Case Management Plan

This plan was written with the Goals, Objectives, and Strategies (Section 3) of the Policies and Procedures in mind.  Every part of the plan touches on the goals and objectives.  A listing of those specific goals and objectives where the focus has been put are listed in the next section of this document.
The Case Manager is meant to guide, listen, and be a voice for our clients. The Case Manager’s position is to create a space that the client can dream, create goals, work on recovery, and rebuild their foundation to enter back into the social fabric of society stronger, better decision-making abilities, and confident in their future.

Individualized Service Plan:

The ISP will start with three goals that the client would like to work towards during their time in the program. They can be related to education, employment, reuniting with family, etc.  Each goal will have action steps (enrolling in one-stop, going to counseling, etc.) that lead up to the goal.  During their time in the program, the client may add goals as they complete some or find that older goals are no longer applicable. All of this will be tracked in Apricot.

Educational/Training Options currently used by Case Management and Providers:

There are many ways for us to direct employment/training and educational goals.  This allows us to find out what our client’s goals ard help them reach them – not just push them into something that they may not enjoy or be good at just to get them into training/education/employment.

  • Tulsa Re-Entry One Stop
  • Workforce Tulsa
  • TCC
  • OTC
  • Tulsa Tech
  • Telelibrary
  • GED Program via Union

Assessments:

An ORAS is done at the beginning of the program to get a baseline. At 6 months, 12 months, and 18 months another ORAS will be done.  After graduation, an ORAS will be done after 6 months out of the program and then 12 months to see if the changes have continued.

Record Keeping:

All information from meetings, needs assessments, the Individualized Service Plan, contact via phone/text to the client or for the client, and other information will be kept in the Apricot Software used for tracking, data, and case management.  These notes will be available to the providers who work with our clients and those given access per our Executive Director. All information within this software is confidential and should not be used for purposes other than as dictated in the release signed by the client at the beginning of the program or subsequent releases signed re confidential information including HIPPA.

Goals, Objectives, and Strategies:

This case management plan fulfills the following Goals, Objectives, and Strategies:

 

Goal 1:                 The 1st Step participant will actively participate in a life changing, character developing, community-based program that provides an alternative to incarceration for 18 to 25 year old non-violent male offenders

Objective 1.1,    Reduce subsequent criminal behavior

Strategy 1.1.3     Base acceptance into the program on screening and a multi-modal assessment of the risk for recidivism, criminogenic needs, and responsiveness of the young man

Objective 1.2:    Reinforce respect for lawful conduct through obedience to the court, making restitution for harms done, and performing purposeful service

Strategy 1.2.1.   Use the court experience, obedience to court orders, and making reparations as an opportunity to practice and develop pro-social attitudes, respect for authority, empathy and compassion for self and others, and focus for developing coping and self-control skills.

Strategy 1.2.2     Obtain legal counsel to assist in court proceedings to teach life coping skills associated with pro-social good citizenship, law and order.

Goal 2:                  Engage participants in individualized case planning that identifies specific strategies to effectively and maximally reduce subsequent criminogenic behaviors, develop pro-social habits, and assume responsibility for the impact and harm their criminal behavior has caused.

Objective 2.1:    Seek counsel from trusted mentors and advisors

Strategy 2.11      Connect each participant with an experienced mentor

Objective 2.2:    Engage in mutually supportive, positive friendships and social circle

Strategy 2.2.3     Reward change-directed and problem solving conversations with mentor about friends and acquaintances developed during the program and coping with intrusion of friends and associates continuing substance abuse or criminal behavior

Objective 2.3:    Perform the roles of loving and reliable son, partner, husband, father, brother, and friend.

Strategy 2.3.2.   Actively engage in cognitive behavioral therapy (CBT) counseling sessions and behavioral approaches to developing moral and ethical consciousness and improving and nurturing family and social role relationships.

Strategy 2.3.4.   Engage is anger management, parenting, and domestic violence recovery programs as appropriate.

Objective 2.4:    Demonstrate reflection on action, taking responsibility for actions, repairing harms done, and willingness to improve.

Strategy 2.4.2.   Begin to understand the health impact of past trauma, substance use disorder, and recurring stress on brain function that results in uncontrolled emotion and anti-social or criminogenic attitudes and behavior and develop  more effective coping behavior.

Strategy 2.4.3.   Reward change talk describing actions taken to improve thoughts, attitudes, and actions using self-assessment, taking responsibility and apology or making amends.

Objective 2.5:    Live in and contribute to a safe, peaceful, and growth promoting household and community

Strategy 2.5.3.   Reward providing community service as a mentor, family member, parent, or community citizen.

 

Goal 3:                  Engage in a life-long program of recovery from substance use disorder, trauma, and concurrent behavioral health problems

Objective 3.1.0.                 Demonstrate pro-health habits.

Strategy 3.1.1.   Eat a healthy diet, buy food for and prepare nutritious meals.

Strategy 3.1.2.   Perform vigorous physical activity.

Strategy 3.1.3     Exercise the mind in reading, conversation, sporting events, music, art, non-violent video games, and creative activity.

Objective 3.2.0.                 Achieve optimal physical and mental health

Strategy 3.2.1.   Seek and follow a primary care clinician’s advice for medical problems.

Strategy 3.2.2.   In addition to active participation in the 1st Step recovery counseling, seek and follow psychiatric medical advice and treatment for mental health illnesses

Objective 3.3.0.                 Demonstrate recovery from addiction behavior

Strategy 3.3.1     Reward recovery from use of addictive substances including tobacco in any form.

Strategy 3.3.2     Reward work with 12 step sponsor or spiritual advisor who guides the young man in developing skills of self-assessment, admitting and forgiving errors, and making amends.

Strategy 3.3.3.   Submit to random urine drug screens, confirm positive results, and take appropriate addiction treatment actions.

Strategy 3.3.4.   Submit to frequent random screens for aberrant behavior indicating substance use disorder, accept referral for treatment, and comply with sanctions.

Strategy 3.3.5.   Monitor medication assisted treatment for substance use disorder, obtaining reports from treating physician on young man’s progress.

 

Goal 4:                  Begin a career of useful and reliable work and service

Objective 4.1.0                  Obtain high school or equivalent educational certification.

Strategy 4.1.1.   Reward study for a GED if he has not graduated from high school.

Objective 4.2.0                  Complete training and education for a career.

Strategy 4.2.1.   Reward pursuit of additional education for a career.

Objective 4.3.0.                 Demonstrate financial self-sufficiency, responsibility, and generosity.

Strategy 4.3.1.   Reward opening a bank account and use of a bank card.

Strategy 4.3.2.   Reward paying bills on time and systematically following a debt reduction plan.

Strategy 4.3.3.   Obtain eligible social support services and funds.

Objective 4.4.0            Achieve recognition for high performance at work.

Strategy 4.4.1     Reward work attendance, increase in benefits and pay.

Goal 5:                  Develop life skills for a healthy, productive, happy, and free life

Objective 5.1.0  Demonstrate effective coping and problem solving skills.

Strategy 5.1.1.   Reward use of effective communication skills in expressing discontent, confronting others, avoiding gossip, respectfully expressing an opposing opinion.

Strategy 5.1.2.   Reward pursing counseling, training, and work for effective problem solving, particularly seeking advice and thoughtfully resolving conflicts or finding workable solutions.

Strategy 5.1.3.   Reward coping with frustration and confrontation without emotional outbursts of anger and hostility.

Objective 5.2.0.                 Demonstrate enjoyment in pro-social leisure activities.

Strategy 5.2.1.   Reward participation in leisure sporting or outdoor activities.

Strategy 5.2.2.   Reward creative, soul nurturing leisure activities.

Strategy 5.2.3     Reward parenting or child mentoring leisure activities.

Objective 5.3.0.                 Provide service for a greater good rather than serving only oneself.

Strategy 5.3.1.   Reward acts of kindness, generosity and service to others.

Strategy 5.3.2.   Reward participation in community service activities.

 

Scope of 1st Step Program Activities for Individual Participant

1) Before Entrance into Program:

  1. A) Conduct a one on one meeting with case manager (CM) to fill out an application, discuss handbook
  2. B) Meet with Executive Director
  3. C) Complete ORAS and BIO/PSYCH/Social Assessment
  4. D) Application reviewed at Social Service Provider meeting to determine final decision on acceptance into the program.
  5. E) CM is in touch with 1st Step applicant (if they are not in custody) to let them know acceptance and to continue to build a foundation/relationship with the applicant.
  6. F) CM will text applicant day before court reminding them what to bring with them – help obtain what they may need if they don’t have it and remind them what will happen at Court and after.

2) Day of Court

  1. A) Court – Executive Director, Case Manager or both will be in attendance
  2. B) Take to Lawrence, Scott, and Neigh House or other assigned housing site
    • If they have their own car, will show them where to go and they can do those items before being back at the house at 5:30. If they do not, then CM will drive them.
  1. C) 1st night in House – be back to the house by 5:30 pm. Meet the roommate.
  2. D) ED will stop by, and CM will stop by later in the evening to see how settling in.

3) First Week

  1. A) CM will schedule the first one on one meeting within the first two days to complete needs assessment as well as discuss One-Stop, Workforce, GED, etc.
  2. B) Work with Amy at Action Steps Counseling on schedule to get needed items/set up appointments
  3. C) Get Bus Passes/Discuss their transportation options
  4. D) Set groundwork to begin the Individualized Service Plan

4) Once a Month:

  1. A) All Client Dinner – at the Nigh House. Two clients (along with help from a Case Manager or mentor) will prepare dinner for the group. Mentors will be invited as well. This is a chance to hang out, connect without the pressures of counseling, meetings, etc. Just food, conversation, and fun.

5) Once a quarter:

  1. A) A full activity such as sports event, camping, cookout, community event for all staff, providers, mentors, and clients to be able to attend. This activity will promote social skills as well as communication and learning to have fun in different circumstances.

Breakdown of Case Management through Phases

Phase 1:

  • Weekly Meetings with Case Manager – these meetings will be time for the CM to touch base with the client. These sessions will be relaxed but focused on seeing where they are mentally in the program, any issues, how they are progressing on their goals.
  • Creation, and periodic revision, of an individualized plan for each client with goals and time-frames
  • Employment goals and opportunities
  • Educational goals and opportunities
  • AA/NA Meetings with completed sign-in sheet documenting attendance, as appropriate
  • UA Testing
  • GPS Monitoring
  • 30-day progress reports with Judge
  • All needs identified in Needs Assessment are obtained or in the process of being met, depending on the length of time needed to accomplish (ex: GED takes longer than Food Stamps)
  • At least one community service project (church, community organization) must be done
  • Connect client with a mentor no later than the end of Phase 1

Phase 2:

  • Weekly Meetings with Case Manager – these meetings will continue to keep a pulse on the client, work on issues, continue work towards goals outside of counseling and meetings with supervisors. This is also the time for the Needs Assessment to be re-evaluated, items added or completed.
  • Continuation of work on an individualized plan – finishing, adding, or continuing work towards goals
  • Employment progress
  • Enrolled in education or technical/vocational training
  • AA/NA meetings with completed sign-in sheet documenting attendance as appropriate continue
  • UA Testing
  • GPS Monitoring – may come off during this time. Depends on sanctions, reviews, etc.
  • 30 or 60-day progress reports with Judge
  • At least one community service project (church, community organization) must be done

Phase 3:

  • Twice a month meetings with Case Manager – at this phase, meetings may move to twice a month, but there will be at least weekly check-in via phone and text. This will be decided by Case Manager based on where the client is in their Individualized Service Plan, mentally, emotionally, etc.
  • Continuation of work on individualized plan adding a component for phasing out of the sober living house into own place
  • Employment
  • Education or technical training continues
  • AA/NA meetings with completed sign-in sheet documenting attendance as appropriate
  • UA Testing
  • 60- or 90-Day Progress reports with Judge
  • At least one community service project (church, community, organization, ) must be done

Phase 4:

  • Twice a month meetings with Case Manager – at this phase, meetings may move to twice a month, but there will be at least weekly check-in via phone and text. This will be decided by Case Manager based on where the client is in their Individualized Service Plan, mentally, emotionally, etc.
  • Continuation of work on individualized plan adding a component for phasing out of the sober living house into own place
  • Employment continues
  • Education or technical training continues
  • AA/NA meetings with completed sign-in sheet documenting attendance as appropriate
  • UA Testing
  • 60- or 90-Day Progress reports with Judge
  • At least one community service project (church, community, organization, ) must be done

Graduation:

After graduation there will be continued follow up. The hope will also be that they will want to mentor new individuals that come into the program.

Life Skills/Healthy Lifestyle – 12-week class

This curriculum is based on evidence-based information from sources including: CDC, DHHS, SEICUS, as well as others.  The sections of this program are meant to assist in continuing to build and create a strong foundation of knowledge leading to the ability to make good, sound, healthy and positive choices in life including relationships with family, partner and children as well as in the world at large.

These skills are necessary to live outside in a pro-social way leading to intra personal transformation.

The curriculum is 12 to 14 weeks. The first part is a basic life skills section. Not everyone will need this section and may not be required to attend the first couple of classes. This will be at the discretion of the Case Manager, Executive Director, and other providers.

Before the classes start, all clients will take the Temperament Sorter. This will allow them to learn a bit about themselves as well as be fun. It also helps the Case Manager understand some of the best ways to approach certain information.

1) Life Skills

1) Basic Skills

  • Laundry
  • Grocery Shopping
  • Cleaning
  • Cooking (OSU Extension classes)

2) Employment Readiness

  • Job Search
    • Resources
  • Resume/Application
  • Interview
  • Getting the Job
  • First Day

3) Financial

  • Budgeting
  • Bank Account/Debit Card
  • Understanding bills/payments
  • Understanding credit

4) Living Arrangements

  • What can you afford
  • House vs apartment
  • Pets
  • Transportation

2) Healthy Lifestyles

  • Men’s and Women’s Health
  • Healthy Communication (social media, talking, text, email, etc.)
  • Decision Making
  • Healthy Relationships
  • Birth Control
  • STDs (Working with HOPE testing we will offer free HIV/HEP C testing to those that may need it)
  • Self-Esteem – Media, Self, Outside Sources
  • Addiction and Relationships

Over 13,000 people are incarcerated in Oklahoma for non-violent crimes.

The 1st Step Male Diversion Program will save Oklahoma taxpayers money by helping men beat their addiction problems and reducing recidivism. It will preserve families, reduce prison populations and return productive young men to our community. Support us with a generous donation to help save young men’s lives

First Step Male Diversion Program
321 S. Frankfort Ave., Tulsa, OK  74120

918-367-0641