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, wha
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.
Chapter 2:
Historical Perspectives on Case Management
Chapter Introduction
· 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—From Sara Bergeron, 2012, text from unpublished interview .
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.
2-1Introduction
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 deinstitutionalization : 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.
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.
Class Discussion
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.
Client Involvement
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.
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.
My Story
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.
Class Discussion
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.
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