A Study of Case Managers' Decision-Making Processes

By Crook, Wendy P. PhD; Vinton, Linda PhD | Care Management Journals, Winter 2000 | Go to article overview

A Study of Case Managers' Decision-Making Processes


Crook, Wendy P. PhD, Vinton, Linda PhD, Care Management Journals


Decision-making processes were explored in a study of 122 case managers from community-based aging network agencies. Of interest was how often case managers employed a consumer-driven model whereby elders' input is always considered during the assessment and decision-making processes. Approximately 80% always used clients as a source of in formation during assessment but less than a majority always used client recommendations in decision making. The case managers indicated that safety was more frequently a guiding principle used in decision making than the least restrictive alternative, disruption to lifestyle, and freedom. When clients disagreed with the case managers' decisions, attempting to convince the client was the strategy the greatest proportion of respondents employed. Case manager characteristics (gender and degree) were not found to be associated with consumer-oriented methods of assessment or decision making. The authors concluded that the respondents tended to use a consumer-oriented approach when assessing clients but moved away from the consumer-driven model when making decisions with regard to clients. Safety, rather than freedom, was the prevailing guiding principle.

An independent living paradigm was described by DeJong (1984) that was contrasted with a medical-rehabilitation paradigm. An orientation toward clients as consumers rather than patients and consumer versus professional-driven control of the helping process characterize the independent living model. The underlying value base of the medical-rehabilitation paradigm is paternalism, whereas self-determination undergirds the independent living paradigm.

It is the contention of Tower (1994) that human services agencies have largely overlooked the fundamental rights and responsibilities of consumers. She points to questions that highlight the obstacles to viewing clients as consumers-"How is an elderly person using inhome supportive services a consumer? What does consumerism have to do with a severely disabled person living independently?" (p. 192). The doctrine of consumerism within the human services holds that individuals are more knowledgeable about their own needs and interests than professionals and concludes that even the most vulnerable clients should be encouraged to exercise the intrinsic power that stems from such knowledge.

According to Robinson (2000), case management occurs within an environment in which agency function, community resources, professional and paraprofessional support, and family all interact with the client. Although the client and family are seen as being at the center of the environmental system, case management with older adults is often fraught with complex, ethical issues. Robinson notes that a dilemma can arise when a case manager must judge an elder's competence in terms of making independent decisions such as continuing to live in the community. She also states there may be tension between an agency's budgetary and time constraints and the needs of elderly clients. Case managers may be called upon to balance responsibility between the client and the agency.

Client-driven models of case management more actively involve clients in constructing service plans than provider-driven models (Rose & Moore, 1995). In the client-driven model, the client's needs and wishes determine the goals and evaluation of goals involves examining client autonomy and the use of informal supports. This model is similar to the consumer-driven model of case management developed by Riley, Fortinskey, and Cogburn (1992). Here, the emphasis is not on the effectiveness of each discrete service but on the entire plan of care. Further, the way case managers think about clients is challenged as the consumer-driven model stresses that individuals are the consumers of services rather than the passive and dependent recipients of care that is determined by others. Choice is exercised by the consumer during each phase of the consumer-driven model of case management: consumer assessment, care planning, monitoring, and evaluation of services. …

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