Page images
PDF
EPUB

Long-Term Care

CASE MANAGEMENT IN LONG-TERM CARE *

INTRODUCTION

Case management is used in many different settings and for a variety of purposes. As a result, the term case management means different things to different people. Researchers, health care and social service professionals, policy analysts, and others who talk about case management may or may not be talking about the same thing.

In developing a national long-term care program, it is important to be as clear as possible about what case management is expected to do and how it should operate in the program, because some of the most significant outcomes of the program are likely to be determined within the case management process. As discussed in this paper, case management is likely to be the mechanism by which decisions are made about the amount and kind of services people will receive through the program. In turn, those decisions will determine the cost of the program, how people perceive it, and whether it meets their needs.

This OTA staff paper proposes a definition of case management and points out several conceptual distinctions that are important in thinking about the case management component of a national long-term care program. The paper discusses whether case managers should determine the amount and kind of services people are authorized to receive through the program and whether the case management component of the program should be split between two agencies. The paper also reviews some findings of OTA's forthcoming report, Confused Minds, Burdened Families: Finding Help for People With Alzheimer's and Other Dementias, that relate to questions about the agencies that might provide case management in a national long-term care program and the appropriate role of the program and the case managers who implement it with respect to the quality of the long-term care services that are provided or paid for by the program.

This staff paper was prepared for the U.S. Bipartisan Commission on Comprehensive Health Care (The Pepper Commission), by the Office of Technology Assessment, Biological Applications Program, February 5, 1990. The views expressed in this staff paper do not represent the views of the Technology Assessment Board, the Technology Assessment Advisory Council or individual members thereof.

Much valuable information about case management in long-term care programs is available from several sources. Case management has been a component of virtually all the long-term care research and demonstration projects that have been conducted in the United States since the mid-1970s, including the National Long-Term Care Channeling Demonstration project (25,40,47,55). Case management is a central component of many State long-term care programs, including State programs that are funded in whole or in part through Medicaid 2176 Home and Community-based Waivers (34,35). Case management is also a central component of the Social/Health Maintenance Organization (S/HMO) demonstration program (3,42). All of these programs allocate long-term care services and/or funding for such services. Research findings and practical knowledge derived from these programs are relevant to many of the difficult issues that must be resolved in designing the case management component of a national long-term care program. For the purpose of designing that component of the program, the research findings and practical knowledge derived from these programs are probably more helpful than theoretical discussions about case management or information about the role and operation of case management in other programs that do not allocate longterm care services or funding for services. It is likely that some of the case management policies and procedures developed by the former programs could be adopted directly by a national long-term care program.

[merged small][merged small][merged small][ocr errors][merged small]
[merged small][ocr errors][merged small]

Most commentators agree that case management in long-term care includes these five functions (6,13,18,24,25,31,36,39,43,51,52,61,63,71,72), but there are still many unresolved definitional issues with respect to case management. First, some commentators include other functions-notably, case finding, screening, client education, and counseling-in their definitions of case management. Second, the implementation of each of the case management functions varies, depending on factors such as the type of the agency that provides it, the objectives and other functions of that agency, whether the agency provides services in addition to case management, the goals, educational background, experience, and training of the case manager, and the number of clients the case manager has. The same factors also influence the relative amount of emphasis the case manager and the agency place on each of the case management functions.1

Many conceptual distinctions have been proposed to categorize the differences in the role and practice of case management in different agencies and settings (see, for example, Austin, et al., 1985 (16); Capitman, et al., 1986 (25); Kane, et al, 1989 (39); and Weil, 1985 (71). Two conceptual distinctions are particularly important in thinking about the case management component of a national long-term care program. The first of these is a conceptual distinction between case management as an administrative process and case management as a clinical or helping process. In many agencies that allocate long-term care services or funding for long-term care services, case managers perform certain tasks that are essential for the administration of those benefits in accordance with agency or program regulations. These administrative tasks include determining people's eligibility for the benefits, authorizing the benefits, and monitoring and accounting for their use. When case managers are responsible for these administrative tasks, the case management functions mentioned earlier are modified to include the tasks. For example, the function of arranging and coordinating services is modified to include administrative procedures for authorizing services and funding for services. The functions of monitoring the services and of reevaluating the client's needs are modified to include procedures to account for the services and

In this paper, the term "case manager" is used to refer to an individual who performs the case management functions listed above. As is true of case management, however, the term "case manager" means different things to different people, and in reality, some individuals who perform these case management functions are not called "case managers" and other individuals who are called "case managers" do not perform the functions.

funds that are used and to recertify the client's eligi bility for services.

In some agencies that allocate long-term care serv ices and funding for services, case management is primarily a series of administrative tasks intended to allocate benefits in accordance with agency or program regulations. In other agencies, case management is primarily a clinical or helping process in which the case manager functions more as a professional helper, counselor, and client advocate than as an administra tor of benefits. Clinical case management responds to a variety of difficult problems that confront people who need long-term care. One of those problems is that the long-term care service environment is er tremely complex and fragmented in many communities, so that some people who need long-term care require assistance to locate and arrange services. A second problem is that some people who need long. term care have multiple service needs, so that they may require assistance in coordinating the services of several different providers. Lastly, some people who need long-term care require assistance in defining the problems they are facing, determining what kind of services might be helpful, and mobilizing informal (unpaid) sources of help (relatives, neighbors, friends, church groups, etc.). As professional helpers, counselors, and client advocates, case managers provide all these kinds of assistance.

If it were possible to make a clear distinction in reality between case management as an administrative process and case management as a clinical or helping process and call one case management and the other something else, it would be easier for everyone to understand and communicate clearly about case management and its role and operation in a national longterm care program. That distinction cannot be applied precisely in reality, however. As practiced in many agencies, case management includes both administra tive and clinical tasks, and many case managers administer long-term care benefits for their agencies perceive themselves as professional helpers, coun selors, and advocates.2 Moreover, OTA is not aware these case of any research that shows that as a group managers perform the clinical case management tasks differently than case managers who do not administer

benefits.

2 In a study by the University of Washington, 127 case managers in agecies that allocate services and funding for services in Oregon and Washingto State were asked to rate the importance of 11 possible goals of case manage ment (15). All these case managers' jobs involved administrative tasks related to allocating services and funding for services, but the goals they identified a most important had to do with helping and advocacy. In the view of these case managers, at least, the administrative and clinical aspects of case mar agement are intertwined.

Even though the conceptual distinction between case management as an administrative process and case management as a clinical or helping process cannot be applied precisely in reality, it is useful in thinking about the role and operation of case management in a long-term care program because it underlies one of the primary areas of disagreement about case management in such program. It is in the context of performing administrative tasks related to the allocation of program benefits that case managers become the "gatekeepers" in a long-term care program, and it is in that context that they are likely to be perceived as restricting clients' access to needed services. Some people argue that case management as an administrative "gatekeeping" process is not compatible with case management as a clinical or helping process and that the "gatekeeping" and clinical case management tasks should be performed by different agencies or different units of the same agency. Other people argue that the two types of tasks can be effectively performed by the same agency or unit. This issue is discussed further in a later section of this paper. OTA's perception is that both the administrative and clinical tasks are performed by the same case manager in most long-term care programs that allocate services or funding for services—at least after an initial determination has been made that an individual is eligible for the program.

The second important conceptual distinction in thinking about the case management component of a national long-term care program is the distinction between a case management process that is "service-centered" vs. one that is "comprehensive." Service-centered case management is case management that is provided in conjunction with the provision of a particular service (e.g., homemaker or home health aide services). Comprehensive case management takes place independent of the provision of any particular service (46).

The distinction between service-centered and comprehensive case management is important because it underlies two other areas of disagreement about case management in a long-term care program. Many agencies and individuals that provide services also "case manage" their clients. One area of disagreement is whether a long-term care program should provide case management for people who are receiving case management from a service provider in conjunction with a particular service (i.e. service-centered case management). The more widely debated issue is whether service providers should be the case managers for a long-term care program. Both issues are discussed later in this paper.

Some commentators make a distinction between case management and "care management," "care co

ordination," "service coordination," or similar terms. Although these distinctions may be meaningful within the conceptual framework developed by a given commentator, the terms are not used in a consistent way by different commentators. Thus, the use of these terms does not facilitate clear communication about case management, and OTA does not consider the terms helpful in thinking about the case management component of a long-term care program.

Should Case Managers Determine the
Amount and Kind of Services
People Receive Through a National
Long-Term Care Program?

3

Case managers determine the amount and kind of services people receive in virtually all existing longterm care programs that allocate services or funding for services. In many of these programs, there are at least two steps that take place before the amount and kind of services a person will receive are determined. First, the person's eligibility for the program is determined. Eligibility is usually determined on the basis of only a few factors and may or may not be determined by a case manager. Once the person is found to be eligible for the program, he or she usually receives an assessment by a case manager. Based on the results of the assessment, the case manager then develops a plan of care which includes a determination of the amount and type of services that will be authorized for the person. The assessment usually addresses many more factors than are considered in the eligibility determination. Factors such as the person's mental, and emotional status, the person's living arrangements and physical and social environment, and the availability of help from informal (unpaid) caregivers are frequently included in the assessment. All of these factors are relevant to determining the amount and kind of services a person needs but not necessarily relevant to determining eligibility for the program.

[blocks in formation]
« PreviousContinue »