Chapter 3 - Case Management in the Community Context: An Interagency Perspective

Characteristics of the Three Models

All three models describe arrangements for interagency case management services and methods for dispensing them. The most appropriate model for a particular agency or program hinges on its own history and mission, the needs of its clients, and the environment in which it operates. In developing a model, it is important to remember that neither organizations nor environments are static, and interagency models may evolve in complexity from the single agency to the informal partnership to the formal consortium. Although each model has advantages and disadvantages, a model's fit with its clients, the agency, and environmental conditions determines its effectiveness for a particular program (Rothman, 1992). Figure 3-1 summarizes the characteristics, advantages, and disadvantages of each organizational model.

Each model offers distinctive strengths suitable for a particular organizational environment. For example, in rural areas that depend on "one-stop shopping" social service programs, the relatively low-cost single agency focus, with its capacity to respond quickly and authoritatively, may be the optimal choice. On the other hand, the informal partnership tends to deliver more diverse services, so it is better suited to culturally diverse communities. In communities dominated by managed care, a gatekeeper must make referrals for every service, and a formal consortium may be the best choice to supply the necessary documentation.

Besides determining resource acquisition, organizational environments impinge on program decisions in other, less obvious ways. In a volatile environment, a single focus agency with its rapid startup and minimal up-front investment may provide the only sensible alternative. Where shared services can produce savings through economies of scale, the partnership arrangement may maximize scarce resources. In an environment in which program operations are routinely disrupted by political upheaval, a formal consortium with its mandated procedures may provide the stability and continuity necessary to ensure that case management services survive.

Forging the Linkages

Interagency case management arrangements are designed to help providers connect with each other to improve client services and enhance the efficiency of their respective organizations. In addition to trading useful information, agencies also may exchange services, money, clients, and client service slots. In the area of substance abuse treatment, some case managers and addiction specialists may be former users themselves and may have known one another in their former lives (Brown, l991). These ties often strengthen or facilitate interagency exchanges and relations. Seasoned case managers tend over time to form personal working relationships with others in the field and often trade on prior contact, previous service reciprocities, and favors owed to get services for clients (Levy et al., l992). Informal "quid pro quo" arrangements are common, as are shared resources to effect economies of scale.

While this system of informal exchange or "social service bartering" is intrinsic to case management, a more formalized connection among agencies sometimes may be required. Examples include memoranda of understanding (MOUs) and interagency agreements and contracts. Each of these methods for formalizing expectations can be used in single agency models, informal partnerships, and formal consortia.

MOUs are a means to structure a relationship among agencies. When agencies rely heavily on each other's services and function primarily as brokers for their clients, MOUs are essential. They specify such crucial information as the number of service slots that agencies will make available to one another's clients and the consequences for failure to implement or comply with specified activities or procedures. Program managers, rather than case managers, typically draft MOUs and other formal agreements and contracts with staff input. They are particularly useful for

• Ensuring continuity of services during staff turnover
• Clarifying lines of authority and control over various aspects of the case management process
• Recording commitments for providing or funding case management resources (e.g., staffing, operating funds, client referrals)
• Providing a formal record of agencies' agreements and responsibilities
• Holding agencies accountable

MOUs and formal agreements have special appeal when crediting or reporting the outcome or delivery of case management services. Among agencies and service providers that are reimbursed for services on a per capita basis, MOUs can be used to specify which agency or personnel will receive credit. When services are delivered as part of a research project, MOUs can specify who has access to data and who may claim authorship when research results are published.

Some agencies also use Qualified Service Organization Agreements (QSOAs) when an agency or official outside the program provides a service to the program itself. QSOAs might be used, for example, when the program uses an outside entity for laboratory analyses or data processing. MOUs cannot be supplanted by QSOAs.

MOUs and QSOAs are not the only type of formalized agreements available to case managers. Some programs use cooperative service agreements to define what the parties deliver to and receive from each other, and to monitor the programs. A legal contract may be needed when the lead agency in a formal consortium subcontracts to other community-based case management agencies to provide specific services. Many case management agencies also enter into agreements with funding sources, including those providing Federal entitlement benefits. Although some experts question whether case managers should function as payees (that is, accept and monitor entitlement payments on their clients' behalf), a substantial number of case managers take on that role. Until agencies become familiar with such documents and procedures, obtaining counsel prior to signing may be prudent.

Identifying Potential Partners

For any case management plan to be successful, a provider must take a hard, objective look at community resources. What form do they take? What are the barriers to access? Who makes the decisions about how they are used, how are these decisions made, and how can they be obtained? If housing is a major client concern, for example, a community assessment should ascertain if housing assistance is available and how case management efforts might help clients attain it. Similarly, a client's legal status can affect both the number and kinds of services needed (e.g., client involvement in the criminal justice system or with child protective services agencies). Such legal pressures, in turn, determine the range and type of agencies with which a case management program must interact and the conditions for these relationships. Thus, depending on the legal needs of its clients, a case management program may need to identify and forge relationships with such service providers as battered women's shelters, public assistance programs, legal aid, churches, 12-Step groups, and other relevant organizations.

Not all needed services are available, of course, and at times the successful case manager must create them. In other cases, needed resources may exist but prove inaccessible or unacceptable to clients. Ideally, case management agencies or programs want to provide or facilitate the full range of services required by their clients. From a feasibility standpoint, however, most providers must confront painful realities during the assessment process and be prepared to scale back expectations.

Fortunately, most communities already have tools to assist case management programs in identifying resources, possible provider linkages, and potential gaps in services. Public Health Departments, United Way, and county governments frequently produce directories of social, welfare, health, housing, vocational, and other services offered in the community. These often include detailed information about hours, location, eligibility, service mix, and costs; some directories are computerized and regularly updated. Although the costs associated with purchasing these automated directories can be steep (and should be considered when planning the program budget), their timeliness and convenience may justify the investment. In many areas, the Yellow Pages serve as an excellent resource for obtaining initial contact information on a variety of health and social services.

Another solid source of information is geomapping, an automated package that assists in resource identification. Philadelphia has developed software that not only provides basic program information but also indicates whether a particular program has any openings. Traditional paper maps or maps equipped with overlays can fulfill the same function.

While directories and other service rosters provide a useful starting point in identifying potential resources and service providers, additional work is required to determine which listings will prove fruitful. There are often delays in publishing and updating such directories, so that they may be out of date even before dissemination. It is critical that they be updated on a consistent, timely basis. Directories may not list all agencies or programs, and more than one directory may be necessary because an agency's focus can shift.

Ouellet and colleagues report some limitations in using directories, encountered when they developed a case management program for HIV-infected injection drug users (Ouellet et al., 1995). Initially, during startup, staff attempted to link clients to services solely using a service directory, followed by contact with organizations expressing willingness to provide support. Some resulting linkages were found to be "largely useless" because

• Some organizations misrepresent the number or types of services they actually offer or have available
• Many services are poorly financed and disappear quickly
• Some organizations are incompetent or too poorly managed or staffed to provide adequate services
• Some agencies are too far away for clients to use (Ouellet et al., 1995)

In addition, Ouellet noted that some organizations, such as hospitals, stigmatized and treated injection drug users so badly that clients didn't want the services at all. Also, many providers genuinely interested in service collaboration underestimated the number of people seeking help and the breadth of expressed needs, and thus were unable to handle the deluge of service requests. Other organizations had the capability to work with these clients but were unwilling to do so.

To counter such limitations, case management programs often conduct "snowball surveys" in their communities, using one interagency contact to lead to another. This technique can yield insider information about other programs and agencies, their capabilities, and experiences in service use. Identifying and documenting resources and entitlements may be best undertaken during the early phases of program startup, when caseloads are low.

Experienced case management personnel also recommend visiting the programs to which clients will most likely be referred. Onsite visits impart a wealth of information that may confirm or refute the impression conveyed in written materials. They also provide an opportunity to establish valuable contacts with agency personnel who can facilitate client services once the case management collaboration is under way.

Accurate, current information about entitlements is essential for sound interagency case management programs and often can be obtained through local governments. New York City, for example, posts menus of entitlements on electronic kiosks. Many public libraries and local government offices display updated entitlement information regularly. Federal Regional Offices of agencies such as the Administration for Children and Families are another resource for entitlement information.

As case managers compile and document resources, they should also identify gaps in services so that they and others understand what is available in the community and where advocacy efforts are needed. It is also important to publicize case management programs throughout the community. Brochures, fliers, and simple one-page fact sheets can be used to advertise or explain a program. Announcements on the Internet, in community newspapers, on bulletin boards, and in local civic and professional club newsletters are inexpensive methods for promoting new services. Apprising local police of a new program's existence and the availability of services may be particularly important as their support can prove quite helpful with clients involved in criminal justice matters.

The Agency Environment

Exploring the environment in which an agency operates is essential in determining the feasibility of mounting an interagency case management effort. Several factors influence the provider's ability to conduct case management within the community, including

• Social service agencies' number, type, historic responsiveness to clients with substance abuse problems, openness to case management, and relationships with each other. Communities with abundant social service resources that address a wide range of human necessities typically are better able to meet the diverse needs of substance-abusing clients than less endowed communities. Similarly, social service infrastructures in which providers are willing to accept substance abusers as clients and to accommodate innovative approaches to addressing their problems are more likely to welcome an agency's case management initiatives than more restrictive organizational structures.
• Community leaders' support for or neglect of substance abuse treatment and their response to case management concepts. Advocacy may be necessary because support or pressure from community and political leaders can facilitate a substance abuse agency's efforts to institute case management. Conversely, implementation can be stalled for months and sometimes stopped entirely in communities when leadership is opposed to substance abuse treatment or case management services for substance abuse clients. Identifying proponents and adversaries is essential in planning strategies that capitalize on support or overcome/sidestep resistance to a case management program. To form a strong supportive voice within a community, provider consortiums are often formed.
• The economic situation in the community. The more economically stable a community, the more resources members of the civic, governmental, and corporate power structure have to bring to the table in negotiations with other power brokers on behalf of a case management program or agency.
• Social climate. Community acceptance of substance abuse treatment and clients can influence some agencies, particularly those with a grassroots orientation, to accept and cooperate with a case management program. Bottom-up community acceptance can exert a powerful force in gaining agency leadership cooperation, although this outcome may take time.
• Geographic considerations (distance, terrain, isolation of the target population from mainstream services). Availability of case management services makes little difference when clients cannot access services because of transportation and other barriers. In fact, accessibility may determine the specific agencies with which programs are able to connect on behalf of clients.
• Legal and ethical issues affecting implementation. Some communities have zoning laws and other legal restrictions specifying which, if any, social service programs can be established within their perimeters or near schools and other public facilities. These statutes need to be clarified before investing in program startup. In addition, clients' possible involvement in the criminal justice system can raise issues of confidentiality and other legal concerns when creating cooperative arrangements with other agencies. Special care needs to be taken when an agency works with clients who are involved with the criminal justice system or who are in any way being coerced or pressured into treatment. Issues that can affect the transfer of confidential or sensitive information need to be carefully worked out before clients are actually admitted for service. Policies and procedures should be regularly reviewed in the face of experience and adjusted accordingly.
• Funding for program startup and program continuation. Amount and type of available funding (e.g., multiyear grant, limited foundation support for project startup, and matching or challenge grants) directly bear on the nature and organizational complexity of an agency's case management program. Multiyear funding permits substantial advance planning prior to program implementation. It also enables agencies to bring current and projected resources into negotiations with other community organizations. Continuing funds also allow interagency linkages to develop and improve over time. In contrast, restricted, one-year funding may argue for front-loading resources and selecting a case management model that can be implemented quickly and with immediate short-term payoff.
• Incentives for entering into an interagency agreement. Stakeholders who recognize the benefits to their agencies will help facilitate case management. Also, cooperative relations tend to be more stable when participating agencies have much to gain by working together.
• Volatility of the political, economic, or social environment, such as the recent introduction of Medicaid managed care. Support for new initiatives can be difficult to obtain in a climate in which reimbursement criteria are being altered, State and Federal funding is being redirected, or political leadership is changing and the new players are unknown. In an uncertain environment, it is critical to justify the cost of a new service with compelling evidence. When chaotic conditions prevail, introducing a case management program gradually protects valuable resources while testing feasibility before full implementation.

Agency administrators, whether they are chief executive officers, executive directors, or program directors, must develop working relationships with the other social and human services agencies with which the case managers will be interacting. To be effective, case management requires that connections be made at the administrative/director levels of agencies. Because case managers may be expected to coordinate and implement a complex service plan in an interagency environment, the case manager needs sufficient power to implement the plan. This comes from the explicit endorsement of an agency's top level administration.

An honest appraisal of the community environment equips an agency or program to make key decisions about interagency case management. Some potential cooperating agencies cannot interact effectively with the larger community or can only provide on-site services. Other agencies may be willing to cooperate, but their organizational missions differ so radically from the case management program's that collaboration is impossible (Ridgely and Willenbring, l992). Part of the environmental assessment involves identifying such providers to avoid creating linkages that will ultimately prove unworkable.

Analysis of the community environment is one in a series of ongoing assessments aimed at understanding the changes that occur among clients, within the program, and in the community. As is true of other agency activities, case management takes place within a dynamic social service environment in which agencies are in constant flux (Rothman, l992). Programs considering interagency efforts must devise coping strategies to respond to change while providing necessary continuity for the client. In addition, interagency networks are fragile and frequently develop through personal trust established between case managers. Staff turnover disrupts such relationships and threatens the case management system unless guidelines or procedures exist to facilitate a smooth transition (Levy et al., l995).

Because social environments for delivering services do change over time, flexibility and individuation are hallmarks of effective case management. When programs become rigid in their conceptualization, case management services suffer. Regular reevaluation of community resources helps ensure continued relevance.

Finally, the philosophical orientation of a program can affect the efficacy of any interagency arrangements. Understanding a program's history and philosophy helps staff members determine the type of interagency case management services they offer their clients. Compatibility in both program philosophy and organizational structure in forging interagency cooperation is essential, because services suffer when the two clash.

Potential Conflicts

The potential for conflict exists whenever two agencies or service providers work together. Tension may be present from the very onset of the collaboration. For example, existing social service agencies may view a new project as competition for scarce resources (Perl and Jacobs, l992). Or, social pressures or the need to maximize resources can force public agencies into joint ventures even if they don't mesh well or have a history of competitiveness (Alter and Hage, l993). Tensions also can develop in the course of delivering services. Interagency collaboration may result in a client having two case managers, each of whom handles a specialized problem, for example, a case manager from a treatment program and a probation officer. In such instances, manipulative clients may pit one case manager against another - a situation that can become tense for all involved.

Recognizing potential triggers for interagency conflict and antagonism is a necessary first step to dealing with it. When problems do erupt, case managers and other agency personnel can use both informal and formal communication mechanisms to clarify issues, regain perspective, and refocus the interagency case management process. The following list highlights some of the common sources of conflict that may arise as a result of interagency case management.

• Unrealistic expectations about the services and outcomes that case management linkages can produce
• Unrealistic expectations of other agencies
• Disagreements over resources
• Conflicting loyalty between agency and consortium or partnership
• Final decisionmaking and other authority over the management of a case
• Disenchantment after the "honeymoon" period ends
• Differences in values, goals, and definitions of the problem, solutions, or roles (e.g., conflict could arise when police officers working with social service personnel perceive that they are being asked to function as "social workers" and vice versa)
• Dissatisfaction with case handling or other agency's case management performance
• Clients who pit one case manager against another
• Inappropriate expectations of case managers (improper demands, "asking too much")
• Resentment over time spent on documentation, in meetings, or forging and maintaining agency relationships rather than on providing client services
• Stratification, power, and reward differentials among various agency case managers
• Differences in case manager credentials and status among agencies
• Unclear problem resolution protocols for agency personnel

The solution to interagency conflict is open, frank communication by personnel at all levels. Frequent meetings and other activities that bring people together foster such communication. In the long run, the client's welfare is a shared objective, and the difficulties that are likely to arise can be successfully resolved.