The Application of Social Work Principles, Ethics, and the
Case Management Approach in Service Delivery to Refugees
USCCB/MRS Refugee Resettlement
Case Management Manual
DEPARTMENT OF MIGRATION AND REFUGEE SERVICES
United States Conference of Catholic Bishops
Washington, DC
Funding for this manual was provided by the Bureau of Population, Refugees, and
Migration at the United States Department of State.
Excerpts and adaptations from the National Association of Social Workers’ Code of Ethics
reprinted with permission from the National Association of Social Workers, Inc.
Author: Barbara Klimek, MSW, PhD.
Copyright © 2011, United States Conference of Catholic Bishops, Washington, D.C.
All rights reserved. No part of this work may be reproduced or transmitted in any form
or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the
copyright holder.
Introduction and Purpose 1
I. Basic Concepts of the
Social Work Profession 3
Concept 1. The Purpose of Social Work 3
Concept 2. Person-in-Environment 4
Concept 3. Social Justice 7
Concept 4. The Role of the Social Worker 11
II. Introduction to National
Association of Social Work
(NASW) Code of Ethics 17
Core Values 17
Ethical Standards 19
III. The Role of Case Management
in a Resettlement Program 33
III.1 General Overview of Case Management 33
III.2 Assessment 36
III.3 Planning 38
III.4 Intervention 41
III.5 The Monitoring Function of Case Management 51
III.6 The Evaluation Function of Case Management 54
IV. Case Recording 56
SOAP Recording Method 58
Conclusion 64
Contents
Introduction and Purpose 1
A
s employees in a refugee resettlement program afliated with the
United States Conference of Catholic Bishops’ Migration and Refugee
Services (USCCB/MRS), we have heard and used the term “case
management” countless times. But what does case management really mean
for us? Do we really understand case management and how to apply this
model in our resettlement programs?
Of course, we know the requirements outlined by the Department of State
(DOS) in the Reception and Placement (R&P) Cooperative Agreement. These
requirements tell us what services must be provided and when they must be
completed. But this is just the beginning.
To do your best in serving your clients, you must understand the basic
principles and ethics of social work. You will need to understand how
these principles apply to everyday situations that you face when
providing services.
To begin, let us describe the resettlement program.
• The program uses a crisis-intervention approach to service delivery. You
often have little time to plan, and you may not know all the information
about your clients ahead of time.
• The program serves diverse clients who are semi-involuntary, meaning that
they usually do not choose which agency will assist them or will not have
an opportunity to change agencies once they arrive.
• The program is short-term.
• The program must demonstrate cultural sensitivity and understanding.
• The program is carried out by a culturally diverse staff, most of whom do
not possess social work degrees.
In addition, our USCCB/MRS programs do not operate in isolation. Most
resettlement ofces must also meet the requirements of a human service
organization, like Catholic Charities or Catholic Social Services. These require-
ments are derived from the social work profession. Often, they also conform to
the standards and guidelines of the Council on Accreditation (COA).
Introduction and Purpose
2 Introduction and Purpose
This manual describes foundational concepts of social work, social
work ethics, and cultural competency that are governed by the National
Association of Social Workers (NASW).
1
The manual also applies these
principles to everyday realities in a resettlement program. Finally, the
manual provides tools to enhance training with case management staff.
Our funding agencies require that all resettlement programs follow the
terms outlined in the various Cooperative Agreements (R&P, C/H, and
MG programs). However, there are many different ways to carry out these
terms. This manual outlines one method that currently is practiced by many
resettlement programs. Each ofce might apply this method differently,
depending on the circumstances. However, we hope that this manual will
help all of you to manage and provide services more effectively.
1
Visit the National Association of Social Workers online at www.socialworkers.org.
Basic Concepts of the Social Work Profession 3
W
hen you rst look at this section’s title, you may think: “Social work?
This has nothing to do with my job, because I am not a social
worker. In fact, I never studied this topic in school, and I have not
received any other formal training. I just want to help refugees.”
Yet whether you are formally trained or not, you are a social worker. You
work in a social service agency and within a program that provides services
for refugees. And because you are a social worker, you are part of a larger
system of theories and principles that should guide your work.
Sometimes it may be hard to see yourself in this picture, given all the
tasks and challenges you face. This manual exists to make your job easier.
It will help you to understand and follow the principles of the social
work profession.
So let us begin with the basics. This section lists the four important concepts
that guide social workers in their work.
I. Basic Concepts of the
Social Work Profession
Concept 1. The Purpose of Social Work
The purpose of social work is to help a person overcome issues he or she
may have, so that he or she can live a better life. A social worker helps a
client in two ways: (1) by creating a safe environment and (2) by connecting
a client with appropriate resources and networks. The case management
method can be used to assist clients in either of these two ways. (See Section
III of this manual for more about case management.)
How does this concept apply to refugee resettlement?
The USCCB/MRS refugee resettlement program is designed to provide
services to refugees and to help them adjust to social and economic life in
the United States. The program connects refugees with anchor relatives and
communities that are already present in their new communities. It promotes
refugees’ nancial self-sufciency and their integration into U.S. society as
soon as possible after their arrival.
4 Basic Concepts of the Social Work Profession
Concept 2. Person-in-Environment
Each person functions within an environment,
which is made up of many structures and
systems. The immediate environment is made
up of systems, structures, and factors that most
frequently affect a person’s day-to-day social
functioning. These may include the following:
• Family (those related by blood
and by association)
• Close friends
• Culture
• Sets of beliefs
• Religion
• Ethnicity
• Neighborhood
• Workplace
The distant environment is de ned by the laws, culture, and social structure
of the country and of the mainstream society in which a person lives.
Consider the larger elements of society that one cannot choose or control.
These elements make up the distant environment.
For a person living in the United States, the distant
environment might include the following:
• The concepts behind the U.S. Constitution
• Political and educational systems
• Federal and state laws
• Classes of society (lower, middle, and upper)
• Issues related to race
Remember, each person is unique. Each person will interact with and react
to these environments in different ways. This is the meaning of the person-in-
environment concept. Acknowledge this concept when trying to help clients.
Basic Concepts of the Social Work Profession 5
How does this concept apply to refugee resettlement?
For you, part of applying the person-in-environment concept means taking
a culturally competent and sensitive approach. Acknowledge your client’s
immediate and distant environments and try to understand them in the
way your client might see them. By doing this, you put the person-in-
environment concept into practice. This will help the refugee client or family
to live a more successful and productive life in the United States.
Consider and respect your clients’ cultural and religious beliefs, family
composition and structure, and culturally dened roles—all elements of
their immediate environment. Also work to orient your clients to their new
distant environment by helping them to understand the basic social norms
and laws of the United States. This step is crucial in their social adjustment
and their acculturation.
Use a cross-cultural approach for service delivery to clients. As the term
“cross-cultural” implies, you must consider the culture and expectation
of your clients as you introduce them to the expectations and culture of
U.S. society. The services they receive must be linguistically appropriate,
culturally sensitive, and competent.
6 Basic Concepts of the Social Work Profession
Consider the following example, which will illustrate these concepts.
Imagn r c nagr ng w Sm M
m, H n Sr, ve tog r t Ute
Stt . B r ie t w clr, n b r
ng t r.
A r, ig t l l t ac sm
roac ng t w m n s, ? B
n r eac m, lwng t r--vrm
cncp, ez th ay e t roac l m ry
rtly t eac t. L s n y.
Fr , t meit n vrmts eac
t m. I ts rc , scvr th thu H d l t
cts r ii, j s en r W tr-tl cl ng, uc
s es. S , hwvr, cu t er r jb (ea scrf).
Sr, t r hn, ts t cu t er r rain s
s r jb, rdr t r v r cr n iis r i.
H n Sr hr t sm meit n vrmts, t
trac t tr vrmts qt rtly. A c nagr d
ogz t r--vrm cncp ig t Sr th
hl er r rain r f ts t l e n accpte
by l t Ute Stt . Hwvr, lyng t r--vrm
cncp, l r Sr’s d r t cu en rain
grmts s ay r vng r cr. If l r
r mn ts s rl, tr ig as t adr
t cncr.
Basic Concepts of the Social Work Profession 7
Concept 3. Social Justice
Social justice principles recognize that all people have basic human rights:
• The right to food, shelter, basic medical care, and essential social
services—all basic human needs to maintain life
• The right to be protected from abuse, neglect, and exploitation
• The right to privacy
• The right to worship based on chosen religious beliefs
• The right to basic education
• The right to participate in the political life of the government and one’s
chosen community
How does this concept apply to a resettlement program?
The pre- and post-arrival services of the refugee resettlement program are
grounded in the basic social justice principles described above. Pre- and
post-arrival services are designed to meet the basic human needs of clients.
The pre- and post-arrival services are known as
core services. They meet the clients’ needs for food,
shelter, basic medical care, and other essential
social services to maintain daily life.
After these basic needs are met, clients can focus on
their goals of social and economic independence.
You can then provide additional social adjustment
services and assist with acculturation processes.
Such additional services may include the following:
• Job readiness and preparation (since
employment is the basis for achieving economic
independence and self-suf ciency in America)
• Introduction to the U.S. school system and to the
United States’ laws and human rights standards
• Learning English
• Other orientation topics required by the
Reception and Placement (R&P), Cuban/Haitian
(C/H), or Matching Grant (MG) program
Core Services
• Pre-Arrival Services
• Case File Preparation
and Management
• Reception Services
• Community and
Other Orientation
• Health—Orientation
and Assistance with Access
to Services
• Health —Class A Conditions
• Resettlement Plans;
Employment Orientation
and Assistance with Access
to Services
• Employment and Welfare —
Communication with State
and Local Authorities
• Health —Noti cation of
Local Authorities
• Assistance to Refugee
Minor Children
8 Basic Concepts of the Social Work Profession
As a basic application of this social justice principle, explain to clients
what they can expect from the agency, what the agency will expect of them
in return, and to what they are entitled—all of which is known as “Client
Rights and Responsibilities” (CRR). Remember that most clients usually are
not familiar with this concept. Therefore, you need to fully understand and
follow the CRR policies of your agency and ensure that clients are informed
about them in an appropriate and consistent way.
Each agency should have its own CRR policy. If your agency does not have
one, your program can develop its own. This policy should be translated
into the main languages of the caseloads that you serve and be reviewed
with clients at the beginning of the resettlement process and throughout the
service period.
Although the content of each agency’s CRR policy may be different, it should
include the following basic client rights:
a. The Right to Consent to or Refuse Any Service
Clients need to afrm their willingness to accept services by signing a
consent form. This form should exist in each client’s primary language. Place
the signed copy in the client’s le.
Remember, your clients are semi-involuntary, meaning they may have little
inuence over where they go and which agency will be assigned to provide
their resettlement services. Because refugee clients often do not have an
option to seek services from another agency, you should clearly explain
what may happen if they refuse to receive services.
Many refugee clients do not realize that they ultimately have the right to
decide whether or not to receive your assistance. Remember that many
of your clients come from societies quite different from the United States.
Because you represent a larger agency, clients may think you have the power
to make them conform to the rules of the agency. They may have difculty
understanding that they have individual rights.
Because of these realities, you may need to spend additional time with the
client to review the consent for service form. You have a responsibility to
help your clients understand this concept. Often, you may be focused only
on the need to have this required form signed. Remember to explain what
the form means, even though it may take extra time.
Basic Concepts of the Social Work Profession 9
b. The Right to Condentiality
This is one of the most important and yet difcult concepts to explain to
refugee clients. Just as clients sometimes have difculty understanding
their individual rights, it can be hard for them to understand the concept
of condentiality. Previously, many clients lived in countries ruled by
oppressive dictators whose governments abused basic human rights. There,
clients certainly did not enjoy the right to condentiality when receiving
services from governmental or private institutions.
Slowly, clients will come to understand and accept the concept of
condentiality, a process that will be helped along by your reinforcing this
concept over and over again. As with the consent for service form, you
may be tempted to review this concept only once, during the initial intake
when the CRR policy is explained. Understand that each client will accept
this concept only over a period of time, as you both work to strengthen and
develop your relationships with the agency and with each other.
You yourself may have experienced difculty with the concept of
condentiality. If you came to the United States from another country,
remember how you thought and felt when you had just arrived. Now that
you work in a resettlement program, you may be playing a dual role—you
represent the social service agency, but you might also participate on a
social level in your cultural community. In itself, your dual role does not
need to present a problem. But if you are not careful, it might compromise
your clients’ right to condentiality.
10 Basic Concepts of the Social Work Profession
Consider the following scenarios:
Y r nng ci gtn th c ci h s t
nng. Dn ts v, sc t d s ts ’s acvi
t t ci. Y d id t sv rf t t ci’s prm
by nng c t t v r t ci t ig. Athu t acis
ay crly rit t b n r ci, t d ilt t
tnrs cfi dity. Crt m n lac —uc s r c
n r hrs—r rit r r acvi . Otrs—uc s
rty t kn—r .
Y r eutly ny cty ci gtns. Suddly,
cfi di frmi n r c cits m cly
nw t cty. Nrly, t ci ay t th tl rs
ts frmi, r r aculy i. Y ay hv t ut
r i t cty r crfly t vi t i r t
typ uis.
Both scenarios demonstrate the need for program leaders to coach you and
other case managers about making appropriate choices with regard to the
role(s) you might play in your community. You may also seek out advice from
your supervisor if you are struggling with issues in this area.
c. The Right to Question an Agency Action or Decision Through
the Grievance Process
A client must be able to voice dissatisfaction or disagreement about the
services or treatment he or she receives. Your agency or department should
have an established protocol for this, and your CRR policy should include
the protocol. The grievance process relates back to a client’s basic right to be
protected from abuse, neglect, and exploitation.
1
2
Basic Concepts of the Social Work Profession 11
Explain the grievance process to each of your clients in detail. Repeat the
explanation from time to time over the course of the service period. Like
condentiality, the grievance process is another concept that the client will
need time to successfully understand.
d. The Right to Participate in Development of an Individual
Service Plan (ISP) or Resettlement Plan (for R&P, C/H, and MG)
In order to successfully implement a resettlement plan, you must involve
your clients in the process of setting goals and timeframes for their own
accomplishments. Explain to your clients why certain types of services may
or may not be a part of their plan. Do not simply inform them, but also ask
for their input and acceptance. Be willing to adjust the plan to the extent
possible within the parameters of the program.
When clients engage in the planning process themselves, and when they
see that you are exible and cooperative, they will be more likely to accept
responsibility for following the plan.
Concept 4. The Role of the Social Worker
As a social worker, you ll many different professional roles while helping
your clients. These roles should be well dened, and you need to understand
what they are. This understanding will help you and your co-workers to
develop an effective case management model for helping refugee clients.
As a social worker, you may function as one or more of the following:
A Broker
As a broker, you link clients to appropriate human services and resources.
As a staff member in a resettlement program, you refer your clients for many
services, such as:
• Health screening
• Other health and mental health services
• Food stamps and/or welfare benets
• Social security cards
• Employment authorization documents
• Employment services
12 Basic Concepts of the Social Work Profession
An Advocate
As an advocate, you help clients to receive available resources and services,
and you represent their rights on an individual and community level. As a
staff member in a resettlement program, you represent your clients as they
obtain the services and resources to which they are entitled. You speak on
behalf of your clients, and you help your clients to speak for themselves.
A Teacher/Educator
As a teacher/educator, you equip clients with the knowledge and skills
needed to prevent problems, improve their lives, and function independently
based on their abilities. As a staff member in a resettlement program, you
provide ongoing orientation on U.S. culture, environment, and laws. You
help them to understand those concepts as they relate to health and mental
health. You also teach clients basic survival skills for their new environments,
such as:
• How to obtain services and resources
• How to pay rent and other related expenses
• How to use food stamps to shop for food
• Where to buy food and necessities
• Where their children might attend school
• Where to attend ESL classes
• How to use other educational/vocational resources
• How to use basic household equipment
• How to use public transportation
• How to make appointments for medical and social needs
On a community level, you might share your knowledge about refugees’
cultural norms and needs. You might speak at workshops and seminars in
schools, colleges, ofces, hospitals—anywhere people provide services to
refugees or want to learn more about refugees.
A Counselor
As a counselor, you help clients improve their own ability to function,
understand themselves, change their behaviors, and cope with problems. As
a staff member in a resettlement program, you provide support for mental
health interventions and consultations. If, like most case managers, you are
not a trained mental health counselor, do not try to modify clients’ behavior
Basic Concepts of the Social Work Profession 13
yourself. However, you can act as a cultural coach when your client sees
a health professional. You can work together with health professionals and
your client to resolve physical and mental health issues.
A Professional
As a professional, you engage in competent and ethical social work
practice. As a staff member in a resettlement program, you must follow the
National Association of Social Workers’ (NASW) Code of Ethics, which is
described more fully in Section II of this manual. You must provide culturally
competent and sensitive services to clients.
A Social Change Agent
As a social change agent, you help to identify and address community
problems. As a staff member in a resettlement program, you understand the
needs of refugee communities and help them to advocate for change and
new resources. You also help refugees to advocate on their own behalf.
A Case Manager
As a case manager, you identify the services needed and ensure that they
are received appropriately. As a staff member in a resettlement program,
your most important role is that of case manager. The role of case manager
combines all of the other roles described above, and it is grounded in the
concept of case management. Case management includes a wide range of
activities and functions, such as the following:
• Client assessment—gathering intake information; assessing the client’s
needs, situation, and resources.
• Service planning—identifying services that your refugee clients can
access to meet their needs; designing and implementing an integrated
intervention plan (resettlement plan).
• Linkage and service coordination—linking your clients with appropriate
services and resources, and coordinating the delivery of these services.
You also coordinate your clients’ use of resources by becoming the main
point of contact for communication between agencies. You not only
set up appointments for clients; you also ensure that clients get to these
appointments. You arrange for interpretation if necessary, help to set
follow-up appointments, and provide clarication for clients and
service providers.
14 Basic Concepts of the Social Work Profession
• Follow-up and monitoring of service delivery—making frequent follow-up
contacts with service providers to make sure they deliver services, and
also with clients to make sure they utilize services properly.
For example, you might make sure clients receive the correct amount of
food stamps on time, and then ensure they can use them to buy food. Or
you might ensure that the client has obtained prescribed medication and
understands its proper use. As a part of follow-up, you should also refer
back to the client’s resettlement plan, monitor the achievement of agreed-
upon goals and objectives, and make appropriate adjustments. Finally,
you must complete the necessary paperwork to document client progress
and the delivery of services.
• Client support—providing ongoing support, which includes the following:
— Counseling
— Helping to resolve family conicts
— Providing information and clarication
— Giving emotional support
— Explaining cultural norms and beliefs
— Advocating on behalf of clients to ensure that they receive
entitled services
For Supervisors
An Administrator
If you are an administrator, you plan, develop, and implement programs,
services, and infrastructures within a human service organization (such
as Catholic Charities). If you are a staff member in a leadership position
in a resettlement program, you seek additional funds to provide culturally
appropriate services that will benet the refugee populations being served.
As an administrator, you participate in different local and national forums to
promote the refugee program. You develop and implement new programs
and services that refugee populations need.
A Staff Developer
If you are a staff developer, you promote the professional development and
growth of human service organization staff through training, supervision,
consultation, and personnel management. If you are a staff member in
a leadership position in a resettlement program, this is one of the most
important roles you will play. Managers of resettlement programs need to
Basic Concepts of the Social Work Profession 15
possess a high level of cultural competency and sensitivity in order to guide
a culturally diverse staff. A well-managed staff will provide the most effective
services to clients.
As a staff developer, you must provide staff with opportunities to receive
basic social work training to master and improve social work skills. This
training will help staff to appropriately meet their clients’ needs. A best
practice is to require staff to take a basic course in social work from an
accredited educational institution. You may also draw on the resources
within your own agency.
You should also provide opportunities for staff to learn more about the
background and culture of new refugee groups scheduled to be resettled.
Create an environment that recognizes the rich cultural and linguistic skills
of staff. Encourage them to share their expertise within the agency and
larger community.
Be the rst to reach out to other agency departments and communities. This
will promote the program, make collaboration easier, and allow others to
benet from your program staff’s competencies.
A Workload Manager
As a workload manager, you work to provide the most efcient services
to clients within the guidelines of the organization. In this role, you must
balance the obligations to clients and the agency alike. As a staff member
in a resettlement program, you must effectively and efciently manage the
assigned case load. At times, this load can be quite heavy. The resettlement
program often operates in a crisis-intervention mode. Therefore, you will
need to be able to set priorities according to importance and urgency.
You will also need to make plans that help you accomplish work in the
most efcient and effective way possible. Effective time management is
critical if you are to give clients proper attention while still meeting other
requirements. You may need to learn how to use new technology, including
agency computer systems.
16 Basic Concepts of the Social Work Profession
Your agency may establish other requirements, such as the following:
• Participation in a quality assurance monitoring process (typically for
accredited organizations)
• Collection of data to document client needs and services provided
• Completion of reports
• Maintenance of case records
• Participation in staff meetings and other program-related activities
Introduction to National Association of Social Work (NASW) Code of Ethics 17
I
n the previous section, you learned about the purpose of social work
and some important basic principles of this profession. This section will
review the values and standards that must guide your daily work as a
social worker. It will discuss why we, as resettlement workers, should follow
such a code of ethical behavior.
The National Association of Social Workers (NASW) is a professional organi–
zation that has established the standards for moral behavior, the Code of
Ethics, to guide the everyday professional conduct of social workers. This
Code of Ethics is based on the following six core values.
II. Introduction to National
Association of Social Work
(NASW) Code of Ethics
Core Values
Core Value 1. Service
This ethical principle de nes the primary goals of a social worker: to help
people in need and to address social problems. The obligation to serve
others takes precedence over any self-interest. Social workers use their
knowledge, skills, and values to help clients function better in society.
National Association of Social Work Code of Ethics: Six Core Values
1. Service
2. Social Justice
3. Dignity and Worth of
the Person
4. Importance of
Human Relationships
5. Integrity
6. Competence
18 Introduction to National Association of Social Work (NASW) Code of Ethics
Core Value 2. Social Justice
This ethical principle prompts social workers to challenge social injustice.
Social workers seek social change on behalf of vulnerable and oppressed
individuals or groups of people. They focus on addressing issues of poverty,
unemployment, discrimination, and other forms of social injustice. Social
change activities promote understanding of oppression and of cultural and
ethnic diversity.
Core Value 3. Dignity and Worth of the Person
This ethical principle teaches respect for the inherent dignity and worth
of the person. Social workers treat each individual with respect. They take
individual and cultural differences into account. Social workers recognize
and promote clients’ self-determination and encourage clients to address
their own needs and to create change. In this capacity, social workers are
conscious of their dual responsibility to clients and to the society.
Core Value 4. Importance of Human Relationships
This ethical principle helps social workers to recognize the central
importance of human relationship and its impact in achieving positive
change. Social workers realize the importance of engaging clients as
partners in the helping process.
Core Value 5. Integrity
This ethical principle prompts social workers to behave in a trustworthy
manner. Social workers recognize the importance of building and develop–
ing trustworthy relationships with the clients they serve.
Integrity conrms a social worker’s honesty and respect for clients’ rights to
privacy. It also demands ethical practices on the part of the organizations
with which social workers are afliated.
Core Value 6. Competence
This ethical principle calls social workers to practice within their areas of
competence and to develop and enhance their professional expertise. Social
workers should participate in continuing education to learn more about
their area of practice. When they do this, social workers contribute to the
knowledge base of the social work profession.
Introduction to National Association of Social Work (NASW) Code of Ethics 19
How are these six core values applied in refugee resettlement?
As a staff member who serves refugees, re ect on your daily commitment to
these six core values:
• Do you put clients’ interests above your own?
• Are you committed to social justice?
• Do you show respect for the dignity and worth of every individual?
• Do you show that you consider human relationships to be important?
• Do your actions display trustworthiness to your clients?
• Do you work to improve your knowledge and your skills?
Recognize the six core values, and re ect on how to apply them to your
daily work with refugees. This practice will improve your ability to provide
quality services to your refugee clients.
You must observe a number of ethical standards in your professional
activities and services with refugee clients. The most critical standard is
your ethical responsibility to your clients. Sixteen standards outline your
responsibilities in this area.
Ethical Standard 1. Commitment to Clients
Every social worker’s rst responsibility is to increase clients’ sense of well-
being and ability to function in society. Certain situations, however, can
override this loyalty to represent the client’s interest. For example, you must
report if a client is engaging in child abuse or if a client threatens harm to
self or others. In such cases, the client’s freedom to choose his or her actions
cannot come before his or her own safety or the safety of others.
How does this standard apply to your work with refugees?
It is important to explain this standard to your clients early in the
resettlement process as part of the orientation process. You might also
provide speci c details so that clients fully understand the de nition of child
abuse and harmful behavior in the United States. Cultural standards, norms,
and belief systems sometimes differ on this de nition. For example, in some
Ethical Standards
20 Introduction to National Association of Social Work (NASW) Code of Ethics
countries, it might be accepted behavior to leave small children alone and
unsupervised. Or it may be accepted for parents to discipline children in a
physical manner that might be considered violent in the United States. Your
clients should understand that, although you are committed to helping them
in any way you can, you must report any instances of abusive or harmful
behavior to the proper authorities.
Ethical Standard 2. Self-Determination
Social workers respect each client’s right to determine his or her own
future. Social workers help clients to dene their own goals. They suggest
ways to achieve these goals, based on the client’s ability and willingness to
work toward certain outcomes. Social workers may limit this right to self-
determination if a client’s actions create a danger to self or others.
How does this standard apply to your work with refugees?
Explain to your clients all the options available to them. Encourage them to
take ownership of the resettlement plan you establish together.
Sometimes, you may face a dilemma when trying to uphold this ethical
standard. Clients’ goals for themselves might directly conict with the
requirements and expectations of federally funded programs (such as R&P
or MG). Or clients may not be able to meet the set requirements within the
prescribed timeframes.
The most common example is the conict that often arises in promoting the
R&P principle of achieving economic self-sufciency as soon as possible
after arrival. But as a part of self-determination, some clients may make it
their rst goal to learn English—before seeking employment.
Self-determination is closely related to the concept of person-in-
environment, discussed in Section I of this manual. Each person will react
differently to immediate and distant environments. Therefore, each will
achieve self-sufciency at different times. Accept your clients’ wishes about
how fast and far they are willing to move forward with self-sufciency
and social adjustment. At the same time, help clients to understand the
consequences of their choices. This is why it is important to involve them in
the development of their resettlement plan.
Introduction to National Association of Social Work (NASW) Code of Ethics 21
Ethical Standard 3. Informed Consent
Social workers should only provide services to clients in the context of a
professional relationship based on valid, informed consent (permission to
serve). Social workers help clients to clearly understand the type of services
being provided. This assistance includes explanation in their primary
language (such explanation can be written, oral, or both). Social workers
should inform clients that clients have the right to refuse services or to
withdraw consent. When clients receive services on an involuntary basis,
social workers should provide information about the nature and extent of
services. They should also inform clients of the consequences that may result
if clients refuse services.
How does this standard apply to your work with refugees?
Think back again to the concept of social justice and client rights, especially
the right to consent or refuse any service. Remember, clients will need your
help to fully understand the concept of informed consent. Each agency
needs to have uniform documents to support this process. If your agency
does not have these documents, your program can develop its own. These
are considered legal documents and should be translated or interpreted
in a client’s primary language. Clients should be required to sign an
acknowledgment stating that they have received the documents and have
given informed consent.
Explain to your clients the consequences (if any) that may result if they
withdraw from or refuse to participate in the services offered. For instance,
an R&P client who refuses services would not be able to receive these
services from another agency.
Ethical Standard 4. Competence
Social workers should provide services and represent themselves as
competent only within the framework of their education, training, licenses,
certication, consultation, and supervised experience.
How does this standard apply to your work with refugees?
As a staff member of a resettlement program, you bring valuable knowledge
and skills to your job, especially cultural and linguistic competency.
To complete your skill set, you will also need to understand basic
social work principles and how they apply to the daily work within a
resettlement program.
22 Introduction to National Association of Social Work (NASW) Code of Ethics
You must also work within the framework provided by U.S. laws and by
agency policies and procedures. Remember that the standard of competency
is meant to safeguard you, your colleagues, your clients, and your agency.
It is important for each of us to recognize our limitations and biases. Know
when you need the help of other professionals. Competency is a process—
every social worker will always be able to further improve his or her skills,
knowledge, and understanding of work with refugees.
Program leaders must ensure that all resettlement staff receive appropriate
ongoing training, especially since most are from other countries and might
not have received formal social work training.
22 Introduction to National Association of Social Work (NASW) Code of Ethics
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The following example illustrates why the standard of competence is so important.
Introduction to National Association of Social Work (NASW) Code of Ethics 23
Ethical Standard 5. Cultural Competence and Social Diversity
Social workers should follow these four guidelines:
a. Understand the concept of culture and its impact on human behavior
and society.
b. Know and understand the client’s culture and its impact on
service delivery.
c. Demonstrate competence in providing services that are sensitive to
clients’ cultures and to differences among people and cultural groups.
d. Obtain education to better understand the nature of social diversity and
oppression with regard to race, ethnicity, national origin, gender, political
beliefs, religion, and other social attributes.
How does this standard apply to your work with refugees?
Within the agency, you are usually considered the expert when it comes
to cultural competency and sensitivity. However, this does not mean that
all staff have a full understanding of U.S. culture and social diversity. All
resettlement staff need ongoing training about cultural differences, with
emphasis on U.S. culture. This training can help both you and your client to
act and interpret appropriately within the culture.
Let us continue with the mental health example above. In many situations,
you are asked to provide interpretation services. Here, you represent the
culture and speak the language of your client. You establish a link between
your client and the helping professional. As mentioned before, you need to
provide cultural background to the helping professional to help him or her
better understand your client. You should also educate yourself about the
helping process within the host culture. When you understand this process,
you can explain it to your client and guide your client through it. In this
way, your expertise can be used effectively by both the client and his or her
professional helper. You are more than an interpreter; you create a link and
provide a context in which both parties can understand each other.
24 Introduction to National Association of Social Work (NASW) Code of Ethics
Ethical Standard 6. Conict of Interest
In this area, social workers should follow these three guidelines:
a. Understand and avoid conicts of interest.
b. Do not take unfair advantage of any professional relationship. Do not
exploit clients or other individuals to pursue one’s own personal, religious,
political, social, or business interests.
c. Do not engage in dual or multiple relationships with clients or former
clients (e.g., friendship or other personal relationship with a client;
someone who exchanges gifts with a client) that could lead to the
potential for harm or exploitation of the client.
How does this standard apply to your work with refugees?
As a member of a resettlement staff, you may have more than one kind of
relationship with your clients, especially those who are from your country
of origin. In addition to your job responsibilities, you might play other roles
within the larger community. Outside of working hours, for example, you
might volunteer in the community or encounter clients in social situations.
Although you have the right to participate in the activities of your choice, it
is important to consider the potential conicts of interest that could occur.
Conicts of interest do not only occur in situations within social
communities based on your culture of origin. They can arise in many other
circumstances. For instance, the manager of the apartment complex in which
you live might offer to reduce your rent if your agency agrees to place clients
in their complex. As another example, a client might want to give you a
personal gift. Your acceptance of the gift would result in a conict of interest
if you benet personally. Also, the client might feel that your acceptance
entitles him or her to preferential treatment or services.
A conict of interest may affect job performance and violate agency
standards or social work ethics. If you nd yourself in this situation, you may
have to either change the situation or resign from the resettlement program.
Program leaders should discuss conict of interest early in the training of
their staff. Different standards govern professional relationships in many
foreign countries. However, those accepted practices, including the working
relationship between helper and client, may be considered culturally
inappropriate within the standards and laws of the United States.
Introduction to National Association of Social Work (NASW) Code of Ethics 25
Ethical Standard 7. Privacy and Condentiality
Social workers should do the following with respect to privacy
and condentiality:
a. Respect the clients’ right to privacy.
b. Protect the condentiality of all information obtained while providing
services, except for compelling professional reasons (such as knowledge
of child abuse or intent to harm self or others).
c. Inform clients, to the greatest extent possible, about what it means to
disclose condential information. Discuss the potential consequences
before making such a disclosure.
d. Discuss the issue of condentiality with clients. Talk about the limitations
of the clients’ right to condentiality.
e. Do not discuss condential information in any situation unless you can
ensure privacy.
f. Protect clients’ condentiality during legal proceedings to the extent
permitted by law.
g. Protect the condentiality of clients’ written and electronic records.
h. Transfer or dispose of clients’ records in a manner that protects the clients’
condentiality and is consistent with state statutes and agency policy
governing record-keeping and disposal.
How does this standard apply to your work with refugees?
Most refugees served by our programs have lived in countries with
oppressive governments that violated basic human rights, including the
right to condentiality. Also, many have come from societies that value
community involvement and that view the larger community as being
responsible for the well-being of its members. Clearly, these societies do
not place the same emphasis on privacy and condentiality that U.S.
society does.
As a case manager, one of your most important tasks is to establish a trusting
relationship with your clients. Many refugees have had negative experiences
with representatives from the government and other institutions. Therefore,
they view these organizations—and those who work for them—as having
great power and control. Some clients may not recognize that here in the
United States, the government and institutions are bound by law to respect
individual rights.
26 Introduction to National Association of Social Work (NASW) Code of Ethics
Help your clients understand that the United States is a democratic society,
built on principles of individual freedom and protection. Only then
will the client begin to see and understand the meaning of the right
to condentiality.
Ethical Standard 8. Access to Records
Social workers should provide clients with access to records that concern
them individually, while also protecting the condentiality of other
individuals identied or discussed in those records.
How does this standard apply to your work with refugees?
At any given time, clients have the right to view case le information related
to the services they have received. This right does not extend to anchor
relatives. All resettlement staff should be trained in appropriate case
recording, which includes keeping accurate and current le documentation.
Information related to other clients should not appear in the case le. Section
IV of this manual provides more specic information on case recording.
Ethical Standard 9. Sexual Relationships
Social workers should not engage in sexual activities or contact with the
following persons:
a. Current clients, whether such contact is consensual or forced
b. The clients’ relatives, or other persons signicant to the client, when there
is a risk of exploitation or potential harm to the client
c. Former clients, because of potential harm to the client
In addition, social workers should not provide clinical services to persons
with whom they have had a prior sexual relationship. This could harm the
client, and it makes it unlikely that the social worker will be able to maintain
appropriate professional boundaries.
How does this standard apply to your work with refugees?
The professional environment in the United States is different from that in
some other countries. In some cultures, it may be accepted for a sexual
relationship to develop and exist between an employee and client. In the
United States, this behavior is not acceptable. It may cause you to lose your
job, and it could even harm your future professional career.
Introduction to National Association of Social Work (NASW) Code of Ethics 27
As a staff member in a resettlement program, you often work with vulnerable
and traumatized clients. These clients might behave in a manner that could
create a dangerous and inconvenient situation for you as a case manager.
You must provide many of the required services in settings outside of the
ofce, such as in client homes and other private settings. Therefore, you must
set boundaries early on in your relationship with a client. Work to create an
environment that protects you and your clients from certain situations.
Ethical Standard 10. Physical Contact
Social workers should not engage in physical contact with a client when
there is a possibility for potential psychological harm to the client. If physical
contact is appropriate, social workers should set clear, culturally
sensitive boundaries.
How does this standard apply to your work with refugees?
You are working with clients from many different cultures, and the
appropriateness of physical contact will vary. You may feel that a client is
in need of physical contact, such as patting on the back, holding a hand,
or even hugging the person. Remember that what you consider as an
appropriate response may not be considered appropriate by the client.
Become familiar with the customary use of physical contact in different
cultures. In this way, you can appropriately choose the best methods for
providing help to your clients.
Ethical Standard 11. Sexual Harassment
Social workers should not sexually harass clients. “Sexual harassment” is
dened by sexual advances, sexual solicitation, requests for sexual favors,
and other verbal or physical conduct of a sexual nature.
How does this standard apply to your work with refugees?
It can be difcult to understand sexual harassment as it is dened
in the United States, particularly for someone from another country.
Most of the time, people do not intend to violate this standard, but a
misunderstanding can easily lead to problems. Examples of behavior that
could be misinterpreted or experienced as sexual harassment may include
complimenting a co-worker on the way he or she looks or offering a ower
as a wish for a great working day. These actions, which may be accepted
norms in the working environment in many foreign countries, might not be
acceptable within the U.S. working environment.
28 Introduction to National Association of Social Work (NASW) Code of Ethics
Other examples of potential sexual harassment situations arise from cultural
norms. For instance, in some cultures an older man is viewed as an advisor
to younger people, including women. In those cultures, he might be
expected to offer advice about male-female relationships. He might feel
obligated to provide a ride home after work. He might even make a courtesy
call if he knows a young woman is home alone. These actions could be
misinterpreted by those not familiar with the man’s culture.
You and your colleagues need to learn about the practices of different
countries and take time to discuss why certain behaviors may be
inappropriate in this country. This knowledge will help you to avoid potential
problems in this area.
As a staff member in a resettlement program, you should receive and keep
a copy of your agency’s sexual harassment policy and learn its contents. If
anything in the policy is unclear, speak to your supervisor. Program leaders
should provide staff with ongoing coaching in this area. Your agency may
have a diversity council or other type of cultural committee that might assist
with the coaching.
Ethical Standard 12. Derogatory Language
Social workers should not use derogatory language while helping clients.
Social workers should use appropriate and respectful language while
communicating with and about clients.
How does this standard apply to your work with refugees?
In a resettlement program, you and many of your co-workers may be
multilingual. While this is a good and necessary skill, it allows for situations
where this standard could be accidentally violated. Two factors especially
contribute to potential problems or misunderstandings.
The rst factor arises from mistakes in interpretation or translation. It is easy
to choose the wrong word or to misunderstand a word’s exact meaning. This
could result in an unintended, offensive, or disrespectful use of language.
The second contributing factor arises from the types of vocal tone and
nonverbal communication that may be appropriate in different cultures. In
certain cultures, communication in a loud tone of voice and with certain
body language may be acceptable. In the United States, the same tones and
gestures may be considered offensive or inappropriate.
Introduction to National Association of Social Work (NASW) Code of Ethics 29
In some situations, you or your client may feel that the use of derogatory
language is the only way to get what you need or want. This behavior
might be related to past experiences in other countries or in refugee camps.
Remember that the current situation is different. Remind yourself or your
client that different situations call for different responses.
It is important to respect other cultural norms and practices of
communicating. However, as an employee of a social service agency in
the United States, you may need to adjust your communication style or
language. Teach your clients about appropriate cultural communication in
the United States, as the appropriate and respectful use of language applies
to them as well.
Ethical Standard 13. Payment for Services
Social workers should ensure that, when required, fees are set in a fair and
reasonable manner, giving consideration to the clients’ ability to pay. In
addition, social workers should (a) avoid accepting goods or services from
clients as payment for professional services, and (b) not solicit a private fee
or other payments for providing clients with services that are available free
of charge through the social worker’s employer or agency.
How does this standard apply to your work with refugees?
With the exception of some immigration services, the help that our programs
provide to clients should be free of charge. This concept may be difcult for
some refugee clients to understand, as they often follow the customs and
standards of their culture.
In many countries, an individual who needs help is expected to provide
a bribe or some type of compensation in order to receive services.
One example of this behavior might be paying extra money to medical
professionals to receive preferential treatment in a hospital. Another is giving
a bottle of expensive alcohol or bouquet of owers to a government ofcial
for help resolving an issue.
30 Introduction to National Association of Social Work (NASW) Code of Ethics
Reinforce the concepts of free and non-preferential treatment with your
clients. If any types of services require fees, your program should post a
fee schedule. If needed, this chart should be translated into the primary
languages of the clients served by your agency.
Ethical Standard 14. Clients Who Lack Decision-Making Capacity
Social workers should take reasonable steps to protect the clients’ interests
and rights while acting on behalf of clients who lack the capacity to make an
informed decision.
How does this standard apply to your work with refugees?
Sometimes you have clients who might not be fully aware of, or understand
the reality of, a situation or issue. They may appear to be confused,
overwhelmed, and incapable of making the best decision. In such situations,
seek advice and help from your supervisor or another qualied professional.
It is not appropriate to make a decision on behalf of the client, even if you
feel it is the right thing to do. While you do have the client’s best interest in
mind, such an action may actually act against the client’s best interest.
For instance, what if your client appears unable to fully understand the U.S.
banking system? You are trying to help your client save money, budget well,
and establish good credit for his or her own future benet. Given this, you
may feel that compelling the client to open a checking account seems like
the best decision. However, it may not be the best course of action for the
client. With an imperfect understanding of the banking system, the client
might, for example, write checks for more money than he or she has in
the account. This could lead to criminal charges or credit problems for
the client.
It is important not to reect an attitude that says to your clients, “I was
once in your shoes, and I know what you should do.” This is not a healthy
approach to use when you have a client who lacks the capacity to make an
informed decision.
Introduction to National Association of Social Work (NASW) Code of Ethics 31
Ethical Standard 15. Interruption of Services
Social workers should make reasonable efforts to ensure that clients will
continue to receive services in the case of interruption due to relocation,
illness, or disability.
How does this standard apply to your work with refugees?
The case management model, which you use to deliver services to your
clients, requires you to provide services without interruption for the service
period(s) of various programs. If one of your clients relocates to another city
or state, you should at least provide the client with the telephone numbers,
addresses, and names of refugee resettlement organizations in the area.
Also, your agency should make reasonable efforts to inform the USCCB/MRS
resettlement program in the state to which the refugee client is relocating
(if there is one). There may also be circumstances when you should contact
USCCB/MRS Processing Operations if an R&P client moves within a
certain timeframe.
Ethical Standard 16. Termination of Services
a. Social workers should terminate services to clients, and end the
professional relationship with them, when clients no longer need such
services and relationships.
b. Social workers should take reasonable steps to avoid abandoning clients
who still need services.
c. Social workers should not terminate services in order to pursue a social,
nancial, or sexual relationship with a client.
In addition, social workers should notify clients promptly before terminating
services. Or, where appropriate, social workers should act to ensure that
services will continue to be provided to clients.
How does this standard apply to your work with refugees?
As someone who works directly with clients, you may sometimes feel it
is difcult to close certain cases. Maybe you just are not ready to let go of
a case that was especially difcult. You have worked so hard for several
months, and you have nally established a relationship of trust. The clients
have nally started to progress. You think that if help is withdrawn now,
they might not function as well. Remember that, as a social worker, you
follow the principle of empowerment. Your goal is to work within clients’
32 Introduction to National Association of Social Work (NASW) Code of Ethics
capabilities and strengths to help them master the skills they need to
become independent.
Introduce the concept of termination to clients from the beginning of
services. Reinforce this idea—in a positive way—throughout the service
period. This helps clients to understand that services in the USCCB/MRS
resettlement program do have time limits. However, we work within those
limits to help clients successfully resettle.
Each program should have a policy that ensures that a nal contact is made
with each client. During this contact, discuss the steps that will be taken to
terminate services. Inform clients about additional resources in case they
should need them in the future.
The Role of Case Management in a Resettlement Program 33
III.1 General Overview of Case Management
III. The Role of Case
Management in a
Resettlement Program
What Is Case Management?
• Case management is the most effective method of delivering services
to clients who have multiple needs. Case management aims to increase
clients’ ability to function independently.
• Case management is one of the methods most commonly used to deliver
services to clients within human service organizations.
• Case management provides a framework that takes the whole person
into account. It does not focus on just one problem that a client has, but
instead focuses on many issues, problems, and concerns.
Goals of Case Management
The basic goals of case management are the following:
• To promote a client’s ability to access and use human services and
social supports
• To create a structure of social networks and service providers
• To promote service effectiveness and ef ciency
Case manager seeks to:
Promote client’s skills
in accessing/utilizing
supports/services
Develop the capacities
of social networks and
service providers
Promote service
effectiveness and
ef ciency
34 The Role of Case Management in a Resettlement Program
Focus of Case Management
Case management focuses on the creation of a client support network.
This network includes the following components:
• Self-care (individual client skill development)
• Professional care (involvement of multiple professional providers)
• Mutual care (involvement of the client’s social network)
Consider all three of these components of a client support network within
the practice of case management.
Practical Functions of Case Management
The ve basic functions performed by case managers are the following:
• Assessment
• Planning
• Intervention
• Monitoring
• Evaluation
Phase 2:
Planning
Phase 3:
Intervention
Phase 4:
Monitoring
Phase 5:
Evaluation
Phase 1:
Assessment
Process of Service Delivery
• Screening
• Eligibility
• Intake
• Screening
• Eligibility
• Intake
Referral
for Services
Referral
for Services
CASE
MANAGEMENT
(CM)
The Role of Case Management in a Resettlement Program 35
Implications of Applying the Case Management Model in a U.S.
Refugee Resettlement Program
The objective of the U.S. resettlement program ts within the overall goals of
case management. Your goal is to help refugee clients become economically
self-sufcient as soon as possible. How do you accomplish this? You help
them to use their own skills and abilities to adjust to a new culture and
environment. You assist them as they draw upon a network of formal and
informal support systems.
The services you provide to refugees are linguistically and culturally
appropriate. They are comprehensive and coordinated. They foster
independence, self-direction, and self-support. Your support and training
increases clients’ abilities to transfer skills from their former countries to their
new environment in the United States.
When you apply the case management model to your program, you provide
clients with the most comprehensive, holistic services in the most effective
and efcient way possible. To put this model into practice, all staff members
need to have not only cultural and linguistic capabilities, but also a chance
to learn basic social work concepts and develop necessary skills. Sections I
and II of this manual address these concepts and skills.
36 The Role of Case Management in a Resettlement Program
III.2 Assessment
Dening Assessment
The assessment phase of case management involves these steps:
• Make a rst contact with the person requesting assistance, in order
to gather and assess information to determine a person’s eligibility
for services.
• Establish eligibility and then accept the individual for services (this is
when the person becomes a client).
• Carry out comprehensive assessment activities, including (a) assessment
of a client’s self-care capacity and human service needs; (b) assessment of
a client’s social network and its capacity to respond to the client’s needs;
(c) assessment of human service providers and their capacity to respond to
the needs of the client.
How do you carry out assessment in your work with refugees?
Eligibility Criteria
• All legally admitted refugees and entrants can receive initial resettlement
services when they are resettled under the sponsorship of USCCB/MRS
through the R&P and Cuban/Haitian (C/H) programs.
• All legally admitted refugees, asylees, Cuban and Haitian entrants, and
trafcking victims can receive Ofce of Refugee Resettlement (ORR)-
funded employment and social adjustment services for the rst ve years
from the date of entry to the United States or from the date of approval for
political asylum status.
Screening Process
Initial screening to determine refugee status takes place overseas. Refugees
accepted for admittance to the United States are referred to a national
agency (like USCCB/MRS). This agency, in turn, assigns cases to local
resettlement programs.
USCCB/MRS resettlement programs do not discriminate in any way. We
accept clients for services regardless of their religious afliation or country
of origin. Anchor relatives may be able to select the agency that will help
their family through Afdavit of Relationship (AOR) ling. Still, remember
that most non-U.S. tie clients rarely have an opportunity to choose their nal
destination. Therefore, they are considered semi-involuntary clients.
The Role of Case Management in a Resettlement Program 37
As a staff member in a local
resettlement program, you assess
and review the biographical
data and other information
provided by MRS Processing
Operations. You consider your
program’s capacity in the areas of
language, available housing and
employment, medical resources,
and other resources the client
needs. Then you decide whether
your program can effectively
resettle the client. For U.S. tie
cases, you also consider the
anchor relatives’ ability and
willingness to help. You consider
how your program might
effectively coordinate services
with these relatives.
Assessment Process
The main purpose of your assessment is to collect information that will
support the development of a resettlement plan. The ultimate goal, of course,
is for clients to obtain economic and social self-sufciency as soon as
possible after their arrival.
First, you assess basic needs, including needs for housing, food, clothing,
and household items. You then assess clients’ needs in the following areas:
• Health and mental health
• Employability
• Education for children
• Guardianship for attached minors
• Orientation to U.S. laws and culture (including issues of family violence,
abuse, neglect, and substance abuse)
• English-language training
Also, you assess special needs for those clients who are disabled, those who
have suffered traumatic experiences or torture, and those who might need
mental health services or other special services.
Phase 2:
Planning
Phase 5:
Evaluation
I
N
D
I
V
I
D
U
A
L
C
L
I
E
N
T
/
F
A
M
I
L
Y
• Problems
• Needs
• Strengths
• Weaknesses
• Problems
• Needs
• Strengths
• Weaknesses
Phase 1: Assessment
CM
ASSESSMENT
38 The Role of Case Management in a Resettlement Program
Many agencies have a written manual that incorporates step-by-step
procedures for how to complete an assessment; this manual would be based
on program and agency requirements and may have more specics if the
agency is accredited by the Council on Accreditation (COA).
The planning phase begins after your agency accepts an individual for case
management services and a case manager completes the initial assessment.
Planning is the link between assessment and intervention. (Intervention is
discussed later in this section. Briey, intervention is when the activities set
in the plan are carried out.)
The planning phase is when you, as a case manager, and your client develop
a resettlement plan and arrange for service delivery. The actual plan addresses
what services will be provided, how they will be arranged, who will carry
out the services, and by when (targeted date of completion). Your client’s
participation in this planning process is extremely important. He or she will
need to identify with and accept the suggested services and desired outcomes.
Development of Service Plan
As a case manager, your involvement in this process is crucial. Consider
these three components while developing a comprehensive resettlement
plan: individual care, social networks, and mutual networks.
In general terms, the planning of client service delivery includes these steps:
a. Determine the client’s needs.
b. Transform these needs into short- and long-term goals and objectives, to
be met with service delivery and other social support.
c. Identify the roles and responsibilities of those involved in service delivery
and social support.
d. Establish timeframes for clients to achieve goals (partial or nal achievement).
e. Develop and establish indicators to measure effectiveness so that you, as a
case manager, can monitor and evaluate your plan for services.
f. Develop a contract.
III.3 Planning
The Role of Case Management in a Resettlement Program 39
You provide a contract in order to follow the Code of Ethics that is reviewed
in Section II of this manual. This contract, or agreement between you and
the client, species which activities each person will conduct. It sets out a
timeframe for action to be conducted or completed during the intervention
phase and is signed by both you and the client. The agreement typically used
in R&P programs is the resettlement plan. In other programs, this type of
plan is often called an Individual Service Plan (ISP).
The resettlement plan should address the following:
• Problems and concerns
• Short-term goals and objectives for the intervention phase, and long-term
goals for increasing the well-being of clients
• Activities to be conducted by the client
• Tasks to be performed by you (or by a third party) during the
intervention phase
• Dates and timeframes for tasks to be completed
• Estimated date by which the intervention will be completed
• Schedule of time and place for particular activities
• Identication of other social and mutual networks (such as anchor
relatives and volunteers) that are expected to participate, and clarication
of their roles during the service delivery process
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40 The Role of Case Management in a Resettlement Program
Each grant program has its own requirements for the development of a
service plan. Since the individual service plan is the foundation of the case
management model, USCCB/MRS strongly encourages each program to
develop a separate resettlement plan for each member of the case for initial
resettlement contracts (such as R&P and C/H). Although developing separate
plans can be time-consuming, this practice is the only way to ensure the
principles of case management are adequately implemented.
How do you develop a service plan in your work with refugees?
Service Planning
As a case manager, you must develop a written resettlement plan in a timely
manner for each client. Your clients should be a part of the process of setting
their own short- and long-term goals toward achieving self-sufciency
through employment as soon as possible after arrival. You should also inform
your clients about different approaches and possibilities. They need to
participate in the preparation of their own resettlement plans.
Both you and your client should understand and agree upon your roles in
preparing and executing the plan. Place special emphasis on explaining the
client’s rights to condentiality. Also, help the client continue to practice
customs that preserve cultural identity.
The resettlement plan incorporates your assessment ndings. It species
which services you and your client have planned. It also includes service
goals and objectives, timeframes, and expected outcomes. Each client
should sign the nished resettlement plan. For a minor (under the age of
eighteen), his or her designated guardian should sign.
Logistics for the Development of the Plan
All resettlement programs face certain challenges in the planning phase. Our
funders already outline the services we must provide, and the core services
checklist is the baseline for the services that refugee clients should receive.
Our cooperative agreement details more requirements related to health,
mental health, employment, and services to minors. So when developing
service plans for clients, we must describe these required services to them.
Many agencies have a manual that incorporates requirements of a coopera-
tive agreement (similar to USCCB program operations manuals) with agency
requirements (and also incorporates COA requirements for agencies that are
accredited). Check to see whether your agency has this helpful tool.
The Role of Case Management in a Resettlement Program 41
The Development of a Resettlement Plan
The resettlement plan is developed within the outline of program
requirements and client needs. This process involves teamwork between
you, the client, other professionals, and social network members. You can
adjust the integrated plan as needed.
What other professionals might play a role? What do you mean by
“other social network members”?
Examples of other
professionals include
• Other staff from the
resettlement program
• Medical doctors
• School teachers
• Eligibility workers in state welfare
or social security of ces
• Mental health professionals.
The appropriate development of a resettlement plan is one of the most
important functions of the case management model. It de nes how needs
will be addressed, and it drafts for each client the steps necessary to ful ll
their needs.
Social network members might be
• Volunteers
• Ethnic community representatives
• Church members
• Neighbors
• Anchor relatives
III.4 Intervention
What are your service functions (roles) in carrying out the case management
model? Answering this question is important to understanding the
intervention phase.
In each case, you, as a case manager, will have to determine the direct and
indirect roles you will need to play in the implementation of the resettlement
plan. The goal in case management is to enhance clients’ ability to function
independently. Remember that each client has a different capacity to ful ll
this goal.
First, assess your client’s skills. Then, adjust your roles and the written service
plan accordingly. In all this, ask the help and support of your supervisor.
42 The Role of Case Management in a Resettlement Program
The Direct Function of Case Management
The direct function of case management, known as micro-intervention,
is performed at a client level. In determining your direct role, understand
that each client has a different capacity to function independently. Develop
a good, trustworthy relationship with each client. This will give you more
chances to appropriately assess what the client is able to do.
Build the plan around the assessment of the client’s attributes. In this way,
you will develop the most suitable plan to increase client independence and
self-direction.
The following are four basic attributes you must consider in developing
the plan:
• Values. Each client is a unique person with the ability to achieve set
goals. Each client also has a particular value system. Develop your
intervention with that system in mind. If you know the value systems
of your client, you will better understand how to work with the client
to achieve their goals.
• Cognition and Attitude. Cognition is a person’s state of mind. It
includes perceptions, reasoning, judgments, mindset, and attitudes.
Consider the cognition of each client when developing your
resettlement plan. The more accurately you can assess a client’s
cognition, the more appropriate your plan of intervention will be.
• Skills. Assess how well the client can use his or her cognitive and
behavioral skills in order to function independently.
• Ability and Willingness to Accept Help. Assess the client’s ability
and willingness to accept your help in achieving the goals set in the
resettlement plan.
You will engage in one or more direct service roles during the service
period, or intervention phase, of case management. These roles will
depend on the client assessment that you conducted using the four
attributes listed above.
The Role of Case Management in a Resettlement Program 43
As a case manager, you need to understand the possible roles you may
play in order to effectively help your clients. Six roles are discussed in this
segment: implementer, teacher/instructor, guide/collaborator, processor,
information specialist, and supporter.
Implementer
As a case manager, you will have a different degree of personal involvement
with each case. Overall, see yourself as a navigator: someone who guides
clients and who ensures services are delivered as designed within the
resettlement plan.
As an implementer, you keep track of deadlines. You evaluate whether your
client has progressed appropriately towards achieving the set goals within
the timeframes originally established. Continually evaluate obstacles, and
adjust the plan as necessary, intervening when needed.
How might you, as a resettlement case manager, assume this role?
This is one of the most important roles when it comes to putting your
resettlement plan into action. If you do not engage appropriately in this role,
the best-developed resettlement plan will not succeed.
Phase 3: Intervention
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Phase 2:
Planning
Phase 4:
Monitoring
Consider the
Following Attributes:
• Values
• Cognition/Attitude
• Skills
• Ability & Willingness
to Accept Help
44 The Role of Case Management in a Resettlement Program
Any person moving to a new environment or culture would naturally have
difculties functioning independently after only a short period of time.
Our clients face these difculties, along with many other obstacles such
as separation from family, the experience of trauma, and prolonged stays
in refugee camps. Some may be unable to fully understand and fulll the
expectation set forth by the U.S. refugee program—economic self-sufciency
through employment as soon as possible after arrival.
As an implementer, you will need to establish a stable situation for your
clients. At some point during the service period, you may need to re-
evaluate the resettlement plan, especially if clients are not meeting the goals
within established timeframes.
A successful implementer works to nd the reasons why goals have not
been achieved (for instance, whether expectations were set too high, or
new obstacles have arisen). Then, he or she will work to reassess the four
basic areas of client attributes (values, cognition and attitudes, skills, and
willingness to accept help). Remember, it typically takes two to three months
for most newly arrived refugees to fully comprehend the concept of the U.S.
resettlement program and actively participate in resettlement activities.
Teacher/Instructor
In this role, you work directly with clients to help them develop skills that
are useful in achieving a higher level of independence. Clients should be
able to perform tasks as described in the resettlement plan. The ve basic
steps of teaching are (1) identifying, (2) explaining, (3) demonstrating,
(4) practicing, and (5) evaluating.
How might you, as a resettlement case manager, assume this role?
The role of teacher/instructor is a very important component within the
intervention phase. As a case manager, you may teach your clients how
to do many things, such as shopping in a grocery store, paying rent, using
public transportation, making appointments with doctors, and using
appliances in the home.
In this process of teaching these activities, you carry out the ve basic
steps of teaching/instructing. You identify and explain the desired skill. You
demonstrate how to use it effectively. Then you provide an opportunity
for the client to practice using the skill. Finally, you evaluate and provide
feedback to ensure that the client can practice the skill in daily life.
The Role of Case Management in a Resettlement Program 45
Remember, each client learns in a different way. Each client needs different
explanations and levels of practice to fully understand what to do and how
to do it. Before you teach or instruct, you must understand what your client
needs to learn, and how he or she can best learn it. You will need to use
different approaches once you recognize a client’s level of familiarity with a
certain subject.
Guide/Collaborator
In this role, you work directly with clients to identify the services, support,
and resources they need. Then you guide clients through the process
of obtaining these resources. In this relationship, you and your clients
collaborate to obtain services and resources. This collaboration better equips
clients to obtain support independently.
How might you, as a resettlement case manager, assume this role?
As a case manager, you prepare your clients to obtain resources and support
for themselves. After guiding clients, you expect them to carry out various
activities on their own. For instance, you expect clients to buy food and
necessities, take the bus to work, pick up children from school, attend ESL
classes, and visit community organizations.
Processor
In this role, you act as an advisor and provide technical assistance to clients,
usually in the later stages of the service period. Clients must be able to
identify their own needs and obstacles. They must have the ability to develop
possible solutions. They may need your help in advising them of available
resources, but then they should be able to access these resources on
their own.
How might you, as a resettlement case manager, assume this role?
Many case managers may not have the opportunity to play this role. This is
because clients rst need to achieve a certain level of self-sufciency and
acculturation before this role is useful to them. For example, one year after
arrival, clients may be ready to look for additional resources and support
to nd better employment, continue their education, move to a better
apartment, or purchase a house or car. At this point, clients may turn to their
former case managers for advice on the best way to achieve these goals.
46 The Role of Case Management in a Resettlement Program
Information Specialist
In this role, you refer clients to appropriate resources. You can use resource
books, pamphlets, handouts, catalogues, and computer databases to nd the
resources. In this role, you also evaluate whether a client is able to access
the opportunities that are available.
How might you, as a resettlement case manager, assume this role?
In most situations, you engage in this role when you help clients fulll
educational or vocational needs. This assistance usually is given when
clients have achieved a higher level of acculturation and adjustment to
life. Most newly arrived clients will not have this need or be able to fulll
the requirements for accessing various resources early on in their
resettlement process.
For instance, many clients want to enroll immediately in university classes.
However, before you provide information about possible opportunities in
this area, you must be sure that the client can realistically enroll in classes
at that time. For instance, make sure there are no constraints related to
nances, language ability, or residential status.
Supporter
In this role, you promote a client’s self-advocacy. You do this through
strategies such as empathizing and empowering. You might engage in this
role when a client has already achieved a high level of independence
and has well-developed problem-solving skills that allow for effective
decision making.
How might you, as a resettlement case manager, assume this role?
As a case manager, you engage in this role while working with clients who
are well-adjusted and productive members of our society. Refugees will face
many obstacles and frustrations with systems and organizations. When they
encounter these obstacles, they may seek support from you.
For example, clients might need your support during accessing or
recertication of certain benets, such as medical coverage or food stamps.
Often, eligibility workers might incorrectly determine the status of clients.
Clients might also experience obstacles in obtaining certain loans—such
as nancial aid for university classes or a mortgage approval—due to
misunderstandings, or perhaps because of problems with their travel
loan repayment.
The Role of Case Management in a Resettlement Program 47
The Indirect Function of Case Management
When engaging in the indirect function of case management, you serve
as the main contact in a complex network between agencies. The indirect
function of case management extends beyond direct work with clients. It
includes functions performed on a broader level within the organization
and community.
Five indirect service strategies that are important
for case managers to recognize
(1) Brokering services to meet client needs
(2) Linking clients to services and resources
(3) Coordinating delivery of services to clients
(4) Advocating for clients
(5) Providing technical assistance and consultation
These ve strategies should be incorporated into the resettlement plan to
ensure that all client needs are met.
1. Brokering Services to Meet Client Needs
Use this strategy to connect your clients to resources and services that can
appropriately meet the needs outlined in their resettlement plans. Determine
which agencies and community resources can best deliver the services
needed by your clients.
How can you e ectively apply this strategy to case management?
First, you will need to know the kinds of services that are available
for clients. Then you will need to determine which services might be
appropriate and accessible.
Know the service areas of the agencies that will provide services to your
clients. In addition, be aware of the quality of services that agencies will
deliver, and know each service provider’s level of competence to address
clients’ needs. Finally, verify that clients will meet the criteria for eligibility to
access those services.
As a case manager, you develop personal contacts with various agencies.
You build relationships that create a professional network. For example, you
stay in touch with people at state welfare agencies, hospitals, local voluntary
agencies, and schools. You communicate with private doctors, leaders of
48 The Role of Case Management in a Resettlement Program
cultural communities, and other refugee service providers. You can connect
your client with these people and organizations so that, in turn, they can
provide the resources and services that clients need.
2. Linking Clients to Services and Resources
You connect clients to all sorts of services. As a case manager, you act as a
mediator between the client and the identied agency when you provide a
referral to a client.
Make sure that clients understand the purpose of a referral. Ensure that they
do not object and do not fear using the selected resources to have their
needs met. Also, work with the selected agency to make sure that referrals
are accepted and that the agency can adequately serve clients’ needs.
In order to ensure this strategy is effectively carried out, establish an
appropriate monitoring system. Document follow-up visits (see Section IV
of this manual, “Case Recording,” for more on this task). Leave a written
record showing that the client has been served and that his or her needs
have been met.
How can you eectively apply this strategy to case management?
Already, you frequently link clients to services and resources. You refer
clients to many outside organizations for services, but you also provide
referrals within your own agency.
For instance, you link clients to social service organizations for food stamps
or nancial benets. You send them to medical facilities for medical and
mental health services. But often, your own agency may provide social
adjustment and employment services.
As a case manager, you need to understand how to function effectively
as a link to resources. Making a simple referral for services to any agency
does not ensure that a service was delivered or that your client’s need was
adequately met. To make this determination, you will need to follow up with
the client and/or agency. Also, make sure you adequately document each
step of this process.
The Role of Case Management in a Resettlement Program 49
3. Coordinating Delivery of Services to Clients
You, as a case manager, make sure that clients receive all the services they
were intended to receive. You regularly monitor the implementation of the
resettlement plan. You ensure that everyone is involved as the plan states
they will be, including formal service providers, informal supporters, and the
clients themselves.
You will use four methods to coordinate client service delivery:
1. Information exchange and monitoring, in which you ensure that all
members of the client support network have the information they need
(for example, leading a case coordination conference, or reviewing
assessment data or progress reports)
2. Capacity building, which includes developing competencies and
skills related to working with clients (such as case consultation and
joint training)
3. Adaptation, in which you respond to changes in client needs (adjusting
the resettlement plan to take into account a changing situation and the
needs of the client)
4. Networking, which helps to enhance or maintain the functioning of the
client support network (consultation, educational sessions, informal
social activities)
How can you eectively apply this strategy to case management?
You lead and coordinate efforts to provide initial resettlement services. You
also ensure that services are provided according to the resettlement plan.
Often, this type of coordination requires special conferences to ensure that
everyone follows the plan you and your client have set.
Employment activities—such as vocational training, job readiness activities,
and job placement—often impact the original resettlement plan, so ongoing
coordination is critical in this area. You will need to continue to follow up
and share information with service providers.
4. Advocating for Clients
Draw on this strategy when a service provider responsible for service
delivery is not responsive to the client’s needs. Figure out how to work
within existing structures to initiate the advocacy process. This strategy
sometimes may require you to involve those in positions of power and
authority, who ultimately can resolve the issue.
50 The Role of Case Management in a Resettlement Program
You must aim to advocate without creating major conicts, if possible. One
approach is to work rst with those immediately responsible for service
delivery before involving higher-level decision makers.
How can you eectively apply this strategy to case management?
As a case manager, you know that you must advocate for clients
continuously throughout the resettlement service period. In today’s environ-
ment of negative attitudes toward immigrants and refugees, this strategy is
especially critical as we work for equal access to services, linguistically
appropriate services within mainstream organizations, professionally and
culturally competent assessment of the refugee children within the U.S.
school system, and non-discriminatory employment practices.
5. Providing Technical Assistance and Consultation
You utilize your knowledge, expertise, competencies, and awareness of
client needs and service delivery problems when advising and providing
assistance to clients. You engage in different approaches to technical
assistance and consultation. These might include responding to an agency’s
request for assistance, educating an agency about unmet needs and relevant
characteristics of your clients, or exploring approaches that might resolve
problems with service delivery.
How can you eectively apply this strategy to case management?
You regularly participate in task forces with other members of the
resettlement staff. Here, you discuss concerns or educate other service
providers about newly arriving refugees. Ideally, these meetings also result in
the development of new resources to meet the needs of refugees. Examples
might include the development of new employment opportunities, special
ESL and literacy classes, or engaging guest speaker/workshop presentations
to recruit more volunteers and mentors.
The Role of Case Management in a Resettlement Program 51
III.5 The Monitoring Function of
Case Management
To ensure effective service delivery, you must monitor the basic functions
discussed so far (assessment, planning, and intervention). The planning
phase is an important time for you to identify the indicators that you and
other staff will use to monitor the client’s progress in achieving the goals
outlined in the resettlement plan.
As part of monitoring, you must also review the progress of others involved
in the implementation of service delivery, such as social and professional
network members. You need to nd out whether services have been
delivered to your clients in an appropriate and timely manner.
When you carry out the monitoring function of case management, you
should track the following:
• Whether the resettlement plan is being implemented in an appropriate
and timely manner
• How the client is doing in meeting goals and objectives identied in the
resettlement plan
• What services have been provided to the client and how the services have
been delivered in order to address the client’s needs (this tracking should
allow for revision and redirection to improve the helping process)
• The service outcomes (these results, tracked over time, may show a need
to revise the resettlement plan)
• Additional client needs, which, if identied, will require changes within
the resettlement plan
The design, chosen techniques, and forms of the monitoring process come
from two basic approaches: informal and formal. In the informal approach,
you gather information and assess progress by communicating and
observing. You use qualitative methods of monitoring, such as exchanging
information with clients, social network members, and service providers.
You review case records, and you visit with clients. These are all methods for
informal monitoring.
52 The Role of Case Management in a Resettlement Program
The formal approach to monitoring is more structured. In it, you use
quantitative methods and instruments to gather information and to evaluate
outcomes of the planned intervention. Some monitoring indicators have
already been developed. You might want to incorporate these tools into your
assessment process. They can help you better monitor the progress your
client is making.
How can you, as a case manager, eectively monitor the resettlement process?
Monitoring is an essential part of a successful intervention—it must not be
overlooked or neglected. As a case manager, you should understand why
monitoring is important.
As resettlement staff, you establish social and professional networks that are
fundamental to the successful delivery of services to your clients. Yet you
must also learn to navigate the helping process effectively. You can do this by
using monitoring techniques to assess the appropriateness and effectiveness
of the intervention.
Phase 4: Monitoring
Phase 5:
Evaluation
Phase 3:
Intervention
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The Role of Case Management in a Resettlement Program 53
Earlier in this section, you learned how effective the case management
model is for providing services to clients. It is important to remember the
larger picture and take a holistic approach. You can do this by focusing not
only on the individual tasks you must complete, but on the larger picture.
Often some tasks that can help your clients the most—such as case staf ng
with supervisors, or follow-up with refugee service providers and other
resettlement staff—remain at the bottom of your to-do list. Try to remember
that these tasks help your clients, even though they do not involve spending
time with clients.
As a case manager, you sometimes will experience dif culty with moving
clients towards goal achievement in a timely manner and reevaluating
their needs. The process of helping clients function better on social and
economic levels can become complicated and lengthy. The on-the-job, in-
house training you receive does not always explain in detail the best ways
to perform monitoring. At best, you may be using designed instruments to
gather and evaluate outcomes of the resettlement process.
For Program Directors
All case managers need more formal, practical training about how
to track each client’s progress. The program director should organize
appropriate training in this area. He or she should require case
managers to receive coaching about how to perform monitoring
techniques and about why they are so important.
You might use a weekly or monthly review system to assess a client’s
movement toward established goals. For instance, say you have a client with
an established goal to start working within four months of arrival. As a part
of your review system, you should be able to verify whether this client is,
in fact, working. Depending on what you nd out through your monitoring,
one of several possible situations may arise:
1. The client may be working as scheduled. This means that the plan toward
self-suf ciency is working well.
2. The client is not working due to some situation such as a newly
discovered medical condition. This means that the plan toward self-
suf ciency is not working. Adjustments are needed.
3. The client was working as scheduled but then was laid off. This means that
the plan toward self-suf ciency is not working. Adjustments are needed.
54 The Role of Case Management in a Resettlement Program
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EVALUATION
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Phase 4:
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Phase 1:
Assessment
III.6 The Evaluation Function of
Case Management
The last section established that monitoring is an essential activity. Now,
look at the data collected during your monitoring, and ask these questions:
1. How well has the intervention plan met the identi ed needs of the clients?
2. Were the goals achieved? Did we (the resettlement program, those
involved in carrying out the plan, and I) make a positive difference in the
areas of identi ed need?
3. Were the goals appropriately established? Should they be rede ned?
4. Did the overall functioning of the client increase?
By addressing these questions, you can evaluate the following aspects of
each case’s management:
• The client service plan—did it contribute adequately to the well-being of
the client?
• The attainment of goals—what overall outcomes did the case
management process produce?
The Role of Case Management in a Resettlement Program 55
• The general effectiveness of case management services—did they help to
maintain or enhance the client’s functional status?
• The client’s satisfaction—what does the client say about the effectiveness
and usefulness of case management in meeting his or her needs? Overall,
is the client satised with the delivery of services?
How can a resettlement program eectively evaluate each case?
Your program’s evaluation examines the client’s overall satisfaction with
the services received. Often, you will be conducting the evaluation as part
of the quality assurance process that assesses the program’s overall goal
attainments. In this case, the agency considers the evaluation to be a part
of the larger program evaluation, not an assessment of the client’s
resettlement plan.
Many refugee clients do not understand the concept of “client satisfaction”
surveys. Make a special effort to explain the important role these surveys
play in evaluating the effectiveness and overall impact of services.
Program directors should advocate for the development of culturally
appropriate and competent instruments within their own agency. You should
use these instruments to evaluate overall satisfaction and goal attainment
for clients. Often, quality assurance teams develop instruments to evaluate
and compare outcomes within different agency programs. However, these
instruments sometimes do not take into consideration the diverse nature of
the resettlement program.
Other indicators or instruments that resettlement programs might use to
evaluate outcomes include the following:
• USCCB or Department of State (DOS) monitoring and evaluation visits,
and the instruments they use to evaluate programs (for example, the
afliate questionnaire)
• Pre- and post-evaluation of improvement in refugee family functioning,
using the Likert scale (for example, a scale of 1 to 5)
• 120-day progress report for Match Grant clients
56 Case Recording
IV. Case Recording
Although the process of formulating a resettlement plan begins the
intervention phase with our clients, an excellent assessment and written
plan will not change a client’s situation alone. To make a difference, you will
need to put the plan into action and treat it as a living, evolving document.
While you must assess and evaluate your clients’ progress in achieving
various objectives, you will also need to monitor and evaluate the services
delivered to clients, which includes case recording. This section of the
manual will show you just how and why case recording is so important in
social work. In short, good case recording protects you and your clients, and
successful service depends on case recording.
Case recording is an integrated part of documenting case management
activities. It is the method commonly used to justify the services delivered to
clients. The case record constitutes an ofcial legal document, which is the
property of the agency within which the client receives services.
Although you would like to spend as much time as possible attending to
your clients’ needs, it is important for you to strike a balance. You must also
meet the requirements of the various grant programs (R&P, MG, and others).
While mastering this part of your job might always be challenging, some
basic rules will at least allow you to know what you are supposed to record
and how you might go about it.
At a minimum, your case les should document the following:
• Exploration into who the client is
— Initial intake
— Review of personal information and social history
— Assessment of needs and of resources available
• Formulation of service goal(s) in a resettlement plan
— What
— Who
— How
— When
Case Recording 57
• Implementation of the intervention
— Updates on the client’s situation
— The impact of the provided services on the client’s achievement of
objectives and goals
— Revisions of available resources
— Plan goals
— Activities and events
— Reection of service review
— Correspondence
— Documents
• Termination of services
— Written summary of status
— What follow-up is needed
— Means and reason for ending services
— Service activities
— Recommendations
Case notes should demonstrate evidence of the following:
1. Service documentation—including pre-arrival biographical data,
government-issued identication documents, agency release of
information, service delivery reports, and any other required documents
2. Case continuity—a complete story of how the client was helped from
the beginning of the service period through termination; should
demonstrate regular contact and show steps taken to resolve identied
needs and concerns
3. Inter-professional communication—statements from you and other
professionals relevant to the case, including medical reports, information
from the welfare ofce, etc.
4. Supervisory and/or peer review—documentation from a review panel
designated to review cases periodically to ensure quality and completeness
5. Monitoring of case progress and the impact of services—case notes
reecting your evaluation of the goals and objectives set for each client,
including revisions and adjustments as necessary
6. Mode of service delivery—notes on whether it was made in person, by
phone, or by letter
58 Case Recording
Your responsibility as a case manager is to record four things promptly
and completely:
1. A description of what took place
2. An assessment of the situation
3. Your immediate response
4. The plan for further action
In order to record these details, you will need to gather and analyze
information about the client’s situation and about the services being provided.
While there are several ways to record information on cases, most social
workers use narrative recording. This means writing most information in
sentence form.
Most refugee resettlement programs also require a narrative format of
case recording, especially given that it complements the resettlement plan.
Several models of recording might t with narrative case notes, but to
meet the requirements of the resettlement program, the SOAP method
is recommended.
SOAP Recording Method
An approach used in social work for case recording and information
gathering is called “SOAP.” The SOAP format allows you to describe the
proposed action and to tell why this action is being suggested. It also helps
to identify a problem that requires intervention.
SOAP is an acronym based on the following types of information:
•
S stands for subjective information—data collected from clients and their
self-reporting. The clients describe and discuss their perception of their
needs, problems, and situations. Examples of subjective information might
include the clients’ values and beliefs, as well as their specic concerns
and experiences as they describe them.
•
O stands for objective information—information that you and
other professionals obtain. This information is based on observation,
examination, and data collection that can be veried and conrmed.
Examples of objective information might include records of the clients’
medical conditions, educational transcripts, and professional histories.
Case Recording 59
• A stands for assessment—a summary statement of professional opinion
(in this instance, your opinion) based on reviews of the subjective and
objective information. The assessment is a professional description of
the client’s needs and the obstacles that prevent client independence
and self-fulllment.
•
P stands for plan—detailed information on how to help clients meet their
needs and overcome obstacles discovered in the assessment. For you, this
will be the resettlement plan. The completed resettlement plan should
clearly show what service will be delivered, when (timeframes), how
(method), and who will be involved in each step of the service plan. This
resettlement plan is only useful if it is kept up to date and if it shows the
continuity of the service delivery process.
Apply the following rules and principles when practicing narrative recording
in the SOAP method:
• Record information that is signicant and relevant to client needs and
problems. This means you should record what is important to know,
not what is nice to know. There are many reasons why this concept is
important. For instance, lawyers in the United States are not required by
law to share any information provided to them by their clients. But in most
parts of the United States, social workers must provide information about
their clients if a court requires it. Although the information your client
shares with you is condential, you should know that your agency may be
required to provide a client case le for legal reasons.
• No matter what is recorded in the case le—or whether or not it is valid—
no one can erase it, blacken it out, cover it with correction uid, scribble
over it, or in any way make it unreadable. If you make a mistake in a case
note, or anywhere else in the le, draw a thin line through the mistake.
Make certain that the original entry is still legible. Put your initials by this
cross-through, and proceed to enter the correct documentation beside
it. If your program uses computer software to record case notes, your
agency should ensure that the system allows you to make corrections in
accordance with this standard of case recording.
• Avoid using the names of other clients and service providers, to the
greatest extent possible.
• Record entries in chronological order (that is, by date) to ensure an
uninterrupted ow of information. This will also show continuity in the
implementation of the resettlement plan and intervention(s) outlined in
the plan.
60 Case Recording
What is missing from this note? While this case note does state what
should be done, the other components—such as how, by whom, and
when—are missing.
• Indicate the method or mode of service delivery.
• Record case notes promptly after service/intervention has been delivered.
Prompt recording is the best way to ensure the documentation actually
takes place. Furthermore, it is the only way to ensure real accuracy.
• Remember that your word that a service was delivered or that an
incident took place is not a valid substitute for case recording. You have
to record these activities to show that they took place and that program
requirements are being met.
Now put what you have learned into practice. Review the following case
notes and decide whether they meet the standards discussed above.
9/1: M ly tr
prm. Bru t t
r c. Exlne t ly
th t e t g t
Het Dprm r ec
scrng n is.
Ifrme cits t o-
ts m n t
e t r tr w clr
sch. W tke
l m n prtnc
nng ESL cl .
-BM
Case Recording 61
9/1: M ly tr prm. Bru t t r c t
t ly es n t dvlo i vc l ( t
lm l). Prvide i iti. A r sc i t ly
rs, t lwng mts r nge:
• Het Dprm scrng—scele r Tu day, 9/5/06. I
rvid rprti; tr r nge by HD. Fly
rs tte th t d hv ny p i ec rls. I
lne t t th t c ke r tr gnr et n
is, s ere by U.S. tnrs.
• Fo-ts m s scele r Mnay, 9/4/06; K-peng
CM ly n ts m. Cty tr
teac ly h t o-ts cr s s t v .
• Sch eg ri s scele r Wen day, 9/6/06; I c
ly 8:00 n t t r tr ngr dutr n
sch. Dutr n ir ig, n g t erby
lmtry sch.
• Ftr, r, n ldr dutr r scele t t b
dvlpr rsay, 9/7/06. Ii iti l m s
rvide by ts CM, n ly ndrtns t prtnc erly
l m. Ftr lace ity . Dutr agre t l
r l m s . S pne r ls t g t sch rdr t
ly nncily. M r tk s s r s lng r
b, t tr ngr clr t aj t sch.
• Tm , ly tr nng ESL cl . I adi, cty
tr rvid ESL tn r r wc . -BM
Now take a look at this note:
What do you think? Of course this note is much longer than the previous
one—but longer is not necessarily better. More importantly, does it meet the
standards? Yes! This case entry tells what, how, by whom, and when services
will be provided.
62 Case Recording
Here is another example:
9/15: Hm . Lerne th
t clr r nng
sch, ldr ly
rs r nng
ESL. M r s ng
r t sch. Tl
ly th f t d
n ESL cl ,
hr r t t n
l m. Ftr sas
hs b tvi. M r
hre t th r
lv cle r tray
Although this case note provides information related to what, the note
lacks continuity, and it is hard to identify just how or whether this family
was helped with their needs. In addition, the note gives information about
the mother’s family member (including her name) that is not relevant to the
resettlement plan of this family. It is “nice to know,” but not essential.
n s ry h y t
ler th r c, Kaj
Mhme, hv bby
.
-BM
Case Recording 63
9/15: Hm t r n tr ts c. CM lerne
r th clr r sch n dn . M r d ide t
r t sch r n r fr s cfrtl lwng
t g s w. Fly ready trte h ng t tr o-
ts cr. Accrng t ly, cty tr s ry pf
lng h t t o-ts cr n ho. M r ready
trte r ESL tn l s, tr n ldr dutr ede t
pn tr ESL cl r n u t cl n cncle. Ftr
frme th hv s r b tvi m m
. H tl th es c r n ts c r
ritly r ts b tvi, n I re t r dni
p i t t ts e. Ovr, ly s dn . N p i
rls r prte n ts .
Now here is a better way to document this home visit:
This case entry provides good follow-up information, and any reader can see
a continuity of services delivered to clients. The case worker who wrote it
will need to note follow-up in a future entry. For example, the case worker
will need to note whether the donation specialist gave the father the clothes
he needed.
64 Case Recording
Conclusion
By now, you are probably wondering, “How can I possibly meet these
standards?” Do not worry. No case managers would say that the reason they
continue working with refugees is because they love to write case notes!
Obviously, many challenges make this task difcult. The nature of the
resettlement program is one of crisis intervention—often, you cannot predict
or plan what your day might be like. Unexpected emergencies, including
unplanned arrivals, can always happen. All social workers struggle with the
dilemma: “Should I go to see my clients? Or should I stay in the ofce to
write case notes and complete other paperwork?” Also, you may not feel
comfortable writing in English, if it is not your rst language. Even so, you
can nd a balance, and you can maintain your les so that they meet
these standards.
Accountability is vital: not only to helping clients, but also to maintaining
funding and accreditation. The federal government (Department of State and
ORR), USCCB/MRS, and your agency are required to make sure that funding
is being used appropriately and adequately. Documentation plays a major
role in this process. In addition, if your agency is accredited, it must meet
certain standards with respect to case recording.
But do not lose hope—the work you do is valued and extremely important.
And remember, if you do it right the rst time, you will save yourself a lot
of time in the long run. Try also to remember that many of the standards
outlined in this manual are there for your protection and for the protection
of the client.
In the end, even case recording relates to helping our clients—and that is
what our jobs in the USCCB/MRS resettlement program are all about.
