All journal entries should be two pages written in APA format. Your journal entry should reflect the assigned course readings. In addition, please use citation or paraphrase from the chapter readings. For example, Woodside M. & McClam T. (2015) stated ” human beings are not always able to meet their own needs.” Remember this is an example, do not use the same quote, and lastly, remember to proofread before submission.
If you have never searched for an article in the Library’s database below are the instructions.
You will need to search for the journal article from the TCC Library Database.
*On the TCC home page click the Library Tab and it will take you the the TCC Library
* In the large section type in ” Type in the title of your article” In this case the article you are to write on is..
Improving Human Service Effectiveness Through the Deconstruction of Case Management: A Case Study on the Emergence of a Team-Based Model of Service Coordination
When you locate this article you can read it by clicking the title or selecting the HTML full text of the PDF Full text.
*Read the article then summarize what you have read and write your paper.
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
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
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).
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
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.
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
IMPROVING CASE MANAGEMENT 19
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 8
22
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.
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
20 BLOCK, WHEELAND, AND ROSENBERG
Developmental disability services for adults begin with an eligibility determination process that is coordinated by a case manager. Applicants for services must meet the state’s definition of a person with a developmental disability, which is an Intelligence Quotient of 70 or below and doc- umented before the individual reaches 22 years of age. Caseloads include persons with intellectual disabilities, autism, cerebral palsy, and Down syndrome, and individuals with other neurological or chromosomal disorders.
After a determination of eligibility, the primary responsibility of the case manager is to develop and implement an individualized service plan by coordinating with selected service providers. The individualized plan can be updated at any time, but the case manager must formally review and re-write a plan on an annual basis. Planning or problem-solving meetings are facilitated by the case manager, and ordinarily include the client, service provider, and other key individuals in the person’s life such as family members, guardians, and friends.
Overall, the case manager is responsible for monitoring the implementation of the individual service plan to ensure that the client is seen for medical, psychiatric, dental and other therapeu- tic appointments, and is receiving appropriate medicines and durable medical equipment. In other words, the case manager is responsible for arranging a comprehensive set of services taking into account the health and safety needs of the individual. Services range from providing housing, voca- tional training, and supportive life-skill services, such as learning to shop, cook, clean house, ride public transportation, or access a community center and other neighborhood resources.
Additionally, case management activities focus on assuring the quality of services clients receive. Case managers must inspect the premises of a program site prior to the start of any new service. The case manager also inspects each home that will be used for residential services, and visits all work settings prior to a person beginning employment services. Case managers also review the administrative files of service agencies to make certain that employees have passed criminal background checks. If a program site appears inadequate or if concerns are raised at any time, the case manager is responsible for finding service alternatives and engaging different providers.
As part of the monitoring process, case managers periodically meet with individuals on their caseloads to ensure they are safe and healthy and their service plans are being fully implemented. Case managers must document their face-to-face and telephone contacts in an agency file. In addi- tion to monitoring services case managers may accompany individuals on their caseload to various appointments, such as attending court proceedings, medical appointments, or psychological coun- seling and testing. Finally, case managers have organizational responsibilities, such as participation in staff meetings, meeting with supervisors, attending professional development and continuing edu- cation training programs, writing contact notes, reviewing client files, as well as devoting time for responding to phone calls and e-mail inquiries within the organization’s 24-hour timely response policy.
THE NEED FOR CHANGE
Each case manager has the daunting responsibility for the well-being of 50 or more individuals with developmental disabilities. A review of the case manager’s major tasks reveals a position with many complex responsibilities (see Table 1). It also raises a concern whether one person can satisfactorily perform the traditional case management function.
A reduction in caseload size might ease the workload burden of a case manager, but it is not a realistic solution in Colorado. Funding levels for case management are established through legisla- tive appropriation. For at least three decades, the State of Colorado has not funded the actual costs necessary to fulfill case management responsibilities. In reality, the state budget appropriation falls short by 26% of the real costs of delivering case management services. As a matter of public pol- icy, the State’s General Assembly and Executive Branch has been content to maintain Colorado’s
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
IMPROVING CASE MANAGEMENT 21
TABLE 1
Key Responsibilities of a Traditional Case Manager
1. Eligibility determination
2. Review of appeals of determination
3. Coordinate Medicaid eligibility
4. Develop and revise the social and medical history and profile
5. Development of an annual Individual Service Plan
6. Identification of appropriate community services and providers
7. Assist in accessing/enrolling in additional community services
8. Crisis intervention
9. Providing counseling and guidance (within the limits of professional expertise)
10. Communicate the breath and limitations of funded services/rules and regulations
11. Monitoring of program service environment
12. Monitoring of service quality
13. Monitoring of contract compliance
14. Monitoring of program budget expenditures
15. Assist in identifying and ensuring the delivery of necessary medical, dental, and psychiatric services
16. Reviewing incident reports
17. Participation in Human Rights Committee (Third Party Reviews)
18. Facilitation of Interdisciplinary Team Meetings for problem-solving
19. Maintaining up-to-date contact notes
20. Administrative responsibilities: staff meetings, training, phone calls, e-mails, etc.
low ranking that ranges annually from 44th to 48th in comparison to all other states’ developmental disability expenditures, on a per capita basis (Braddock et al., 2011).
Over the years, a case manager’s inability to meet performance standards was attributed to inadequate funding, large caseloads, or blamed on the case manager’s limited skill set and lack of motivation to do the work. Consequently, supervisors continued to pressure case managers to improve performance and fulfill responsibilities that were nearly impossible to complete. The stressors of the position contributed to a high rate of staff turnover. In fact, case management super- visors anticipated their staff would burnout and leave the agency within a period of two to three years. Beside the human factor, the expense of turnover was an ongoing financial burden for the organization. It costs $3,000 to $5,000 to recruit and train each new case manager.
A defining moment prompted Rocky Mountain Human Services’ management staff to think dif- ferently about the chronic issues and repeated failures that were blamed on and attributed to the competency levels of case managers. Within a period of one month there were a series of case management problems that could be explained away if viewed on a case-by-case basis, but viewed collectively they could not be dismissed. The proverbial “elephant in the room” could not be avoided as noted by the following five examples of health, safety, and customer service issues:
1. A case manager was on her way to inspect a residence prior to the client moving into the home. On route, the case manager received an emergency page that required her immediate attention. Meanwhile, the residential service provider moved the individual into the home. A crisis occurred when it was discovered that the client was endangered since his mobility was dependent on a wheelchair and the home was not fully accessible.
2. A case manager was unable to meet with a married couple contracted to care for the residen- tial needs of a young woman with a moderate level of intellectual capacity coupled with a thought disorder. Later, it was discovered that the couple were monolingual Spanish speak- ing and the woman in their care only spoke and understood English. Thus, not only was there
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
22
3. 4. 5.
BLOCK, WHEELAND, AND ROSENBERG
difficulty in communication between client and provider, but also the language differences exacerbated the client’s state of confusion.
A new case manager assumed an existing caseload and discovered that the previous case manager had not entered contact notes for several weeks. Thus, there was no historical record of any substantive issues and interventions.
Rocky Mountain Human Services’ staff discovered that some contracted service agencies hired direct care staff with criminal records that should have automatically disqualified the individuals from being hired.
Supervisors spent considerable time handling complaints of family members who did not receive return phone calls from case managers. Eventually, family members called the executive director to express dissatisfaction with case management services.
A NEW MODEL OF CASE MANAGEMENT
A task force of managers and line staff were assembled to study and propose solutions to the grow- ing number of case management problems. An obvious solution of hiring more case managers and downsizing caseloads was not possible due to severe limitations in state funding. Three other pro- posed solutions included filling vacant positions with individuals with graduate social work degrees, providing more frequent supervision and offering continuing education to enhance knowledge and skills. All three recommendations were implemented, but it did not solve the problem.
As long as the attempted solution was of the first-order type, that is, relying on one person to perform the traditional case management role, then the quality of the work and ability to meet work objectives remained problematic. The solution required a more radical fix, using a second-order problem-solving approach:
When the first-order solution does not work, there is an inclination to repeat the same solution over and over . . . If the person does not know how to act differently, they generally do more of the same, more of what they know. Instead of detaching themselves from the thought processes that proved ineffective in solving the problem, they hamper progress by relying on the same old solution . . . Because the intended (first-order) solution becomes part of the problem, second-order change efforts may need to target the first-order approach that fueled the problem . . . A successful change effort must foresee a change in the structural issues . . . that underpin the problem (Block, 2004, p. 30–32).
Because of the ongoing failure to improve the traditional case management service model, a second- order type of decision was made to cease all attempts to improve it. Instead, a decision was made to create a new model of case management. The first step was to gain a thorough understanding of the component parts of case management by deconstructing the role of case manager. A task force examined every aspect of the job. Process mapping (Hyerle, 2009) was used to identify how key functions were carried out and how to ideally execute them (Marlenefiol & Sigismund, 1992). Additionally, process maps illustrated the intersection between case management with other staff positions and departments in the organization.
The outcome of the mapping process reinforced the decision to abandon the traditional case management model and, in its place, create a project team of case management specialists. In this new team model, each specialist would be responsible for one major aspect of the traditional case management function. For example, one specialist would only perform monitoring duties; another specialist would only develop individualized plans, one specialist would only do intake, and another specialist would only do service placements. One case manager would coordinate the implementa- tion of the individualized service plan and serve as the key contact with the client. The case manager with the primary coordination responsibilities would be known as the primary service coordinator.
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
IMPROVING CASE MANAGEMENT 23
In many ways, the team model mirrored the practice of a health maintenance organization’s (HMO’s) use of a primary care physician. In the HMO model, the primary care physician would decide when a specialist was needed to provide the patient with a service, such as, inoculations, x-rays, blood tests, and surgical intervention, among others. Similarly, the design of the new case management model had one person serve as the primary service coordinator with overall responsi- bility for an individual’s services. The Primary Service Coordinator would request the assistance of a specialist as needed. For instance, the planning specialist would be called in to develop the annual individualized plan. If the client were to move to a new residence, the monitoring specialist would be asked to inspect the premises. The working hypothesis was that by having a team of specialists, there would be fewer situations that prevented the completion of a major case management task. Since client information would be continually shared with team members, important knowledge about the specialized needs of the person would not be lost. In this way, the client would receive continuity of care should a service coordinator leave the organization.
The group that planned the new model grappled with a formidable question that could not easily be answered, that is, how many primary service coordinators could draw on the same specialist without creating a hardship for that specialist to complete his or her assignment in a timely and effective manner? To address this issue, there were a series of time studies and process mapping activities for each major case management task. To no surprise, it was determined that the number of different types of specialists would vary based on the specialized function that was needed. The only way to truly address the question was to implement the model and generate a database that would provide comparative and historical information to use to make hiring decisions.
While the caseload size increased for each primary service coordinator, there was a significant decrease in the primary tasks and functions that would normally be assigned to a case manager working alone. The decision makers estimated that one specialist could support four or five primary service coordinators. There was also an assumption that with a change in the case management model, there would be a significant decrease in staff turnover, thus being able to reallocate funds associated with advertising, reviewing applications, interviewing, hiring, and training of new staff.
Finally, Rocky Mountain Human Services had to be realistic about facing the unknown. They forecasted that the conversion and redeployment of staff would be cost neutral. If incorrect, there were two contingency options. First, if the grand experiment was more costly and did not yield significant improvements in case management services, the organization could convert back to the traditional delivery system. Secondly, if Rocky Mountain Human Services discovered that its new model was more costly to implement, but there were significant improvements in the quality of services, especially in matters of health and safety, then the new system would be continued and the organization would use supporting data to increase its fund raising requests. If necessary, during an exploration of new funding, management staff was prepared to freeze their pay and have the cost savings allocated to the hiring of new service coordinators.
A commitment was made at all staff levels in the organization and among the board of directors to embark on a planned change effort to improve the traditional case management system of services. Four teams were created.
RESULTS OF THE TEAM PROCESS: A CASE EXAMPLE
Gregory is a 23-year-old man who immigrated to the United States when he was 6 years old from a war-torn Middle Eastern country. He resides at home with his parents, Helen and Ted. His dis- abilities include pervasive developmental delay and posttraumatic stress disorder (PTSD) and he functions at an IQ level below 70. Gregory requires total assistance with all of his personal needs, including bathing, grooming, and incontinence. He appears to have good receptive language skills and understands and communicates in English and his native language. However, he often mimics
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
24 BLOCK, WHEELAND, AND ROSENBERG
what is being said to him. Gregory’s safety skills are limited. Although he would likely evacuate the home in case of a fire, he would not warn others of the need to flee. Also, he would not dial 911, because he does not know how to use the telephone.
Other challenges for Gregory include a fear of leaving his home, particularly at night. Helen believes that the stars or nightlights remind him of his experiences as a child in the war zone where they resided. From time to time, Gregory hits, kicks, or throws things at others, and he exhibits self-injurious behavior. He has a history of property destruction including breaking toilets, faucets, and windows. On occasion, his parents have called the police out of fear of his aggressive behaviors toward his father. Gregory is treated by a psychiatrist and takes two psychotropic medications. Helen has refused the offers of out-of-home residential services for Gregory. However, she and Ted continue to struggle to provide daily support for him.
Under the traditional model of case management, Gregory and his parents relied on one case manager to help develop his service plan, meet with potential providers, access services, maintain contact notes and records, monitor service quality, and respond to all crises. In addition to working with Gregory, his case manager would juggle similar responsibilities for as many as 50 to 60 other adults with developmental disabilities. Consequently, the quality of Gregory’s service and resource coordination was compromised by the limitations in time and energy that one case manager could devote to him. During a crisis, Gregory and his parents required extra attention. The only way his case manager could be responsive was to sacrifice other duties, including cancelling appointments with individuals on her caseload.
When Gregory’s case manager experienced burnout and resigned, her personal knowledge of him and his parents would disappear. It was not unusual for Gregory to have a new case manager assigned every 24 months.
In contrast to the traditional model of relying on one case manager, the new case management model provided Gregory with five service coordinators from the Green Team. During weekly team meetings, members of the Green Team reviewed significant and challenging events they experienced with Gregory in addition to reviewing other people on their shared caseload. Working as a team, they were able to provide an appropriate level of support and services:
· An annual individual plan was developed with the facilitation of the planning specialist.
· TheserviceplacementspecialistassistedGregoryandhisfamilywithidentifyingandselecting
an appropriate day program provider.
· Themonitoringspecialistperformedseveralonsitestudiesforhispotentialprogramplacement
sites.
· The crisis team specialists helped access emergency respite and psychiatric services on the
occasions of Gregory’s unmanageable aggression.
When providing case management under the traditional model, Gregory would have contact with his case manager on average of 72 times over a three-year period. In the first three-year period using the team-based model, Gregory’s Green Team totaled and recorded more than 350 case management contacts with him and his parents:
• 3psychiatrichospitalizations
• 9IndividualPlansandamendments
• 21Psychiatric/BehavioralConsultations
• 6sitevisitsbytheMonitoringSpecialist
• 19InterdisciplinaryTeamMeetingsforproblem-solving
• 36placementrelatedcontacts(emergency/crisisresponse)
• 6InvestigationsofallegedMistreatment,Abuse,Neglect,orExploitation • 19incidentreports
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
IMPROVING CASE MANAGEMENT 25
• 4 appeals to the Department of Human Services to prevent providers from terminating Gregory’s day program services
• 232follow-upcontactswithGregoryandhisparents
The team-based model provided Gregory and his family with assistance from several specialists who were able to bring varied perspectives to his life situation. With the support of his team consist- ing of his primary service coordinator, a planning specialist, a placement specialist, a monitoring specialist, and a crisis specialist, Gregory’s needs were addressed with more immediacy than would be possible by one person working in isolation. All of the team members are familiar with Gregory and his family, so knowledge about his special needs and personal idiosyncrasies will not be lost should a team member leave the organization. In the event that the primary service coordinator left the organization, each remaining member of the team has the case management knowledge and skills to step-in to the role of Gregory’s primary case manager on a temporary or fulltime basis.
ADDITIONAL FINDINGS
Ten years of comparative data collected annually through surveys on client perception of service quality and satisfaction as well as a significant improvement in activities to ensure a client’s good health and safety, reveal a successful transformation to a more effective and efficient model of case management. For each of the ten years that were examined, measures of satisfaction increased as reported by individuals in services (see Table 2).
More important than just measures of satisfaction, the change in the case management model contributed to the improvement of conditions that can affect the health and safety of individuals in services, as illustrated in Table 3.
The approach of using specialized case management staff uncovered many hidden issues that could jeopardize a person’s health or safety. In order for service agencies and providers to remain under contract with Rocky Mountain Human Services and to ensure that they receive timely pay- ment for services rendered, all program deficiencies identified by a case manager must be resolved. Improvements to monitoring program quality during the first three years of the new case man- agement model uncovered instances of neglectful practices and, consequently, contracts with five provider agencies were cancelled. These provider violations had not been identified under the tra- ditional case management model. Additionally, service agencies that demonstrated a marginal level
TABLE 2
Annual Report of Customer Satisfaction
Years
Population Sample
Return
40 (16%) 56 (22%) 74 (28%) 94 (34%) 85 (32%)
114 (38%) 112 (37%) 129 (42%) 127 (41%) 128 (41%)
Average (L) 1 to 5 (H)
3.55 3.75 3.84 4.01 4.24 4.58 4.73 4.61 4.64 4.66
822 247 860 258 875 263 903 271 947 284 998 299
1
2
3
4
5
6
7
8
9
10 1038 311
1006 302 1025 308 1033 310
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
26 BLOCK, WHEELAND, AND ROSENBERG
TABLE 3
Indicators for Improving Health & Safety
Number of Events
Indicator
Pre-move site visits
Dental visits
Quality assurance monitoring of day & residential programs Annual staff turnover
2002 (n = 822) 181
232 202 52%
2012 (n = 1038) 654
1,604 1,004 15% 9%∗
∗Eliminating the count for individuals who left to go back to school, moved out of state with their spouse or partner, or left under the Family Medical Leave Act.
of quality programming experienced a “freeze” on their referrals. Individuals seeking new ser- vices were channeled away from those organizations until the agency could demonstrate measurable improvement.
LIMITATIONS
The demonstration of the organization’s successful transformation to a new case management model does have some limitations. Our report of the positive results of client satisfaction might be tempered by the recognition that some undetermined numbers of questionnaires were completed with the help of providers, family members, or other guardians. While some clients of the services may not have completed the questionnaire on their own, those closest to them seem to approve of the services being delivered, but their responses were not necessarily representing the client’s point of view.
We made claims of improvement in health and safety based on information collected from case files. Although the information was encouraging, this administrative data was collected primarily for non-research purposes. Since each of the events was recorded over the years by various case management staff, some events may not be adequately accounted for in the interpretation of the findings. Furthermore, the overall data that was collected and analyzed from historical records were evaluated using a single subject design. While we are proponents of the use of a single subject design for use in the field by social workers, there have been some detractors of this type of evidence-based approach (Berger & Witkin, 1978; Gray, Plath & Webb, 2009).
CONCLUSION
Underlying the theme of this article is the message that human service managers have an obli- gation to examine the quality of their organization’s services. When program outcomes produce only mediocre results, planned organizational change and not maintenance of the status quo is the appropriate response.
Rocky Mountain Human Services recognition of the chronic case management issues led to the development of a team-based model that has:
• Mitigatedliabilitythroughimprovedriskmanagement;
• Increasedcross-departmentalcooperationandcommunication; • Achieved a higher level of staff morale;
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
IMPROVING CASE MANAGEMENT 27
· Achieved a significant reduction of staff turnover; and
· Achieved significant gains in customers’ expressions of satisfaction.
Management’s optimism led them to assume their organizational conversion would be cost neutral. In reality, costs did escalate. However, the ability to raise the additional funds did not pose a hard- ship and was easier than the challenge of raising money to support a dysfunctional system of case management. In fact, along with the improvement of case management services there has been a sig- nificant increase in solicited and unsolicited contributions, as well as memorial gifts by families and guardians of the individuals who receive services. In 2002, the organization had relied exclusively on its contract with the Colorado Department of Human Services for 100% of its funding. By 2012, 42% of the organization’s budget was comprised of funding from other sources of revenue.
The change to a new model of case management contributed to an organizational culture of support. With improvements in staff retention and turnover going from more than 50% a year to a range of 9% to 15%, the organization received recognition by the Denver Business Journal as one of the best places to work in Colorado.
To maintain its earned reputation and organizational strength, Rocky Mountain Human Services will continue to evaluate its team-based model of case management services along with assessing its other programs. Should significant external or internal issues emerge that interferes with the delivery of quality case management services or the organization’s plans for growth, then its organization’s leaders will not hesitate to go through the challenging process of a risk assessment. If a planned change effort is warranted, then systematic planning and implementation of strategies will be relied on to improve services for individuals with developmental and intellectual disabilities.
Whether it is a case study on the implementation of case management or a report on the findings from researching social work practice, the lessons learned and shared can have an immediate, direct, and constructive application for social workers. As demonstrated in this article, there is value to evaluating one’s own organizational practices and to assess the validity of one’s work. The processes of change that Rocky Mountain Human Services experienced is being shared as a result of its senior managers’ adherence to the deep-rooted idea that social workers should evaluate what they do, report on what they have discovered, and continue to seek more effective ways of helping individuals, families, and larger social networks. The social work profession can only benefit from additional evaluative research and dissemination of reports of relevant changes and improvements of social work practices.
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
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
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).
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
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.
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
IMPROVING CASE MANAGEMENT 19
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 8
22
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.
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
20 BLOCK, WHEELAND, AND ROSENBERG
Developmental disability services for adults begin with an eligibility determination process that is coordinated by a case manager. Applicants for services must meet the state’s definition of a person with a developmental disability, which is an Intelligence Quotient of 70 or below and doc- umented before the individual reaches 22 years of age. Caseloads include persons with intellectual disabilities, autism, cerebral palsy, and Down syndrome, and individuals with other neurological or chromosomal disorders.
After a determination of eligibility, the primary responsibility of the case manager is to develop and implement an individualized service plan by coordinating with selected service providers. The individualized plan can be updated at any time, but the case manager must formally review and re-write a plan on an annual basis. Planning or problem-solving meetings are facilitated by the case manager, and ordinarily include the client, service provider, and other key individuals in the person’s life such as family members, guardians, and friends.
Overall, the case manager is responsible for monitoring the implementation of the individual service plan to ensure that the client is seen for medical, psychiatric, dental and other therapeu- tic appointments, and is receiving appropriate medicines and durable medical equipment. In other words, the case manager is responsible for arranging a comprehensive set of services taking into account the health and safety needs of the individual. Services range from providing housing, voca- tional training, and supportive life-skill services, such as learning to shop, cook, clean house, ride public transportation, or access a community center and other neighborhood resources.
Additionally, case management activities focus on assuring the quality of services clients receive. Case managers must inspect the premises of a program site prior to the start of any new service. The case manager also inspects each home that will be used for residential services, and visits all work settings prior to a person beginning employment services. Case managers also review the administrative files of service agencies to make certain that employees have passed criminal background checks. If a program site appears inadequate or if concerns are raised at any time, the case manager is responsible for finding service alternatives and engaging different providers.
As part of the monitoring process, case managers periodically meet with individuals on their caseloads to ensure they are safe and healthy and their service plans are being fully implemented. Case managers must document their face-to-face and telephone contacts in an agency file. In addi- tion to monitoring services case managers may accompany individuals on their caseload to various appointments, such as attending court proceedings, medical appointments, or psychological coun- seling and testing. Finally, case managers have organizational responsibilities, such as participation in staff meetings, meeting with supervisors, attending professional development and continuing edu- cation training programs, writing contact notes, reviewing client files, as well as devoting time for responding to phone calls and e-mail inquiries within the organization’s 24-hour timely response policy.
THE NEED FOR CHANGE
Each case manager has the daunting responsibility for the well-being of 50 or more individuals with developmental disabilities. A review of the case manager’s major tasks reveals a position with many complex responsibilities (see Table 1). It also raises a concern whether one person can satisfactorily perform the traditional case management function.
A reduction in caseload size might ease the workload burden of a case manager, but it is not a realistic solution in Colorado. Funding levels for case management are established through legisla- tive appropriation. For at least three decades, the State of Colorado has not funded the actual costs necessary to fulfill case management responsibilities. In reality, the state budget appropriation falls short by 26% of the real costs of delivering case management services. As a matter of public pol- icy, the State’s General Assembly and Executive Branch has been content to maintain Colorado’s
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
IMPROVING CASE MANAGEMENT 21
TABLE 1
Key Responsibilities of a Traditional Case Manager
1. Eligibility determination
2. Review of appeals of determination
3. Coordinate Medicaid eligibility
4. Develop and revise the social and medical history and profile
5. Development of an annual Individual Service Plan
6. Identification of appropriate community services and providers
7. Assist in accessing/enrolling in additional community services
8. Crisis intervention
9. Providing counseling and guidance (within the limits of professional expertise)
10. Communicate the breath and limitations of funded services/rules and regulations
11. Monitoring of program service environment
12. Monitoring of service quality
13. Monitoring of contract compliance
14. Monitoring of program budget expenditures
15. Assist in identifying and ensuring the delivery of necessary medical, dental, and psychiatric services
16. Reviewing incident reports
17. Participation in Human Rights Committee (Third Party Reviews)
18. Facilitation of Interdisciplinary Team Meetings for problem-solving
19. Maintaining up-to-date contact notes
20. Administrative responsibilities: staff meetings, training, phone calls, e-mails, etc.
low ranking that ranges annually from 44th to 48th in comparison to all other states’ developmental disability expenditures, on a per capita basis (Braddock et al., 2011).
Over the years, a case manager’s inability to meet performance standards was attributed to inadequate funding, large caseloads, or blamed on the case manager’s limited skill set and lack of motivation to do the work. Consequently, supervisors continued to pressure case managers to improve performance and fulfill responsibilities that were nearly impossible to complete. The stressors of the position contributed to a high rate of staff turnover. In fact, case management super- visors anticipated their staff would burnout and leave the agency within a period of two to three years. Beside the human factor, the expense of turnover was an ongoing financial burden for the organization. It costs $3,000 to $5,000 to recruit and train each new case manager.
A defining moment prompted Rocky Mountain Human Services’ management staff to think dif- ferently about the chronic issues and repeated failures that were blamed on and attributed to the competency levels of case managers. Within a period of one month there were a series of case management problems that could be explained away if viewed on a case-by-case basis, but viewed collectively they could not be dismissed. The proverbial “elephant in the room” could not be avoided as noted by the following five examples of health, safety, and customer service issues:
1. A case manager was on her way to inspect a residence prior to the client moving into the home. On route, the case manager received an emergency page that required her immediate attention. Meanwhile, the residential service provider moved the individual into the home. A crisis occurred when it was discovered that the client was endangered since his mobility was dependent on a wheelchair and the home was not fully accessible.
2. A case manager was unable to meet with a married couple contracted to care for the residen- tial needs of a young woman with a moderate level of intellectual capacity coupled with a thought disorder. Later, it was discovered that the couple were monolingual Spanish speak- ing and the woman in their care only spoke and understood English. Thus, not only was there
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
22
3. 4. 5.
BLOCK, WHEELAND, AND ROSENBERG
difficulty in communication between client and provider, but also the language differences exacerbated the client’s state of confusion.
A new case manager assumed an existing caseload and discovered that the previous case manager had not entered contact notes for several weeks. Thus, there was no historical record of any substantive issues and interventions.
Rocky Mountain Human Services’ staff discovered that some contracted service agencies hired direct care staff with criminal records that should have automatically disqualified the individuals from being hired.
Supervisors spent considerable time handling complaints of family members who did not receive return phone calls from case managers. Eventually, family members called the executive director to express dissatisfaction with case management services.
A NEW MODEL OF CASE MANAGEMENT
A task force of managers and line staff were assembled to study and propose solutions to the grow- ing number of case management problems. An obvious solution of hiring more case managers and downsizing caseloads was not possible due to severe limitations in state funding. Three other pro- posed solutions included filling vacant positions with individuals with graduate social work degrees, providing more frequent supervision and offering continuing education to enhance knowledge and skills. All three recommendations were implemented, but it did not solve the problem.
As long as the attempted solution was of the first-order type, that is, relying on one person to perform the traditional case management role, then the quality of the work and ability to meet work objectives remained problematic. The solution required a more radical fix, using a second-order problem-solving approach:
When the first-order solution does not work, there is an inclination to repeat the same solution over and over . . . If the person does not know how to act differently, they generally do more of the same, more of what they know. Instead of detaching themselves from the thought processes that proved ineffective in solving the problem, they hamper progress by relying on the same old solution . . . Because the intended (first-order) solution becomes part of the problem, second-order change efforts may need to target the first-order approach that fueled the problem . . . A successful change effort must foresee a change in the structural issues . . . that underpin the problem (Block, 2004, p. 30–32).
Because of the ongoing failure to improve the traditional case management service model, a second- order type of decision was made to cease all attempts to improve it. Instead, a decision was made to create a new model of case management. The first step was to gain a thorough understanding of the component parts of case management by deconstructing the role of case manager. A task force examined every aspect of the job. Process mapping (Hyerle, 2009) was used to identify how key functions were carried out and how to ideally execute them (Marlenefiol & Sigismund, 1992). Additionally, process maps illustrated the intersection between case management with other staff positions and departments in the organization.
The outcome of the mapping process reinforced the decision to abandon the traditional case management model and, in its place, create a project team of case management specialists. In this new team model, each specialist would be responsible for one major aspect of the traditional case management function. For example, one specialist would only perform monitoring duties; another specialist would only develop individualized plans, one specialist would only do intake, and another specialist would only do service placements. One case manager would coordinate the implementa- tion of the individualized service plan and serve as the key contact with the client. The case manager with the primary coordination responsibilities would be known as the primary service coordinator.
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
IMPROVING CASE MANAGEMENT 23
In many ways, the team model mirrored the practice of a health maintenance organization’s (HMO’s) use of a primary care physician. In the HMO model, the primary care physician would decide when a specialist was needed to provide the patient with a service, such as, inoculations, x-rays, blood tests, and surgical intervention, among others. Similarly, the design of the new case management model had one person serve as the primary service coordinator with overall responsi- bility for an individual’s services. The Primary Service Coordinator would request the assistance of a specialist as needed. For instance, the planning specialist would be called in to develop the annual individualized plan. If the client were to move to a new residence, the monitoring specialist would be asked to inspect the premises. The working hypothesis was that by having a team of specialists, there would be fewer situations that prevented the completion of a major case management task. Since client information would be continually shared with team members, important knowledge about the specialized needs of the person would not be lost. In this way, the client would receive continuity of care should a service coordinator leave the organization.
The group that planned the new model grappled with a formidable question that could not easily be answered, that is, how many primary service coordinators could draw on the same specialist without creating a hardship for that specialist to complete his or her assignment in a timely and effective manner? To address this issue, there were a series of time studies and process mapping activities for each major case management task. To no surprise, it was determined that the number of different types of specialists would vary based on the specialized function that was needed. The only way to truly address the question was to implement the model and generate a database that would provide comparative and historical information to use to make hiring decisions.
While the caseload size increased for each primary service coordinator, there was a significant decrease in the primary tasks and functions that would normally be assigned to a case manager working alone. The decision makers estimated that one specialist could support four or five primary service coordinators. There was also an assumption that with a change in the case management model, there would be a significant decrease in staff turnover, thus being able to reallocate funds associated with advertising, reviewing applications, interviewing, hiring, and training of new staff.
Finally, Rocky Mountain Human Services had to be realistic about facing the unknown. They forecasted that the conversion and redeployment of staff would be cost neutral. If incorrect, there were two contingency options. First, if the grand experiment was more costly and did not yield significant improvements in case management services, the organization could convert back to the traditional delivery system. Secondly, if Rocky Mountain Human Services discovered that its new model was more costly to implement, but there were significant improvements in the quality of services, especially in matters of health and safety, then the new system would be continued and the organization would use supporting data to increase its fund raising requests. If necessary, during an exploration of new funding, management staff was prepared to freeze their pay and have the cost savings allocated to the hiring of new service coordinators.
A commitment was made at all staff levels in the organization and among the board of directors to embark on a planned change effort to improve the traditional case management system of services. Four teams were created.
RESULTS OF THE TEAM PROCESS: A CASE EXAMPLE
Gregory is a 23-year-old man who immigrated to the United States when he was 6 years old from a war-torn Middle Eastern country. He resides at home with his parents, Helen and Ted. His dis- abilities include pervasive developmental delay and posttraumatic stress disorder (PTSD) and he functions at an IQ level below 70. Gregory requires total assistance with all of his personal needs, including bathing, grooming, and incontinence. He appears to have good receptive language skills and understands and communicates in English and his native language. However, he often mimics
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
24 BLOCK, WHEELAND, AND ROSENBERG
what is being said to him. Gregory’s safety skills are limited. Although he would likely evacuate the home in case of a fire, he would not warn others of the need to flee. Also, he would not dial 911, because he does not know how to use the telephone.
Other challenges for Gregory include a fear of leaving his home, particularly at night. Helen believes that the stars or nightlights remind him of his experiences as a child in the war zone where they resided. From time to time, Gregory hits, kicks, or throws things at others, and he exhibits self-injurious behavior. He has a history of property destruction including breaking toilets, faucets, and windows. On occasion, his parents have called the police out of fear of his aggressive behaviors toward his father. Gregory is treated by a psychiatrist and takes two psychotropic medications. Helen has refused the offers of out-of-home residential services for Gregory. However, she and Ted continue to struggle to provide daily support for him.
Under the traditional model of case management, Gregory and his parents relied on one case manager to help develop his service plan, meet with potential providers, access services, maintain contact notes and records, monitor service quality, and respond to all crises. In addition to working with Gregory, his case manager would juggle similar responsibilities for as many as 50 to 60 other adults with developmental disabilities. Consequently, the quality of Gregory’s service and resource coordination was compromised by the limitations in time and energy that one case manager could devote to him. During a crisis, Gregory and his parents required extra attention. The only way his case manager could be responsive was to sacrifice other duties, including cancelling appointments with individuals on her caseload.
When Gregory’s case manager experienced burnout and resigned, her personal knowledge of him and his parents would disappear. It was not unusual for Gregory to have a new case manager assigned every 24 months.
In contrast to the traditional model of relying on one case manager, the new case management model provided Gregory with five service coordinators from the Green Team. During weekly team meetings, members of the Green Team reviewed significant and challenging events they experienced with Gregory in addition to reviewing other people on their shared caseload. Working as a team, they were able to provide an appropriate level of support and services:
· An annual individual plan was developed with the facilitation of the planning specialist.
· TheserviceplacementspecialistassistedGregoryandhisfamilywithidentifyingandselecting
an appropriate day program provider.
· Themonitoringspecialistperformedseveralonsitestudiesforhispotentialprogramplacement
sites.
· The crisis team specialists helped access emergency respite and psychiatric services on the
occasions of Gregory’s unmanageable aggression.
When providing case management under the traditional model, Gregory would have contact with his case manager on average of 72 times over a three-year period. In the first three-year period using the team-based model, Gregory’s Green Team totaled and recorded more than 350 case management contacts with him and his parents:
• 3psychiatrichospitalizations
• 9IndividualPlansandamendments
• 21Psychiatric/BehavioralConsultations
• 6sitevisitsbytheMonitoringSpecialist
• 19InterdisciplinaryTeamMeetingsforproblem-solving
• 36placementrelatedcontacts(emergency/crisisresponse)
• 6InvestigationsofallegedMistreatment,Abuse,Neglect,orExploitation • 19incidentreports
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
IMPROVING CASE MANAGEMENT 25
• 4 appeals to the Department of Human Services to prevent providers from terminating Gregory’s day program services
• 232follow-upcontactswithGregoryandhisparents
The team-based model provided Gregory and his family with assistance from several specialists who were able to bring varied perspectives to his life situation. With the support of his team consist- ing of his primary service coordinator, a planning specialist, a placement specialist, a monitoring specialist, and a crisis specialist, Gregory’s needs were addressed with more immediacy than would be possible by one person working in isolation. All of the team members are familiar with Gregory and his family, so knowledge about his special needs and personal idiosyncrasies will not be lost should a team member leave the organization. In the event that the primary service coordinator left the organization, each remaining member of the team has the case management knowledge and skills to step-in to the role of Gregory’s primary case manager on a temporary or fulltime basis.
ADDITIONAL FINDINGS
Ten years of comparative data collected annually through surveys on client perception of service quality and satisfaction as well as a significant improvement in activities to ensure a client’s good health and safety, reveal a successful transformation to a more effective and efficient model of case management. For each of the ten years that were examined, measures of satisfaction increased as reported by individuals in services (see Table 2).
More important than just measures of satisfaction, the change in the case management model contributed to the improvement of conditions that can affect the health and safety of individuals in services, as illustrated in Table 3.
The approach of using specialized case management staff uncovered many hidden issues that could jeopardize a person’s health or safety. In order for service agencies and providers to remain under contract with Rocky Mountain Human Services and to ensure that they receive timely pay- ment for services rendered, all program deficiencies identified by a case manager must be resolved. Improvements to monitoring program quality during the first three years of the new case man- agement model uncovered instances of neglectful practices and, consequently, contracts with five provider agencies were cancelled. These provider violations had not been identified under the tra- ditional case management model. Additionally, service agencies that demonstrated a marginal level
TABLE 2
Annual Report of Customer Satisfaction
Years
Population Sample
Return
40 (16%) 56 (22%) 74 (28%) 94 (34%) 85 (32%)
114 (38%) 112 (37%) 129 (42%) 127 (41%) 128 (41%)
Average (L) 1 to 5 (H)
3.55 3.75 3.84 4.01 4.24 4.58 4.73 4.61 4.64 4.66
822 247 860 258 875 263 903 271 947 284 998 299
1
2
3
4
5
6
7
8
9
10 1038 311
1006 302 1025 308 1033 310
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
26 BLOCK, WHEELAND, AND ROSENBERG
TABLE 3
Indicators for Improving Health & Safety
Number of Events
Indicator
Pre-move site visits
Dental visits
Quality assurance monitoring of day & residential programs Annual staff turnover
2002 (n = 822) 181
232 202 52%
2012 (n = 1038) 654
1,604 1,004 15% 9%∗
∗Eliminating the count for individuals who left to go back to school, moved out of state with their spouse or partner, or left under the Family Medical Leave Act.
of quality programming experienced a “freeze” on their referrals. Individuals seeking new ser- vices were channeled away from those organizations until the agency could demonstrate measurable improvement.
LIMITATIONS
The demonstration of the organization’s successful transformation to a new case management model does have some limitations. Our report of the positive results of client satisfaction might be tempered by the recognition that some undetermined numbers of questionnaires were completed with the help of providers, family members, or other guardians. While some clients of the services may not have completed the questionnaire on their own, those closest to them seem to approve of the services being delivered, but their responses were not necessarily representing the client’s point of view.
We made claims of improvement in health and safety based on information collected from case files. Although the information was encouraging, this administrative data was collected primarily for non-research purposes. Since each of the events was recorded over the years by various case management staff, some events may not be adequately accounted for in the interpretation of the findings. Furthermore, the overall data that was collected and analyzed from historical records were evaluated using a single subject design. While we are proponents of the use of a single subject design for use in the field by social workers, there have been some detractors of this type of evidence-based approach (Berger & Witkin, 1978; Gray, Plath & Webb, 2009).
CONCLUSION
Underlying the theme of this article is the message that human service managers have an obli- gation to examine the quality of their organization’s services. When program outcomes produce only mediocre results, planned organizational change and not maintenance of the status quo is the appropriate response.
Rocky Mountain Human Services recognition of the chronic case management issues led to the development of a team-based model that has:
• Mitigatedliabilitythroughimprovedriskmanagement;
• Increasedcross-departmentalcooperationandcommunication; • Achieved a higher level of staff morale;
Downloaded by [EBSCO Publishing Distribution 2010] at 11:41 08 April 2015
IMPROVING CASE MANAGEMENT 27
· Achieved a significant reduction of staff turnover; and
· Achieved significant gains in customers’ expressions of satisfaction.
Management’s optimism led them to assume their organizational conversion would be cost neutral. In reality, costs did escalate. However, the ability to raise the additional funds did not pose a hard- ship and was easier than the challenge of raising money to support a dysfunctional system of case management. In fact, along with the improvement of case management services there has been a sig- nificant increase in solicited and unsolicited contributions, as well as memorial gifts by families and guardians of the individuals who receive services. In 2002, the organization had relied exclusively on its contract with the Colorado Department of Human Services for 100% of its funding. By 2012, 42% of the organization’s budget was comprised of funding from other sources of revenue.
The change to a new model of case management contributed to an organizational culture of support. With improvements in staff retention and turnover going from more than 50% a year to a range of 9% to 15%, the organization received recognition by the Denver Business Journal as one of the best places to work in Colorado.
To maintain its earned reputation and organizational strength, Rocky Mountain Human Services will continue to evaluate its team-based model of case management services along with assessing its other programs. Should significant external or internal issues emerge that interferes with the delivery of quality case management services or the organization’s plans for growth, then its organization’s leaders will not hesitate to go through the challenging process of a risk assessment. If a planned change effort is warranted, then systematic planning and implementation of strategies will be relied on to improve services for individuals with developmental and intellectual disabilities.
Whether it is a case study on the implementation of case management or a report on the findings from researching social work practice, the lessons learned and shared can have an immediate, direct, and constructive application for social workers. As demonstrated in this article, there is value to evaluating one’s own organizational practices and to assess the validity of one’s work. The processes of change that Rocky Mountain Human Services experienced is being shared as a result of its senior managers’ adherence to the deep-rooted idea that social workers should evaluate what they do, report on what they have discovered, and continue to seek more effective ways of helping individuals, families, and larger social networks. The social work profession can only benefit from additional evaluative research and dissemination of reports of relevant changes and improvements of social work practices.
Essay Writing Service Features
Our Experience
No matter how complex your assignment is, we can find the right professional for your specific task. Achiever Papers is an essay writing company that hires only the smartest minds to help you with your projects. Our expertise allows us to provide students with high-quality academic writing, editing & proofreading services.
Free Features
Free revision policy
$10Free bibliography & reference
$8Free title page
$8Free formatting
$8How Our Dissertation Writing Service Works
First, you will need to complete an order form. It's not difficult but, if anything is unclear, you may always chat with us so that we can guide you through it. On the order form, you will need to include some basic information concerning your order: subject, topic, number of pages, etc. We also encourage our clients to upload any relevant information or sources that will help.
Complete the order form
Once we have all the information and instructions that we need, we select the most suitable writer for your assignment. While everything seems to be clear, the writer, who has complete knowledge of the subject, may need clarification from you. It is at that point that you would receive a call or email from us.
Writer’s assignment
As soon as the writer has finished, it will be delivered both to the website and to your email address so that you will not miss it. If your deadline is close at hand, we will place a call to you to make sure that you receive the paper on time.
Completing the order and download