For example, few standardized assessment instruments were being used; thus, the assessments of clients differed across sites and across case managers at the same site. Assessment instruments were often simply brief checklists. Need-based triage was virtually nonexistent, meaning that client services could not be decreased if clients' needs lessened, and the most vocal clients received the most services. The few case plans that existed were not useful to anyone but the original case manager. Paperwork was a low priority, and documentation was informal, a situation that works best with a small caseload and few providers. In addition, few agencies had formal monitoring policies, and changes were seldom noted in case records. Finally, client-centered advocacy was valued, but system-level advocacy received little financial support (Piette et al., 1992). The authors cautioned that these results should be interpreted in light of the following facts: (1) data were collected in 1988, when all the participating CBOs were very young organizations, (2) caseloads were growing rapidly, (3) resources were sparse, and (4) the development of a coordinated case management system was just beginning.

Despite the caveats, some of the authors' suggestions seem relevant. The importance of a thorough assessment and proper assignment of clients, or triage, was emphasized. As practiced, AIDS case management was crisis-focused and reactive, leaving case managers to spend most of their time with clients who were most in need or most vocal. The use of "high-need" and "low-need" client categories with separate protocols for frequency and type of interaction was one suggestion for managing caseloads (Piette et al., 1992). Monitoring client status is crucial to any two-tiered system so that clients can be moved as their needs change. Such monitoring may require structured, regular contact with clients (according to explicit protocols). Monitoring ability is enhanced with a manageable caseload and adequate case records. If a team approach is used, professionals, paraprofessionals, and volunteers must have an explicit, structured way to communicate (for example, case conferences or case notes in a central file used by all staff).

Regarding the level of training required for AIDS case managers, Piette and his colleagues (1992) suggested that bachelor's-level social workers were optimal because they were trained in making the crucial service linkages while remaining sensitive to psychological issues. Master's-level case managers also were effective case managers, but many of them complained that the job did not allow them to use their therapy training. Unfortunately, because of high turnover and burnout, inexperienced people often stepped into case manager positions. Thus, detailed protocols and procedure manuals were suggested to ensure the effective delivery of services and adequate minimum standards of care (Piette et al., 1992). Regarding system-level advocacy, the authors suggested that a specific person be hired to perform this task so that case managers could focus on client-level advocacy. Finally, client advocacy requires that case managers closely monitor their clients' needs and the delivery of services to the client, a skill for which case managers should receive training.

More recently, a framework was proposed for evaluating the community programs funded by the Ryan White CARE Act (Aday et al., 1994). Although these programs encompass more than just case management, the framework is instructive for the potential evaluation of PCM. In this framework, three criteria were used to evaluate how well the programs met their objective: (1) the structure, or design, of the program; (2) the process, or method, by which goals were achieved; and (3) the out-comes, or effects, of the program on the population served (Aday et al., 1994). Process evaluation may be particularly important in AIDS case management, in which some clients may be functioning more poorly over time in some areas, for example, physical status or the ability to live independently (Sowell & Meadows, 1994). Thus, case managers can meet acceptable standards by following and meeting certain process goals even if client functioning declines in some areas. Sowell and Meadows also specified client satisfaction as an important measure of success for AIDS case management.

Go to section 2.2.3 Conclusions