Abstract
Case management (CM) is increasingly used in community settings to support individuals as they transition from one point in their lives to the next. This study sought to explore the perspectives of front-line Community Health Workers CMs working in Albuquerque, New Mexico. The objective of this study was to answer the question ‘How do CHWs define effective CM and outreach?’ A follow-up question was, ‘What are the barriers to conducting CM and outreach?’ Qualitative research methods, Critical Race Theory, and Social Work Theory guided this study. Five CHW CMs participated in a 90-minute focus group. Results present their perspectives on effective CM and outreach. Barriers include limited collaborations, excessive documentation requirements, and communication. Findings demonstrate that what constitutes effective CM and outreach is based on the program and context. Future work must focus on balancing the need for shared definitions and embracing the flexibility required for CMs working on the ground in diverse settings and populations.
Introduction
Case Management (CM) is increasingly used in community settings to support individuals as they transition from one point in their lives to the next. CM is often defined as a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes. Components of CM often begin with case finding and end with discharge and linkages to community based services and supports (Lukersmith et al., Citation2016).
A growing body of literature demonstrates positive outcomes of CM within various healthcare settings, programs, intensities, and rationales. The benefits of CM are irrefutable, from addressing health and social needs (McGregor et al., Citation2018; National Academies of Sciences et al., Citation2019) to improving the use of services, patient knowledge, and behaviors (Zuvekas et al., Citation1999) and reducing hospital use (Joo & Liu, Citation2017) and overall costs associated with hospitalization or institutionalization. The National Association for Social Workers (NASW) developed twelve standards for clients, systems, and CM (National Association of Social Workers, Citation2013). These range from ethics and values (standard 1) to professional development and competence (standard 12); however, because CM is used in diverse settings and with varying populations, there are different approaches and CM definitions. And there are different types of CM, for example, Intensive CM, Clinical and Brokerage CM (Holloway & Carson, Citation2001; Kanter, Citation1989), Generalist CM, and Strengths Based CM (Vanderplasschen et al., Citation2007). Intensive CM is often relegated to the severely mentally ill or individuals with acute conditions who require ongoing and assertive CM (Group et al., Citation2000). In contrast, the Strengths-Based CM model is based on client strengths rather than their illness or pathology. In this model, goals come from the individual client and are strengths-based and person-centered (Holloway & Carson, Citation2001). With varying definitions and approaches, it can be difficult for individuals working in community settings to provide consistent CM strategies informed by similar knowledge, skills, attitudes, and standards (Bachrach, Citation1989).
Another issue is that CM is sometimes conflated with outreach, but these are distinct. Differences in CM versus outreach have been noted in the literature and are generally based on the CM program or system implementing services (Macan et al., Citation2008). Outreach is generally shorter term with more individuals and focuses on community, agency, and organizations with the goal of increasing awareness of available resources. An example of outreach is setting up an informational booth at a community event and sharing information about various resources and agencies with individuals and families in need. CM is longer term with fewer individuals; it focuses support at the individual level and connects these individuals to tailored resources and services. For example, case managers at a homeless shelter may conduct a client intake, identify needs, refer individuals to services, and follow individuals over time to ensure their needs are being met. While differences exist, the overall goal is the same, to reach people where they are and connect them with services and resources that will help them live a full and complete life. For example, both CM and outreach may advocate for spiritual diversity (Canda et al., Citation2019), support mental health (Bland et al., Citation2021), address homelessness (De Vet et al., Citation2013), promote health and social needs (Knox et al., Citation2022), and provide support in a healthcare setting (Johnson & Gunn, Citation2015). There is no taxonomy or instrument used to measure CM and or outreach services, and services are often provided by case managers and outreach workers or both (Macan et al., Citation2008). Outreach is often defined by who is providing the CM; for example, Community Health Workers (CHWs). CHWs are recognized as culturally competent lay healthcare workers who provide support to individuals or patients in conjunction with the broader healthcare team (Crespo et al., Citation2020). Importantly, CHWs utilize their knowledge and position to conduct outreach informally in public settings. In contrast, therapists may conduct outreach in an office or using social media resources, flyers, and other educational materials.
In recognition of the diverse methods, definitions, and approaches involved in CM and outreach, this study sought to explore perspectives with front-line CHW case managers working in Albuquerque, New Mexico. The objective of this study was to answer the question ‘How do CHWs define effective CM and outreach?’ A follow-up question was, ‘What are the barriers to conducting CM and outreach?’ Findings from this study fill an important gap in the current literature where CHW definitions about CM And outreach are not known. Additionally barriers to conducting CM and outreach are constantly changing, documenting these is the first step in providing effective CM.
Study setting and design
The University of New Mexico’s Health Sciences Center (UNM HSC) Office for Community Health (OCH) Community Health Workers Initiatives (CHWI) Pathways Program and local community-based organizations (CBOs) work to support the implementation of various programs in the City of Albuquerque. CBOs serve multiple populations at risk for homelessness, including individuals and families experiencing substance abuse, domestic violence, mental and behavioral health challenges, and poverty. Other CBOs served First Nations, Asian, and Immigrant populations. The UNM HSC created the CHWI Unit in 2014 as part of the OCH to design, implement, and evaluate projects that utilize case managers as CHWs. UNM HSC utilizes CHWs as a strategy to increase well-being, promote health equity, and minimize the negative impacts associated with the SDOH among New Mexico residents. The CHWI oversees several innovative programs that engage the support of CHWs as case managers and intensive case managers to address community health issues primarily impacting low-income populations.
We used qualitative research methods to inform the entire study. Following published recommendations on qualitative study designs with focus groups, the aim of the focus group was to collect information on CM using participatory discussion methods for a defined period of time (Kinalski et al., Citation2017). Two theoretical frames guided this entire study. The first is Critical Race Theory (CRT). CRT tells us that racism is normal and ordinary in the United States (US); race as a social construction informs the racialized experiences of people of color and race, class, gender, sexuality, ability, and religion and must be acknowledged as such (Ford & Airhihenbuwa, Citation2010). The second is the Direct Social Work Practice Theory. Here, the practice involves intake, conducting screening, determining client eligibility for programs and services, and providing CM (Hepworth et al., Citation2016). Institutional Review Board (IRB) approval was not required because this study was determined to be exempt by an internal review committee within the UNM HSC department.
Methods
The focus group facilitators (authors 5,6,7) met multiple times to discuss the focus group. The positionality of the focus group facilitators and analysis team was diverse with a blend of Hispanic, Latino, American. Many had the lived experience of homelessness and recovery from trauma and alcohol use disorders. The team works together to increase access, knowledge, and power to underserved and under resourced communities in the US. All were familiar with the UNM CHW program as external consultants. One was fluent in Spanish and served as a cultural communications lead. This was important because the UNM CHW group serves predominantly Spanish speaking populations, most CM and outreach is tailored for this population. Planning conversations centered around the purpose of the focus group, selection, questions, and analysis. The strategy for participant selection was based on qualitative research method recommendations where the focus was on the quality of the data rather than the quantity (Starks & Trinidad, Citation2007). We selected the participants based on their current roles and position as case managers at UNM CHW program. Before starting the focus groups, we explained the nature of the study, and a virtual Zoom meeting was scheduled to conduct the focus group in English. Before the focus group started, verbal consent was received, and the purpose of the focus group discussion was further explained. The semi-structured focus group interview guide included six open-ended questions related to CM and outreach services. The focus group lasted 90 minutes.
Sources of data and analysis
The source of data for this research was the recorded focus group. Questions were open-ended and designed to explore perspectives about CM and outreach rather than simply answer yes or no questions (Supplemental File 1). The interview questions were as follows:
If you could define case management in one sentence, what would that be?
If you could define outreach in one sentence, what would that be?
In your opinion, what does effective case management look like?
In your opinion, what does effective outreach look like?
What are some of the barriers you encounter when you provide case management services?
What are some of the barriers you encounter when you conduct outreach services?
Results
Core characteristics of effective case management
There were similar definitions of CM across the five participants. Focus group participants agreed that the core characteristics of CM include the CHW willingness to learn and be educated, being culturally and person-centered, adapting to client needs, and practicing humility and transparency, and providing support, mentorship, and guidance (). As one focus group participant stated, […] ‘as a case manager, you can’t be wearing the cape you are not a hero, you are here to guide, support, teach, educate, give them the skills to help [clients] do it on their own.’
Table 1. Effective CM and outreach themes.
Focus group participants stressed the importance of providing resources and support and giving individuals a sense of hope. For example, one case manager shared, ‘Today I was able to help somebody get an ID. He had no birth certificate or anything. What we are doing is for the hope. We are some of these people’s mouthpieces. We speak on their behalf because sometimes they forget they have a voice. When they have no hope, that is our role. We are hope for them, that is it.’ Similarly, another participant shared that CM was all about creating a ‘hope factor and a sense of community, fighting for change, especially for the unheard because everyone has a voice [,]’ but not all clients are being heard. Participants also described that CM can be seen as the ‘opportunity to connect people with resources and build community through those connections.’
Approaching the work through a person-centered lens was also seen as a key characteristic of effective CM. Case managers should ‘put [their] bias off to the side’ and understand that ‘every case is different [and must be treated] as its own’. Each client requires a different level of support, resources, and guidance. As one focus group participant stated, ‘[CM is about] understand[ing] your clients and where they are. […] Actively listen to the client, they know what they need. Acknowledge them, take yourself out of it.’
Another foundational characteristic of CM is the ability to model healthy behaviors while practicing non-judgment and approaching the work through a culturally centered lens. For example, one case manager shared that CM is ‘[m]odeling. A lot of the time, our clients have tough situations in life, historical trauma, and other traumas, and don’t have access to someone mimicking or modeling behavior. Personal history is how you react to situations.’
Core characteristics of effective outreach
When asked about outreach, focus group participants stated the following as core characteristics of effective outreach: consistent community engagement, showing genuine interest in client outcomes, being passionate about the work, conveying compassion, providing support and guidance, and collaborating with other organizations by sharing resources and tools (). One focus group participant defined outreach as a ‘short-term connection to resources with many individuals, where [as] case management is long term with few.’
Helping clients navigate the system is an important core function of outreach workers. For example, one focus group participant stated that ‘[outreach] is about providing that resource but letting them know that they have access to that resource and helping them navigate the systems, coaching them on how to navigate not only for themselves but also their own family. If you coach, you strengthen’ and build a sense of community and support. Consistency and sharing resources were also seen as a very important characteristics of community outreach. One outreach worker stated that outreach is ‘not just sitting at a table and sitting at a chair. […] outreach is education, going out there and letting [the community] know’ about the services that are available to them. Outreach is about ‘going out into the community, not having them come to you because they won’t. Even when you are in the community and have an event, [clients] still don’t know what we do. We have to educate people. We need to go to areas where other people do not go. Highways and byways. They don’t know that we exist, that we are out there, [or] what our services are. We need to go to them. They might not need what we have to offer at the time they connect with us, so we have to keep going out. [We] need to be consistent. You have to be there, and they need to know that you really care.’
Being passionate about the work and practicing compassion is also an important core characteristic of community outreach. One case manager shared, ‘when I hit the streets, I know what I am doing this for. Be genuine, compassionate, and supportive, [with] no judgment. [It’s about] word of mouth through feeling the support, love, [and] help.’
To conduct effective outreach, it is important to engage with other organizations to share up-to-date resources and work together to serve marginalized communities successfully. As one focus group participant put it, outreach is ‘collaboration of community organizations and […] knowing what else is out there. [Knowing] the resources that are available […] and the support that is out there from other programs. [Outreach is] building collaboration with other organizations on top of going and talking and supporting the underserved communities.’ An important component of collaborating with other organizations is the ability to share resources and ensure they are up-to-date. Collaboration […] ‘is about having the right resources and having people in different agencies talk to each other. We are all in it for the same things – we are trying to build our clients and help them. So share resources, [the] […] right resources that are actually working’ and can be used by the client.
To engage deeply and build trust in the community, outreach workers must convey compassion and non-judgment, provide support and guidance, consistently engage with the community to educate them about resources, and communicate with each other to create stronger networks for the community. As one individual stated, ‘the idea of social work is to put yourself out of a job.’
Barriers to CM and outreach
Focus group participants also discussed the challenges and barriers they face when conducting outreach or providing CM services. One of the biggest challenges is the lack of cross-collaboration and communication across community-based organizations, healthcare providers, and local agencies that provide similar services to the same population. One focus group participant shared, ‘agencies aren’t collaborative communities; they don’t share resources and services. We are all trying to meet the same needs of our clients, the ones that are underserved and in need. Together we need to meet the needs of the clients. We are not siloed. Organizations should be working together. This is the biggest challenge I have, that there isn’t shared resources.’ The lack of cross-communication and collaboration makes it challenging for case managers and outreach workers to develop an inventory of up-to-date resources that they can then share with their clients.
Another barrier to conducting community outreach or providing effective CM services is the criteria limitation. For example, one case manager shared that clients must score a certain number during the intake and needs assessment phase in order to receive CM services, regardless of the need. The CM shared, ‘[I am] floored when I have to go off of a point system, needing to score a certain thing to get services. Criteria limitations are a barrier for those in need.’ Another CM shared, ‘Intensive Case Manager’s have a point system as well; ER at least 1 time, incarcerated in the last 2 years, have a substance use disorder. Sometimes you have to move things around because someone is in need. You have to do what you need to do to make it happen for them.’ The systems that are put in place are sometimes what cause the most harm to the client; as one CM put it, ‘[this is] systemic discrimination against the underprivileged – the people don’t deserve to [receive services], or they have to complete x,y,z in order to [receive services]’ (e.g. sobriety, medication adherence, treatment). The need for clients to meet certain criteria in order to be eligible for services creates challenges for case managers and outreach workers to provide effective services.
Discussion
The objective of this study was to answer the question ‘How do CHWs define effective CM and outreach?’ A follow-up question was, ‘What are the barriers to conducting CM and outreach?’ This study illuminated definitions and perspectives about effective CM and outreach in Albuquerque, New Mexico among staff involved in UNM HSC CHWI programs. Results here are similar to previous literature and NASW CM principles where social work case management is person-centered, strengths-based, and targets multi-level approaches to influence change (2013). Another theme in this study was the importance of instilling hope in clients and the role of case managers in the process. Loss of hope, deaths of despair and loneliness are one of the most pressing public health issues of our time. While hope may be an implicit approach for CM, this study found it to be one of the most effective strategies for CM and addressing systems that marginalize, oppress, and traumatize individuals and families. Another theme was using person and culturally-centered approaches and trust; these have been identified by other researchers as principles for effective social work CM (Kanter, Citation1989; Rapp & Goscha, Citation2004; Vanderplasschen et al., Citation2007). Participants in this study stressed the importance of building one-on-one trust with clients first and less on team work and collaboration. Collaboration was identified as a significant barrier in this study, and this is consistent with previous research where poor collaboration with other healthcare providers and agencies challenges service delivery and support (Huber, Citation2017). Criteria and eligibility requirements were also a significant barrier. This finding may be unique to this population and the CM program, where excessive and unrealistic documentation requirements and criteria were established to determine eligibility for services. Continued work is needed to document barriers encountered and solutions to barriers identified. Barriers are often related to policies, procedures, funding, or practices, but change over time and space. This necessitates frequent review of challenges and ways to address them. National efforts to implement core competencies and categories for CHWs stress the importance of training, workplace, and scope of practice. Findings from this study tell us that caution must be exercised when categorizing, classifying, and implementing CHW competencies. What is most important is that the CHW has extensive knowledge and empathy for the community they are serving (Covert et al., Citation2019). In sum, these findings underscore the importance of working toward a similar vision and goal, with flexible definitions and agreements about CM and outreach (Kirk, Citation1999).
Limitations
While there are several strengths in this study approach, there are some limitations. The primary limitation is that responses are based on case managers working at UNM HSC with similar backgrounds, experiences, and ideas about what CM and outreach look like. These perspectives may not be representative of other case managers or CHWs working in the field. Second, there was just one focus group and a limited number of questions asked because of the time-consuming nature of the process. Third, confidentiality is often difficult to maintain in a focus group format (Linhorst, Citation2002). However, confidentiality was not a significant concern in this study. Participants were professionals working as case managers; they were asked to participate because of their position at UNM HSC. Finally, social desirability bias may contribute to responses presented here, although external consultants conducted the focus group and analyzed data, it’s possible that participants responded in a manner that was socially desirable rather than reflective of their true feelings.
Conclusion
Effective CM and outreach are possible in community-based settings, even with varying definitions and perspectives. Some feel that shared definitions, instruments, taxonomies, and rubrics are necessary to fully tap the potential for CM and outreach. Others feel that flexibility is most important. By creating static definitions and guidelines, case mangers are not empowered to flexibly reach individuals in need. It may be impossible to create fixed definitions for CM and outreach in all communities, contexts, settings, and spaces. But it is possible to implement CM and outreach with individuals and communities, ‘giving them the skills to help them do it on their own.’
Submission declaration and verification
Our manuscript has not been published previously and is not under consideration for publication elsewhere. The manuscript is approved by all authors and by the responsible authorities where the study was conducted. We affirm that if accepted, the manuscript will not be published elsewhere in the same form, in English, or in any another language, including electronically, without the written consent of the copyright holder.
Supplemental Material
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The authors report there are no competing interests to declare.
Additional information
Notes on contributors
Mayra Perez
Mayra Perez is a Senior Program Manager at the UNM Health Sciences Center Office of Community Health Initiative where she leads community health and education programming. With over 10 years in academia, she has broad experience in community-based participatory research, social work, case management, and culturally-centered social work strategies. Mayra holds a Master of Social Work degree.
Venice Ceballos
Venice Ceballos is the Program Operations Director at the UNM Health Sciences Center Office of Community Health Initiatives where she oversees community-health programs that address social determinants of health and promote community connection, health equity, health literacy, and connection to resources. She is a Certified Community Health Worker with a long career of building, implementing, and supporting CHW programs in under-resourced communities.
Nathaniel Rubio
Nathaniel Rubio is a Coordinator of the Pathways to a Healthier Bernalillo County Program at the UNM Health Sciences Center Office of Community Health Initiatives. In this role, he provides expertise, advocacy, and support for CHW programs that work with the most under-resourced groups in Bernalillo County.
Jennifer Garcia
Jennifer Garcia is the Program Manager for the Intensive Case Management Program at the UNM Health Sciences Center Office of Community Health Initiatives. She provides expertise, advocacy, and support for individuals who need ongoing assistance.
Delfino Rubi
Delfino Rubi works with the UNM Health Sciences Center Office of Community Health Initiatives. In this role, he provides expertise, advocacy, and support for CHW programs that work with the most under-resourced groups in Bernalillo County.
Alejandra Cabrera
Alejandra Cabrera, MPH, is an experienced programs manager who has worked with tribal communities to implement, monitor, and evaluate multifaceted community-based research and programs. She has deep knowledge of trauma-informed care models, harm reduction approaches, and client-centered practices and has a background in HIV/AIDs treatment and prevention, substance misuse and overdose prevention, resilience-focused interventions, community engagement and outreach, tribal public health capacity-building and quality improvement, and strategic planning. She is passionate about supporting programs and services that aim to improve health equity and social justice and reduce health disparities among vulnerable and marginalized communities, with a focus on Hispanic populations and cultural values. Alejandra holds a Bachelor of Science in Molecular Biology from the University of California, Santa Cruz, and a Master of Public Health from San Diego State University. She works in partnership with AKA on project management, community engagement, evaluation and research support, and content development.
Kelley Milligan
Kelley Milligan, AKA Senior Evaluation Consultant, is a research and evaluation specialist that has experience serving tribal communities and underserved populations on behavioral health and public health initiatives. Kelley earned her master’s degree in Public Health with an emphasis in environmental health from the University of Southern California and her bachelor’s degree in Psychology and Social Behavior from the University of California, Irvine. Kelley lives in Sacramento, California, and loves spending her time with her husband and two-year-old daughter.
Allyson Kelley
Dr. Allyson Kelley is the founder of Allyson Kelley and Associates (AKA), a small woman-owned business serving Indian country, non-profits, universities, and behavioral health programs. Her research interests include building community capacity to address the cultural, social, and environmental factors that contribute to differences in health outcomes among underserved populations. She is the author of three books published by Routledge, Evaluation in Rural Communities, Public Health Evaluation and the Social Determinants of Health, and Treatment Program Evaluation. Allyson earned her Doctorate in Public Health from the University of North Carolina at Greensboro. Allyson currently resides in the mountains of central Oregon.
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