Abstract and Keywords
A generic set of case management functions are performed in most practice settings. To improve outcomes within a complex service delivery system, case managers need to collaboratively work with clients and care providers. By incorporating the paradigm of evidence-based practice, case managers can improve decision making through integrating their practice expertise with the best available evidence, and by considering the characteristics, circumstances, values, preferences, and expectations of clients, as well as their involvement in the decision making.
Barker (1999) defined case management as, “A procedure to plan, seek, and monitor services from different social agencies and staff on behalf of a client” (p. 62). Usually, one agency takes primary responsibility for the client and assigns a case manager to coordinate services and to advocate for the client. The reader should refer to the NASW (1992) Standards for Social Work Case Management that clarifies the nature of case management as well as the role of a case manager.
A generalist model of case management practice consists of several functions in which the case manager is primarily responsible for coordinating and expediting the care delivered by others and for involving the client in the decision making (Roberts & Stumpf, 1983; Roberts-DeGennaro, 1986, 1987, 1988, 1993). Most of these functions are generic to different types of case management in various practice settings with diverse client populations (Madden, Hicks-Coolick, & Kirk, 2002; Minkoff & Cline, 2004; Naleppa & Reid, 2003; Reid & Fortune, 2006; Tolson, Reid, & Garvin, 2003; Ziguras & Stuart, 2000).
Good case management implies continuity of services, rational decision making in designing and executing a treatment package, coordination among all providers of services, effective involvement of the clients, timeliness in moving clients through the process, and maintenance of an informative and useful case record (Cohn & DeGraff, 1982, p. 30). Designating one person as the case manager ensures that there is someone who is accountable, who helps the client hold the delivery system accountable, and who cannot “pass the buck” if services are not delivered quickly and appropriately (Miller, 1983). Rothman (1992) contends that it may be taxing for a practitioner to take full responsibility for the diverse elements of any given case, if many cases are assigned to the practitioner.
In some agencies, the comprehensive responsibility for the case is assigned to an interdisciplinary team rather than to an individual case manager. An interdisciplinary team usually consists of a case manager and a variety of professionals from different disciplines. If the team structure is not appropriate or feasible, adequate support must be provided to the individual case managers (Intagliata, 1991).
In designing a case management system, administrators need to fully understand the functions performed by case managers, as well as the practice realities of serving the client population. “Without the support of appropriate administrative structures and community organization, case managers are relegated to a role not unlike the proverbial Dutch child who had only fingers to plug a leaking dike” (Moore, 1990, p. 447). In turn, the case managers should be aware of the issues that administrators must address in designing, planning, and evaluating services.
The philosophy and process of evidence-based practice (EBP) supports the expertise of case managers in using their professional judgment to integrate information about each client's unique characteristics, circumstances, preferences, and actions with external research findings (Gambrill, 2004). Taking appropriate action guided by evidence includes ensuring that data on intervention and case progress are systematically collected and used to make decisions on whether to continue, revise, or discontinue the problem-solving effort (Rzepnicki & Briggs, 2004). The EBP paradigm supports the ethical obligation to involve clients as informed participants and to promote client self-determination (Gambrill, 1999, 2003; Gray, 2001; Sackett, Richardson, Rosenberg, & Haynes, 1998; Straus, Richardson, Glasziou, & Haynes, 2005).
Generalist Case Management Functions
Job descriptions of case managers vary among service areas (Zastrow, 2003, p. 21). Yet, there are a generic set of functions that are performed by case managers in developing a resource network, accessing the clients, assessing the client's needs and strengths, developing the care plan, designing the service network, establishing a written contract, implementing the care plan, monitoring and evaluating the services, closing the case, and conducting follow-up.
Developing a Resource Network
Both the administrative and case management staff need to work together to develop a formal network of resources that can be accessed for and with the client. In building a network of resources, the primary focus should be on the continuity of care that is needed by a client population. Usually, this requires interagency cooperation, coordination of services, and information sharing.
In establishing the resource network, case managers should be aware of existing informal networks and use these when appropriate. Self-help groups, families, friends, and others can provide on an informal basis the kinds of reinforcements, social supports, and casual caring activities that enhance a client's capacity to attain the desired outcome (Collins & Pancoast, 1976).
Accessing the Clients
In some agencies, an outreach concern is case finding or recruiting clients to use services, especially if new programs are being tested or implemented. In other agencies with waiting lists, outreach activities may focus on educating prospective clients of the eligibility requirements of the program and promoting awareness of other resources that may be available in the interim.
In neighborhoods where prospective clients reside, it may be helpful to conduct orientation sessions on the nature of the program at local civic, religious, and community group meetings. An interdisciplinary team is useful in a program's outreach efforts, because its members have links with other significant agencies in the community.
Assessing the Client's Needs and Strengths
Case managers collaborate with the client to assess the sources of limitation as well as strengths that the client brings to resolving the situation. The focus should be on enhancing the client's ability to function more effectively in life situations. From the ecological perspective of Germain's (1973, p. 327; Germain & Gitterman, 1996) life model, problems are defined not as reflections of pathological states, but as consequences of interactions between the individual, the family, service organizations, the environment, and others.
Case management practice, regardless of the setting in which it is utilized, focuses on the client's strengths and needs rather than a laundry list of problems. In cases where there are multiple needs, priorities must often be established.
Developing the Care Plan
It is essential that case managers include clients in the decision making during the assessment process. The case manager and the client should assess the client's strengths, needs, and situation. Based on this assessment, the case manager and the client collaborate to develop a specific and measurable goal(s) related to a desired outcome. Clients should be able to choose what they want help with and what they do not (Reid, 1978, 2000; Reid & Epstein, 1972; Reid & Fortune, 2006). The NASW (1999) Code of Ethics states that social workers have an ethical responsibility to respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals.
The tasks that are necessary to reach each goal should be specified (Reid, 2000). Task planning is intended to clarify and specify procedures for both the client and practitioner (Rothman & Sager, 1998). Every participant in the care plan should have at least one specific task to perform for which he or she is accountable.
Designing the Service Network
After developing the care plan, the case manager and the client select the services and supportive resources for the client's individualized service network. This is a collaborative and integrative process that includes a systematic search, appraisal, and synthesis of the evidence in answering a practice question such as, “What is the most effective intervention to best meet the client's needs and attain the desired outcome?” (for example, see Gibbs, 2003).
In designing the service network, other factors need to be considered including (a) professional values and ethics, for example, “How can the case managers advocate for the client to receive fair and equitable services?”; (b) thoughtful professional judgments, for example, “How can the case managers use their practice experience and available evidence to help the client?”; and (c) consideration of the characteristics, values, and condition of the client, for example, “Is the client willing or able to receive the services?”.
Establishing a Written Contract
Before implementing the care plan, a primary contract is constructed between the client and the case manager. A secondary contract is established between the case manager and a service provider, such as a psychotherapist to whom the client was referred. At least six items should be included in the contract (Jones & Biesecker, 1979; Stein, Gambrill, & Wiltse, 1977):
1. Realistic goals from the care plan based on an assessment of the client's situation
2. Time limits of the contract terms
3. Planned actions that the client, case manager, and others will take to realize the stated goal. The actions should be defined in terms of what, where, when, and with what frequency
4. Individual responsible for carrying out the planned actions in their specific time frames
5. Costs for failure to carry out the contracted responsibilities
6. Signatures of all parties, for example, case manager, client, and the significant others, responsible for carrying out the planned actions
Implementing the Care Plan
Implementation of the care plan is the setting into motion of professional actions by the various service providers. This means that the client is engaged with these service providers in achieving the goals of the contract. The case manager should help the client to set into motion the energies, such as self-motivation, that are necessary to benefit from the services.
The case manager orchestrates the services of the collaborating providers according to the timetable in the contract, maintains communication with the service providers, and meets on a regular basis with the client. Likewise, the case manager should have frequent communication with the natural helping network. These persons need to have a sense of accomplishment and worth in helping the client.
Monitoring the Services
The case manager needs to systematically record and verify the delivery of intended services in the care plan. The case manager should be able to identify what services have been provided to the client during the time frame of the contract terms. By using the secondary or collateral contract with other service providers, the case manager can identify whether reports have been received, for example, from a consulting psychologist. Communication with the service providers, as well as the natural helping network, is necessary to be aware of what resources are being provided to the client, as well as the level of involvement from the client.
The case manager, client, and other significant persons can collaboratively measure the impact of the services and assess whether desired program and client outcomes were attained. An evaluation is the best guide to improve the provision of services, as well as document any unintended consequences from implementing the care plan. A fundamental principle in any case management system is to help the client assume an appropriate level of responsibility for achieving and evaluating progress in attaining their desired outcomes.
Closing the Case
Planning for termination begins when the case manager initially discusses with the client (a) eligibility requirements to receive services, (b) evidence on which services are based, (c) case manager's practice expertise in service coordination, (d) expected outcomes from receiving the services, and (e) restrictions in delivering the services. The case manager facilitates the decision-making process with the client around case closure and informs other service providers about progress made or not made. In programs with time-limited services, the client should be alerted to the circumstances of need and eligibility that can lead to reentry into the program.
A plan should be made at the last client session for the case manager to follow up with the client. These contacts are important, especially when the services were terminated prematurely by outside contingencies or unrealistic optimism (McBroom, 1984). Follow-up provides an opportunity to determine if any new problems or recurring ones have emerged that require further intervention and to assess whether the intervention was effective. This learning should be shared with administrators and other case managers to gain a greater understanding of what client strengths are necessary to resolve a situation, when using certain evidence-based interventions. A learning network of case managers, administrators, and other practitioners should be constructed to manage and store the evidence of best “practices” so that it is easily accessible (Roberts-DeGennaro, in press-a, in press-b).
A competent case manager has the knowledge, skills, and values to appraise and use evidence in selecting interventions and organizing the delivery of these interventions across agency boundaries. An effective case management system advocates for clients to be involved in the decision making to determine what they hope to achieve from their participation in the care plan.
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