1. Individual-level or primary personal services - assessment, planning, treatment, and monitoring

2. Community-level or secondary personal services - advocacy, support, linkage to services, and networking

3. Interface services - client identification and outreach, administration, public relations, and education and training Lauber (1992) noted that traditionally trained case mangers are schooled in providing individual-level and community-level services, but they receive little training in public relations, organizational theory, and management, which would aid in providing interface services. The fact that case managers must use these types of "management" skills, for which they are seldom trained and that are distinct from individual- and community-level service, has been emphasized by other commentators (Wolk, Sullivan, & Hartmann, 1994).

2.1.4.1 Case Management as an Individual-Level Activity

Rothman's (1992) first generalization about case management as an individual-level activity is that "effective outreach and intake efforts are associated with a quick response time and assertive follow up" (p. 17). Thus, time is of the essence early in the process to bring clients into case management. Second, the need for a thorough assessment was found to be essential for case management practice (this has particular implications for the educational level of case managers and for staff development). Third, Rothman's review found that "effective case management planning includes clients in the process" because many clients are already aware of their goals and what would help them meet those goals (p. 19).

Regarding linking clients to services, Rothman (1992) found that "effective case managers take an active and facilitative practice role in connecting clients with service agencies" (p. 20). As for the content of advice-giving, counseling, or therapy, Rothman found that it is more effective when it focuses on advice and information giving, problem solving, reality testing, and socialization skills rather than traditional intrapsychic therapy (Rothman, 1991, 1992). Because clients who are appropriate for case management programs generally have significant difficulties, it is not surprising that they benefit most from a present-focused, reality-based approach. Finally, Rothman's guidelines indicate that client monitoring and evaluation are essential parts of case management, "because services are needed on a continuous and indeterminate basis" (1992, p. 22-23). These guidelines, developed from Rothman's review of the research, highlight effective individual-level case management activities and practices.

2.1.4.2 Case Management as a Community-Level Activity

Because case managers often are aware of clients' needs, they could be individual- and system-level advocates. Many programs, however, focus primarily on the client level (Graham & Birchmore Timney, 1990; Rothman, 1992). Barriers to systems-level advocacy by case managers include lack of power and fear of complaining about the system that employs them. In addition, because the activities of case managers are affected by the service system in which they operate, work setting may facilitate or inhibit community-level activities (Piette et al., 1990). Rothman (1992) reported on several community-level factors that influence case management:

• Organizational base or setting, for example, case management provided as a free-standing service or a service within another program
• Degree of involvement in direct service provision
• Professional reference group of case managers, for example, mental health, medical, or health education professionals
• Target population
• Authority base, for example, control over funding and services

Although little research has been conducted on the relationship between the first three variables and case management practice, we discuss the last two factors to illustrate the concept of community-level activity.

Authority base is defined as the ways in which an agency and its employees can elicit favorable responses - services - from other agencies for their clients. An authority base can be established through informal or formal agreements, contractual arrangements, or specific legislative enactments (Rothman, 1992). Having an authority base, whether it is administrative, legal, fiscal, clinical, or some combination thereof, allows case managers both to procure services for their clients and to engage in community-level advocacy for improvements in service systems. Rothman (1992) developed a generalization based on the research: "an authority base for case management facilitates the ability to integrate services for clients. Successful integration of services necessitates case managers to have 'clout'" (p. 26). In other words, case managers more successfully integrate services for clients to the extent that they have the ability or the clout to provide or procure a range of services. Although this point may seem obvious, in some situations, case managers are expected to provide or link clients to services when they do not have the ability, administratively, legally, or through formal interagency agreements, to do so.

Regarding target population, Rothman (1992) found that case management programs were affected by the population served. Population characteristics and needs affect the range of case management tasks provided and the way in which the service is marketed and delivered. The target population also affects caseload size. The suggested ideal caseload for case managers ranges from 10 to 35 clients, depending on client characteristics (including severity and type of need) and role expectations for the case manager. When case managers deliver many direct services or when the clients are younger, harder to engage in treatment, or more vulnerable to environmental forces (such as poverty), smaller caseloads are expected (Rubin, 1992). Also, case managers with smaller caseloads may be expected to develop a more counseling-like alliance with clients.

Go to section 2.1.5 Key Questions