One feature of case management that may distinguish it from other interventions, is that, in some instances, the core services provided by the case manager are not sought by the client. This fact affects not only evaluation, but decisions about implementation. People who are eligible for case management are usually those society has decided "need" to be case managed, on the basis of some external criteria such as having a severe mental illness or being unable to change unsafe sexual behaviors. These types of people may be interested in some of the services that the case manager can provide (food, clothing, and shelter) but uninterested in core services such as a structured day program (for patients with severe mental illness) or HIV prevention (for PCM clients). In other words, potential clients rarely come to an agency or health department seeking their core service. Thus, persons to be managed often must be found and recruited for a case management intervention.

In general, outcome studies of case management have been poorly designed and have provided inconsistent results and thus do not strongly support the effectiveness of case management (Orwin et al., 1994; Piette et al., 1990; Rothman, 1992; Rubin, 1992). In fact, much of the case management research has focused on the process of case management rather than on any particular outcome (Rubin, 1992). Differences in community resources affect evaluation because the same program may be effective in a resource-rich community but not in a resource-poor community. If difference in resources are not accounted for when the results are examined, the conclusions may be erroneous. Further, as mentioned earlier, deciding whether the entire system is being evaluated or whether the case management program is being evaluated becomes difficult. Rothman's (1992) review provides the following generalization about resources: "Practice outcomes are related to both the availability of relevant resources in the community and to supportive structural factors in both the agency itself and within the larger community system" (p. 72).

Although resource issues may obscure the effectiveness of case management programs, the effectiveness of case management also remains unresolved because of two crucial definitional problems: (1) difficulty in defining or placing clear boundaries around case management (discussed earlier), and (2) difficulty in defining appropriate outcome variables to measure the effectiveness of the intervention (Rothman, 1992

Case management has been used to advance two social goals (coordinate or maximize resources and contain costs); therefore, it is not surprising that studies on the effectiveness of case management have focused on two types of dependent or outcome variables: (1) client, service, or access issues, and (2) cost variables. For example, some studies have examined how well case management has increased access to care for clients or improved client well-being (Piette et al., 1990). Other studies have focused on financial savings and improved client functioning through decreased patient use of services, such as shortening the average length of hospital stay for psychiatric patients.

Regarding client functioning, three potential classes of dependent variables for case management have been described: (1) social functioning or quality of life, (2) intra-psychic variables, and (3) behavioral variables (Rothman, 1992). In measuring the effectiveness of case management for improving the functioning of seriously mentally ill clients, potential outcome variables have included rehospitalization rates, number of days in the hospital, quality of life, role performance, social functioning, social isolation, occupational functioning, medication compliance, service use, number of contacts with the legal system, and the cost of all services.

Regarding persons with serious mental illness, case management programs generally have affected the client's community adjustment positively and decreased the number of rehospitalizations, although not all studies have supported this positive association (Rothman, 1992). Data on the cost-savings of case management with this population are mixed. Some of the variables that potentially influence the effectiveness of case management are client characteristics, the clarity and scope of a case manager's role, the size of a case manager's caseload, case manager characteristics, quality of supervision, agency support for case management, and the adequacy of the service resources in the community (Rubin, 1992). Unfortunately, many of these variables are poorly measured or not accounted for in research on the effectiveness of case management. Thus, not only are outcome variables difficult to define but other potentially important variables that might influence the outcome are difficult to measure or are ignored in the research.

Go to section 2.1.8 Conclusions