluntary basis (Valtonen, 2008, p. 5). Migration can be viewed along a continuum from voluntary migration at one end including, for example, one who arrives from being transferred from a multinational corporation, to the other end, where a family is forced to flee due to human rights violations in their home country (Valtonen, 2008, p. 5). The differences in immigration experience, including how immigrants and refugees are welcomed by their receiving country, can lead to various expressions of personal identity. Again, along a continuum, is self-identification based on experience. At one end of the continuum is a sense of pride with refugee status and having survived both persecution, for example, and the difficulty of the immigration and integration process in their new country (Riaño-Alcalá et al., 2008). At the other end of the continuum is a feeling of disempowerment, depression and the impression that they are seen as “needy” and “deserving of pity” (Riaño-Alcalá et al., 2008). Immigrants and refugees form complex


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identities that incorporate identities as they once saw themselves, as well as, with newly formed identities as they integrate into their new country (Riaño-Alcalá et al., 2008). Due to the differences in experiences between voluntary and involuntary migration, the settlement needs of every group on this continuum will be different, particularly for those of refugees. For refugees fleeing their country of origin, it is often a matter of survival. The stress and trauma associated with forced and unplanned migration mean that any preparation prior to leaving was not possible (Valtonen, 2008, p. 14). This results in refugees having very little information on their new country or on the settlement process that could have helped with strategies to integrate successfully (Valtonen, 2008, p. 1415). It has been suggested that resiliency and the development of life skills, especially for refugees, relies heavily on social connectedness, and family reunification programs (Valtonen, 2008, p. 130; Riaño-Alcalá et al., 2008). Citizenship and Immigration Canada (CIC) developed a Modernized Approach in 2009 that is an outcomes-based program. Instead of several programs providing service, the Modernized Approach is one program with several services (cic.gc.ca). The elements of the Modernized Approach are: a) Outcomes  Language training  Information in order to make informed decisions on settlement experience  Assistance with employment and education  Help with establishing networks and contacts b) Needs assessment  Preferably to begin overseas c) Planning  All activities will be harmonized through improved coordination and collaboration  Communities develop and implement strategic settlement plans that respond to regional issues. Best practices are shared. d) Performance Measurement  Monitoring outcomes and financial resources to ensure activities continue to achieve expected results and link services to specific settlement outcomes (Citizenship and Immigration Canada, 2009). The assessment phase of case management is a time for the worker and client to solicit and identify external resources and personal strengths of the individual or family. External resources can be identified as: a) Friends, relatives, neighbours b) Social assistance and government programs


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c) Community/non-profit organizations d) Income sources e) Other support groups (Yan, n.d.) Personal strengths can be identified as: a) Successful migration experience b) Strong family relationship and networks c) Expectation of new life d) Stable emotions e) Ability to express self f) Motivation to change g) Coping with daily living h) Positive worldview i) Practice of self-care (Yan, n.d.) There is tangible and intangible knowledge that is important for the settlement case manager to possess. Tangible knowledge includes: a) Facts and figures of immigrants and refugees b) Policies, procedures and eligibilities c) Resources: services, programs, agencies and people Intangible knowledge includes: a) Clients‟ unique experiences, client strengths and limitations, interpretation of context b) Practice wisdom: how policies and needs are interpreted, how to work with individual service providers c) Dynamics and power relationship: what can be done within and between institutions, stakeholder expectations (Yan, n.d.) Case managers use a wide variety of basic, but important, skills in their work. These include, but are not limited to: a) Basic counselling skills: building rapport, listening, empathy b) Psycho-social assessment skills: soliciting and identifying one‟s relevant psychological and social history including migration experience c) Basic group skills: facilitating meetings, seeking compromises


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d) Community organizing skills: identifying and mobilizing resources, linking people together for a common goal e) Managerial skills: time management, planning, writing and recording, organization, evaluation f) Advocacy: understanding the system and its limitations, negotiation skills, taking risks (Yan, n.d.) 6. Core Values and Best Practices The Canadian Council for Refugees (2000) propose 12 core values that govern best practices in settlement work. These values include: 1) Access is assured by: a. offering services in the client‟s own language, where possible and appropriate b. offering culturally appropriate services c. where possible, offering services irrespective of immigration status or other criteria of eligibility 2) Inclusion is assured by: a. recognizing the diversity of needs and experiences (e.g. young, old, highly educated, those without education, singles, families) b. offering anti-racist services c. respecting different perspectives within newcomer communities 3) Client empowerment is assured by: a. fostering independence in clients b. recognizing, affirming and building on the resources, experiences, skills and wisdom of newcomers c. providing information and education to allow clients to make their own informed decisions 4) User-defined services are assured by: a. involving newcomers in needs assessments b. responding to the particular needs of refugees (recognition of differences, changing needs) c. incorporating flexibility into programs, in order to allow them to adapt to changing needs 5) Holistic approach is assured by: a. recognizing the diversity of an individual‟s needs (physical, social, psychological, political, spiritual) b. avoiding compartmentalization c. recognizing the importance of the family in the lives of individuals


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6) Respect for the individual is assured by: a. confidentiality b. services free of racism, sexism and other forms of discrimination c. compliance with a Code of Ethics 7) Cultural sensitivity is assured by: a. having staff and volunteers from the same background as the clients served b. ensuring that service providers are knowledgeable about the culture of those being served c. offering services in a culturally appropriate manner 8) Community development is assured by: a. investing in the development of newcomer communities b. building bridges between communities c. working towards changes in public attitude towards newcomers 9) Collaboration is assured by: a. promoting partnerships between organizations that build on strengths of each b. providing opportunities for community problem-solving c. referral services 10) Accountability is assured by: a. evaluation, involving the participants b. ongoing monitoring c. close connection with immigrant and refugee communities 11) Orientation toward positive change is assured by: a. advocating for improvements in policy b. recognizing and building on the possibility of change in the lives of newcomers and in society c. celebrating successes 12) Reliability is assured by: a. keeping information up-to-date b. using social research c. exchanging information (Canadian Council for Refugees, 2000). These standards, or values, draw from the work of OCASI-COSTI (OCASI, 2001) (COSTI is a multi-service agency in Ontario) and have also been accepted by the Manitoba Immigration and Multiculturalism‟s Settlement and Labour Market Services Branch (n.d.).


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7. Conclusions about Case Management from the Literature Review It is clear from the preceding review that the definition of case management, the elements (person centred assessment, goal planning, intervention, monitoring, evaluation) and the case management role, with some minor variability, are similar across jurisdictions and within settlement services literature. Knowing that we did not need to „reinvent‟ the wheel, we used this literature as a baseline to create our data collection instruments. We turn now to the methodology for our data collection phase of the project. C. METHODOLOGY We conceived of four avenues to capture data about existing case management practices: (1) Consultations with staff of ministries external to the settlement and integration services sector; (2) Feedback sessions at four Regional Meetings of the sector held by AMSSA; (3) Completion of a survey available to anyone working in the sector; and (4) Completion of interviews with experts in both case management and settlement and integration services. The first set of consultations (external) were on the general practices and understanding of case management in each of the Ministries; the following three sought to answer a number of questions as to knowledge, skills, and practices of case management in the settlement and integration services sector. Copies of the data collection instruments are found in the Appendix to this report. D. FINDINGS FROM EXTERNAL CONSULTATIONS WITH OTHER MINISTRIES Within the British Columbia context, the Ministries of Children and Family Development (MCFD), Health, and Social Development, among others, utilize case management approaches. Between the Contract Manager and the Research team, we consulted with staff in the Ministries of Children and Family Development and Health with the aim of getting a general overview of these Ministries‟ approaches and procedures. We were unable to find someone from the Ministry of Social Development to consult with. From MCFD, we consulted with two line workers and a data analyst working on its large data collection redesign. And from the Health Ministry, we consulted with a middle manager. We asked them about their experiences with case management, and what best practices were from their point of view. In terms of definition, elements, best practices, and other points, all respondents echoed those found in the literature in section “B” and summarized in #7 above, with no new or different ideas added. Staff consulted agreed with our definition of case management, as “a process through which the professional practitioner and his/her service user collaboratively determine, secure, coordinate and monitor an orderly and planned provision of services intended to facilitate a client‟s functioning at as normal a level as possible and as economically as possible” (Weil and Karls, 1985).


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Interviewees described a five-step process (person centred assessment, goal planning, intervention, monitoring, and evaluation) of case management. For three of the four interviewees, case management was a fundamental aspect of their daily work. One of the MCFD workers noted, “I believe that it is of utmost importance that the proposed new model for case management for settlement workers include the development of a clear vision, goals and practice standards to which each worker should strive to achieve.” He added, “An integral part of case management is ensuring that all stakeholders, family members and community members are involved in the creation of a service plan.” And finally, “Communication is the key between and among all parties and service providers.” The transition to an Integrated Case Management System, which is currently underway, links all Ministry files and information together so more effective case management can occur. The ICM system may well serve as a prototype for exploration by the Ministry for use with GP and their other programs, although the mandated service demands a more rigorous system than a Guided Pathways Model would require. E. INFORMATION FROM THE REGIONAL MEETINGS ORGANIZED BY AMSSA We attended four Regional Meetings organized by AMSSA to consult about the major areas of inquiry with 55 individuals participating. Focused discussions were with agency representatives from four different regions: the Fraser Valley (11), Interior/North (8), Vancouver Island (7), and Vancouver (29). The meetings revealed much rich information to guide the development of the project. We report here on the collated themes from all meetings, summarized under each question. 1. Based on our research, we have defined case management as, “ a process through which the professional practitioner and his/her service user collaboratively determine, secure, coordinate and monitor an orderly and planned provision of services intended to facilitate a client‟s functioning at as normal a level as possible.” (Weil and Karls, 1985). Do you agree with our definition of case management? Many respondents critiqued the definition for being “too clinical” and “too professional” (i.e., not humanistic, or partnership oriented enough) for the purposes of the target population of workers and service users. They also commented that case management is not always “orderly” and that usage of the word “normal” is unclear, i.e., whose definition of “normal” does one use. They agreed with the words “collaboratively,” “coordinate” and “monitor.” Additional comments focused on the pathways metaphor, and noted that: 

Goals must be customized to the client since everyone‟s level of adaptation to the culture will be different.


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 

There must be multiple pathways and the ability to enter and exit at different points. There must be responsiveness from the worker.

Based on the feedback from the Regional Meetings, our emerging definition for the GP approach is, “A process through which a settlement and integration worker and his/her service user work together to determine needs and strengths and create a coordinated plan of action to integrate economically and socially into Canadian Society.” The responses to this question also revealed strong sector values and principles that can inform the Guided Pathways Approach. These included: inclusive, client directed or client centred services, optimal lives or optimal integration, collaboration, flexible services/responses, dynamic and responsive work. Each of these can be elaborated on and a definition attached, as the model develops. 2. What are some of the key elements of case management, in your opinion? (e.g., needs assessment? Planning? etc.) There was much agreement across the respondent groups to this question. The elements echoed our literature review, and the key ones noted were:         

Developing awareness of the program and getting clients in the door. Building relationship through the lens of collaborative partnership and holistic approaches. Assessing not only needs and barriers but also strengths and assets. Setting goals and identifying priorities. Collaboratively developing action plan with service users. Service user signing off on the plan. Ongoing (re) assessment and modification of the plan through follow up (monitoring). Reporting of the work through data entry. Planning transition and exit strategy.

Some other points raised were:      

Accreditation standards must be met in any model developed. Ensure clients understand what informed consent is. Use visual tools to help with outlining processes and begin dialogue and discussions. (An example given was a genogram). Be aware of barriers to client expressing needs and/or not being able to identify them. Manage cultural sensitivity. Clarify the role of the GP worker.


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3. Do you „do‟ case management in your agency? If yes, what does this service look like? Virtually every agency represented indicated that they did some form of case management both in practice and through data collection instruments. From the point of view of data based systems, some models are very simple: a two page assessment and tracking tool; others are longer - sophisticated databases developed at great cost by the agency themselves; still others are half way between these two. Some are web based; others aren‟t. Some are linked to existing services in the agency; others are linked beyond. The databases are as numerous as the agencies represented. The challenge for the data collection instrument(s) for GP is to honour all this work and expense to the sector, and to think through what system(s) meet everyone‟s mutual needs without creating more work and expense for the agencies. Several respondents noted that perhaps if there is a clear system on what is required to be reported, then agencies might be better off adapting their own databases. 4. What do you need answered in the Operational Guidelines for Guided Pathways? The respondents were very clear about their requirements in the Operational Guidelines, and they are listed below.                  

Glossary with clear definitions. Flow chart/diagram with clear process. Time frame from initial intake to the transition and support plan. Identification of who the population is for GP. Is it the family? An individual? Labour market destined? Multi-barriered families? Requirements for reporting. Identification of which staff is doing GP and what their qualifications are. Scenarios to demonstrate “how”. Living document – possibility for modification. Informed consent guidelines. Confidentiality guidelines. Which forms to use for what. How to manage excess demand – wait lists. When is file closed, how to do follow up & what kind of system. How it‟s supposed to be done both in terms of standards of practice, and forms completion. Transferring of case files. How it will work within PIPA. How to work with SWIS. List of service providers.


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      

Risk management. Liabilities. Boundaries. Report writing template. Ratio of staff to clients. Who is the case management when service user has multiple systems involved? Guidance on referrals to professional services.

5. What resource materials should we be developing that would be helpful for you? While indicating that several resources already exist in the sector, respondents gave a long list of potential resource materials. Some of them „mirror‟ what respondents said should be in the Operational Guidelines.                   

Better ways of analyzing needs assessment to determine appropriateness of their participation in GP. Integrated database. Glossary and definitions as well as comments relating with success stories from their particular culture. Assessment tools – needs, strengths, genogram. Service standards. Identifying outcomes of settlement services, GP. Action plan template. Job description for a GP coach. Definition of roles and responsibilities. Use of AV materials. Sample client agreement, coaching plan to assist with understanding. Compendium, repository of resources/community services that is accessible to GP Service Providers. Template with key elements that could be adapted according to need. Measurement tool. Electronic forms. Follow up tool post closure. Samples of Release of Information/consent form Training manual. Database.

6. Given the usage of the words “Guided Pathways” should we be changing the language found in the literature to „fit‟ the new model? There was a “tension” identified here. Many respondents liked the idea of building on the metaphor of GP and using other terms to match, such as journey, mapping, stations, milestones, etc., and making the language specific to the settlement sector.


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On the other hand, many respondents wanted to keep the language the same for a variety of reasons. Some noted that because a long-term goal of the settlement sector is professionalization, keeping more „professional‟ language would therefore make it more acceptable. Others noted that the existing language has meaning, and why change for the sake of change. 7. What recommendations do you have about what the training plan should include? There were several „categories‟ of responses that emerged here. a) What content the training should include               

How to work in a collaborative model where there is not one „lead‟. Helping clients to feel comfortable with the model and how to navigate through the system. Model, concepts and how to apply them, data entry, reporting. STARS (database for ESL students). Defining successful outcomes. Building trust with clients. How to develop effective rapport and honour individual skills, competencies, assets. When to do follow up, how often, when to exit. How to empower clients to incorporate technology. Records management. Time management. Teamwork. Connecting with others who provide the service. Boundaries. Cultural orientation for settlement workers to Canadian values/professionalism in social work. b) What processes of training should be taken into account

         

Target to ESC staff. Explore whether the training should be offered in two parts: one to managers and one to staff. Make the training flexible and use a range of options of delivery. Address diverse adult learners. Don‟t assume everyone has a social service background. Make it experiential – try out scenarios and tools through case scenarios. Train in stages – ongoing, refreshers. Don‟t assume every worker understands immigrant settlement experience. Create multiple dates. Record training sessions to view later.


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8. What else do we need to know? The respondents ended with a few words of caution:      

Concerns around building capacity in the sector to meet the needs of service users from a wide background of different cultures. Concerns around standardization (needs differ by community). Lots of money is already invested in databases in the sector. Fine line between vulnerable populations and other clients who could benefit from GP. Shouldn‟t be about numbers especially for small communities. What do we do when we identify that another ministry is presenting barriers?

And a final thought, “Keep it simple”. F. DATA COLLECTED FROM THE SURVEY AND INTERVIEWS The survey and interviews were developed based on the literature review, and the external consultations. These tools were approved by the UBC Behavioural Ethics Board. Attached with a recruitment email, the questionnaire and interview requests were sent by AMSSA to all its members on June 6, 2011. For the survey, anyone in the settlement and integration sector was invited to respond; for the interviews, the recruitment criteria considered those who had worked in their agency in a senior position and/or someone who had had extensive experience in case management models by virtue of their position and/or accreditation standards. 1. Findings from the Survey We received a total of 62 returns. Except two, all were fully completed. a. Background information of respondents The majority of the respondents are line staff and coordinators who are the frontline operators of the settlement programs. In other words, the data collected from this survey are largely grounded in the day-to-day operation of settlement service workers. Executive Director

2

Manager of services

5

Coordinator

15

Line staff

26

Other (line=8, coordinator/consultant =4)

12

Missing

2


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A majority of the organizations (n=47, 76%) in which these respondents are working have two types of funding sources. Nine (close to 15%) respondents reported that their agency has 3 or more sources of funding. Among all the listed sources of funding, BC Ministry of Jobs, Tourism and Innovation is the top source of most respondents‟ agency (n=42, 67.7%). Next one is CIC (n=9, 15%) and United Way (n=6, 14.2%). Municipal government and private donation were reported by 3 and 2 respondents respectively. 60 out of the 62 respondents reported that their organizations provide settlement services which cover all listed programs, see below. Program

No. of Respondents

Information referral

54

Settlement service counselling

55

English as second language training (e.g., ELSA)

32

Mentorship program (e.g., Host program)

30

Employment service

39

Family program

31

Youth Program

37

Other service for marginal groups

18

Other programs

18

Most agencies (n=41, 66.2%) in which the respondents are working have provided at least 4 types of settlement services. 22.6% (n=14) have 3 types of services. Number of types of service 9

Number of respondents 6

Percentage

8

8

12.9

7

7

11.3

6

5

8

5

8

12.9

4

7

11.3

3

14

22.6

2

3

4.8

1

1

1.6

None and missing

3

4.8

9.7


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b. Case management elements In the survey, we asked a few questions regarding case management and the existing services in the respondents‟ agency – and their suggestions as to what case management elements should be included in GP. The following table provides an overview of answers to these two sets of questions. Element 1. Included 2. Continued (Italics are elements indicating a large in existing in GP discrepancy in column 1 and 2) service Needs assessment 58 60 (What does the service user need?) Goal planning 54 56 (What does the service user want to achieve?) Coordinating services and resources (Ensuring 52 53 no duplication) Linking client with services and resources (Ensuring that needs are met through other 59 59 resources) Advocating for service user (Arguing for the 48 53 needs of the individual) Advocating for services and resources 36 43 (Arguing for the needs of the collective group) Coaching and on-going support (Supporting 54 56 and directing the work with the service user) Progress and outcome monitoring (Checking in to ensure movement towards service user 45 48 goals) Evaluation of achievement of goals (Ensuring 39 45 service user goals are met) Transitioning out or disengagement (Leaving 19 34 guided pathways process) There is a high similarity between what case management elements are included in existing services and what are suggested to be continued. However, a relatively significant difference can be identified among four items between the two sets of information. Respondents seemed to suggest that in GP, more attention and efforts are needed in the areas of advocacy, evaluation and transition. This suggestion is consistent with their answers to what elements should be included in GP. c. Training needs Among the 10 listed elements, seven of them were suggested by close to or more than 50% of the respondents as areas that need training. More than 60% of the respondents expressed training needs in monitoring, evaluation and transition. Although respondents


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tended to have a lower training need in the areas of needs assessment, service coordination and service linkage, the demand is still not insignificant. Element Needs assessment (What does the service user need?) Goal planning (What does the service user want to achieve?) Coordinating services and resources (Ensuring no duplication) Linking client with services and resources (Ensuring that needs are met through other resources) Advocating for service user (Arguing for the needs of the individual) Advocating for services and resources (Arguing for the needs of the collective group) Coaching and on-going support (Supporting and directing the work with the service user) Progress and outcome monitoring (Checking in to ensure movement towards service user goals) Evaluation of achievement of goals (Ensuring service user goals are met) Transitioning out or disengagement (Leaving guided pathways process)

Need training 23 30 19 18 32 30 32 39 45 42

Thirty-three (53.2%) and 35 (56.5%) respondents suggested respectively that in class and combination of in class and online training modality are preferable. Only 6 suggested online and 8 self directed learning. In other words, in class training may be the way to go. d. Data collection system In terms of existing reporting systems, 26 respondents reported that their agency uses computer data collection methods. Twenty-three of them reported that they have some computer assisted program for this purpose. Half reported using MS office programs and another half with in house designed databases. Out of the 27 respondents who reported that their agency uses paper data collection methods, 26 of them also reported that their agency has standard forms for data collection. When asked an open ended question, respondents reported that currently they tend to collect information according to the reporting requirements of the funder, i.e., the Ministry. Roughly that information can be classified as: 1. 2. 3. 4.

Biographical information including ethnicity and country of origin Family information Contact information Education and work experience


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5. Immigration related information such as immigrant category and date of arrival 6. Language skills 7. Service information: type of service asked, provided and outcome. Other than these, a few reported that they also collected case management related information such as assessed needs, goals set and achieved, and/or action plans. When asked what kinds of data should be collected to track service user progress and results in GP process, other than the existing information, respondents also suggested a variety of extra information to be tracked. They can be roughly classified as: 1. 2. 3. 4.

Needs and barriers that clients have Goals set and achieved (outcomes) Service referrals and utilization both within and outside the agency Measurable progression such as actions and activities planned and actually performed.

Some respondents listed in detail, information to be collected in every step of case management. However, there was also a concern about the amount of information to be reported. It was suggested that both quantitative and qualitative data should be recorded and reported. e. Items to be included in GP Operational Guidelines Many respondents suggested that how to ensure confidentiality and privacy is necessary to be included in any guidelines. The other major item that many respondents suggested to have included in the guidelines is a step-by-step manual which also needs to specify the roles, rights and responsibilities of worker and client. Other than these key suggestions, one respondent provided a list of items to be included in the guidelines which may be a useful reference for consideration. 1. Philosophy and intent of GP process 2. Key principles of the GP process (including being client focused, strengths-based focused, equity based, confidentiality and client directed) 3. Terminology definitions (coaching, service elements, exit, closed file etc) 4. The legal context (if and how files could be sequestered, client access to files etc) 5. Protocols for client confidentiality and access to files. 6. Guidelines on client eligibility for GP services 7. Guidelines on training necessary to deliver GP services. 8. Protocols of practice for each service element 9. Protocols for eligibility 10. Protocols for clients in crises 11. Protocols for client exit strategies (including non-complying clients Finally, many respondents reminded that the guidelines should be written in simple language.


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f. Resources needed To make GP successful, many respondents felt that extra resources are needed. These resources include: 1. Funding for standard computing system is useful to facilitate their work. 2. Funding for on-going training and support. 3. Textual and online resource on best practice, past experiences, community resources and FAQ. 4. Simple, standard but flexible forms (or templates) for different stages of GP process: assessment, action plan, referral, tracking and evaluation. 5. Textual or online operation manual: explaining the process and guideline of howto. g. Overall comments Overall, the respondents expressed a positive response towards GP, but they do not want to see the GP increase their administrative duties. They want to see a quick and simple database and short and easy to use forms and templates. Due to the unique nature of their clients, services and locality, respondents from different services and agencies consistently asked for flexibility and client participation and determination in GP process. To make GP successful, respondents also saw the importance of training in skills to conduct a proper GP process. 2. Findings from the Qualitative Interviews With the assistance of AMSSA, 21 individuals were interviewed. The purpose of the interview was to capture personal experience and opinions from people who have been directly involved in S/I service in BC. Most interviews in Vancouver and its vicinity took place at the interviewee‟s office. Those interviewees who were located outside the Lower Mainland were interviewed by telephone. Most interviews lasted approximately one hour and were taped and fully transcribed. Others were transcribed concurrent to the interview. Respondents came from different organizations providing settlement and integration services and from different regions in the province. Most of them are at the managerial level. A rich set of data were generated. We will present the main themes according to the key questions that we raised in the interviews. a. Understanding of case management In the interviews, we offered a working definition of case management which is “Case management is a process through which the professional practitioner and his/her service user collaboratively determine, secure, coordinate and monitor an orderly and planned provision of services intended to facilitate a client‟s functioning at as normal a level as possible and as economically as possible” (Weil and Karls, 1985). Interviewees


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expressed different perspectives on how this working definition fits into their agency‟s service delivery model. Most interviewees agreed that their existing service delivery models more or less fit into this definition but in a more informal, relaxed and flexible manner. Like interviewee 14 said, "Case management is a collaborative process of assessment, planning, facilitation, and advocacy for options and services - we thought it pretty much defined what we were doing.” However, how this process and elements of this process played out in each agency is different due to the unique nature of their services. Most of the time, their services are not as well ordered and planned as what this definition suggests. As well, most of their service users do not necessarily need this process. As interviewee 8 observed, “There is a good number of them that come in expecting something immediate.” Regarding the working definitions, there are a few concerns raised. The idea of “normal” as found in the definition drew a few comments from the interviewees. Interviewee 5 recalled that in a regional meeting people questioned many ideas of case management, “…one of them had to do with the word „normal‟ – functioning at as normal level as possible – because it stuck out as who determines what is „normal‟?” The idea of “monitoring” also drew a few comments. As interviewee 16 told us, this word “is a trigger for a lot of us.” “The word monitor is not something we‟ve talked a lot about. People don‟t want to be monitored, they want to be supported and empowered.” An interviewee cautioned that monitoring is not quite doable in settlement and integration service when the workers cannot get hold of their service users whose participation is strictly voluntary. Another concern raised by the interviewees is about the idea of “economically” which seems to signify “output” not “outcome”. The latter one requires efforts to develop and nurture. It was commented by interviewee 16 that, “So, economically, it will save them money if the client will get a job right away and they don‟t have to worry about it, but it kind of becomes a revolving door.” In summary, many interviewees emphasized case management in settlement and integration service should take into consideration the unique nature of their service, i.e., voluntary, spontaneous, flexible and immediate. b. Understanding the elements of case management Interviewees were asked to go through a list of nine elements of case management and to describe what they do in relation to each of these elements.


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1. Needs assessment: Interviewees unanimously agreed that this is a critical step of their work. It builds the foundation of their work and determines not only the eligibility of service users but also what kinds of service and resources are needed. In practice, needs assessment is done in different ways. Some reported a more formal (by appointment and with fixed duration) process and some a more informal process which sometimes took place during home visits. 2. Goal planning: Setting goals, particularly short to medium terms, are common practice, as reported by most interviewees. Although the formality of the process varies, almost all interviewees emphasized the importance of a collaborative goal setting process. As one interviewee suggested, the goal setting process is also a means to assure service user‟s personal esteem. “When you are talking about people coming in, we are trying to increase a sense of belonging and capacity to be able to do things within the system. The more we can show people that they are doing it, it has positive implications for identity and self esteem.” (Interviewee 18) However, not all service users will be able to set their goals particularly in the early phases of their encounter with settlement and integration services. If possible, most interviewees reported, they will collaboratively develop an action plan with their service users to actualize those goals. 3. Coordinating services and resources: Interviewee 16 summarized the understanding of coordination of most interviewees well. According to this respondent, coordination means connecting with services, liaising, making referrals. It can also be understood as arranging for/referring to/connecting with/providing resources. Service users‟ needs should direct the coordination efforts. Many interviewees reported their coordination work includes services and resources within and outside their agencies. From a holistic service perspective, as interviewee 4 suggested, coordination is “not one agency acting on behalf of clients, it‟s a coordinated process amongst agencies in the community that work with newcomers to identify and address those needs.” 4. Advocating for the service users: Interviewees tend to understand advocacy is part of their daily work. In settlement and integration services, advocacy is driven by the needs of service users and mostly related to resources. As interviewee 1 suggested, it is small “a” advocacy work. To a certain extent, it is about “service bridging.” As interviewee 5 suggested, “we‟ve called it „bridging‟, „service bridging‟, „trying to raise awareness‟ – not only with the client about how the system works but also within various systems about the needs of the particular client group or that specific client.” There are many ways to do advocacy including calling other agencies on behalf of service users, educating service users how to navigate the systems, attending community meetings, actively engaging in interagency networking. At


27

the management level, as interviewee 2 reported, they also advocate for policy change. 5. Advocating for services and resources: Many interviewees felt that this is “pretty fundamental” to their work (interviewee 21). But unlike advocacy for service users, advocating for resources is more an organizational level activity, which requires dialogue with the governments and other tables in the community. As interviewee 19 suggested, “This is more at the managers and executive directors level and we are looking at taking the issues identified in the field to a higher level for funding, for identification, different circles of influence.” 6. Coaching and ongoing support: Many interviewees suggested coaching is seen as a continuous process for some but not all service users. Therefore it is a tailored process for individual families. The idea of the coach role is to help service users to be independent and integrate into Canadian society. However, as interviewee 6 reminded us, “We walk a fine balance of wanting to help but also not creating dependency.” Interviewee 13 echoed this perspective, “And as long as we‟re not developing a dependency, because we are really careful to try and empower them to be independent in doing that…. So teaching them how to do that, the coaching part is the really important piece.” Many interviewees agreed that other than knowing how to build a trusting rapport with service users, the coach would need proper training to make it work. As interviewee 10 suggested, “Coaching ... takes a whole range of knowledge, skills and attitude for a mentor to be able to be effective.” 7. Progress and outcome monitoring: Individual base monitoring of progress was commonly reported among the interviewees. However, there is not one standard way of monitoring which ranges from mental notes, regular debriefing meetings to systematic tracking systems. A few interviewees raised the concerns that the voluntary nature of settlement and integration service has led to a user-driven monitoring process. As interviewee 3 said, “we do rely on clients coming back to see us.” In terms of measurable indicators for monitoring, particularly of outcomes, interviewee 3 saw this as a huge issue: “How do you do this in the sector and sort out all the variables and identify how what we do is causal or impactful in the outcomes?” This was echoed by interviewee 17 who thought this is a concern because, “we cannot track the ripple effects of the interventions we make.” 8. Evaluation of achievement of goals: There were many dilemmas among the interviewees who generally seldom expressed any resistance to evaluation. Indeed, one way or the other they reported that there is some sort of evaluation component in their existing programming:


28

from clients‟ satisfaction, feedback forms, oral evaluations, to systematic tracking systems. However, similar to their concerns about monitoring, many interviewees were concerned about what kinds of indicators can truly capture the “real” outcome of their service users. As interviewee 3 said, “Not meeting a goal isn‟t a bad thing, it means something has changed.” As interviewee 12 said, “It‟s a reality, and I‟d want to demonstrate our success. What we may think is useful or an achievement may not be what the client and/or funder thinks is good.” 9. Transitioning out or disengagement: Most interviewees agreed that the settlement and integration service should have a limited duration and no dependency should be created between the worker and the service user. To most interviewees, a smooth transition means that the service users can now be independent in dealing with their own issues. One indication is to have the service user decide when to end the process. As interviewee 4 observed, “When people have had a good experience it‟s hard for them to disengage. So that process of exiting is a process. It‟s not just one meeting. It happens towards the end of somebody achieving a goal so you‟re giving them more independence and you‟re stepping back and letting people make decisions more so that when the point of exit comes persons are ready.” This seems to be a “tricky” moment of the case management processes in settlement and integration service to some interviewees because their service users may either disappear suddenly and/or they may come back a few months or years later for service. Transition can be an emotional process particularly to both workers and service users when people have good experiences of working together. Many interviewees reminded us that transition does not imply the door for the service user is permanently closed. Other than these nine elements which are extracted from the literature, interviewees also suggested other issues to be considered for case management in the settlement and integration field. These suggestions are summarized as: 1. Caseload management: As interviewee 2 said, “You can do perfect case management but looking at the demand of service, looking at the number of clients we have to serve through our funding relationship with the provincial government, there are certain things, certain numbers, that they have to do, that could limit the level of case management because there is a huge case load.” 2. Team and case meetings: Ensure a collective effort is happening. Interviewee 15 suggested, “Meetings are useful about problem solving on behalf of clients.” 3. Culture- and language-sensitive service. 4. Clear eligibility criteria. 5. Confidentiality guidelines need to be clear.


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c. Documentation system in use The majority of the interviewees reported a dual database system which is largely a hardcopy based system plus some computerized programs such as Excel. Information collected is quite fragmented and piecemeal. Roughly only five of the interviewees reported some customized database systems such as Sugar CRM, CAMS, and Client Manager. A few noted that their frontline staff keep notes but not in a standard manner. To support a new case management system, a few hoped that a non-paper based system would be designed not only for the case management services but also to incorporate all settlement and integration services. Any system developed should be able to help the sector to “get comprehensive information on different supports and needs for individual clients, and barriers and so on, and collect data that we really wanted to see” (interviewee 13). In terms of information to be collected, interviewees identified the following. 1. Biographical information that should be basic and standardized across all settlement and integration services. The name is critical and should be clear. 2. Family information 3. Immigration related information 4. Education, language skills, and employment history 5. Case management related information a. Needs and barriers b. Goals c. Progress (including indicators and timeline) d. Outcome (measure of success). Some interviewees were cautious about “over collecting” data. However, as interviewee 12 suggested, “I‟m always in favour of less documentation rather than more, because of privacy issues and all of that. But I think for guided pathways there would have to be more documentation, at least from what we‟re doing now.” So, a balanced approach in deciding the amount of information is important to the documentation system. d. Operational Guidelines The general sentiments regarding the operational guidelines are that it should be written in simple language and allow some room for innovation by the individual agency and/or needs of individual service users. As interviewee 8 proposed, “I think in order for this to work out well, people need to know that this is a model that they should follow, but there are still some freedoms in there that they can take, in customizing it or doing things in their own way…. People are used to thinking „this is what the client needs, and I‟ll just do that‟… and don‟t worry about the guidelines so much.” In terms of items to be included, the principle of clarification of confidentiality has been raised by many interviewees. Other than this, suggestions are made to include:


30

1. 2. 3. 4.

Ministry expectations and/or purpose and philosophy of GP. Clear eligibility criteria. Implementation procedures from intake/assessment to transition. Roles and responsibilities of workers: how much freedom they have to make decisions.

e. Resource materials and training Many interviewees asked for a universal hands-on training manual particularly for new settlement workers. Sample documents, such as intake forms and informed consent were proposed. Best practices and case scenarios that can illustrate how GP works step by step were suggested. Some also wanted to have an online Q and A. Interviewees noted they would like to have training on almost every step of GP. Ongoing training in different forms (face to face, manual and online) was recommended by a few interviewees. Instead of theory-driven, interviewees strongly suggested that experiential (such as role play) and scenario-based training will be more useful. Like interviewee 8 suggested, “A lot of this kind of work you learn by doing, a lot of this kind of knowledge you can‟t really learn in a classroom setting. The best way to train would be to do it in an interactive way. Bring the people together and offer the opportunity to actually put the knowledge to work.” f. Conclusion Interviewee 4 had a final comment that echoed most interviewees‟ feedback of GP: “I‟m really excited that they have moved in this direction. I think it‟s long overdue. It is an efficient way of working with people. It‟s promoting independence, self-management, self-direction, and independence towards their adaptation and settlement.” However, many also expressed their wish that GP will be a user driven and friendly approach which will have enough room for flexibility. Some also worried that this new approach may replace the long standing community based tradition of settlement and integration service which focused on humanistic, advocacy and social justice work. These are concerns and worries that will need to be addressed G. PROPOSED GUIDED PATHWAYS PROCESS 1. What can be learned from the findings? The previous section of the report introduced the results from the literature review on case management and the findings from consultations with representatives from the settlement sector and a small sample of staff from Ministries outside the settlement field, and from a survey and interviews conducted for this project. Here we provide a summary of key themes extracted from this analysis. These themes and a summary of key elements identified for a case management model provide the background rationale for the


31

formulation of the guiding principles, process and steps of GP that will be presented in the following section. A first important observation is that the themes and viewpoints that emerge from data collected through consultations, surveys and interviews support those found in the academic and more informal literature. This provides a measure of validity to the findings and a strong basis to define core elements of the Guided Pathways process. Furthermore, the consultations and data collection indicated that there is a knowledge base and a skill set on case management already present in the settlement sector given that all the participant agencies reported that they implement some form of case management and data collection methods. The implementation of a GP process will greatly benefit from this existing expertise in the field and, as several of the participants in the consultations and interviews highlighted, from a clear communication system. There were three cross cutting themes that inform the vision for a case management process in the settlement and integration sector: 1. An understanding of the process as a humanistic and collaborative process of case management and towards the relationships between client and the worker/agency; 2. An approach to the process as a holistic and person/family centred that supports clients‟ self-determination of needs and actions, and focuses on strengths and independence towards their settlement and integration process; 3. A recognition of differences in experience and needs according to the characteristics of the immigrant or refugee migration process (forced migration and voluntary migration) as a key element in applying procedures and goals. These elements are consistent with the observation expressed by content experts and settlement workers that GP should be a user centred and friendly approach which will have enough room for flexibility. A remaining concern for them is that this new approach may replace the long standing community based tradition of settlement and integration service which focused on humanistic, advocacy and social justice work. Associated to the elements outlined for the vision, workers and experts stressed that the application of the model cannot be expected to follow a linear path or strict stages. It rather should be approached as a fluid and flexible process that avoids compartmentalization of processes and services. In this regard, comments made in the consultation with the sector and in interviews with experts noted the importance to avoid normative definitions of what constitutes “normal functioning” of a client, as well as, standardized understandings of the integration process. They stressed the importance of embracing a person/family centred vision that focuses on the uniqueness and particularities of each client‟s situation and process. A conclusion that can be drawn from the review of literature and data collected is that the potential success of a case management model lies on: a) its focus on a user centred and collaborative vision, b) the understanding that there are multiple pathways to settlement


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and integration and, c) the development of a vision, goals and practice standards that are clearly communicated and that workers strive to achieve. Taking into account particularities of the social context, the profile and background of the client, the following key elements of case management were identified: a) Person-centred assessment of needs: using a strength based approach for needs assessment and recognizing the diversity of individuals‟ needs; working collaboratively with the client to explore areas of need and ensuring basic needs of housing, food, immigration status and health, be met before other settlement tasks are undertaken; b) Collaborative goal planning to develop action plan to meet needs and clients‟ goals; c) Advocating and bridging: linking clients to resources and services, raising awareness within various systems of clients‟ needs and, embracing a community development perspective by building bridges between communities and connecting clients to community based organizations; d) Monitoring to ensure client needs are being met and the ongoing (re) assessment and modification of the plan. Monitoring also involves a critical review and awareness of workers‟ role as supportive but that does not create dependency. e) Evaluating whether goals have made a positive impact on the person or family and reporting of the work through data entry; f) Transitioning planning and exit strategy: transitioning users to other services when user and worker agree to end the process. Three key observations were made for the overall implementation of a GP process. They are: a) Avoid increase of administrative duties. Overall, the respondents expressed a positive response towards GP, but they do not want to see it increasing their administrative duties. They want to see a quick and simple database and short and easy to use forms and templates. The process and procedures, the participants observed, should avoid labour intensive methods of documenting. b) Attention to monitoring indicators. Respondents reminded us of the voluntary nature of settlement and integration services that has led to a user-centred monitoring process. There are concerns that indicators for service users progress, meeting goals and monitoring end up relying on program and funder driven expectations and may miss the service users‟ assessment of success as well as an analysis of how broader social factors (i.e. funding cuts) may affect the way that goals are met or not. c) Additional training and resource needs. Respondents expressed training needs in most aspects of the process but particularly in regards to monitoring, evaluation and transition. In class training was the preferred method identified for training. They also saw emerging needs for resources associated to the new demands for data collection, storage and monitoring.


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Incorporating what we have read, heard, and consulted about, in this section, a Guided Pathways Process is presented. However, please note that the articulation of this new mode of service is a work in progress. There will be further opportunities for modification. 2. Guided Pathways Process as a New Service Mode The GP process is a new service mode of the BC Settlement and Integration Program, the primary goal of which is to “support immigrants and their families to understand, navigate, and access BC‟s social and economic systems, in order to ensure their successful Settlement and Integration in BC‟s communities” (RFP, p.9). Settlement and integration can be a life-long process. GP is not a “problem-oriented” approach. Instead, it is a capacity building process. Therefore in this report, instead of labelling it as a model, we connote it as a process. Through working with their GP coach, service users will utilize their potential and strengths, learn new knowledge and skills, establish new social connections, and strengthen their self confidence. In other words, GP is a process to strengthen service users‟ capacity to pursue a smooth, gradual, self-directed and successful settlement and integration in BC‟s communities. As a capacity building process, it requires a voluntary, frank and open exchange of information and ideas between the service user and the GP coach who are partners to move the process forward collaboratively. 3. Definition Defined in the RFP documents, “Guided Pathways means individualized, cohesive and continuous support provided by a coach for navigating various service systems” (p.6). In this report, based on this preliminary definition and our findings, we refine the definition of Guided Pathways as: “A user centred process through which a settlement and integration worker and a service user create a coordinated plan of action to assist integration socially and economically into Canadian Society.” 4. Principles From the data, we determine that the GP process should have a principled lens. In the RFP, the Ministry has laid out twelve program principles some of which focus largely on accountability issues. We highlight only those principles here that are directly instructive to the service aspects and revise them to fit the GP process. a. Client–centred and Holistic Approach GP process is user-centred and relevant to service users‟ circumstances, taking into account their and their family‟s multiple needs, specific assets and barriers, and the different pathways that the individual may take to integrate into BC society. UBC School of Social Work: Guided Pathways – Final Report October 21, 2011

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b. Early intervention GP is made accessible as soon as possible to immigrants, as early supports can make a significant difference in immigrants‟ long-term Integration. c. Client Capacity Building GP process aims at building service users‟ capacity to access, navigate and participate independently in BC‟s social and economic systems to achieve their goals. d. Responsiveness GP process is responsive to service users‟ changing needs. e. Outcomes Focused GP process aims at supporting service users toward S/I Outcomes. f. Diversity of Service Providers GP process involves a variety of service organizations that offer different community connection opportunities. g. Integrated and Co-ordinated GP process is integrated and coordinated in order to best provide service users with the full range of information, support and bridging services. h. Partnership and Collaboration The engagement of multiple sectors and a network of partners are critical to support local coordination, referral and linkages of programs to support clients and create opportunities for capacity building in communities and across BC Systems. Many of these principles are echoed by our respondents who also pointed out some other principles that can supplement the Ministry‟s. Those principles include: i. Participation of service users As a user-centred approach, GP coaches should work inclusively and collaboratively with service users in every step of the GP process. j. Self-Determination GP should be a process that assists service users to live optimal lives as self determined. k. Flexible process We are aware that people‟s lives are dynamic and therefore always changing. Although GP has specified „steps‟, it will build in flexible planning and services to adjust to the changing conditions and needs of service users.


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l. Multiple pathways We know there are multiple pathways to the achievement of integration and settlement. GP is not a cookie cutter process. Instead, it needs to take into consideration of service users‟ unique needs, barriers, strengths and assets. 5. GP process Synthesizing all the information that we collected in the preparation phrase, we present a GP process with six steps. Each step has its unique purposes and tasks to be completed. However, the stepwise process should be understood as a flexible and non-linear process. The movement from one step to the other should be a collaborative decision and highly sensitive to the changing needs and life conditions of the service users. In terms of timeframe of GP process, three recommendations are made: First, as a new approach to settlement and integration service, the GP process is a work in progress. We need more data to determine what an optimal duration will be the most suitable timeframe. We need to take an incremental and realistic approach. Second, the beginning phase of a settlement process can be very unstable. It is unrealistic to expect a long-term commitment from the service users whose life conditions are always in the state of flux. For instance, relocation is not uncommon to many newcomers particularly outside major urban centres. Third, settlement and integration program is the first-line of contact with the BC systems and is never intended to replace or substitute other BC systems. In other words, newcomers should extend their help-seeking to other appropriate BC systems. Prompt transition to other systems, such as MCFD, agencies working with domestic violence victims, mental health service, are crucial particularly in crisis situations even though this referral may cut short the GP process prematurely. Therefore, we suggest up to a maximum of a 12-month timeframe for individual GP process at least in the first year of this RFP contract. Within this timeframe, we propose that an action plan should be set within a short-term range, e.g., a maximum of 3 months. Upon the review of progress, the action plan will be renewed and revised to help service users to achieve their S/I goals gradually. Here is a conceptual map of the Six-Step GP Process.


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Direct Exit a. Transition to other BC systems b. Transfer to other BC S/I agency

Service User

Step 3: Guided Pathways Service Process Step 1: S/I Service Intake

Step 2: Guided Pathways Visioning & Assessment

Goals Setting Action Planning

Step 4: Guided Pathways a. Transition to other BC systems b. Transfer to other BC settlement agency

Monitoring

Intervening Regular Settlement Service


Step 5: Guided Pathways Evaluation (Outcomes and other) & Exit

Step 6: Guided Pathways Follow Up (To be determined with client)

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Details of each step will be elaborated below. The organization of the following materials is in this order: 1. Overview of the step: why and what is it about? 2. What actions and procedures are needed? 3. What are the roles and responsibilities of the settlement worker or GP coach? 4. What forms are to be used and what kind of information or data will be collected in the service user‟s file and for ministry reporting? 5. When and how to move to the next step? These materials serve as the developing Operational Guidelines for the Ministry, which can be extricated and edited as staff wish. We have developed some ideas for sample forms for different steps. However, these are only templates for reference. We understand that many S/I agencies have already developed their own forms systems. Some items included in the sample forms are for reporting purposes to the Ministry. We suggest that S/I agencies incorporate those items into their existing form system if they decide to keep their own. Finally, we would like to acknowledge the fact that most of the language used in this report is for a professional level understanding and discussion. We do not mean to suggest the GP coach to use the exact language when they work with their service users. Instead, a culturally and linguistically appropriate use of language is a critical component of any successful inter-cultural engagement in S/I services.


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Step 1: Settlement and Integration Service Intake Direct Exit a. Transition to other BC systems b. Transfer to other BC S/I agency

Service User



Goals Setting

Action Planning


Monitoring

Intervening

Regular Settlement Service



An overview Step 1 starts when the service users first approach the S/I agency for services. This is the Step to determine the eligibility of the service users, types of service and level of engagement that the service users will need. In most cases, service users may only ask for basic services such as seeking settlement related information, processing forms and applications, and enrolling into the ELSA program. Based on the information collected (see Form 1), settlement workers will determine if service users will stay on the regular S/I services mode, refer to GP, or to Vulnerable Populations Program. Note: Some service users may come in or call the S/I agency only for quick and fast information. It is important to keep track of this kind of “drop-in” style service. However, a mandatory intake process seems both unrealistic and bureaucratic. We suggest that in these cases, the intake process may not work for them. Procedures and Actions Procedures: 1. Settlement workers need to comply with their agencies‟ policy and procedures. 2. Since the intake interview takes time, an appointment system may work well. Designated intake workers can set up formal intake hours. Nonetheless, given the flexible nature of S/I service, the agency may also consider a drop-in intake system in which settlement workers are assigned to be on duty to do random intake in person. UBC School of Social Work: Guided Pathways – Final Report October 21, 2011

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3. Before starting the intake process, settlement workers need to explain clearly the rationale for the intake form and the general S/I consent form (Refer to RFP document). Service users should be informed of their rights to withdraw from the intake process. 4. If GP is a suitable option, the settlement worker should explain the GP process and the required commitment to the service users. If service users agree to participate in GP process, they will be referred to a designated GP coach for further assessment. Actions: 1. Settlement workers will conduct an intake interview with service users. 2. In the interview, both the intake form (See Form 1) and the general consent form (refer to RFP package) will be explained and signed by the service users. 3. Based on the information collected, the settlement workers assess the issues and desires of service users. 4. If GP is suitable to the service users, settlement workers will explain the GP process to them. 5. Only when service users agree to engage in the GP process will the settlement workers refer them to a GP coach. Roles of Settlement Worker Settlement workers are: 1. Caring agent: representing the S/I program generally and individual S/I agency specifically. 2. Facilitator: assisting service users to determine their needs and level of engagement with S/I program. 3. Broker: connecting service users to appropriate mode of services. 4. Cultural navigator: equipping service users with knowledge of mainstream cultural practice and norms that can empower their adjustment capacity Form to be used The intake form includes two sections. The first section collects general biographical and immigrant status information which are in compliance with requirements of the RFP. Section two is designed to collect information that will be used to determine if GP is suitable to the service user. The first section will be for regular identifiable data:  Name  Contact information (address, telephone #, email address)  Gender  Age  Country of origin  Primary language


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      

Immigrant status Category of entry Date of entry to Canada Level of education Current employment status Family constellation Unique client ID

Information collected in the second section will be used to decide on a GP referral. A quick check list of common issues in 11 domains will be used. Based on our findings and the RFP documents, we propose that GP coaches should focus on the assessment of 11 life domains which have the greatest impacts on service users‟ successful settlement and integration. At this stage, settlement service workers are not expected to go through a detailed assessment. They can check items on the list that service users feel a need to work on when they are referred to GP. Domain 1. Family

Common Issues Family relationship and dynamics Individual members S/I issues Issues related to family members outside Vancouver and/or Canada Family reunion

2. Housing

Accessibility Affordability Housing condition Conflicts with landlord

3. Education

Credential recognition Upgrade Accessibility to education system Children‟s school adjustment Language training

4. Financial

Immediate financial shortage Banking system Taxation system Budgeting Sponsorship breakdown Financial resource to support qualification upgrade


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Domain 5. Immigration

Common Issues Family reunion Refugee claimant Citizenship application

6. Social benefits

Access to social assistance Employment insurance Child benefits Sponsorship breakdown

7. Health

Specific needs regarding physical and mental health, disability and HIV/AIDS Access to health care Navigation of the health care system

8. Legal

Legal rights and responsibilities Navigating the legal system Needs for representation and/or advocacy

9. Labour market

Canadian labour market information Culturally appropriate job search skills and strategies Skills and qualification upgrade Canadian workplace culture and legislations Work permit application and renewal

10. Adjustment/ integration

Perception of social wellbeing Establishing functional social networks Perceived ability to engage in social activities Dominant cultural norms and practice Experience of discrimination

11. Others

S/I issues identified by service users

Criteria to Consider for Guided Pathways There is no hard and fast rule to decide who should go to the GP process. In the intake stage, settlement service workers are to facilitate service users‟ choice to go through the GP process. We recommend that the decision of referring to GP must meet three sets of criteria. 1. Willingness of Service Users: a. Service users express a desire to work with someone in a cohesive and comprehensive manner to resolve multiple settlement and/or employment challenges.


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b. Service users demonstrate an interest in progressing but are in need of more support to achieve their goals and/or they want to pursue a more focused approach. 2. Competence and barriers of Service Users: a. Service users demonstrate limited competence in meeting their needs independently. b. Service users have language and other identified barriers that limit service users to meet their needs independently. 3. Complexity of Issues: a. Extensivity: Number of issues checked b. Intensivity: Severity of issues as expressed by service users and judged by the workers c. Immediacy: Urgency of the issue. We strongly advise that not all service users need GP and GP is not a one-way process. There are a few different ways that service users can enter the GP process in a later stage. Meanwhile, the intake process is a preliminary streaming process. Service users referred to GP may be referred to other service modes after a thorough GP assessment. Three Options While completing the intake process, service users and settlement workers can collaboratively decide one of the three possible service options: 1. Option 1: Regular Settlement Service – Service users will stay in the regular services: such as information referral, ELSA, orientation and other services. Regular service means that service users will have to initiate the contact with settlement worker when they need help. When the condition of service users changes, and they are interested and need to have a more intensive S/I service, settlement worker can refer them to GP at a later time. As indicated in our process, if possible, service users stay in the regular settlement service mode are expected to have a program outcome at exit. However, since this document is only about GP, we will not further discuss the operation of regular service. 2. Option 2: Direct Exit – Service users have urgent and even life threatening needs that require immediate intervention from other BC systems or other BC S/I agency is more suitable to work with service users. 3. Option 3: Guided Pathways – Service users meet the criteria of GP and are willing to engage in GP process.


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Step 2: Guided Pathways: Assessment Direct Exit a. Transition to other BC systems b. Transfer to other BC S/I agency

Service User



Goals Setting

Action Planning


Monitoring

Intervening




An Overview Step 2 is where the Guided Pathways starts. Assessment is a collaborative process. In this Step, based on the intake information, GP coaches will work with the service users to identify their vision for a better life, and the needs, barriers, strengths, assets, and goals along the pathway to get to that vision. To reiterate, GP is not merely a problem-solving process. It is also a capacity building process. Assessment is not interrogation. Instead, it should be respectfully conducted in a culturally and linguistically sensitive manner. Service users should be informed of their risks and rights of disclosure of private information. Their participation is strictly voluntary. Actions and procedures to be taken 1. Since the assessment process requires a focused conversation and needs time (approximately 30 minutes to an hour), a scheduled appointment is needed. GP coaches should contact their service users in advance to explain the process and the time needed and remind service users to bring with them appropriate documents. 2. If language is an issue, GP coaches may need to arrange interpretation services in advance. 3. Before the assessment, GP coaches should remind service users of the consent form signed in Step 1 and explain the agency‟s confidentiality policies to service users. 4. GP coaches can start the process by encouraging service users to envision a desirable settled and integrated condition which can serve as a guiding post for the GP process.


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5. GP coaches should seek appropriate information from service users. Information collected should not only be limited to problems and barriers. Service users are also encouraged to identify and review their strengths and assets. 6. The assessment process may require service users to reflect back on their past experience. To some service users, this can be emotional. GP coaches are expected to use basic counselling skills and/or containment skills to support service users if needed. However, sometimes it is also a good idea to halt the process to allow service users to absorb all the information and have a „time out‟. 7. As part of the assessment process, any other existing service providers need to be identified in order to ensure a larger coordinated effort on behalf of the service user. The GP coach will focus only on settlement issues and will participate at the service users‟ request in any other processes. 8. GP coaches work with service users to preliminarily determine realistic and achievable S/I goals emerging from the identification of strengths, assets, needs and barriers and ensure that these goals fit with the GP process as determined by the agency GP coaches should also ensure service users understand the S/I process. Note: S/I service is not to replace or substitute formal psychological and family counselling service. If service users disclose and express strong emotional instability, mental disturbance, and family violence, the GP coach should consider terminating the assessment process and encourage service users to seek immediate help from the appropriate services. Referrals can be made as necessary. Suspected child abuse situations must be reported to MCFD promptly (Child, Family and Community Service Act of BC). Roles of GP Coaches In Step 2, the roles of GP coaches are: 1. Motivator: encouraging service users to look for a desirable future 2. Needs assessor: professionally assessing service users‟ expressed needs, barriers, strengths and assets 3. Facilitator: helping service users to identify their felt needs, barriers, strengths and assets 4. Advisor: providing guidance to service users in identifying and setting realistic and achievable goals 5. Emotional supporter: providing immediate brief counselling 6. Cultural navigator: equipping service users with knowledge of mainstream cultural practice and norms that can empower their adjustment capacity Forms to be used A GP assessment form (Form 2) is designed to facilitate the assessment process. Information included in the assessment forms the basis of GP intervention. The focus of the assessment is on service users‟ vision for a better life, and the needs, barriers, UBC School of Social Work: Guided Pathways – Final Report October 21, 2011

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strengths and assets in 11 major domains that are relevant to their settlement and integration vision and process. 1. Needs, barriers, strengths and assets There are many ways to understand what needs, barriers, strengths and assets are. Here are some basic understandings of these terms: a. Strengths are about personal qualities such as education, qualification, personality, skills (technical, language, life-skills), personal and work experience. b. Assets are resources that service users can mobilize such as material assets, familial and social networks. To many newcomers, their assets are both local and transnational. c. Needs are unmet wants and desires that service users will need in order to achieve a successful settlement and integration. d. Barriers are social, economic, structural, cultural, and personal obstacles that service users need to overcome to achieve a successful settlement and integration. We can roughly classify needs, barriers, strengths and assets into two different categories: a. Expressed: explicitly stated by service users b. Latent: indirectly indicated in the conversations and require GP coaches to probe and clarify with service users. GP coaches need to respectfully check with their service users if they observe any latent need, barrier, strength and asset in the process before they include this information in the assessment form 2. 11 domains Unlike the intake process, GP coaches will conduct an in-depth assessment on issues identified preliminarily in the intake form. Comprehensive review of assets, needs, and barriers in such life domains as: LIFE DOMAIN Family Housing Education Financial Immigration Social benefits Health Legal Labour market Adjustment/integration Other (as identified by service user)

STRENGTHS

ASSETS

NEEDS

BARRIERS


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It is understandable that the classification of these domains is always arbitrary and issues in these domains are very often intertwined in real life. However, intervention into any complex condition will still need some entry points. We recommend that at the beginning of GP, service users and coaches should collaboratively identify and determine no more than 3 domains that are the most critical to address. Then they will begin to identify goals within those three domains. 3. Service user: individual or family Very often, S/I service users are individual adults who seek help not only for themselves but also for their whole family. In the assessment process, GP coaches need to be cognizant of service users‟ scope of concerns: whether it is about themselves, other individual member, or about the whole family. In other words, the assessment should be multi-levelled (individual, couple, and family). However, the needs of individual members are not necessarily consistent with the needs of the whole family. We strongly advise that if service users have a concern about the S/I issue of individual members of the family, GP coaches should culturalsensitively encourage the service users to involve that particular member in the GP assessment and planning process. Unless service users express the need to have a GP process for an individual member, the assessment form should be used to include all concerned members. Options When the assessment is done, vision is set and preliminary goals are identified, there are three possible options for next steps. 1. Step 3: For service users who are ready to move on to a more intensive and structured working process, and the assessment of their needs and barriers matches with the GP, they will stay in the GP process and move on to Step 3. GP coaches at this point might invite the service user to think about what would work for them and to prioritize preliminary goals. Service users may return in a few days. If the needs assessment is only done with one member of the family, GP coaches should encourage service users to discuss with their family members their participation and level of involvement in the coming steps of the GP process. 2. Direct Exit – Service users have urgent and even life threatening needs that require immediate intervention from other BC systems or other BC S/I agency is more suitable to work with service users.


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3. Regular S/I Service: For service users whose needs can be met in an easier and faster way, and for service users who do not feel comfortable moving on to a more intensive and structured working process, they can be transferred back to the regular settlement service mode. When they are ready to go for the GP process again, they can contact their GP coach for a re-entering assessment. A re-entering assessment should be based on existing assessment to identify unmet and/or new needs.


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Step 3: Guided Pathways: Service Process


Service User



Goals Setting

Action Planning


Monitoring

Intervening




An Overview This step involves the development of a plan in collaboration with the service user, reflecting the vision, goals, and strengths of the service user while building an action plan that addresses needs, aspirations, and barriers. The GP service process includes four core components: Goal Setting, Action Plan, Intervention and Monitoring. The GP service process is cyclical and dynamic. Although each component has unique purposes and tasks, they are inseparable. Together they form the key working process in which service users and coaches realistically and flexibly address the S/I needs of the service users. With the support and guidance of GP coaches, service users will lay out and actualize a gradual and feasible action plan. In this process, through ongoing contacts and regular meetings with service users and other service partners, GP coaches monitor the planning and implementation process. When necessary, GP coaches and service users will revise or develop new action plans and activities to address changes in service users‟ life conditions. Actions and Procedures The separation of Step 2 (GP Assessment) and Step 3 is artificial and conceptual. In real situations, they can take place simultaneously and be time consuming and energy draining. GP coaches need to check in with service users before they start these steps as more than one appointment may be required to complete the full process. Each of the four components will require different actions and procedures. However, the inseparable and cyclical nature of the GP service process requires a high level of sensitivity and flexibility of GP coaches to work with service users to adjust the plan and procedures in accordance with the changing life condition and needs of service users.


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a. Goals Setting 1. Reviewing preliminary goals identified in Step 1, GP coach should encourage service users to brainstorm any goals that are relevant to the identified issues. 2. After the brainstorming, goals should be discussed and evaluated according to three criteria: a. Feasibility: availability of resource, service user‟s competence and skill level, accessibility to appropriate system, duration. b. Specificity: identifiable actions can be developed. c. Measurability: the progress and completion of the goal can be quantitatively measured by some agreed markers (see below). 3. Goals that meet the three criteria should be prioritized before moving to develop an action plan. The general principles of prioritizing goals include: a. Level of difficulty: Easier ones come first to build confidence. b. Immediacy: Goals that meet immediate need. c. Primacy: Goals that are prerequisite of other goals. d. Duration: Goals that require longer period of time to complete. b. Action Planning 1. The action plan should respond to the assessment of service users‟ vision, goals, needs, and barriers. A proactive approach is encouraged to assist service users to better utilize their strengths and assets in meeting their needs. 2. The action plan should outline an agreement on the responsibilities and tasks to be completed by both GP coaches and service users. 3. A finalized action plan will be signed by the GP coach and the service user. Service users will receive a copy of their plan. Note: Each family should have ONE action plan in which there can be separate items for individual members of the family. Records of all activities within the same action plan should be kept in the same file and reported as one case. However, if requested by an individual ADULT member of the family, GP coaches can consider opening a separate GP file for this member if they think this can better serve the individual and his/her family. For reporting purposes, each file is an independent case of the S/I program. c. Intervening: Provide Advice and Support 1. The GP process may involve other services from the same agency or other agencies. GP coaches need to advise service users of service options. 2. As noted in the assessment step, there may need to be a coordinated, cross agency meeting if other BC systems are involved (e.g., MCFD, Health UBC School of Social Work: Guided Pathways – Final Report October 21, 2011

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Authority, etc.). GP coaches are only responsible for the mandated settlement and integration issues and are expected to collaboratively work with other BC systems representatives in developing and monitoring a cohesive and complementary plan for the best interests of the service users. 3. Although GP process aims at fostering service users‟ independence, as part of the intervention, GP coaches will very often need to identify resources, make referrals, and advocate for services for service users. 4. GP coaches should maintain a regular contact with other service partners involved to ensure service user‟s progress in S/I process. Note: It might be useful for the Ministry to develop a protocol with other Ministries with whom they intersect on particular cases, especially MCFD and the Health Authorities. This would assist the settlement and integration sector workers to have valid reasons for being involved in any collaborative practices with BC systems. d. Monitoring 1. Based on the agreed timeline, GP coaches will schedule regular contact with service users to ensure implementation of mutually agreed upon activities. 2. A regular meeting should be scheduled at least once a month to review the action plan according to the agreed markers toward goal achievement, and the changing life conditions and needs of service users. 3. GP coaches maintain a regular contact with service partners to collect feedback for revising the action plan. 4. Discuss with service users any need for revising the short-term goals and action plan. 5. Any revisions of the action plan should be agreed by the service users and documented in the file. If new (or revised) timeline and markers are developed, they should be documented in file. Roles of GP Coaches In Step 3, the roles of GP coaches are multifaceted. 1. Planner: providing guidance to service users converting their needs into achievable goals, and developing step-by-step activities within reasonable timeframe to meet the goals. 2. Motivator: proactively motivating service users to maximize their strengths and assets and to seek and advocate for themselves new resources to meet their own needs and overcome their barriers. 3. Catalyst: creating opportunities for service users to utilize their own potentials and appropriate resources to make positive changes.


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4. Educator: sharing direct and instructive knowledge with service users to navigate the systems. 5. Advocate: advocating on behalf of the service users for appropriate resources. 6. Service liaison: liaising with multiple service partners to ensure meeting the agreed goals. 7. Emotional supporter: dealing with service users‟ emotional ups and downs when facing difficult challenges. 8. Cultural navigator: equipping service users with knowledge of mainstream cultural practice and norms that can empower their adjustment capacity 9. Monitor: assuring a proper implementation of an action plan and a smooth and prompt adjustment of service process. Forms to be used Two forms are recommended to be used in Step 3. The Action Plan is the most crucial one. For reporting purposes, a quarterly monitoring form will track information that is required by the Ministry. 1. Action Plan (Form 3): This is an orderly scheduled series of actions to fulfill the goals agreed by the GP coaches and the service users. A plan will include achievable goals, actions to address the goals, timeline, markers of progress and desirable outcome. GOALS

ACTIONS

TIMELINES

MARKERS

OUTCOMES

(Where do you want to go?)

(What needs to happen to complete the goals?)

(Who does what, when?)

(How do you know you are on your way?)

(What is the desirable condition after actions are taken as planned?)

a. Based on the assessment, GP coaches and service users need to prioritize the goals into a) short-term (within three months), b) medium-term (within 12 months) and c) long-term (over 12 months). In the beginning of GP, we strongly recommend that GP coaches realistically focus on the short-term and medium-term goals of the up to three domains that are identified in the assessment by the service user. It is important that GP coaches work with service users to plan for a stepwise strategy to meet the agreed medium-term goals. A stepwise strategy means using two to three consecutive periods (a maximum of three months), during each of which not more than 3 short-term goals are set and expected to be completed, to reach the medium-term goal in 12 months. b. When planning for action, the following issues should take into consideration: i. Service users‟ vision for their life. ii. Service users‟ own strengths, assets and readiness. UBC School of Social Work: Guided Pathways – Final Report October 21, 2011

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iii. Availability and accessibility of resources and services. iv. Potential safety and risk issues to service users and others. c. A timeline is a realistic duration within which an action will be completed. GP coaches should use the timeline to assist service users to move forward gradually towards their goal. In other words, the timeline is also a tool for monitoring. The timeline is not only to keep track of service users‟ actions. It is also an important tool to ensure GP coaches and other service partners provide timely services to support service users‟ to meet the identified goals. Therefore, a timeline on the action plan should specify who will do what by when. The time frame for achievement of goals should be realistic, and iterative. In other words, there should be acknowledgement that the plan may change as goals are achieved or not, others emerge, through the monitoring process. d. Markers help tracking progress. There are three types of markers to be considered: i. Behavioural: Markers indicate action/activity taking place, e.g., service users are in ELSA class regularly. ii. Normative: Markers indicate professional rated progression, e.g., service users can put a two-page resume together. iii. Perceptual: Markers indicate service users‟ subjective perception of progress, e.g., service users feel they are more confident in negotiating with landlord. Both behavioural and normative markers are quantifiable and the perceptual one is subjective but will need to be converted into measurable scale such as a Likert scale. An example of a five-level Likert item for a perceptual marker: I am achieving the agreed goals. 1. Strongly disagree 2. Disagree 3. Neither agree nor disagree 4. Agree 5. Strongly agree e. Outcome: Measurable and quantifiable indicators are needed to measure the level of achievement of the stated goals. 2. Quarterly Monitoring Form (Form 4): This form is to capture data in a snapshot status of GP at a fixed time (please refer to the Ministry‟s reporting requirements). The data include: UBC School of Social Work: Guided Pathways – Final Report October 21, 2011

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a. Regular S/I data (please refer to RFP document). b. Domains identified: domains under which the identified needs and agreed goals in the GP action plan are listed. c. Which GP Step the service user is currently at? d. If the service user is in Step 3, what is the progress? (Refer to Markers) e. *If the service user has exited from the program, what is their exit outcome? f. *If post-exit follow-up has been done, what is the follow-up outcome? *For details of d and e please refer to Steps 4, 5 and 6. Options Preparing for next step: 1. Close to the end of GP Service Process, GP coaches review service users‟ readiness to exit from GP process. 2. Explain and reiterate the likely or potential transition to alternatives, roles, and responsibilities to the service users at appropriate junctures that allow ample time for considerations, questions and adjustment (NCMN, p.14). Options for next step: There are three possible options for service users when the GP Service Process finishes. 1. 2. 3. 4.

Transition to other BC systems. Transfer to other BC S/I service agencies. Exit from GP and refer to regular S/I process. Exit from GP and service users do not need any further kind of assistance in settlement and integration process.

All these 3 options signify the termination of GP process. An exit outcome will be needed. Option 1 and 2 are exit outcomes. For option 3, as exit outcome, it will be split into two: exit when completed the GP process as planned and exit but GP process was not completed as planned. S/I service is a voluntary service. Although expected, service users may not necessarily follow through the agreed action plan. Service users may quit the program without informing their GP coaches. GP coaches should respect service users‟ decision to quit the GP process prematurely. However, if possible, GP coaches should explore the reasons and clarify the exit status with service users. Relevant information should be documented in service user‟s file and reported in the Quarterly Report Form. On-going and regular contacts with service users are useful to prevent losing contact and premature termination.


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Step 4: Transition


Service User



Goals Setting

Action Planning


Monitoring

Intervening




An Overview Transition is a concept proposed in the National Case Management Network (2009). As stated (NCMN, 2009), this is “a process that supports disengagement or shift in the mechanisms for achieving client goals” (p.16). S/I can be a complex and life-long process. In some situations, GP service users may require extended support from other BC systems. These situations include: 1. Service users‟ S/I needs are met but the users have issues that are beyond what the GP process can support. 2. Some complicated personal and family issues hamper service users making further progress in the GP process. 3. Service users relocate to different locations. In these situations, GP coaches discuss with service users shifting to different systems for extended assistance. Note: Transition means shifting from BC S/I system to other BC systems such as MCFD, hospitals etc. Transfer means shifting from existing BC S/I agency to other provider of BC S/I system.


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Actions and Procedures 1. Identify unmet needs and gaps in service or support structure for service users that hamper service users from meeting their needs. 2. Discuss disengagement and the options of transition/transfer with service users as early as possible. 3. Provide service users with information of different alternatives and make sure that they understand the service and commitment 4. Support service users to seek and secure appropriate service. 5. If necessary, initiate transition and transfer with potential transition/transfer agency. 6. Seek service users‟ consent of sharing information with other agencies. 7. Ensure a timely exchange of information with transition/transfer agency when it is needed for the execution of transition. Roles of GP Coaches GP coaches are expected to be: 1. Enabler: supporting and encourage service users to independently seek and advocate services that can meet their unmet needs 2. Broker: identifying alternative services with service users and connect them with the potential service organization 3. System navigator: assisting service users to navigate the BC system Forms to be used The transition/transfer process may require exchange of service users‟ information including records of GP process. Very often transition and transfer are done through phone contact. Therefore, no form may be required. But information about the service user‟s transition or transfer should be documented in the file and reported in the Quarterly Report Form. And some BC systems may have their own referral form which GP coaches may have to use. The consent forms in Step 1 and 2 should be reviewed with the service user to remind them of the guidelines for principles safeguarding privacy. Options When service users are transitioned/transferred to other systems, the GP process finishes. An exit evaluation and outcome will be needed.


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Step 5: Evaluation (outcomes and other) and Exit Direct Exit a. Transition to other BC systems b. Transfer to other BC S/I agency

Service User



Goals Setting

Action Planning

Step 4: Guided Pathways a. Transition to other BC systems b. Transfer to other BC settlement agency Step 6: Guided Pathways Follow Up (To be determined with client)

Monitoring

Intervening



An Overview Evaluation is a part of the monitoring process. Its purposes are to: 1. Check the status of service users before they exit the GP process. 2. Determine if service users made progress towards the identified goals within the action plan (short to medium term). 3. Determine the level of success of the GP process in assisting service users in the S/I process (long term). 4. Inform the readiness of service users for post-GP S/I process. 5. Seek information that can improve future GP process. Evaluation can be simple and easily adaptable to existing databases. Evaluation should maintain a balance of three different dimensions: 1. Were the set goals of the GP process met? 2. How helpful has the GP worker been in the process? 3. According to the Ministry‟s logic model and reporting requirements, were the desired client outcomes achieved? a. Were there any unintended outcomes related to S/I issues, which were not part of the set goals of the GP engagement?? Answers to these questions should be both qualitative (service users‟ narratives) and quantitative (measurable indicators).


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Actions and Procedures Step 4 (GP Transition) and Step 5 are almost simultaneous, although most GP service users may not need to go through Step 4 and move directly from Step 3 (GP Process) to Step 5. GP coaches should be sensitive and flexible that some service users may have to return to Step 4 when unmet needs are found in the evaluation. Evaluation can be sensitive. GP coaches need to be respectful, reflective, and openminded particularly when seeking service users‟ feedback on the services that they provided. There may be different ways to collect data that do not involve the GP coaches that will need to be thought through. 1. If possible, make sure a neutral formal evaluation process is in place. 2. Document quantifiable impact on and specific movement towards service users‟ goals. 3. Collect quantifiable data to evaluate conditions. 4. Document service users‟ narratives of their GP experience. 5. Discuss a timeframe for post-GP follow up. Roles of GP Coaches In the evaluation stage, GP coaches are: 1. Evaluator: collecting and analyzing relevant data. 2. Planner: assisting service users to plan for post-GP S/I process. 3. Enabler: encouraging service users to learn from the GP process and to solve future S/I related problems independently. Forms to be used An evaluation form will be a useful guide for the evaluation process and document outcomes. The form captures the following information: 1. Action plan related indicators: a. How many of the service users‟ goals are met? b. How well was the action plan followed in terms of timeframe and activities? c. Were the preset outcomes met? d. How satisfied are service users with their own efforts? e. How satisfied are service users with the GP coach‟s assistance? 2. Service users‟ perception of their improved confidence and comfort with service users in independently managing future S/I needs and processes. A Likert scale measurement of these indicators is useful for evaluating BC S/I program.  Service users gain knowledge related to selected domains of life in Canada.  Service users understand social expectations and norms of selected domains.


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 Service users have the ability to function in daily life of selected domains.  Service users have access to public services and community resources for

issues of selected domains.  Service users make connections to social and economic networks as well as the broader community.  Service users have the ability to navigate various systems related to the selected domains independently.  Service users experience higher life satisfaction. Options Evaluation is a status or progress check to make sure S/I needs are met according to the agreed action plan. If unmet needs are identified, the GP coach should discuss with service users the need to reinitiate a new GP process. Before service users officially exit the program, GP coaches should discuss a post-GP follow up.


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Step 6: Follow up Direct Exit a. Transition to other BC systems b. Transfer to other BC S/I agency

Service User



Goals Setting

Action Planning


Monitoring

Intervening




An Overview The purpose of GP follow up is to: 1. Collect data on the updated status of service users. 2. Ensure service users‟ independence in handling their S/I process. 3. Identify new service needs that may require a renewed GP process. Actions and Procedures GP follow up should be done with mutually agreeable frequency and timeframe. Realistically the first follow up should be within three months of exit and the GP follow up be at most up to six months. Generally, follow up will be done by phone. However, if necessary, a formal in person appointment may be needed particularly when service users indicate a need to renew the GP process. Roles of GP Coaches In the follow up process, GP coaches are expected to maintain a minimal role. 1. Friendly supporter: ensuring service users feel competent in handling S/I process. 2. Evaluator: collecting update data regarding the status of service users. 3. Resource person: providing quick advice and information to service users for some minor S/I issues.


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Forms to be used The exit and evaluation form (Form 5) will also be used to track the information collected, which will include: 1. Updated status. 2. Narrative. 3. Follow up actions. Options In principle, this is the last step of GP process. However, in some situations, service users may experience new unmet S/I needs that require the attention and action from S/I program providers. We recommend three options: 1. Referring to providers of other BC systems. 2. Referring to regular settlement service within the same agency or other provider of BC settlement service system. 3. Reinitiating the GP process.


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H. SUMMARY OF RECOMMENDED FORMS We propose at least five forms and possibly one consent form, building on the one found in the RFP. We would like to receive more feedback on the substantive areas to be included in these forms before we develop any form templates. Therefore, items of each form included below are not in an actual format. They are for discussion purposes only. We also recognize the fact that many S/I providers have already developed their own forms and recording systems. Therefore, we are open to the idea that we do not need a set of standardized GP forms. Given the strong desire of flexibility and respect of each agency‟s own strengths and limits, we feel that S/I agencies may consider modifying their own systems by integrating items suggested here into their existing forms instead of us reinventing a new forms system.

Form 1: General Intake Form Purpose: The form is to serve collecting baseline information for the settlement workers to determine the needs of service users who seek help from S/I system. Design and use: The form should have at least two key sections. 1. The first section will be for regular identifiable data:  Name  Contact information (address, telephone #, email address)  Gender  Age  Country of origin  Primary language  Immigrant status  Category of entry  Date of entry to Canada  Level of education  Current employment status  Family constellation  Unique client ID  Experience with S/I system (first time or repeat or user of other S/I agencies) Section Two is about identifiable needs according to 11 major domains. It will be in a check list format. Intake workers can either go through the list one by one or extract information from a casual conversation with the service users. Once the form is done, it should be dated and signed by service users and intake workers.


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Domain 1. Family

Common Issues Family relationship and dynamics Individual members S/I issues Issues related to family members outside Vancouver and/or Canada Family reunion 2. Housing Accessibility Affordability Housing condition Conflicts with landlord 3. Education Credential recognition Upgrade Accessibility to education system Children‟s school adjustment Language training 4. Financial Immediate financial shortage Banking system Budgeting Sponsorship breakdown Financial resource to support qualification upgrade 5. Immigration Family reunion Refugee claimant Citizenship application 6. Social benefits Access to social assistance Employment insurance Child benefits Sponsorship breakdown 7. Health Specific needs regarding physical and mental health, disability and HIV/AIDS Access to health care Navigation of the health care system 8. Legal Legal rights and responsibilities Navigating the legal system Needs of representation and advocacy 9. Labour market Canadian labour market information Culturally appropriate job search skills and strategies Skills and qualification upgrade Canadian workplace culture and legislations Work permit application and renewal 10. Adjustment/ Perception of social wellbeing integration Establishing functional social networks Perceived ability to engage in social activities Dominant cultural norms and practice Experience of discrimination 11. Others S/I issues identified by service users


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Form 2: GP Assessment Form Purpose: This form is a tool for GP coaches and service users to collaboratively identify and record the service needs, barriers, strengths and assets of service users. Design and use: GP coaches should use this form in a creative way. The assessment process should be conducted in a friendly manner. GP coaches should confirm with service users before writing any information on the assessment form. Items to be included in the form are: 1. Vision: A statement to document service users‟ vision of the desirable S/I condition. 2. Assessment of Strengths/Assets/Needs/Barriers/Goals of selected domains. LIFE DOMAIN Family Housing Education Financial Immigration Social benefits Health Legal Labour market Adjustment/int egration Other (as identified by service user)

Needs

Barriers

Strengths

Assets

Preliminary Goals

Generally, each family should have one assessment form. Nonetheless, depending on the complexity and nature of issues that service users identified, we may need a separate assessment form for individual family members. GP coach can discuss with the family to determine the best way for the family as well as its individual members to optimally utilize the GP to enhance their settlement and integration process. To do so, the individual members should take part in the assessment process in person.


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Form 3: GP Action Plan Purpose: This is a form that serves as a working agreement between GP coaches and service users. The form should precisely and concisely document the prioritized goals and the actions agreed by both parties. It also serves as a work schedule to track the activities and progress. Design and use: The form will include information on five interconnected items. 1. Based on the assessment form, GP coaches should work out a priority among all preliminary goals identified by service users. 2. Within each goal, GP coaches and service users should determine what possible activities and what kind of resources are needed to achieve the goal. 3. When the activities and resources are decided, it should be noted clearly who should do what by when. 4. Markers of progress should be mutually established and documented. 5. Facilitated by the GP coaches, service users are expected to anticipate a desirable condition when activities are done and resources are solicited. Outcomes should be modest and realistic. GOALS

ACTIONS

TIMELINES

MARKERS

OUTCOMES

(Where do you want to go?)

(What needs to happen to complete the goals? What resources will be needed?)

(Who does what, when?)

(How do you know you are on your way?)

(What is the desirable condition after actions are taken as planned?)

6. Signatures from both parties on the action plan are needed. 7. If later changes are made, service users‟ initials on the changed items will be needed. Form 4: Quarterly Monitoring Purpose: This form is to track the progress and current status of the service user. Agencies can consider if in their existing information system, they have other channels collecting these data already. Design and use: Each GP coach will need to fill in ONE Quarterly Monitoring Form once every three months. On the form, there will be a column to identify each service user by case number with whom the GP coach is working.


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Items on the form are: a. Regular S/I data (please refer to RFP document). b. Domains identified: domains under which the identified needs and agreed goals in the GP action plan are listed. c. Identification of which stage of GP Step the service user is currently at. d. If the service user is in Step 3, what is the progress (in percentage of achieving goals)? e. If the service user has exited from the program, what is their exit outcome (Transition to where, Transfer to where, Exit with completion and Exit without completion)? f. If post-exit follow-up has been done, what is current situation of service users? Tentative categories of these situation can be: i. No need of S/I service ii. Considering returning for S/I service iii. Receiving service from other BC S/I agency (which agency?) iv. Receiving service from other BC systems (which agency?) v. Others Form 5: Exit, Evaluation and Follow Up Purpose: This form is to capture the outcome at exit and to capture outcome at follow up. It will be an important indicator to show the success of each GP case. Design and use: Under desirable conditions, when the service users finish their GP process, they have time to either sit down with or talk on the phone with their GP coach to debrief the GP process. However, in many situations, this may not happen. GP coaches are expected to contact service users to collect information for this form. Items to be collected: A. Exit options: 1. Action plan related indicators: a. How many of the service users‟ goals are met? (simple counting) b. How well was the action plan followed in terms of timeframe and activities? (in Likert scale) c. Were the preset outcomes met? (in percentage) d. How satisfied are service users with their own efforts? (in Likert scale) e. How satisfied are service users with the GP coach‟s assistance? (in Likert scale) 2. Service users‟ perception of their improved confidence and comfort of service users in independently managing future S/I needs and processes. A Likert scale measurements of these indicators are useful for evaluating BC S/I program.


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   

Service users gain knowledge related to selected domains of life in Canada. Service users understand social expectations and norms of selected domains. Service users have the ability to function in daily life of selected domains. Service users have access to public services and community resources for issues of selected domains.  Service users make connections to social and economic networks as well as the broader community.  Service users have the ability to navigate various systems related to the selected domains independently.  Service users experience higher life satisfaction. GP coaches are encouraged to take down notes (even in verbatim manner) of comments made by service users on the evaluation form. B. Follow Up: 1. Updated status: any change (good or bad) from outcome at exit. 2. Narrative: what happened and why? 3. Follow up actions: see Step 6.

Consent form(s) At this point, we recommend only one consent form should be used. We understand that the Ministry has a consent form on the RFP document which seems to be for all S/I service users. We propose a revision of this consent form which could include: 1. 2. 3. 4. 5. 6. 7.

Principles of confidentiality and privacy. Rights to stop and even withdraw from the process with no penalty. Benefits for sharing information with GP coaches. Possible risks and harms for sharing information with GP coaches. What measures will the agency do to mitigate these possible risks? Needs for exchange and sharing information for transition and transfer purposes. Rights to refuse or select partial exchange of information with involved or receiving BC systems.

The form should be explained and signed in the intake process.


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Case Management Reference Resources Ballew, Julius R. & Mink, George (1997). Case management in social work: Developing the professional skills needed for work with multiproblem clients (2nd Ed). Springfield: Charles C. Thomas. Barrett, William, Todahl, Jeffrey, & Christensen, Dana. (1999). Solution-based casework: An introduction to clinical and case management skills in case work practice. Aldine Transaction. Cesta, Toni G., Conover, Mary Boudreau, & Tahan, Hassein, A. (2002). The case managers survival guide: Winning strategies for clinical practice (2nd Ed). Mosby Connecticut Department of Public Health (2008). Case Management Standards of Care Manual. Website: http://www.ct.gov/dph/cwp/view.asp?a=3135&q=387020, Frankel, A.J. & Gelman, S.R. (2004). Case management: Introduction to concepts and skills. Chicago, Il. : Lyceum Books. Gursansky, Di, Harvey, Judy & Kennedy, Rosemary (2003). Case management: policy, practice and professional business. Columbia University Press. Holt, Barbara (1999). The practice of generalist case management. Allyn & Bacon. Moxley, D.P. (1989). The practice of case management. Newbury Park, CA.: SAGE. Moxley, David, (1997). Case management by design: Reflections on principal and practices. Brooks Cole. Mullahy, Catherine (2010). The case managers‟ handbook (4th Ed). Sudbury, MA: Jones and Bartlett. National Case Management Network. (2009). Canadian Standards of Practice for Case Management. Health Canada. National Settlement Service and Standards Framework. (2003). Ontario Ministry of Children and Families (1999). Integrated Case Management: Participants‟ Manual. Downloaded from http://www.mcf.gov.bc.ca/icm/pdfs/participants.pdf. Ontario Ministry of Community Safety and Correctional Services (2004). Ontario Major Case Management Manual. Downloaded from http://www.attorneygeneral.jus.gov.on.ca/inquiries/cornwall/en/hearings/exhibits/OP C/pdf/56_MCM_Manual.pdf.


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Plocher, David. W. & Metzger, Patricia (2001). The Case manager‟s training manual. Aspen Publishing. Powell, Suzanne K. (2000). Case management: A practical guide to success in managed care. Baltimore: Lippincott Williams & Wilkins. Raiff, Norma R. & Shore, Barbara (1993). Advanced case management: New strategies for the nineties. SAGE. Roger G. Kathol, Perez, Rebecca, & Cohen S.Janice.(2010). The integrated case management manual: Assisting complex patients regain physical and mental health. New York: Springer Publishing Co. Rothman, Jack & Sager, Jon Simon. (1997). Case management: Integrating individual and community practice (2nd Ed). Allyn & Bacon. Saleeby, Dennis. (2009). The Strengths Perspective in Social Work Practice. (5th Ed). Pearson. Spindel, Patricia (2008). Case management from an empowerment perspective: A guide for health and human service professionals. Mississauga: Nu-Spin Publications. Summers, Nancy (2008). Fundamentals of case management practice: Skills for human services (3rd Ed). Brooks Cole. VanDenBerg, John, Grealish, Mary. (1997). Finding Families Strengths: A MultipleChoice Test. Reaching Today‟s Youth: The Community Circle of Caring Journal. (Volume 1, Issue 3). National Education Service. Vermont Agency of Human Services (2008). Case management certification Exam: Study guide and reference manual. Downloaded from http://www.ddas.vermont.gov/ddas-policies/policies-qmu/policies-qmudocuments/oaa-cfc-case-management-certification-reference-manual-and-studyguide. Walker, J. S., Koroloff, N., & Schutte, K. (2003). Implementing high-quality collaborative individualized service/support planning: Necessary conditions. Portland OR: Research and Training Center on Family Support and Children's Mental Health.

Weil, M., Karls, J.M. & et al., (1985). Case management in human service practice: A systematic approach to mobilizing resources for clients. San Francisco, CA.: The Jossey-Bass.


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References

Citizenship and Immigration Canada. http://www.cic.gc.ca/ Canadian Council for Refugees. (2000). http://ccrweb.ca/ De Coito, P., & Williams, L. (2000). Setting the Course: A Framework for Coordinating Services for Immigrants and Refugees in Peel Region. Mississauga: The Social Planning Council of Peel. Creese, G., Dyck, I., & McLaren, A. (1999, March). Reconstituting the family, Negotiating Immigration and Settlement, Working Paper Series, Research on Immigration and Integration in the Metropolis. Day, C. (1996). The evolution of case management: One organization‟s experience. Nursing Case Management, 1(2), 54-58. Hiebert, D., & Sherrell, K. (2009, November). The integration and inclusion of newcomers in British Columbia. Working Paper Series, Metropolis British Columbia. 44. Hiebert, D. (2005, June). Migration and the demographic transformation of Canadian cities: The social geography of Canada‟s major metropolitan centres in 2017. Working Paper Series, Metropolis British Columbia. Heinonen, T. & Spearman, L. (2010). Social work practice: Problem solving and beyond (3rd ed.). Toronto, Ontario: Nelson Education. Moxley, D. P. (1989). The practice of case management. California, USA: Sage Publications Inc. National Case Management Network. (2009). Canadian Standards of Practice for Case Management. Health Canada. National Settlement Service and Standards Framework. (2003). Ontario Council of Agencies Serving Immigrants, (2000). Training Guide. Drolet, J., Robertson, J., & Robinson, W. (2010). Settlement experiences in a small city: Voices of Family-class Immigrants, and of Settlement Workers. Canadian Social Work,12(1): 218-223. Riaño-Alcalá, P. R., Colorado, M., Díaz, P., Osorio, A. (2008). Forced migration of Columbians: Columbia, Equador, Canada. Medellín, Columbia: Corporación Región and Vancouver, Canada: University of British Columbia.


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Tocchi, S. (Oct. 2008). Hiring Immigrants - Not just a social justice proposition: A Canadian Perspective. 13th International Metropolis Conference. http://www.metropolis2008.org/pdf/20081029/workshops/w065-29_tocchisilvano.pdf Valtonen, K. (2008). Social work and migration: Immigrant and Refugee Settlement and Integration. Surrey, England: Ashgate Publishing Inc. Werrback, G. B. (1994). Intensive child case management: work roles and activities. Child and Adolescent Social Work Journal, 11(4), 325-341. Yan, M. C. (n.d.) Case Management: Why, what and how. PowerPoint presentation.


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APPENDIX 1. Regional Meeting Questions........90 2. Interview Guide............................91 3. Survey Guide ................................93


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CASE MANAGEMENT MODEL FOR THE IMPLEMENTATION OF THE GUIDED PATHWAYS PROGRAM - REGIONAL MEETINGS QUESTIONS FOR CONSIDERATION Please invite someone to summarize your groups’ conversations in point form for submission to the UBC Research Team. Thank you.

1.

Based on our research, we have defined case management as, “ a process through which the professional practitioner and his/her service user collaboratively determine, secure, coordinate and monitor “an orderly and planned provision of services intended to facilitate a client‟s functioning at as normal a level as possible.” (Weil and Karls, 1985). Do you agree with our definition of case management?

2. What are some of the key elements of case management, in your opinion? (e.g., needs assessment? Planning?, etc.) 3. Do you „do‟ case management in your agency? If yes, what does this service look like? 4. What do you need answered in the Operational Guidelines for Guided Pathways? 5. What resource materials should we be developing that would be helpful for you? 6. Given the usage of the words “Guided Pathways” should we be changing the language found in the literature to „fit‟ the new model? 7. What recommendations do you have about what the training plan should include? 8. What else do we need to know?


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CASE MANAGEMENT MODEL FOR THE IMPLEMENTATION OF THE GUIDED PATHWAYS PROGRAM INTERVIEW GUIDE Preamble: Introduce the project, the Guided Pathways is a case management approach for settlement and integration sector, the model being developed based on literature review, feedback from sector both qualitative and quantitative, then draft model to regional meetings, final feedback and presentation to the Ministry by the end of summer. Questions 1. What services does your agency provide? 2. What is your position at your agency? How are you involved in case management? 3. The working definition of case management we are using is “Case management is a process through which the professional practitioner and his/her service user collaboratively determine, secure, coordinate and monitor “an orderly and planned provision of services intended to facilitate a client‟s functioning at as normal a level as possible and as economically as possible” (Weil and Karls, 1985). How does this definition fit into your agency‟s service delivery model? 4. Case management in settlement services has been described as consisting of these main elements: a. Needs assessment b. Goal planning c. Coordinating services and resources d. Advocating for the client e. Advocating for services and resources f. Coaching and ongoing support g. Progress and outcome monitoring h. Evaluation of achievement of goals i. Transitioning out or disengagement. 5. From your experience of working in your agency, please describe what you do in relation to each of these elements. Please go through the list one by one. 6. Are there any elements of case management missing from this list? Please explain.


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7. What kind of documentation system does your agency have for case management and how does it work? (Probe for: written policy, standard forms, computerized data collection, how client progress is monitored, what kind of data is being collected) 8. What kind of data do you think should be collected to track service user progress and results in a Guided Pathways process? 9. What should the Operational Guidelines include? (Policy about Guided Pathways) 10. What resource materials would help you? 11. We have been asked to make recommendations about training Guided Pathways. What ideas do you have about the best way for staff in the sector to be trained in this model? 12. Can we contact you again for more information or any possible clarification? 13. Any final comments or questions?


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CASE MANAGEMENT MODEL FOR THE IMPLEMENTATION OF THE GUIDED PATHWAYS PROGRAM SURVEY

Conducted by a group of researchers from the UBC School of Social Work, this survey is part of the Delivery Assistance Project, Case Management Model for the Implementation of the Guided Pathways Program funded by the Ministry of Jobs, Tourism, and Innovation, (formerly Ministry of Regional Economic and Skills Development) Immigrant Integration Branch. The project is to develop a case management model of service delivery, which is also called by the Ministry, the Guided Pathways, for the settlement services sector. The purpose of this survey is to find out the elements of case management you and your agency might currently be using and/or want to use in your settlement practices which will help inform the development of the Guided Pathways model. We appreciate your knowledge and expertise. It should only take approximately fifteen minutes of your time. Your participation is purely voluntary. You are under no obligation to complete the questionnaire, and you may stop participating at any time after you start. If you complete and return the questionnaire, this will be considered as your consent to being a participant in the study. All the information that you share with us will be kept strictly confidential. No one outside our research group at UBC, nor the Ministry, will see your responses, and your name and responses will not be identifiable in our analysis. If you have any questions about your rights or treatment as a research subject, you may contact the UBC Research Subject Information Line at 604 – 822 – 8598. Members of the Research Group: Elizabeth Jones ([email protected], 604 822 6220) Miu Chung Yan ([email protected], 604 822 8688) Pilar Riaño (priañ[email protected], 604 827 5493)


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QUESTIONS: A: Tell us about you: To put your responses into context, it is important to give us an idea of what type of agency you work at and the position you hold. Please indicate your answer by circling or underlining the correct response. 1. What is your position at your agency? a) Executive Director b) Manager of services c) Coordinator d) Line staff e) Other (Please specify) ______________________________________ 2.

Does your agency provide settlement and integration services? a) Yes b) No (If you choose this answer, please jump to question #5.

3. What are the major funding sources for your settlement and integration services? a) BC Ministry of Jobs, Tourism, and Innovation b) Ministry of Citizenship and Immigration Canada c) Municipal government d) United Way e) Private donation f) Others (Please specify)________________________________________ 4. What kind(s) of settlement and integration service does your agency provide overall? a) Information referral b) Settlement service counselling c) English as second language training (e.g., ELSA) d) Mentorship program (e.g., Host program) e) Employment service f) Family program g) Youth Program h) Other service for marginal groups (please specify) i) Other program (Please specify)____________________________________ B. Case Management: Case management is a process through which the professional practitioner and his/her service user collaboratively determine, secure, coordinate and monitor “an orderly


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and planned provision of services intended to facilitate a client‟s functioning at as normal a level as possible and as economically as possible” (Weil and Karls, 1985). 5. There are numerous case management elements that are used across a variety of social service practices. Below is a list of elements with a clarifying definition following. Please check those that you and/or your staff currently include in your agency‟s settlement and integration service delivery process. (Please check all the appropriate ones).

Element Needs assessment (What does the service user need?) Goal planning (What does the service user want to achieve?) Coordinating services and resources (Ensuring no duplication) Linking client with services and resources (Ensuring that needs are met through other resources) Advocating for service user (Arguing for the needs of the individual) Advocating for services and resources (Arguing for the needs of the collective group) Coaching and on-going support ((Supporting and directing the work with the service user) Progress and outcome monitoring (Checking in to ensure movement towards service user goals) Evaluation of achievement of goals (Ensuring service user goals are met) Transitioning out or disengagement (Leaving guided pathways process)

Include

Not sure


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6. Are any of these elements not applicable to the work you and/or your staff do in delivery of the settlement and integration services at your agency? (Please check all the appropriate ones). Element Not applicable Needs assessment (What does the service user need?) Goal planning (What does the service user want to achieve?) Coordinating services and resources (Ensuring no duplication) Linking client with services and resources (Ensuring that needs are met through other resources) Advocating for service user (Arguing for the needs of the individual) Advocating for services and resources (Arguing for the needs of the collective group) Coaching and on-going support ((Supporting and directing the work with the service user) Progress and outcome monitoring (Checking in to ensure movement towards service user goals) Evaluation of achievement of goals (Ensuring service user goals are met) Transitioning out or disengagement (Leaving guided pathways process)


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7. In future, as you implement the Guided Pathways model, what elements would you like to continue to include in your agency‟s service delivery process? (Please check all the appropriate ones).

Element Continue to include Needs assessment (What does the service user need?) Goal planning (What does the service user want to achieve?) Coordinating services and resources (Ensuring no duplication) Linking client with services and resources (Ensuring that needs are met through other resources) Advocating for service user (Arguing for the needs of the individual) Advocating for services and resources (Arguing for the needs of the collective group) Coaching and on-going support ((Supporting and directing the work with the service user) Progress and outcome monitoring (Checking in to ensure movement towards service user goals) Evaluation of achievement of goals (Ensuring service user goals are met) Transitioning out or disengagement (Leaving guided pathways process)

Not sure


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. 8. In future, as you implement the Guided Pathways model, what elements would you like to include that have not yet been included in your agency‟s service delivery process? (Please check all the appropriate ones.) Element Needs assessment (What does the service user need?) Goal planning (What does the service user want to achieve?) Coordinating services and resources (Ensuring no duplication) Linking client with services and resources (Ensuring that needs are met through other resources) Advocating for service user (Arguing for the needs of the individual) Advocating for services and resources (Arguing for the needs of the collective group) Coaching and on-going support ((Supporting and directing the work with the service user) Progress and outcome monitoring (Checking in to ensure movement towards service user goals) Evaluation of achievement of goals (Ensuring service user goals are met) Transitioning out or disengagement (Leaving guided pathways process)

Would like to include

Not sure


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9. Which of the elements do you and/or your staff need training in? (Please check all the appropriate ones? Element Need training Needs assessment (What does the service user need?) Goal planning (What does the service user want to achieve?) Coordinating services and resources (Ensuring no duplication) Linking client with services and resources (Ensuring that needs are met through other resources) Advocating for service user (Arguing for the needs of the individual) Advocating for services and resources (Arguing for the needs of the collective group) Coaching and on-going support ((Supporting and directing the work with the service user) Progress and outcome monitoring (Checking in to ensure movement towards service user goals) Evaluation of achievement of goals (Ensuring service user goals are met) Transitioning out or disengagement (Leaving guided pathways process)


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10. What modality would you like this training to be? (Please circle or underline all the appropriate ones). a) b) c) d) e)

Online In class Combination of in class and online Self directed learning Other (Please specify)__________________________________________

11. If you are currently using a case management model, how do you currently collect data? a) Computer program: (Please specify the program‟s name) __________________ b) Paper format i. No ii. Yes:  If yes, do you have a standard form?  No  Yes 12. Describe what kind of data is being collected if you are already using a case management approach.

13. Describe what kind of data you think should be collected to track service user progress and results in a Guided Pathways process.

14. What should the Operational Guidelines, which is the Policy for Guided Pathways, include?


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15. What resource materials would help you implement the Guided Pathways approach?

16. Do you have any final comments that will inform the development of the Guided Pathways approach?

17. Can we contact you to consult on your case management model? If yes, please provide your name, email address, and phone number.

Thank you very much for taking the time to complete this questionnaire.


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GUIDED PATHWAYS PROCESS FINAL REPORT ... - Open School BC

GUIDED PATHWAYS PROCESS FINAL REPORT ... - Open School BC

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