PCAP is a social work-based case management-focused home visiting program that incorporates the Case Management Society of America’s case management principles and standards. Paraprofessional case managers provide individually tailored, multidisciplinary, community-based advocacy designed to promote client competency and timely coordination of health and social services to address a family’s specific needs.
Through home visits, case managers assess and monitor a family’s needs and well-being; connect the family with community services to address those needs; monitor service receipt; facilitate communication among the client, family members, and community service providers; and address service barriers. The case managers also teach, role model, and guide the development of clients’ interpersonal, parenting, household management, and community living skills; and provide practical assistance such as transportation to appointments.
The case managers strive to move the client along a continuum from dependence on the case manager’s support to the development of confidence in her ability to independently care for herself and her family. PCAP recognizes that setbacks are common and continues to offer services even if relapse occurs. Clients who experience setbacks are not asked to leave the program.
During the first few visits, the case manager conducts an initial assessment of the mother’s physical and mental health needs and connects her with services such as substance abuse treatment. Using a PCAP-developed assessment tool, the case manager then helps the client identify additional needs, define personal goals such as reducing substance use and obtaining further education, identify the incremental steps necessary to meet those goals, and supports the client’s work toward those goals. Every four months, the case manager and the client jointly assess progress, and update the goals and action steps.
Case managers develop and maintain professional relationships with community service providers in order to link clients to services such as family planning, safe housing, domestic violence services, parenting programs, and health and mental health services. To foster support for the client’s recovery, the case manager also seeks to develop relationships with her family and friends, and may also advocate for them as needed by providing referrals for services.