The Practice of Case Management

Effective strategies for positive outcomes

Peter Camilleri

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000248135
• Edition: 1
• Topic: Business
• Subtopic: Human Resource Management
• Index: Business

Case management is used across a diverse range of organisational settings, from child protection to aged care; disability services; acute and community health; courts and correctional services; employment services; veteran services; education; and immigration programs. However, case management is not always successfully implemented, and practitioners often feel they are not given sufficient support. The Practice of Case Management draws on extensive practice research to identify the key characteristics of successful case management: organisational support; developing delivery models to suit individual client needs; preparation of staff at all levels; and affirmation of the central and active role of the client.The authors outline the challenges and complexities faced by case managers, acknowledging that their role is often poorly conceptualised and articulated. They demonstrate that true engagement enables effective service provision and offer practical strategies for everyone involved in the case management process to facilitate negotiation, accountability and the achievement of positive outcomes.

1
WITH A FOCUS ON PRACTICE, WHAT IS ON THE AGENDA?

Declaring our position

Why another book on case management? After all, case management has been on the scene for some 40 years, and in the Australian context has been established as a service-delivery approach since the mid-1980s. Few human service organisations or practitioners remain untouched by the influence of case management. This may mean that the organisation has adopted case management as a service- delivery approach; alternatively, if the organisation is a service provider, it will find at least some of its practitioners engaged in case management hosted by other programs or organisations. We often talk about ‘doing case management’ or ‘working with case management’ as a reality of the practice world in the human service and health sectors. However, as familiar as many practitioners are with case management, our practice research suggests that confusion still exists about the concept, as well as about what is different in the practice and what is expected of the case manager and those involved in this service-delivery approach.

Much of the significant work on the conceptualisation and documentation of case management practice was entrenched in the international literature by the late 1990s and in the Australian literature during the early 2000s (e.g. see Austin & McClelland 1996; Greene & Vourlekis 1992; Gursansky, Harvey & Kennedy 2003; Holt 2000; Moxley 1989, 1997; Rose 1992; Rothman & Sager 1998; Weil, Karls and Associates 1985). While there continues to be writing about case management, the commentaries often document particular applications of the service-delivery approach, processes, practices or the evaluation of specific aspects of case management-based programs. Most recently, Elizabeth Moore (2009) has edited a book that provides insight into Australian applications of case management in different fields of practice. Texts such as this provide evidence of the many forms of case management that have been developed in response to different settings, client populations, policy and program agendas.

Characteristically, much of the contemporary literature remains descriptive, and assumes the value and virtue of case management. There is a sense that case management is part of the landscape, and that it no longer warrants critical debate in relation to its strengths and limitations as a service-delivery approach or practice modality.

Have we, as human service professionals, succumbed or been seduced by the mantra and rhetoric of case management? Or is there evidence that case management continues to promise outcomes that are consistent with the mandates given to human service and health organisations? Has case management provided effective and individualised service-delivery responses that promote individual change, positive service development and collaborative practices? While some believe the jury is still out on the cumulative impact of case management, there remains a significant level of scepticism about the value of case management and its place in professional practice. However, there is an undeniable logic to the systematic practice arrangements that distinguish this approach from traditional casework or individual work across the professional spectrum. Has this rhetoric been accepted and accommodated? Has familiarity with the notion of case management eliminated the drive to challenge its place in service delivery and the practice world? Has its widespread adoption diminished the need to evaluate case management and refine the practice?

As is often the case, the adoption of extreme positions can distort the issues inherent in any argument about service delivery in health and human services. In the practice world, it is becoming increasingly evident that organisations and practitioners confront complexity in the presenting situations of their clients or consumers. There are few soft edges in practice for human service and health professionals. This reality is mirrored in the job advertisements in these sectors that declare the importance of skilled, knowledgeable, adaptable employees with high-level communication and negotiation skills. The expectation of employers is explicit. They are looking for professional staff with knowledge, skill and capacity to work at the complex end of practice. For many professionals, their work will incorporate the management of support workers who represent a major proportion of the employment growth in these sectors. Inevitably, complexity requires the involvement and contribution of multiple service providers. These demands have been heightened with a service system that has moved from institutional care to community-based service support for increasingly high numbers of vulnerable individuals and client populations. Additionally, in this environment there is an increasing demand for the ‘coordination of services’. The human services and health marketplace has diversified. The change in the role for government services and the commensurate growth of service provision through the non-government sector have generated new forms of contractual relationships around service provision. We are seeing a proliferation of contracted providers who are used to support case management for complex situations. Increasingly, these providers are in agencies funded by government but located in non-government organisations (NGOs) (both not-for-profit and forprofit organisations).

We hold the position that the conceptual foundations of case management, both as a service-delivery approach and as a practice, are well established. In taking this position, we recognise that case management cannot be viewed as homogenous, either in its development as a service-provision approach or as practice. Models of case management vary, there are multiple applications in diverse service contexts and it is practised by many different players. What remains contentious, however, is the value of the case management approach—whether case management in its various manifestations does achieve all that its adherents claim it can, or whether it is as problematic as its opponents suggest. For some, case management represents a genuine alternative to the traditional casework practices of professions. Those holding this view emphasise the value of case management principles that are client focused, promote collaborative practices and seamless service delivery, generate planned intervention and use a mix of service providers to achieve declared goals. For others, case management remains suspect, viewed as an imposed approach that reflects the dominance of neoliberal and managerial principles that deskill the practitioner, and that routinise and undercut the integrity of professional practice. These opponents to the approach believe case management places an untoward emphasis on ‘managing’ cases, addressing outcomes without a commitment to process and relentless attention to cost-effectiveness.

This book is designed for people engaged with case management: the policy-makers who inevitably shape the practice world; the practitioners who are faced with making it work; and those who are interested in human services and their potential to make a positive difference to the lives of those who present with complex needs. We take the position that, for better or worse, case management exists. We do not see it as a panacea or as the only appropriate response to all presenting client situations. However, we are interested in exploring what makes it work well.

Remaining curious and building knowledge

We have continued to be fascinated both by the ideas that underpin case management and the challenge of its practice. Over the last fifteen years, we have individually and collectively engaged in practice research and consultancy activities around service delivery, in particular case management. Our work has taken us into national organisations like the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) (now the Department of Immigration and Citizenship) as it addressed demands for major service-delivery reform in the face of negative findings arising from the inquiries into the cases of Cornelia Rau and Vivian Alvarez (Palmer 2005; McMillan 2005). The recommendations flowing from these inquiries identified case management as a desirable service-delivery approach. The argument behind the recommendations clearly articulated service problems where ‘incidents’ rather than ‘clients’ were the focus of departmental response.

We have worked with veterans’ counselling services to incorporate case management as a service option for clients with complex and ongoing needs. In these settings, traditional clinical modalities have dominated service arrangements and significantly limited the capacity of the service to address the multiple needs presented in an increasing number of client situations. As contemporary defence forces face involvement in conflicts that are shaped by underlying civil unrest, terrorism, genocide and displaced populations, it is inevitable that there will be social and psychological as well as physical risks to personnel. Not surprisingly, the nature of individuals’ personal responses to such experiences will for some precipitate emotional and mental health issues that impact on family members, social networks and the capacity for ongoing employment. The lessons we have learned from the experiences of the Vietnam War remain. Today, defence management and veteran-support services are alert to the negative consequences for returning personnel and ageing veterans living with multiple needs. As a result, many of these organisations have extended their service options to include case management.

At state government level, we have worked with correctional services in a number of jurisdictions. In particular, we have had long-term involvement with ACT Corrective Services as an integrated service system based on ‘throughcare’ principles has been developed. The completion of the first prison in the Australian Capital Territory generated opportunities for comprehensive system design that operationalised a single system approach with ‘throughcare’ policy and addressed the imperatives of human rights-based legislation. Case management was the service-delivery approach identified as the best strategy to meet policy and legislative specifications. Significantly, the organisation’s leadership recognised that case management required a new way of ‘doing business’ that would involve all levels of the organisation. As a result, a unique developmental plan was established that included a training agenda for case managers and all staff contributing to case management practice (from front-line custodial staff to managers).

With varying levels of involvement, we have engaged in consultancy work with child welfare agencies, homelessness programs, drug and alcohol services, Indigenous services, mental health and aged care programs delivered through state government departments and NGOs. The history of case management in these particular settings is well established. However, in practice there has been limited attention to the development of the skill base for effective case management. In adopting a case management approach, presumptions have been made about the capacity of professionals to make the shift to a different service-delivery modality, the support provided to them, preferences for a particular practice approach and their capacity to take on the role of case manager. In our work we have found that established organ-isational practices remain entrenched and have not been adapted to support case management.

This commentary does not negate either effective practices generated by skilled and particular practitioners or the veracity of program design. However, the evidence from the practice world all too often suggests that traditional practices remain the default position whenever case management becomes difficult to implement. For the practitioner, this means reverting to being the sole provider and referring the client to other services as needed. For the organisation, it means reverting to the silo approach where the client enters the organisation, is assessed and is offered those resources available from within the organisation. For the client, it means uncoordinated service experiences with multiple assessments, multiple service plans and serendipitous outcomes. At best, the client must use all their ‘system savvy’ to achieve what they need. At worst, the outcomes can be disastrous and attract significant criticism to organisations and professionals.

To illustrate this point about disasters and mishaps, the media provide frequent reports on those cases where things have not gone well. There are recurring examples from the mental health system that illustrate the challenge of coordinating services for people living with mental illness in the community. The stories of aged people found dead in their homes have generated critiques of both the quality of community care and the level of resources available. Most recently, the South Australian Coroner’s finding on the death of a ten-year-old child highlighted the disastrous consequences of the organisational silo, an incident-management orientation and inadequate strategies to address collaboratively situations where problematic history, complexity and multiple needs are evident (see Chapter 8 with reference to the case of Jarrad Roberts). The recommendations from various inquiries move beyond the issue of blame. They declare the need for reform of service delivery and strategies that ensure appropriate levels of collaboration between organisations and professionals so that they can work together around and with clients who present with multiple needs. Again in South Australia, a mother of a significantly disabled adolescent has been charged and subsequently acquitted for his murder (The Advertiser, 17 June 2011). The circumstances of the case have drawn attention to the system failures in the disability sector, where family care is not actively sustained with responsive supports. There is no denying that community care is a preferred response for many families who have children with disability, but this commitment does not abrogate responsibility for additional care—particularly in the face of changes in the level of dependence or challenging behaviours. These most recent examples are not unique. We continue to hear of the failure to establish a seamless service system for many clients and families. Inevitably, case management is seen as the problem when systems do not work. However, as we argued in our previous book (Gursansky, Harvey & Kennedy 2003), the adoption of case management alone does not solve these problems. Case management cannot redress the impact of limited or inadequate resources; without system change, it does not reduce resistance to working across organisational boundaries. Finally, the introduction of case management alone does not ensure that professionals have the capacity or commitment to work differently with clients and other service providers.

A final comment reflects on our work with NGOs. Here we find case management is frequently asserted as the service-delivery approach. In many situations, this is because case management is specified in funding agreements—a fact that can complicate efforts to determine appropriate lead agency status. Organisations sponsoring programs where case management is the designated service approach may need to maintain evidence of their role as the case managers to protect funding. In other situations, the practical lead agency may not have an authorised case management mandate. Both in mental health and accommodation services for young and high-risk adolescents, we see examples of the support services—with their intensive levels of involvement with the clients—carrying more of the coordination responsibilities than the formally designated case manager. In programs in sectors such as domestic violence and homelessness services, there is evidence that clients often have transitory links with the service. This may make a case management approach unrealistic. Of course, such contact does not minimise the agency’s serious responsibility to engage the client and provide initial assessment. However, to declare that this is case management is a misrepresentation of the approach. It can be equally problematic to apply the term to specific direct interventions that are problem-specific in focus. We are of the view that there is a valid place for both case management and direct service provision (casework). The former cannot be activated without the existence of services (both formal and informal) that will constitute the package of care or operationalise the service plan in any given situation. Effective service provision requires a mix of service responses. Our experience indicates that in the non-government sector there are some very effective applications of case management. For example, in the complex area of homelessness, where issues of mental health, drug and alcohol dependency, and offending behaviour come into play, the non-government agency may provide a critical lead role in case management—even if it is not always formalised. But that expertise needs to have the active support of other specialist services. Where young people live in supported accommodation because of a range of factors, case management can provide the focus for a service arrangement that addresses their various needs. The challenge is to be clear about the parameters and specificity of the case management being offered.

Preparing for case management: Skilling service providers to participate

As consultants and practice researchers, we have taken the position that engagement with case management requires more than a one-off training session for practitioners to shift effectively to case management. Any organisation that decides to adopt a case management approach, or offers this as a service option, needs to recognise that such a move inevitably will require organisational sup...