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Case Management with At-Risk Youth
Available online: [http://smhp.psych.ucla.edu/qf/case_mgmt_qt/Case_Management_with_At-risk_Youth.pdf]
Hector is a seventeen year old dropout, living on the streets. Barely literate in English and Spanish, he left school two years ago after repeating the ninth grade unsuccessfully. He has never held a steady job and has had several run-ins with the law. He is alternately charming and angry, and not sure what he wants. He needs, at the very least, basic education, skills training, housing assistance, counseling, and a job.
Julia is fifteen, a high school sophomore, and several months pregnant. She has gotten along in school, but she only reads at the seventh-grade level. She is planning to drop out of school soon and go to work, though her only experience is as a babysitter. She is going to need help staying in school and staying healthy: remedial education, health and day care, career education and some initial work
Hector and Julia represent a growing challenge for youth practitioners: how to access and manage the increasingly complex set of services needed by at-risk youth. As youth employment and education programs expand their services to those most at risk, they need to coordinate not only employment and training services, but such services as remedial education, family counseling, health, housing, public welfare, and daycare. And as the number of organizations involved in serving each youth grows, so do the problems of determining service options, making successful referrals, and tracking client progress over an extended period of time.
For many youth practitioners, the answer to these problems is case management: the use of a broker – the case manager – to help at-risk youth identify, gain timely access to, and successfully complete an individualized set of services provided by a variety of institutions. Case management is not a new idea – social workers and others have made use of it for decades. But it is one that has only begun to apply in the fields of education and youth employment.
Recently, the Center for Human Resources at Brandeis University was asked to examine case management practices in several fields and to provide some guidance for youth practitioners. What we found was that case management is an exciting concept. It offers the potential for customized services, coordination, and a coherent, comprehensive approach to the problems of at-risk youth. But case management is not a magic bullet. The reality is that an effective case management effort is tough and time-consuming to implement. Whatever form it takes (and it takes many forms), case management is more likely to pave the way for valuable but incremental, improvements in services rather than
wholesale change. Moreover, case management is, ultimately, a “political” system. Case management’s success depends in large part on the willingness of established institutions to change their traditional ways of doing business. This article presents some of the basic lessons that we synthesized from our review of case management in employment programs, and in services for teenage parents, the elderly, and the developmentally disabled. Its goal is not to provide a simple, standard case management formula – there is none. But it does attempt to identify some important ingredients for case management and to describe some of the key steps common to case management systems.
What is Case Management? One reason why it is difficult to provide a state-of-the-art formula for successful case management is that nobody agrees about what case management actually is.
After reviewing the literature on the use of case management with the elderly, James Callahan, a Brandeis University policy expert concluded that it has become “a Rorschach test. Each professional tends to understand case management based on his or her own setting and experience.” Others have drawn similar conclusions, commenting that the term is “mired in controversy and confusion” and that “its functions have been interpreted in disparate ways, often making case management a paradoxical assortment of activities….”
Common Definitions Some common themes, however, can be found. One authority, the Joint Commission on Accreditation of Hospitals, defined case management services as “activities aimed at linking the service system with a consumer, and coordinating the various system components to achieve a successful outcome. Case-management is essentially a problem-solving function designed to ensure continuity of services and to overcome systems rigidity, fragmented services, misutilization of certain facilities, and inaccessibility.”
A second definition echoes the first: “At the systems level, case management may be defined as a strategy for coordinating the provision of services to clients within that system. At the client level, case-management may be defined as a client-centered, goal-oriented process for assessing the need of an individual for particular services and obtaining those services.” As we reviewed more than a dozen definitions, several consistent ideas emerged. Case management is an approach that seeks to make service delivery:
- Goal Oriented
It can best be appreciated as an opportunity for institutions to link with other institutions in a coordinated fashion that ultimately benefits the client because it:
- incorporates a coherent, sequential, multidimensional, problem-solving approach;
- locates the client within a particular “life space” and social framework;
- seeks to stimulate change both within the client and the overall environment of
which he or she is a part.
Why is Case Management Needed?
At-risk youth have needs that are often complex and intertwined. They require help determining which among a variety of services they need, when, and in what order. They require assistance finding and accessing those services, and support to successfully complete those services.
Human service institutions, on the other hand, are often one-dimensional and specialized. They typically offer services that are funded and provided as separate entities: housing is the niche of one agency, education that of another, and job training that of a third.
The result is that there is often a mismatch between the behavior of the helping professions and the needs of the youth whom those services intend to help. Without case management, interventions are often uncoordinated and scarce resources squandered. A young person can easily fall through the cracks or give up trying to navigate what is, in most locales, a disjointed multi-institutional “nonsystem.” The function of case management is to overcome the mismatch between institutions and client needs and to provide the continuity of services that are critical for at-risk youth.
Effective Case Management
In order to locate and walk a young person through a sequence of services, the typical case management system has the following components:
- Finding and attracting appropriate clients;
- Intake and assessment;
- Designing a service plan;
- Intervening in the community: brokering, advocating, and linking;
- Implementing and monitoring the service plan;
- Evaluating the effectiveness of case management.
What makes these activities effective, however, is the philosophy or approach that guides them. As we reviewed the literature and talked with practitioners, four major themes stood out as central to almost every aspect of the case management process:
Case Management Requires Partnership Case management is, first and foremost, a system of partnerships: between the case manager and client, and between organizations. In an effective case management system, the case manager works in partnership with the client, sharing responsibility, rather than working on the client. There is a division, rather than a substitution, of labor. Case management also involves partnerships among institutions. At some level, each must be willing to be flexible and to share access to services or resources. In that context, the case manager works for all the partners, helping institutions access clients and linking clients with those institutions that offer the services young people need.
Case Management Must Provide Predictability Many disadvantaged youth experience life as a series of random events over which they have little control. Successful case management systems work to rebuild that sense of control and predictability by helping young people to plan, to set goals, and to undertake a systematic process of meeting those goals. Young people learn that they can make choices and that their actions lead directly to concrete.
Case Management Demands Accountability Client trust and effective coordination rest on the delivery of promised services. For case management to work, clients, case managers, and institutions must be clear about their roles and responsibilities; tasks and associated timelines must be written down, and ambiguity must be replaced by explicit agreements. When accountability is not clear, case management systems break down.
Case Management Communicates Respect for the Client The success of any case management effort depends on the degree to which the young person is engaged in the development and joint ownership of a remediation plan, and has a major stake in ensuring its success. A strategy that is imposed with little regard for a client’s interests or concerns has little chance to bear fruit. In every aspect of case management, then, the client has to be treated as a mature, responsible adult, not as a number or a child.
Making Case Management Work
These themes set the context for case management and shape much of what takes place in each step of the case management process.
Finding and Attracting Appropriate Clients The initial contacts with a case management system are an important opportunity to establish a relationship and set expectations. Predictability and accountability should be hallmarks of those contacts. Potential clients need to be oriented to the purposes and structure of case management, what it can and cannot provide, and what their responsibilities will be. They should clearly understand early on that case managers work in partnership with them, not on them, and that development of a case management plan may constitute a commitment to long-term services.
Equally important, those initial contacts need to convey an attitude of respect. Case managers and their supporting service providers need to show a genuine feeling of enthusiasm, caring, and dignity to the youths who approach them. This includes initial telephone contacts. No contact with a young person should be conducted in an impersonal, bureaucratic manner: it will only turn that young person off.
Lastly, case management is not for everyone. To be effective, a case management system needs to identify a target population that can benefit from long-term, holistic services, and that is amenable to receiving them. The marketing and outreach campaign needs to be clear about what is being offered while highlighting the benefits of a long-term, individualized approach.
Intake and Assessment Intake and assessment should also be caring, professionally-handled experiences that communicate respect to the client.
The enrollment process sets a tone for an ongoing relationship. When the case manager (not a clerical functionary) interviews the client, he or she should retrieve not only the information typically sought in the organization’s regular intake process, but also data related to comprehensive, long-term services. This information will contribute to current and later accountability. At the same time, to contribute to the client’s sense of predictability and partnership, care must be taken to inform him or her about why data is being gathered and how it will be used.
The most effective assessment tool is a series of personal appointments in which the case manager hears, sees, and senses the young person’s situation. The case manager can learn who this person is, what strengths can be worked with, and what vulnerabilities must be compensated for. Interviews should shed light on such questions as:
- What social skills does the client possess? How developed are verbal and expressive capacities? What affect and emotional tone are conveyed? How organized is the client? How does he or she describe problems, possible solutions, and future ambitions?
- What support network already exists? Who within the client’s environment can be turned to for help? Are there role models?
- What is the client’s school history? What problems crop up and when? Do patterns emerge in the relationship of the client to teachers and school authorities?
- What is the client’s employment experience? What issues recur? What vocational interests are expressed? Are the client’s expectations realistic?
- What is the client’s service history? Is it possible to pick up where a previous service provider left off?
Assessment will probably also involve testing; however, it is important to choose tests capable of generating information that is accurate and that a program will actually use. Many testing instruments exist; however, no one test renders a complete understanding of a client’s problems and potentialities. In addition, unless testing is related to real program options and can help determine which options make sense for a client, the entire process becomes a misleading exercise. Respect for the client leads to the rule: “collect all the information you can use, and use all the information you collect.”
In sum, the intake and assessment process helps map out the terms of the case manager/client partnership, subject, of course, to revision and renegotiation. But it is equally important to note that, while there are advantages to gathering lots of good data up front, assessment is an ongoing process. The case manager will need to work hard over time to develop a relationship with the client and to continually track his or her progress.
Designing a Service Plan The alliance between the case manager and client is intended to bring about change. The case manager works in partnership with the client to develop clear expectations and set realistic goals. The client’s views of what she or he wants must be acknowledged, respected, and then tempered with the case manager’s input about reality.
How goals are subsequently translated into changes, through what means, and over what period of time, are issues that are addressed and pinned down in a written service plan. To assure predictability, the case manager needs to explain how one service precedes another and to help the client sequence each service. Together, they work as partners to formulate a written contract that ensures mutual accountability – one that delineates their respective responsibilities and is explicit about the nature of the partnership being agreed to.
An ideal plan includes long-term goals accompanied by short-term objectives that are quickly achievable – the client can experience regular, predictable “wins.” The plan translates those objectives into the services necessary to achieve them and identifies organizations or individuals who provide those services.
A well-designed service plan ensures client ownership. Specific, mutually defined tasks, clear timelines, and delineation of mutual roles help the young person feel that it is his or her plan and that he or she is empowered to carry it out. To reinforce ownership, predictability, and accountability represented by the plan, the case manager should also include dates to review the plan with the client and a projected date for termination of case-management.
Intervening in the Community: Brokering, Advocating, and Linking For a case manager to make effective referrals, institutions at the receiving end must have slots available on a needed basis. They must be willing to grant timely admission to their programs, rather than placing the client on a waiting list. Ideally, the case manager can say: “I need my client enrolled in your program this week,” and have it happen. Persuading institutions to do this is not easy.
Agencies providing case management have taken a variety of approaches to the referral process. Some, place primary responsibility for identifying and securing services with the case manager, who works to develop needed slots on a case by case basis. Other agencies have organized the referral process more formally by assigning the task to a “resource developer” who secures service slots from agencies in the
same manner as job developers have traditionally obtained employment slots from businesses.
Both of these approaches, however, are far from ideal. Both are essentially piecemeal approaches that do little to encourage institutions to move away from “business as usual.” As a result, case managers and “resource developers” continue to face problems securing slots. Both approaches lack predictability (the case manager cannot guarantee a slot to the client) and accountability (agencies are not accountable for the failure to provide services). And neither can guarantee respect for the client (institutions have no rules or buy-in related to this aspect of client service). While both approaches place a case manager in charge of identifying and linking together a sequence of services, they offer
few tools for assuring the quality of services or that the necessary linkages will actually take place.
The tools needed to assure timely referrals and to institutionalize case management over the long-term are most likely to result from the creation of a formal inter-agency partnership or providers alliance in which member institutions empower case managers to “requisition” slots across institutional boundaries. Formed specifically to enable case managers to arrange fast admission to services for their clients, these collaborations can be organized with clear rules that ensure accountability, communicate respect, and build in predictability. (See the discussion of the Boston Education and Employment Project in this issue for information on one case management alliance.) Collaborations of this type take hard work to develop and maintain. But without the establishment of a network of explicit agreements – partnerships – case management is unlikely to offer significant improvements over the existing service delivery system.
Implementing and Monitoring the Service Plan The partnership between client and case manager
continues in accomplishing the terms of the service plan. That process involves a division of labor in
which the young person carries his or her weight: showing up for appointments, enduring testing,
attending training classes, etc. The case manager provides oversight, ensures coordination and
continuity of service, and gives the youth opportunities to show initiative and develop competence.
The relationship is dynamic and shifting, sometimes requiring hand-holding, sometimes stern lectures
(“tough love”), sometimes nagging, sometimes a gentle push to risk “going it alone” – always based in
A case manager skilled in the use of referral procedures can help a young person become an active partner in his or her own service plan.
After assisting a client to identify the problems he or she faces, translating those problems into service needs, and giving each an appropriate priority, the case manager generates a set of service options from which the client can choose. Before choosing, the case manager and client discuss how each option might meet the client’s needs – issues such as the reputation of each agency, their eligibility requirements and fees, the amount of time the client will have to spend in service, and agency locations and proximity to transportation.
Once the client has chosen an option, he or she needs to hear about the referral procedure in simple step-by-step terms. Ideally, the client will then, in the case manager’s presence, call a known person at the referral organization and schedule an appointment. In all cases, the client should write down the appointment date, time, contact person’s name, and directions to the referral agency. Predictability is the watchword.
The case manager also needs to determine how much additional support the client needs to carry out the referral successfully (transportation, hand-holding, babysitting, etc.) and help the client arrange for that support.
To ensure accountability, the case manager usually contacts both the client and the referral agency shortly after the client’s appointment to identify what transpired as seen through the eyes of both parties – perceptions often differ. The client and case manager can then determine what the client’s next steps are, how the case manager can support their implementation, and whether a revision of the service plan is called for. These tasks are written down and become part of the service plan. Of course, if the client did not attend the appointment as planned, it is through such monitoring that the case manager learns that corrective action is necessary.
After a client has been successfully placed into a program, the case manager monitors the placement to assure that it meets the needs set forth in the service plan. If the client completes a service, he or she can then move on to the next (predicted) aspect of his or her service plan. On the other hand, if the client is unable to achieve his or her goals through the referral, it may be time for the case manager to
intervene with the referral agency, or even to review and adjust the service plan.
Accountability and predictability in implementing a service plan also depend on communication among the service providers. As much as possible, there should be regular team meetings, face to face, with the various human service workers associated with each case.
Problems must be worked out, histories shared, expectations established. Team meetings (case conferences) are at the heart of “continuity of care.”
Finally, the long-term goal of any service plan should be for a client eventually to no longer need case management. Partnership, predictability, accountability, and respect are all aimed at helping young people to complete their service plans, learn how to access other services on their own, and feel ready to handle life without professional intervention: in short, to be ready to break from case management
Evaluating the Effectiveness of Case Management Case management is expensive and time-consuming. It is important, therefore, that its results be evaluated. Some of the questions that need to be asked are:
- Over several years, do the numbers financial analysis, placements, positive terminations, etc. – bear out what practitioners’ gut-level views may have called”success?”
- Have the services and resources to which clients have been referred to been appropriate and adequate to meet their needs? Was case management effective at accessing and coordinating those services and resources?
- What has happened to clients one year, and two years, after ceasing case management support? What might have happened if case management had not been provided?
- If evaluation indicates that case management may not have been successful, should it be discontinued, or could some adjustment make it viable?
While these are tough questions, they are critical to understanding if case management is working and whether the effort going into it is ultimately paying off.
The Case Manager’s Role
The basic principles of case management point to a multifaceted role for the case manager. In essence, case managers are “jacks of all trades.” They stimulate, coordinate, and monitor service delivery so that youth do not fall through cracks. They do whatever is necessary to remove barriers hindering a client’s advance towards self-sufficiency.
According to one text, case managers “help clients develop and effectively utilize their own internal problem solving and coping resources, and facilitate ongoing interactions between resource systems to enable those systems to work together more effectively. Case managers facilitate and improve interaction between staff within resource systems to promote the effective and humane operation of these systems and to make them responsive to client needs. They establish linkages between clients and resource systems, and between resource systems themselves to make them accessible to each other. They develop new resource systems to meet the needs of clients.” [Anne Minahan, “Generalists and Specialists in Social Work,” Arete (Fall, 1976)]
Case managers serve as surrogate parents, role models, counselors, social entrepreneurs, and political advocates. They nag, cajole, prod, and encourage clients. They pressure institutions to act responsibly or lubricate the gears between institutions. They make referrals and monitor client fit. They deal with the client’s family life; work and school; social services and public institutions. They alter client behaviors strengthening client capacity to exercise self-determination and autonomy.
Qualifications for Case Managers What are the proper qualifications of a case manager? They vary according to the context. A national study examining 140 case managers in six cities, for example, found that roughly a third had less than a college degree, 55% had four years of college and only 15% were master’s level. Social work training was typical, but not obligatory. Case managers serving teenage girls often had a nursing background. Ex-gang members sometimes did case management work with gangs. At times, parents served as case managers for developmentally disabled children.
Disciplined Empathy Case management qualifications reflect local environments; nevertheless, some cross-cutting criteria can be identified. For example, effective case managers seem to exhibit what might be called “disciplined empathy.” They respect and care about their clients, and can develop partnerships with those clients. They listen to what clients say, read between the lines, and size them up. They can work with the client to develop a service plan and can have the client “buy in” to it as if it were his or her idea in the first place.
Effective case managers demand accountability from clients. They have a compassionate but tough-minded understanding of the youth they work with – an ability to develop a therapeutic alliance and to challenge and confront kids to meet their end of the bargain.
Partnership Skills At the same time, case managers have to have the skills to develop partnerships with institutions. Diplomatic sensitivity is a key trait. Case managers negotiate with bureaucracies for services. To do so well requires adept social skills, and an ability to read institutional cultures. Crossing jurisdictional lines entails a delicate balancing act – doing business on someone else’s turf.
Out-stationed staff must be able to assert client interests while being creative and flexible enough to make case management complement the mission of the host.
Being indigenous to, or at least to have a working knowledge of their community can be a plus for a case manager. Being of the same racial or linguistic background as the majority of clients is also desirable. Neither is a precondition.
It also helps if case managers have a human services orientation. They need to adopt a philosophy that barriers to client self-determination are both internal and external and constantly interact. Interventions must aim at changing both the individual and the environment.
Entrepreneurial Ingenuity Finally, case managers should exhibit entrepreneurial ingenuity. Because resources are not immediately accessible, effective case managers need to be able to fashion client support networks from resources under others’ control. They need to be able to mediate alliances among competing agencies, establish trust and articulate mutual interests.
Staff Development Key It must be acknowledged, up front, that it is rare for an organization to hire an ideal, ready-to-operate case manager. In fact, it is neither feasible nor desirable that case managers have a standard resume. Rather, good case managers are created. They enter the field with solid “raw material,” but it is training that molds them into effective professionals.
The key to that process is on-going staff development that acquaints potential case managers with the multiple elements of good case management and conveys the capacity to design – in partnership with clients – a strategy of predictable remediation and support. Case managers should learn to conceptualize the importance of family, group, community, and social policy as they affect schemes of intervention. They should understand the components of accountability – a good case record, and clear entries for intake, referral, service delivery, termination, and follow-up. Case managers should be able to define and give examples of advocacy techniques. Finally, case managers must grasp the need for partnership agency coordination and institutional collaboration – and understand the barriers which stand in the way of building such alliances, and how these barriers can be overcome.
The Case for Case Management
In the end, case management cannot be seen a cure-all for all the problems of serving at-risk youth. It is difficult to implement, time-consuming and resource-intensive to operate well, and depends on the willingness of established institutions to change their long-standing ways of doing business.
But case management still has much to offer practitioners serving at-risk youth. When given the care and attention required, a case management approach can provide an essential measure of coordination and support for youth in need of assistance. And as human service professionals confront increasingly complex problems and seek new ways to respond, case management can provide a valuable conceptual framework in which services can be planned and new techniques for bringing those plans into operation.
This article draws on research conducted by Andrew Hahn, Paul Aaron and Chris Kingsley at the Center for Human Resources for the New York Community Trust and the Exxon Education Fund. It also builds on the Center’s work for the Annie E. Casey Foundation’s New Futures initiative. This and additional material form the basis for a forthcoming (Spring, 1989) Center for Human Resources publication on effective case management practices. For more information on that publication, contact The Center for Human Resources, The Heller School, Brandeis University, 60 Turner Street, Waltham. MA 02254-9110.
Special Thanks to UCLA School of Mental Health, for this crucial and valuable information.