With mounting fiscal constraints in home care, case managers find themselves increasingly confined in rationing roles and pressed into a narrow focus on the individual case. These pressures frustrate case management's potential to inform and contribute to more broadly-based improvements in service systems, policy formulation, and resource development. A study of home care users'perspectives in a jurisdiction where fiscal pressures have been rapidly increased reveals how rationing and service reduction affect service recipients and shape their relationships with case managers. The study sheds light on the challenges and opportunities for case managers of practicing in such straitened circumstances. Combined with their own detailed understanding of front-line service delivery, case managers can build on the knowledge of service users' perspectives to make critical contributions to both the well-being of the generally jeopardized populations who need home care and to the broadening of case management practice in keeping with its commitments to advocacy and systems level change.
The literature on case management documents two kinds of tension in its practice: tension between client and systems level interventions and tension between gatekeeping and advocacy. With respect to the first, Austin (1993, p. 453) notes that, despite claims to a combined focus, the balance of attention in case management has been heavily weighted toward the client level and that". . . systemsoriented case management activities are frequently not clearly specified." With respect to the second, Yarmo (1998) suggests that the practice of advocacy in case management has been similarly underspecified, with the balance of attention directed toward funders' and employers' imperatives rather than toward service recipients' perspectives. The mounting fiscal constraints under which health and social services are currently delivered deepens these imbalances of attention and action; systems-level interventions and collective advocacy are squeezed still further to the margins of case management practice. Thus in the context of home care, the focus of concern in this article, case managers find themselves increasingly confined in rationing roles and pressed into an ever tighter focus on the individual case (Arce, 2000; Lemire & Austin, 1996; Lewis et al., 1997). Attention to the broader landscape of case management-unmet need, resource development or service users' perspectives-shrinks accordingly.
A study of home care users' perspectives in a jurisdiction (Ontario, Canada) where fiscal pressures have been rapidly increased reveals how rationing and service reduction affect service recipients and shape their relationships with case managers (Aronson, forthcoming; Aronson and Neysmith, forthcoming). Reports of mounting strains and vulnerabilities in home care recipients' lives shed further light on the challenges for case managers of practicing in such straitened circumstances. Combined with their own detailed understanding of front-line service delivery, case managers can use this knowledge to make critical contributions to both the well-being of the generally jeopardized populations who need home care and to re-energizing case management's commitments to advocacy and systems level change.
To this end, a brief description of the home care environment in Ontario and of the study of home care users' perspectives follows. Key aspects of the findings are then presented, followed by discussion of their implications for practice, education, and research.
HOME CARE IN ONTARIO AND THE CONTEXT OF THE STUDY
Home care in Ontario was reorganized in 1996 when publicly funded Community Care Access Centres (CCACs) were set up across the province (Williams et al., 1999). Each center is charged with contracting out all direct service provision to a mix of for-profit and non-profit provider organizations. Case managers employed by each CCAC are assigned to home care clients to determine eligibility, assess need and coordinate and monitor packages of services drawn from the providers with whom their CCACs have contracted. …