Advances Vol. 3, No. 1 In the Belly of the Beast: A Case Study of SocialWork in a Managed Care Organization Lisa S. Patchner Abstract: The employment of social workers within managed care organizations is a new phenomenon. As such, this case study utilized an exploratory-descriptive design that assessed social workers as case managers within a Medicaid HMO. The semi-structured interviews, focus groups, and participant observation suggested that the use of casemanagement services, delivered primarily by social workers,was effective in addressing the bio-psychosocial needs of Medicaid consumers within a provider-drivenHMO.Study findings recommend specific knowledge and skills that social workers need in order to prepare for practice within managed care environ- ments. Keywords: Managed care; Medicaid; case management; HMO, health care policy As managed care more completely penetrates the health care and public service delivery markets, the industry can expect to enroll increased num- bers of high-risk populations.With advances in medicine, coupled with the aging of the population, there are increased numbers of individuals with chronic illnesses and complex psychosocial concerns that require long-term health and community-basedservices (U.S.GeneralAccountingOffice, 1996).Themanagedcare industry, familiar with the provision of a lower-cost alternative to traditional indemnity insurance forhealthypopulations, has limited experience servinghigh-risk populations (Kaiser Commission, 1995). As Kelly (1997) reported, most managed care companies are inexperienced in the supply of community support services (i.e., psychosocial services, outreach, casemanagement, and transportation) needed to manage health care and promote wellness among high-risk populations.With the increased privatization of Medicaid, leading to managed care arrangements, the industry has had to hasten delivery systems to meet the health and social service needs of a growing, heterogeneous population. Even thoughmanaged care continues to grow at a rapid pace, there have been no empirical studies of social workers’ involvement in private managed care organi- zations. This study represents a beginning attempt at understanding professional social work involvement in the evolving managed health care delivery system by examining social workers employed in a Medicaid managed care organization. Specifically, this case study investigated the role and functions of social workers in a 16 Lisa S. Patchner, DrPH., LSW., ACSW is Associate Professor, SocialWork Department, Ball State University, Muncie, Indiana 47306-0525. Copyright© 2002 Advances in SocialWorkVol. 3 No. 1 (Spring 2002) 16-32. Indiana University School of SocialWork. Medicaidmanaged care organization, and determined the structure and function of casemanagement servicesofferedby these socialworkers. Implicationsaredrawn for social work’s involvement inmanaged care organizations and for the education of future professional social workers for casemanagement positionswithinmanaged health care organizations. BACKGROUND Managed care will increase its penetration into the continuum of care in order to demonstrate efficient and cost-effective health improvement for large, chronically ill populations (Goldsmith, Goran&Nackel, 1995). Expansion into the provision of community services alters the treatment focus from acute care to chronic care, and highlights the need for cost-effective, long-term care management of the chronically ill and other high-risk consumers (Moore-Greene, 2000). Social work case management models have traditionally been applied in the coordination and linkage of service components within the service delivery con- tinuum. In providing case management services, social workers transition high- risk clients with chronic illnesses to appropriate levels of care in order to increase desired health outcomes and decrease inappropriate utilization of services. Traditionally found within community service settings, case management services have begun to emerge as an important component of insurance utilization man- agement. Managed care systems have begun to integrate case management strategies into their organizational processes in order to coordinate acute and chronic care services for increased Medicaid enrollments (Kaiser Commission, 1995). As Medicaid managed care systems provide the consumer with a primary care provider and facilitate the coordination of integrated services through case management services, better population health outcomes should emerge. According to a recent Health Care Financing Administration (HCFA) Press Office Fact Sheet onManaged Care in Medicare andMedicaid (U.S. Dept. of Health and HumanServices, 1997), enrollment inmanaged care plans has experiencedunprece- dented growth. In 1999, more than half (55.59%) of the national Medicaid popula- tionwas enrolled in amanaged health care plan (U.S. Dept. of Health andHuman Services, 2000). The accelerated growth ofMedicaidmanaged care systems, which serves the most vulnerable populations, is the result of a failure to agree upon a national healthpolicy, increased fiscal deficits, and inequalities of access toprimary medical care. Most states have focused theirmanaged care enrollments on low-income families, which constituted approximately 73% of the Medicaid population in 1994 (U.S. General AccountingOffice, 1996). As states initiatemandatedmanaged care for their entire Medicaid populations, individuals with disabilities, who represented approximately 15% of the 1994 Medicaid population and account for more than one-third of Medicaid expenditures, will also challenge states to provide quality health care to a diverse population. Additionally, the prevalence of chronic illnesses and disabilities among children enrolled in the former AFDC and current TANF programs isapproximately twice thatof children fromthegeneralpopulation (Meyers, Lukemeyer&Smeeding,1998).Accordingtoarecentstudy(Shatin,Levin, Ireys&Haller, 1998), children with selected chronic health conditions are enrolled at a higher 17Patchner/IN THE BELLY OF THE BEAST: A CASE STUDY OF SOCIALWORK IN AMANAGED CARE ORGANIZATION 18 ADVANCES IN SOCIALWORK rate inMedicaidmanaged care plans than inprivatemanaged care plans, and those enrolled inMedicaidmanaged care plans requiremore services than childrenwith similar conditions who are enrolled in private managed care plans. Due to the heterogeneity of chronic disabling conditions and demographic trends, individu- als with chronic illnesses and disabilities will need awell-designed service delivery continuum (The Institute for the Future, 2000). Somers and Martin (1997) state: Health plans entering the Medicaid marketplace must adapt their health care delivery systems to serve the disabled and aged populations. Purely medical-model health care delivery systems must become social-model organizations able to coordinate bothmedical care and social services. (p. 2) A series of recommendations is beginning to emerge from advocacy, research, government, and industry experts indicating that a refined and informed approach to meeting the unique health care needs of high-risk populations, including those with chronic health care needs, is urgently needed. The Kaiser Commission (1995) asserts that the special needs, ethnic characteristics, and other unique features of the Medicaid population must be addressed when designing effective managed care systems for low-income consumers. Their report further indicates that such services as case management and care coordination have the potential to improve health delivery by modifying managed care services to address unique health concerns. The PewCommission (1995) predicts that the future Americanhealth care system will bemore concernedwith disease prevention, health promotion, and careman- agement, and less focused on specific medical treatments. The Commission rec- ommends that health professionals broaden their understanding of the psycho- social-behavioral sciences, population health promotion strategies, and health management sciences in order to better meet national health needs. The Pew Commission also asserts that thenewly emergingdemand-drivenhealth care system warrants consumer-focused and culturally-sensitive health care delivery. Preister (1996) recommends a new model of consumer-focused delivery that incorporates four characteristics: community-based human services; flexible and holistic services; family-centered services; and professional services that reflect accountability. Additionally, Preister (1996) stresses that families need to partner with case managers to design consumer-focused interventions. McManus, Fox, and Newacheck (1996) acknowledge the important contribu- tions of case management services to families of children with special health needs. According to Nicolaysen (1996), the need for case management within managed care will continue to grow as wellness among high-risk populations is promoted, thus indirectly reducing costs and contributing to cost containment. Harris (1992) anticipates that in addition to educating consumers about health prevention, there will be more emphasis on improved health outcomes by better management of clinical interventions. Others predict thatmanaged carewill focus more uponmanaging health outcomes of high-risk populations (Goldsmith, et al., 1995; U.S. GAO, 1996). As managed care better adapts its service delivery systems to address the needs of high-risk populations, increased opportunities for professional case managers 19 will emerge. Although various professions have provided case management serv- ices, social workers continue to bemost commonly associated with case manage- ment, especially at the community level. The National Association of Social Workers (1992) defines social work case management as: Amethod of providing services whereby a professional social worker assesses the needs of the client and the client’s family, when appropriate, and arranges, coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific client’s complex needs. (p.5) Long familiar to social workers, case management has grown in importance in health care due to the changing health needs of the population and the resulting changes in health delivery systems. Landgarten (1988) argues that the growth of case management services reveals the fragmentation and inefficiencies through- out the health care delivery system. He asserts that case management attempts to reintegrate the fragmented health delivery system tomeet the convergent needs of the consumer, payers, and providers. As the U.S. population is increasingly covered under managed health and wel- fare services, the expertise of social work case managers in serving high-risk pop- ulations will be sought out by the private managed care sector. Social workers are specifically trained to utilize tested interventions from community-based pro- gramming and adapt these to managed care settings in order to deal with prob- lems of access to services, continuity of care, and chronic care management (Hughes, 1999). Despite these opportunities, social workers have generally avoided working for managed care organizations even though their knowledge, skills, and values could greatly benefit persons served by these plans. Reluctance on the part of professional social workers to seek employment in managed care systems is due, in part, to an historical aversion to participate in the for-profit sector of the economy. In addition, the ethical issues surrounding cost-containment measures implemented by these systems have made them suspect to the profession. However, due to their specific skills and training, social workers can make signifi- cant contributions to the availability, accessibility, and quality of services provided through managed care arrangements. METHODOLOGY This case study examined social workers in a Medicaid managed care system and described the unique applications of social work casemanagement services in this environment. Specifically, the study had two major foci. The first was to analyze the role and functions of social workers in a Medicaid managed care organization serving thewestern region of aMiddle Atlantic state.The secondwas to describe the structure and functionof casemanagementwithinaMedicaidmanagedcare system. Setting A for-profit, managed care organization that delivers an HMO product specifically designed for the Medicaid population served as the setting for the study. The health plan began in November 1992, when an Agreement and Plan of Limited Partnership was signed by three major health care organizations. Two of the three partners are not-for-profit organizations and the third is for-profit. The health plan Patchner/IN THE BELLY OF THE BEAST: A CASE STUDY OF SOCIALWORK IN AMANAGED CARE ORGANIZATION 20 ADVANCES IN SOCIALWORK began enrollingMedicaid recipients in July 1993 with a start-up population of 111, and at the time of this study, covered more than 102,000 beneficiaries. The health plan began serving one county and expanded to a 16-county area. As a network model HMO, the health plan concentrated on developing a quality provider net- work with a strong internal utilization management structure during its early development. As membership increased, attention to both the external and inter- nal delivery process led to further refinement of health services, specialized case management, quality improvement techniques, and utilization management. Incrementally, health improvement strategies utilizing disease prevention pro- grams (i.e., asthma program, maternal health program), member education, and targeted casemanagement were implemented. This particularMedicaidmanaged care organization was selected for study because they had a unique Case Management Unit where social workers played an integral part in the delivery of case management services to a high-risk Medicaid population. Design Given the complexity of case management, several data collection methods were employed. These included interviews with case managers and the MSWManager of the Unit, focus groups with consumers, and participant observation. Face-to-face interviews were held with eight case managers. Five were MSW- level social workers, two were BSN-level nurses, and one was a MS-level Rehabilitation Counselor. The interviews focused on assessing their specific roles and functions and ascertaining the model of intervention that they employed. Semi-structured interviews allowed for in-depth questioning about the caseman- agers’ specific roles and functions, and their use of case management interven- tions. Each interview occurred at the casemanager’s workstation and took approx- imately 45 minutes to complete. In addition, this investigator engaged in participant observations of the opera- tions of the Case Management Unit. These day-long observations occurred one- to-two days a week for a 15-month period. The purpose of these observations was to gain a comprehensive understanding of the structure, function, and practices of the CaseManagementUnit at the health plan. This researchwas authorized by the Managed Care Organization for the purpose of sharing information regarding their Social CaseManagementModel with other stakeholders. The researcher was not monetarily subsidized by the Managed Care Organization for this research. During the 15-month period, the investigator interacted with a variety of staff within the Medicaid health plan and attended departmental staff and other cor- porate meetings that addressed case-management related activities. The researcherwas given a cubicle, limited access to themanagement information sys- tem, and a telephone within the CaseManagement Unit to better assess the oper- ations andprocesses of the department and to participatemore fullywith the staff. The researcher signed a confidentiality statement pledging not to disclose identi- fying information about any of the cases. Staff routinely shared case situations with the researcher. Observations were noted either in writing through daily field notes or mentally. Daily field notes included the activities of the investigator and impressions of the observations being made, such as how case management was conceptualized and carried out. 21Patchner/IN THE BELLY OF THE BEAST: A CASE STUDY OF SOCIALWORK IN AMANAGED CARE ORGANIZATION Two focus groups were held with consumers who had recently received case management services to evaluate their satisfaction with those services and their perceptions of their health status. The focus groups were designed in such aman- ner that those individuals who directly interfaced with a case manager (i.e., they had telephone or face-to-face contact with a case manager) were invited to one group (Focus Group A) and those who did not interface with a case manager (i.e., casemanagement serviceswere provided, but the individual had no direct contact with the case manager) were invited to the other (Focus Group B). All focus group members were chosen from a systematic random sample of recently closed case management cases. Two other selection criteria for participation in the focus groupswere residency in the primary county served by the health plan and current membership in the health plan. Application of these criteria resulted in a pool of 36 potential participants for Focus Group A and a pool of 26 for Focus Group B. Attempts weremade to phone all of the eligible members to invite them to partic- ipate in the focus groups. Those contacted were assured that their participation was voluntary and that their anonymity was guaranteed. Those who were unable to participate indicated a variety of reasons including: work schedules, child care issues and not wanting to participate. Approximately one-third of the eligible focus group members were unable to be reached by phone. Letters inviting par- ticipation in the focus groupswere sent to all eligible focus groupmembers, except those who declined to participate. Seventeen people accepted the written invita- tions and participated in the process: 12 participated in Focus Group A and five in Focus Group B. Free transportation to and from the focus group meetings was provided to any participant who needed it, and each participant was given $20.00 for participating in the focus group. Focus groups were held at the corporate office of the health plan and lasted for two hours each. The following areas of inquiry were addressed: the consumers’ views of the health plan, case management services, case man- agers, medical services provided, and past and present health status. FINDINGS CaseManagement Process By its very function of providing and coordinating services to consumers, social work case management within health care delivery uses a client-driven approach to meet consumer health needs. Case management services at this health plan accomplished this by focusing their interventions on client-centered needs by coordinating services, communicating health concerns, educating consumers about health promotion, advocating for necessary services, assessing health needs, and informing consumers about care options. The traditional casemanagementmodel that uses a client-driven approach is in sharp contrast to the provider-driven approach which has increased in recent decades due to accountability and profitability factors. At this health plan, a very structured, client-driven approach was in operation within the CaseManagement Unit, where individual consumer health care needs were the primary focus of the case manager’s intervention. 22 ADVANCES IN SOCIALWORK To bridge the client-driven and provider-driven approaches to case manage- ment services, the CaseManagement Unit adapted a practicemodel developed by the Case Management Society of America (CMSA) (Smith, 1995). This model places the case manager as the central figure who addresses the various concerns and desires of client, provider, and payer in order to develop effective services. The CMSA model directed case management practice, interventions, and services to meet consumer needs within the managed care health delivery environment, wheremediation between the payer, provider, and client occurs. Advocacy, assess- ment, collaboration, communication, coordination, empowerment, evaluation, facilitation, planning, andproblem solving are utilized by the casemanager to bro- ker resources for the member of the health plan. Case management services focused on intervening with complex, catastrophic cases that benefited from increased coordination of medical and community- based services. Using a bio-psychosocial assessment to determine medically nec- essary care, case managers assisted the members in accessing health and social services through advocacy, coordination, monitoring, counseling, and education functions. The case management process consisted of referrals, screening, assess- ment, intervention, and quality monitoring (see Figure 1: Case Management Decision-Making Process). High-risk cases were routed by utilization nurses, customer services, marketing, providers, members directly, and community-based services to the Case Management Unit. The referral process was accomplished through the manage- ment information system, which allowed internal routing of cases on-line rather than on paper. Cases with specific psychosocial andmedical indicators were auto- matically referred to the Case Management Unit for assessment and, if necessary, intervention. When personnel within the health plan, community providers, or the health planmembers themselves identified a psychosocial need, caseswere routed to the Case Management Unit for intervention. Certain illnesses or conditions, such as mental illness or substance abuse, automatically triggered a referral.When a refer- ral was made to the Case Management Unit, the member was assigned to a spe- cific case manager who provided the necessary intervention. The case managers were assigned to specific cases where their expertise in behavioral health, high- risk pregnancy, geriatrics, rehabilitation, developmental disabilities, cancer, or HIV/AIDS was needed. Once a referral was received, a screeningwas performed to assess health plan eli- gibility, case management criteria eligibility, and member’s willingness to partici- pate with case management. An assignment of the member, based on diagnosis and caseload, was made to a specific case manager. The BSW Intake Coordinator, in consultation with the Manager of the Case Management Unit, made these assignments. Next, the case manager completed a bio-psychosocial assessment. The assessment was done in narrative format on-line. The case manager then assigned a level of case intensity—general, moderate, or complex. These case intensity levels depended upon the amount of time and effort that the case man- ager would be involved with the case. A plan of care was then developed in con- junction with the health plan member, the family, and/or the provider. 23Patchner/IN THE BELLY OF THE BEAST: A CASE STUDY OF SOCIALWORK IN AMANAGED CARE ORGANIZATION Figure 1: Case Management Decision-Making Process InternalReferrals • Members Services •Marketing • Utilization Management ExternalReferrals • Health PlanMembers • Health Plan Providers • Social Service Agencies EligibilityVerified • Cordination of Benefits Meet CM Criteria? • Utilizing Route to Reason Criteria Yes Assignment of Case-to-CaseManager Based on Specialty, Case Load, & Primary Diagnosis Bio-Psychosocial Assessment Assign Level of Case Intensity • General, Moderate, or Complex Development of a Service Plan with Member and/or Family and/or Provider Implementation of Service Plan • Coordinate Medical Services • Coordinate Community Referrals • Provide Counseling • Provide Education Monitoring Case Status • Telephone vs. Face-to-Face CaseManagement GoalsMet? Refer toAppropriate Department •OtherDept. •OutsideProvider Continuous Documentation No Yes CaseClosure Yes No No Or 24 ADVANCES IN SOCIALWORK The case manager coordinated the implementation of the interventions speci- fied in the plan of care. This required a variety of contacts with medical and com- munity services and themember and the family. Throughout this process, the case manager strived for the self-determination of themember through education and counseling of the member regarding service alternatives. On-going monitoring of cases to determine whether treatment goals had been met was an integral com- ponent when implementing interventions. Regardless of the professional orientation of the casemanager, services were ini- tiated when there was an onset of chronic or catastrophic illness or injury that required coordination of multiple medical and psychosocial needs. It was essen- tial that the case manager focus on an individual treatment plan that was cost- effective, satisfying to the consumer, and guided by professional standards. Complex medical referrals of consumers were routed into the Case Management Unit for individualized attention and action by a casemanager who addressed the multiple psychosocial needs that impeded medical treatment. Due to the com- plexity of health care delivery, casemanagement services had grown into a power- ful tool formanaging the health needs of high-risk populations that exhibitedmul- tiple bio-psychosocial needs. Quality monitoring was a continuous process where case reviews on intensive cases were presented within the department or discussed with themanager of the Case Management Unit. Case management activity was monitored weekly through the management information system documentation to determine the case manager’s workload and efficiency in processing the cases. Monitoring of phone calls for quality assurance purposes and adherence to corporate standards were available tomanagerial staff. An audit, conducted quarterly, was designed by case management staff to assess the quality of the case manager’s interventions and documentation through peer and supervisory review. Consumers Served by CaseManagement At the time of this study, the health plan served more than 102,000 individuals within a 16-county network. Since the inception of case management MIS data collection capability, the Case Management Unit received 16,713 referrals, which included 3,502 separate individuals. These individuals accounted for 3.5% of the membership in the health plan. Of those served by the Case Management Unit, 70.2%were female and29.8%weremale.Their ages ranged fromnewborn through 95 years of age, with amedian age of 25.6 years and amean age of 28.9 years. For their primary care physicians, 42.6% of the members who utilized case management services chose family practice physicians, 40.4% chose internal medicine physi- cians, and 17.0% chose pediatricians. These health plan members, all of whom wereMedicaid recipients, fell into 45Medical Assistance categories. These include 33.2% AFDC—Cash Medicaid, 20.1% SSI—Disabled, 8.1% Disabled Elderly, 7.0% General Assistance or Chronically Needy, 6.9% AFDC—Medicaid No Grant, 1.4% SSI—Aged, 16.3%Not Classified, and 7.0% that were dispersed among the remain- ing categories. Of the 16,713 referrals, 69.9% came from the health plan Utilization Management Unit, 11.4% from the Behavioral Health Unit, 4.0% from community agencies, 3.7% from the health plan maternity program, and 2.5% from a self- referral or a referral of a family member. The remaining 8.5% came from social workers in hospitals, rehabilitation units, nursing homes, and home health agen- cies, OBClinics, Primary Care Physicians,member services within the health plan, and several other sources. Each time a member was routed for services, the member’s diagnosis was recorded for each specific episode of care. A member’s diagnosis could vary each time the Case Management Unit was involved. For example, a member could receive casemanagement services because of a behavioral health problem on one referral into case management, and, on the next referral, the samemember could receive casemanagement services due to a bone fracture. Thus, each time an indi- vidual received case management services, the primary diagnosis might be retained, as might typically be the case for a chronic illness, or could change due to a change in condition for each episode of care. Theprimarydiagnosesof the16,713 referrals that receivedcasemanagement serv- ices fell into 921 unique classifications utilizing the International Classification of Diseases (ICD-9) (Practice Management Information Corporation, 1996), thus demonstrating that the Case Management Unit handled consumers with a wide variety of presenting diagnoses and resulting psychosocial problems. The ICD-9 classification system is elaborate and specific. For example, among the 921 diagnoses of consumers who used services of the CaseManagement Unit, therewere nine different codes for bipolar disorders, 22 for substance abuse, 10 for high-risk pregnancies, and 14 for diabetes. For analyses purposes, these 921 unique diagnoses were reclassified into 11 general categories and an “other” cate- gory for those diagnoses that did not fit into one of the 11 categories. The 12 reclas- sified categories included: 1) AIDS/HIV, 2) Bipolar Disorders, 3) Depression, 4) Alcohol/Drug Abuse, 5) Asthma, 6) Diabetes, Injury/Trauma/Fractures, 8) High- Risk Pregnancy, 9) Normal Pregnancy, 10) Congenital Anomalies, 11) Neurological Diagnosis/Cerebrovascular Disease, and 12) Other. When reclassified, the distri- bution of diagnoses addressed through case management services revealed that High-Risk Pregnancy accounted for 10.7% of the diagnoses, Injury/Trauma/ Fractures accounted for 6.8 %, Normal Pregnancy accounted for 6.7%, Depression accounted for 5.4 %, Neurological Diagnoses/Cerebrovascular Disease accounted for5.1%,Asthmaaccounted for5.0%,Alcohol/DrugAbuseaccounted for2.7%,Diabetes accounted for 2.6%, Congenital Anomalies accounted for 1.8%, AIDS/HIV accounted for 1.6%, Bipolar Disorders accounted for 1.1%, and Other accounted for the remaining 50.6% of the diagnoses. The “Other” category is quite high because it includedseveral hundreddiagnoses.However, eachoneaccounted for less than one percent of the total diagnoses. SocialWork CaseManagement Roles and Functions The working environment at the managed care organization reflected an integra- tion of aspects of both social welfare and business paradigms.The publicmandate to serve theMedicaid consumer was a priority within the CaseManagement Unit. On the other hand, the corporate mandate to be efficient and cost-effective was also routinely evident. Usually, the two mandates could be accomplished by staff within theUnitwithout anyprofessional conflict of interest.When the publicman- 25Patchner/IN THE BELLY OF THE BEAST: A CASE STUDY OF SOCIALWORK IN AMANAGED CARE ORGANIZATION date and the corporate mandate conflicted, however, the Case Management staff conferred with other co-workers in this interdisciplinary unit and with supervi- sors, including the Unit manager and the health plan medical director. They weighed the benefits and costs to the individual consumers before making any decisions. This allowed for a more informed decision-making process and facili- tated a collaborative approach to conflict resolution. An example of such a conflict would be in a case where a prescribed medication that the primary physician had ordered was not included in the organization’s drug formulary. For a special needs consumer, the task of case managers would be to advocate for a waiver to permit the consumer to receive the prescribed medication. Case managers reported that their advocacy efforts were usually successful. When asked to describe their duties, roles, and responsibilities as casemanagers, all eight individuals identified coordination of services and service as a resource specialist formembers. Four of the casemanagers considered themselvesmember advocates, with one case manager describing empowerment of members as a key job function. Other job functions described by case managers included: consulta- tion with providers, crisis management, development and monitoring of treat- ment plans, education of the member, promotion of good health practices, and service as a liaison between themember and community services. One caseman- ager described her function as “assisting members in getting appropriate, cost- effective care in a timely fashion.” Irrespective of their professional identification as a social worker, nurse, or rehabilitation counselor, all eight case managers responded by identifying job functions performed by professional case managers and not necessarily those of their individual professions. The Case Management Unit used a social case management model staffed pri- marily with social workers. However, as the department expanded, it developed an interdisciplinary approach to case management by adding the other professional disciplines of nursing and rehabilitation counseling. All but one of the case man- agers interviewed felt that this interdisciplinary approach influenced what they did as case managers. The case managers generally felt that the collaboration and consultation among staff from different disciplines allowed them to become bet- ter informed andmore efficient in decision-making. Therewas a high level of comfort among the social workers that functionedwith- in an interdisciplinary approach while utilizing their specialized discipline specif- ic skills to address individual consumer needs. There were few value conflicts or professional conflicts observed or reported among Unit staff. Social work case managers reported performing similar functions to those used by social workers in the community setting (i.e., advocacy, counseling, coordination, brokering, pro- gram development). Generally, they did not view their telephone interventions with consumers and providers as problematic. According to all case management staff, providing services through community providers also appeared to work well when the consumer and provider had developed a good working relationship. There were instances where casemanagers had to advocate for members’ needs that were not covered by the health plan. Some of these advocacy efforts (such as a member needing supplies or medications) may have cost the health plan more in the short-run, but in the long-run was considered preventative and cost-effec- 26 ADVANCES IN SOCIALWORK tive in nature. Staff indicated that they were comfortable working within this cor- porate setting, and it appeared that they were well respected by other units throughout the managed care company. As a profession, social work has been lukewarm regarding its role in providing services within corporate managed care settings primarily because of our unfa- miliarity withmanaged care, lack of direct access to themanaged care policymak- ing process, and the desire to adhere to the profession’s ethics and values (Epstein & Aldredge, 2000). In contrast, case management staff within this Managed Care Organization possessed a clear understanding of the organization’s role in providing health care delivery, their role as advocates and facilitators in securing necessary and appropriate services, and their potential to impact organizational policies and procedures that affected the overall health of consumers. Benefits of interdisciplinary casemanagement included the convergence of per- spectives, more in-depth assessment, and a more holistic approach to service. None of the workers could identify any specific weaknesses with the interdiscipli- nary approach. One suggested that “the informal nature of their professional col- laboration might need to be formalized in the future should the department grow significantly.” When asked what other disciplines should be added to the Case Management Unit, all but one of the casemanagers suggested that additional staff should have a background in the area of developmental disabilities. Other sug- gested areas of expertise for new staff were in benefits and funding, early inter- vention and education, behavioral health, community outreach, homehealth, and rehabilitation and orthotics. One worker felt that until the needs of the growing membership could be determined, it was premature to anticipate what additional areas of expertise would be needed within the Case Management Unit. Staff indicated their concern that communication among unit case managers might be challenged as additional professionals are added to the unit and new procedures for addressing larger numbers of high-risk populations emerge. Staff indicated that the interdisciplinary approach was well-integrated into daily oper- ations of the CaseManagement Unit. Utilizing a quality improvementmechanism to address staffing loads, communication patterns, casemanagement policies and procedures, documentation of case findings, and consumer outcome measures could enhance successful future growth of the Case Management Unit. Consumer Satisfaction In general, members who participated in the focus groups were very positive about the health plan and the case management services they received. Members who interfacedwith casemanagement weremuchmore favorable than thosewho had not. Indicative of the enthusiasm demonstrated by members who had inter- faced with case management staff, some described the health plan as “Miracle Insurance” and a “Thank You Health Plan.” Members who interfaced with case managers reported that the case manager listened and responded to their needs, remembered who they were, indicated genuine concern for their unique health concerns, had good communication skills, and were knowledgeable about resources. Members generally noted prompt follow-up by casemanagers following hospitalizations andmember-initiated calls to theUnit. Of significant helpwas the 27Patchner/IN THE BELLY OF THE BEAST: A CASE STUDY OF SOCIALWORK IN AMANAGED CARE ORGANIZATION 28 ADVANCES IN SOCIALWORK brokering role of case management, where case managers linked members to other health plan services, such as a high-risk maternity program, or to community agencies providing services for alcohol or drug problems, mental health issues, special needs children, and the like. Members noted the tangible services they received, such as assistance with alcohol rehabilitation assistance, transportation, rehabilitation therapies,maternity outreach assistance,medical equipment, infor- mation on available services, and coordination of services prior to and after hos- pitalization. They were particularly pleased that case managers understood their needs, were kind and respectful, and were resourceful. They acknowledged the efficient manner in which the Case Management Unit appeared to operate. Somemembers who did not have direct contact with the health plan case man- agers did receive case management services from providers and vendors who served them following an illness or injury. Members of this group generally felt pleasedwith the services they received from the providers and vendorswho assist- ed them in the home. These services, many of which were arranged by the case managers, included home health assistance with insulin training, high-risk preg- nancy bed rest with home health and homemaker assistance, and orthotics with follow-up physical therapy. Generally, these members were pleased with the prompt arrangements for services, the effectiveness of the service, and the quality of the personnel providing the services. One member indicated that “I wouldn’t change if I had the choice.” Although members were quite satisfied with case management services, both groups of members—those who had interfaced with case management and those who had not—provided suggestions for the improvement of services. Some sug- gestions that related to case management interventions included: assistance with prescriptions not covered under the health plan, education of procedures for emergency room visits and ambulance transport, assistance in obtaining respite help and parenting skills in dealing with challenged children, and assistance in locating providers within the health plan network for their unique family needs. Suggestions related to overall services provided both in the home and for follow- up of chronic conditions included: the need for information on continuity of care decisions, future involvement of the member in the decision-making process on services, education of procedures for emergency room visits, a desire to have one primary provider and not multiple providers at a PCP site, and referrals to special- ists for chronic care problems. CONCLUSIONS AND IMPLICATIONS The utilization of social workers within managed care organizations is a recent development. This case study represents an effort to describe this phenomenon. An exploratory-descriptive design permitted a broad assessment of social workers utilizing casemanagement services at a specific health plan and demonstrated the perceived effectiveness of casemanagement in deliveringMedicaid HMO services to vulnerable high-risk populations. The findings of the semi-structured inter- views, the focus groups, and the participant observation indicated that the use of casemanagement services, delivered primarily by social workers, were effective in addressing bio-psychosocial needs ofMedicaid consumerswithin a provider-driven managed care system. This case study demonstrated that social workers utilizing case management skills are highly effective in a managed care organization, suggesting that other managed care organizations can employ social workers to improve the quality of services. However, individualized attention to client needs is essential to effective case management. In this case study, the interdisciplinary approach to the deliv- ery of casemanagement servicesmaximized the capabilities and unique talents of personnel in theCaseManagementUnit. Othermanaged care organizations inter- ested in emulating thismodel should consider having social workers at the core of such aunit. Successful delivery of casemanagement services included formal link- ages with community-based organizations that weremaintained through ongoing quality assessment and improvement activities. Consequently, other managed care organizations employing this case management model would be wise to develop strong linkages and relationships with community-based organizations. Social workers interested in seeking careers inmanaged care organizations need to garner specific skills for such practice. In studying the growth of managed care and its effect on the training of professional social workers, Strom-Gottfried (1997); Strom-Gottfried, et al. (1998); and Jarman-Rohde, McFall, Kolar, and Strom (1997) recommended additional training of social workers and social work stu- dents inmanaged care. Black (1997) identified several competencies for emerging professionals in managed care that will be needed within the near future. These include familiarity with the systems’ perspective, familiarity with multidiscipli- nary teams both within and across organizations, computer literacy, data analysis skills, familiarity with management techniques, knowledge of case management, familiarity with epidemiological research techniques, and interpersonal skills that assist the consumer and the community (Black, 1997). Professional skills for prac- tice need to be focused in three areas: basic professional skills, population-specif- ic skills, and autonomy-building skills (New York Academy of Medicine, 2000). There may be a growing gap between the training given social work students and the real-life needs of health care consumers (CSWE, 1998; The NewYork Academy ofMedicine, 2000). If so, emerging professionals will benefit from specific training on the actual mechanics of managed care systems and how they operate. Such specialized trainingmight include coverage of health care delivery systems, health care policy issues and analysis, medical terminology, outcomes measurement research and program evaluation techniques, accountability techniques, develop- ment of individual treatment plans, and health promotion and disease prevention strategies. As social workers serve as both primary care providers and function in a variety of case management roles within managed care settings, a thorough understanding of the managed care environment is essential (National Association of SocialWorkers, 2000). In the future, case management will increas- ingly be applied to chronic disease caremanagement (The Institute for the Future, 2000). Educators need to examine their curricula and field placement options to ascertain how they relate to the competencies and skills demanded frommanaged care organizations. Social work educators will need to enlighten policymakers on the state and local level of the value and need for professional social workers with- in managed care systems. Future health care delivery systems will provide new employment opportunities for social workers and other allied health profession- als. As managed care systems employ a wide variety of disciplines and profession- 29Patchner/IN THE BELLY OF THE BEAST: A CASE STUDY OF SOCIALWORK IN AMANAGED CARE ORGANIZATION als to staff this growing field, research conducted with managed care systems will strengthen pre-employment training. On-site participant observation can be highly valuable in developing foundation knowledge about emerging service delivery environments such as managed care. While much has been learned about the utilization of case management at a Medicaid managed care organization, a major limitation is that only one Case Management Unit at one Medicaid managed care organization was examined. Therefore, the findings of this case study are limited in their generalizability. Nonetheless, the implementation of a social case management model with high- risk populationsmay prove to be as effective in other locations where similar pop- ulations are served bymanaged care organizations committed to providing quality services. A possible confounding factor in this study is that of social desirability. Even though the interviewswith the casemanagers appeared to be balanced and objec- tive, there may have been a bias with presenting information in a manner that would positively reflect upon the Case Management Unit and the health plan. Similarly, and perhaps even more of a factor could be the responses by the con- sumers in the focus groups. Historical recall of the services received was difficult for a few consumers, and somemay have been reluctant tomention service deliv- ery problems even though confidentiality was assured. Some consumers might have felt intimidatedwhen participating in the study or even fearful of sharing any negative experiences. These factors could have contributed to the high regard that the consumers held for the Case Management Unit and the health plan. Nonetheless, the perceptions of the consumers allowed for an understanding of their basic health care needs.These perceptions provided a basis for understanding the primary impact of social work case management services upon high-risk con- sumers. Subsequent replication of this study should be conducted in otherMedicaid set- tings and in the private, commercial, managed care arena with larger populations. Such replication would be prudent in light of continued scrutiny of managed care arrangements by policymakers and consumer groups. Additionally, continued research and examination of best practices will assist stakeholders to modify and improve Medicaid managed care in order to safeguard particular populations. In particular, the delivery of social work case management to vulnerable high-risk populations should receive increased attention due to the aging of the population and the subsequent increase in related bio-psychosocial needs. This case study indicated high consumer satisfaction by high-risk populations with case manage- ment services. Further research is needed to ascertain future consumer satisfac- tion as more heterogeneous high-risk populations enroll in managed care arrangements. Research comparing customer satisfaction and health perceptions for those high-risk populations under traditional fee-for-service and Medicaid HMO arrangements would enlighten policymakers in addressing the challenging and unique needs of this population. Replication of this case study within other Medicaid HMOs serving similar high-risk populations in other states would be beneficial to policymakers as they implement mandatory managed care for Medicaid recipients as part of welfare reform initiatives. 30 ADVANCES IN SOCIALWORK References Black, J. T. (1997,May 5). The revolution in health care: Trends and implications. Public Health SocialWork Institute Presentation. Pittsburgh, PA. Council on Social Work Education. (1998). Report identifies health care issues affecting social work edu- cation. SocialWork Education Reporter, 46(3), 8. Epstein, M., & Aldredge, P. (2000). Good but not perfect: A case study of managed care. Needham Heights, MA: Allyn and Bacon. Goldsmith, J. C., Goran, M. J., & Nackel, J. G. (1995). Managed care comes of age. Healthcare Forum Journal, 38(5), 14-24. Harris, N. (1992).What’s ahead in health care for 1993? Business and Health, 12, 32-38. Hughes,W. C. 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(1996).Medicaid managed care: Serving the disabled challenges state pro- grams. (GAO/HEHS-96-136).Washington, DC: U. S. Government Printing Office. Author’s Note: Address correspondence to: Dr. Lisa S. Patchner, Ball State University, Social Work Department, AR 227, Muncie, IN 47306-0525 USA. E-mail: lpatchner@bsu.edu. 32 ADVANCES IN SOCIALWORK