Unit 2.1 db: elements for success
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One way to think about the case management process is to examine the key elements for success: responsibility, continuity, and accountability. In the context of case management, what do responsibility, continuity, and accountability mean to you? How might you ensure that these ideas are incorporated into your own professional activities?
In response to your peers, explore each other’s ideas by asking questions and building upon them based on your own experiences.
Historical Perspectives on Case Management
· Chapter Two addresses Social Work Case Management Standard 2, which is focused on knowledge of the history of case management.
· Chapter Two addresses Human Service–Certified Board Practitioner Competency 1, Ethics in Helping Relationships, which is focused on the history of case management.
The agency I work for started out just working with pregnant teenage women. It has expanded greatly within the time that I have been there, and its purpose is prevention.
—From Sara Bergeron, 2012, text from unpublished interview
The purpose of this chapter is to establish an historical context for case management. It describes four perspectives on case management that have evolved in the past 40 years: case management as a process, client involvement, the role of the helper, and utilization review and cost-benefit analysis. A brief history of case management in the United States follows, including its evolution to broader service coordination responsibilities within the past decade and an introduction to managed care.
By the end of each section of the chapter, you should be able to accomplish the performance objectives listed.
Perspectives on Case Management
· Identify four perspectives on case management.
· Trace the evolution of case management.
· Describe the impact of managed care organizations on case management and service delivery.
The History of Case Management
· Assess the contributions of the pioneers in the areas of advocacy, data gathering, recordkeeping, and cooperation.
· Using the Red Cross as an example, describe casework during World War I and World War II.
· Name the key pieces of federal legislation that spurred the development of case management.
The Impact of Managed Care
· List the goals of managed care.
· Summarize the impact of managed care on human service delivery.
· Differentiate between the various types of managed care organizations: Pharmacy Benefits Management, HMOs, PPOs, POSs, Health Savings Accounts, Health Reimbursement Arrangements, and plans offered under the health insurance exchanges.
Expanding the Responsibilities of Case Management
· Trace the shift in emphasis in case management.
· Explain the strengths and weaknesses of managed care.
Case management has long been used to assist human service clients. Today, professionals are discovering new and more effective ways to deliver services, and there is no longer a standard definition. Modern case management does resemble the practice of the past, but many dramatic changes have occurred. Among them are the changing needs of individuals served, financial constraints on the human service delivery system, the increasing number of people needing services, and the growing emphasis on client empowerment, evaluation of quality, and service coordination.
One consistent theme that pervades the study of human service delivery is diversity. The three helping professionals quoted here describe the services of their agencies and illustrate how diverse the services can be.
Families we work with, they have lots of needs and many of the families get really lost in the system. Some never had services before. Our job is to provide casework … this means helping them pay for services such as utilities … we also work with them in their homes. Going there lets them know we will extend ourselves for them. It is respectful … and we help our clients help themselves by advocating for them. Things at the local, state, and federal levels change so rapidly and we help our clients respond to those changes and how they influence the services they receive or can receive.
—Case manager, family services, New York, NY
We absolutely refuse to work against other agencies … we build a cooperative environment … we believe there are enough clients for everyone … our case managers work with intake and establishing eligibility. That means they are gatekeepers … we have a certain district that we serve … a good number of our clients come from the hospital. This is continuing to increase with the change in healthcare delivery.
—Director and case manager, counseling center, Tucson, AZ
Our services began with the apartments in the northeast part of the city. We needed housing for clients coming out of psychiatric hospitals. The clients had a difficult time finding a stable place to live other than the traditional SROs … The goal was to provide a more supportive and stable environment. This is a really difficult goal for us and for them.
—Director and care coordinator, housing services center, New York, NY
The caseworker from a family services agency describes the work of her agency as providing financial assistance and advocacy for families for whom there is no other support. The counseling center, however, gives patients just discharged from the hospital only the aftercare services they need. This often includes support to meet psychological, social, medical, financial, and daily living needs. The housing services center began by providing temporary housing with accompanying support services.
Much of the foundation of case management service delivery developed to serve those people with mental illness who were deinstitutionalized in the 1970s. Illustrating our discussion here is the story of Sam, who was diagnosed as mentally ill and promptly institutionalized. Sam has received many services since that first diagnosis, and his history with the human service delivery system reflects the evolution of service delivery from the traditional form of case management to the new paradigm that is applied today. We use early sources that describe case management to capture the meaning of the term and the services in their historical context. We use more current services as we move forward in our discussion of case management and its dynamic nature. In addition, we weave Sam’s story through our discussion of the various changes in the perspectives on case management. To make Sam’s case easier to follow we present
Table 2.1, which describes Sam’s journey in chronological order.
2-1aPerspectives on Case Management
This section explores four different perspectives on case management that together illustrate the development of case management since the 1970s.
Case Management as a Process
In the 1970s, the mental health community was involved in the process of
: the movement of large numbers of people from self-contained institutions to community-based settings, such as halfway houses, family homes, group homes, and single residential dwellings. A member of the American Psychiatric Association’s Ad Hoc Committee on the Chronic Mental Patient offered the following definition of case management.
My view is that [case management] is a vital, perhaps the most primary, device in management for any individual with a disability where the requirements demand differential access to and use of various resources. Far from a new concept, it has long been the central device in every organized arrangement that heals, rehabilitates, cares for, or seeks change for persons with social, physical, or mental deficits…. Case management is a key element in any approach to service integration…. A counselor manages assessment, diagnosis, and prescription … synthesizes information, emerges with a … treatment plan, and then purchases one or more interventions. (Lourie, 1978, p. 159)
Many clients need assistance in gaining access to human services. Often they have multiple needs, limited knowledge of the system, and few skills to help them arrange services. Sam’s case reflects the experiences of many clients who were institutionalized in the 1950s and 1960s and were later deemed appropriate for discharge during deinstitutionalization. The case management process illustrated next is an elementary one: limited assessment followed by placement.
Sam’s Story 2.1
After several ear infections, Sam became severely hearing impaired when he was 3. He was the youngest of four children and lived in a small town with his mother, two sisters, and a brother. His mother took care of him, and he became dependent on her. They learned to communicate with each other using a sign language they devised themselves. None of his siblings learned to sign. Sam was often unruly and found that tantrums would get him what he wanted. The older he got, the harder to handle he became. When Sam was 15, his mother died. None of his siblings would assume responsibility for him, so they decided to have him admitted to the state mental hospital in the capital. This occurred in the early 1950s; the exact date is unknown because a fire at the institution in the 1960s destroyed the records of those who were admitted previously. Sam was in the mental institution for many years before the deinstitutionalization movement started. At that point, Sam’s long odyssey began.
Sam’s Story 2.2
Sam’s first case manager was an employee of the institution, and his job was to identify patients who could function in a community setting. Limited assessments of Sam’s mental and emotional state indicated that he was not mentally ill but simply hearing impaired. Unfortunately, his time in the institution had compounded his problems. He did not know American Sign Language (ASL) and he had begun to behave like other patients who did have mental illness. The case manager decided that Sam should be moved from the institution to another setting. The case manager located Sam’s oldest sister, but he stayed with her for only one weekend. She returned Sam to the institution on Monday morning, saying that she couldn’t handle him and his presence was too disruptive to her family. None of his other siblings was willing to help, so Sam remained in the institution while his case manager searched for a group home that had an opening. Eventually, Sam did move into a group home, but he lived there for just 6 days before returning to the institution. According to the home’s director, no one could communicate with Sam, his behavior was inappropriate, and he needed constant supervision.
The responsibility of Sam’s case manager was to find Sam an environment that could foster his growth and development. Unfortunately, the search for such an environment was quite difficult because of Sam’s institutional behavior and the limited assessment of his abilities. Sam is one of those clients who need access to multiple services before they can make the transition from an institution to a community setting.
One way to think about the case management process is to examine the key elements for success: responsibility, continuity, and accountability (Ozarin, 1978). Responsibility means that one person or team assesses the client’s problem and then plans accordingly. Linkages “must be established to form a network of service agencies which can provide specific resources when called upon without assuming total responsibility for the client, unless responsibility for carrying out the total plan is also transferred and accepted” (Ozarin, 1978, p. 167). In other words, there must be a clear line of responsibility for the case and the client.
Continuity is another significant element of good case management. Planning is the key that ensures continuity. It is important not only during the intensive treatment phase but also in aftercare. To foster accountability, methods “must be in place to assure the patient is not lost …. The case management process must help the client increase the ability to function independently and to assume self-responsibility. The client should be involved in all aspects of decision making” (Ozarin, 1978, p. 168). Guided by these goals, organizations and professionals at every level work hard to develop systems that participants understand by working together to serve and involve the clients.
Case management can be seen as a “set of logical steps and a process of interaction within a service network which assure that a client receives needed services in a supportive, effective, efficient, and cost-effective manner” (Weil & Karls, 1985a, p. 2). In a more recent definition, a social work best practice white paper (n.d.) described case management as “a method of providing services whereby a professional Social Worker collaboratively assesses the needs of the client and the client’s family, when appropriate, and arranges, coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific client’s complex needs” (Social Work Best Practice: Health Care Management, n.d.).
Case management is an important and necessary component of the human service delivery system because it provides a focus and oversees the delivery of services in an orderly fashion. As you read about Sam’s case, you will see case management evolve into a more logical and complex process that focuses on client participation, integration of services, and cost effectiveness.
Relate Sam’s Experience to the Case Management Process
After reading about case management as a process as a class, in small groups, or as an individual, describe the characteristics of the process. Use the information you learned about Sam to illustrate the characteristics that you presented. Also, you can use the text material and the quotes from the three case managers presented at the beginning of the chapter to illustrate what you learned about case management as a process.
Share this information with your classmates.
In the 1980s, client involvement came to be emphasized more strongly. A model of case management was proposed based on the concept of enabling clients “to solve problems, meet needs, or achieve aspirations by promoting acquisition of competencies that support and strengthen functioning in a way that permits a greater sense of individual or group control over its developmental course” (Dunst & Trivette, 1989, p. 93). Sam’s experience in the human service delivery system reflects the beginning of changes in service provision.
Sam’s Story 2.3
Sam remained institutionalized for the next 4 months because there was a shift in the case management process. The institution decided to contract with a local mental health agency for case management services. Case management was a new role and responsibility for this agency; it assigned two individuals 50 cases each, with few guidelines for performing this new function. Sam’s new case manager, his second, spent some time assessing Sam’s needs, getting to know him, and talking with the mental health professionals within the institution. In concert, they determined that Sam needed a very structured environment in the community if his deinstitutionalization was to succeed. He also needed to learn sign language and to begin to communicate with others using this medium. Because he was hearing impaired but did not have mental illness, he needed to be in contact with the deaf community, where he could find support and role models for independent living. At the age of 27, he had little ability to care for himself.
Sam’s Story 2.4
Unfortunately, his case manager left her position before she had the opportunity to implement the plan. A third case manager assumed responsibility for Sam’s case, with much determination. Her own brother had been hearing impaired since birth, and she recognized Sam’s potential. She could communicate with him using ASL. She was also committed to planning, documenting her work, involving Sam in the case management process, and following through on referrals and the involvement of other professionals.
Sam’s Story 2.5
The goals of the plan included having Sam learn ASL, teaching him socialization skills and independent living skills, and introducing him to members of the deaf community. His case manager was able to find a day care program where Sam could learn independent living skills. Three times per week, he went to the local school for the deaf for ASL lessons. Once per week, Sam and his case manager joined other hearing impaired adults for a special community program and social hour. Sam still lived at the institution. By the end of the second year, the case manager was able to include Sam in the process of setting priorities and planning for his treatment.
Sam’s Story 2.6
After 2 years, Sam had made considerable progress. He was able to use ASL to communicate his needs, and he had developed several friendships with people he met at the school for the deaf and at the community programs. On his thirtieth birthday, he celebrated with his friends from the school. Tantrums continued to occur, but less frequently.
After a rocky beginning, Sam benefited from the service delivery process as it evolved. His third case manager assumed responsibility for his case, provided the continuity needed for him to make progress, and was accountable for his care. She used a process of logical steps to establish goals and set priorities. She also established a partnership with Sam by involving him in problem identification, plan development, and service provision. By learning daily living skills, Sam reinforced his ability to care for himself, and his increasing mastery of ASL gave him a new medium for self-expression and communication.
Sharon Bello, Entry 2.1
Marianne asked me if I would read through this chapter about the history of case management and pay attention to Sam and his story. She wanted me to write about my reactions to the history and to Sam. I wanted to talk about Sam first because my heart went out to him. He seems to move from place to place and go from help to help. I think that my life was something like his because I really didn’t know where to go for help. But I did have a good neighborhood and friends that could really help me. The death of my sons shook my life and me. But I had Lucia and Maria depending upon me, so I felt I had to hold on. I am not much on history, but when I talked with Marianne, I told her that it seemed to me that before I was born case management was just beginning. But when I go to meet with my case manager, there is no hesitation about what he or she can do to help me. Even though I have changed case managers, because they moved on for one reason or another, I feel the way services were delivered didn’t change. I think that Sam’s experience was different than mine. I am glad that I am receiving case management now, when the agency is sure of the services they want to deliver.
The Role of the Case Manager
Chapter One lists an array of job titles that have emerged to reflect the new goals of service delivery. Traditionally, terms such as caseworker and case manager described the efforts of helpers. Today, job titles include service coordinator, liaison worker, counselor, case coordinator, health care case manager, and care coordinator. There are also new titles such as self-care manager. These new job titles represent not only the diversity of service delivery today but also the broader range of responsibilities and the different ways case managers perceive their roles. The change in job titles reflects the evolution of case management and, in a larger context, of service delivery. The emphasis shifted from what was previously understood to be case management, when it meant the skills of managing someone, to terminology reflecting a more equitable relationship, such as coordination and liaison. A change in philosophy had occurred regarding the role of the case manager, emphasizing working with other professionals, coordinating care and other services, and empowering individuals to use the system to help themselves. The focus became the client’s ability to develop the skills needed to work within the human service network.
Sam’s Story 2.7
The next 10 years were a struggle for Sam and for those who worked with him. His case manager of 2 years left her job for a promotion in a nearby city, and his case was transferred to Lois Abernathy, a care coordinator at a different agency. Because of increasing pressure to deinstitutionalize, it was decided to move Sam to a halfway house before helping him establish residence in the local community. Over the course of the decade, Sam lived in three halfway houses, in four group homes, at the school for the deaf, with his siblings, and in an apartment with a roommate. Ms. Abernathy was the link between Sam and each of these placements. Her responsibilities included meeting with Sam regularly to review his needs, problems, and successes, and arranging any additional services for him. Often, she and Sam would meet with other professionals who were involved with his case. Ms. Abernathy was committed to giving Sam choices about his future. When he expressed the desire to work at a job, she helped him determine exactly what he would like to do. After exploring the options available to him, Sam decided that he would like to work with a local vending machine business program that Ms. Abernathy knew about. After Sam received some education and training, his responsibilities with this program came to include stocking machines, collecting money, and minor repair work.
The assignment of a care coordinator to Sam’s case signaled a shift in the role of the case manager—from management to coordination. The client’s participation in the process also became significant; a partnership emerged to identify, locate, link, and monitor needed services. In this way, case management built on Sam’s strengths and empowered him to help himself.
Utilization Review and Cost-Benefit Analysis
One result of the spiraling cost of medical and mental health services and the push for healthcare reform has been the growth of the managed care industry. The purpose of managed care is to authorize the type of service and the length of time care is provided and to monitor the quality of care. In the managed care environment, case managers function very differently from those described previously.
What makes case management in managed care distinctive is the emphasis on the efficient use of resources. Case managers are involved in utilization review and have the responsibility of authorizing or denying services. Also, they must know how to interact with insurance providers and how to process claims through the insurance system.
The case manager is also responsible for cost-benefit analysis. Today, this is a critical responsibility. Such an analysis does not include the traditional reporting that is found in a case history in the form of notes or recommendations and follow-up. It is focused on the financial matters of the case, specifically the cost and efficiency of services.
Sharon’s Case Manager, Tom Chapman, Entry 2.2
I was amazed to read about the history of case management, especially the part about cost-benefit analysis. I guess we are most involved with that type of analysis at the beginning of the case. Remember the early forms that we fill out about the client. We want to know about the client, employment, other income or support, and support from family or friends. We also need to know, for Sharon’s case, about the cost of school and how the cost of school matches her goals. We also need to make a judgment if the client, when eligible, can meet the goals and outcomes we established. When Sharon’s goals changed and she decided to major in interpreting, we had to cost out how the financial expenditures would differ from her first plan. And for each amount of money and service we provided, I had to verify this on the record. Costs also included the time that I spent and the amount of time we contracted with other professionals, such as mental health and other medical professionals. I want to believe that we always do the best we can for our clients, but there is always the concern for and verification of expenditures.
Sam’s Story 2.8
As we leave Sam at the age of 42, he is 2 months away from assuming responsibility for all the vending machines in a nearby neighborhood. It has taken two successive 6-month training sessions to teach Sam the necessary job skills and repair techniques. Sam is living with a new friend in a small apartment near his vending area. This friend is also a client at the rehab center and is helping Sam train for his new job. Sam’s rehabilitation counselor and his care coordinator from the mental health center have met and developed a coordinated plan, with input from Sam. Because of his recent success in rehabilitation, mental health services are no longer authorized for Sam.
Sam’s experience with a care coordinator has led him in a new direction. The emphasis on tapping Sam’s potential and coordinating care has given him a major voice in decision making. This requires coordination between two systems: rehabilitation and mental health. Sam does make progress, and the managed care case manager decides to discontinue mental health services. As we leave Sam, his rehabilitation counselor supports him with job training and housing. If he again needs professional mental health support, then it is hoped that the rehabilitation counselor can arrange these services for him.
Describe Sam’s Involvement in the Case Management Process
After reading about client involvement in case management, the role of the case manager, and utilization review as a class, in small groups, or as an individual, describe how each of these concepts played a role in Sam’s case.
Share this information with your classmates.
2-1bThe History of Case Management
As important as various current perspectives on case management are, the historical roots are equally informative. The pages that follow trace the history of case management from its origins in institutional settings through the work of early pioneers, the impact of the American Red Cross, and the influence of federal legislation. The chapter concludes with a discussion of case management as it is practiced today.
Documenting the history of case management, Weil and Karls (1985a) stated, “The process of service coordination and accountability has a century-long history in the United States” (p. 1). As first used in institutional settings, case management included the responsibilities of intake, assessment of needs, and assignment of living space. These institutions provided residential services to people incarcerated for crimes, orphans, people with mental illness, people with disabilities, and elderly people. Which professionals performed the case management function depended on the particular institution; among them were doctors, nurses, psychiatrists, psychologists, counselors, and teachers (Weil & Karls, 1985b). In
Figure 2.1, we look at various influences in the development of case management.
Figure 2.1Influences on the Development of Case Management
A Pioneering Institution
One example of an institution with an early commitment to case management was the Massachusetts School for Idiotic and Feebleminded Youth, established in 1848. This school promoted the belief that people categorized as “idiotic” or “feebleminded” could improve if they were given appropriate clinical, social, and vocational services and support (Weil & Karls, 1985b). In 1839, a child who had mental retardation as well as vision impairment had come to the Massachusetts institution for the blind. It was clear that the child had needs beyond the expertise of the institution, and the director, Samuel Howe, was determined to help this child and others with similar needs. He convinced the state that he could improve these children in three areas: bodily habits, mental capacities, and spirituality (Winsor, 1881). The institution he founded was the Massachusetts School for Idiotic and Feebleminded Youth.
Contributions to Case Management
This Massachusetts school provided services in case management, such as tracking student progress, providing follow-up services, and managing information. Early services at the school included observation and diagnosis of physical and mental behavior. The helping professionals tracked clients’ progress, and they soon began differentiating and individualizing treatment: “… [W]e cannot properly care for a young and helpless idiot in the houses devoted to the brighter moron children” (Trustees, 1920, p. 17).
When demand for the services increased, the school established outpatient clinics in several cities (Trustees, 1919). These clinics supported families who cared for children at home. Aftercare was also an important service provided by trained “visitors” who helped plan the transition from the institution to the home or other setting. The visitor would gather information to determine whether the child should be sent home on trial or released for vacation with family or friends. They would also follow-up after transition to determine whether the release and placement were appropriate. This emphasis on aftercare was the forerunner of modern continuity of care and today’s commitment to provide services as the client makes a transition from the treatment setting to a less restrictive one.
In the early 1900s, the school made two improvements in the management of information, which is an important component of case management. In 1916, the institution began an evaluation of its services. This included a study of clients who had been discharged and those in aftercare. The information gathered included where patients lived, with whom they were living, whether they supported themselves, and, if so, how. The information was gathered first by survey, and then patients, families, and friends were interviewed in their homes. In 1919, new legislation established a Registry for the Feebleminded in an effort to catalog the state’s population of people with retardation (Trustees, 1920). These advances in recordkeeping and information management contributed to case management as we know it today.
Early Pioneers discusses the work of some early pioneers in human services who developed case management further, especially regarding coordination of services and interagency cooperation.
Early case management took one of two forms: a multiservice center approach or a coordinated effort of service delivery. Jane Addams, Lillian Wald, and Mary Richmond were three early pioneers who contributed to the development of the emerging case management process.
Jane Addams and Ellen Starr, classmates at the Rockford Female Seminary, founded Hull House in Chicago in 1889. In their 20s, while traveling in England, they visited Toynbee Hall, a university club that had established a recreation club for the poor. Addams and Starr were committed to increased communication between social classes, and the activities of Toynbee Hall inspired them. They returned to America and moved into a poor section of Chicago, hoping to improve that environment (Addams, 1910).
They bought Hull House, an older home on Chicago’s West Side. Committed to sharing their home and their love of learning, they opened the house to the neighborhood. They acquired collections of furniture, art, and literature; soon, they became involved with music and crafts. The purposes of Hull House were three-fold: to provide a center for civic and social life, to improve conditions in the neighborhood, and to provide support for reform movements (Addams, 1910).
Contributions to Case Management
As the number of services expanded, Hull House’s need for effective administration and recordkeeping increased. Many participants would have been suspicious if formal files were kept; therefore, an informal card system was housed in the administrative office and its contents were shown only to people who could establish a need to see it (Woods & Kennedy, 1911). Information about demographics, participation, and attendance was gathered. In addition to recordkeeping, advocacy was a case management function that was integrated into the work of Hull House. Jane Addams and her colleagues were involved in many efforts to improve the living and working conditions of the neighborhood and its inhabitants. Promoting better housing and improving sanitation services were two areas of focus (Polacheck, 1989) (see
A Hull House Girl
Hilda Satt Polacheck was born in 1882 in Wolclawek, Poland. She was the eighth child (out of 12) born to a well-to-do Jewish family. Because of oppression by the Russian government, her family immigrated to America in 1892. During their early years, Hilda and her sister attended the Jewish Training School on Chicago’s West Side. After the death of their father, however, they joined the ranks of the working poor. Hilda began working in a knitting factory when she turned 13. She first came to Hull House for a Christmas party in 1896, and it soon became the center of her social life. She attended classes and club meetings, read literature, exercised, and performed in plays there. Later she worked there as a receptionist and a guide. Hilda grew up with Hull House and spent much of her time there from 1895 until 1912. In her autobiography, she provides the following description of Jane Addams and her advocacy work.
Bad housing of the thousands of immigrants who lived near Hull House was the concern of Jane Addams. When there were alleys in the back of the houses, these alleys were filled with large wooden boxes where garbage and horse manure were dumped…. When Jane Addams called the attention of the health department to the unsanitary conditions, she was told that the city had contracted to have the garbage collected and there was nothing it could do…. She was appointed garbage inspector for the ward. I have a vision of Jane Addams … following garbage trucks in her long skirt and immaculate white blouse….
Hull House was in the Nineteenth Ward of Chicago. The people of Hull House were astonished to find that while the ward had one-thirty-sixth of the population of the city, it registered one-sixth of the deaths from typhoid fever. Miss Addams and Dr. Alice Hamilton launched an investigation that has become history in the health conditions of Chicago…. Whatever the causes of the epidemic, that investigation, emanating from Hull House, brought about the knowledge of the sanitary conditions of the Nineteenth Ward and brought about the changes we enjoy today.
SOURCE: From I Came a Stranger: The Story of a Hull-House Girl, by H. Polacheck, pp. 71–72. Copyright © 1989 University of Illinois Press.
Henry Street Settlement House
Lillian Wald and Mary Brewster, who were nurses, established the Henry Street Settlement House organization in 1895 in New York City. Early in their careers, they decided to provide services to the city’s Lower East Side, home to a large number of immigrants. Wald and Brewster lived in the neighborhood and provided healthcare services.
They established a system for nursing the sick in their own homes, thereby promoting the dignity and independence of the patient. According to Wald (1915), “the nurse should be as ready to respond to calls from the people themselves as to calls from physicians … she should accept calls from all physicians, and with no more red tape or formality than if she were to remain with one patient continuously” (p. 27). There was an explicit focus on accessibility.
Contributions to Case Management
The work at Henry Street led to two significant innovations: the designation of the visiting nurse and the development of the Red Cross. Both of these services were important in promoting public health. One important function of the visiting nurse was to establish an organized system of care and instruction for people with tuberculosis and their families. Early in its history, the Red Cross facilitated the use of the public schools as recreation centers, taught housekeeping skills to women, and provided penny lunches for children (Wald, 1915).
Mary Richmond, a social reformer at the turn of the century, had a similar commitment to bettering the lives of individuals and families living in poverty. She, too, made significant contributions to the development of case management. Richmond promoted the idea that each person was a unique individual whose personality, family, and environment should be respected. Working with immigrants, she emphasized the need for social workers to resist the tendency to stereotype or overgeneralize (Lieberman, 1990). Richmond wrote, “[T]he social adjustment cannot succeed without sympathetic understanding of the old world backgrounds from which the client came” (1917, p. 117). She also believed that professionals should work with clients rather than doing things to them.
Want More Information? Learning about the History of Case Management
The Internet provides in-depth resources related to the study of case management. Search the following terms to read more about individuals and agencies who provided the foundation for case management practice.
· Hull House
· Henry Street Settlement House
· Mary Richmond
Contributions to Case Management
One method Richmond developed to focus on the individual was
, a systematic way for helping professionals to gather information and study client problems. She established a series of methods for gathering information about individuals to assess their needs and to determine treatment. This process is often referred to as social casework, and it became a part of the case management process. Richmond contributed a case record form designed to focus on individuals and their unique problems (Pittman-Munke, 1985; Trattner, 1999).
She also recognized that gathering data is a complex process and urged the use of different methods for different individuals. According to Richmond (1917), some clients should be interviewed in an office; for others, the home is the preferred location. She believed in multiple sources of information and warned that data gathering was a complex and often incomplete process.
During the early part of the twentieth century, the Red Cross emerged to meet the multiple needs of individuals. The subsection that follows describes its involvement in providing assistance, primarily to servicemen and their families, during World War I and World War II.
2-1dThe Impact of World War I and World War II and the American Red Cross
During the World War I, there was an increased interest in casework as developed by Mary Richmond. The American Red Cross, whose roots are found in the work of Clara Barton and the Civil War, used casework to address individuals’ problems and their psychological needs. The use of a casework approach to assist individuals began during the Mexican Civil War (1911–1917), when the American Red Cross provided a variety of services to support the daily life of civilians and troops along the Mexican border (Dulles, 1950). Subsequently, the services were extended to dependents of military personnel in army installations throughout the country. These services, performed by the Home Corps of the Red Cross, helped address the needs of the families of military personnel. In World War I, the Home Service Corps (later known as the Social Welfare Aide Service) provided help to families experiencing problems such as illness and marital difficulties.
The Home Service Corps addressed a wide variety of problems. Dulles (1950, pp. 391–392) presents the following example of messages received and sent by the Home Service Corps.
MILITARY AUTHORIZE INFORM FAMILY SERVICEMAN WELL ON ACTIVE DUTY NOT REPEAT NOT THE MAN THEY SAW IN NEWSREEL
MESSAGE DELIVERED FAMILY MUCH RELIEVED MOTHER IMPROVING
SERVICEMAN REQUESTS MATERNITY REPORT WIFE EXPECTING CONFINEMENT EARLY JULY
SON BORN JULY SEVEN BOTH WELL
SERVICEMAN INFORMED BY FRIEND MOTHER DIED TWO MONTHS AGO STILL RECEIVING LETTER FROM HER REGULARLY INVESTIGATE
MOTHER DIED CANCER BREAST APRIL TWENTY SEVENTH SISTER FEARED SHOCK TO SERVICEMAN HAS BEEN WRITING IN MOTHERS NAME WILL WRITE IMMEDIATELY
SERVICEMAN BEGS WIFE DISREGARD HIS LAST LETTER MAILED JULY SEVEN RECEIVED ONE HUNDRED FIFTEEN LETTERS FROM HER YESTERDAY
MESSAGE RECEIVED WIFE WILL WRITE
SERVICEMAN REQUESTS HEALTH CONFINEMENT REPORT WIFE
WIFE DIED CHILDBIRTH JULY TWENTY SEVEN SON WELL WITH SERVICEMAN’S MOTHER-IN-LAW GETTING GOOD CARE MOTHER-IN-LAW WILL KEEP CHILD UNTIL SERVICEMAN’S RETURN
Contributions to Case Management
The Home Service Corps workers made two contributions to the development of service delivery. First, they offered extended help to individuals and their families. The intervention was problem-focused but not time-bound. A Home Service Corps volunteer helped identify the problem and worked with the family until it was resolved. Second, the volunteer not only solved problems but also became a broker of services. He or she would often coordinate communications and requests for services between the family and the agencies that could provide help and support. The work often involved helping families communicate with the military (Dulles, 1950; Hurd, 1959).
After World War II, it became increasingly evident that many people needed assistance to improve their quality of life. In the early 1960s, the federal government became increasingly involved in helping people in need.
2-1eThe Impact of Federal Legislation
Several pieces of federal legislation were passed between the mid-1960s and the late 1980s and were modified in recent years. These legislative efforts recognized the need for a case management process to provide social services to people in need. Serving older adults, children with disabilities, and families and children who live in poverty requires the services that case management represents (see
Figure 2.2Federal Legislation and Case Management
Contributions to Case Management: The Older Americans Act of 1965
The Older Americans Act of 1965 (Public Law 89-73) focused on providing services for older individuals to improve their quality of life. Among its contributions to the development of case management was an emphasis on the multiplicity of human needs. This act advanced case management by recognizing the need to coordinate care. Section 101 of the act describes its goals and the services to be provided (see
Box 2.2). The services were designed to meet a variety of needs: financial, medical, emotional, housing, vocational, cultural, and recreational.
The Older Americans Act of 1965
Title I—Declaration of Objectives: Definition
Sec. 101. The Congress hereby finds and declares that, in keeping with the traditional American concept of the inherent dignity of the individual in our democratic society, the older people of our Nation are entitled to, and it is the joint and several duty and responsibility of the governments of the United States and of the several States and their political subdivisions to assist our older people to secure equal opportunity to the full and free enjoyment of the following objectives:
1. An adequate income in retirement in accordance with the American standard of living.
2. The best possible physical and mental health which science can make available and without regard to economic status.
3. Suitable housing, independently selected, designed, and located with reference to special needs and available at costs which older citizens can afford.
4. Full restorative services for those who require institutional care.
5. Opportunity for employment with no discriminatory personnel practices because of age.
6. Retirement in health, honor, dignity—after years of contribution to the economy.
7. Pursuit of meaningful activity within the widest range of civic, cultural, and recreational opportunities.
8. Efficient community services which provide social assistance in a coordinated manner and which are readily available when needed.
9. Immediate benefit from proven research knowledge which can sustain and improve health and happiness.
10. Freedom, independence, and the free exercise of individual initiative in planning and managing their own lives.
SOURCE: Older Americans Act of 1965, Public Law 89-73.
Today, the need for support and care of the elderly has increased, because the number of individuals in the United States older than 65 is projected to more than double by 2050 (Clubok, 2001). Plagued by chronic illness, depression, insufficient financial resources, and many other difficulties, this population is already placing demands on many families and communities, and on the human service delivery system. Even though federal programs such as Social Security, Medicaid, and Medicare support many individuals, these resources need to be used effectively and efficiently (see
Box 2.3). Case management will continue to be used in elder care to serve these individuals with complex short-term or long-term needs, especially as the number of seniors needing support increases.
Federal Programs SSDI Program
Title II of the Social Security Act establishes the Social Security Disability Insurance Program (SSDI). SSDI is a program of federal disability insurance benefits for workers who have contributed to the Social Security trust funds and become disabled or blind before retirement age. Spouses with disabilities and dependent children of fully insured workers (often referred to as the primary beneficiary) also are eligible for disability benefits on the retirement, disability, or death of the primary beneficiary. Section 202(d) of the Social Security Act also establishes the adult disabled child program, which authorizes disability insurance payments to surviving children of retired or deceased workers or workers with disabilities who were eligible to receive Social Security benefits, if the child has a permanent disability originating before age 22.
Hereinafter in this policy brief, the term SSDI refers to all benefit payments made to individuals on the basis of disability under Title II of the Social Security Act.
SSDI provides monthly cash benefits paid directly to eligible persons with disabilities and their eligible dependents throughout the period of eligibility.
Title XVI of the Social Security Act establishes the Supplemental Security Income (SSI) Program. The SSI program is a means-tested program providing monthly cash income to low-income persons with limited resources on the basis of age and on the basis of blindness and disability for children and adults. The SSI program is funded out of the general revenues of the Treasury.
Eligibility for SSI is determined by certain federally established income and resource standards. Individuals are eligible for SSI if their “countable” income falls below the federal benefit rate ($512 for an individual and $769 for couples in 2000). States may supplement the federal benefit rate. Not all income is counted for SSI purposes. Excluded from income is the first $20 of any monthly income (i.e., either unearned, such as Social Security or other pension benefits, or earned) and the first $65 of monthly earned income plus one-half of the remaining earnings. The federal limit on resources is $2000 for an individual and $3000 for couples. Certain resources are not counted, including, for example, an individual’s home and the first $4500 of the current market value of an automobile.
The Ticket to Work and Work Incentives Improvement Act of 1999
On December 17, 1999, President Clinton signed into law the Ticket to Work and Work Incentives Improvement Act of 1999 (Public Law 106-170). Hereafter in this policy brief, Public Law 106-170 is referred to as the Act. The Act has four purposes [Section 2(b) of the Act]:
· To provide healthcare and employment preparation and placement services to individuals with disabilities that will enable those individuals to reduce their dependency on cash benefit programs.
· To encourage states to adopt the option of allowing individuals with disabilities to purchase Medicaid coverage that is necessary to enable such individuals to maintain employment.
· To provide individuals with disabilities the option of maintaining Medicare coverage while working.
· To establish a return-to-work ticket program that will allow individuals with disabilities to seek the services necessary to obtain and retain employment and reduce their dependency on cash benefit programs.
This Act improves work incentives under the SSDI and the SSI and expands healthcare services under Medicare and Medicaid programs for persons with disabilities who are working or who want to work but fear losing their health care.
SOURCE: Center on State Systems and Employment (RRTC). (2000). Policy Brief: Improvements to the SSDI and SSI Work Incentives and Expanded Availability of Health Care Services to Workers with Disabilities under the Ticket to Work and Work Incentives Improvement Act of 1999. Policy Brief, Vol. 2, No. 1. [Online]. Available: http://www.communityinclusion.org/publications/pdf/pb2.pdf
Medicare is a health insurance program for:
· People 65 years of age and older.
· Some people with disabilities younger than 65 years of age.
· People with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant).
Medicare provides hospital insurance. Most people do not have to pay for this insurance. Medicare also provides medical insurance and most people pay monthly for this insurance. There are several ways that individuals can access their Medicare benefits.
· The Original Medicare Plan—This plan is available everywhere in the United States. It is the way most people get their hospitalization and medical insurance benefits. They can go to any doctor, specialist, or hospital that accepts Medicare. Medicare pays its share and the recipient pays a share. Some services are not covered, such as prescription drugs.
· Medicare Managed Care Plans—These are healthcare choices (like HMOs) in some areas of the country. In most plans, individuals can only go to doctors, specialists, or hospitals that are part of the plan. Plans must cover all Medicare hospitalization and medical insurance benefits. Some plans cover extras, such as prescription drugs. Individual out-of-pocket costs may be lower than in the Original Medicare Plan.
· Private Fee-for-Service Plans—This is a new Medicare healthcare choice in some areas of the country. Individuals may go to any doctor, specialist, or hospital. Plans must cover all hospitalization and medical insurance benefits. Some plans cover extras like extra days in the hospital. The plan, not Medicare, decides how much you pay.
SOURCE: Medicare: The Official U.S. Government Site for Medicare Information. (2000). Available at www.medicare.gov
Title XIX of the Social Security Act is a program that provides medical assistance for certain individuals and families with low incomes and resources. The program, known as Medicaid, became law in 1965 as a jointly funded cooperative venture between the federal and state governments to assist states in the provision of adequate medical care to eligible needy persons. Medicaid is the largest program providing medical and health-related services to America’s poorest people. Within broad national guidelines that the federal government provides, each of the states:
· Establishes its own eligibility standards.
· Determines the type, amount, duration, and scope of services.
· Sets the rate of payment for services.
· Administers its own program.
Thus, the Medicaid program varies considerably from state to state, as well as within each state over time.
SOURCE: Health Care Financing Administration. (2000). Available at http://www.cms.hhs.gov/medicaid/default.asp?
Contributions to Case Management: Rehabilitation Act of 1973
Client involvement, a basic principle of case management today, was also an important theme in the Rehabilitation Act of 1973 and its subsequent amendments through 1986. These pieces of legislation promoted consumer involvement while serving individuals with severe disabilities (Rubin & Roessler, 2001), particularly in eligibility determination and plan development. Client satisfaction and the adequacy of services also received attention. Client involvement was further strengthened when the Rehabilitation Act Amendments of 1992 and 1998, which emphasize consumer choice and control in setting goals and objectives, were passed.
In July 2005, the IDEA was revised for several purposes, including aligning the IDEA with the regulations under No Child Left Behind. In addition, the revisions revise the “individual student planning, transitions, litigation, and due process protections, monitoring and enforcement, and federal funding” (National Collaboration on Workforce and Disability, 2015). Helpful to understanding these changes is a new US Department of Education website that was developed as the IDEA contributions to children continued and as resources to implementing its changes continue to develop. The US Department of Education developed a website designed to maintain a dynamic source of information about the various IDEA laws, about how IDEA integrates with other federal laws related to children and education, and about support for those who service children (U.S. Department of Education, 2015). Information about programs is disseminated as related to serving children from birth to 2 years old and from ages 3 to 21.
Contributions to Case Management: Children with Disabilities, Education for All Handicapped Children Act of 1975
Public Law 94-142, the Children with Disabilities, Education for All Handicapped Children Act of 1975, included an explicit case management process to treat the client as a customer. The client was to be involved in identifying the problem, given complete information about the results of the assessment of needs, and empowered to help determine the type of services delivered. The client also participated in the evaluation of the helping process and in any decision to terminate or redirect activities (Jackson, Finkler, & Robinson, 1992).
The passage and subsequent implementation of this act serves as an excellent example of how federal legislation applies the case management process (Weil & Karls, 1985a). One tool to assist with planning, implementation, and evaluation is the individualized educational program (IEP). The IEP articulates a plan of intervention for each child based on goals and recommended intervention strategies. Although educational agencies have implemented the IEP in numerous ways, it has always been critical for the case manager to assume the leadership role on the team of participants who develop the IEP.
On June 24, 1997, President Bill Clinton signed into law the IDEA amendments. These amendments reflect changes in the values and process of case management and the planning and implementation of the IEP, focusing on four important areas: strengthening parental participation, creating accountability for student participation in general education, addressing remediation and behavior problems within the educational environment, and preparing students for independent living. Client empowerment was strengthened and there was an emphasis on client strengths. These are two values and goals of the case management process.
The values of the Individualized Education Programs continue to be at the heart of providing services for children who qualify for IDEA services (birth to 2 years old and from 3 to 21 years old). Working in teams and with the full participation of families and clients (children), dynamic programs help students’ participation in educational services that meet their needs within the “least restrictive environment.” The new changes to the IDEA affirm these values and these processes.
Contributions to Case Management: The Family Support Act of 1988 and the Personal Responsibility and Work Opportunity Act
In 1988, the Family Support Act was passed. As described here, the act mandated that case management must be applied to the process of serving those who were deemed eligible. This marked a new status for the case manager. The act was passed with the express goal of increasing the economic self-sufficiency of families who receive Aid to Families with Dependent Children (AFDC). In 1996, AFDC was replaced by the Personal Responsibility and Work Opportunity Act. This new welfare legislation required young mothers to receive financial support for 2 years while they received vocational education and training to join the work force. Case managers became a key component in these welfare-to-work programs because they helped develop and coordinate the plans that move young mothers toward self-sufficiency. For example, in New Jersey, Atlantic and Cape May counties developed a collaborative case management model that included the New Jersey departments of labor, human services, and health and senior services. The collaboration included representatives from state and local government agencies as well as more than 42 community-based organizations. They developed “One Ease E Link,” an electronic link that serves as the basis for an elaborate collaborative case management and referral system (Welfare & Workforce Development Partnerships, 2000). Congress reauthorized the Personal Responsibility and Work Opportunity Act in the Deficit Reduction Act of 2005.
Just as social legislation was a major factor in the development of case management in the 1960s, 1970s, and 1980s, the advent of managed care during the 1980s expanded the range of case management in the 1990s.
The Impact of Managed Care describes managed care and explores its impact on service delivery.
Sharon Bello, Entry 2.3
I don’t really have much to say about the history presented here. When I read about the Hull House and about Mary Richmond, well, it made me wish that I knew these women. And I wish we had the Hull House here in my city. I was sad that it closed. Imagine needing something and walking into that old building! The information about federal legislation, well, I don’t know much about that—except I do know about welfare and I do know about Medicare and Obamacare. Well, here in the book, we call it the Affordable Care Act. When I dropped back to fewer hours working in the grocery store, I had to apply for health care in the state. It was really complicated, but I was finally able to receive health care from our state policy. I don’t know how this really fits into the history. It doesn’t seem like history to me.
A Look at the History
In this section focusing on the history of case management, you learned about various individuals, services, and legislation that influence the definition of and the use of case management to help others. As a class, in small groups, or as an individual, choose two of these factors and make a case regarding why the two you chose are most important and highlight their importance.
After reading about case management as a process, share this information with classmates.
2-1fThe Impact of Managed Care
The emergence of managed care as a model of health care delivery has increased the demand for case management services and provided new models and definitions of service delivery. To understand its impact, one must first grasp what managed care is.
History of Managed Care
Until the 1930s, most medical care in this country was provided on a
basis. This means that a patient would be assessed a fee for each health or mental health service provided by a professional. When a client went for her annual checkup, she might receive, for example, a bill for the doctor’s consultation time plus additional services and tests such as a tetanus injection or an EKG.
In the early 1930s, physicians implemented prepaid group plans, which were managed plans for medical services. This was an alternative way of organizing medical care. The basic concept of a prepaid plan was to guarantee a defined set of services for a negotiated fee. On such a plan, the client would pay a yearly fee that covered a set of services such as those provided at her annual checkup.
The growth in prepaid group plans was relatively slow until the 1970s. Then, the Health Maintenance Organization Act of 1973 (Public Law 93-222) allowed managed medical plans to increase in number and expand the numbers of patients being served (MacLeod, 1993). The prevalence of managed care is now commonly regarded as connected to the increasing cost and decreasing quality of health care and mental health care. The escalation of costs reflects many trends: improved technology, shifting of costs from nonpaying patients to paying patients, an older population, higher expectations for a long and healthy life, increased administrative costs, and varying standards of efficiency and quality care.
Defining Managed Care
There are several ways to define
. First, the term may simply refer to an organizational structure that uses prepayment rather than fee-for-service payment. Second, it can designate an array of different payment plans, such as prepayment and negotiated discounts. It may also imply the inclusion of quality assurance practices, such as agreements for prior authorization and audits of performance (Mullahy, 2014). Third, managed care may refer to the policy of restricting clients’ access to providers such as physicians and other health professionals. Instead, the providers or professionals are paid a flat fee to provide service to a certain group of patients or clients. Most simply stated, managed care is an agreement that health providers will guarantee services to clients within specified limits. The restrictions are intended to improve efficiency of services (Mullahy, 2014). The goals of managed care are as follows:
· To encourage decision makers (providers, consumers, and payers) to evaluate efficiency and priority of various services, procedures, and treatment.
· To use the concept of limited resources in making decisions about services, procedures, and treatment.
· To focus on the value received from the resources as well as the lower cost.
Models of Managed Care
Three types of managed care models have evolved to meet the goals stated in the previous paragraph. Various types of managed care organizations (MCOs) represent models that include pharmacy benefits management (PBM), health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS). In addition, since the passage and implementation of the Affordable Care Act (ACA), plans also include Health Savings Accounts (HSAs), Health Reimbursement Arrangements, and plans offered under the Health Insurance Exchanges (Small Business Majority). Each has a particular strategy for maintaining cost and ensuring quality.
Pharmacy Benefits Management
The primary responsibility of
pharmacy benefits management
(PBM) is to manage the costs of programs related to drug prescriptions. This administrative responsibility involves working with pharmaceutical companies and pharmacies to reduce expenses and provide quality care. In other words, the focus is controlling costs of prescriptions. The PBM negotiates with companies to provide discounts, examines alternative treatments or generic treatments, and uses lower-cost mail-order prescription delivery services. Jobs performed by managers include health consultation, business and management, data management, and project management (American Associations of Colleges of Pharmacy, 2015). The primary responsibility of these managers is to review drug benefits and determine payments. The characteristics and work of PBMs encompass the following:
· Develop standards of best practice to treat medical conditions and help the medical community best serve patients using the lowest cost for quality care as a guideline.
· Develop formulas or formularies established by experts that describe reimbursement policies and drugs that are eligible for reimbursement.
· Develop a system based on electronic processing that helps pharmacies and patients determine lower-cost pharmaceutical options.
· Develop networks of pharmacies that serve the public.
· Establish networks of mail-based pharmaceutical services.
Health Maintenance Organizations
The HMO managed care model, which is the most structured and controlled, emphasizes positive health promotion.
is a generic term covering a wide range of organizational structures; unlike traditional fee-for-service health care systems, it combines delivery and financing into one system. Most HMOs have three characteristics (Small Business Majority, 2015):
· An organized system for providing health care or otherwise assuring health care delivery in a geographic area.
· An agreed-upon set of basic and supplemental health maintenance and treatment services.
· A voluntarily enrolled group of people.
The HMO assumes the financial risk for providing the contracted services. There are advantages and disadvantages to the HMO model. One immediate benefit is that the HMO constantly monitors both the services available and the cost of providing them. Physicians and other health professionals must establish a rationale for recommending services, procedures, and treatment, and their rate is monitored. Client spending is also monitored because enrolled members can receive services only from the professionals participating in the plan. In some instances, the clients must obtain preauthorization from someone outside the plan. Through its leverage at the site of services, the HMO can control utilization and improve the efficiency of service delivery (Trends in Health Care Costs and Spending, 2009).
One special version of the HMO is the independent practice association (IPA). The IPA hires physicians to provide services for HMO members. Physicians may contract with several HMOs. In most instances, the fee for service is negotiated between the HMO and the physicians. In many areas of the country, the IPA advocates for quality services for clients and uses collaborations to improve client care.
From the client’s perspective, the site-of-services restrictions also represent the greatest disadvantage of an HMO. Clients do not like limits on their use of providers; they wish for more freedom to choose. In response to members’ demands for freedom to choose their own providers, two other managed care systems have emerged: PPOs and POS.
Preferred Provider Organizations
preferred provider organization (PPO)
does not describe any single type of managed care arrangement. Rather, this plan falls between the traditional HMO and the standard indemnity health insurance plan. The following characteristics apply to PPOs (Joint Interim Committee on Managed Care, 2000):
· Contracts are established with providers of medical care.
· These providers are referred to as preferred providers.
· The benefit contract provides significantly better benefits for services received from preferred providers.
· Covered persons are allowed benefits for nonparticipating providers’ services.
PPOs point with pride to their prompt payment of claims. The providers accept a negotiated discount, which represents the PPO fee, and they do not bill patients an additional amount. Based on the negotiated fee, both the clients and the PPO can anticipate their costs, and providers can anticipate their income. From the providers’ perspective, they are assuming a business risk in terms of the fees that they agree to accept. However, they expect to increase the number of patients under their care. Many providers also maintain independent medical practices.
Point of Service
The third option of managed care offered today is the POS. It is often adopted by traditional HMO members who want more flexibility than the HMO or the PPO provide. The following features characterize a
· Customers are allowed to use out-of-plan providers; however, if they do, they receive reduced coverage.
· To participate in a POS plan, clients pay higher premiums, higher deductibles, and a higher percentage of the medical fees.
· Clients are encouraged to use the providers in the managed care system, but they receive partial benefits if they choose medical care outside the system.
Health Savings Accounts
Health Savings Accounts (HSAs)
provide employers a way to offer benefits to their employees. The federal government authorized the development of these accounts in 2003. They are high-deductible/lower-cost health care plans that provide increased employer affordability and consumer flexibility. The characteristics of these plans include:
· Employers provide employees high-deductible/low-cost plans.
· Employers and employees are able to contribute to these savings plan.
· The savings plans can pay for medical expenses that qualify under the plan.
· Employees are able to determine, to some degree, how they might spend the resources in the savings account.
· The contributions made by the employer and the employer are tax-free.
· Contributions not spent during a given year may be rolled over to the following year.
· Under ACA (2013), the contributions are limited to $2500 (Small Business Majority, 2015).
Health Reimbursement Arrangements
Health Reimbursement Arrangements (HRAs)
, similar to the HAS, is an employer/employee health savings plan. The HRAs provide the employer with a flexible savings plan to offer its employees. In addition, other health plans can be added to the HRA. Participating in this plan means:
· Employees do not report their HRA contributions as part of their gross income.
· Plans may be tax free.
At the end of the year, unused savings may be rolled over to the next year.
· There is no cap to employer contribution (Department of Treasury, 2015).
Plans Offered under the Health Insurance Exchanges
This category of managed care, mandated by the ACA, requires every state to offer its citizens a way to buy health insurance, optimally within a health exchange or marketplace for health insurance offered online. There are four designations of health care coverage available through the exchanges. Each offer minimum coverage and cover 60%, 70%, 80%, or 90% of medical costs. The minimum coverage includes:
· Ambulatory care
· Emergency care
· Maternity care
· Newborn care
· Mental health and substance abuse care
· Prescription drug care
· Rehabilitation services
· Preventive and wellness care
· Chronic drug management
· Pediatric services (Small Business Majority, 2015)
The types of managed care will continue to develop and change with the implementation of the ACA. In this section, we covered managed care as it relates to employers and employees. Under the ACA, many uninsured individuals will qualify for insurance under guidelines for Medicaid and Children’s Health Insurance Program (CHIP). Unemployed individuals not eligible for Medicaid or CHIP may buy their insurance on the “Marketplace” at an affordable price (Health care.gov, 2015).
Research and Practice: Case Management Society of America: Our History
Case Management Society of America is an international, nonprofit organization founded in 1990 dedicated to the support and development of the profession of case management through educational forums, networking opportunities, and legislative involvement. Unique in its composition as an international organization with more than 70 affiliated and prospective chapters in a tiered democratic structure, CMSA gains its success and strength through a member-driven society.
CMSA’s emergence as a prominent national organization is in large part due to its unique and involved membership. To enhance this process, the society provides ongoing leadership training seminars geared toward the local leaders.
CMSA developed the nationally recognized Standards of Practice for Case Management. This publication was officially released in early 1995, and it is a forerunner in establishing formal, written standards of practice from a variety of disciplines. During that same year, the National Board approved a peer-reviewed Ethics Statement on Case Management Practice, a base foundation from which to apply ethical principles to the practice of case management. The Standards of Practice and Ethics Statement are both available from CMSA National.
In response to payer and purchaser expectations for demonstrating value in the marketplace, CMSA created the Council for Case Management Accountability. This new division of CMSA will establish evidence-based standards of practice and help its members achieve those standards through the measurement, evaluation, and reporting of outcomes.
Education, research, and networking continue to be top priorities sought by CMSA members. Proactive measures from grassroots lobbying to national briefings have been at the forefront of CMSA legislative activity. Government Affairs committees are currently active in most of the local and state chapters across the country.
Through the support of a certification program, CMSA continues to enhance the level of case manager professionalism, furthering the development of a new, higher level of industry expertise. For more information, please contact the Commission for Case Manager Certification at (856) 380-6836. CCMC is a separate entity and is independent from CMSA.
Ultimately, the quality and productivity of CMSA’s services rely on the commitment of its membership. Because case managers are effective communicators, problem solvers, and visionaries, CMSA offers an opportunity for members to utilize their skill sets and maximize their talents. The enormous success of the organization lies in one simple concept—professional leadership.
SOURCE: Case Management Society of America: Our history. Retrieved from http://www.cmsa.org/Home/CMSA/OurHistory/tabid/225/Default.aspx
Historically, managed care has emerged as a response to the fact that employers, governments, payers, clients, and providers are all seeking ways of containing health care costs. The various types of plans emphasize management of medical cases, review and control of utilization, and incentives for or restrictions on providers and clients to reduce costs and maintain quality. Managed care systems are achieving many of these goals, but even in the environment and implementation of the Affordable Care Act some clear advantages and disadvantages have emerged. Proponents of the managed care systems point to the following advantages of managed care:
· For many individuals, accessibility to medical care has expanded.
· Providers, clients, and payers involved in health care prioritize among services, procedures, and treatments provided.
· Providers carefully consider any plan of action prescribed for the client because they must provide justification for each component of the plan.
· There is an efficiency of service delivery because services are to be provided in the shortest time needed to meet the goals established.
· Evidence-based practice standards articulate what defines quality care.
· From the client’s perspective, there is a single coordinated point of entry into the system.
· Resources are saved.
· Resources are spent according to priorities.
Those who question the virtue of the managed care system focus their concerns on two areas: the quality of services delivered and the efficiency of service. They see the following disadvantages of delivering services through managed care:
· Professionals do not believe that they are offering the best services available because they are constrained by resource limitations.
· Managed care staff are making judgments about the suitability of proposed treatment without adequate training or professional knowledge.
· Services are not delivered in a timely manner because of the extra layer of bureaucracy.
Managed care organizations require paperwork that limits the amount of time the professional can give the client.
· Clients worry about the quality of the care they are receiving.
· Clients do not have access to all the services they believe they should have.
· Clients cannot choose their service providers.
Because of the importance of case management in the implementation of managed care, institutions and organizations dedicated to the professionalization of case management emerged during the late 1980s and during 1990s. One example of an organization developed to establish standards and develop a professional orientation for case managers is the Case Management Society of America (Case Management Society of America, n.d.). This organization is committed to the development of professional case management, especially as it relates to managed care (see
Voices from the Field).
In response to professional and patient or client frustrations with managed care, several advocacy efforts have evolved. One example is a patient bill of rights that was developed by the American Association of Marriage and Family Therapy, American Counseling Association, American Family Therapy Academy, American Nurses Association, American Psychological Association, American Psychiatric Association, American Psychiatric Nurses Association, National Association of Social Workers, and National Federation of Societies for Clinical Social Work; it articulates recommendations for clients and patients.
· Individuals have a right to know and understand the benefits of the managed care plan in which they are enrolled. Managed care organizations must provide this information and explain the information when asked.
· Individuals must have full access to the names of the professionals eligible to provide treatments. They must also have access to the professionals’ qualifications, experience, and areas of expertise.
· Individuals must know if the medical professional has an agreement with the managed care organization to limit treatment options, and if the professional receives monetary incentives for restricting treatments.
· Individuals must know the methods to appeal or to grieve a decision.
· Individuals must know the policies on confidentiality of decisions and records.
· Individuals must know the parameters of choice of professionals.
· Individuals must know all of the individuals involved in making treatment decisions.
· Individuals must know if substance abuse and mental health treatments are part of the plan.
· Individuals must know if the professionals are liable for their actions.
· The concept of a bill of patient rights has evolved (Patient Bill of Rights, n.d.).
Despite the criticisms raised, managed care is no longer just one alternative in the health care delivery system; it is part of the structure of service delivery. It has expanded beyond the traditional medical arena. Further, with the passage and implementation of the Affordable Care Act, managed care is expanding its influence on service delivery. This model of oversight regulates employment assistance programs, long-term services for people with mental retardation, child and adult rehabilitation, behavioral health (mental health), and child welfare, to name a few. The educational arena and the criminal justice system interact with managed care when services for their clients cross into these areas.
The use of managed care in human services will continue to influence the delivery of services. Throughout this textbook, you will see how managed care has influenced the practice of case management.
2-2The Professionalization of Case Management and Expanding Responsibilities
Chapter One, we introduced the professionalization of case management within human service delivery that includes national certifications offered by several professional organizations and states. In this chapter, we provide more in-depth information about several of these certificate efforts and definitions of standards of practice. For example, the Human Services Board-Certified Practitioner (HS-BCP) certification includes demonstrated competence in case management, professional practice, and ethics as one of the four knowledge and skills assessment components (Center for Credentialing and Education, 2015). Eligibility includes a degree “earned at a regionally accredited college or university or a state-approved community or junior college at the Technical Certificate level or above. Applicants must also have completed the required Postdegree Experience” (Center for Credentialing and Education, 2015) ranging from 1 to 5 years and contingent on educational level. A few competencies related to the case management function relevant to the HS-BCP are as follows:
· Collaborate with professionals from other disciplines.
· Identify community resources.
· Utilize a social services directory.
· Coordinate delivery of services.
· Participate as a member of a multidisciplinary team.
· Determine local access to services.
· Maintain a social services directory.
· Participate in case conferences.
· Serve as a liaison to other agencies.
· Coordinate service plan with other service providers (Center for Credentialing and Education, 2015).
In addition, the National Association of Social Workers offers BSW social worker case managers the Certified Social Work Case Manager (C-SWMC) credential (National Association of Social Workers, 2013). The National Association of Social Workers (NASW) developed areas of specialization in 2000 that included the C-SWMC. The purpose of this specialty area is to provide visibility to the function and role of the case manager and to develop recognition of social workers in the role. Eligibility requirements include the following:
· A baccalaureate degree in social work from an accredited university
· Documentation of at least 3 years and 4500 hours of paid, supervised, post-BSW professional experience in an organization or agency that provides case management services
· Current state BSW-level license or an ASWB BSW-level exam passing score
· Adherence to the NASW Code of Ethics and the NASW Standards for Continuing Professional Education. (National Association of Social Work, 2013)
We discussed the certification and guides provided by the Substance Abuse and Mental Health Services Administration (SAMHSA) and several states in
Given the various perspectives on case management, its historical development, the impact of managed care, and the professionalization of case management, the roles and responsibilities of case management and the case management process continue to develop. In this text, you will see shifts in client involvement, the roles of the helper, and the emphasis on cost containment. Historically, the case management process has emphasized coordination of services, interagency cooperation, and advocacy, but the process of service delivery is expanding. Other trends have emerged from federal legislation, including coordination of care, integration of services, the client as a customer, cost containment, and the assessment of outcomes and the quality of services. Clients and families are now being encouraged to become their own case managers. Accountability reflected in the new certifications for case managers continues to become more important. And, as we indicated, these shifts in emphasis are reflected in the roles and responsibilities of the professionals involved in service delivery today.
Talking about Managed Care
Managed care is a relatively new component of the service delivery system. As a class, in small groups, or as an individual, describe the purpose of managed care and the way it influences the delivery of medical services. According to your understanding, describe the way that managed care might influence the work of the case manager.
Share this information with your classmates.
Deepening Your Knowledge: Case Study
Nancy, a 42-year-old White woman, began her career in case management 11 years ago in a welfare office in Cincinnati, Ohio. She earned her bachelor’s degree in sociology and married soon after college. She and her husband decided that they wanted to start a family soon after, so they agreed that he would work and she would stay at home to help with the children, who are now 17 and 15. When her youngest child was a year away from kindergarten and had settled into preschool, Nancy decided that she was ready to enter the workforce. She had thought a lot about the helping profession while her children were growing up and knew from her involvement in church and community service that she felt called to social work. With her education in sociology, she found a position working with the many clients who needed guidance and direction in navigating the welfare system.
After spending 3 years working with this population, she thought that she would be happier with more flexibility and diversity in her work. She enjoyed discussing approaches to working with clients with her coworkers and thought on many occasions that her direct supervisors did not do enough to help the case managers or the clients they served. Nancy began to realize that she desired to help clients and other social workers more fully by assuming a managerial role in the office.
At this time, Nancy decided to enroll in a local master’s of social work program and took classes at night over the next 3 years. During this time, she continued her work for 2 years at the welfare office until she became aware, through one of her professors, of an opening at a local center for adults with pervasive developmental disorders. She investigated this opportunity and realized that it would let her work with fewer clients in both group and individual settings; therefore, she could address their needs in greater depth and have more impact on their lives. Nancy interviewed and accepted the position with 1 year of coursework remaining on her master’s degree.
She loved the work and, upon completing her degree, made plans to pursue licensure with the National Association of Social Workers as a Certified Social Work Case Manager (C-SWMC). Her supervisor was supportive of this decision and helped her with the supervised hours requirement. By working with her previous supervisor at the welfare office as well as taking and passing the ASWB-BSW exam, Nancy was able to receive her certification 1 year after pursuing the credential. The license, coupled with her master’s degree, allowed Nancy to ascend to the level of program coordinator at the center during her ninth year as a social worker.
Discussion Questions about Nancy
1. Identify the key steps that Nancy took toward enhancing her professional identity as a social worker. What further steps could Nancy take to develop her role and career?
2. If Nancy had decided to explore work in substance abuse after the welfare position, how might her path toward enhancing her professional identity have differed?
3. Think about your current stage in your professional development. What steps would you like to consider and pursue over the next 10 years? Who might you consult to help you achieve these steps?
Author Note: We think that it is important for you to review the chapter you just read. We suggest the following.
· First, re-read the class discussion questions in the text and answer these as comprehensively as possible.
· Second, once you complete the discussion questions, review the
Chapter Summary, define the
Key Terms, and answer the questions in
Reviewing the Chapter.
· Third, make notes of what stands out for you during your review. Also, record any questions that you might have.
· Finally, take time to discuss the Questions for Discussion with another class member, either face-to-face or online. Answering these questions with a peer will help you solidify the understanding you have of the contents of the chapter.
Methods of Delivering Case Management Services
· Chapter Three addresses Social Work Case Management Standard 2, Knowledge, which focuses on the ways that case management services are delivered.
· Chapter Three addresses Human Service–Certified Board Practitioner Competency 9, Intervention Models and Theories, which focuses on the ways that case management services are delivered.
For most of the kids that get referred up to continuous treatment, there is more of a mental health component to their treatment. There is still another level up from that, which is called intensive case management. Case managers are with the child every day.
—From Katie Ferrell, 2012 text from unpublished interview. Used with permission
This chapter introduces the various methods of delivering case management services and reflects the creative ways that helpers implement services to clients. Also, in this chapter, we present the roles that helpers assume within the context of case management. We also present the topics described when case managers talk about their work. Focus your reading and study on the following objectives.
Methods of Delivering Case Management Services
· List reasons why it is important to understand the different methods that helpers use to deliver case management services.
· Illustrate four ways that case management services are delivered (e.g., comprehensive services.
· Illustrate what case management looks like when different individuals assume the role of case manager.
Roles in Case Management
· Identify the roles in the case management process. Provide an example of how a case manager might perform each of the roles.
Topics in Case Management Today
· List the topics that case managers identify when they talk about their professional work.
· Define what case managers mean by a Jack or Jill of all trades.
· Illustrate why communication is important in case management.
· Describe the use of decision making and critical thinking skills in case management.
· List three personal qualities that help case managers perform their jobs.
As indicated by the history of case management in
Chapter Two, case management and its components are rooted in a long-standing tradition that comes from relating to clients and their needs. Two of the ways to understand case management are to explore the many ways it is delivered and examine the goals, roles, strengths, and weaknesses of the various approaches. Let us look at several case managers and see what they say about how case management services are delivered across various settings.
I enjoyed my work as a rehab case manager. Sometimes it was really challenging. I remember one of my clients had a heart attack and she had physical limitations after that. Her three adult children lived out of town and she did not have anyone to help her. So I worked with friends and other agencies to provide her services after she left the rehabilitation center. She was a good client. We got home health to come to the house to continue her rehab. And some members from her church took her to doctor’s appointments and church services and events. She just could not live independently without support. The Office on Aging provided meals and friendly visitors for her. I think that the transportation piece was the most difficult.
—Rehabilitation case manager, rehabilitation services agency, Kennesaw, GA
Our primary focus is providing housing for the HIV and AIDS clients. We pride ourselves on offering a safe, comfortable place for these clients to live. Short- and long-term housing is available. Our services have changed over the years. The changes reflect the changing populations we serve and the medical treatments that allow clients a longer life. We continue to grow, and now we offer crisis intervention and prevention services. Our case managers are the lifeblood of our service delivery.
—Director, housing services nonprofit, New York, NY
Parole is an important part of the criminal justice system. We work hard to help parolees before they are released so they can have a smooth transition. Part of the information I use to support the release process is on the release plan. This is a form that inmates fill out; it helps me know about where they might want to live and work when they leave prison. Once I get this information, then I begin to explore living accommodations and possible employment opportunities. It is my job to make sure that rooms can be rented and the landlords will accept the ex-inmate. I also talk with the employer. It is important I find out if the work is legitimate. If I cannot verify housing or employment, then I contact the institutional parole officer and he or she helps the inmate submit another plan. We try to make sure that the parolee has an important responsibility during the transition process.
—Parole officer, adult corrections parole, Knoxville, TN
The preceding quotations relate to roles that case managers perform in service delivery, the different methods used to delivery services, and the topics that case managers describe when they talk about their work. The director of housing services in New York, who works with individuals and families affected by HIV/AIDS, supports clients by providing a variety of services, including housing, recreation, and vocational rehabilitation. The case managers at her agency serve as coordinators, planners, and problem solvers. This director talks about the multiple roles she performs and how important communication with others is. The rehabilitation agency provides services in the hospital and after hospital discharge. The program makes a long-term commitment to clients, regardless of their abilities or status. This requires case managers to be flexible in their roles to accommodate the needs of the client. Working from a very different method, the parole officer’s roles are defined by the state and shaped by her large caseload. Because the parolees assume most of the responsibility for themselves, the parole officer is primarily a recordkeeper, monitor, and problem solver. She has to keep her boundaries and allow her clients to succeed or, sometimes, fail.
3-1aMethods of Delivering Case Management Services
As we indicated, it is important to understand that there are different approaches to case management. In fact, after reading more about case management, you might conclude that each case management delivery method has some common features of case management as broadly understood and some unique to the specific setting. As a way of describing the different features of case management, this section introduces two ways of looking at service delivery. First we consider how the case management services are delivered. Then, we describe who, during the delivery of services, functions as the case manager.
Why is it important to understand the various ways of viewing service delivery? First, case management service delivery can occur in a variety of ways; it is a flexible process. Viewing case management as a flexible service helps you to better meet the needs of clients. Second, various approaches to case management service delivery may reflect the different goals. For each approach, the case manager’s responsibilities, roles, and length of involvement with the client may differ. Third, each way that case management is delivered has its particular strengths and weaknesses. Understanding these helps a case manager approach case management in a realistic way. Fourth, knowing the many ways that case management is delivered helps you to better understand any delivery system you may encounter and how you might participate in it. We refer you to
Table 3.1 to review the various ways that case management services may be delivered and a list of possible individuals who may serve as case managers. In fact, as you begin to read about and see case managers in action, you may encounter a mix of delivery systems. You may also be able to add different ways of delivering services to this list. You can use
Figure 3.1 and
Table 3.1 as you make your own assessment of what a delivery system looks like. At the conclusion of this section, we provide an example to help you use this information (see
Comprehensive Case Management: Wisconsin’s Model Approach for W-2 Participants).
Methods of Delivering Case Management Services
How services are delivered
Who delivers the services
One-stop comprehensive center
Family, friends, community volunteers
Psychosocial rehabilitation center
Figure 3.1Characteristics of Methods; Determinants of Services
In the next two sections, we describe in more detail the common characteristics of how case management services are delivered and who assumes the responsibility of the case management in more detail. We provide descriptions of case management methods used to meet the needs of multiple problem clients. Each of the descriptions will help you see how complex and unique each case management service delivery is.
3-1bHow Case Management Services Are Delivered
At the heart of how case management services are delivered is how an agency organizes its services. In most cases, for each of the methods of delivering services, the goals of case management are to provide a comprehensive set of services to meet the needs of clients. As indicated in
Table 3.1, this comprehensive delivery may occur in a variety of organizational contexts, such as a one-stop comprehensive center, an interdisciplinary team, a psychosocial rehabilitative center, or as a crisis response. For example, a previous quotation in the chapter described an agency that serves individuals with HIV/AIDS. In the case of this case management service, the agency provides a range of services available in one location. Some clients live at the center. This is an example of a one-stop comprehensive service center.
Let us consider what case management looks like when we consider how agencies organize their services. The four examples of organization-based case management presented in
Table 3.1 have the following characteristics in common (see
· There is a multiproblem client.
· There exists a collaborative atmosphere among many helping professionals.
· Each person on the case management team has a specific assignment and responsibility.
· The services are organized so that relationships among professionals are integrated to serve the clients’ needs better.
Now, from the perspective of how case management services are delivered, let us look at the goal of case management, the responsibilities of the case managers, the primary roles of the case managers, the length of involvement, the strengths, and the weaknesses.
Case managers meet multiple needs through a single point of access, with one location for service delivery. This comprehensive service delivery sometimes resembles that provided by the traditional extended family.
The organization of the agency provides comprehensive case management. Each client receives an individual assessment and plan, which may include social support, housing, recreation, work, and time to integrate into the community. The case manager’s responsibilities range from coordinating services (supervision of intake, assessment, planning, brokering, monitoring, and termination) to leading a team of professionals who provide services to the client. Sometimes there is a professional whose primary responsibility is management of the case, and at other times the one who initiates services also assumes the management role.
A case manager is an advocate, broker, coordinator, planner, problem solver, and recordkeeper. You will learn more about these roles later in this chapter.
Length of Involvement
The duration varies. If the case is complicated and several specialists are needed, then services are provided for a longer time. In other cases, short-term service is adequate. For example, in terms of a crisis response, the care is short-term and clients are referred to longer-term care if needed.
Services are provided on an inpatient, outpatient, or residential basis, but all are provided in one location. Client assessment is multifaceted, with a holistic approach. The plan is individualized and easily monitored. Staff members function as a team with a common goal and have regular meetings and a common reporting scheme.
Resource availability may be a problem if the client needs services not available at the center. Service integration depends on clear organizational structure and lines of authority; the staff must agree on the problem, the plan, and the implementation. Resource availability can be a problem. The family of the client may be less engaged in the helping process because the staff role is strong. In addition, the client may become accustomed to the environment and never grow beyond it. We provide descriptions of the four types of organizational services delivery. However, remember that there may be many more.
One-Stop Comprehensive Services
One example of the comprehensive services that are provided is a program available in the state of Wisconsin. The Wisconsin Works (W-2) program provides services to parents with children. To be eligible for the program, these parents must earn a salary that is 115% below the federal poverty level. Case management is a key component of the services available to individuals who qualify for the program. Read further to understand the case management functions related to comprehensive case management for Wisconsin’s W-2 program.
3-1cComprehensive Case Management: Wisconsin’s Model Approach for W-2 Participants
The comprehensive case management method is a process, not a program or a type of service. It represents a fundamental change in the way services are designed and delivered. In a comprehensive case management method, families involved in W-2 with substance abuse issues are to receive individualized wraparound services. It is value-based and has an unconditional commitment to customizing services on a “one-family-at-a-time” basis to support normalized and inclusive options for families with complex needs. At its core, the comprehensive case management method is based on interventions that are collaborative and community-based, emphasizes the strengths of families, and includes the delivery of highly coordinated, individualized services for families. This process addresses the unique needs of families and focuses on achieving positive and effective partnerships with families, the community, and agencies that provide children’s and family services.
Successful treatment programs that focus on recovery to work should not only offer a continuum of services but also integrate these services within the larger community. Because many factors affect a woman’s substance abuse problem, the purpose of a comprehensive case management approach is to address a woman’s substance abuse in the context of her health and her relationship with her children and other family members, the community, and society. This type of case management can generally be described as a coordinated approach to the delivery of health, substance abuse, mental health, vocational, and social services, linking participants with appropriate services to address specific needs and stated goals. All services and supports must be culturally competent and tailored to the unique values and cultural needs of the family and of the culture that the family identifies with. When implemented to its fullest, comprehensive case management will enhance the scope of substance abuse treatment and the recovery continuum, and it will stress the following goals:
· Provide the participant with a single point of contact for multiple health and social services systems
· Advocate for the participant
· Be flexible, community-based, and family-focused
· Assist the participant with needs generally thought to be outside the realm of employment and training and substance abuse treatment
· Develop a universal service plan that integrates activities from all service providers and is outcome-based (Wisconsin Department of Children and Families, 2015)
Studying the One-Stop Comprehensive Services Method
Figure 3.1 and
Table 3.1, as a class, in small groups, or as an individual, read about the services delivered in the Comprehensive Case Management: Wisconsin’s Model Approach for W-2 Participants section. Use the information gained from this description to determine how the services are delivered and who delivers the services. For instance, ask yourself:
· Does the Wisconsin method delivery service use a comprehensive one-stop center, an interdisciplinary team, a psychosocial rehabilitation center, or a crisis response?
· Maybe the Wisconsin method uses other methods of delivering services. If so, what are they?
· Who delivers the case management services in the Wisconsin method?
After you answer these questions, describe the strengths and weaknesses of the Wisconsin method of services. Each question can have more than one answer.
When you have completed this exercise, share this information with your classmates.
The example of an interdisciplinary team providing services to a multiple-problem client is represented by a program in the United Kingdom that provides services for older people with mental health issues. In the United Kingdom, services to these individuals centers around Community Mental Health Teams (CMHTs) to help meet the wide variety of services required for clients. The teams include psychiatrists, mental health nurses, social workers, occupational therapists, psychologists, and counselors. Teams may add members depending on the needs of the client (Wilberforce et al., 2015). The aim of these teams is to provide services that allow adults, ages 18–65 years, with mental illnesses to remain in the community and to avoid unnecessary hospital stays. Individual mental health issues might include severe and persistent issues such as schizophrenia and manic-depressive psychosis. The work of the CMHT with each client is personalized. The care available includes: care management, mobile crisis response, community psychiatric nursing services, and community networking.
Urgency of care is important when considering serving this population, and the definition of urgency often determines the time of the first intervention and the type of intervention. The decision related to how urgent the care is from the CMHT often is made through referral. The team confirms the urgency of care needed. A few of the reasons to recommend urgency of care include suggested harm to self and others, a low-level ability to care for oneself (e.g., cognitive functioning), primary physician suspects mental illness and need for care, and client is at risk because of no or little support from others (Hilton et al. 2008).
Because the services that clients need vary, each of the clients receives very different services. Types of care included needs relating to their mental health diagnosis, their need for help with daily living activities, their behavior related to risk, and their behavior related to challenge (Wilberforce, 2015). For instance, clients who have mental health problems that influenced their daily function received more services, and they received those services for a longer period of time. These individuals, more than likely, also had complex mental health issues. This was especially true if the clients were assertive or aggressive.
Psychosocial Rehabilitation Center
A car hit John H., a senior at a college in New England, when he was attending Mardi Gras in New Orleans. After hospital discharge, John entered a rehabilitation center for the assessment of job skills and personal and social adjustment. The brain damage he suffered is permanent, and he must cope with a number of limitations. The center provides vocational assessment, counseling, independent living skills, and education. Staff also dispense medication and make referrals when necessary.
John has already been in the facility for 2 months. His parents live out of state. They are working to transfer him to another facility that is located in the town where they live. The staff believe that he will be able to transfer in approximately 60 days. They will begin to work with the staff in John’s hometown to provide continuity of John’s care. Because of John’s limited cognitive functioning, his need for comprehensive services will continue. What makes this type of care psychosocial rehabilitation is the emphasis on the goal of rehabilitation. This means returning the client to good health and the ability to work.
A crisis response represents immediate and short-term help for individuals who are involved in an event evoking strong physical, emotional, or behavioral stress. In addition, the individual is unable to cope with the stress of the event (Encyclopedia of Mental Disorders, 2015). A crisis may reflect a trauma such an experience of violence to self or others, a natural disaster, an illness, or a change in a relationship, to name a few. At times case management services focus on issues that begin with a crisis but later demand longer-term care. Using this method of service delivery, these services identify immediate needs and plan to support clients on a short-term and long-term basis.
Safe Horizon is an organization that addresses violence in our society and serves adults and children in New York City. One of its programs addresses domestic violence. It is a comprehensive program that supports women living in abusive situations. The agency is structured so that women and their children receive full support once they decide to leave their abusive relationships. Services delivered within the case management framework include short-term and long-term housing, child care, vocational support, legal aid, transportation, and other services. The case management also encompasses counseling and support groups. As stated, the services of Safe Horizon range from crisis support to more comprehensive, one-stop, long-term care (Safe Horizon, 2015).
Determining the Best Method of Service Delivery
After reading about the several ways services may be delivered, as a class, in small groups, or as an individual, choose one client group and describe how services might be delivered using the various ways shown here and listed in
Table 3.1. Describe the pros and cons of using each of your approaches to case management services delivery.
When you have completed this exercise, share this information with your classmates.
Sharon Bello, Entry 3.1
Hi! I was able to comment on the history of case management in
Chapter Two. Marianne asked me to read through this chapter and describe how the organizational methods of delivering case management services and how who assumes the responsibility for delivering case management services fit with my own experiences in human service delivery. Right now, I think that my experience with Tom Chapman and Susan Fields represents a combination of the characteristics of several of the methods. I only have one case manager, and that case manager helps me integrate my services. But many other professionals helped provide assessments before we decided on my goals. So that experience represented coordinating services. I don’t think I had an interdisciplinary team; I didn’t participate in a team decision. I just worked with my case manager. And because I found my major (at last), I was the one who brought that to my case manager. My case manager helped me work with officials at school to change my major and to have it approved. I don’t know if I am answering the question, because I am picking and choosing more than one method of how services are delivered and who delivers services.
Thinking about case management and when my two sons were killed, I wish that I had a case manager then. I was so lost, and I knew that, for the sake of my children still alive, I had had to go on. But to have someone like Tom Chapman or Susan Fields by my side and help me through the early times, well, it would not have taken away the pain, but it might have taken away the loneliness. My friends helped, but they did not know what I needed and the services that might have helped my remaining family and me. I am not sure what method that would follow, probably the interdisciplinary team including a case manager, but I relied on the help of family and friends.
3-1dWho Assumes the Responsibility of the Case Management?
An examination of who assumes the responsibility of the case management is an important factor in how case management services are delivered. Many times, determining who assumes this responsibility reflects the needs of the client and the goals of case management. As indicated in
Figure 3.1 and
Table 3.1, various individuals may assume the primary case management function; these individuals may include, but are not limited to, the helper, the family, peers, or the client. In the third chapter-opening quotation, the parole officer described how the parolee assumes responsibility for a release plan. At her agency, the client has many responsibilities and is empowered by the case manager to find a job and housing.
At times, the focus of responsibility-based case management is the transition of care from human service professionals to nonprofessionals. Often, clients continue to need assistance long after the professional case managers have terminated their work with clients and families. To meet the ongoing or recurring need for case management services, teams of family, friends, or community volunteers are trained to provide continuing case management. Professional case managers support the caretaker and are available to help during emergencies, crises, and other stressful times.
Let us consider what case management looks like when we consider who serves as the case manager. The following four considerations help determine who provides the case management services presented in
· The severity of the client’s problems
· The duration of the client’s need for professional services
· The existence and strength of the support system
· The skills of those involved with the case
· The resources available to provide client support
Now, from the perspective of who delivers the case management services, let us look at the goal of case management, the responsibilities of the case managers, the primary roles of the case managers, the length of involvement, the strengths, and the weaknesses.
The goal of case management from the perspective of who functions as a case manager can be both short-term and long-term involvement with the case, the coordination of services, the help of volunteers, and the empowerment of clients.
The individual or group responsible for case management provides coordination, finds assessment services, and networks with others in the human services delivery system to provide access to needed specialists and services. Problem identification, plan development, and implementation are other responsibilities. The case manager also provides support and assistance in making and maintaining other linkages.
The case manager is a broker, coordinator, planner, problem solver, and recordkeeper.
Length of Involvement
The involvement may be short-term, during a crisis or developmental problem, or long-term, as with a physical or mental illness, a disability, or geriatric problems.
Strengths There is flexibility in who assumes case management responsibilities, including family, neighbors, volunteers, and the client. In many cases, the designated case manager may already have an established relationship with the client. Involving family, neighbors, and volunteers at times improves client access to services. Under this model, service delivery is cost-effective, the community is involved, and independence is encouraged.
In some cases, the person designated as case manager may not have the client’s best interests at heart, may lack the necessary knowledge and skills, or may be ineffective in monitoring service provision. Training and supervision may be costly. Accepting a family member or volunteer as a case manager may be difficult for the client. Case managers who are not part of the human services delivery system may have trouble coordinating and gaining access to services.
Helper as Case Manager
Audrey is a 78-year-old pensioner who lives alone in rural Victoria. Audrey has two daughters—one lives in another state and the other one lives overseas. Audrey has osteoarthritis, rheumatoid arthritis, cardiac problems, and glaucoma. Audrey suffers from insomnia, anxiety, and depression. Six months ago she fractured her hip, and she experiences chronic and ongoing pain as a result. The Office on Aging is 80 miles away. The outreach program provides case management for senior care in the more rural areas. Audrey has been assigned a case manager. The case manager is in touch with Audrey’s eldest daughter but works primarily with Audrey. The case manager is providing Audrey with care on a long-term basis.
Currently, Audrey has many medical appointments. Audrey has been missing appointments because she is unable to access public transportation. Her telephone has recently been disconnected because she has not been able to pay the bills. Audrey had been completely independent, but since fracturing her hip she has lost her confidence and has become overwhelmed and anxious in managing her day-to-day affairs.
Audrey’s general practitioner (GP) believes that she should be assessed for low-level residential care because he is concerned that she can no longer manage on her own. The GP contacted the local Community Options (COPS) package service, and after meeting Audrey they agreed to provide a package in the interim. As a result of this, Audrey was assigned a case manager. The case manager spent time getting to know Audrey and identifying the various issues that were making Audrey feel that she could no longer cope at home.
The case manager has three primary goals: to work together with Audrey to assess Audrey’s needs; to network to provide services to meet the established needs; and to communicate with Audrey on a regular basis to continue to assess Audrey’s needs and to problem-solve when issues change. Right now, Audrey is working with a physician who makes house calls once every month. Audrey also uses a telemedicine system to send reports to her doctor. The case manager has arranged for transportation for Audrey to see a counselor every 2 weeks. In addition, the case manager arranged for a home cleaning service to visit every 2 weeks and arranged for a financial counselor to work with Audrey to develop a budget.
A larger issue is retrofitting Audrey’s home to meet her physical needs. Audrey is on a list to have changes made to her home by the senior housing department. Audrey will probably have to wait 6 months for these changes. Next month, Audrey, her two daughters, and the case manager will meet in Audrey’s home to talk about Audrey’s services and the case management plan.
Note: The idea for Audrey’s case began with her story presented by Aged and Community Services: Australia and Case Management Society of Australia, 2006. The authors adapted the case to reflect their experience with serving the needs of seniors.
Many professionals regard the approach to care that Audrey received as an excellent treatment approach. As with other organization-based services, the care is comprehensive and the client receives social support. Among the criticisms of these organizations are that they may resemble institutions and can be very expensive.
Family as the Case Manager
It is a current trend in human services to ask families to act as case managers and then provide them with the support to do so. With costs escalating and institutional care being replaced by community care, it is cost-effective for families to perform this central role. However, for such a system to be effective, the family must receive continuing education about the human services delivery system and must have professional help available when crises arise.
The family as the case manager is a model prevalent in cases of families who are meeting the needs of a child with a chronic illness. The child requires continual support from a medical team and there are also multiple needs that must be met. In addition, there are financial considerations for needed care and various psychosocial needs of the child. We present the case of “Evan” to illustrate the family as the case manager.
Evan was 6 years old when he was diagnosed with leukemia. He had been tired for approximately 3 months, so much so that his mother, Randy, took him to see the pediatrician 3 months before he was scheduled for his wellness check-up. The entire family, Evan’s father, Ivan, and his two older brothers, were in shock and grief after the diagnosis. Six months after the diagnosis and, in the middle of Evan’s treatment, the family and its routines and relationships had completely changed. The family managed its multiple needs, which included social, psychological, physical, financial, education, and spiritual needs of all five members of the family. Even though the majority of the time Randy and Ivan focused on what Evan needed, the needs of the two older boys, Stephen and Sevan, were also important.
In one of the first meetings that Randy and Ivan had with the oncologist, they received excellent advice about Evan, his condition, treatment options, and the medical demands of the next year. Their oncologist also learned about the importance of their assigned nurse case manager. The oncologist described the nurse case manager’s responsibilities as a coordinator of medical care. He also outlined the responsibilities of the parents and stressed the importance of the additional responsibilities they, as parents, would assume. After 2 months of Evan’s treatment, Randy outlined her responsibilities, Ivan’s responsibilities, and Stephen’s and Sevan’s new tasks.
· Coordinate Evan’s presurgery, surgery, and postsurgery physical needs
· Maintain contact with the nurse case manager
Maintain good communication among family members
· Communicate with the school and maintain Evan’s continued school work (as well as possible)
· Support Stephen’s and Sevan’s school work and extracurricular activities
· Help all three boys maintain their friendships and peer obligations
· Arrange family counseling
· Attend a bi-weekly support group for parents
· Keep up with daily living responsibilities such as grocery shopping, errands, meals, and laundry
· Keep up with carpool responsibilities
· Support school work for Stephen and Sevan
· Maintain good communication among family members
· Support school work for Stephen and Sevan
· Participate in carpooling
· Handle most of the financial arrangement and paperwork
· Attend family counseling
· Attend support group
· Support Randy
· Help Randy meet Evan’s physical needs
Stephen and Seven
· Assume more responsibility for household chores
· Spend time each day with Evan
· Communicate to each other and to Randy and Ivan when they need help
· Be honest about their feelings
· Attend family counseling
· Continue to participate in school and extracurricular activities
· Help Randy and Ivan arrange carpooling
Peers Performing the Case Management Function
Because of the increasing cost of service delivery, many agencies and communities have developed strong volunteer programs. The agencies provide excellent training, ongoing education, and good supervision, thus allowing volunteers to assume case management responsibilities. In this way, the volunteers are able to contribute to the welfare of their local community. In the following case, Elaine Mayer forms a case management team of her own.
Elaine Mayer lives in a rural area in Kansas. She was diagnosed with a failing kidney, or imminent renal failure, approximately 2 years ago. She only has one kidney because she had donated a kidney to her twin brother 10 years ago. She lives in a small community and has been an active part of that community for more than 30 years. Now, at the age of 55, she needs help from others to receive the medical care she needs to save her life. The doctor recommended dialysis at a clinic approximately 20 miles away. Approximately 2 months ago, Elaine visits the dialysis clinic three times per week, Monday, Wednesday, and Friday, to receive dialysis. With the help of the pastor at her parents’ local church, Elaine formed a group of helpers she calls the “sandlot crew,” a name she adopted from her early childhood memories of summer softball. One of her friends, her hairdresser, Sandy, agreed to coordinate the care that Elaine needs and receives. The sandlot crew helped her with some of her basic needs. Going to the dialysis clinic three times per week and receiving treatment is time-consuming and tiring work. Elaine works at a local clothing store and she has had to alter, and later reduce, the hours she works. With the team she assembled, she feels like she has support and friendship. She is grateful for both the help and the special engagement with others
Members of the team include the local pastor, her primary care doctor, her hairdresser (Sandy), and her attorney. Each of her team has specific responsibilities. And the youngest of her team is a teenager who lives across the street. He can drive and he comes over once every week to help her with a list of chores that she writes during the week. They call him the “everything else man.” Once every week, Sandy drives her to the dialysis clinic. Her pastor makes sure there are groceries in the house. She calls Sandy if a crisis arises. Each month, the team and Elaine go out to lunch. The lunch is more fun, but at times they also talk about Elaine and her care. Communication is the key to this type of peer or volunteer case management. To give back to the others for the help she receives, Elaine writes cards to those in her community who are sick or who have experienced loss. She says it is the least that she can do.
The Client as Case Manager
When the client serves as his or her case manager, the majority of the responsibility for providing services, advocating for needs, establishing a network of resources, and linking the client to resources are the responsibilities of the client. This approach develops the client’s maximum potential, which is emphasized by strengths-based case management (Rapp & Goscha, 2006). This type of case management stresses building on the strengths and resources of individuals, thus distinguishing it from more traditional approaches that focus on deficits and needs. Self-determination—the right to establish one’s own goals and to have an active role in problem resolution—is of primary importance here. The belief is that a client who has learned to act as manager can provide long-term care for himself or herself and for others.
Reynda was just accepted into transitional housing. She is allowed to stay in this housing for up to 2 years if she is able to follow the rules established for all residents. She must pay $85 each month for her room. And she has her own key to her room. Imgaine! She has not had a key, her own key, well, longer than she can remember. Right now, she has a job downtown. She is making minimum wage, but because her new room is downtown, she can walk to work. She doesn’t need a car! So to stay in her new residence, she needs to continue to pay her rent. She also needs to stay clean and to retain her good standing with the correctional system. That means she cannot have any felony charges brought against her. Reynda is amazed how much is under her direct control here. There are individuals on duty 24-7 in case she needs help. And there are group meetings once every week and exercise facilities in the building. But she does not have to use any of these services. She does complete a care plan once every 3 months and she reviews it with a social worker. But it is up to her to determine her own goals and to decide how she will meet them. And she can change her goals any time that she likes. Honestly, she is in charge of herself. Because Reynda has only been living in this facility for a month, she has decided she will not establish any goals until she has lived here for 3 months. She will concentrate on her work, staying clean, and keeping out of harm’s way. That seems like a lot for her to manage for now.
Susan Fields, Sharon Bello’s Case Manager, Entry 3.2
You met me in
Chapter One when I became Sharon Bello’s case manager while she was a client receiving rehabilitation services. She entered the agency with Tom Chapman. He was her first case manager. I was the second case manager that she had. While I was reading about the way that services were delivered, I tried to fit in our work at rehabilitation services with the service delivery presented in this chapter. I think that we operate using a mixed model. The client comes to our agency and our assessment involves lots of different professionals. Once we accept a client for services, the client may receive various services, depending on the client’s needs. And the responsibility of our case management is to coordinate care. The care that each client receives depends on the severity of the disability and what services will be needed to move the client to some type of self-sufficiency. In Sharon Bello’s case, her primary need was education and training so that she could work within her physical limitations. Because of the death of her two sons, she also needed mental health support. Even though we provided Sharon services, once she was in school, she was able to coordinate her own care. We met with her periodically to assure that she was moving toward her treatment goals successfully. Sharon was so motivated to do well and so grateful for the help that we were providing her. By the middle of the case management process, in many ways, she managed her own case.
Voices from the Field
Research and Practice
The Reach to Recovery International Network’s mission is to “improve the quality of life for women with breast cancer and their families” (Bloom, 2011). One online service recently developed in Australia provides a case management function (that of linking with services) to all who visit the website, along with peer counseling and support. An announcement of this new case management-related service follows:
· The Network not only offers members an online peer support network where they can find and connect with others affected by breast cancer but also actively seeks out recommendations from members about support services in their local communities that they have found to be beneficial.
The idea for the Local Services Directory, as it is called, came from members of BCNA. It has been designed to help people find services such as:
· A hairdresser who is understanding and will provide assistance and a private space for a woman who wants her hair shaved because of illness
· A specialist lymphedema massage therapist
· Counseling services that extend to families and to those who have been diagnosed with breast cancer
· Wig and prosthesis suppliers
· Breast care nurses and other health professionals
Local knowledge is key to the success of the Directory, so members are encouraged to submit and maintain their own entries, and service providers can also submit entries for the directory.
Users can search the directory by:
· Keyword, such as wigs, hairdresser
· Categories, such as health services, emotional wellbeing, physical wellbeing, practical support, or products
· Location, such as distance of 3, 5, 10, 30, and 100 km from a specific postcode
The online network is another key initiative that helps BCNA members connect and stay in touch. Members can use the network to:
· Connect with others with a similar experience, regardless of location
· Set up a profile and personal blog to keep a record of their breast cancer journey
· Create and join online interest and support groups
· Use the privacy settings to control who can access their information and the content they create
BCNA has provided these projects as part of the Supporting Women in Rural Areas Diagnosed with Breast Cancer’ Program, which is funded by the Australian Federal Government.
From Online Support Connects Survivors to Services and from Bloom, November, 2011. Retrieved from http://www.reachtorecoveryinternational.org/bloom/issue_10_2011/files/bloom%20-%20november%202011.pdf
Discussing Who Should Assume the Role of Case Manager
After reading about who might function as a case manager, as a class, in small groups, or as an individual, describe one client situation and describe the ways that different individuals might serve as the case management. Use the individuals suggested in
Table 3.1 or others you might like to consider. Describe the pros and cons of each individual who takes on the case management role. Consider what might happen if individuals share the case management role. How would that work? What would be the advantages? The disadvantages?
When you have completed this exercise, share this information with your classmates.
Roles in Case Management, we focus on roles in case management service delivery. These roles help you understand more clearly what responsibilities the case manager and other human service professionals may assume when working with a client.
3-1eRoles in Case Management
Who Assumes the Responsibility of the Case Management? of this chapter, we presented how case management services are delivered and who delivers these services. The methods of delivering case management services represent various combinations of roles and responsibilities assumed by the helper. The responsibilities, described as roles, constitute the tasks—the actual work—that case managers perform when they provide services to their clients.
Topics in Case Management Today describes examples of case managers who are performing those roles (see
Figure 3.2Roles of the Case Manager
speaks on behalf of clients when they are unable to do so, or when they speak but no one listens. The case management process presents many opportunities for advocacy. Working at various levels, the case manager represents the interests of the client, helping him or her to gain access to services or to improve their quality. At the organizational level, the case manager serves as a community organizer who influences the policies that control eligibility and access to services. The case manager also works with the clients within the legal system, helping them make or defend their case. The case manager helps agencies work together to assess the needs of the community and plan how the local human service delivery system will meet those needs. At the legislative level, case managers can work to influence government policies and programs that serve the needs of their clients, which include addressing issues of inequality and discrimination. Case managers also help clients to become advocates for themselves and their families. This is one way to empower clients.
Jim was an advocate for Bryan, a 19-year-old recently admitted to a Veterans Affairs inpatient program for treating individuals with a dual diagnosis of substance abuse and depression. Bryan, a veteran of the conflict in Afghanistan, had participated twice before in a short-term inpatient program, and each time he had returned after 6 months. This time he was admitted after attempting suicide. As Jim, his care coordinator, evaluated Bryan’s history, it became obvious that the previous treatment had not been effective. Jim petitioned the managed care team and the alcohol treatment team to develop an individualized program for Bryan. Jim also decided that the VA standard treatment for individuals with dual diagnosis was not effective. He met with four case managers from three counties. Together, they wrote a paper that outlined more current best practices for the veterans with a dual diagnosis of depression and substance abuse and presented it to the regional director.
, the case manager links the client with needed services. Once the client’s needs are clear, the broker helps the client choose the most appropriate service and negotiates the terms of service delivery. In this brokering role, the case manager is concerned with the quality of the service available and any difficulties the client may have in accessing it.
When Jo Sinclair assumed the brokering responsibilities for her son, Jasper, who had just left an inpatient mental health treatment facility, she found that she needed help. Jo had decided to take a leave of absence from her job so she could provide major support for Jasper. His father had left the home the previous month, and Jasper had had several anxiety attacks. As the broker, Jo arranged appointments for Jasper to see a psychologist, a physician, and a lawyer. When Jo needs professional help, she calls the outpatient facility located next to the inpatient facility. The broker role is a difficult one for Jo because she is unaware of which services are available and their terms of eligibility. Jo would like more help from the inpatient team that worked with Jasper, but team members are restricted because of the fee structure and how services are delivered.
Many clients have multiple problems and need more than one service to meet their needs. In the role of
, the case manager works with other professionals and agency staff to ensure that services are integrated and to expedite service. The case manager must know the current status of the client, the services being delivered, and the progress being made. Monitoring the client’s progress and interfacing with professionals are important roles for the case manager. In this way the case manager can help the client with problems such as ineligibility, seemingly closed doors, poor service quality, and irrelevant services. Case managers also collaborate with other professionals during team staffing and program planning.
Jamie Wolfenbarger assumes the coordinator role for the local hospital’s long-term care clients. In this role, she plans the aftercare for patients who will require long-term care. She coordinates previously unrelated services performed by professionals from different agencies. For Rose Woodson, a patient soon to be released from the cardiac observation unit, Ms. Wolfenbarger has arranged home health care visits once per day, a housekeeper to clean twice per week, meal deliveries at noon each day, and special ambulatory equipment. Ms. Wolfenbarger will contact these professionals each week for the next month for feedback on Ms. Woodson’s progress.
Often an outside professional can help solve case management problems. An organization may need assistance with matters such as cost analysis, quality control, and organizational structure. A
may have the expertise to identify the problem, study it, and make recommendations. Consultants can also assist with the case management of individual clients when special information or expertise is needed. This is especially true in small agencies that employ only generalist case managers.
Ann Marsella is a well-known expert on the treatment of young children with developmental disabilities. She is often called in for consultation on particularly challenging cases. Her expertise is in the legal and ethical aspects of serving these children and their families; she is respected for her ability to clarify a situation’s ethical issues and the logical consequences of the proposed alternatives.
At times, the case manager is asked to perform the responsibility of cost containment in working with the clients and matching client needs to resources available. The case manager is a representative of the agency who follows the cost containment and resource allocation guidelines and an advocate for the client and his or her needs.
Case manager Debbie Palenki is in charge of recommending how to allocate resources for her clients who have been discharged from the hospital. One of her clients has been discharged. The medical staff is providing care for the client in the home of the client’s sister. The medical supplies have already exceeded the $50,000 limit. This includes both physical and mental health care.
The client has been referred to two services, one to address the pneumonia and the other to address the mental health issues. Both of these companies will prorate the cost of services: the insurance company will pay 90% of the services and the family will pay 10% of the services. Debbie helped her client complete the requests for services; otherwise, her client would have to return to the hospital. This case is typical for her and her work as a case manager.
The case manager who is a
or therapist maintains a primary relationship with the client and his or her family. By having a thorough understanding of the client’s mental health and medical history, this professional can tell what aspects of his or her current situation support or discourage progress.
David Tanaka maintains therapeutic relationships with 15 sexual assault victims for whom he also serves as a caseworker. He sees each client once every week for an hour and talks weekly with other professionals involved in each case. These clients were considered high risk prior to the sexual assault. They are enrolled in a special program designed to provide more than crisis care. He expects to retain these 15 clients for the next year, without increasing his caseload.
One of the primary responsibilities of the case manager as
is preparing for the service or treatment that the client is to receive. Planning is directly connected to the findings of the assessment phase of case management. The planner evaluates the client to determine his or her functioning and to assess service provision. Then, the planner compiles data in medical, psychological, financial, social, and vocational areas that inform the implementation phase of case management. This phase includes setting goals, determining outcomes, and implementing the plan with input from the client, family members, other professionals, and other agencies. The case manager’s planning role begins in the early stages of the helping process and continues until services are terminated. Planning may include a transition period that lasts until the client is able to manage his or her own case.
Tony Nix is in her first year as a case coordinator for the state parole board. She works with juvenile offenders after they have been paroled. Her first interaction with her clients occurs before they are released. At this time, she evaluates the status of the client. The evaluation includes a mental status exam, a physical exam, a social history, and an assessment of their family and environmental settings. Then, she develops a plan for their integration into their home environment. One of her greatest challenges is to plan for the first weeks after release because these young people often believe that being released means they can do anything they wish. To solidify their commitment to the stated goals and outcomes, she includes them in the planning process.
The goal of the
is to make clients self-sufficient by helping them determine their strengths, find alternatives to their current situations, and learn to solve their own problems. One area of problem solving is clarifying the roles of the client, the family, the caregiver, and the case manager. Disagreements about services, the direction of case management, or the plan often lead to conflicts. The case manager is continually involved in problem solving; many problems arise unexpectedly, and time must be allotted each day for them.
Sonja McCreless has always admired her direct supervisor, Jim Fitzpatrick, because he is an expert problem solver. She remembers his work with a very difficult client, Sue D’Ambrosio, a scattered and unfocused mother who lost custody of her children. Jim Fitzpatrick was able to work with Sue to determine her own strengths, which included accomplishing very short-term tasks that would demonstrate that she could provide her children with a stable environment. So, he modified the case management process into small tasks while clearly spelling out both of their responsibilities. Together, they decided what the outcomes were to be and what behavior was acceptable, as guided by the restrictions of the program. Components of the work were learning to manage money, making better decisions about her sexual behavior, and controlling her alcohol consumption. Sue responded positively to structured problem solving and eventually learned how to use the process without the guidance of her case manager.
Throughout service delivery, it is necessary to document assessment, planning, service provision, and evaluation. As a recordkeeper, the case manager maintains detailed information relating to all contracts and services. This is important for providing long-term care, communicating with other professionals and agencies, and monitoring and billing for services. Good documentation constitutes the linking element in the case management process. Many electronic systems of information management can help record, track, plan, monitor, and evaluate client progress, but the key is the quality of the data entered. This type of recordkeeping is essential for program evaluation. Agencies and individual case managers can determine if goals are being reached and if quality services are being provided. These data help determine if changes to organization, staffing, or service delivery need to be made.
Eli Brawley works with families and children with severe medical problems. He keeps detailed computer records of his activities. Each client has a file that contains a record of every interaction and action taken for or with that client. This serves as the official record of service delivery, as well as the basis for accountability and quality assurance evaluations. The cases of these children are very complicated. Many of them have received human services since birth. One of the challenges is to keep the record current. Clients work with a variety of professionals (beyond the case management system), and family members do not always inform the case manager about the other services they are receiving.
Want More Information? Roles, Responsibilities, Jobs
The Internet provides in-depth resources related to the study of case management. Search the following terms to read more about how roles of case management are defined:
· Case management roles
· Case management responsibilities
· Case management jobs
Wanted: Case Managers
An increasing number of agencies use case managers to provide services for their clients. The vignettes in this chapter illustrate case managers working with the aging, those with developmental disabilities, youth and adults in the criminal justice system, children and families in foster care, families on welfare, and those in many other settings. Described here are two job announcements for case managers. Let us look at these to see what methods are used and what roles the case managers are being asked to assume.
The state of Missouri provided information about Corrections Case Manager II. In the following box, the information for this position focuses on three questions: What will I be doing? Do I qualify? Will I be successful? The description is found at https://oa.mo.gov/personnel/classification-specifications/5092#class-spec-compact5
Job Announcement #1: Case Manager
What Will I Be Doing?
This is mid-level professional case management work in the Missouri Department of Corrections, Division of Adult Institutions.
Serves on a classification team; evaluates the offender’s institutional adjustment attitude toward society and release plans; prepares Transition Accountability Plans (TAPS); and makes recommendations relative to job assignments, facility transfers, and disciplinary actions.
Secures, verifies, and evaluates information from incarcerated adult offenders concerning their home life, family relationships, work history, and other pertinent personal and social factors; develops, maintains, and reviews classification files.
Assesses classification status and prepares analysis for program eligibility determinations using Adult Internal Classification System (AICS), Reclassification Analysis (RCA), and Initial Classification Analysis (ICA) instruments.
Acts as grievance officer; processes and responds to Informal Resolution Requests (IRRs); and holds disciplinary hearings on conduct violations.
Processes offenders by completing initial file review and protective custody assessment; enters enemy waivers and updates enemy lists.
Maintains open-door office policy; handles offenders’ laundry, property, and financial concerns, as well as mail and censorship notices; and notifies offenders of the critical illness/death of immediate family members.
Participates and assists in the vocational, educational, and social adjustment planning for all assigned offenders; facilitates offender programs.
Evaluates civilian visiting applications and determines whether to approve or deny the individuals request to visit with an offender.
Cooperates with public and private agencies and law enforcement agencies in matters relating to assigned offenders; arranges and facilitates calls to attorneys, public agencies, law enforcement agencies, etc.
Provides pre-release counseling; researches and identifies community resources and services prior to processing offenders for release.
Participates in treatment team meetings.
Performs work in accordance with established rules and regulations; receives general administrative direction.
Performs other related work duties as assigned.
Areas of Interest
Corrections and youth services
Do I Qualify?
(The following requirements will determine merit system eligibility, experience, and education ratings, and may be used to evaluate applicants for Missouri Uniform Classification and Pay System positions not requiring selection from merit registers. When practical and possible, the Division of Personnel will accept substitution of experience and education on a year-for-year basis.)
One or more years of experience as a Corrections Case Manager I with the Missouri Department of Corrections.
A Bachelor’s degree from an accredited college or university with a minimum of 15 earned credit hours in one or a combination of the following: Criminal Justice, Social Work, Sociology, Psychology, Counseling, Education, Political Science, or Pre-Law;
One or more years of professional experience in corrections case management, adult probation and parole, or substance abuse counseling.
(24 or more earned graduate credit hours from an accredited college or university in the specified areas may substitute for the required experience.)
Experience as a Corrections Classification Assistant with the Missouri Uniform Classification and Pay System (work experience in substance abuse counseling or juvenile or social case management may substitute on a year-for-year basis for a MAXIMUM of 2 years of the required education.)
Can I Be Successful?
Intermediate knowledge of the general methods of social casework and job placement as applied to corrections case management.
Intermediate knowledge of the methods of obtaining reliable social and personal information and the development of classification files.
Intermediate knowledge of human behavior, attitudes, and motivation, and their applicability in the rehabilitation of criminal offenders.
Intermediate knowledge of the principles and procedures of offender classification in adult correctional facilities.
Intermediate knowledge of the general techniques of communicating with and advising offenders.
Intermediate knowledge of the methods used in the supervision of offenders.
Intermediate knowledge of the causes of crime and related issues of substance abuse and mental illness.
Ability to conduct effective interviews with hostile or reluctant individuals.
Ability to prepare accurate and complete classification files and reports.
Ability to develop and maintain effective working relationships with other employees, offenders, outside agencies, and the general public.
From Corrections Case Manager II https://oa.mo.gov/personnel/classification-specifications/5092#class-spec-compact5
Job Announcement #2: Case Manager/Administrator
Oversees and administers all aspects of a specialized, community-focused case management program designed to serve the needs of a selected target population. Includes supervision, training, and support of the operational and administrative duties of case managers. Provides case management services to individuals referred from domestic violence shelters. Compiles and prepares educational materials as necessary.
Duties and Responsibilities
Supervises and trains case managers and associated support staff
Administers the day-to-day activities of the program
Oversees the quality of the case management program
Carries a caseload of clients as a case manager
Reviews case management records to evaluate quality
Maintains confidentiality of records
Develops educational materials
Performs miscellaneous job-related duties as assigned
Minimum Job Requirements
Bachelor’s degree in human services, social work, psychology, nursing, or directly related behavioral health field; at least 3 years of experience directly related to the duties and responsibilities specified.
Knowledge, Skills, and Abilities Required
Ability to understand and implement confidentiality policies
Ability to supervise case managers for organizational and time management skills
Knowledge of community resources and how to use them
Knowledge of case management skills and abilities
Ability to gather data, assess information, and write reports
Ability to supervise staff
Ability to prepare reports and other written documents
Ability to foster cooperation
The second job description is for an individual to work as an administrator of a case management service and as a provider of case management services for women and their children who are preparing to leave short-term shelters. This service illustrates case management whereby the case manager is the center point for these services. The case manager will work with the individual clients to determine needs. In this situation, the case manager serves as the link to a variety of needed services, provides therapeutic care, and monitors the efficiency and quality of services. What roles will the case manager be performing? This case manager has multiple responsibilities to plan and problem-solve, write and keep records, coordinate care, and broker additional services. Of course, the job is complicated by these additional administrative responsibilities.
What Roles Are Most Important?
After reading about the case management roles and thinking about the two job descriptions, as a class, in small groups, or as an individual, determine what roles appear to be most important for a case manager. List three roles and make a case for the importance of each role on your list.
When you have completed this exercise, share this information with your classmates.
3-1fTopics in Case Management Today
In the earlier sections of this chapter, we examined the methods of case management service delivery and described the many roles that case managers may be expected to assume. In this section, we present the voices of actual case managers working in social services agencies across the United States. They either identify themselves as having the job title of case manager or describe their primary job responsibility as case management. They may have different job titles, such as caseworker, social worker, family advisor, or behavior specialist. Our study of the interviews we conducted with more than 85 human service professionals resulted in the articulation of eight common topics. These topics help describe what they do and what they need to know how to do to be effective case managers. The topics respond to the complex and sometimes difficult situations case managers encounter as they cope with large caseloads, clients with multiple needs, and scarce resources. In addition, case managers often work with clients who are silent, reluctant, or resistant in a bureaucracy that requires detailed documentation for each interaction. The eight topics are:
the performance of multiple roles;
ethical decision making;
critical thinking; and
personal qualities (see
Reading about these topics and case manager experiences helps put a realistic “voice” to both methods of human services and roles and responsibilities.
Figure 3.3Case Manager Themes
Performance of Multiple Roles
Every day when case managers work with their clients, they perform multiple roles, including advocate, broker, coordinator, planner, and problem solver (all discussed earlier in this chapter). It helps to be a
Jack or Jill of all trades
Many helpers combine the planner, broker, and coordinator roles into an intensive case management function and assume responsibility for determining the real issues, developing care plans, finding resources, and coordinating care among other professionals. Problem solving is often part of case management, and occurs when everything is going smoothly as well as when there is a crisis. Problem solving requires a plan A, a plan B, and a plan C, if necessary. For many helpers, the final goal of managing cases is self-sufficiency or the resolution of issues for the client.
Advocacy, introduced in
Chapter One and discussed in detail in
Chapter Twelve, is an example of the complexity of roles in case management. One interviewee suggested that “services begin with advocacy,” and another described the advocacy role as a means to “instill in clients what is best for them.” Advocacy occurs when case managers are fighting for quality services for their clients, helping families treat their members fairly, working with agencies and other bureaucracies to serve clients better, and supporting clients “when they can no longer even support themselves.” One helper’s approach to advocacy was “to teach clients how to deal with their problems … how to deal with the system.” On another level, interviewees defined advocacy for the agency as fighting for resources, attracting clients, and representing the agency. At the beginning of
Chapter Eleven, Jessica will talk about being passionate about her work and helping the children with whom she works. She feels incredible support for this advocacy from her supervisor and her agency.
The successful case manager is the professional who has multiple skills and is able to use them as needed, sometimes simultaneously. The complexity of a particular role, coupled with other job demands, often makes this especially challenging.
Several case managers emphasized the importance of
, and they mentioned the disasters that can occur when professionals are not organized.
The job and the work are incredibly complex: it is like a crystal chandelier, with so many pieces working together to give light—or, in this case, help. Yet it is so fragile. You think that you have stability, but within each case there are 10, 20, or more pieces—and if you have 30 cases, well, you are constantly juggling all of the responsibilities.
They are also aware that if they are not organized, then it is their clients who will suffer. For them, being organized means managing time and completing paperwork.
Susan Fields, Sharon Bello’s Case Manager, Entry 3.3
By now, I am sure you know that the section about being a “Jack of all trades” and being organized in my work strikes at the heart of my work. The nature of my work as a case manager means having lots of responsibilities: you have heard me talk (in
Entry 3.2) about my work, especially about coordinating care. I have other responsibilities, too, such as determining eligibility, conducting intakes, developing goals and priorities with the client, developing plans and interventions, and monitoring client progress. Of course, there is always formal and informal assessment, making referrals, and working with our staff teams and my supervisor.
Because I inherited Sharon’s case from Tom Chapman, I have not performed all of those roles. But with all of my work I try to be organized because my client load is high. And all of my clients are at different stages in the case management process. For instance, I am coordinating Sharon Bello’s care. And we are not near her end of services. My job with her is primarily monitoring. I also have 10 clients who are applying for eligibility, 5 who have been deemed eligible and I have to begin the intake process, 15 who are at various stages of planning, and 53 who are involved in vocational training and receiving other services. I am ending services for 28 clients right now. When I write this down, sometimes I can’t believe it!
What helps me manage all of this is a new computer system that I share with all of the other case managers and staff. We worked hard to develop a system where information only has to be entered once. If information changes, then we revise. We also have an office manager and several staff who help make my schedule. What works against this is, with several of us scheduling my time, well, it gets wild. Sometimes I am double scheduled and other times there are crises that I must attend to. Yesterday, one of my clients got hurt at his training site. During the day, I coordinated his care and filled out the paperwork; last night, I visited him in the hospital. But yesterday I was also scheduled to see six clients for their bi-monthly visit. All of those visits had to be re-scheduled. Thank heavens for such good office staff.
We talk about the concept of time in the next section. All I can say about my time is that it is too fast and too slow all at the same time. Or maybe I should say it goes quickly but I am still too slow to get everything done! My day is so fast-paced that my mind and body demand a break at the end of the day. Even though I do not have a moment to myself, it feels good to be working hard to help our clients.
The Concept of Time
The concept of time influences case management in a variety of ways: organizing, budgeting, scheduling, responding, balancing, and slowing down. Case managers recognize the need for time to “let things percolate,” “sit down and remember everything that was done during the week with that client,” and “take one step at a time.” Even though time management was consistently mentioned as a tool to alleviate stresses and pressures, many admitted that the workload is so “horrendous” that they never gain control over their work situations. They say that they are so busy that they do not have time to seek a resolution to a client’s problem. One participant said, “Clients have to come to me.” The difficulty with time management arises from several sources, including the unpredictability of the workday, external deadlines, and the ever-changing bureaucracy.
Topics for case managers (Woodside, McClam, Diambra, & Varga, 2012) related to the meaning of time center around pace, change, choices, and service delivery. All four of these topics relate to different facets of the work: the agency, the human service professional, and the client. Case managers talked about how their work on each level is significantly impacted by time as it relates to the “never-ending” pace of demands and pressures in their work; the “now and then” aspects of changes in protocol and policy over time; the “influence of time” on decisions about agency availability, caseloads, and policies; and the “one step at a time” notion of service delivery relating to repeated services and goal setting with clients.
For example, in the life of the case manager there is a “never-ending” tempo, as described in the previous quote; the work is constant and the clients and the needs they present are at times overwhelming. Case managers describe their work in terms of how to “fit it all in,” having too much to do, and responding to crises. In addition to the workload, there is a constancy of pressure within the job. Case managers talk about “the work as ‘day after day,’ ‘one right after another,’ ‘happening over and over again,’ and ‘never ending’” (Woodside et al. 2012). The scheduling alone is intense. Another case manager decried, “It is horrible. It is awful. It is terrible. It is a slave [driver]. I wish they would have 24 hours that I can work. It is not enough.” In
Chapter Twelve, we talk more about time management and guidelines to use when balancing such a large workload.
Discuss Your Organizational and Time Management Skills
Some individuals find themselves holding their breath just reading the section on managing time and completing documentation. Wow! A case manager’s job is fast-paced and demanding. And it is clear that good time management and organizational skills are important for the job.
As an individual, think about your strengths and limitations related to both of these topics. Answer the questions about yourself and your past behavior and emotional responses to the following situations.
List three times or situations in your life when you felt you had too much to do and not enough time to do it. For each time or situation, answer the following:
· What created this situation? Did you anticipate life being so fast-paced or seemingly impossible?
· What was your emotional response?
· How did you manage your time? What were the strategies you used?
· What was the outcome?
List three times or situations in your life when you were either extremely organized or completely disorganized (choose at least one of each). For each time or situation, answer the following:
· What created this situation? Did you anticipate life being incredibly structured or so disorganized?
· What was your emotional response?
· How did you manage the situation? What were the strategies you used?
· What was the outcome?
Discuss your responses with your classmates. Follow-up the discussion by reflecting on your responses in terms of being a case manager.
Paperwork and Documentation
Completing paperwork or documentation is another organizational skill that case managers practice daily. They understand the purpose of the paperwork that flows through their offices and its importance in building records, making requests, accounting for expenditures, documenting a “client’s whole life on paper,” jogging the memory, and providing an audit trail. The documentation they describe includes initial assessments, family histories, psychosocial assessments, contact notes, goals, service plans, and evaluations. Many of these are discussed in this text, especially in
Chapter Six. The extensiveness of paperwork is illustrated by the following quote:
We have to keep copies of all of our records and the files become almost unwieldy. Right now, by law, we keep information on the computer, the server. We also keep hard copies of all official records such as birth certificate, Social Security card, Medicare card, Medicaid card…. Last year our server went down and we were without our records. We hired a company to retrieve the data for us and we got back all but 1 week. It was a crisis and a wake-up call.
These professionals face the dual challenge of knowing how to write reports and how to find time to do their paperwork. In addition, they struggle to “set up a work space where you can find … 5000 pieces of paper needed at any moment.”
Organizational skills, then, pervade each day’s work providing case management services. Even though many helping professionals choose this field because of the client contact, they are often surprised at the responsibilities of case managers, including the required documentation. Case managers who fail to master organizational skills experience overload, frustration, and eventually burnout, which forces many to leave the profession. Organization (of time, paperwork, caseloads, daily schedules, and emergencies) is a critical survival skill.
Katie describes how she organizes her work as a case manager.
I kind of have an organization problem. I feel like I’m borderline obsessive compulsive with stuff like that. So, I have my different folders for different things. I have my case management folder, which has a face sheet for all of the kids that I’m working with and some of their basic information in case their school needs it. Things like their medications and contact numbers and also the goals that we are working on. I also have a place to keep things that we are working on together. For example, if we are doing worksheets or whatever the case may be, it’s all there in my notebook. I also have separate folders for my paperwork, like my productivity numbers, my mileage. Also, I’m very diligent about keeping up with my schedule. If I don’t write something down, then I will forget to do it and it doesn’t happen. I know my schedule a week ahead of time, at least, so I do my schedule for the next week, including when I am going to be at which school, and I already have home visits scheduled. My planner is also color-coded, so I have certain colors for school visits and certain colors for home visits and certain colors for office work I have to do. It gets kind of ridiculous but that’s what I do.
—Permission granted from
Katie Ferrell, 2012, text from unpublished interview.
The case managers we interviewed claimed that “communication is more important than any other skill” and is tied directly to establishing a helping relationship, assessing needs and situations, and selling and persuading clients. Central to these results are the
of listening, questioning, and persuading.
These case managers talked about “really listening” to what is being said by the client to establish a helping relationship, identify problems, and move through the case management process. For them, bonding is an important part of the helping process because the case manager must get clients’ “trust … so they will tell you what the real problems are.” Without this relationship, clients are less likely to accept services or to continue to reach out over a long period. Case managers form strong attachments to their clients; several agencies support clients through death, and case managers can be involved in arranging and attending funerals and “sharing grief with the family.”
Good listening helps these case managers understand and evaluate what the client is saying (e.g., “Is the client telling you about the real problem?”). Listening also makes a therapeutic contribution to the client’s progress: “Often times a client will start talking to you and … will ask … questions and answer the questions in one breath.” Listening helps some clients let off steam. In other instances, clients have multiple problems that are jumbled together. “You can listen so you can see questions that will help them be more clear about what they mean.”
Questioning is another communication skill that facilitates the assessment process. It involves “gathering information from lots of people,” “assessing people’s needs,” and “figuring out what is important and what is not.” Interviewees discussed the art of questioning, emphasizing asking “the right questions” to gather information for social and client histories, needs assessments, and intakes. Questions enable case managers to “look in every corner,” assess the situation as well as client needs, and make appropriate decisions regarding case management (we discuss questioning in
To persuade clients to become involved in receiving services and to be active in their own self-care is an important communication tool. Sometimes case managers have to “sell the mother on letting her daughter be independent” and “sell parents whose children are involved in the criminal justice system on helping the case manager.”
Clients today are consumers of services, because many of them, under the auspices of managed care and other funding models, are able to choose where they will receive the services to which they are entitled. In other words, “it goes back to client choices … it is the consumer’s choice to participate.” Therefore, some agencies find themselves competing with other agencies for clients, so they spend time convincing clients to come to them for services.
Communication with other professionals is also viewed as a valuable skill (discussed in
Chapters Ten and
Eleven). Networking is an important tool for finding resources for clients. Having a good relationship with other professionals and knowing which person or agency to call for help ultimately benefits clients. A second part of communication with other professionals involves relating to other staff, especially other team members. For most of these case managers, working with their colleagues is “pretty family-oriented, everybody is really close.” These professionals use each other for support so they do not feel “they are just hanging out there” alone. They are also working on problems that demand “getting a lot of heads together” to solve problems. For many case managers, the following quote summarizes the feelings they have about the people with whom they work: “I have survived these past two and one-half years … [by] establishing a relationship with my team.”
Case managers also mentioned setting-specific knowledge as critical to their job performance. This includes general skills, such as typing and computer usage, as well as more specialized knowledge (e.g., medical terminology, medications and their side effects, drug regimens). For others, a thorough understanding of human behavior, psychosocial issues, and various helping methods form a basis from which to work with clients, make assessments and recommendations, and develop plans. Also important is knowing how systems, such as Medicaid, probation, child welfare, and housing, help the case manager support the client’s interaction with other agencies and services. Finally, many helpers believe that “street smarts” are essential for case management. Street sense allows case managers to provide realistic assistance to clients very different from themselves. We discuss this setting-specific knowledge related to culture in
Ethical Decision Making
Another case management skill discussed by the case managers who participated in this study was
ethical decision making
Chapter Four). They must be able to identify ethical issues (e.g., self-determination, confidentiality, and role conflict), to ask the questions that surround the issues, and to make appropriate professional responses. One case manager summarized the issue of self-determination this way: “People have the right to poor judgment…. We can educate them, but we can’t take away their rights.” The case managers interviewed gave many examples of incidents in which, in their opinion, clients made bad choices. Clients refused services, chose to retain independence rather than receive complete services, refused medications, ate poorly, returned to abusive situations, and violated parole agreements. Case managers often described their frustration when clients refused services or did not heed sound advice, but they were passionate about the rights that clients have to determine their own destinies.
One ethical dilemma concerns confidentiality. For many of the case managers we interviewed, there is often a question of what information goes into a report and what should be omitted. Another issue of confidentiality emerges as computers are more widely used. One case manager expressed a hope that computer security is receiving the attention that confidentiality demands. This concern was addressed in
Chapter Four. Another issue for those whose agencies serve immigrants is the legal status of the individual. Is the person in the United States legally? If not, then should you report it? One case manager simply doesn’t ask. Another dilemma that case managers describe, related to roles, confidentiality, and boundaries, is how to use social media. Some indicate that social media is just a way of life for them and they use it on the job. Other case managers are more reluctant and see social media strictly as a personal communication tool.
One of the most difficult dilemmas that case managers face is role conflict. They describe it as “working both sides of the fence,” “walking a thin line,” or “protecting two sides.” When role conflict occurs, case managers are asked to assume dual responsibilities that may be at variance with one another. One helper shared a role conflict she encountered as a parole officer. The parole officer’s primary responsibility is to support the parolee’s life outside the prison environment. If the parolee “messes up,” then the parole officer becomes the prosecutor. This type of conflict makes it difficult to maintain a supportive, trusting relationship with a parolee after the prosecution (these issues related to ethics are discussed in more detail in
Surviving the intensity of helping was a concern to the case managers in this study. They felt it was essential for the case manager to establish
between self and client. One helper explained, “You have to watch yourself because you get too attached to clients.” Another elaborated: “You have to have an idea of your own boundaries and what your issues are. You don’t want to get yourself confused about what is going on…. Sometimes it’s helpful to step back and ask, ‘Whose problem is this?’” Even though case managers work hard to establish boundaries between themselves and their clients, they still agonize over their clients and the difficult situations they face. One interviewee described it as “close detachment.” One case manager described her reactions to client problems as follows: “Sometimes I have had to go to the restroom to cry for a few minutes because it was a really hard case.” Many workers even dream about their clients. These professionals are committed to handling boundary issues and recommend “staying realistic” and “leaving work at work.” Again, several case managers explored being “friends” with clients and being careful to screen their friends. But they also see that clients have access to information about them just because of their online presence. One case manager summed it up by saying, “It’s complicated.” We discuss ethical issues of boundaries in
Chapter Four. In
Chapter Twelve, we describe the harmful effects that may occur as case managers work with clients and suggest ways to promote wellness and self-care.
The effective case manager is one who needs to think critically and clearly. One of the
skills needed is “seeing the whole in addition to individual, narrow parts.” Because individual cases are so complex, there is a danger of focusing on the details and “not seeing the forest for the trees.” For one case manager, critical thinking is “being able to procure and digest a large body of information from different people” and then determining the real issue. The existence of underlying issues means that case managers are “detectives” who are able to ask the right questions, not take things exactly as they are presented, conduct continual evaluations, and assess communication as it is happening. Helpers then “put it all together to get a better picture.” Interviewees suggested that using their years of experience, tuning into their insight, “going in with a clear mind,” and “performing a reality check—my fantasy versus reality” all enhance their critical thinking abilities. Using critical thinking is important in much of the case management process.
The people we interviewed identified a number of personal qualities that enable a case manager to be effective, including
. Two interviewees likened the desirable personal qualities to those of a fairy godmother and a chameleon.
Flexibility was a consistent recommendation. Constant interruptions to the plans for the day, unpredictable and emergency client needs, interviews conducted under unusual circumstances, and interactions with different clients and professionals who demand different styles are examples that illustrate the need for flexibility. Case managers also need to be “firm” in communications and “soft” at other times. One participant explained, “I just kind of roll with the punches. Whatever needs to be done, I just do it.”
The ability to form good working relationships with clients is essential. For some case managers, this is carried to an extreme of “somehow being reasonable to the point where you can no longer be reasonable.” Others describe it as being tactful and respectful of others, “going out of the way to communicate with others,” and “taking time with people.” The case manager is in a people-oriented field, and whether working with clients or other professionals, it is important to “be able to talk with people and get along with them.”
Another necessary quality for case managers is patience. One participant described her willingness to “take one step at a time” when working with her clients. According to these case managers, it is sometimes difficult to be patient. They reported that they remind themselves and their colleagues of the importance of “being able to let go and wait.” Part of patience comes from being realistic, including having realistic expectations for clients. These helpers also realized that “when you are allowing clients to learn to help themselves, you cannot be in a hurry.” A second factor in patience is persistence. For many professionals, “you just keep plugging.” They acknowledge the difficulties and the resistance encountered from both clients and bureaucracies during the helping process.
Self-esteem provides the foundation for many of the difficulties encountered in case management. According to participants, “you must have self-confidence.” It helps to maintain a positive perspective when things do not go well: “You realize that you will get over it [failures] and things will move on.” This confidence also fosters
when dealing with other professionals or resistant clients. One special challenge of working with other professionals is the bureaucratic hierarchy; many higher-ups do not acknowledge that case managers have important professional contributions to make. Self-esteem also helps them assume a leadership role when it is required and (as you will read in
Twelve) leadership is required more often today. These case managers recognized the need to assume authority to accomplish their goals.
Finally, according to participants, case managers need to have both a “sense of adventure” and “excitement” about their work. Terms like anthropologist, private eye, and detective described the challenges of case management: Human services providers must accurately identify problems, develop service plans to meet client needs, provide and seek out services, and evaluate the process. For many, the challenges are stimulating, not depressing; these people thrive on working in a demanding, fast-paced environment.
What Are Your Strengths or Personal Qualities That Will Support Your Work as a Case Manager?
As an individual, spend 10 minutes brainstorming all of your strengths or personal qualities or characteristics. Write as many as you can and do not pause to reflect about them. Then, using
Table 3.2, review your strengths. Review the skills and personal characteristics discussed in this section. For each skill or personal characteristic, identity the strength, quality, or characteristic that supports it.
You may wish to share the results of this exercise with your classmates.
The importance of the multicultural perspective for all helping professionals cannot be overstated. For several reasons, this is especially true for case managers. First, the basic values that guide the case management process are linked to support advocacy as a form of social justice, right of self-determination, and empowerment for diverse populations. Case managers are committed to knowing their clients from a holistic perspective and understanding the individual issues and context that they bring to the case management process. Because of this commitment, it is essential for the case manager to attend to the ethnic and cultural dimensions of who the client is, the experiences the client brings, and where the client wishes to go at the conclusion of the process. In
Chapter Five, you will learn more about multicultural case management and begin to gain the knowledge you need to be a sensitive and effective multicultural case manager. As you learn more about the cultures of various client populations, you will begin to understand the importance of using a multicultural approach to foster social justice and advocacy, and how power, oppression, and prejudice influence the client’s identity and experience. Specifically, you will gain knowledge about specific populations related to race, ethnicity, gender, and other groups.
In the following chapters related to implementing the process of case management, we highlight implementation performed in a culturally sensitive way.
We confirm the importance of the multicultural perspective because it pervades each of the methods of case management presented in this chapter. We encourage you to give special attention to this critical aspect of your role and responsibility as a case manager.
Deepening Your Knowledge: Case Study
This chapter focuses on the methods used to deliver case management. The case study in this chapter reflects one aspect of human services: providing effective services for individuals involved in drug-related crimes. These efforts result from the Anti-Drug Abuse Act of 1988, an act that established the White House Office of National Drug Control Policy (ONDCP). The ONDCP’s mission is “to establish policies, priorities, and objectives for the Nation’s drug control program. The goals of the program are to reduce illicit drug use, manufacturing, and trafficking, drug-related crime and violence, and drug-related health consequences” (U.S. Department of Justice, National Drug Court Institute, 2011, first paragraph). Goals for the drug court programs include decreasing “illicit drug use, manufacturing, and trafficking, drug-related crime and violence, and drug-related health consequences” (U.S. Department of Justice, National Drug Court Institute, 2011, first paragraph).
Case management for clients involved with the drug court is the centerpiece of intervention services. According to Monchick, Scheyett & Pfeifer (2006) in a report published by the Department of Justice, “Case management is essential to carrying out the mandate of the key components of drug court. Without case management, the integration of AOD treatment services and justice system processing would be limited” (p. ix). Read through the Key Components of Case Management described in Drug Court Case Management: Role, Function, and Utility while keeping in mind the methods of case management described previously. Then, answer the questions that follow.
Key Components of Case Management
#1: Drug Courts Integrate Alcohol and Other Drug (AOD) Treatment Services with Justice System Processing
This component highlights the necessity of a multifaceted, collaborative “team” approach for integrating the delivery of services into the administration of justice and enhancing the justice and treatment systems’ joint mission of promoting abstinence and law-abiding behavior. It underscores the need for collaborative goal setting and program monitoring through ongoing communication and continuous processing of timely and accurate information about each participant’s performance in the program. It is the case manager who coordinates the flow of drug court information across and within the treatment and justice systems.
#2: Using a Nonadversarial Approach, Prosecution and Defense Counsel Promote Public Safety while Protecting Participants’ Due Process Rights
The case manager assists in keeping these traditionally adversarial parties focused on the primary purpose of the program: the participant’s movement toward fulfilling his or her recovery plan. As an advocate for the participant’s recovery, the case manager supports due process, ethics-based and strengths-based treatment, and confidentiality while simultaneously promoting individual accountability and community safety. It is in this sense that the case manager helps bridge the traditional gap between the coercive traditions of justice, the protection of the public, the privacy mandates of treatment, and respect for individual rights.
#3: Eligible Participants are Identified Early and Promptly Placed in the Drug Court Program
The case manager helps ensure the coordination of this process by “tracking” and facilitating the prompt sharing among the team of all relevant information arising from the initial referral, eligibility screening, and assessment process.
#4: Drug Courts Provide access to a Continuum of Alcohol, Drug, and Other Related Treatment and Rehabilitation Services
The case manager identifies and monitors each participant’s unique needs for support and rehabilitation services, coordinates participant access to these services, and ensures linkage and coordination among the drug court service providers. The case manager works closely with the clinical treatment provider(s) and community supervision officers to provide ongoing assessment and communication of the participant’s progress and to coordinate referrals to appropriate ancillary service providers.
#5: Abstinence Is Monitored by Frequent Alcohol and Other Drug Testing
The case manager ensures that drug test results, whether obtained by probation, treatment, law enforcement, or other court partners, are promptly and accurately recorded and disseminated to the drug court team.
#6: A Coordinated Strategy Governs Drug Court Responses to Participants’ Compliance
As the central person responsible for coordinating team information flow, the case manager tracks and monitors the court’s allocation of sanctions and incentives to each participant to help ensure that subsequent sanctions, incentives, and interventions are graduated, treatment-relevant, strengths-based, and otherwise consistent with the program’s philosophy.
#7: Ongoing Judicial Interaction with Each Participant Is Essential
As the primary link between the treatment and justice systems, the case manager serves as the bearer of much participant information and, in this role, can give critical insight and input to the drug court judge.
#8: Monitoring and Evaluation Measure the Achievement of Program Goals and Gauge Effectiveness
The case manager ensures that all relevant information is accurately, promptly, and systematically documented so that ongoing monitoring of the participants and evaluation of the program can occur.
#9: Continuing Interdisciplinary Education Promotes Effective Drug Court Planning, Implementation, and Operations
Because the case manager deals daily with clinical and ancillary service providers as well as justice system partners, he or she is well situated to facilitate interdisciplinary education within the drug court team. In some jurisdictions, case managers integrate interdisciplinary training into drug court meetings by periodically enlisting an ancillary service provider or justice system professional to address the team and, if appropriate, participate in the staffing process.
#10: Forging Partnerships among Drug Courts, Public Agencies, and Community-Based Organizations Increases the Availability of Treatment Services, Enhances Drug Court Effectiveness, and Generates Local Support
While all drug court team members contribute to the formation and maintenance of these critical partnerships, it is the case manager who sustains ongoing contact with key line staff of the partnering agencies and organizations. This consistent and direct contact with other community-based service delivery professionals puts the case manager in a position to learn about the policies, procedures, capacities, strengths, and limitations of existing support service organizations. With this knowledge base, the case manager is well positioned to identify service gaps and community needs, and to offer strategies to facilitate collaboration between the court and the community.
Case Study Questions about the Drug Court
1. Read each of the Key Components. Explain how each component relates to one or more methods described in Chapter Three.
2. List roles needed to perform each Key Component.
Author Note: We think that it is important for you to review the chapter you just read. We suggest the following.
· First, re-read the class discussion questions in the text and answer these as comprehensively as possible.
· Second, once you complete the discussion questions, review the
Chapter Summary, define the
Key Terms, and answer the questions in
Reviewing the Chapter.
· Third, make notes of what stands out for you during your review. Also, record any questions that you might have.
· Finally, take time to discuss the Questions for Discussion with another class member, either face-to-face or online. Answering these questions with a peer will help you solidify the understanding you have of the contents of the chapter.
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