Case management in social and health care. Lessons from a United Kingdom program.

In the United Kingdom, despite a stated commitment to community care, centralized planning and financing through the Social Security System, rather than the Social Services Department, resulted in a serious distortion in policy. Social Security funded care in residential and nursing homes, and not community care. As in the United States, central government expenditures for expensive institutional care rose dramatically in the 1980s as a result. By the end of the decade, changes were implemented to decentralize the provision and funding of social care. Several projects were undertaken to demonstrate effective means of applying the new policies. In each instance, case managers worked with relatively small caseloads of the frail elderly and were responsible for allocating funds to purchase the services needed within a fixed budget. In all settings, there was a reduction in the use of institutional care facilities; the quality of life of both the clients and their caregivers improved significantly; and these gains were achieved at no greater cost than for individuals receiving the traditional services without case management. Despite the fact that issues such as what happens to costs when the system is expanded to other target clienteles remain to be resolved, the success of the projects highlights the significant gains to be achieved with case managers who have control of both service selection and budgets.