JOURNAL
ISSUE 2
1999/2000
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.
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