HHS 201 Introduction to Human Services Wk5
Chapter 10 Case Management/Counseling
Reading this excerpt from a human service student’s journal is a very appropriate way to begin a discussion of case management/counseling:
I was having a real hard time studying and I was sure I was going to flunk my courses. I couldn’t concentrate because my family was going through a divorce. I felt like I was being pulled apart by my parents. Who was I supposed to be loyal to? I knew I was getting to depend on cocaine too much. I was stoned most of the time. I figured I better talk to someone soon before I blew my stack. I started asking my friends and my dorm supervisor for the name of a good therapist. People would ask me if I wanted to see a psychiatrist, a psychologist, a social worker, a family therapist, a drug and alcohol counselor, or what. I’d ask what the difference was but no one gave me a clear answer. So they didn’t know and I didn’t know! I felt more confused than when I began looking for help.
Thus far in this book you have met many human service workers. The majority of them were delivering direct services and spending most of their day working one-on-one with clients. Although doing similar work, they were likely to be referred to variously as:
Case workers
Social workers
Counselors
Advocates
Therapists
Case managers
Clinicians
Therapists
All this semantic fuzziness can be confusing to a client who must figure out whom to go to with a problem. And a worker searching the job listings in the newspaper or a web site can never tell from the title of the position exactly what tasks or problem areas it will include. The general public, accustomed to name brands, finds it difficult to understand how a middle-aged woman with a doctorate in psychology and a young man with an associate’s degree in human services can both assert that they do “counseling.”
In an effort to make job titles uniform, some professionals in the human service field have suggested that a distinction in title should be made according to how much a human service worker deals with highly charged emotional material rather than with the ordinary problems of daily life. They might say
A social worker or therapist who has an advanced degree helps clients deal with deep-seated intrapsychic problems. A case manager or counselor (a less academically trained person) helps clients make decisions and then use social resources to implement them.
But we don’t think that is a sensible distinction! All human service workers, regardless of their backgrounds, job titles, or their clients’ problems, must inevitably deal with inner emotions as well as external pressures. Of course, with more study, experience, and training, a clinician can work more effectively with the deep emotions that surround problems.
Human service problems stem from the interaction of biological, emotional, and environmental stresses. If we ignore one set of forces, we get a lopsided view of a problem. And lopsided views lead to inadequate interventions.
For example, Timothy, a counselor in a residential prison-diversion program, has been asked by Barry, one of the residents, for a change of roommates. Before Timothy began to juggle rooms to accommodate Barry’s request, he encouraged Barry to clarify the problem he was having with his present roommate. Timothy asked Barry about:
Barry’s expectations of his present roommate and what he thought his roommate’s expectations were of him
The similarities and differences in their habits, routines, and lifestyles
The extent to which they both tolerated differences in styles
The methods of conflict resolution they had already tried when they had a disagreement
The stresses of study, family, work, or social life that may have been aggravating their problem
After several conversations with the two men, some separately and some together, Timothy suggested that the tension between them might lessen if they set up a more workable system for cleanup. He offered to help them design a chore chart. They also agreed to make some mutually acceptable rules about playing the radio and going to bed. Through their sessions, one of the young men realized that some of his anger at his roommate probably stemmed from his past irritations with his brother and that, in fact, there were many parts of living together that he enjoyed. They agreed to try to use the chore chart and a few rules they both could agree on for two weeks. They also agreed to check in with Timothy for ten minutes each day. Thus, both young men found possible solutions to a relationship problem that at first seemed insurmountable.
There might have been other root causes for the tension. Perhaps Barry brought home a great deal of anger from his job and that was the primary source of tension between the roommates. If that had been the case, Timothy could have referred him to a vocational counselor and a youth employment agency to help him change jobs or cope better with the one he had.
Although the counseling assignment of beginning human service workers might involve helping clients find and use resources, they should never lose sight of the fact that a client’s unexplored feelings can subtly sabotage even the simplest solution.
10.6 Case Management/Counseling in the Era of Managed Health Care
At a recent public forum on managed health care, audience members lined up in front of the microphone to tell their legislators what was on their minds. A local real estate agent came up to the microphone and said:
I had a blocked valve in my heart and they had to do extensive surgery. I was in the hospital three times, the last time for seven days. When I was released, they put me in cardiac rehab. I see a physical therapist and do stress management three times a week now. My bills must come to thousands of dollars but I have paid almost nothing out of my pocket. Without my managed health care plan, I would be dead or totally bankrupt. I am so damned grateful for the plan.
An elderly man faced the audience and stated with strong emotion:
I absolutely refuse to give up my regular Medicare and be forced into a private managed health plan, even though I could probably get some financial help with my prescription costs. I have a friend who died waiting while his plan argued about whether he needed a certain procedure. My internist is very independent and doesn’t belong to any of the plans. I won’t give him up! He knows me and my health conditions so well. And I want to go to the specialists he recommends, not be forced to choose a doctor from some impersonal list.
Health care delivery is a much debated subject that no reader of this book can afford to ignore. It is vital—for both your personal and professional life. But if you are a young person whose parents have reasonably high incomes and jobs that offer them health insurance, paying medical bills probably hasn’t been much of a worry. If you are in college now, although you may not be thrilled with its services, your school most likely has a free health clinic funded by the fee you paid along with tuition.
But if you took time off between high school and college, worked at an entry-level job, and turned 19, you might have been surprised to discover that you had been dropped from your parent’s health insurance, and your entry-level job didn’t offer any medical insurance. As a young person—with the illusion of invulnerability—that probably wouldn’t have bothered you very much until:
You came home from a camping trip with a strange rash that wouldn’t heal
You broke your leg in a waterskiing tumble
You faced the stark reality that you needed help controlling your drinking or drugging behavior or your starving and binging behavior
You wanted to try some new techniques such as acupuncture or hypnosis for an intractible sports injury (Becvar & Pontious, 2000)
Recent Developments in Health Care Delivery
Throughout most of the last century, medical care has been delivered by independent private doctors along with a mix of private and for-profit hospitals. The bills for medical care have been paid by the patient who received the treatment. Only very poor people (or those who are currently in or have served in the armed services) received free or subsidized care in clinics.
During the second half of the last century, hospitalization insurance, paid for by individuals, sometimes with the help of their employers, became part of the funding picture. As early as the 1920s, there were a few scattered small-scale experiments that offered prepaid doctor visits with a panel of medical practitioners. But it was not until the Depression that a large-scale innovative program, the nonprofit Kaiser Permanente—the grandparent of all health maintenance organizations (HMOs)—came into being (Lowman & Resnick, 1994). This early HMO had a populist flavor to it. The designers of the plan wanted to deliver accessible, high-quality care to a large portion of the neglected population. This experiment and others patterned on it were enthusiastically received years later, as health care costs and the demands for services spiraled out of control. Congress passed the Federal Health Maintenance Organization Act (PL 93-222) of 1973, which established nationwide standards and offered financial incentives to fledgling HMOs.
health maintenance organization (HMO)
A health care institution or an association of doctors that contracts with its members to collect a fixed sum of money monthly or yearly in exchange for doctor visits, tests, medications, hospital care, and preventive services, as needed.
While employer-supported and private health plans expanded their reach, social activists have long been prodding Congress to pass health care legislation that would cover everyone in the country and be paid for from income taxes—the kind of universal coverage that Canada and several European countries have had for many years. After much acrimonious debate between the social service establishment and organized associations of medical doctors, Medicare, prepaid health care for those sixty-five years of age and older, was finally passed by Congress in 1965. It still wasn’t universal coverage, but it represented a beginning.
Even though we are not health care workers, we need to understand the impact that serious health problems, such as obesity, have on our clients. We try to help them anticipate and avoid these problems.
The Rise of For-Profit Managed Health Care
During the first two years of President Bill Clinton’s administration, tax-supported universal health insurance looked as if it had a good chance of passing. But it suffered major political and public relations setbacks. Fearful of more “big government,” Congress wiped it off its agenda.
However, it was clear to everyone that health care options were multiplying along with health care costs and that some type of managed system was vital. As these private plans for both medical care and prescription drug coverage grew in number, they formed what is now admiringly referred to by stockbrokers as the health care industry, the fastest-growing sector of the economy. The number of people enrolled in these plans continued to rise (Dee, 2007; Psychotherapy Finances, 1998; Vallianatos, 2001).
Some Problems with the Expansion of the Health Care Industry
Although more people had prepaid health care coverage than ever before and many were receiving care they never dreamed of in the past, both human service practitioners’ and the public’s attitudes about for-profit care have been conflicted (Corcoran & Vandiver, 1996; O’Neill, 2001). There is an odd mix of negatives and positives; there have been more medical options available; people are living longer, but health plans still need to turn a profit.
As one anonymous critic summed it up, “The doctor’s credo of ‘Do no harm!’ sometimes seems to have evolved to ‘Do no harm—to the stockholders!’” A review of the issue published by the National Association of Social Workers, titled “Humane Managed Care?” suggests that those words might be an oxymoron (Schamess & Lightburn, 1998). The following are some of the criticisms that have been discussed in human service agencies, by patient advocacy groups, and even the medical establishment:
Some plans offer doctors financial incentives to keep costs down by not recommending expensive tests or procedures that might be of critical importance.
Panels of approved health care providers are not necessarily screened for quality but simply for their willingness to accept the fee for service stipulated by the company. Often a limited list of providers means long waits for medical procedures or visits.
fee for service
A prearranged amount of money that will be paid to a health care provider each time he or she delivers a specific service to a plan member in accordance with the plan’s criteria for that service.
Many plans have been accused of rationing or denying requests for respected experimental or complementary medical procedures.
Most plans have gatekeepers (often untrained in the particular medical specialty) who have the power to veto a doctor’s choice of a treatment plan.
gatekeeper
A person in a health plan organization who decides whether a prescribed medical service will be paid for, based on its set of criteria for care.
When a requested service is rejected, some plans have no genuine appeal mechanism for the consumer’s protest.
Mental health practitioners are often forced to affix a diagnosis or label to persons seeking help. They might not believe it is accurate but must do so in order to obtain approval for counseling sessions with a person in crisis.
Computerization of personal health and mental health information might be used to reject a prospective enrollee or it might be divulged to a current employer without the patient’s knowledge or consent.
Some plans have routinely rejected applicants who have “pre-existing conditions” such as diabetes or cancer. Other plans have cancelled coverage of already enrolled people who develop serious health problems that need costly treatments.
The Current Status of Health Care Coverage
In 2010, in a very narrow, and mostly partisan vote, both houses of Congress passed a sweeping health care bill. It was carved out of many compromises but is not the universal coverage that many hoped for. In addition, many Congresspersons who voted against it have vowed to overturn the legislation or make it very ineffective by denying funding. As the eighth edition of this book goes to press it is anyone’s guess what will happen to the new Health Care Bill. Whatever happens, it will affect you and the people you work with.
In our current era, speed has become the new normal. Clients often cannot understand why there are few “quick fixes” for human service problems.
