Monday, August 31, 2009

Healthcare Bureaucracy and Client Persistence

A couple weeks ago Kenny, a client I don't hear from often, called me, close to tears, and told me that he had been unsuccessful in trying to reach his healthcare provider to get him a new battery for his wheelchair. His chair stopped working a couple of weeks before that so he had called the company and someone did come out to look at his wheelchair and told him he needed a new battery. But from there to getting the battery -- Kenny wasn't able to get a straight answer from anyone, he told me. Due to his health condition not having a wheelchair meant he had no way of leaving his home without help. He relied on a good friend to take him to various appointments but his friend wasn't always able to take him because he worked two jobs.

After getting him a temporary wheelchair I started making the round of calls and was finally able to find the right person. The friendly rep checked the computer and told me an order for a new battery had been placed a week before. My client would be called within a day to follow up, she said. I thanked her and hung up the phone and thought to myself, all right, well, it's good to hear confirmation and know his insurance covered the battery as well. Two minutes pass and my client calls me and elatedly tells me his new battery arrived that morning!

Kenny thanked me for my help and went on to say that a few people had been on his side through this process. His good friend, he said, had been calling the provider as well for the past few weeks before he called me. And I said happily, well it's you and your friend's hard work that got you the battery! "Well you know,” he said and I could hear him still smiling, “it's every little help that matters."

Saturday, August 29, 2009

One, Two, Three Times a Request

Patrick, a client, called me to make an appointment. At the appointment he told me he and his partner got accepted into a subsidized apartment. He had had the chance to see the new apartment and he had a lot of good things to say about it. It was bigger than his current one and seemed in great condition. I was thrilled for this couple because I knew they had wanted to move for some time. They had recurring bed bug issues at the apartment they’ve been staying at as well as occasional problems with getting hot water. The place was also not ready when they moved in and management had not fixed things like they said they would. Not just that but the couple was also using almost all of Patrick’s income towards rent (Patrick’s girlfriend has a pending application for Social Security benefits and isn’t working currently). In short, they were interested in moving for some time.

A case manager from different agency worked with Patrick to find the apartment. Patrick told me he’s looking forward to moving to the new place but felt nervous because there was a lot to do.

Hesitating, Patrick asked me to help him with the physical move since he lacks the funds. I’ve known both Patrick and his girlfriend for some time and they aren’t able to physically move their belongings. He then said they’re leaving behind most of their furniture because that’s what their case manager told them to do because they likely have bed bugs (furniture essentially being a dresser and table). Patrick said his case manager told him to ask my agency about getting replacement furniture. And also, he continued to ask would it be possible for us to help with security deposit at the new place, since they just paid rent at the old apartment (before finding out about getting the new apartment)?

My initial quick reaction was admittedly a bit surprised at the number of requests, perhaps even at the audaciousness of asking for all of this. At the same time I felt annoyed with his case manager because he prefaced each request “my case manager sent me to you with this question.” How easy for your case manager, I thought, to make this our problem. It took me a few seconds to channel my initial thoughts to a more productive path. I realized my annoyance partially came from guilt of knowing we couldn’t honor all his requests even if I wanted to. I felt bad for Patrick because it would be virtually impossible for him to move without help because of his and his girlfriend’s lack of resources as well as their health. It wasn’t going to be a simple move because although they have been staying in a studio they have a lot of taped boxes that they never had the place to unpack.

Being familiar with the agency Patrick worked with to find the subsidized place I knew of their limitations in moving clients and appreciated they were able to find the couple subsidized place. And going back to my agency, because of our lack or resources and funds we too would be limited in how we could help. Putting my petty annoyance and my feelings of guilt aside, of course I wanted to see this couple move to a better apartment.

While Patrick came to me with several requests he did approach me sheepishly, without a sense of entitlement. Which I admit made it easier to want to help him. I also thought, after he left my office, that it was quite clever to approach us with three requests. Approach us with one, it’s easier to say yes or no and call it a day (and I’ll explain in a bit how my department would approach each of his requests). Ask us for three, well, chances of having one request approved increase greatly. Foot in the door technique. I ask you to lend me $1000 and you say no. Then I ask you for $50 and you are much more likely to hand it over because you compare it to the initial request. It’s not quite as simple of this because many factors come into approving a financial decision but sometimes it can be effective.

All financial requests are considered as part of a team decision. I don’t make financial decisions alone (which in some ways makes it easier). Each of us weighs in during our department meeting. I knew this would be a tough case to present. First, we really don’t help with moves – though we’ve made a couple of exceptions for various reasons (and I can only attest for the couple of years that I’ve been at the agency). We refer out for furniture requests but most agencies I know have no money/temporarily froze their programs. Finally, we had also helped this couple before with partial rent in the past year. This is a biggie when you have a good deal of clients and you want to be able to help as great deal of them as possible.

At the end of our appointment I told Patrick that I’ll bring his requests to my team. I also told him I want to see him and his partner move and that we’ll see what the decision is and go from there. Again, in the end I do think this move would be great for him and his girlfriend and I know their limitations which makes this difficult. We’ll see how this goes.

Friday, August 28, 2009

Online Journals / Homelessness

I wanted to share some journals I’ve been reading that folks may or may not be familiar with. The three journals below are written by people who experienced or are currently experiencing homelessness. Captivating is the closest word I can think of to describe them.

Wandering Scribe

Survival Guide to Homelessness
Unfortunately this journal seems to no longer be updated.

The Homeless Guy

Wednesday, August 26, 2009

A+E’s ‘Hoarding’ Show

A+E starting airing a documentary a couple of weeks ago that grabbed my attention. Each episode follows two sets of people (one couple till now, rest are individuals) who are struggling with hoarding. In each segment folks must clean out their home or face serious consequences, like eviction.

The first segment (though editing intersperses the two) follows Jennifer and Rob, parents of three young children. Here mom’s described as a shopaholic and dad as a hoarder. Mom and dad need to clean out their home or risk losing custody of their children. The second segment follows an older woman, Jill, who has an excruciatingly hard time throwing food away so she rarely does. Her landlord has given her limited time to clean her apartment out or face eviction.

So a cleaning crew is paired with Jennifer & Rob as well as Jill to work with them for a few days to get their homes cleared out. Interestingly it seems only Jill gets a clinical psychologist during this time. It’s also Jill who we see carefully and slowly go through each food item one by one, while Jennifer seems to take the lead with the throwing party and consequently the cleaning out process is quicker at her home.

It was particularly difficult to watch some of Jill’s scenes, especially those focusing on the overflowing fridge with its multicolored liquids. Since though I have a hard time throwing things away (particularly school related items, books) I don’t have particular attachment to food so it was very hard for me to empathize with Jill – though I felt bad for her. It was during Hoarders’ last episode while I watched Linda and her assigned psychologist stand side by side as she threw old items away that I felt equally empathetic with both. I understood how patient a person needed to be to support a person through the slow process of throwing things away, and I felt the woman’s pain for throwing away items she’s become emotionally attached to.

I’m intrigued. I’ll be following this show.

Latest episode is viewable on A&E’s site. Update (10/25/2009): It looks like only deleted scenes are available now.

Read more about hoarding in this post.

Tuesday, August 25, 2009

"Free with Purchase" Credit Reports

Lately I seem to have been seeing a lot of commercials sponsored by a company advertising so-called free (but actually not) credit reports. This ad has been on TV for some time. A guy and his guitar chirp along about how his life has taken a turn to the better since he got his credit report for free. How lucky he was. At the end in small print I manage to see “with purchase” before the commercial fades out and a new one starts with a kid frolicking about yogurt. Or something of that sort.

I considered posting the commercial’s website address as a warning but I don’t even want to give it bad advertisement. Here’s the only free resource for credit reports: https://www.annualcreditreport.com
(And it’s also possible to request the report by mail or phone).

Note folks can only apply for one free credit report per year from either Experian, Transunion, and/or Equifax (so people could apply for one credit report from one or all these three agencies, but once they receive it they would need to wait a year before applying again).

I also had a whole spiel about how FTC (Federal Trade Commision, that links to the free credit report resource) doesn’t resort to annoying singing commercials, but then I found out that’s not true.

Monday, August 24, 2009

The Dreaded Weekend Question

Enjoying my lazy Sunday I thought back at two questions that bug me: “What’re you doing this weekend?” and the inescapable Monday question, “What did you do last weekend?”

It’s a simple, get the conversation rolling question. At the office, Stilted Monday Conversation draws it out. Then one person answers by giving a laundry list of everything she or he did over the weekend. Usually it’s pretty familiar because you’ve heard a similar list the week before. Then the conversation goes around and each person tries to one-up each other. “I went to see the new Brad Pitt movie,” “I went hiking in Yosemite and camped under the stars,” “Oh, nice. I went camping with Brad Pitt in Yosemite and we skinny dipped.”

The truth is, I like to take it easy during the weekend, but I know that if I don’t do anything special and answer “Not much, you know, just hung out with a friend,” I get sympathetic looks.

I find myself feeling bad if I didn’t do something like go to the theatre or go on a trip somewhere. I don’t need a lot to be entertained. Hanging out with a friend, reading a book, walking around in a park can entertain me for hours. That’s how I relax. But that’s not exciting to share.

I realize this weekend question is a catalyst for conversation and that some people are actually interested in the answer, but I’m more interested in a story. I don’t mind hearing what other people did per se, but for some reason the introducing question of “What did you do this weekend” irks me.

My rule for my friends is that if they had a good weekend and did something, tell me. I’m sure to tell you because I don’t wait to be asked. But for office post-weekend conversations I sometimes just make things up. “I auditioned for Ripley’s for being able to juggle jelly beans with my tongue. Wanna see?”

Sunday, August 23, 2009

Hello, I’m Your Case Manager and I’ll be Your Superhero Today

I admit that after I started working as a case manager I initially had something of a savior complex. Which is interesting because at the same time I also greatly valued client empowerment and wanted to cultivate this in my clients.

Maybe my savior tendencies had a bit to do with this being my first job post college and my bright eyed interest in getting out there and changing the world. It wasn’t that I wanted to save people exactly. It’s not even that I necessarily thought they were incapable of helping themselves (ex. In advocating for themselves), though some clients, due to their disabilities, needed more support.

I readily recognized my own need to rely on others for help, if in a big project like moving to a new apartment to more simple tasks that were challenging for me. And in many of my clients I saw loneliness and lack of community to tap for help and I wanted to fill in that gap. It took me a few months to get over the instinct of rushing to take the lead on helping to solve a client’s problem.

I slowly learned to distinguish a situation when a client needed more support to work out a problem or need me to advocate on his behalf. A way of doing this was learning to ask “What would you like me to help you with?” to understand what kind of help my client needed if at all. Or my favorite, “What would you like to do about [problem, concern]?” These two variations, but particularly the first, have been helpful when talking to clients whose thought processes haven’t been focused and who may discuss 3 different topics in one conversation – sometimes in one sentence.

Of course, sometimes my clients just want to vent.

Friday, August 21, 2009

Translating Slumlord into Russian

11:50, almost time for lunch I thought as I typed a case note. The phone rang and I saw it was reception. “Do you speak Russian?”
“Uh… High school level Russian.”
“Can you please help me? There’s a client here who speaks Russian and I have no idea what he wants.”

Feeling the nervousness yet slight pride of being the only Russian speaking person in the agency I quickly got over myself and rushed around the offices to make sure no one else spoke it. After all I always used the “high school level” answer to the question of how well I spoke Russian while the truth was I had studied it for a few years but never mastered conversing to say the least. Though I believed I perfected the ability to speak Russian using English grammar.

Finally I went to the lobby. A tall man turned around, looked at me and smiled as I greeted him with a “Hello” in Russian. It turned out this man, Alexei, was a refugee who spoke his local language but had also spoke fluent Russian. He came to my agency to look for work (we have job counseling services) and even had our agency’s generic business card with a job counselor’s name on it. Since no job counselor at my agency spoke Russian nor remembered talking to this guy it was very curious how he got the card yet it was going to remain an unsolved mystery.

During the first meetings with me and our job counselor (who took Alexei on even though he spoke no Russian) I tried to call every agency I could think of to find a case manager who could support Alexei through his transition into US life and specifically one who spoke Russian. Due to his address Alexei wasn’t eligible for a case manager through my program. The truth was that despite my background in Russian conversation was stilted and very difficult. Even with him holding a dictionary and me looking up words on my online dictionary.

Unfortunately, the end results of my agency search were that I was extremely frustrated because each agency would refer me to someone else. More annoyingly, I may as well have been looking for an Urdu speaking case manager as each international or refugee agency told me that they didn’t have a Russian speaking case manager. Finally I found a couple of semi relevant contacts that I gave to Alexei. I also knew Alexei had income to pay his rent, he was taking night English classes and was working with our job counselor. He had a wife with him who was also learning English and their daughter was going to school.

I didn’t hear from him for a few months and then he came to my agency one morning with a five day notice (meaning he was late in rent) and asked for financial assistance. He explained his “public aid” stopped so he couldn’t pay his rent. Since my Russian language abilities don’t cover intricacies of “public aid” and because he didn’t have paperwork with him I kept it simple and told Alexei that once his income would resume we would consider his request and I would make a case for him. Alexei was confident his income would be renewed since he was filling out the application and said he had talked with his landlord who told Alexei he understood and that he would wait (at this point Alexei’s English was still basic but he was able to converse better). It would be much later that I would learn that Alexei received several notices from the public aid office requesting he provide them information but not understanding them, the family threw the letters away.

A week later Alexei came back, shaking with anger and showed me a court summons. “I don’t understand! I called him twice – twice and he said he would meet with me to negotiate this matter and twice he didn’t come. I just don’t understand this. Why does he put my family through this?!”

Since we weren’t able to get Alexei a lawyer in time for court he and I went and I asked for a continuance (postpone trial) to get a lawyer. I also went to the intake appointment with the lawyer to translate the intake worker’s questions and Alexei’s answers – though Alexei seemed to understand about half the questions without translation. Alexei repeated several times to anyone who would listen that he didn’t understand his landlord’s actions. “What is it about? Is it about money? I was going to pay him, I told him I was with an agency that would pay him. Why go through all of this?” He also said other refugees live in the building so the landlord should’ve been familiar with his situation. “What about my daughter,” he looked at me at one point. “She sees all of this, that we have to move, she thinks dad can’t provide. And moving to a new place will be hard for her. Hard for my wife.” The lawyer who joined the intake worker sat with us after the intake was over and I did appreciate that she took the time to listen to Alexei and understood he needed to get his anger out. “We know that landlord and we see him at court all the time. He's not a good landlord," she said. About the US legal system, she said, "It’s a completely different system here,” she explained and even went into detail about how law is different here. “Even if I explained [the system] in Russian it wouldn’t make sense to Alexei. He didn’t grow up in this system.”

The lawyer took Alexei's case and said she’ll be in court and added that Alexei himself didn’t need to come from here on out. “It’s going to be taken care of, it’s pretty much standard procedure from here,” and explained how the process would continue from this point. One essential point being that Alexei and his family would have more time to move to another apartment. I asked Alexei if he would still be interested in going to court because they would have a Russian interpreter for him (as they did when I went with him before) and he would be able to get a fuller picture of what’s going on. “Of course I’m going,” he said. Though it looked like the situation was indeed beyond translation at the end of the intake Alexei seemed less agitated. Maybe not fully accepting what’s going on but more at ease.

After leaving the legal aid office and heading to the bus stop Alexei said with a matter of fact grimace, “I’ve seen dead bodies, people in their cars die, their car and all and… Money is nothing.”

Thursday, August 20, 2009

Odd/Uncomfortable Moments with Clients (3)

I was meeting with a client when suddenly I notice a large cockroach scurrying on my desk. I leap off my chair while grabbing a few items off the table so the cockroach doesn’t disappear out of sight. As I’m trying very hard to resist my urge to panic at the terrifying view of this tiny creature (but really I'm moving things off my desk as quickly as possible while jumping up and down), my client sits still. “Yeah, I hate cockroaches too,” he says calmly.

I close the door after letting a client in my office. As I sit down on my chair he looks at me for a moment and blurts out: "Are you pregnant?" (Interestingly, I was wearing a shirt that, while trying it on at the store, I was hesitating to buy it because I thought it looked a bit like a pregnancy shirt)

(The following didn't happen with a client, but a fellow passenger on the bus)
I sat sit down next to a passenger who asksed me how to get to an address. I answered him and he nodsded at me. After ten seconds he asks me, "Do you want to buy a house?" and takes out his business card.

I'm filling out intake paperwork with a new client. As I'm writing down her answer about her work history, she puts her hand on my desk, taps it and says, "You know, I wish we could eat furniture. Wouldn't that be something? (Thinks) Tables would taste like maple syrup. Don't you think?"

Also see part 2

Tuesday, August 18, 2009

Ways to Keep Sane as a Case Manager

Yeah I could write take in all in stride and do it with a smile. I practically alluded to this in my “Distancing yourself from clients” post. But even I don’t smile often. My mom likes to say that you can enjoy most everything but in moderation (she was talking more about food but I think her advice eclipses beyond that). Keeping this in mind here are a few of guidelines to keeping a hold of your sanity while working as a case manager.

1) When you find the time to read try not to exclusively focus on books relating directly or loosely to your work, like Homelessness in New York or The Working Poor in America. Find literature that lightens the mood after dealing with difficult work related issues. While I have a few recommendations, I'm using this opportunity to give a nod to Miss Manners columns which I find immensely entertaining. A good balance of politeness and snarkiness.

2) With all my love to my coworkers and hanging out with them outside work, spending similar time with friends who have nothing to do with my case management job is essential. With coworkers you inevitably start talking/complaining/venting about the office, clients, other coworkers, and clients. Though some venting is helpful and I’m the first person to say I’m guilty of doing my share of this with coworkers it’s nice to talk with other friends who have other problems they want to vent to you about. Also, while you're sitting at the coffee shop with your coworkers their mere presence is more likely to remind you of something you've forgotten to do ("Man, I forgot to call-----").

3) After having a difficult interaction with a client it helps me to write down what I’m thinking about and add 20 or 30 exclamation points. Sometimes just doing that lets out my negative thoughts and cleans out my mind.

4) And of course, a favorite -- vacation.

Friday, August 14, 2009

Silence Sometimes Key for Good Conversation

It's often effective, when interviewing people for a documentary, to wait quietly for a few moments after the interviewee is done answering your question. The interviewee is likely to fill in the gap of silence with another thought or insight. Maybe she does it because the silence makes her nervous, maybe it actually creates a comfortable environment. You may get some valuable info using this tactic.

Practice of using silence occasionally translates well into case management. It's sometimes appreciated by a client as encouragement to keep speaking or share something new. Quieter clients especially seem to benefit from this -- although some rapport needs to be established for this to work.

Also, sometimes clients just need to vent and since some have very few outlets for this they use you, the case manager, to do this, and here a bit of silence of course works great.* Recognizing when a client is just complaining because 1) they want to be listened to or 2) they want you to do something about it is not always clear cut. It's almost disorienting for me when I understand a client just wants to vent because I'm so used to problem solving mode for a good part of the day. The other day I got a call from an elderly gentleman about a woman who lives down the street from him and insulted him who said something insulting to him. What she said wasn't exactly a threat but certainly made him feel uncomfortable. So I started asking him specific questions (because I have a history with this client of making false accusations) and eventually learned that what he wanted to do was get what happened off his chest.

* I don't mean complete silence, but more focus on listening than asking questions or taking control of the conversation.

Tuesday, August 11, 2009

A Bit More on Hoarding

I recently wrote about Cynthia, a client who struggled with hoarding to the point it endangered her keeping her housing. The other day I watched a hoarding show to scare me a bit (can be found here). One person kept hundreds and hundreds of bikes in one room, another had shelves of boxes filled with objects from trinkets to hundreds of the same items. I watched as she sat on one chair and talked about her experience and was reminded of Cynthia. But when I write that I watched it to scare myself it's because I relate a bit to the hoarding experience.

I consider myself to be a mild keeper. I don't collect items religiously per se but I have a hard time throwing away papers and books. Not so much newspapers, but college papers, even articles I used for homework. I remember seeing other students throw books and papers without hesitation at the end of the semester and not be able to understand how they could dispassionately get rid of all of their work. Feeling some envy too at how easily they did it.

Already in my teens I started having a problem with holding on to some things. Similarly to now, it was school papers and such. But back then I also collected a teen magazine and eventually it wasn't me who threw these away but my mom. My explanation for my difficulty in throwing these items away is because my family and I moved around a bit while I was growing up. As I left friends and homes behind when we moved, keeping old items gave me some stability, even support. But it was even more than that -- the emotional connection to the things I owned.

What is that cliche, that belongings end up owning you? The best part is of course that I barely ever look at my college papers. I usually don't look at them until I try to throw them away -- then resisting the temptation of reading them is very hard. And as I go through the papers (as I did today with the hopes of getting rid of some) my brain thinks, maybe I'll need to look at this at some time again for when I go back to school. Maybe.. Maybe... And I weigh to myself whether I should throw something away or not and the idea of keeping it is so comforting. It's one long and exciting throwing away party.

Also see my post about Cynthia.

Monday, August 10, 2009

Detested Work Jargon -- I Didn't Get it

I like reading rants on various topics. Office humor amuses me, for example. I came across an article called ‘Annoying Work Jargon Phrases” that listed 15 words/phrases that annoy office workers. I was annoyed when I finished reading it. By #13 I realized that I had only heard of a select few of those listed. I thought I'd see phrases like "Case of the Mondays", cliches like that, but that wasn't to be.

Not only didn't I hear these words before in my office, most of the words were brand new to me. Now maybe I don't work in the 'classic' office because of the social work setting, but I'm sure I hear common office jargon words. One of the few words I shared with the list were "piggyback" which doesn't bother me because I like the image I see in my mind when I hear it. Someone mentioned "touch base" as a phrase that bothers them, and I use it all the time. I mostly don't like small talk phrases. How are you, how was your weekend, what are your weekend plans, what are you doing, who are you. Those vague questions bother me.

Saturday, August 1, 2009

Challenge of Self Analysis

I sometimes ask my clients why they made a certain decision. This question more often comes up if the client's decision was harmful in some way, like deciding not to go to a job interview though it would've been a sure thing, to takingdrugs or assaulting someone.

The replies vary. Some clients have developmental or mental health disabilities that make self analysis even more challenging. But most of us don't think about how they make decisions. Some of us also think too much about our decisions, but that's another issue (also, I don't think this alternative necessarily means the decision will be a better one).

I don't even necessarily mean the decision process of weighing the cons and pros because sometimes decisions happen on a quicker basis and are based on how we made decisions in the past. A client of mine was arrested for assaulting another man who tried to hit on and touch his girlfriend. I've experienced this client be angry at me before but I've also seen him control his anger (usually to shutting off). When I asked him about how he reacts to me (with some control of his anger) following his arrest my client said that he can't express his anger to me in the same way because he needs things from my agency. While I understand this, I also told him that he was able to control his anger while interacting with me so I know he has the ability to do it. But there's an honor code, the client tried to explain to me. Giving a look, which may be enough to diffuse a conflict in some situations could also be interpreted as an aggressive act, which is what my client explained to me would happen if he didn't use force and push the other guy away. The thought process was quick here and was based on previous patterns. What I go by is that if clients think about why they made a decision they may be more aware of their choices in the future. Some self reflection is good for everybody.

The idea of self analysis reminds me of one psychology class I took where I learned about early students of psychology when it was still a young science. These students tried to learn about people by asking subjects how they felt doing different tasks, including sex, and describe their sensations. It struck me as intuitive but limited -- while we may know ourselves best, we're all limited in our ability to analyze our behavior through our perceptions alone.But it's a start.