• Should case managers adopt a broad range of helping roles and proactive interactions with the client?
• Should case managers be primary therapists?
• Should case managers be involved in community-level activities such as resource development and class advocacy, including supporting case management services, increasing the supply of services, and improving access to services?

The answers to these questions overlap and high-light some of the difficulties in clearly defining the boundaries of case management.

2.1.5.1 Breadth of the Case Manager's Role

Models of case management differ about the range of tasks the case manager is expected to perform. This range is influenced not only by resources allocated to case management but also by the availability of community resources (Rubin, 1992). For example, in areas with fewer resources, case managers may be expected to go beyond resource-linking roles and become providers of direct services. In such areas, the skills of the case manager may need to be broader and more advanced than in resource-rich areas; in resource-poor areas, the case manager may have to fill many roles (resources are discussed in more detail in Section 2.1.5.3). The case managers' roles also are affected by whether the program uses an individual approach, in which case managers perform many tasks, or a team approach, in which case managers specialize in one or a few tasks. Neither an individual nor a team approach has been found to be superior (Rothman, 1992), and many programs are based on local need and talent rather than on any specific model.

The range of helping roles adopted by the case manager also is influenced in part by whether a particular case management program is implemented to provide services or to ration resources or both. A potential conflict of interest may arise concerning the case managers' roles in procuring services if the goal is also to decrease costs (Baldwin & Woods, 1994). This conflict can be conceptualized by viewing case management activities along a continuum from one extreme, where greater emphasis is placed upon financial responsibility so that case managers are budget-holding service providers, to the other extreme, where case managers are service brokers who have no responsibility for the rationing of resources. Case management programs should clearly define goals and boundaries for their case managers because they have implications for training and for resources (Baldwin & Woods, 1994).

2.1.5.2 Case Manager as Primary Therapist

A second question about case management concerns the extent to which a case manager should be the primary individual therapist. By providing the broad range of services that are part of the case management process, the case manager becomes the "human link" between the client and the potentially confusing array of services (Piette et al., 1990, p. 746). Even though the development of a relationship between the case manager and the client through periodic personal contact is implicit in case management, these relationships can differ dramatically. Most case managers counsel their clients to some extent as a natural part of relationship development, but role definitions for case managers range from coordinating and facilitating services to extensive, regular, supportive contacts in which the focus is counseling (Graham & Birchmore Timney, 1990).

In the case management context, therapy can be divided into short-term, or crisis-oriented, therapy, focused on immediate living problems, and long-term therapy, focused on long-standing personality issues (Rothman, 1991). According to Rothman's (1992) review case managers' practices differed widely in the emphasis on therapy. Benefits and problems result when one mixes case management and therapy. Some commentators have argued that the development of a therapeutic relationship is the key to engaging the client in case management. Therefore, only clinically trained staff are qualified to be case managers (Lamb, 1980). This argument suggests that case managers skilled in counseling might best understand clients' needs and sub-sequently link them to appropriate services. On the other hand, case managers with at least a master's degree may prefer therapeutic interventions to the brokerage of "hard" resources such as housing, food, medical attention, and transportation services (Austin, 1990). Consequently, some case managers may experience a conflict in roles between directly providing services and coordinating services - and in some instances, the case coordination aspects of case management may be ignored in favor of providing direct service (Schwartz, Goldman, & Churgin, 1982

Therapy-oriented professionals also may be more comfortable working in their offices and may not be willing to perform those tasks necessary to be good case managers such as client outreach, which often is done outside the office (Schwartz et al., 1982). Rothman (1992) found that clinically trained practitioners prefer individual therapy or counseling to case management, and that students in master's of social work programs expressed this view even at the beginning of training. Finally, counseling by case managers may be influenced by the availability of mental health and substance-abuse resources in the community, an issue we address later.

2.1.5.3 Effect of Community Resources

Commentators disagree whether case managers should advocate only for their particular clients (for the individual), or whether they should be advocates for the class of clients they serve (Graham & Birchmore Timney, 1990). One of the inherent weaknesses of case management is that it is dependent on the availability and accessibility of other medical, social, and psychological resources.

Many case management systems have been established without the benefit of a network of community support programs (Rubin, 1992). Without referral sources, a skilled case manager can assist a client personally, for example, by providing counseling. However, without some additional authority over resources, the case manager cannot address environmental, structural, and political constraints, for example, by changing the local service delivery system, creating services, or improving the quality of services (Austin, 1990). The question remains whether a case manager should do some of these community-level activities. Rubin (1992) summarized this dilemma as follows:

Does it make sense to hire young, inexperienced, and low-paid individuals who lack professional authority; give them few resources and little or no formal organizational clout; and then expect them to work miracles in overcoming serious deficiencies in poorly funded service delivery systems? Is case management nothing more than a seductive notion for those who would like to think that society's care of its needy citizens can markedly improve without more money being spent? (p. 141)

This is an issue that programs can address in advance by knowing what community resources are available and by being clear with case managers about the extent to which they will be expected to engage in community-level activities.

Go to section 2.1.6 Education and Training of Case Managers