By Stephanie Johnson, LICSW

Introduction
Providing HIV Care: The East Boston Experience
Care Managers: Service Brokers or Individual Clinicians?
Dual Roles: Advantages in a Fragmented System
The Dilemma of Dual Roles: Whom Do We Represent?
Bridging Different Treatment Philosophies
Key Issues and Conclusions

In social work practice we are challenged to go beyond the confines of the conventional clinical role to address a complex array of client problems. To best serve our clients' needs, we are called to integrate micro and macro approaches to practice and to embrace a broad generalist perspective. However in day-to-day practice the role of the social worker has become increasingly specialized. There exists a clear division between clinical duties, such as psychotherapy, and the traditional case management functions of advocacy and service coordination.

Certain populations bring problems to treatment that are so complex they cannot be solved by strict adherence to a prescribed role. Individuals struggling with HIV/AIDS and substance abuse pose such challenges. These clients may need simultaneous help securing concrete services, obtaining substance abuse treatment, and receiving support for trauma and loss. Social work intervention that separates these issues risks delivering fragmented care that does not treat the client in a comprehensive, holistic manner.

The clinical case management model of care integrates the traditional social work roles of clinician and service coordinator. This paper will describe this role, its use in managing a complex patient population, and the dilemmas that can arise when attempting to bridge potentially conflictive clinical roles. Using the experience of social workers in a clinical case management program in Boston, Massachusetts, we will explore the advantages and disadvantages in combining multiple roles in clinical practice.

East Boston Neighborhood Health Center (EBNHC) is a large community health center in one of the poorest sections of Boston. It offers comprehensive primary care, some specialty services and HIV/AIDS primary care, case management, mental health and anonymous/confidential counseling and testing. Many of the HIV-positive patients contracted the virus from intravenous drug use or sex work. Some are homeless while others live chaotic lifestyles that make managing their illness difficult.

In the past, the EBNHC physicians working with the more complicated HIV-positive patients would make referrals for services such as detoxification, counseling, or housing assistance to help stabilize these patients. They often lost track of the outcome, either because the patient did not follow through or because it was too difficult to bridge the communication gap between the Health Center and the community agencies. Even when the majority of treatment took place within EBNHC, the time it took to consult with and contact other providers made care coordination a constant struggle.

The Collaborative Care Management Program (CCMP) was developed to overcome these difficulties. At the core of the program are "Care Managers," masters level social workers with extensive experience in substance abuse treatment. CCMP Care Managers followed clients throughout the health care system acting as therapists, case managers, service broker and/or advocates depending on client need. Through having a more flexible role, the social workers hoped to improve clients' abilities to negotiate the health care delivery system while they used the therapeutic relationship to foster personal growth and change. The Care Managers believed that integrating the roles of therapist, community activist, and client advocate would ease the longstanding tension that has existed in social work practice.

While the title of Care Manager was developed specifically for CCMP, the social workers involved considered their role to be similar to that of clinical case managers. In this model of intervention, social workers utilize their expertise as individual clinicians to help improve access to services and foster greater systemic coordination. Attention is focused both on the client's concrete needs and the individual dynamics they bring to treatment that may help or hinder work toward their goals.

Theoretically, the Care Managers called upon several sources in developing their intervention. They explored the ideas of Foucault who believed that disease was not only a physiological phenomenon but a concept constructed by society. Examining the range of social, biological and behavioral factors that contributed to society's understanding of and reaction to HIV/AIDS helped place the disease in a wider socio-political context. Because HIV modes of transmission are associated with behaviors and beliefs that society deems "bad," the disease often becomes a physical manifestation of a "diseased" self-image for patients. The Care Managers therefore set out to create connections and develop relationships to form a system that functions like D.W. Winnicott's concept of a "holding environment." By giving clients a sense of containment, they believed that there could be a healing of the fragmented sense of self that these individuals brought to treatment.

Healing the system that treated the clients was considered equally important. The Care Managers hoped to break down barriers to access that would leave clients and workers frustrated and disillusioned with treatment. To achieve this objective, they developed linkages and affiliations with other community agencies that provided services not available in the Health Center (such as detoxification, housing, and inpatient hospitalization). More formal relationships were formed between EBNHC and other agencies by signing Letters of Agreement which outlined the intent to work collaboratively. Care Managers visited these agencies and became part of the treatment team. They also planned to be the designated provider who relayed information between the primary care physicians and other caregivers to foster a more seamless care delivery network.

Developing and maintaining these affiliations proved to be similar to the work of forging relationships with clients. Initially, the CCMP staff believed that Letters of Agreement alone would create the continuity needed to improve care and communication. They soon discovered, however, that the linkages took months to formalize and required consistent monitoring and maintenance. The Care Managers worked to move the linkage agreements beyond the level of top administration to the front line staff by forging individual relationships with clinical providers. It was only after acknowledging linkage development as a fluid process that required time and attention that the Care Managers were able to fully benefit from it.

The Care Managers also reported a constant struggle to define their role within the larger health care environment. While the role was designed to be flexible depending on the need of the client, they discovered that too much flexibility in role definition was confusing for clients, for other providers, and for the Care Managers themselves. As they increasingly felt pulled to set more parameters around their role, they fluctuated between defining themselves as service brokers or as individual clinicians. Each role had its own set of challenges.

Towards the start of the project, the Care Managers defined themselves more as service brokers than as individual clinicians. The clients often came into the program without any of the services they needed or with multiple providers who were duplicating services. In the former case, the Care Managers would make the necessary referrals to therapists and case managers and then work with the assigned providers to coordinate the client's care. In the latter situation, the Care Managers would help identify the key providers and attempt to clarify roles. In both situations, however, there came a point in which the Care Manager felt his/her role was obsolete. Clients and outside providers would wonder why there was an additional person involved in treatment. As clients got more connected to other providers, they did not always want to have another worker involved simply to coordinate their care. Rates of missed appointments increased and the Care Managers' caseloads dropped dramatically. The Care Managers began to question whether the treatment team really needed a separate person to serve in this role.

These lingering questions about the need of a specifically defined service broker prompted the Care Managers to make some changes in their practice. They started taking a more active role in the clients' treatment and began to see themselves as individual clinicians with roles that extended beyond the traditional therapeutic relationship. They provided case management services, advocated for clients and accompanied individuals to appointments at outside agencies. They theorized that by providing multiple services they could decrease the confusion that takes place when there are too many providers involved.

This new treatment approach did help to provide more integrated care but the Care Managers sometimes wondered if this was a realistic role for one clinician to hold. Many of the more complicated clients had multiple needs that required attention simultaneously and it proved difficult to prioritize between the many pressing issues. For example, one client seen in the program needed assistance in finding housing due to an imminent eviction, wanted to process how to handle an unintended pregnancy, needed help dealing with a persistent clinical depression, and required assistance accessing affordable medications. Ordinarily a therapist, case manager, and housing advocate would have worked together to help the client manage these issues. While it decreased fragmentation and the likelihood of service duplication to have one clinician work on everything, the Care Manager felt overwhelmed and isolated as the sole provider to a client with this level of need. In this case, the Care Manager realized that the experience of being overwhelmed was a real and empathetic connection with what the client was experiencing. However, having a caseload full of complicated, high-need clients can, at times, feel like too much for one worker to manage.

To manage these issues the Care Managers realized that they needed to use the flexibility the program offered to create different roles depending on client need. These roles will be discussed in more detail below but often depended on the level of client functioning. The ability to craft treatments for the individual involved help alleviate the stress levels of the Care Managers and helped better serve the clients in the program.

Dual Roles: Advantages in a Fragmented System  TOP

The Care Managers found some aspects of this new role to be extremely successful. Holding multiple roles proved beneficial in providing the continuity of care and flexibility necessary when working with complex HIV-positive clients. Care Managers maintained an empathic therapeutic connection with their clients while simultaneously helping them to negotiate the health care system. This enabled the Care Managers to help clients work through barriers to accessing services that were partially caused by the clients' own issues and/or ambivalence.

The clients enrolled in CCMP no longer traveled from hospital to detoxification facility to homeless shelter with the fragmentation of care commonly affecting those who use multiple services. The Care Managers became consistent, reliable allies for these vulnerable clients in their struggles to negotiate the continuum of health care services. They brought information about the clients' histories to the agencies the clients used outside of the Health Center. Working with outside providers, they reviewed what had worked in the past and what had been least successful. They helped with treatment and discharge planning. The Care Managers also kept the Health Center physicians informed about the issues in the clients' lives that affected their health maintenance and readiness for antiretroviral therapy.

One case that exemplified the advantages of having a flexible therapeutic role is that of a woman in her mid-thirties diagnosed with AIDS. She had a long history of crack cocaine addiction and rarely kept medical appointments. Her health status deteriorated until she had to be admitted for a long-term stay on the sub-acute AIDS unit of a local hospital. As she prepared for discharge, the hospital staff, the Care Manager, and the client's probation officer held a treatment-planning meeting. The Care Manager reviewed past intervention attempts with the staff in order to help develop a plan that might work for the client. The Care Manager also worked with the client's family to ensure that all of the important people in the client's life were involved in the treatment team. The agency chosen to provide follow up care was initially reluctant to accept the client. However, after they were assured that the Care Manager would continue to follow her, they felt ready to admit the client into their program. The Care Manager then brought the information about the intervention back to the client's primary care physician so that she was aware of the client's status. Thus, the Care Manager worked on individual, family, team, and systems levels to provide integrated care for the client.

There were other situations, however, in which the Care Managers felt that simultaneously serving the client and the larger system created a conflict of interest. The struggle to determine exactly whom the Care Manager represented posed numerous dilemmas that were not easily resolved.

In more traditional social work roles there is generally a clear mandate to represent the individual client in his/her struggle to enact change. Therapists and case managers meet with clients, evaluate their needs, and try to meet the clients where they "are at" to work on mutually identified treatment goals. Conflict and ethical dilemmas can arise when the social worker has goals that differ from the clients or if the worker must become an advocate for a larger systemic or societal mandate. Examples include situations in which a clinician must file a report of child abuse/neglect or hospitalize a client against his/her will. Ideally, the worker and client can reconcile any perceived violations with the empathic connection thereby strengthening the therapeutic alliance.

While this traditional stance taken by the social worker supports the individual, the role of clinical case manager held by the Care Managers was designed to represent both the individual and the system. Although the best interest of the client is at the heart of the intervention, working openly with other providers is considered equally important. This philosophy is based on a belief that the best interest of multiply challenged clients is most effectively served by an open collaboration among all providers. Client self-determination is addressed through full disclosure and informed consent about the collaborative nature of the CCMP model. When the needs of each are synonymous, this role works well. However, when the needs of the system are not in accord with those of the individual, the clinician can feel stuck between two worlds.

A case example helps illustrate this point. Randy S. is a 40-year-old man with HIV due to years of IV drug use. At the time of his enrollment in CCMP he had just started trying to get clean, get housing, and focus on his deteriorating medical condition. He was living in a shelter-based program that required strict adherence to a rule of total abstinence. Randy knew that one positive urine screen would result in immediate discharge from the program. He admitted to his physician that he had indeed been using "every once and a while". However, since enrolling in the program he had secured a stable place to live, three meals a day and had dramatically decreased his drug use.

In an effort to collaborate about Randy's care, his physician informed the Care Manager of his current drug use right before she was leaving to attend a case conference at the program. The Care Manager had defined her role as representing Randy in order to help him improve his quality of life and as working with the program to set limits and expectations for Randy about the consequences of his drug use. She felt an obligation to confront Randy about his use, in order to help him deal honestly with his addiction and the program. She also believed that withholding this information from the program staff, after being such a strong proponent of collaboration, constituted dishonesty on her part. Her dilemma was that once the program discovered that he was using, Randy would be asked to leave. He would likely go back to living on the streets and using heroin heavily. The physician also felt that disclosing Randy's drug use to the program staff would violate doctor/patient confidentiality.

If the social worker's role was strictly to provide individual counseling, this issue could be discussed and processed with Randy in a weekly session. The focus would be on how his decisions to use substances affected his goals and his recovery. Yet the Care Manager felt a dual obligation to work openly and honestly with the program. She felt that by withholding information about Randy's drug use she was colluding with his desire to manipulate the system. This dual role was intended to create a collaborative team in which Randy could work on his addictions. Instead the Care Manager felt stuck in a situation with no "good" outcome.

The Care Manager decided not to directly discuss her knowledge of Randy's drug use with the program staff. Instead she confronted him directly and explained the dilemma she faced. Randy expressed confusion and frustration after hearing the Care Manager's position. He felt as if she should be his advocate and keep this information private. This struggle about whether the Care Manager should represent his interests only or should enforce the rules of the agency became an ongoing theme and struggle in their meetings together.

Randy's case highlights another dilemma of holding more expansive roles as clinicians. The Care Manager must simultaneously operate within the fields of conventional medicine, substance abuse, and mental health, each having its own cultural norms and expectations. To be effective, the clinician must be able to negotiate each one, yet they often seem to be worlds apart.

In the medical model the focus is on diagnosis and treatment and a clear path is seen between the problem and its solution. Medical practitioners are expected to make straightforward recommendations to patients and patients are expected to follow these recommendations in order to be "cured". Psychotherapy is a more process-oriented form of treatment in which ambiguity and ambivalence are embraced and explored. Clients are given more responsibility for their treatment and are expected to develop their own path to wellness. Substance abuse treatment differs theoretically from both medicine and therapy. It often links issues back to the recovery process; attempts to explore other material may be seen as avoidance. People are often considered either "clean" or "active" and confrontation is a treatment norm. Clients are expected to embrace recovery and "work the program," which often means giving up control and following the recommendations of program veterans.

Care Managers are expected to collaborate with providers from each of these disciplines and develop treatment plans that factor in all relevant problems. Differing expectations about the course of treatment and outcomes can make reaching consensus about treatment plans difficult. Physicians might expect a successful outcome to mean the elimination of all physical symptoms while a substance abuse counselor might consider total abstinence as the only goal in treatment. Therapists are often more process oriented which other providers could perceive as unclear or ambiguous. The Care Managers have to be adept at moving back and forth between these treatment approaches and at helping the client integrate the diverse approaches into a realistic plan for action.

Social work theory has often encouraged clinicians to bridge the gap between micro and macro practice by incorporating advocacy and systems work into individual treatment. The East Boston Neighborhood Health Center has attempted to meet this mandate by creating CCMP, a pilot program that expanded the traditional social work role. Straying from established expectations to deliver services in a different way proved to be both exciting and challenging. The Care Managers learned important lessons from the project but were also left to grapple with several key issues that arose during their work.

One important question raised by the project was how to determine which clinical approach was most effective, that of service broker or of "enhanced" individual clinician. While each approach had its advantages and disadvantages, the Care Managers found that certain individual characteristics determined which role was most suitable for a given client. People who were considered "higher functioning" worked well with a Care Manager who served as a service broker. These individuals had more internal structure, were familiar with the health care delivery system and could easily understand role differentiation in the treatment team. Other clients had difficulty connecting to providers and became confused when there were numerous people on the treatment team. These individuals functioned better when they could identify one person with whom they could work on all of their issues.

The Care Managers had the flexibility to shift roles according to client need. However, this added a degree of ambiguity to the role that often confused other providers. The Care Managers found that in order to affect change on the larger systemic level, it was important that other providers agreed with the need for change and understood the parameters of the shift in roles. Without both client and provider "buy-in" the system continued to operate as it had in the past.

The Care Managers also questioned whether their role was needed on an on-going basis or if it would be more effective to intervene briefly and then discharge clients from the program. Again, they determined that the best outcome depended on the client profile. Some clients admitted into CCMP needed only to be reconnected to providers in the existing system of care and were then able to negotiate on their own. The clients who benefited from prolonged intervention by the Care Managers had fewer internal and external resources. They were often more medically compromised and had difficulty remembering and recounting details about their life and their past medical care. These clients, when left to manage the health care system themselves, did not function well. They quickly decompensated, both medically and psychologically, and were often at risk of death if not properly assisted.

It was often difficult to determine whether a client needed brief or extended intervention at the time of initial referral. Many clients that looked similar on paper had quite different abilities to adapt and manage their own care. It generally took the Care Managers six months to determine whether a client could manage their care on their own or needed further assistance. Again, the ability to remain flexible in the clinical intervention proved beneficial.

Finally, the Care Managers wondered if their role was really so different from roles held by other social workers in the field. They decided that the response to this question was two-fold. In many respects, all community-based social workers aspire to enact change on many different levels by being both a client advocate and promoter of accessible systems of care. Certainly, there have been an increasing number of programs developed to address clients' needs in a more comprehensive way. However, the intense pressure of the new health care environment makes it difficult for social workers to take on multiple roles. More and more emphasis is placed on generating billable hours jeopardizing the support and coordination roles that are vital elements in caring for complicated client populations.

The Care Managers realized that one of the most important aspects of CCMP was that it gave them the time and space to closely examine what really worked with the clients they served. Because the project had a built in evaluation and development component, the Care Managers were able to continuously re-evaluate their effectiveness, a luxury often missing in the pressured managed care environment. As with most pilot projects, the reality of the intervention often looked quite different than the original intent of the program. However, the Care Managers felt they were able to provide needed services to a vulnerable client population while remaining true to the founding principles of social work practice.