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Improving Human Service Effectiveness Through the Deconstruction of Case Management: A Case Study on the Emergence of a Team-Based Model of Service Coordination
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Improving Human Service Effectiveness Through the Deconstruction of Case Management: A Case Study on the Emergence of a Team-Based Model of Service Coordination
Stephen R. Block
Nonprofit Management Concentration, School of Public Affairs, University of Colorado–Denver, Colorado, USA; Rocky Mountain Human Services, Denver, Colorado, USA
Lance Wheeland
Rocky Mountain Human Services, Denver, Colorado, USA
Steven Rosenberg
Department of Psychiatry, University of Colorado–Denver, Anschutz Medical Campus, Aurora, Colorado, USA
This case study describes the development of an innovative case management team model consisting of functional specialists. Ten years of comparative data demonstrate client satisfaction, a significant reduction of health and safety concerns, and a transformation to a more effective and efficient model of case management.
Keywords: accountability, case management, planned change, program effectiveness, team model
INTRODUCTION
Human service organizations rely on the practice of case management to effectively serve individ- uals with complex needs while “simultaneously seeking to reduce utilization and costs” (Murer & Brick, 1997, p. 40). The task of providing efficient and effective case management services is both a complex and pressing task, especially during periods of stagnated or reduced funding. Funders, such as the Centers for Medicare and Medicaid Services and private foundations, will often require evidence of quality care, financial efficiency, and organizational effectiveness (Carman, 2009; Golensky, 2011). Not surprisingly, case managers are more likely to focus their clinical concerns on meeting the needs of people on their caseloads, and are less inclined to worry about cost containment and the outcomes sought by funders (Cornelius, 1994). That task of ensuring that
Correspondence should be addressed to Stephen R. Block, School of Public Affairs, University of Colorado–Denver, P.O. Box 173364, Campus Box 142, Denver, CO 80217-3364, USA. E-mail: stephen.block@ucdenver.edu
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IMPROVING CASE MANAGEMENT 17
case management services are efficient and effective is the responsibility of organizational program managers, executive directors, and boards of directors.
By assessing his or her human service organization’s strengths and weaknesses, an executive director exercises accountability (Kearns, 1994). Another accountability exercise includes scanning the external environment to determine whether there exist more effective tools and methods for delivering services than are currently used in one’s organization. If more effective practice tools and alternatives become evident, then adopting those methods and implementing organizational change should be the optimal strategic response. As stated by Latta (2009, p. 35), “change resides at the heart of leadership.” What should an executive director do in response to an organizational assessment that reveals less than adequate results through traditional methods of case management? Without alternative case management models to adopt and replicate, one option is to try to improve existing practices. Another approach is to abandon current practices and develop an alternative. Some might consider organizational experimentation to be a high-risk management decision. Others might view organizational experimentation as a necessary risk management decision, especially after weighing both the human and financial outcomes associated with maintaining the status quo.
The risks associated with a planned change effort can be mitigated by using an established orga- nizational development (OD) framework: diagnosis, action planning, intervention, and evaluation (Robbins & Judge, 2012; Block, 2004). However, it is important to recognize that OD is not a solution to all organizational problems (Dubrow, Wocher & Austin, 2005). According to Young (2001), creating a positive identity must be an integral part of the change process. Additionally, change and innovation require organizational flexibility and a willingness to examine the organiza- tion’s culture (Jaskyte & Dressler, 2005) and reorient the values, beliefs, and assumptions that led to organizational deficiencies (Schein, 2010).
This article presents a case study of a human service organization that was dissatisfied with its overall case management performance. It chose to engage in planned change in reaction to runaway costs, staff burnout, and ongoing staff turnover, which inadvertently caused major health and safety risks for clients. The solution necessitated the abandonment of the traditional case management model and the development of an innovative resource coordination model consisting of functional specialists working in teams.
RELEVANCE OF CASE MANAGEMENT
For approximately 140 years, different forms of case management practice have evolved. In the United States, a comprehensive approach to coordinating aid to individuals in need can be traced to an adaptation of the settlement movements that were started in England. The American model of settlement services attracted attention through the work of Chicago’s Hull House, Boston’s’ South End House, Northwestern University’s Settlement House in Chicago, and the Neighborhood Guild in New York. The objective of these settlement houses was to provide opportunities for social change in poor neighborhoods by having volunteers match available services to individuals in need and promote ideas of independence and self-direction. Additionally, the charity organization movement, another English invention that took hold in the United States, refined the idea of almsgiving by matching financial resources to an individual’s specific short- and long-term goals (Block, 2001).
Many human service values essential to contemporary case management services can be traced to the social work pioneering activities of Mary Richmond and Jane Addams (Weil & Karles, 1985). Richmond and Addams broke new ground with interdisciplinary approaches to problem solving and introducing the case conference review as a mechanism for planning services for vulnerable individuals. As social work schools began to develop in the early 1900s, the principles and processes of case management were integrated into methods used in social work fields of practice (Bartlett, 1970).
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18 BLOCK, WHEELAND, AND ROSENBERG
The social work profession attempted to retain the domain of case management, but over the years this role has expanded to practitioners of other disciplines employed by human service agen- cies. The outcome of this expansion has meant that not all case managers may be schooled in a uniform framework of social work theory and professional practice. In fact, many case managers have degrees in fields other than human service fields and often no human service background of any kind. This broadening of qualifications has led to a steady pool of available personnel and driven down the cost of staff salaries.
Since many employees do not come to the case management role with a theoretical framework or the benefit of a supervised field practice internship, the alternative process for learning the func- tions and responsibilities of case management is primarily through on-the-job training. Supervisors trained in the traditional model of case management would naturally train their novice staff in sim- ilar practice methods. Although supervisors may have significant case management experience, it does not mean they have effective instructional skills to teach and convey practice wisdom to the inexperienced employee.
THE TRADITIONAL CASE MANAGEMENT MODEL
As with the general practice of social work, traditional case management is typically a service deliv- ered by a single individual sometimes referred to as a social worker, service coordinator, resource coordinator, case coordinator, care coordinator, or caseworker. The job title is dependent on the ser- vice setting; additionally, the target of services has multiple identifiers, such as, client, consumer, patient, customer, student, or family group.
Differences may exist in the job requirements of case management services in hospitals, schools, mental health centers, or other settings. However, the general focus of case management practice, its scope of responsibilities and processes are very similar. Within varied settings, the traditional role of a case manager can be described as a generalist who coordinates resources to meet the details of a service plan designed for a targeted individual or family. Measures of successful case management include meeting the objectives of the service plan within a specified time frame and the limitations of the agency’s financial and human resources.
METHODS
This study examined the transformation of case management services for adults with developmental disabilities. As a case study (Yin, 2013), our goal was to determine whether changes in case man- agement processes would lead to increased client satisfaction and improvements in their health and safety. Based on process theory (Maxwell, 2012), our objective was to demonstrate a relationship between improved outcomes and a newly designed case management model.
The study obtained quantitative measures of client and service outcomes. Data collected during the first year of implementation of the new model established a second year baseline measure for determining improvement in client satisfaction and health and safety objectives. The approach to establishing a baseline and evaluating outcomes of health and safety employed a single subject design (Bloom, Fischer, & Orme, 2006), since it is theory free and can be applied in the field by case managers (Bloom & Block, 1977). Single subject designs are used to evaluate the results of an intervention on a single client and are not meant to prove a hypothesis. Instead, the importance of the single subject design is on observations and the effects of an intervention on identified objectives (Zimbalist, 1983). An individual’s data can also be combined with data collected from other clients to create overall group data (Polster & Lynch, 1985) to analyze and use to support organizational decision-making.
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Each case manager was trained to follow an evidenced-based process by evaluating all of their clients’ progress and functioning in the everyday environment (Walker, Briggs, Koroloff, & Friesen, 2007). At a minimum of once a month, the case manager has contact with his or her clients and records a contact note on the status of the implementation of each client’s individualized plan of services. Contact notes serve as a continuous record of progress made toward the client’s plan objectives, as well as documenting the conditions of the client’s living and work environment to ensure the client is safe and healthy. Every six months, the case manager evaluates the data collected on the client’s progress and compares it to the individualized plan’s objectives. Using evidence, experience and practice wisdom (Hawkins, 2006), the case manager can determine whether the client’s desired results have been produced or whether the plan needs to be modified.
In addition to developing the case study, we evaluated organizational change over time including changes in client satisfaction using a survey questionnaire that was administered on an annual basis between 2002 and 2012. Customer satisfaction data were collected annually for 10 consecutive years using a survey of 15 questions (Fowler, 2009). Ten clients with cognitive limitations pretested the questionnaire to determine whether potential respondents would understand the wording. The first eight questions used a Likert scale of 1 to 5 with the higher numbers representing greater levels of satisfaction. The questionnaire targeted satisfaction with current services, staff returning phone calls in a timely way, staff responsiveness when help was needed, satisfaction with staff interaction, overall helpfulness, and staff performance matching client needs with appropriate services. Five questions were demographic in nature covering age, gender, number of years receiving services, if help was needed to complete the questionnaire (relying on a parent, guardian, friend or paid staff), and whether the individual had a legal guardian. Two questions were open-ended. One was to discover how the individual first found the organization and applied for services. The second open- ended question provided an opportunity for additional comments about the client’s experiences with staff, services, or other aspects of the organization.
Surveys were annually mailed to adult clients of Rocky Mountain Human Services (RMHS). Each year, 30% of the population was randomly selected to receive the client questionnaires. The number of surveys distributed changed from year to year according to the census of clients in service. In the initial years the number of adult clients numbered approximately 822 and rose to 1,038 between 2002 and 2012. The response rate for the surveys improved from 16% to 42% in 2012.
Krahn, Hammond, and Turner (2006) observed that individuals with intellectual disabilities rely on providers for health promoting behaviors and the status of health and safety varies with care giving arrangements. Consequently, administrative data were collected and reviewed to determine if there were any positive or adverse trends in the conditions that affect client health and safety. The information included outcomes of site visits, investigations into allegations of abuse or neglect, medical and dental care utilization, and staff turnover.
THE CASE STUDY
Rocky Mountain Human Services (RMHS) is a nonprofit human service organization contracted by the Colorado Department of Human Services to manage and coordinate the delivery of services and supports for children and adults with developmental disabilities residing in Denver. The client base is drawn from the City and County of Denver and represents approximately 17% of the community- based developmental disability services delivered statewide. The organization uses a combination of service agencies, individual providers and its own staff to serve approximately 3000 children, adults, and families. Under the state contract, the one activity that is prohibited from being contracted out is case management services.
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