Lesson 8: Taking Histories

Attention

Collecting historical information from another person takes skills and patience.

Learning Outcomes

Upon completion of this lesson's material, students will be able to:

  • Describe how to gather and document a client's social history

Teaching

Gathering the Story

Gathering information for the social history is very important. This information helps determine your impressions and recommendations for treatment.

A "social history" is a description of the history of the problem that has brought the client to services. It also includes all the relevant background information about the person because these factors may contribute to the problem as well.

We might envision this as the persons' "story".

DETAILS are what are important...you may have heard the saying that the "Devil is in the details"...this might be true, but the solution to the problem is often there as well!

This is why it is so important to NOT jump to conclusions and solutions too early in the case management relationship...take the time to get to know the details of the story.

Information we Need

Click HERE to review the Maine DHHS standards for assessment

Ongoing Story-Gathering

As a CM, part of our relationship building function with our clients is to continue to get to know them and their history over time. We will never have the WHOLE story but if we remain open to the conversation, we can learn a lot.

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Changes in Case Management Delivery

There is a movement going on right now to change how mental health case management is being delivered within communities. One of the most significant changes is the implementation of the Behavioral Health Home model. Please read the following article to learn more about what is driving these changes (primarily financial which should not be surprising $$).

Article on Behavioral Health Homes

Mental health agencies here in Maine have been implementing this model for a couple of years. It is a different model than the traditional one case manager working with one person in the community model we have been teaching you about. As we hear about upcoming changes to the Accountable Care Act (ACA), otherwise known as ObamaCare, we should expect to see more changes with the case management models that will be reimbursed under Medicaid funding.

Assessment

Lesson 8 Assignment

Using the interview you conducted last week write up a treatment plan based on the example provided below. Submit a written treatment plan to the Lesson 8 Assignment Drop box that includes all of the necessary information (based on the example) presented in an organized and logical format.

Here is the example Treatment Plan for T.C. (PDF Version)

Lesson 8 Discussion (online class only)

Share what you have learned about the Behavioral Health Home model and what the implications are for the future of case management/community integration.