Historically, AIDS case managers work primarily in two settings - (1) within CBOs or (2) in public hospitals that provide medical care for persons who have many needs and who are HIV-seropositive or have AIDS (Mor et al., 1993; Piette et al., 1990). The activities of AIDS case managers, in terms of structure and content, differ substantially, depending on the work site. This finding is consistent with studies that found that the location of the organization significantly shapes the content of case management services (Intagliata & Baker, 1983). Piette and his colleagues (1990) found that hospital-based case managers served more people who injected drugs as well as clients who needed long-term care, housing, transportation, and psycho-logical counseling. In contrast, CBO case managers served primarily gay or bisexual clients who more often needed emotional support, usually provided by volunteers, and legal assistance. Furthermore, hospital-based case managers were significantly more likely to provide psychological counseling or therapy, whereas case managers in CBOs were more likely to work to expand or develop services (Piette et al., 1990).

Evaluation of the Robert Wood Johnson AHSP projects found similar results: hospital case managers focused on discharge planning, obtaining entitlements, and making referrals for home care; CBO case managers linked clients with emotional support programs, "buddies," emergency housing, and financial support (Mor et al., 1993). Piette and his colleagues (1990) also found that case managers in CBOs had significantly less education and less experience with case management than hospital-based case managers. In the early 1980s, because of the stigma surrounding AIDS, CBOs that were already working with the gay and lesbian community were the first to offer support services for people with AIDS, and the initial qualification for case managers was a willingness to work with gay clients. In contrast, most hospital-based case managers had a nursing or a social work background. Interestingly, no differences in sizes of the caseloads were found of hospital- and CBO-based case managers (median, 50 cases). These findings are based on research conducted in the late 1980s; thus, it is unclear whether there continues to be such a sharp difference between hospital- and CBO-based case managers. Three changes in the 1990s may affect these results: an increase in the number of CBO clients who are not gay, better educated case managers in CBOs, and less stigmatization of the organizations and people working in AIDS-related CBOs.

One possible reason for the differences between hospital- and community-based case management is that hospital-based case management is much better defined than community-based case management (Sowell & Meadows, 1994). In other words, expectations and requirements are clearer for hospital-based case management, partly because the case management system is part of a large medical system with strict documentation and qualification requirements and a history of providing social work services. In contrast, the expectations for community-based case management programs are more abstract. Piette and his colleagues (1990) found that cities with hospital- and CBO-based case management systems had few protocols for sharing client information, transferring primary responsibility for clients, and differentiating the roles of the two systems (Piette et al., 1990). To resolve issues of coordination when multiple case managers are involved, Piette and his colleagues (1990, 1992) recommended an explicit protocol for structuring the relationship between case managers. Sowell and Meadows (1994) recently reported on a comprehensive program to integrate CBO case managers into a variety of community settings including local hospitals serving AIDS patients.

Go to section 2.2.2 Evaluation