Managing to Care

Ann Dill

• Publisher: Routledge
• Year: 2017
• eBook ISBN: 9781351507158
• Topic: Politics & International Relations
• Subtopic: Social Policy
• Index: Politics & International Relations

The point of departure for Managing to Care is widespread concern that the present delivery of health and social welfare services is fragmented, uncoordinated, inefficient, costly, wasteful, and ultimately detrimental to clients' health and wellbeing. Dill traces the evolution of case management from its start as a tool for integrating services on the level of the individual client to its current role as a force behind the most significant trends in health care. Those trends include the entrenchment of bureaucracy, the challenges of once dominant professions, and the rise of corporate control. The author's purpose in adopting this analysis is to invite further scrutiny of the case management profession, and at the same time to identify new possibilities for its application.This volume brings together thoughts developed over many years of observing and participating in case management programs. It provides a multilayered perspective of case management, showing linkages among its social and historical contexts and the ways it is practiced today in diverse service settings. The author emerged convinced about the essential need for care coordination, and that present ways of providing care can work against our highest objectives in doing so. The paradoxes and contraindications embedded in case management practice became a major theme of the book.Managing to Care is highly critical of the ways case management has come to absorb and reflect the organizational flaws of the very service systems it was intended to reform. Too often management of the case comes to dominate care. The author does not call for a rejection of professional systems in favor of a resurrected informal community. While much can and should be done to strengthen our ties to one another, there will always be people whose problems require more expert help. Dill argues here that case management can provide such help, and provide it well, but only if it is grounded in the human dimension of a caring relatio

1
Introduction

What Is “the Case,” and Why is It Managed?

Forged in response to social problems of human suffering, poverty, and distress, America’s systems of health care and social welfare have themselves become social problems. Reforming those systems has led the domestic policy agenda and dominated front-page headlines throughout the past decade. National opinion polls in the 1990s found more Americans naming health care as the most important problem facing the country, save crime and violence, while the issue of welfare topped taxes, the environment, the trade deficit, and the international situation as an area of primary concern (Gallup, 1994). At its core, the public’s sense of the problem is that these systems are out of control and we are paying for it, individually and collectively, with our money, our well-being, and even our lives.

The charges against human services are profound: that they are ineffective or inefficient, fragmented, uncoordinated, wasteful, and not affordable. The problems of service systems are also closely tied to much broader social concerns and controversies. Some of these address the actions of “players” and “payers”: the role of the government versus the market; the administrative costs of insurance; the threatened autonomy of professional providers; the motives behind managed care. Yet others center on care recipients: Which groups are deserving and more (or more truly) needy than others? Which should be ineligible for a piece of the public pie?

The recent rounds of public debate on these issues rekindle much longer standing areas of discontent with the design and operation of human services. Over the three decades since present systems emerged from Great Society initiatives, policymakers, public administrators, and the public at large have actively pursued an array of programs attempting to bring those systems in line with desired goals. While the goals themselves have varied, from access and continuity in the 1960s and 1970s to coordination and cost constraint in the 1980s and 1990s, the constant expectation has been that the right reconfiguration of service systems can produce the right outcomes.

Case management has appeared throughout those decades as part of efforts to bring service systems into order and under control. Initially and still basically a tool for integrating services on the level of the individual client, case management has become a means of coordinating and rationalizing service delivery, rationing service resources, and constraining the costs of care. Short of the caring disciplines themselves, it is hard to think of a practice more widely distributed or accepted: In programs as diverse as public assistance, Medicaid, long-term care, mental health services, child welfare, care for people with AIDS, orthopedic rehabilitation, and services for the homeless, case management has become a fixture on the service landscape. It has found its way into health care and welfare reform proposals from proponents across the political spectrum and almost certainly will be central to any measures eventually adopted in the political arena. It would be easy to explain such remarkable and persistent popularity if case management were a clearly defined practice with a winning track record. This would require definite and agreed-upon standards about what it is, who should do it, and how it should be structured within particular organizations, as well as demonstrated success at achieving stated outcomes. Yet none of that is the case.

There is little consensus about the essential ingredients constituting case management, within, let alone across, service sectors. In long-term care, for example, there are presently no uniform state or federal standards for its practice, and three separate professional organizations have each developed standards which fall short of including specific performance guidelines with measurable outcome criteria (Geron & Chassler, 1994). In addition, case management has taken a variety of forms in different settings within and across sectors. In fact, the organizational structures, procedures, and personnel used under this rubric have been so diverse that one commentary in the mental health field likened case management to “a Rorschach test” onto which “an individual, agency, or a community will project … its own particular solution to the problems it faces…” (301, p. 1006). Because of this, it is difficult even to offer a comprehensive definition of the practice.

Moreover, the overall results of case management programs are consistent only in being strikingly ambiguous. In sector after sector, evaluation research outcomes vary from study to study and show at best modest gains from case management programs, often with offsetting deficits. Though assessing such outcomes is notoriously subject to bias from project and research design flaws, equivocal results emerge even from sophisticated, randomized control evaluations. Similarly, little conclusive evidence has accumulated about which forms or models of case management produce the best outcomes. Even the most systematic, experimental efforts to compare different types of programs yield few outcome differences, and those are as likely to disappoint as to validate the advocates of different approaches.

Why, then, has case management achieved such sustained and ubiquitous expansion as a feature of service systems? What accounts for the differences that have developed across and within service sectors? In what ways do case management programs accomplish their goals, and what helps them succeed? What happens when they fail? I contend that answers to these questions can be found by examining case management in social and historical context; that is, by understanding the social forces leading to the development of case management, the historical dynamics shaping it in particular sectors, and the social and organizational contexts in which case managers practice.

Case management has been the object of attention in the most significant trends in American health care and social welfare in the past quarter-century. It has also been one of the driving forces propelling those trends. These include the evolution and de-evolution of public bureaucracies; the challenging of once dominant professions; the shift from centralized institutional structures to community-based care; and the rise of corporate control, privatization, new technologies and professions, and managed care. To understand how case management has developed over time and in different sectors, we need to see it through a pinhole view of these forces transforming our human service systems and shaping particular programs. In turn, analyzing case management in this manner opens to scrutiny often taken-for-granted aspects of its practice and can help identify new possibilities for its application.

My purpose in this book is to explore the social history of case management strategies in order to examine critical service system issues and assess how case management practice reflects the social forces affecting systems, programs, and providers. I am particularly concerned with the symbolic as well as the structural basis of case management; that is, how the concepts, ideologies, and norms that define case management programs and practice are related to those shaping organizations, social systems, and society at large.

I have chosen to focus on three sectors which have relatively long histories of case management and which include among them particular case management approaches representing the range of practice found in other areas: long-term care, mental health, and welfare. Chapters 2 through 4 present historical and case study accounts of case management in each of these sectors. A major purpose in each chapter is to reveal the connections among the forces promoting case management programs, the historical environments in which they have developed, and the daily experience of case managers and their clients. To focus in on this last level, I draw from firsthand research on case management programs in each sector. This enables a comparative analysis of the dominant case management form or approach found in each: the “brokerage” model in long-term care, the “therapist” approach in mental health services, and the “gatekeeper” form of service management in welfare programs.

Looking across these sectors then prompts an examination, in Chapter 5, of recurrent issues in case management practice, program design, and standards. This review of other arenas—including care for people with AIDS, corporate programs, third-party payers, and private practice case management—leads to a critical discussion of the reasons for case management’s continued popularity. Analyzing case management comparatively also opens to scrutiny what are often taken-for-granted aspects of its structure, and in particular the way it has been linked to the structures of gender, class, and race embedded in service systems. The chapter assesses the reasons for these connections and their significance for social policy and program design. Finally, the chapter explores the parallels and links between case management and managed care, illustrating as well the transformation in case management objectives from social casework to service management.

Chapter 6 concludes the book by assessing the strengths and limitations of the case management approach to service coordination, as well as ways in which it can be combined with broader-scale attempts at policy reform.

Before turning to the specific forms case management has taken in diverse sectors, we need to understand at a general level what it is and where it has come from. While it is difficult to offer a uniform definition of case management practice, it is possible to discern certain features crosscutting its diverse populations, goals, and structures. Similarly, the logic, objectives, and norms guiding case management in different settings have a common legacy in the origins of service systems. The next sections thus provide an overview of the distinguishing features and historical development of case management.

What is Case Management?

An intervention using a human service professional to arrange and monitor an optimum package of services … (Applebaum & Austin, 1990, p. 5)

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. (356, p. 2)

A problem-solving function designed to ensure continuity of services and to overcome systems rigidity, fragmented services, misutilization of certain facilities and inaccessibility. (JCAH, 1976)

As these definitions imply, case management is less a concrete program than a service, a technology, a system, and a process (Bower, 1992). As a service provided to individual clients, case management includes many objectives: increasing their access to formal services, informing and assisting their decision making about service options, ensuring service continuity and integration, overseeing service effectiveness and productivity, and providing a human link to often impersonal systems.

Case management also encompasses the technology necessary to work toward those objectives. This includes the information, record-keeping, administrative, and evaluative systems needed to time, sequence, and coordinate complicated service programs for clients both individually and as a caseload. Not the least important component of case management technology is the role of case manager, the practitioner who (whether individually or as part of a team) bears the responsibility, authority, and accountability for managing the care of clients.

As a system, case management’s functions encompass case identification, needs assessment, care plan development, service implementation and coordination, monitoring of clients and services over time, periodic reassessment of the client’s condition, and adjustment or discontinuation of the service plan as appropriate. Regardless of the structure or components of specific case management programs, it is these functions that together comprise the essential elements of case management practice.

As recognized recently by the National Advisory Committee on Long-term Care Case Management, any one of these functions performed separately may be necessary to the success of a case management program, but does not in and of itself constitute that practice. The committee also acknowledged, as have previous analysts, that case management can also incorporate other functions to a greater or lesser degree, depending on the objectives to be served and the context of the program; these include outreach to identify clients, crisis intervention, counseling, advocacy on behalf of the client, and service development, or “class advocacy” (Geron & Chassler, 1994; see also Raiff & Shore, 1993).

Case management builds on established casework practice such as that found in nursing, social work, and some branches of medicine, elaborating a multifaceted and longitudinal process. The case manager simultaneously adopts an holistic view of client needs, organizes and coordinates care provided by multiple sources, and balances the task requirements of a caseload. Over time, the focus is on service episodes and changes in client needs. The locus of service delivery can cut across multiple settings, involving variable intensities, levels, and specialties of care (Bower, 1992).

While the operational goal of case management is to coordinate services at the level of individual clients, case management programs are also connected with multiple objectives related to the overall organization of service systems. Figure 1 illustrates how each of the core case management functions serves objectives for both clients and service systems.

Figure 1. What Case Management Tries to Do: Goals for Clients and Service Systems

Sometimes client- and system-level objectives represent different sides of the same goal. For example, many case management programs arose from attempts to construct a community-based care package in order to prevent or delay placement in institutional settings such as mental hospitals and nursing homes. On the systems’ level, such efforts derived from interests in cost containment as well as concerns about the humaneness and quality of institutional care. For clients, preventing institutional care has the goals of promoting care in the least restrictive environment, enhancing quality of life, and encouraging self-care and independence (Bower, 1992).

On the other hand, the goals that case management programs seek for clients may conflict, or coexist in a dynamic tension, with those related to the functioning of service systems. For example, a common finding of case management programs in long-term care is that linking more clients with community-based services raises overall service expenditures even while offsetting institutionalization (360). Advocacy for particular cases may be in opposition to the organizational objective of ensuring broader interagency cooperation (Raiff & Shore, 1993).

The dual focus and complex, dynamic nature of case management reflect the complicated and changeable nature of the problems it attempts to address:

Case management is a synergism evolving from the concern for humane care of the troubled, disabled, or sick individual combined with concern for the scientific management and conservation of community resources. It seems fair to speculate that case management would not exist if human problems were singular or simple, if they could be resolved with a single intervention, and if the needed interventions were readily available and inexpensive. (356, p. 10)

This said, it must also be acknowledged that case management has not come into existence simply because of the complexity of human problems and service systems. Case management has evolved in a particular social, historical context, the elements of which have fundamentally shaped its organization, operations, technology, and goals.

The Origins and Evolution of Case Management

Case management as a distinctive service component began as part of broader policy efforts to coordinate service systems. These efforts themselves evolved out of the concept of “service system” first developed in the Progressive Era, then expanded through Great Society initiatives. Techniques of case management also have multiple origins, linked to early 20th century welfare, social work, and nursing practice. To trace the history of case management thus requires us to begin by examining the roots of our service systems and their professions.

The System in “Service System”

Human service systems consist of organizations, institutions, providers, payers, clients, and, perhaps most critically, ideas and principles about how all these things should fit together and work as part of a system. In all these areas, many parts of our current systems trace their origins to the period from the Civil War to the First World War. It is in this time that we find the forebears to modern hospitals, pension systems, social service agencies, and public bureaucracies. This era also sees the beginning of the professional projects that would produce the current shape of medicine, nursing, and social work. The organizational cultures of present service systems—that is, the concepts, paradigms, and values that gird and guide them—are the outgrowth of ideas, interests, and social movements of those decades.

Two trends of this era have particular significance for the ancestry of case management: the entrenchment of bureaucracy and the rise of dominant professions. Bureaucratic organization spread within and parallel to the growth of capital industry in the late 19th century. Public, private, and voluntary systems of health care and social welfare formed largely in response to the social dislocation and economic instability created by industrial expansion and the resulting phenomena of immigration and internal migration (Quadagno, 1988; Haber & Gratton, 1994). Industry also provided the model of mechanical efficiency and productivity that became the standard for bureaucratic systems, as evident in Weber’s classic description:

The decisive reason for the advance of bureaucratic organization has always been its purely technical superiority over any other form of organization. The fully developed bureaucratic mechanism compares with other organizations exactly as does the machine with the non-mechanical modes of production. … Precision, speed, unambiguity, knowledge of the files, continuity, discretion, unity, strict subordination, reduction of friction and of material and personal costs—these are raised to the optimum point in the strictly bureaucratic administration. (355, p. 973)

The human service professions developed in tandem with service bureaucracies in the early years of the 20th century. The movements of the Progressive Era asserted not only the imperative of social reform but also “a technical and scientific elitism” (Lubove, 1975, p. 84) stressing the importance of professional expertise in defining and resolving social problems. In medicine, nursing, and social work there were collective efforts to garner the bodies of knowledge and corporate structures that are essential to the development of professional autonomy. In the process, professionals developed the technical ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Preface and Acknowledgments
• 1 Introduction: What is Case Management?
• 2 Long-Term Care for the Elderly: Case Management as Black Box and Social Movement
• 3 Case Management for People With Chronic Mental Illness: Institutions Without Walls
• 4 “Not Alms But a Friend”: Case Management and Social Welfare
• 5 Questions Answered and Unasked: Themes and Tensions Across Service Sectors
• 6 Policy for Future Practice
• Bibliography
• Index