JOURNAL ISSUE 2
1999/2000

table of contents | abstracts

 

Collaboration and Case Management in Social Services

Mari-Anne Zahl

 


ABSTRACT

Cooperation and coordination are politically correct terms. They can occur at either organizational or case levels. An example of a public social service cluster surrounding nineteen year old women with multiple agencies illustrates the difficulty of case coordination. The involvement of a number of workers is, in itself, neither effective nor a guarantee of quality care.

This paper is based on a research project focusing on case problem definition, cooperation, and coordination presented at Social Welfare Departments. Definitions of the terms "cooperation, coordination and collaboration" are overlapping, ambiguous, and context related. However, they are frequently used in relation to the helping professions, where they appear to be presented both as ends and means. These taken-for-granted terms are of theoretical interest to organizations, professionals, clients, and their environments.

 

CO TERMS: COOPERATION, COORDINATION, AND COLLABORATION

The "co" terms of cooperation, coordination, and collaboration appear in everyday life and in the professional literature as more mixed and intertwined than as seprate entities. The phenomena constituting cooperation, collaboration, and coordination occur at different levels, from government to individual level.

Cooperation is "Deliberate relations between otherwise autonomous organizations for the joint accomplishment of operating goals" (Schermerhorn cited in Rogers & Wetten 1982, 13). Information is exchanged and "authority is retained by each organization so there is virtually no risk. Resources are separate as are rewards" (Mattessich & Monsey 1992, 39). Cooperation takes place between individuals ad hoc and has the core elements of no formal rules, trust between workers, freedom of choice based on self-interest, and with the duration varying case by case.

Interorganizational coordination : "the process whereby two or more organizations create and/or use existing decision rules that have been established to deal collectively with their shared task environment" (Mulford & Rogers 1982, p.12). Coordination results in adjustments among the organizations in their respective outlooks, objectives, and methods of operation. It represents a threat to the autonomy of each unit. The term includes the dimensions of giving an order as well as the bringing order. These are both elements in a top-down phenomenon. When an organization experiences a threat to its existence, coordination can be used as part of a strategy of survival.

"Collaboration is a process through which parties who see different aspects of a problem can constructively explore their differences and search for solutions that go beyond their own limited vision of what is possible" (Gray 1991, 5). Gray (1991) calls involved parties stakeholders, indicating

57.

that they are all involved and influenced by actions taken by others to solve a common problem. "The objective of collaboration is to create a richer, more comprehensive appreciation of the problem among the stakeholders than any one of them could construct alone" (Gray, 1991, p.5). Each party will try collaboration only if they believe they have something to gain from it. Collaboration is an accomplishment. The challenge, when collaboration is sought, is how to enhance the process towards this end, and how to keep it working. Collaboration is not an end in itself; the intention is not to establish practices which become rituals for insiders.

Gray presents five key aspects necessary for collaboration:
1. The stakeholders are interdependent.
2. Solutions emerge by dealing constructively with differences
3. Joint ownership of decisions is involved.
4. Stakeholders assume collective responsibility for the future direction of the domain.
5. Collaboration is an emergent process (Gray, 1991, 227).

This does not indicate who the beneficiaries are supposed to be. Will the stakeholders be agents of and for their agencies, their funding sources, or for the population they are expected to serve?

A get-together of professionals during work hours does not in itself qualify for "co." We note an interaction and assume that those involved are working. A meeting, however, might easily be said to be part of case related cooperation which occurs ad hoc. In mundane ways we see worker and organizational interaction, a normative process which is taken as self-evidently good and beneficial, with presumed benefit to participants and to the subject of their attention.

These mundane acts and meanings are of interest to human services in several ways. They are essential to everyday human service practice. They are real acts seen as a moral good, and they are part of managerial ideologies of good acts often regardless of the ends they serve. The end goals might never be raised, discussed, or studied because this is self-evident, self-referential goodness. The status of a social phenomenon as self-evidently good calls for understanding it not as an intention or as a goal, but as an accomplishment.

The "co"terms have an important common element- - their potential for conflict on all levels. On a superficial level, conflicts can be attributed to persons, to personalities, and not analyzed as a social and psychological phenomenon in its own right. The conflict understanding is reflected in research and professional literature, and is to be taken seriously on the managerial level. The conflict understanding asks for strategies to minimize the occurrence of conflict and ways of handling damaging potentials on different levels when conflict is a fact. This task is rarely a job for those who are or could have been involved in the conflicts. It needs intervention from outsiders.

CASE MANAGEMENT

Case management is a managerial response to increasing service demand and simultaneous budget restrictions. It has become a way of getting more service per dollar. It is about cost and fully socio-political as well as economic. It is a professional term used to designate philosophy, strategy, and practices of delivering social services. It is also about decisions, and about the authority and the power to make these. It deals with privatization as ideology and as strategy for moving public services into the voluntary and private sector. It is, however, about more than services and therefore it includes education and what one is to be trained to do.

The term management suggests that workers and clients are given a passive, rather than an active role; that they are expected to be "things" which are manipulated by administration, professionals, secretaries, and computer programs, rather than supported as self-determining human beings. All of this is important in social work, a professional field whose values assert the latter.

How is case management defined in social work? In the U.S. National Association of Social Workers (NASW 1992, 5) defines case management as a method of providing services by a social worker "who assesses the needs of the client and the client's family, when appropriate, and coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific client's complex needs." Case management is part of professional social work. "The social case manager shall treat colleagues with courtesy and respect and strive to enhance interprofessional, and interagency, cooperation on behalf of the client." (NASW, 1992, 21).

Case management is not a one-person, one-organization activity. It requires the voluntary participation of persons or organizations, and their provision of resources. It is practically impossible to establish

58.


the kind and quality of interaction necessary for effective case management when political instability and active conflict takes place between potential partners (Kingsley, 1993, 81).

Case management is a conservative activity because it does not represent a threat to the existing order (Austin, 1993). Case management cannot compensate for fiscal or other inadequate resources, but, it can be a good way to administer what resources are available. "Case management is a client-centered, goal-oriented process for assessing the need of a young person for particular services and assisting him her to obtain and complete those services" (Kingsley, 1993, 2). The case manager can be expected to be qualified to do a clinical assessment and to have the skills, insight, and overview of the service system to carry out the plan of clinical work. This plan can lead to several case-management models.

Austin (1993, 452) presents three models for case management:
- broker,
- service management, and
- managed care.
Each model has its origin in the implementation of the care-planning function. Case managers who function as brokers, allocate services of the agency to which referrals are being made. Brokers do not determine the cost of their care plans. In service management the case manager is fiscally responsible for the plans developed. The plans are limited by available services that can be authorized. Managed care incorporates prospective payment. This has influence on the care planning process. It puts pressure on the providers to keep costs low without sacrificing quality. A care plan includes a client-specific plan that comprises services, activities, and material resources.

 

A PUBLIC SOCIAL SERVICE CLUSTER FOR COORDINATION

Social services in Norway includes public agencies where services are free of charge, apart from medical services that have a base fee of approximately $12. Public agencies are established according to political policy and law, and are influenced by social, health, and educational policy. Norweigan social policy, as stated in The Act of Social Services (Lov om sosiale tjenester 1991), promotes the active involvement of other agencies to solve problems presented by clients at the Social Welfare Department (SWD).

The Act stresses that coordination must occur on the case level with agencies named in the Act required to respond in a positive manner to requests from the Social Welfare Department . SWD workers will want assistance from colleagues in other parts of the service system because of workload, diversity in problems presented, and the limitation of professional resources at the SWD. This results in a sense of "co" relationships. The everyday ideology in agencies , however, is not to exhaust the resources in one's own agency before inviting the inclusion of others. Thus, there is a built in danger of passing clients on and hoping their pending.

Clusters of public employees were interviewed to learn about a sample of cases in a recent study, focusing on problem definition, cooperation, and coordination in public agencies. One cluster was brought together around Kristin, age nineteen, in an effort to respond to problems she lived, faced, and presented. She first contacted the Social Welfare Department because she needed money. At that time she was not in school or employed. Her story included problems related to her immediate family, her relationship with boys, and her alcohol use. She had come to the attention of the health system because of an attempted suicide, an act that scared away friends. Some in the helping professions also became reluctant to work with her. Kristin and her living problems became the focus of multi-worker and multi-agency efforts to respond to her needs. The result was an interagency cluster.


Figure 1 CLUSTER OF AGENCIES AND WORKERS

CLUSTER


Kristin presented problems which were seen as requiring extensive social, health, and educational services. These included financial problems, lack of education, sexual assault some years back, anxiety, loss of control when drinking, issues with boys, and being ignored by her divorced parents. This was Kristin and her life. Her workers were her cluster.

Kristin named the Social Welfare Department, Municipal Health Service, Medical Center, Young Adult Project, and Mental Health Center (MHC). These are shown in figure 1 as circles. The squares indicate other agencies added by those in the circles. In the interviews, these respondents added

 

59.

 

school, Employment Office, and Psychiatric hospital. The overall figure shows the public network designed partly by Kristin, partly by workers, and partly undesigned, just springing into existence.

The cluster is the public network around Kristin. Of special interest is the Project (P). It was a collaboration established between the Social Welfare Department and the Employment Office focusing on young adults out of work and school. Both the Employment Office and the Social Welfare Department had invested resources and would share the responsibilities for the results. The Social Welfare Department made contacts with the Employment Project and the Muncipal Health Service. Kristin herself contacted the Medical Center, where she had been seen by several doctors. She had been referred to the Mental Health Center at a Psychiatric Hospital.

The wide range of problems presented shows that the public network has core work regarding Kristin. She meets requirements for financial support and counseling services from several agencies. Is that a ground for joint action? What agent has the most appropriate services for her? Who should volunteer and/or be required to serve her?

The cluster includes agencies where there are clear expectations regarding coordination and cooperation. Thus, Kristin's story is, on its face, one in which cooperation, collaboration, and case management might be taken for granted. How did each of them define Kristin as theirs? Where did Kristin as a person fit in with her story? Deliberate cooperation between and among workers at the Social Welfare Department and the Young Adult Project can be seen. We also see other worker relations, but these can hardly be called deliberate and mutual. The attempt to involve Mental Health, was deliberate and might also have had elements of self interest. Collaboration assumes interdependency. What overlapping definitions of Kristin and resulting sense of responsibilities, knowledge, skills, and services do we find in this cluster? Are these in moral, professional or legal terms?

It might be assumed that the quality of direct services will increase proportionately to the number of agencies involved and to the time spent on a case. The quality could increase since a range of professionals, agencies, and alternative services provides different points of view and selection in services. This specter of options presumably gives Kristin a choice from a broader range; thus a better fit is possible and this means better quality. A get-together of agents could give the impression that they wanted others to perceive that what they were doing was fine, that they had good intentions, and behaved in accordance with the "co" ideology. Is this what we saw?

We learned that the Social Welfare Department took care of immediate financial problems, and also discussed financial matters with Kristin, such as budgeting and her pattern of lending money to friends and family. Kristin confided in the social worker. The social worker, due to her assigned work tasks and lack of professional resources to draw on, referred Kristin to the newly established Young Adult Project, one with little formal structure. The staff there had available time and Kristin belonged to their target group. The Young Adult Project offered the counselling that the SWD had not.

Kristin's doctor no longer worked at the Medical Center when the interview took place. Other doctors had handled her requests and the referrals from her doctor, but had no further involvement with her. The Municipal Health Center, where the worker involved felt competent and wanted involvement, took in Kristin.

The Young Adult Project worker tried to strengthen the contribution of the Mental Health Center, taking it upon herself to challenge what she saw as Mental Health Center's moving away from its responsibilities. She did not think the Mental HealthCenter had much to contribute, partly due to a poor match between Kristin and its worker. Kristin herself felt she was getting little help. She wanted to be admitted to a psychiatric ward, wanted assistance in handling her family, her anxiety, and her alcohol usage; in time, she wanted to focus on education and work.

Kristin comes across as overwhelmed by her problems, and also by agencies and workers who had become presences in her world. While she knew of meetings where her situation had been discussed, these had seemingly not led to the development of a comprehensive and joint work plan for the workers involved on her case. Their contributions seemed partly to be at cross purpose, and yet none believed that Kristin tried to play one off against the other. Their impression was that she sought help, got confused by having to handle so much good advice, and did not quite know when to listen. This insight, however, did not result in their assisting Kristin to move beyond this dilemma.


COORDINATION AND THE CLUSTER

 

60.

What do we see when looking at this cluster of workers and agencies from the perspective of efficiency? This is an "it depends " question. If we start with Kristin and the problems she presented, we can ask: Did the input:
- Take care of immediate financial problems? Yes.
- Reduce anxiety? Most likely not.
- Connect with social network? No.
- Bring her closer to parents? Given minimal attention.
- Provide Kristin with education? Plans were made for her to reenter the school/system.
- Move closer to employment and financial self-support? Long term goals.
- Reduce alcohol consumption? Not known.
- Prevent suicide? Short term - yes; long term, not known.

The severity of these problems differed, to Kristin, and to each worker. The time and investment each would need differed, as did available resources such as knowledge, skills, and time. These resources were limited at all the agencies. What is a worker to do when facing a similar client and her troubles and problems?

Workers spent time with Kristin and gave her attention. An extensive public network was created. Kristin felt that workers understood her situation and responded more adequately than her friends and family. The latter either stayed away or took over. The seemingly extensive agency involvement influenced her chance of gaining access to scarce services, like the Mental Health Center where priority might have been given to others who did not have as complex a public services network.

Kristin was not given a choice with whom to work. She was not assisted in moving away from and beyond services involved. The cluster emerged unplanned out of day-to-day responses to her needs and wants; no-one was planning or responsible for its composition. There was never a decision made as to who should be involved, when and who should deal with specific terms in her case. Kristin had brought a strong public services network into being. Even though she spoke favorably of their involvement, it appears as if they took over her situation just like her family had done previously. Her own priorities and wants did not serve as a focus, or lead and integrate the workers, efforts on her behalf.

Officially, workers were there for Kristin. Her presenting issues asked for professional contributions that were not a fast cure. Her situation was serious. and she wanted to be admitted to a psychiatric ward. Yet, in the best of worker intentions and skills, Kristin remained a troubled person with everyday pain and problems.

When cluster members were interviewed, Kristin had again been hospitalized due to attempted suicide. This was not known to these workers, who told the interviewer that they had lost track of Kristin who had moved to another municipality. According to Kristin, she did not move. And if so, there was no sign of any worker having tried to connect Kristin to the health and social services in her alleged new locality. Given this story, what does Kristin disclose about these structures and processes, as strategies and tactics, and as forms of caring?

This brief case presentation illustrates some challenges connected to "co"terms, good intentions, and case management. Some cooperation took place between workers at the Social Welfare Department and the Young Adult Project. There was mutuality and a sharing of work in recruiting clients and sticking to her defined job, to handle financial problems. Yet she did not restrict her efforts to this limited area of Kristin's problems, made contacts between Kristin and services she thought useful. She played an active part in creating the public network around Kristin.

When Gray's key aspects of collaboration are used to examine this example on the agency and worker levels, we find different degrees of interdependency but no joint ownership of decisions. The differences between and among agencies were not responded to constructively. They were either suppressed or played out in confrontive ways. No worker can be said to have become a broker to open access for Kristin in Mental Health.

The worker in the Young Adult Project tried to make the Mental HealthCenter accessible for Kristin, but the result was not an enhancement of interprofessional and interagency cooperation on Kristin's behalf. This worker was the one in closest contact with Kristin, the one who saw her hurts, and was willing to fight for her. After the Social Welfare Department had pulled out, the worker in the Yound Adult Project held a key position and put herself in a role similar to case manager. She seemingly tried to manage other workers, but did so without a jointly agreed upon work plan. Shared responsibilities did not emerge and no team was formed.

 

61.

 

The cluster was composed of parties with different influences on the agency and worker levels. The worker in the Young Adult Project was not in a position to refer to Mental Health and had to negotiate and while at the same time reactivating earlier referrals.


CONCLUSION

Cooperation and coordination are among the politically correct terminology of today; they are self-righteous and accepted in every-day life at face value. Management seems to transfer the order dimension in coordination over to cooperation. Thus, a concept where trust and freedom of choice are core elements, is transformed into a managerial tool.

Case management is about more than services and worker and agency interaction. It involves what students are to be taught, how to secure client participation, and preventing that the managerial part becomes an end in itself. Kristin illustrates that the involvement of a number of workers is, in itself, neither effective nor a guarantee of quality care or services.


LITERATURE

Austin, C.D. (1993). Case management: A systems perspective. Families in Society 74(8):451-459
Gray, Barbara (1991). Collaborating. San Francisco: Jossey-Bass Inc.
Kingsley, Chris (1993). A Guide to Case Management for At-Risk Youth. Waltham: Center for Human Resources, Brandeis University.
Lov om sosiale tjenester m.v. av 1991. [The Social Service Act]
Mattessich, Paul W. & Monsey, Barbara R. (1992). Collaboration: What Makes it Work? St.Paul: Amherst H. Wilder Foundation.
Mulford, Charles L. & Rogers, David (1982). Definitions and models. In D. Rogers & D. Wetten Interorganizational coordination: Theory, research, and implementation. Ames: Iowa State UP.
National Association of Social Workers (1992). Standards for social work case management . Washington.
NOU 1986:4 Coordination in health- and social services [Samordning i helse- og sosialtjenesten]
Rogers, David, & Wetten, David (1982). Interorganizational coordination: Theory, research, and implementation. Ames: Iowa State UP.
Zahl, Mari-Anne (1997). Social Work in a Social Political Frame. [Sosialt Arbeid i Sosialpolitiske Rammer].

62.

Back to Top
Next Article


Copyright for the I.U.C. / B.S.U. Journal of Social Work Theory and Practice is owned by the Social Work Program, Department of Social Relations and Services, Bemidji State University, Bemidji, Minnesota, USA. One copy may be made (printed) for personal use; teachers may make multiple copies for student use if the copies are made available to students without charge. Permission must be secured from the editors for sale of any copies of articles or for any commercial use of the material published in the Journal.

2001 Copyright BSU/IUC Journal of Social Work Theory & Practice