Strengths-based case management: The application to grandparents raising grandchildren

Abstract

Strengths-based case management is an alternative service modality for work with individuals and families. This method stresses building on the strengths of individuals that can be used to resolve current problems and issues, countering more traditional approaches that focus almost exclusively on individuals' deficits or needs. This article expands the literature on the application of the strengths-based model by using a project that provides health and social services to grandparents raising their grandchildren. Based on anecdotal resuits, the strengths-based model appears to have value in fostering a sense of independence and self-assurance among grandparents, as well as enhancing their level of confidence to nurture and support their grandchildren. Suggested limitations and implications for family practice and future research are noted.

DURING THE PAST DECADE, many helping professionals have given considerable attention to the utilization of strengths-based case management as a service modality. According to Saleebey (1997), strengths-based case management focuses on directly assisting clients to achieve their personal goals by helping them ". . . discover and embellish, explore and exploit [their] strengths and resources. . ." (p. 3). It is a client-driven model based on principles of systems and empowerment theories (Frankel & Gelman, 1998). Strengths-based case management supports active client involvement in a joint participatory process to enhance social functioning. Other assessment models, primarily problem-based or "deficitbased" assessments, engage the client less prominently and are more provider driven, adhering to "labels and theories" of case mangers (De Jong & Miller, 1995). In either case, according to Frankel and Gelman (1998), the goals of case management is to connect clients to resources to meet their particular needs, and secondly, to help them become their own case managers. It is the second goal that is overtly emphasized in strengths-based case management. Because problem-based assessment focuses on the negative events or characteristics in individuals, case managers often fail to appreciate or acknowledge individuals' assets. This failure serves to lessen an individual's capacity to solve his or her own problems. This is supported by the fact that many need-assessment tools tend to measure individuals' weaknesses and not their strengths. Another unfortunate occurrence is that clients sometimes develop a paternalistic dependency on case managers; they become dependent on the worker's "definition" of the client's problems, thereby deferring to the worker to both define their problems and to identify strategies to resolve them. Weick, et al. (1989) suggest there is considerable "power" that professionals possess in defining individual's problems and thereafter devising a strategy to overcome the defined problem. This appears to give case managers undue control over clients' lives and diminishes clients' autonomy and sense of competence (Saleebey, 1997). As such, strengths-based case management takes a more positive approach to addressing the needs of clients and gives them an active role in the problem resolution process. This article describes the application of the strengths-based case management model to a community-based health and social service program that provides supportive services to grandparents raising their grandchildren in parent-absent households. It serves to further expand the literature on the model's effectiveness in the practice field using a vulnerable group who have multiple social, health, and economic challenges but who also are endowed with considerable talents and treasures.

Background

It is purported by Saleebey (1997) that assisting clients with their problems using a strengths-based approach permits them to take an active role in identifying the source(s) of their own problems, to make a selfassessment of their personal and environmental resources, and to assume ownership and responsibility for the final outcome. The strengths-based process is a collaborative one between clients and case managers and incorporates five principles expounded by Saleebey (1997). First, case managers must recognize that all individuals, groups, families, and communities have strengths. The challenge often is to discern those strengths when there appears to be only adversity. For clients' strengths to be recognized and appreciated, case managers must have a good understanding about the clients' experiences, the environment, and cultural makeup of the family and its community.

The second principle stated by Saleebey (1997) is that adversity can be a source of challenge and opportunity. Case managers should recognize that many families with whom they are working have faced trauma and abuse previously and have survived it. The challenge is to help clients draw on those same resources not yet realized to address their current issues. This principle speaks to the level of resiliency (the capacity to come back after experiencing hardship and despair) many families possess and use to manage and overcome numerous hardships in their lives. Often families' levels of resiliency are tested as new challenges occur. However, the role of case managers is to help clients recognize their own strengths so they can use their own attributes to move toward hope and change.

A third principle espoused by Saleebey (1997) is that case managers do not possess all the power to move their clients to a state in which they are capable of bringing about change in their lives. Rather, it is the job of case managers to understand clients' motivations and aspirations for change and to use that motivation as a basis for providing support. In some cases, clients' lives are assessed and are prescribed care plans with little regard for what is important to the client. Therefore, this principle emphasizes the power of the client's emotional state to bring about change. Understanding the source of the client's motivation is an essential factor that case managers need to identify, accept, and incorporate in the support process. A highly motivated client is more likely to be successful than one who has little motivation or is presented with goals they are compelled to accept.

The fourth principle of strengths-based case management is the recognition that the support process must be a collaborative one between case managers and clients (Saleebey, 1997). This principle acknowledges that a partnership needs to develop between the client and case manager; a partnership that recognizes the experiences and knowledge of clients, as well as the skills of case managers. Together, a process for support is inferred that is likely to be more effective because it lessens the potential for dependency on case managers.

The final principle that Saleebey (1997) identifies is that strengths can be found in any environment. Although many communities are the result of great social and economic injustices that require change extending from sources external to that environment, this principle takes into account that such communities also have many persons with talents, aspirations, and ideals. These communities also have established institutions that are stable and capable of providing different types of resources. These positive resources should be identified and utilized for the benefit of the client. Too often clients are portrayed as "products" of dysfunctional communities (e.g., areas with high crime rates, low school attendance, high teen pregnancy, and a disproportionate number of female-headed households). This principle implores case managers to leave the security of their offices and seek out the positive resources of communities in which their clients reside.

Since the late 1980s, strengths-based case management has increasingly become recognized as a viable service model for practitioners working with a variety of groups. This is evidenced by the expanding literature on the subject and the growth in educational forums that focus on informing and training case managers about how to use the model in their practices. Besides publications on putting strengths-based case management in the proper theoretical and methodological context of social service practice (Weick, et al., 1989; Weick & Saleebey, 1995), much of the literature on the model illustrates its applicability with a variety of population groups. In particular, the literature shows that the process has been employed with juveniles (Clark, 1996), substance abusers (Berg & Miller, 1992; Miller & Berg, 1995), the mentally ill (Rapp, 1992), and the elderly (Sullivan & Fisher, 1994). Now, in this article, we will show how selected principles of practice of the strengths model were applied in an interdisciplinary program that provides community-based services to grandparents raising their grandchildren.

Grandparents Raising Grandchildren

Intergenerational caregiving is an ever-increasing phenomena in this country. Reports from the U.S. Census Bureau (1990) estimate that there are approximately 1.1 million American households in which children live with their grandparents. Although not a new phenomena, public recognition of this family structure has increased largely due to a myriad of social problems existing in our society. For example, the "crack-cocaine epidemic" has played a significant role in determining why grandparents are raising their grandchildren. A study of grandparents raising grandchildren in Oakland, California, determined that the majority of these grandchildren were in the care of grandparents due to neglect by their substance-abusing parents (Minkler & Roe, 1993). Other studies also have found that neglect related to substance abuse was the primary reason grandparents were raising their grandchildren (Kelley, 1993; Dowdell, 1995; Jendrek,1994). Less common reasons why grandparents are raising their grandchildren include parental death due to AIDS (Schable, et al., 1995), homicide (Kelley & Yorker, 1997), incarceration (Dowdell,1995; Dressel & Barnhill, 1994; Kelley, 1993; Gaudin & Sutphen, 1993), and mental illness (Dowdell, 1995; Kelley, 1993).

Intergenerational caregivers are under significant stress as they attempt to provide a stable and nurturing environment for their grandchildren. Research indicates that excessive psychological stress in caregivers has negative outcomes for children (Crnic & Greenberg, 1990), including an increased risk of abuse and neglect (Abidin, 1990; Milner, 1995). Other stress effects experienced by grandparents include physical health problems. Dowdell (1995), in a study of caregiver burden, found 45% of grandmothers identified themselves as having a physical problem or illness that seriously affected their health. Single grandmothers were more likely than married grandmothers to report health problems. Those who indicated their health had worsened after assuming parenting responsibilities also reported financial problems and lack of family support as major issues.

Isolation from peers is often an effect grandparents raising their grandchildren must endure at a point in their lives when they would otherwise have few child care responsibilities (Dowdell, 1995; Kelley, 1993; Minkler & Roe, 1993). The finding that these grandparents are socially isolated from their contemporaries is of concern given that social support is often found to be a mediator of stress in parents (Crnic & Greenberg, 1990; Crockenberg, 1987; Tellen, Herzog, & Kilbane, 1989).

Project Healthy Grandparents

In response to the growing incidence of intergenerational caregiving, and recognizing the numerous stresses that many caregivers encounter, Project Healthy Grandparents (PHG) was established in 1995 at Georgia State University (GSU) in Atlanta, Georgia. The general purpose of PHG is to determine the effectiveness of an interdisciplinary, community-based intervention to improve the social, psychological, physical, and economic wellbeing of grandparent-headed households in order to prevent child neglect. The program's goal is to strengthen the confidence of grandparents regarding the decisions that affect their grandchildren's lives while providing a nurturing and stable environment for them. Too often, grandchildren enter grandparents' lives during a time of crisis, giving little time for rational decision making. There is also little time to prepare for the immediate and pressing needs of having children back in their lives, e.g., school and medical authorizations, legal issues surrounding custody and child protection, additional financial assistance to provide for expanded basic necessities, such as, clothing, diapers, and formula. The services offered by PHG provide health and social support to the grandparents on many of these pressing issues in order to lessen the risk of child neglect.

Participant Description

There are approximately fifty families served by PHG at any time. The participating families are all African American and predominately low income in parent-absent households. Grandparents are referred to the program by a variety of sources, including social workers at a substance abuse clinic for pregnant women located in a major public hospital, local child protective service offices, day care centers, and by grandparents themselves. The ages of the grandparents range from thirty-eight to seventy-eight years, with a mean age of fifty-seven years. Approximately half of the grandparents did not complete a high school education, with an average grade completion of eleven years. Only 36% of the grandparents are currently working, while 64% are unemployed or retired; over 90% of the families are receiving financial support from TANF (Temporary Assistance for Needy Families) grants. Eighty-two percent of the grandparents are currently not married and are raising their grandchildren primarily alone, although in twentythree households the grandparents indicate they are receiving some support from other immediate relatives such as a son or daughter. This support varies from babysitting the grandchildren while the grandparent takes a respite, to providing some financial assistance. The mean number of grandchildren raised by their grandparents is 2.6, with a range from 1 to 7; the mean age of the grandchildren is 9.3 years, with a range of

Program Services

Service interventions are designed to ameliorate the effects of child neglect and provide grandparents with resources needed to prevent subsequent neglect, as well as improve social supports. A staff of social workers and registered nurses perform monthly home-based, case management duties. Third-year law students, supervised by the attorney faculty member of the project, conduct assessments regarding the legal relationships between grandparents and their grandchildren. Grandparents are informed of the various levels of possible legal relationships with their grandchildren. The legal options for relationships between caregivers and children, in order of least to most secure, are: guardianship, temporary custody, and adoption (Yorker, et al., 1998). Once knowledgeable about custody issues, grandparents determine whether they opt to improve their legal arrangement. The legal relationship between the grandparent and grandchildren is considered "improved" if the legal relationship is strengthened. Access to tutorial services also are available through the program, however, due to resource constraints, these services are provided on a very limited basis or through referrals to local community resources. All participants in the program receive services for a period of one year, after which they are invited to continue attending limited activities, not involving home visitation, by project staff (i.e., social support groups, parenting education classes). A community advisory board consisting of five grandparents, community professionals, and a GSU university administrator provides input into program direction.

Case Management Process

Social workers and nurses inaugurate grandparents into PHG using a sequence of primary steps for case management: assessment (problem/strengths), care planning, implementation, evaluation, and termination. During the initial home visit by social workers, grandparents are asked to identify and prioritize their needs, goals, and strengths. Emphasis is placed upon using those personal, familial, and community strengths that could facilitate problem resolution and goal achievement. Nurses perform a similar function with specific attention given to health issues.

Problem Assessment

At this point, the grandparent talks about the conditions within the family that impede or challenge optimum social and physical functioning. Again, the responsibility of project staff is to enable grandparents to identify and define the concerns that trouble them. The following types of problem-focused questions are asked during the assessment: What are your family's primary problems at this time? How are the problems affecting your family, particularly the grandchildren? How do you want to solve these problems; what goals do you want to achieve relative to these problems? Based on the responses to these problem-focus questions, the social worker, nurse, and the grandparent decide on a mutually acceptable statement of the problem(s) that will be the focus of their work together. If necessary, the social worker/nurse and grandparent then begin to prioritize multiple problems based on their importance to the grandparent or the urgency to resolve the problems as quickly as possible.

Strength Assessment

Family focus. Specific questions on family strengths are based on solution focused interviewing techniques reported by De Jong and Miller (1995). The strengthsassessment tool, designed by project staff, directs grandparents to characterize the most salient personal, family, and community assets. The strength-based questions are formed from the specific problems and goals identified by the grandparent, with special attention given to how the grandparent may have resolved similar problems in the past. These past "exceptions" are defined as "those occasions in the client's life when the client's problem could have occurred but did not" (De Jong & Miller, 1995). The following are the kinds of questions asked during the strengths assessment that address past experiences and are used to engage grandparents to converse about themselves, their families, and communities: What is a current problem that you also faced in the past? What did you do to solve the problem in the past? Can you now use the same resources you used in the past to solve your current problem? Were there occasions in the past when the problem occurred, but did not turn into a crisis, and what did you do to keep it from turning into a crisis? Why are you needing to address this problem again at this time?

Generally, it is during this assessment that grandparents begin to tell their stories about how they have come to raise their grandchildren and some of the difficulties they might have experienced in the past. In most cases, the grandparents are raising their grandchildren because they were looked upon as "the solution" to a crisis occurring with the biological parent(s) when few other options were available or desirable. The grandparents' stories give insight to their strengths, resources, and motivations that may be used to address their current issues. More importantly, it is at this point grandparents begin to realize that despite their current problems, they possess certain positive attributes that can be relied upon to help them overcome their present circumstances. By formally engaging the grandparent in conversation about positive experiences and attributes, each one begins to acknowledge strengths he or she did not realize, which serves to affirm some degree of self-competence (Sullivan & Fisher, 1994).

Health focus. A registered nurse assigned to the family schedules a home visit to conduct a physical health assessment on the grandparent and grandchildren. The health assessment includes the administration of a standardized tool, the Health Risk Appraisal developed by the Healthier People Network, which evaluates information concerning health status, lifestyle, and family history of an individual. An assessment of the grandparent's functional ability is also measured, using the SF-36 General Health Survey. In addition, several other physical health measures are taken: blood pressure, weight, height, cholesterol, and glucose levels.

The nurses also conduct a general health assessment on all grandchildren under the age of sixteen living with the grandparent. Assessments on grandchildren include weight and height measurements, as well as head circumference measures on children aged three years or younger, to screen for any growth delays. For children less than six years old, nurses perform a development screening using the Denver Developmental Screening Test. The nurses also review with the grandparent each grandchild's immunization and preventive health care records to determine if each child is adequately immunized and has received the level of preventive health care recommended by the American Academy of Pediatrics.

As part of the strengths-based assessment, the nurses help grandparents understand the benefits of proper health behaviors. One of the most important health education functions conducted by nurses is assessing their prescribed medication plans. During each monthly visit, the nurses routinely ask the grandparents to present the medications that have been prescribed for them, check the dosage for each medication, and assess what nonprescription medications the grandparent might be consuming. In a small number of cases, the nurses have detected grandparents who were over medicating themselves by taking double doses of their prescriptions because they did not clearly understand how they were supposed to take their medicine.

Using the physical health assessments as a basis, nurses engage grandparents in discussions about positive and negative health behaviors (e.g., proper weight control, good dietary habits, or maintaining a clean environment). Positive behaviors are emphasized and grandparents are encouraged to maintain them. Negative health behaviors are dealt with in a sensitive manner, as nurses realize that some behaviors are based on certain cultural or religious beliefs and customs. In discussions with the grandparent, nurses try to learn whether certain health behaviors are related to customary practices and whether or not alternative methods are possible. So with gentle guidance, grandparents learn how they can modify their behaviors to minimize negative health outcomes as much as possible, e.g., modifying recipes to reduce fat and sodium content, initiating a moderate exercise routine, and emphasizing the importance of maintaining prescribed medication protocols.

Care Plan Development and Implementation The family's goals and strengths provide the focus for developing family care plans for PHG participants. Focusing on the grandparents' goals and assets avoids the development of care plans to be dominated by the professional judgement of the social worker or nurse and allows for the uniqueness of the individual to prevail (Sullivan & Fisher, 1994). The individualized care plans are designed to promote optimum choice and to enhance full social functioning. They generally encompass a series of referrals to community agencies for various material goods (e.g., food, clothes and other consumable products), referrals for individual and/or family therapeutic counseling, monitoring family behavior relative to child protective service orders to preclude further sanctioning by the local child welfare agency, and advising/monitoring grandparents on various health, educational, and legal issues.

Serious health problems are addressed by including in the care plan steps the grandparent should take to move toward addressing the problem effectively. For example, if further medical testing and evaluation is necessary, appropriate names of health care resources are left with the grandparent who follows up on the referral (e.g., making necessary appointments, providing all information regarding the health concern to health providers, preparing appropriate questions to be asked during the health consultation, etc).

Generally, the grandparent takes an active and leading role in developing and implementing these care plans. However, it must be noted that the level of involvement by the grandparent is highly dependent upon his/her physical and psychological capacity. If the grandparent is severely limited by physical or psychological state, the social worker or nurse may assume a greater role in assessing needs and developing a care plan, as well as taking an active role in implementing it for the grandparent. This occurs, of course, if no other family member is able (or willing) to assume a more involved role in participating in the development and implementation process. But this does not mean that the grandparent has no role; instead the grandparent's role is defined by his/her capabilities. Grandparents with greater physical or emotional difficulties are given smaller tasks by the social worker or nurse that relate to the defined goals. In other words, even though some grandparents have diminished capacity, considerable efforts are made to enhance their self-esteem. The more the grandparents are able to accomplish, the greater their activity in resolving their own issues.

However, there is one exception to this perspective that points to the advocacy skills needed by case managers working with low-income clients. Since most of the grandparents participating in PHG are connected to TANF by receiving child-only grants or regular family grants, one of the primary areas where the functions of social work staff are most valued by grandparents is helping them maneuver various bureaucratic institutions, primarily the local welfare office. This has become a particularly important advocacy effort for service providers since the new welfare reform law came into effect in 1996 (Kelley, Yorker, & Whitley, 1997). Careful attention is given to monitoring the implementation of the law at the local level, and if possible, preventing any undue anxiety and stress within families.

A written copy of the care plan given to the grandparent serves to document expectations and responsibilities to be assumed by the social worker, nurse, and the grandparent. Review of the care plan is conducted periodically with the grandparent to evaluate the progress made on resolving problems and achieving goals. In most cases, care plans need to be revised when urgent issues arise, warranting attention to be drawn away from previous goals to the present crisis. However, even during crisis intervention, efforts are made to get the grandparent to assume greater responsibility in resolving the issue. The social worker or nurse makes certain the necessary supports are available to help the client overcome the crisis, but it is the grandparent (if capable) who assumes the leadership role in resolving the issue.

Monitoring and Evaluation

Social workers and nurses have the responsibility of monitoring their assigned case loads to determine how well their families have progressed in meeting their goals. The level of monitoring given to each family is dependent on how well the grandparent is able to manage the family's issues. All family cases are routinely categorized by the project staff into one of three groups ranging from "mild" to "severe," which reflects a grandparent's ability to be active participants in resolving the issues.

The families categorized as "mild" have few challenges and barriers to achieving their particular goals and require the least amount of supervision by project staff. Families in the "severe" group have multiple, complex issues, as well as many barriers to overcoming their issues, including physical and/or psychological deficits. Such families require greater monitoring by the project staff. By categorizing families according to the grandparent's ability, staff have a better sense of how to effectively monitor families and where they need to put forth greater efforts in helping families achieve their goals.

The-nurse/social work team, during their individual monthly visits, monitor the grandparent's progress to improve or sustain the family's current health state and social functioning. Nurses monitor basic physical health measures (e.g., blood pressure, pulse, respiration, weight) and the prescribed medication plans during each visit as a monitoring check. Since the nurses have regular contact with the social workers working with the families, the social workers are also able to assist the grandparents in monitoring and managing their health behaviors. Social workers also monitor the progress the family has made in getting needed resources or achieving their social goals, (e.g., applying for TANF, filing for adoption assistance, getting a GED application).

Each staff person maintains detailed progress notes on his/her assigned families, which are maintained in one central file. The file notes are reviewed by assigned staff (nurse and social worker) before going out on home visits or making telephone contacts. To coordinate the work of the nurses and the social workers, regular staff meetings are held to discuss each family based on the information obtained during the assessment and follow-up visits by social workers and nurses, including plans to address family goals, current strengths and resources, any social or economic barriers that might impede successful problem resolution, and how PHG can best service the family. The staff review process is highly regarded by all because it enhances the efficient use of project resources, particularly staff time.

Termination

All participants are informed before entry into the project that home visitation services will be provided for one year. Approximately two months before exiting the program, both the nurse and social worker reinform the grandparent of the impending close of their home visitation services. At that time, a review is made of the family goals, progression toward those goals, and a listing of resources needed to continue progress toward the goals. The final two months are focused on transitioning the family from PHG to another community program that can provide case management support if necessary or to self-management by the grandparent.

A final letter and community resource manual are presented to each family exiting the program. All "alumni" participants are maintained on the project's mailing list, and they are invited to continue to participate in the support group meetings, parenting education classes (described below), or other social activities sponsored by the project.

Support Group and Parenting Education Classes

Raising a second family can be an exhausting experience for grandparents. Shouldering the myriad of tasks necessary to care for children can be physically and emotionally draining. Recognizing that these stresses exist, PHG encourages grandparents to attend an open, monthly support group meeting. The purpose of the support group is to lessen the social isolation experienced by many grandparents through peer support, as well as to provide a physical and emotional respite for them. Facilitated by a master level social worker, the support group allows grandparents to share and discuss common issues involving their grandchildren, the parents or other family members who often have direct (albeit not consistent) contact with them, and their grandchildren. The support group also provides a socialization function. On occasion, the meetings have been used to plan social events organized by the grandparents, e.g., Thanksgiving dinners, Christmas gift exchanges, and the annual summer picnic.

Extending from the support group, a subgroup of highly motivated grandparents has evolved, and its members have assumed leadership roles within the project, including serving on the project's advisory council. Each support group meeting is held in a community setting at a time and location convenient for participants. Transportation and child care arrangements are provided by the project.

Another supportive resource provided to grandparents through the project is parent education classes. Many grandparents raising their grandchildren are concerned about parenting after having not done so for many years. Examples of topics include exercising appropriate methods for disciplining children, maintaining authority within the home when a parent returns periodically to that home, talking to children about substance abuse, issues related to child abuse and neglect, and various types of legal custody that may be assumed by grandparents. These and other topics are designed to give grandparents a knowledge base on issues that are most relevant to their lives while raising their grandchildren.

The classes are directed by a social worker, and in most cases, guest speakers serve as instructors to lead the grandparents on a specific topic. The nurses in the program sometimes serve as instructors when topics related to adult or child health are scheduled. The classes are presented in modules of ten classes, extending over approximately a ten-month period.

Both the support group and the parenting classes reflect the principles of the strengths-based model. Each allows grandparents to express and exchange ideas with others who are in similar circumstances. As such, not only do they become a mutual support network for each other, but by being able to help others, they begin to recognize their own strengths and competence levels. Also, by increasing the grandparents' knowledge about child care and increasing their socialization outlets, comfort in their ability to care for their grandchildren is potentially increased.

Discussion

Strengths-based case management strives to move beyond the limits of a deficit perspective to bring to light the individual's and family's positive attributes and resources as the means for resolving problems. It requires case managers to view individuals' and their problems from a positive perspective. Although this is not a totally new conceptualization for helping professionals, it has not been practiced widely across disciplines. Case managers too often view clients strictly from a problem perspective and not from a perspective that recognizes the hidden talents possessed by individuals who may only be overwhelmed by current circumstances.

A clear limitation of the current program regarding the strengths model in this article is the lack of empirical evidence to clearly validate its effectiveness. A series of objective measures for mental health, psychological distress, social support, and incidence of child neglect is currently being evaluated by the authors on a small sample of grandparent-headed families to be presented in a future publication. At that time, objective data will be available to quantitatively evaluate the program's service strategy. There is also the recognition that future work in the use of this service model should also include an empirical analysis that clearly illustrates the significance of strengths based case management as compared to other case management models.

In the meantime, other evidence that tentatively supports the value of PHG and its case management method is apparent from numerous anecdotal statements derived from satisfaction surveys obtained from the support group and parenting education classes, as well as exit interviews. In addition, a focus group was held with ten current and former program participants. The focus group was designed to gather information on participants' satisfaction with the program and how the program services benefited them and to suggest any program changes. While overall program satisfaction is very high, it is the qualitative statements from grandparents that indicate their knowledge of how far they have come in moving beyond their problems. When asked how PHG has supported them, one grandparent reported the following:

Nurses that come to visit . . . I didn't find out that I had diabetes until I got down here. . .. But once a month, you know they would come and talk to you, and they brought me literature for my diet.... Now I'm happy to say that I'm off the diabetes medication.

Another said:

I understand the grandparent project. To me I feel as though I took over the ship. In order for something to work, if I'm a part of it, I have to be a part of making it work. So, you go into exploring what it is that you need or want . . . I did not need a tutor for my grandson. . . but I needed other things to help me with parenting, because parenting is different today.

Yet another answered:

. . . I have become less angry. They encouraged me . . . they encouraged me to keep going. . . I've been to hell and back with these three children. But you know, I'm better because I can come with these other women, and I can come with a lot of comfort from here, they talk to me, make me feel better and then, by the grace of God, can take the anger [toward] my son-in-law away.

The above statements, and many others, illustrate how the approach implemented by an interdisciplinary team of professionals has left a positive effect on the grandparents. Reflected in their statements are the definitive effects Saleebey (1997) and other researchers have recognized to be the ultimate goal of strengths-based case management. Specifically, the grandparents recognize that they possess personal resources to address many of the new challenges they are encountering in raising their grandchildren and that professionals do not hold all the answers. Yet, by working in collaboration with professionals, issues can be resolved to their satisfaction. In most cases, what grandparents needed was a little direction - a little guidance - that enabled them to move forward independently.

A uniqueness of this model applied to the grandparent program is the fact that this population is one of the most vulnerable groups in our society. Yet, despite their social and economic adversities, many grandparents have moved to a level of recognizing their self-worth and have the potential to become strong advocates for their grandchildren. However, the present application of the strengths-based model makes one aware that "one size may not perfectly fit all." Strengths-based case management objectives are easily met when working with families in which members have good physical and mental health capacities. Such individuals are better able to identify their needs and resources and manage the necessary responsibilities to move forward to address their issues. Further, such families are better able to draw upon past positive experiences to meet current or future needs. Families in which the grandparent has moderate to severe physical and/or mental health incapacities warrant greater involvement by professionals and require greater use of community resources. Potentially, this would seem to undermine the basic principles of the strengths concept, however, professionals working with families should recognize that by assigning even the smallest tasks to persons with certain incapacities, they are facilitating some level of independence and self-awareness.

In conducting strengths-based case management, case managers will need to look at the whole family picture and perhaps categorize families according to their capabilities. This serves to make the best use of program resources while also maximizing the assets of clients. This becomes an important point when limited resources for programs preclude the ability of administrators to service all families in need. The most discerning course of action may be to target intensive case management services to the most needy, while giving more able families services that promote their strengths to the fullest, which in effect, saves resources because their time in receiving services is potentially less. Of course, such action requires thoughtful consideration by agency administrators on how to integrate the strengths-based model into current practice, to realize potential consequences of diminishing current practice methods for the strengths model, how funding and other policy regulations serve or hinder the implementation of the strengths-based model, and to consider what kind of training is needed to get case managers (and administrators) knowledgeable about this alternative service modality.

As the model is being implemented with various population groups, questions are still emerging about its validity as a viable service model. Even in Project Healthy Grandparents, little is known about the indirect impact the service model has on the grandchildren. Program services are primarily directed toward the grandparents based upon the assumption that if the grandparents are healthy and strong, the grandchildren also will benefit. As part of the process, when grandparents and their grandchildren leave PHG after a year in the program, a reassessment is made of the grandparent and grandchildren's physical and psychological status using objective assessment forms, as well as anecdotal information. Much of this data is currently being collected and analyzed and will be presented in a future publication and should go far in beginning to assess the model's viability on the total family system. Other research questions that should be explored include ascertaining the long-term effects of strengths-based case management with individuals and families and exploring the real value of the model in addressing community-based issues.

Conclusion

In raising grandchildren, many grandparents continue to face challenges such as confronting the substanceabusing parent of the grandchild, handling housing problems, dealing with multiple physical and mental health conditions of the grandchildren, and residing in neighborhoods with high crime rates and poor educational resources. However, in spite of these challenges, many grandparents in PHG have reported they have gained a greater sense of empowerment and self-confidence. Working in collaboration with the project staff and participating in the support group and parent education classes, grandparents have verbally indicated that they have a greater sense of self-assurance to face whatever adversities they may encounter - thus lessening the potential for child neglect. As one grandparent stated:

. . . I am very grateful for this project, to know that there are other parents that are going through, experiencing, or have been where I am now. I had no idea. I would not have come to know what I know now . . . had it not been for this project, so I'm very grateful.

Strengths-based case management is a process that helps individuals and families reconnect to their inner strengths. It serves to compel case managers, regardless of discipline, to acknowledge the whole person and not to narrow their perspective to the boundaries of expressed problems. Through Project Healthy Grandparents, it is realized that even the most vulnerable families have strengths and resources that can be used as assets to address needs. Its success is measured in the expanded choices and opportunities the grandparents believe they have acquired. As stated by one grandparent, they have "control of the ship" again. Getting control over one's "ship" is the essential outcome that any case management approach attempts to achieve. Strengths-based case management is one alternative service model to securing that outcome.

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Deborah M. WhOUey is assistant professor, Department of Social Work, Susan Kelley is professor and acting dean, College of Health and Human Sciences, Beotrice Yorker is associate professor, School of Nursing, and Kim It White is social services coordinator for Project Healthy Grandparents, Georgia State University. Send all correspondence to: Dr. Deborah M Whitley, Department of Social Work Georgia State University, One University Plaza, Atlanta, GA 30303. Office phone: (404) 651-2505, FAX: (404) 651-1863, E-mail address: SWODMW@gsu.edu

Authors note: Funding for this project was provided by grants from the National Center on Child Abuse and Neglect and the Georgia Department of Human Resources. A special thank you to the project staff of Project Healthy Grandparents for their assistance and support in gathering data for this manuscript

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