What You Need to Know About Clinical Case Management

Social work case managers often find themselves on the “front lines,” working with difficult and often unstable clients without the back-up of nurses, attendants and physicians traditionally found in inpatient settings. Knowledge of psychiatric disorders, medications, relational dynamics and environmental resources are essential for these social workers. Hence, the term “clinical case management,” which emerged over 20 years ago to convey the many challenges and responsibilities inherent to this difficult work.

What is Clinical Case Management?

The term “case management” now reflects two diverse perspectives. Initially, it was a semantic replacement for traditional social casework interventions; those where social workers directly assisted clients by obtaining resources or modifying environments. More recently, “case management” is most often used within the healthcare field to reflect assistance with discharge planning or “management” of medical care by insurers or managed care organizations. Within the area of mental health, “case management” often connotes a simplistic, paraprofessional intervention whereby case managers help clients with psychiatric disorders, obtain entitlements or link them to needed services.

Evolving Roles & Responsibilities

Without the conventional parameters of the 50-minute hour and usual consulting room, the clinical case manager is often a “first responder,” addressing complex crises involving both psychological and environmental components. For example, if a person with a psychotic disorder decompensates, he or she is often at risk for homelessness. Preventing relapse may involve directly supporting the “holding environment,” while preventing homelessness may involve temporarily removing the relapsing client from a stressful living situation. In such situations, the clinical case manager may simultaneously be working psychotherapeutically with the client, collaborating with a psychiatrist and consulting with families and residential providers.

The transference and countertransference responses are often intense, and clinical case managers must learn how to recognize and contain these phenomena. Boundary issues cannot simply be managed by resorting to the usual psychotherapeutic conventions and require considerable clinical sensitivity.

Clinical case management interventions require a high level of clinical social work expertise, and, sadly, neither graduate nor post-graduate education currently offers the integrative perspective such work demands. However, there is emerging literature offering guidance to clinical social workers in this area, supported by empirical research that demonstrates the effectiveness of clinical case management with several client populations. Object relations theory is especially useful in understanding the dynamics involved as one explores how “holding environments” support recovery and development.

While conventionally practiced in agency settings, clinical case management can be effectively implemented in private practice settings with child, adult and geriatric populations. In such instances, the psychotherapeutic elements in this work may be reimbursed through conventional insurance while other interventions, including phone contact, travel time and collateral contacts, can be reimbursed on a fee-for-service basis.

An MSW@USC faculty member, Joel Kanter, MSW, LCSW-C teaches Social Work Practice in the Virtual Academic Center and is in the private practice of psychotherapy and clinical case management in Silver Spring, Maryland. Recognized as a Distinguished Practitioner by the National Academy of Practice in Social Work, he has written extensively on many topics involving the community care of the mentally ill and is a Consulting Editor of the Clinical Social Work Journal. His publications include Coping Strategies for Relatives of the Mentally Ill (NAMI, 1984), Clinical Studies in Case Management (Jossey-Bass, 1995), and Face to Face with Children: The Life and Work of Clare Winnicott (Karnac, 2004). A selection of his writings on case management can be found at Clinical Case Management Resources.

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