East Bay HIV/STI Case Management Manual

By Dr. Tony Sillemon, Sutter Bay Hospital-East Bay Advanced Care (EBAC)

Building Rapport  

Building rapport is the cornerstone of effective case management. A strong rapport fosters trust, cooperation, and openness, enabling a collaborative relationship where clients feel valued and understood. 

Here are several techniques you can use to build rapport with your clients:

• Active listening: Pay full attention to the client. Show you are listening through nodding, maintaining eye contact, and providing verbal affirmations (e.g., “I understand,” “Tell me more”). Reflect what the client says to ensure understanding and show empathy.
• Empathy: Express genuine concern and understanding of the client’s feelings and experiences. Remember to avoid judgment and offer your client unconditional positive regard.
• Consistency and reliability: Be dependable and follow through on commitments you make with your client. Establish regular contact and be punctual for appointments.
• Clear communication: Use simple, direct language to avoid misunderstandings. Be honest and transparent about the case management process and any potential limitations.

These exercises can help you practice active listening, approaching with empathy, and other skills needed to build rapport with clients.

1. Role-playing scenarios:
   • Participants pair up and take turns being the case manager and the client.
   • Practice active listening and empathy by discussing a client’s hypothetical situation.
   • Debrief as a group, discussing what worked well and areas for improvement.
2. Reflective journaling:
   • Participants write about their personal biases and how these might impact their interactions with clients.
   • Share insights in small groups to promote awareness and growth.
3. Group feedback sessions:
   • After role-playing, participants provide constructive feedback to each other.
   • Focus on specific examples of effective communication and areas for improvement.

Cultural Humility

Cultural humility involves a lifelong commitment to self-evaluation and self-critique, recognizing and challenging power imbalances, and developing partnerships with people and groups who advocate for others.

Principles of cultural humility include: 

• Self-reflection: Make a commitment to continuously examining your own cultural identities and biases, and reflecting on (and addressing) how these influence your interactions with clients.
• Respect for clients’ cultural identity: Ask your clients about their cultural background and preferences, then integrate this cultural knowledge into care plans and decision-making processes.
• Advocacy: Work to identify, address, and reduce systemic barriers that affect marginalized populations. Partner with community organizations to support culturally relevant services for your clients.

The following exercises can help you practice cultural humility in your work.

1. Cultural humility training workshops:
   • Engage in activities and discussions that explore different cultural perspectives.
   • Develop strategies for integrating cultural knowledge into case management practices.
2. Discussion groups:
   • Share personal cultural experiences and biases in a safe and open environment.
   • Discuss how these experiences impact interactions with clients, and explore ways to practice cultural humility at your site.
3. Role-playing diverse client scenarios:
   • Simulate interactions with clients from various cultural backgrounds.
   • Focus on asking culturally sensitive questions and showing respect for diverse perspectives.

Supporting Self-Efficacy

Self-efficacy is the belief in one’s ability to succeed in specific situations or accomplish a task. As a case manager, enhancing self-efficacy in your clients empowers them to take active roles in their care and make positive changes.

Try these strategies for supporting clients in developing self-efficacy:

• Set achievable goals: Work with your clients to set realistic and incremental goals for positive change, such as securing a bus pass or keeping an important appointment. Celebrate small successes to help build clients’ confidence.
• Provide positive feedback: Offer constructive feedback that emphasizes your clients’ strengths and progress. Encourage your clients to reflect on their achievements and skills.
• Skill-building: Provide opportunities for clients to learn and practice new skills, and offer resources and support to help them overcome obstacles.

Exercises like these can help you gain necessary skills to support your clients’ self-efficacy.

1. Goal-setting workshops:
   • Participants identify and plan their objectives in small groups.
   • Share goals and action plans with the larger group for feedback and support.
2. Skill-building activities:
   • Tailor activities to individual client needs, such as job interview practice or financial management.
   • Use role-playing to simulate real-life scenarios and build confidence.
3. Success story sharing:
   • Encourage participants to share personal success stories.
   • Discuss the strategies and supports that contributed to their achievements.

Motivational Interviewing

Motivational interviewing is a client-centered approach that enhances motivation to change by helping clients explore and resolve ambivalent feelings. It involves a collaborative conversation style that strengthens a client’s commitment to change.

Key components of motivational interviewing include:

• Stages of change: In this model of behavior change, people progress through five stages of “readiness to change.” These are precontemplation, contemplation, preparation, action, and maintenance. Understanding these stages can help you tailor your interactions to best support your clients.
  
  In precontemplation, the client is not yet considering change. In the contemplation stage, the client is aware of the need for change but unsure about taking action. In preparation, the client is planning to act soon. In the action stage, the client is actively taking steps to change. And in maintenance, the client is working to sustain the change over time.
• OARS: This approach can help guide conversations with clients in a way that builds trust and elicits more meaningful information. OARS has four parts: open-ended questions, affirmations, reflective listening, and summarizing.
  
  Unlike questions that can be answered “yes” or “no,” open-ended questions encourage clients to really think about their responses and express their thoughts and feelings. For example, asking “What do you know about PrEP?” instead of “Do you know about PrEP?” invites a client to share their knowledge and perspective.
  
  Affirmations are sincere statements that recognize and reinforce a client’s strengths and efforts toward positive change. These can be as simple as saying, “I’m really glad you came here today” or “I can tell you’re working hard on your goal.” 
  
  In reflective listening, use your own words to mirror what the client communicates, to show your understanding and to prompt further exploration. An example might be, “From what you’ve just shared, it seems like you’re worried about being able to refill your prescriptions on time; did I get that right?” 
  
  With summarizing, sum up and reflect the main points of the conversation to ensure clarity and understanding. Summarizing can also help redirect or wrap up a conversation, such as saying, “We’ve made your first PrEP appointment for tomorrow and discussed how you’ll get to the clinic. Is there anything else you’d like to discuss before you leave today?”

These exercises can help prepare you to use motivational interviewing with your clients. 

1. Role-playing:
   • Practice the OARS technique in pairs, with one participant acting as the client and the other as the case manager.
   • Rotate roles and discuss the experience in a group debrief.
2. Case studies:
   • Analyze case studies to identify the stages of change.
   • Discuss strategies for using motivational interviewing techniques at each stage.
3. Group simulations:
   • Conduct group simulations where multiple participants interact with a single client scenario.
   • Focus on collaborative problem-solving and motivational strategies.

Positive Reinforcement

Positive reinforcement involves encouraging desired behaviors by rewarding them, thereby increasing the likelihood that these behaviors will recur.

Some basics of implementing positive reinforcement are:

• Identify desired behaviors: Clearly define the behaviors you want to encourage your client to engage in, such as regularly attending their medical appointments.
• Choose appropriate rewards: Select rewards that are meaningful and motivating to the client. Rewards can be tangible (e.g., gift cards) or intangible (e.g., verbal praise).
• Consistent application: Apply positive reinforcement consistently to establish a clear connection between the behavior and the reward.

Try these exercises to practice using positive reinforcement in your work.

1. Behavioral contracts:
   • Create contracts that outline specific behaviors and associated rewards.
   • Discuss and adjust contracts in group settings to ensure fairness and motivation.
2. Group discussions:
   • Share experiences with different reinforcement strategies.
   • Discuss the effectiveness of various approaches and brainstorm new ideas.
3. Role-playing rewards:
   • Simulate scenarios where participants practice giving and receiving positive reinforcement.
   • Focus on timing, delivery, and appropriateness of rewards.

Therapeutic Counseling

Therapeutic counseling in case management involves using evidence-based techniques to support clients in addressing any psychological and emotional challenges. (Providing mental healthcare is outside of the case manager’s scope, however; please seek referral and supervision from licensed mental healthcare providers if your client needs additional support.)

Therapeutic counseling techniques and approaches include: 

• Building a therapeutic alliance: Establish trust and rapport to create a safe space for your clients. Within that safe space, be consistently empathetic, non-judgmental, and supportive.
• Cognitive-behavioral techniques: Help clients identify and challenge any negative thought patterns. Encourage the development of healthier thinking and coping strategies.
• Solution-focused approaches: Focus on your clients’ strengths and resources, such as their determination or their strong support network. Collaborate on finding practical solutions to current problems.

The following exercises can help you put therapeutic counseling techniques to work.

1. Guided self-reflection:
   • Conduct exercises where clients identify and reframe negative thoughts.
   • Share reflections in small groups to promote understanding and support.
2. Problem-solving workshops:
   • Use real-life scenarios to practice solution-focused techniques.
   • Work in teams to develop practical solutions and present findings to the group.
3. Role-playing counseling sessions:
   • Simulate counseling sessions to practice therapeutic techniques.
   • Rotate roles and provide feedback on the effectiveness of different approaches.

Harm Reduction Principles

Harm reduction principles aim to minimize the negative consequences associated with certain behaviors, without necessarily requiring that those behaviors stop. Syringe exchange programs are an example of harm reduction: Rather than trying to eliminate injection drug use, these programs work to reduce the likelihood of HIV transmission, overdose, and other potential harms associated with injecting drugs.

Some basics of harm reduction in the setting of case management are:

• Acceptance: Accept that potentially harmful behaviors are part of the client’s life. Focus on reducing the potential harm rather than eliminating the behavior. 
• Human rights: Respect the client’s autonomy, choices, and expertise in their own life. Consistently provide non-judgmental support.
• Incremental change: Encourage small, manageable steps toward reducing harm. Celebrate the client’s progress, no matter how small.

Use these exercises to practice applying harm reduction principles in your own work. 

1. Harm reduction planning:
   • Work in groups to develop harm reduction plans for hypothetical clients.
   • Present plans and discuss strategies for implementation and improvement.
2. Case studies:
   • Analyze case studies on harm reduction strategies and their outcomes.
   • Discuss the successes and challenges of different approaches.
3. Role-playing scenarios:
   • Practice harm reduction techniques in simulated client interactions.
   • Focus on building trust and supporting incremental change.

Trauma-Informed Care

Trauma-informed care recognizes the impact of trauma on individuals, their families, and their communities, and integrates this understanding into all aspects of service delivery to promote healing and avoid re-traumatization. This approach acknowledges that trauma can affect clients’ physical, emotional, and mental health, as well as their behaviors and how they engage with services. 

Core principles of trauma-informed care include:

• Safety: Always ensure your clients’ physical and emotional safety at your site. Create a welcoming and secure environment, so clients can feel secure with you, your fellow staff, and your site’s environment.
• Trustworthiness: Maintain transparency and honesty in all client interactions. Build trust through consistency and reliability.
• Choice: Empower your clients by offering choices and respecting their autonomy. 
• Collaboration: Foster a partnership approach between clients and service providers, to help level the power differences between clients and staff. Value client input and perspectives, and collaborate with clients on all decision-making. 
• Empowerment: Focus on your clients’ strengths and resilience, and center their ability to heal. Encourage their self-advocacy and skill-building.

The following exercises can help you incorporate trauma-informed care practices into your work. 

1. Trauma-informed care training:
   • Engage in sessions that cover the principles and practices of trauma-informed care.
   • Participate in role-plays to practice trauma-sensitive interactions.
2. Reflective practice:
   • Conduct reflective exercises to assess and improve trauma-informed approaches.
   • Share reflections and strategies in small groups.
3. Scenario-based learning:
   • Work through scenarios that involve trauma-informed care principles.
   • Discuss the challenges and solutions with peers.

Conflict Resolution & De-escalation Techniques

As a case manager, knowing how to manage conflicts that arise with a client can help reduce stress, preserve client trust, and maintain the client’s and staff’s physical and emotional safety. Conflict resolution and de-escalation techniques are essential for managing and resolving disputes or potentially volatile situations calmly and constructively.

Strategies include:

• Staying calm: Maintain your composure to avoid escalating the situation with reactive behavior.
• Active listening: Show empathy and understanding for your client to help defuse tension. Validate their feelings and concerns.
• Non-confrontational language: Use “I” statements to express your perspective without blaming. Avoid aggressive or accusatory language. 
• Problem-solving: Focus on finding a mutually acceptable solution. Collaborate to address the underlying issues that led to the conflict.

Exercises like these can help build your de-escalation and conflict resolution skills.

1. Role-playing conflict scenarios:
   • Simulate conflict situations and practice de-escalation techniques.
   • Rotate roles and discuss the effectiveness of different strategies.
2. Workshops on effective communication:
   • Participate in workshops that teach communication and negotiation skills.
   • Practice these skills through interactive exercises.
3. Group problem-solving:
   • Engage in group activities to solve hypothetical conflicts.
   • Discuss the approaches taken and the outcomes achieved.

Personal Safety in the Field

Your work with clients matters, and your safety matters. Maintaining personal safety in the field is crucial for case managers who work in diverse and sometimes unpredictable environments.

The following safety practices can be helpful: 

• Situational awareness: Be aware of your surroundings always. Identify potential hazards around you and plan for how to avoid them.
• Safety protocols: Always follow your organization’s established safety guidelines and procedures. Use safety check-ins, such as texts or phone calls, with a designated colleague.
• Self-defense training: Consider taking a training in basic self-defense techniques. Carry any necessary safety equipment as recommended by your organization and/or your self-defense instructor.
• Emergency preparedness: Have a plan for emergencies and know how to execute it. Carry emergency contact information and a fully charged mobile phone every time you’re in the field.

The following exercises can help you be prepared and stay safe in the field. 

1. Safety drills:
   • Participate in drills to practice emergency response scenarios.
   • Discuss and refine safety plans based on drill outcomes.
2. Workshops on personal safety:
   • Attend workshops that cover situational awareness and self-defense techniques.
   • Engage in hands-on practice to build confidence and skills.
3. Group discussions:
   • Share personal experiences related to field safety.
   • Discuss strategies for improving safety practices and protocols.

Reinforcing Professional Boundaries 

It can be tempting to “go the extra mile” for clients—we want to support them and help them succeed!—but reinforcing professional boundaries is essential for maintaining a healthy and ethical relationship with clients. Clear boundaries help protect both the client and the case manager and uphold professional standards.

Strategies for setting and maintaining boundaries include:

• Set clear expectations: Communicate the boundaries of your role and the limits of your relationship with clients. Be clear about what clients can expect from you, such as your availability and how they can and cannot contact you.
• Maintain consistency: Once you’ve established boundaries with clients, adhere to them consistently. Avoid making exceptions that can blur professional lines, such as meeting with a client socially.
• Seek supervision and support: Regularly consult with supervisors or peers to discuss any boundary challenges. Use your support networks to maintain perspective and accountability.

Try these exercises to help set and maintain your professional boundaries.  

1. Role-playing boundary scenarios:
   • Practice setting and maintaining boundaries in simulated client interactions.
   • Discuss the challenges and strategies for upholding boundaries.
2. Reflective journaling:
   • Write about personal experiences with boundary-setting.
   • Share insights and strategies in small group discussions.
3. Boundary workshops:
   • Attend workshops that focus on the importance of professional boundaries.
   • Participate in activities that reinforce boundary-setting skills.

By incorporating these comprehensive strategies and exercises, case managers can enhance their effectiveness, support their clients more robustly, and maintain a professional, ethical practice.