Case Management for Teenage Parents: Lessons from the Teenage Parent Demonstration

Submitted to:

U.S. Department of Health and Human Services
Assistant Secretary for Planning and Evaluation (ASPE)
Rm. 404E, HHH Bldg.
200 Independence Ave., SW
Washington, DC 20201

Project Officer:  Reuben Snipper (reuben.snipper@hhs.gov)

Submitted by:

Mathematica Policy Research, Inc.
P.O. Box 2393
Princeton, NJ 08543-2393
(609) 799-3535

Project Director:  Rebecca A. Maynard

Contract No.:  HHS-100-86-0045
MPR Reference No.:  7700-925

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Acknowledgments

Many people contributed significantly to the information assembly and analysis for this report.  I am indebted to the state project directors, first Lydia Davis-Barrett and then Janet DeGraaf of the New Jersey Department of Human Services, and Denise Simon of the Illinois Department of Public Aid.  They have been consistently helpful and supportive throughout all of the evaluation efforts.  The demonstration site project directors and managers, Frank Ambrose and Kathy Abbott in Camden, Yvonne Johnson in Newark, and Melba McCarty in Chicago, not only provided much of the input for this report through our ongiong dialogues, but also facilitated our continued access to the case management staff and observations of program operations.  This report depended critically on the willingness of the case managers to be observed, to have their work reviewed, and to participate in extensive reviews of cases and the specific case management approaches used to address particular circumstances.

No less important to the production of this report was the ongoing support of the Federal project officers for the evaluation and the demonstration in the U.S Department of Health and Human Services.  Reuben Snipper, the evaluation project officer in the Office of the Assistant Secretary for Planning and Evaluation, and Judith Reich and Nancye Campbell, demonstration project officers in the Administration for Children and Families have provided perceptive and valuable guidance and comment.  Other staff in ASPE and ACF provided useful comments as well.

The help of staff at Mathematica Policy Research, Inc., has also been valuable. Thoughtful review and comment was provided by Rebecca Maynard, Project Director for the evaluation.  Denise Dunn provided expert production support.  Faults in the report remain the responsibility of the author, however.

DISCLAIMER

This report was prepared for the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, under contract HHS-100-86-0045.  This report does not necessarily represent the official opinion or policy of the Department of Health and Human Services.  The results of this study and the views expressed are solely the views of the authors.

Introduction

From 1986 through 1990, the States of New Jersey and Illinois conducted the Demonstration of Innovative Approaches to Reduce Long Term AFDC Dependency Among Teenage Parents -- also known, and referred to here, as the Teenage Parent Demonstration.  With grants from the Office of Family Assistance (OFA) of the U.S. Department of Health and Human Services (DHHS), awarded in September 1986, New Jersey and Illinois implemented Teenage Parent Demonstration programs in the fall of 1987, after an initial planning and pilot phase.  The demonstration programs were known as Teen Progress in Camden and Newark, New Jersey, and as Project Advance in the south side of Chicago, Illinois.  The general features of these programs are reflected in some of the major provisions concerning adolescent parents in the Family Support Act of 1988 (FSA) and the Job Opportunities and Basic Skills (JOBS) Training program it created.

In these three demonstration sites, all teenage parents of a single child who began receiving Aid to Families with Dependent Children (AFDC) for the first time for themselves and their child were required to attend a baseline intake session, and were then randomly assigned, for evaluation purposes, to program or control status.  Over the period of the demonstration, those assigned to program status were required to participate in appropriate education, training, or employment as long as they were receiving AFDC.  Failure to participate could result, after prescribed warnings, in a sanction -- reduction in the AFDC grant -- until the teenage parent complied with program requirements.  The programs provided case management support, child care assistance, allowances for transportation and other training-related expenses, and a variety of workshops designed to develop the teenagers' personal life skills, motivation, and ability to pursue continued education, training, or employment.  Those assigned to control status could not receive the special services of Teen Progress or Project Advance and were not required to participate in education, training or employment, but were free to pursue other sources of training and education on their own.  A total of 5,297 eligible teenage parents were referred to the demonstration and completed intake during the research intake period (1,218 in Camden, 1,190 in Newark, and 2,889 in Chicago) [During the time period for this report, more completed for later reports.].⁽¹⁾ 

The experiences of these two States in operating the Teenage Parent Demonstration provide valuable guidance for other jurisdictions as they develop approaches to serving teenage parents under the provisions of the Family Support Act of 1988.  The demonstration was designed and implemented, of course, before passage of the Family Support Act and its requirement for all states to implement the JOBS program, and there are some differences in service definitions, but the role of case management in the Teenage Parent Demonstration is fully consistent with the terms of the Family Support Act.  In the demonstration, case management was an essential and integral part of the program design; case managers were intended not only to help teenage parents participate in education, training, and employment, but to serve as a direct source of support, counseling and motivation to them.  Although case management is defined as an optional service in the JOBS program, and States have considerable latitude in how they define and implement it, case management is consistent with the broad intent of the JOBS program design -- to help participants obtain and make effective use of available services.  The Teenage Parent Demonstration therefore provides useful lessons about case management as an element of States' JOBS programs.

This report examines the role of case management in the Teenage Parent Demonstration; it is the third in a series on various aspects of the design and operations of programs for teenage parents on AFDC.⁽²⁾  The opening section of the report summarizes lessons and conclusions about case management, drawing primarily on observation of program operations and the views of demonstration staff.  The next two sections describe the definition of case management in the demonstration, the specific services provided by case management staff, and the organization of staff.  Finally, three broad questions are addressed based on the demonstration experience:

1. How can case managers promote teenagers' productive participation in education, training, employment, and other program activities?
2. What factors contribute to the effectiveness of case management?
3. How can program managers maximize the effectiveness of case managers?

Major Conclusions Concerning Case Management

Case management may be defined and practiced in a variety of ways.  In the Teenage Parent Demonstration, staff units consisting of case managers and specialists in employment, training, education, and child care worked with participants as long as they were on AFDC, providing personal support, planning and monitoring, and referral into available education, training, and jobs.  The experience of the Teenage Parent Demonstration suggests conclusions about case management for teenage parents that are likely to be relevant in ongoing programs.  Conclusions about "effective" case management are drawn from the insights shared by program staff about their experiences, the obstacles they had to overcome as they worked with participants, and the approaches they tried to motivate and guide them.  They are not based on rigorous estimates of the impact of various practices on measurable outcomes such as school retention, training participation, or employment.  Information was drawn from case conferences with case managers and interviews with program managers, a series of site visits during the course of the demonstration, and regular discussion with site managers as part of demonstration monitoring.  The main conclusions of this study are as follows:

1. Case management encompasses a wide range of staff functions.  A case management unit is likely to be involved in providing initial and ongoing assessment and service planning, personal counseling and support, advocacy on behalf of clients, delivery of child care subsidies, enforcement of participation requirements, and thorough maintenance of case records.
2. Case managers' persistent enforcement of program participation requirements can be a constructive intervention in clients' lives.  Insisting on participation is a way of establishing a set of clear expectations, often an essential ingredient in motivating and guiding adolescents, and one which many participants have not had.  The process of enforcement itself involves ongoing communication -- even when possible during periods of sanction -- that can provide time for initially resistant teenage parents to become acquainted with program staff and interested in participating, and serve as a clear reminder of where these young mothers can turn for help when they need it.  In many cases, teenage parents may resist pressures to participate and seem immune even to the financial incentives created by sanctions, but changes in their lives -- getting older, losing income or the support of a boyfriend -- can lead them into productive participation if they are kept aware of the program, the requirement to participate, the services the program can offer, and the potential it offers for improving their future lives.
3. The process of case management is likely to be helped by an informal environment where supportive conversation and the development of trusting relationships can occur.  Program staff can make the case management unit a place of refuge and interest for teenage parents by promoting a cooperative staff spirit, providing attractive and comfortable facilities, and encouraging clients to visit whenever they need support or advice. 
4. Personal skills are important ingredients of successful case management.  Good case managers are both tough and supportive with their clients -- setting consistent expectations for client effort, but providing the warmth and encouragement the teenage parents need to overcome often daunting obstacles in their personal lives in order to pursue self-sufficiency goals.  Good case managers are open-minded, comfortable dealing with teenagers and their sexuality, and benefit from having in their backgrounds something in common with the clients they are helping.  They also need to be well- organized in their work habits to deal with the pressures of high caseloads and often very unpredictable demands on their time.
5. Program managers can help case managers be effective by creating specialized positions in their units, thus maximizing the time case managers can spend with clients.  Clerical staff can be used for scheduling clients for group sessions, monitoring client attendance, maintaining liaison with income maintenance staff concerning sanction actions, processing child care vouchers, and performing data entry.  Special expert staff can be used to conduct program workshops, and child care counselors can be used to great advantage to develop appropriate providers for teenage parents and link up clients with providers who can help them best. 
6. Program managers can help their staff by taking the lead in developing and shaping the array of services available to teenage parent clients.  Program managers can arrange briefings for case managers by community service providers, "market" their program to other agencies, and in some instances use their funding to encourage other agencies to tailor their services to the special needs of teenage clients. 
7. Program managers need to monitor and control case managers' caseloads, and use a measure of caseload size that reflects the different stages of client participation.  Although the total number of clients assigned to a case manager over time will continue to grow, some clients will leave AFDC each month.  Moreover, the total assigned caseload will at any given time include individuals who have been sanctioned or deferred, and some who are well established in ongoing training or education -- because caseloads build up over time and include clients at very different stages of program involvement.  Attention must be paid to the portion of assigned caseloads that actually represent ongoing demands on case managers' time.  Although total assigned caseloads in the demonstration grew as high as about 140 in one site, the demonstration experience suggests that the number of active cases per case manager -- excluding cases that are deferred, have gone off AFDC, or are under sanction -- probably ought not to exceed about 80 cases.  Larger active caseloads threaten case managers' ability to provide personal attention when it is needed. 
8. Program managers can help to maintain the morale of case managers and promote staff stability.  Managers should focus on ways to promote recognition of staff effort and accomplishments, vary their work assignments and allow room for creativity.  Ongoing training can strengthen staff understanding of their daily challenges, provide some occasional break in routine, and demonstrate management recognition of the complexity of the problems they are working on. 

HOW WAS CASE MANAGEMENT DEFINED IN THE TEENAGE PARENT DEMONSTRATION?

Although case management has become a widely used term, its actual form and content vary widely depending on the target population it is meant to serve, the professions and training levels of the staff who provide the service, legislative or regulatory definitions, and administrative and financial constraints.  It is therefore important to clarify what case management was designed to be in the Teenage Parent Demonstration. 

Case Management Was Viewed as a Key Service in the Demonstration

The demonstration design as set forth by DHHS, and as implemented by the two States, made case management an important service in itself.  Some models for case management -- such as the medical "managed care" model -- focus primarily on managing services provided by others.  The demonstration case management staff were expected to help participants gain access to appropriate education, training, employment, and child care services.  An equally important element of their jobs, however, was their direct interaction with participants -- motivating and encouraging them, helping them deal with crises in their personal lives, monitoring their attendance in program activities, and enforcing the rules that required their active participation. 

Case Management Was Planned as a Distinct Service Apart from AFDC Income Maintenance Functions

The demonstration design envisioned delivery of services in a setting apart and distinct from the administration of income maintenance eligibility functions.  Demonstration staff, although expected to maintain necessary communications with income maintenance staff, were to provide services and not be involved financial or categorical eligibility determination.  The programs were therefore physically and organizationally distinct from the AFDC income maintenance staff.  In Camden, the County Board of Social Services created a demonstration office near the main welfare office, in a building that also housed the Food Stamp Employment and Training unit.  In Newark, the State Division of Economic Assistance ran the program directly, in rented space in a building occupied as well by a variety of outpatient medical services and a health-related job training program.  An alternative originally suggested by the local Board of Social Services -- using income maintenance workers as case managers - - was rejected as not providing suitably focused, concentrated attention to participants' needs for services and personal attention.  In Chicago, the Illinois Department of Public Aid leased offices in a building centrally located in the catchment area of the four local public assistance offices from which the demonstration population was drawn. 

Case Management Practices Were Defined for the Context of a Mandatory, Publicly Funded Program

Demonstration guidelines, state regulations, and practical realities established the framework and constraints for case management practices.  First, demonstration guidelines required 30 hours per week of active participation, and thus created clear demands not only on participants but on case managers as they developed plans with participants for the activities they would pursue.  The guidelines specified that sanctions -- the removal of the needs of the teenage mother in the AFDC grant calculation -- should be imposed on teenage parents who failed to participate as required in program activities.  Both states adopted specific regulations defining the steps that case managers would take in response to non- compliance with program requirements -- warning notices, conferences with participants, imposition of grant-reduction sanctions through the income maintenance units -- and the conditions under which sanctions would be lifted. 

Anticipated and actual resource constraints also affected case management in the demonstration.  In keeping with DHHS intentions to simulate the services that might realistically be provided in conjunction with the AFDC program, the two States planned for caseload levels higher than those often found in small, voluntary agency programs.  Based on their projections of program staffing, intake rate, and rate of teenage parents' departure from AFDC, the States anticipated that on average case managers would serve 60-70 active participants.  Actual caseloads (not counting teenage parents who had left AFDC) reached levels of 80-85 in one site.  Caseload sizes naturally affected the range and intensity of case managers' roles. 

WHAT SERVICES DID CASE MANAGEMENT INCLUDE AND HOW WERE STAFF ORGANIZED AND PREPARED?

Although demonstration plans and guidelines anticipated a central role for case management, the details of the case managers' work and the structure and organization of case management staff were defined by the States and evolved with experience.  The programs also developed their own staff structures, which allocated certain roles to case managers and some specialized or support roles to other staff in the demonstration units.  The case management function performed by this overall unit included six broad roles:

1. Initial and Ongoing Assessment and Planning.  When teenage parents had completed their intake session, they were assigned to a case manager, who conducted a comprehensive assessment and worked with the participant to develop a self-sufficiency plan for full-time program activity.  Assessments drew on information collected in several ways.  Case managers conducted an in-depth interview using a specially prepared interview guide that covered educational progress and aspirations, work experience and occupational interests, child care needs and resources, transportation problems, housing situation, history of substance abuse, health problems, legal problems, family planning practices and attitudes, and general self-esteem.  The Test of Adult Basic Education (TABE), administered at intake, provided grade-equivalent measures of math, reading, and language skills.  TABE scores were used in conjunction with information on school progress and staff's observations of new participants, rather than as a decisive factor alone.  Participants sometimes did not take the TABE seriously at intake because they were not aware that it could affect the choice of their program activities; case managers therefore had to be careful to consider other indicators of participants' skills, and in some instances read ministered the TABE when clients had entered the program.  Demonstration staff also had available an occupational interest questionnaire, which was useful primarily with older participants who had a clearer awareness of occupations.  Depending on available time, home visits were sometimes made as part of assessment. 

   Assessment was an ongoing process.  The initial assessment interview and intake TABE scores provided the basis for an initial plan, but further events provided more information and circumstances changed.  Case management staff observed new participants in initial program workshops, and in the process uncovered new information about their strengths and weaknesses which could suggest that plans for post-workshop activity should be changed.  Reassessments of activity plans were repeated as changes occurred in participants' personal or family lives, as they progressed through program activities or had difficulties in them, and as changes occurred in the types of available services.

2. Personal Support and Motivation.  A large part of the challenge the staff faced in working with many clients was to overcome the personal, family, and community pressures that could discourage teenage parents from participating and seriously divert their attention from the effort the program demanded of them.  Case management staff had to strengthen participants' faith in the possibility of building a better life for themselves and their children, and help them build confidence and self-esteem that in many cases had withered over years of difficulties in school, chaotic family ties, and sometimes abusive relationships with men.  Case managers provided encouragement and sympathy, but also the kind of clear and consistent expectations that they perceived had been missing in many participants' lives and that many adolescents need for motivation and guidance.
3. Service Coordination and Advocacy.  An important concern of the case managers was to ensure that participants gained access to the services they needed.  Case managers had to keep track of the availability of desirable education and training courses and program workshops, and fit together plans which made optimal use of available resources and participants' time.  Often they had to intercede on behalf of clients.  For example, they might talk to income maintenance workers to help get benefit errors corrected or with local school officials to obtain permission for a client still of mandatory school-age to enroll in GED classes.  Case managers might persuade a nursing school to waive a registration fee or defer a payment deadline, convince a welfare department housing unit to provide a near-homeless client with an apartment deposit, or enlist the help of relatives or the cooperation of landlords to stabilize a client's housing situation.
4. Providing Child Care and Transportation Assistance.  Demonstration staff helped participants locate child care arrangements, and when necessary inspected them.  In many cases they repeated this effort when arrangements with a particular provider broke down or when clients' participation in the program was interrupted and then resumed.  The counseling role played by demonstration staff was particularly important, because many teenage parents had strong reservations about using non-relative child care.  They often had to be helped to appreciate both the overriding importance of their own continued education or training and the potential benefits to their children of choosing a stimulating child care environment.

   To varying extents, the demonstration programs offered limited on-site child care, mostly for periods when participants were attending workshops, classes, or appointments at the program offices.  Unit staff also processed vouchers from child care providers and authorized issuance of payments to them, and authorized issuance of weekly checks to participants for bus fare and lunch expenses.  In Camden, the program operated a van to take some participants to training or to take groups of participants on cultural or educational outings.

5. Enforcing Participation Requirements.  The case management unit enforced the requirement that eligible teenage parents attend the initial intake session.  Once new participants had completed intake, their assigned case managers, with support from clerical staff, monitored their attendance at scheduled assessment interviews, workshop sessions, on-site classes, public school, and other off-site education and training courses.  When participants failed to attend scheduled activities as required, case managers sent warning notices to them, tried to set appointments to discuss problems that might be interfering with their program attendance, and in many cases eventually requested grant- reduction sanctions if the participant failed to comply.  Sanctions were treated as a last resort; case managers tried first to persuade and pressure clients to participate, and often developed alternative plans for activities that seemed more likely to motivate them.
6. Maintaining Case Records.  The program staff at the demonstration sites used a combination of computerized and manual systems to maintain records concerning assessment and self-sufficiency plans, participants' program activity and attendance, case notes, and payment issuance for child care and transportation.  Both states developed microcomputer-based tracking systems in which staff entered extensive baseline data, and recorded completion of program workshops, entry to and exit from education, training, and employment activities, and sanction actions.  These systems were designed to use information on participant status as a basis for issuing notices of scheduled workshops, warnings of sanction action for failure to attend program activities, other notices, and management reports.  Case managers also maintained written case narratives; in some sites these narratives were conveniently maintained with word processing tools available to the case managers through the same terminals as the formal case tracking system.

Some aspects of the case management role evolved over time based on experience.  For example, early in the demonstration home visits were used fairly frequently -- to promote attendance at intake sessions, to complement the in-office assessment process, and in some instances to clarify a home situation or confer with a participant's parent.  As the pressures of increasing caseloads grew, the practice of making home visits was scaled back to relatively infrequent use.  Experience also led program managers to recognize the need to help case managers avoid excessive involvement with individual participants whose problems could consume large fractions of their attention and might, in some cases, need the attention of more specialized, clinically trained professionals.

The Programs Developed a Staff Structure and Specialized Roles

To deliver the range of services described above, each site created a structure of supervisory relationships, specialist roles, and support roles.  Most staff at the demonstration offices were directly employed by the unit of the public assistance agency sponsoring the demonstration, but staff on loan from other agencies or units in the public assistance agency were also located on site, full-time or part- time.

The basic staff structure at all three sites consisted of a site manager, assistant managers or supervisors, and a team of case managers.  The Camden and Newark sites each had five case managers, overseen by an assistant site manager or case management supervisor in addition to the site manager.  At the larger Chicago site, the staff of ten case managers was divided into two units, each with a supervisor reporting to the site manager.

The sites also developed roles for specialists who worked directly with participants in aspects of the broad case management functions described earlier.  All three programs used specialists to focus on helping participants make a transition into employment or job training, or back to school.  In Chicago, an employment specialist ran job clubs, sought out promising job openings, working with the State employment service and employers.  An education specialist conducted intensive "study skills" sessions with participants preparing to go back to school to help them schedule their time and develop effective study habits, drawing in part on a computer-equipped learning center developed at the demonstration site.  The Camden program had the services of a training counselor on loan from the county Job Training Partnership Act employment program and a part-time job placement counselor, and the Newark program had an employment training counselor who conducted job clubs and found job placements.  The Camden and Newark programs also had child care counselors who helped educate participants about the use of child care, find suitable child care openings, inspect providers' homes or facilities if necessary, and serve as a liaison to providers.⁽³⁾  These specialists were integral parts of the case management staff.  They worked closely with the case managers and, in some instances, played important counseling roles with individual participants.

Clerical staff performed important support roles in the demonstration units to help case managers monitor their caseloads and take required actions.  They performed -- to different degrees in the three sites -- five kinds of tasks:

1. Client Call-in and Scheduling.  Clerical staff scheduled newly identified teenage parents for program intake, and used program computer systems to generate call-in notices.  This function corresponds approximately to the step in many states of calling in AFDC recipients subject to JOBS requirements for an initial evaluation.  In ongoing JOBS programs, this function may be handled by general AFDC eligibility systems which flag teenage parents.
2. Attendance Monitoring.  Demonstration participants attended a variety of off-site activities (e.g., high school, GED classes, job training).  Collecting regular, frequent information on their attendance at these activities was an essential part of monitoring compliance with participation requirements and identifying problems so case managers could intervene rapidly.  Clerical staff were used to maintain contacts with service providers, record attendance, and inform case managers of attendance problems.
3. Liaison with Income Maintenance Unit on Sanction Status.  When a client persistently failed to respond to repeated call-ins or failed to attend later program activities, case management staff initiated requests to income maintenance staff to impose sanctions.  Clerical staff were used to monitor sanction status, checking to be sure that sanctions were implemented as requested and that they were removed when requested by case managers upon clients' compliance with program requirements.
4. Data Entry.  All three demonstration programs trained case managers to use an automated case management system directly, but they also used clerical staff for entry of certain types of information.  For example, attendance at initial group intake sessions was entered by clerical staff, and clerical staff then used the system to generate repeat call-in notices.  Data entry staff were also used to enter baseline information collected in intake interviews.  In all programs, it was possible for either case managers or data entry staff to input information on participants' ongoing activities, although each site followed a general practice of relying primarily on one or the other.
5. Voucher Processing.  The case management units had to approve payments for child care and transportation -- functions also required in the JOBS program.  The demonstration programs used clerical staff to review child care providers' invoices, check to be sure that the period of child care corresponded to actual client attendance at program activities, and authorize payment.  Clerical staff prepared authorizations of payments to clients for transportation, which also involved reviewing their activity schedules and attendance records.

Other special functions that might be viewed as beyond the definition of case management were performed at the sites -- by demonstration staff or staff from other agencies.  The programs used various combinations of case managers and outside specialists to run initial workshops for new participants and other ongoing workshops for selected active participants.⁽⁴⁾  In Chicago, a representative of the child support enforcement unit of the Illinois Department of Public Aid was stationed part-time at the demonstration office to conduct interviews with participants and promote their cooperation with and understanding of the child support process.

Case Managers Were Recruited Through Different Channels, and Received Special Training

Circumstances gave rise to quite different approaches to recruiting case managers in each of the three demonstration sites and, as a result, to case management staffs with quite different backgrounds.  In Chicago, civil service rules required that case managers be recruited from the ranks of income maintenance workers; as a result, most case managers' highest credential was a high school diploma, the educational requirement for income maintenance positions.  In Newark, case managers were recruited largely from the ranks of the State's Division of Youth and Family Services and its Bureau of Employment Programs; this process yielded case managers with at least bachelor's degrees and in several cases with master's degrees, and considerable experience in social work and counseling.  In Camden, the County Board of Social Services was able to recruit at large; in this process, personal skills were given substantial weight, and the staff hired had a variety of educational levels and professional experience.

In all programs, case managers were given initial and ongoing training, but the extent of training and the emphasis on approaches to working with adolescents and their problems were clearly greater in Chicago.  In New Jersey, a total of four days of case manager training was conducted in the first several months of the demonstration, focusing heavily on procedures for intake and client data collection.  This training was held before most of the Newark case managers had been hired.  Over the next year, several days of additional training focusing on techniques for working with teenage parents were provided.  In the third program year, about nine additional days of training on case management techniques were provided by an outside consultant.

Training was more extensive in Chicago.  Two weeks of initial training sessions were conducted, mostly by outside experts invited to speak about issues such as adolescent health risks, pregnancy prevention programs, employment problems facing teenage parents, the child support enforcement process, adolescent development, teenage sexuality, parenting and child discipline, in addition to demonstration procedures and data collection.  An additional 20-30 days of ongoing training sessions were held during the course of the demonstration, covering topics such as adolescent health, reproduction and family planning, parent-child relations, child care and child safety, child sexuality, group dynamics, sexual assault and abuse, domestic violence, child abuse and neglect, managing stress and conflict, AIDS, promoting self-esteem, and methods for motivating youth.  The substantially greater level of training provided in Chicago probably reflected the availability of a well-developed State training capacity and procedures for using training, as well as the relatively lower level of formal education and relevant experience among the Chicago case managers.

HOW CAN CASE MANAGEMENT STAFF PROMOTE CLIENT PARTICIPATION?

Some teenage parents came to the demonstration programs already strongly motivated to continue their education, or to find and succeed in a suitable training course, and had a strong personal sense of direction and purpose.  They needed no prodding or coaxing by case managers to pursue a path off AFDC and towards self-sufficiency, and appreciated the program's help with child care and expense subsidies.  In the view of case managers, these very motivated participants were likely to succeed even without the program.  In the program, given access to educational opportunities, a training course, or employment guidance, these clients generally applied themselves and succeeded, without the need for case managers to spend very much time working with them.  Case managers described such cases as relatively rare, however.

The potential impacts of a program for teenage parents on AFDC are therefore more likely to be achieved by the staff's work with the larger segment of the target population who are less motivated and have less sense of direction, or who face severe countervailing pressures that can overwhelm their own strengths and ambitions.  Case managers spent most of their time working with such clients, although levels of motivation, direction, and personal problems -- and the attention required of staff -- were of course a matter of degree.  The case managers worked case-by-case to find the right combination of supportiveness and helpfulness, on the one hand, and pressure and clear expectations, on the other, that could draw clients into sustained contact with the program staff, and guide them into activities that were motivating and rewarding and could potentially lead towards decent future employment.

It Was Important to Persist in Efforts to Draw Less Motivated Teenagers into Productive Activities

Among the less motivated or less self-directed clients, a variety of factors interfered with their ability or willingness to take part in demonstration activities, and case managers had to take a persistent approach to identifying these factors and helping clients overcome them.  Many participants suffered from general lack of confidence and self-esteem, and lacked the kinds of supportive relationships that could help them develop these strengths.  In some instances clients' families objected to their pursuing education or training.  Some participants' boyfriends interfered with their involvement in the demonstration.  Crime and drug abuse in their neighborhoods threatened their security and could make them uneasy traveling to program activities or jobs.

Case managers had to use a variety of approaches to overcoming clients' reluctance to participate.  They reasoned with clients -- trying to help them understand the connection between efforts to improve their skills and their long-term prospects for employment and a better life for themselves and their children.  They encouraged them, reassuring them that they would make friends in the new environment of the class they were to enter, and that they could succeed.  In some instances case managers spoke to clients' mothers to win their support for their daughters' participation or to cooperate in joint efforts to persuade them to participate.  Case managers chided clients when they missed appointments or slacked off in their attendance at education or training classes, and reminded them that they had to choose between participating and the possibility of a sanction that would reduce their AFDC grant.  They used the formal tools they had for enforcing participation requirements -- sanction warning notices and, when necessary, grant reductions.  These efforts were often made over extended periods, because some clients went through recurrent cycles of participation and resistance.

Case managers found that these persistent and varied efforts to involve less motivated clients had the desired effects with some of them.  They reported cases in which teenage parents who were at first very reluctant to participate in the program, and even resisted participating for long periods, eventually showed a striking turnaround in their attitude and behavior.  In in-depth interviews, some teenage parents clearly reported their initial skepticism about and resistance to the program, and attributed their decision to participate to the persistent, caring, but insistent attention paid to them by the demonstration staff.  Inevitably, however, some teenage parents chose to accept ongoing sanctions rather than participate, and some -- according to case managers' perceptions -- may have chosen to leave AFDC rather than attend program activities.

Formal Participation Requirements and Sanction Rules Were an Important Foundation for Staff Efforts to Promote Participation

The threat of a sanction or the actual financial effects of a sanction were clearly an important foundation for the varied approaches described above that case managers took to get reluctant clients to participate.  The premise of sanction policy in the demonstration -- and in JOBS -- is that the reduction of an AFDC grant, or the possibility of such a reduction, is an effective financial incentive to comply with program requirements and participate in program activities.  In New Jersey, teenage parents of one child with their own AFDC cases lost $160 off their monthly $322 grant when they were sanctioned.  In Chicago, a mother of one child lost $56 per month off her $268 grant.⁽⁵⁾  The States followed their own individual policies with regard to continuation of Medicaid eligibility and adjustment of Food Stamp benefits associated with an AFDC sanction.

These financial incentives were clearly at work in the demonstration.  In the New Jersey programs, for example, large proportions of the teenage parents who completed intake -- 26 percent in Camden and 49 percent in Newark -- were later either warned of a sanction or were sanctioned.  In about half of these cases the action led to at least some further program activity -- either completing a workshop or some other activity.  In one illustrative case, a client was at first very depressed and insecure, lacking in self- confidence, and very reluctant to participate.  She failed to appear for program workshops, but eventually complied after receiving several sanction warnings.  By the time she had completed a few workshops, she had become more comfortable and interested in the program.  She expressed an interest in working with computers, received data entry training, got a job with a major insurance company, and within a short time was promoted -- which she reported with great pride to the program staff.

Although the prospect of the financial effects of a sanction -- or an actual sanction -- could be expected to be one factor in encouraging teenage parents to cooperate, demonstration staff pointed out that the mandatory nature of the program promoted participation in ways other than simple financial incentives.  Persistent insistence on participation was beneficial in some instances because it maintained contact with the client over a long enough time for the client to become acquainted with the program staff, recognize that they were supportive and helpful, and overcome fears of the unknown.  Before imposing sanctions, case managers used the formal notices and conferences with clients as prescribed in demonstration rules, and in some cases these succeeded in drawing reluctant clients into the initial stages of program involvement such as assessment and workshops.  Such program exposure could overcome some clients' reservations and lead them into further activities.

Patient adherence to program participation requirements could also, according to some staff, be a useful ingredient in the search for the right activity that would spark a client's interest.  When a client repeatedly missed a particular class despite several warnings, or dropped out of a course but professed a general willingness to participate in the program, the participation requirement pressed program staff to reexamine what other paths the client might take, rather than accepting non-participation as an acceptable status.  The case manager had to continue to communicate -- and often struggle -- with the client over the program participation requirement.  This sustained communication could increase the chances of identifying an activity that would engage the client and help her make progress.  One Newark client, for example, entered the program with a cooperative, willing attitude; she had already graduated from high school and started a BA program at Rutgers University.  She seemed unsure of what she wanted out of school, however, and ended up dropping out of college.  The program staff quickly insisted that she attend Teen Progress workshops; she missed some classes and was warned to keep up her attendance.  By coming to the program offices, she was exposed to an allied health training program available in the same building, and ended up enrolling there and doing very well in a medical technician course.  Demonstration case managers have pointed out that some clients visited them for company or advice even when they were sanctioned; such visits were continued opportunities to guide and persuade clients towards later participation.

According to staff, continued efforts to gain compliance, or simply the long application of a sanction, had a positive effect in some cases by keeping the client aware that there was a program to turn to when it eventually became more attractive to her.  One client, for example, refused to complete intake and had been sanctioned for about 18 months when she finally showed up and said she wanted to participate in the program because, in her own words, she had become "ashamed" of being on AFDC.  Within two months she had entered an office skills training program, which she completed successfully.

The Threat of Sanctions is Often Ineffective When Clients are Less Dependent on AFDC, but Circumstances Can Change

The prospect or the reality of a sanction seemed to program staff to work in inconsistent ways, depending on client circumstances.  Based on staff perceptions of clients' circumstances and behavior, sanctions seemed least effective when AFDC was relatively unimportant to the client.  Demonstration staff pointed out that some teenage clients who were included in their mothers' AFDC grants seemed insensitive to the financial consequences of their actions because they did not have to manage their own household budget.  Some clients were unresponsive because, it appeared to the case manager, they had other non-AFDC sources of income, such as support from a boyfriend or their own unreported earnings or other income.⁽⁶⁾

The lives of teenage parents change, however, and some changes made clients more sensitive to the financial loss they incurred by not participating in the program or simply motivated them to pursue some productive activity.  Most obviously, teenage parents get older and in some cases become more aware of the life choices they have to make.  For example, one client described by program staff completed program intake at 14, but was then sanctioned for about a year for non-participation.  After this extended period of non-compliance, however, she came back to the program exhibiting a completely different attitude and even greater attention to her personal grooming and dress.  She completed program workshops and began attending ABE classes regularly and looking for a part-time job.

This kind of turnaround after a period of sanction largely depends on changes in the teenage parent's life and personal initiative.  For the most part, once clients were sanctioned the case managers could not devote any substantial effort to repeated attempts to persuade them to rejoin the program.  In some cases, however, ongoing contact was possible, and in a few instances even sought by sanctioned clients who resisted program activities but seemed anxious to maintain contact with program staff.  Continued contact with the teenage parent's mother sometimes helped prod a client into action -- perhaps due only to the older mother's concern about sanctions resulting from the teenage parent's noncompliance, but in some cases because the mother was earnestly seeking an ally in her own efforts to guide and motivate her daughter. 

According to program staff, some teenage mothers' relationships with men -- and changes in those relationships -- affected their willingness to engage in the program.  Case managers perceived the role of men in some clients' lives as undermining the goals of the program and the chances for their clients' progress.  In some instances, case managers saw the teenage women they worked with entering into or remaining in exploitative or abusive relationships.  Some male partners discouraged the teenage mothers from pursuing education or training.  Case managers could discuss the effects of such relationships with some clients, but more often it was their natural deterioration and dissolution, and the loss of the financial support from male partners, that led clients to respond to sanctions and reconsider the possibility of participating in the program.  Persistent contact with clients to enforce the program participation requirement can maximize chances that when such changes occur the teenage mothers will turn back to the program.  Periodic reminders while sanctions are in effect were not consistently used in the demonstration, but they might be helpful in encouraging such changes in response to the program.

Program Pressures Did Not Always Get Clients to Participate

Even the prodding of case managers and financial sanctions did not prevent some teenage parents from refusing all program activities or complying only temporarily.  Some of the teenage parents in the demonstration sample seemed to be trapped in family behavior patterns that created insurmountable barriers to participating in or benefitting from the program.  Some came from severely troubled families and lacked the personal skills and strengths to escape them.  In some such instances, case managers reported that clients were responsive to the caring attention of program staff, but that family pressures interfered with effective participation.  Case managers found clients like these to be impossible to help through a program that could not remove them from the home and neighborhood environment that had so affected their lives.

Some teenage mothers seemed to case managers to be entrenched in their dependence on public assistance.  For example, one client, whose mother was herself a long-term welfare recipient with six children, some already with their own AFDC cases, took continued evasive action over a period of two- and-a-half years to avoid any meaningful involvement with the program.  She repeatedly refused to participate, allowed sanction action to proceed against her, then agreed to comply just long enough to have the sanction lifted at least for a probationary period, and then resisted participation again, filing repeated but unsuccessful fair-hearing petitions along the way to delay or minimize her loss of AFDC benefits.  She devoted great energy and considerable intelligence to resisting the program and preserving the stability of her AFDC-based life, and seemed to have no idea of the possibility of a different life.

In some instances, neither available program services nor the pressures of demonstration sanction policy could overcome family and community views about the roles of women in society; this obstacle to participation was reported by case managers to be somewhat more common among Hispanic clients.  Hispanic teenage parents were described as more likely to emphasize their roles as mothers to the exclusion of other pursuits, and to be wary of leaving their children in child care to pursue education or training.  In addition, they more often came from an extended family in which their role as breadwinners was discounted, and when in relationships with men they were often pressured not to pursue education or training.

Creating a Setting for Open, Informal Communication Helps Make Opportunities for Case Managers to Guide and Motivate

Not surprisingly, case managers found that guiding and motivating their teenage parent clients entailed a great deal of listening, not just telling clients what to do.  A willingness to be patient and receptive and to engage in a lot of informal conversation was important for several reasons.  First, it was often only through repeated conversations, sometimes over the course of months and numerous turns in a client's commitment, that case managers became aware of the full range of home circumstances and personal strengths and weaknesses that explained the client's behavior and identified issues to be addressed.  Second, some clients developed trust in their case managers only over extended periods, and thus only slowly became willing to talk openly about important concerns.  Finally, program managers pointed out that ongoing, informal contact was important if staff were to serve in any measure as role models for clients.  Informal conversation created natural opportunities for case managers to reveal something of their own lives and, in an unforced way, to present themselves to their clients as real people whose lives offered some examples they could follow.

Much of the success of case management, therefore, is likely to hinge on the atmosphere created by the case managers, their supervisors, and the physical place where they work, and the degree to which these factors combine to encourage open and informal communication between staff and clients.  Demonstration staff in one site described their ideal of creating a "clubhouse" atmosphere at the case management unit.

Several program factors can promote such an atmosphere.  Fostering a close-knit, cooperative working relationship among staff is one important ingredient.  Case managers have to be willing to help each other, deal with each others' clients when necessary, and generally avoid "compartmentalizing" themselves and the program clients, so that clients feel they have a group of friends rather than just an "assigned worker."  Group activities at the case management offices, particularly early in clients' experience with the program, also contribute by helping them forge supportive relationships with their peers in the program.  The initial workshops that new demonstration participants went through as a group -- particularly the four-week "boot camp" regimen used in the Camden program -- were particularly useful in this respect.  Case managers reported that clients often dropped by the case management office to chat with the staff, and to meet new-found friends.  This kind of atmosphere is probably most readily created if the case management unit is housed in its own location, rather than being in a few assigned offices or cubicles in a maze of welfare offices.  Physical facilities -- such as the attractive kitchen facility installed at the Chicago demonstration program to allow preparation of healthy snacks and nutrition demonstrations -- can promote the informal clubhouse atmosphere that demonstration case managers sought to maintain.

WHAT DOES IT TAKE TO BE A GOOD CASE MANAGER?

Case management is a very demanding job.  It requires energy and patience, imagination and discipline, warmth and realism, a capacity for insight about human emotions and motivation, and well-organized work habits.  As described above, the demonstration sites took different paths to recruiting and training case managers, but program managers shared common perceptions of the important qualities of a good case manager and of some factors to be considered in building a case management staff.

Case Management Requires a Balance of Caring and Toughness

In any case management staff, there is likely to be a variety of personal backgrounds, styles of interaction with clients, and strengths and weaknesses.  Case managers' own personalities will determine the relative emphasis to which they rely on supportiveness, warmth, trust, and encouragement to motivate and guide clients, and the degree to which they push clients forward with strict demands, deadlines, and tough application of sanction policies.  Case managers and supervisors clearly recognized the need to balance these two qualities to be effective, and supervisors and managers can promote this balance.  They can recognize individual case managers' personal styles, guide those who lean towards a supportive, lenient approach to recognize the circumstances in which a stern, insistent stance can be productive, and likewise help the natural disciplinarian to see the value of warmth and empathy in communications with clients.

Case Managers Need to Be Able to Talk Comfortably and Constructively About Sensitive Topics

Case managers' ability to help clients into education and training and to overcome personal barriers depends on their ability to identify and address personal issues that are often very difficult for clients to acknowledge and discuss, and that are widely avoided in general in our society.  Demonstration clients, as teenagers, struggled with the typical confusion and uncertainty over sexuality and relationships to men and their own families.  As very young parents, they had to deal, relatively unprepared, with the difficult demands of caring for an infant.  Beyond these typical concerns, numerous clients had suffered sexual, physical, and emotional abuse.  Case managers had to uncover and discuss these issues as they affected their clients' lives, in a down-to-earth, nonjudgmental manner, and to try to guide them towards recognizing the choices they had available to them.  Although case managers were certainly not trained as clinical therapists, they could apply their own personal skills to make it easier for clients to talk about these issues and to give constructive support.  When necessary, they had the option of making referrals to other mental health agencies for more specialized counseling.

Good Case Managers Actively Initiate Client Contact

One demonstration program manager reported that a useful criterion for judging the performance of case managers is their level of client contact.  All case managers are likely to have clients contacting them, so the major variable affecting levels of client contact is likely to be what the case manager does to encourage or explicitly initiate contacts.  On the one hand, case managers initiate contacts with clients in the process of identifying and addressing problems in client attendance.  Case managers who follow a more "formal" approach, relying mostly on written sanction warnings, are likely to have less client contact than case managers who insistently reach out to try to discuss problems with clients.  Levels of client contact are also likely to vary with the degree to which case managers initiate periodic "check-up" calls with their clients who are successfully pursuing program education or training courses or are working.  Making the time for such calls underscores the fact that program staff care about how the clients are doing as people, and not just about whether they comply with program requirements; this kind of communication can increase chances that clients will turn quickly to the case manager if a problem arises.

Ideally, case managers will attempt periodic contacts with clients who are sanctioned, although time constraints inevitably affect their ability to do so.  As explained earlier, such contacts can increase the chances of either convincing a noncompliant client to participate or creating enough continued informal communication so the client comes back to the program staff when circumstances change.  JOBS rules require that program staff send a notice three months after the start of a sanction, reminding clients that they can return to a full benefit level by participating, but this requirement is likely to be satisfied by a formal printed notice.⁽⁷⁾  More personal contact by case managers will likely have a stronger effect on clients' perceptions of the program.

Case Management Requires Teamwork

The pressures of case management, the use of specialized staff, and the importance of successful personal interaction as an ingredient in case management make it important that staff be able to work as a team and avoid jealousies or turf issues.  Case managers reported that clients often seek help with very urgent problems, and if these crises arise when the client's assigned case manager is out of the office, other staff must be ready to respond.  A spirit of helpfulness and an ability to avoid being possessive about one's caseload are important to make this kind of teamwork successful.  Staff specialists form relationships with clients, and the specialists and case managers must work in partnership rather than in competition for the attention or recognition of clients.  These issues are particularly important because, according to demonstration staff, there are times when a client may gravitate towards a staff member other than the assigned case manager; it is important that staff be able to take advantage of these affinities and promote the formation of any positive relationships rather than react jealously to them.  At the same time, of course, staff must take care to avoid conveying conflicting guidance or expectations.

A Mix of Personal Styles and Backgrounds Can Strengthen a Case Management Unit

Program managers and case managers pointed out the value of having a variety of personal styles and backgrounds represented in the case management unit.  To some extent, the staff mix may be affected by the recruiting methods used and the effect these methods have on educational qualifications and relevant job experience.  Educational qualifications of at least some staff can enhance the understanding of other unit members of adolescent development and behavior and ways of working with teenage parents.

Program managers pointed out the comparable importance of having at least some staff with strong "street savvy" -- familiarity with the neighborhoods where clients live, some personal experience with the life problems they face, and awareness of the strategies that people growing up in poverty can develop to overcome the terrible problems they face or to avoid dealing productively with them.  Case managers with such backgrounds are sometimes best equipped to see through evasive justifications that some clients may offer for not participating in the program, to detect the underlying circumstances that contribute to such behavior and that must be overcome, and to have a realistic sense of what clients can do to help themselves.  Within the limits of personal safety, it is valuable to have case managers willing and able to circulate in the community where their clients live, making home visits when necessary and as time allows.

Case Managers Need to be Organized in their Work Habits

Case managers have to be both systematic -- keeping track of their own agenda of planned work -- and also responsive -- able to deal with interruptions and crises that are thrust upon them by the inevitably unexpected needs and demands of teenage clients.  Individuals who need the structure of a rigid schedule of appointments to maintain their composure and their forward progress on scheduled work are likely to fare poorly as case managers.

Organized work habits are particularly important because case managers must engage in extensive client contact and also keep case records up to date.  They must find time to write case notes and prepare or enter structured data into whatever automated client data system is used.  Effective time management is likely to maximize both time spent with clients and the completeness and accuracy of client records.

Efforts to Find Creative, Personally Tailored Solutions Are Particularly Valued

Case managers deal with individuals, and the activities toward which they guide clients will ideally reflect the attention they pay to individual clients' specific needs, the constraints in their lives, and their strengths and interests.  However, if service options are relatively narrow, case managers may rely on "cookbook" solutions such as courses to prepare for General Educational Development (GED) examinations, Adult Basic Education (ABE) classes for low-skilled high school dropouts, referral to the JTPA agency for high school graduates, or job club for those who resist school and training and say they want a job.  Relying routinely on certain activities in plan development is a particularly easy habit to fall into, because case managers are likely to develop relationships with certain service providers whom they trust and respect.

Finding creative approaches to individual clients' circumstances requires thinking specifically about each client's goals and what specific steps will help her toward that goal.  For example, a Camden case manager realized that for one client having a driver's license was going to be essential to attaining her goals, and incorporated driving lessons and taking the motor vehicle test into her self-sufficiency plan.  For a client interested in becoming a nurse, a case manager might help arrange visits to a local hospital to talk to nurses about their jobs.  A creative case manager might assemble small groups of clients in similar circumstances -- for example, clients who are deferred from full-time program activity requirements after child-birth, clients in active job search, or those on "hold" awaiting a training start -- for informal conversation, to maintain communications and motivation.

Being creative does not necessarily imply using unusual service providers or activities, but it does mean being very conscious of and attentive to the advantages and disadvantages of each activity for each individual client.  One program manager pointed out that it is important, for example, that case managers have a very tangible sense of what a training site looks like, the setting of a GED class, or the atmosphere created by the staff at a youth corps site.  Program managers can help develop contacts for the case management unit with local service providers, but creative case managers will make the time to become personally familiar with available program options by visiting program sites themselves.  Program managers can help in this respect, of course, by organizing visits to major service sites for groups of case managers.

WHAT CAN PROGRAM MANAGERS DO TO HELP CASE MANAGERS?

Case management in the Teenage Parent Demonstration involved a variety of specific staff tasks and skills.  Program managers had to organize their staffs and define staff roles for a broad range of staff functions: counseling individual clients, leading group intake sessions, conducting program workshops, maintaining client case records, entering data to automated case management systems, collecting and recording attendance data concerning both on-site and off-site program activities, issuing sanction warning notices and communicating with income maintenance workers to impose or end sanctions, developing child care resources and arranging child care for individual clients, developing contacts with community service providers and encouraging special service features of value to teenage parents, and a variety of special tasks to support the research data collection aspects of the demonstration.

It is important, therefore, to think of case management as the job of a case management team rather than just a set of case managers, and to focus on the question of how to help case managers be most effective in their direct relationships with clients.  The demonstration experience showed the importance of support and specialization, service development, and supervision.

Specialized Staff Roles Can Increase Case Manager Time with Clients and Access to Special Expertise

The kinds of case management staff specialization described earlier have several potential advantages.  They can increase the time that direct service staff spend with clients, promote the use of special expertise, and develop special case management resources.

Assigning tasks to specialized staff is valuable because it relieves case-managers of quasi-clerical tasks and allows them to spend a greater portion of their time in client contact.  For example, clerical staff can be used to check attendance of clients enrolled in local high schools and other education and training programs, for all case managers.  Clerical staff can be used to schedule clients for group activities, and to maintain contact with income maintenance staff to monitor the implementation and termination of sanctions requested by case managers.

In other instances, defining specialized staff roles allows greater expertise to be brought to bear on specific services to program participants.  Specialized staff were used to lead and coordinate program workshops, to varying degrees in the demonstration sites.  In the New Jersey programs, specialists were brought in from other agencies to conduct initial workshops on nutrition, grooming, family planning and parenting, drug abuse and AIDS, and other topics.  In all of the programs, specialist staff from other agencies conducted workshops for ongoing clients, on topics such as employment readiness and home and life management skills.  Case managers generally felt that specialized staff could be more effective in this role, particularly in workshops concerning topics requiring up-to-date knowledge in health, nutrition, and physiology.

Specialized staff may also be particularly suitable for developing an aspect of the program by focusing attention and energy on it in a way that general case managers might find more difficult.  This was particularly evident in the role of the Camden child care counselor, who played a very active role in identifying suitable family day care providers in the community, maintaining ongoing contact with providers, and encouraging them to communicate with program staff about problems they observed in the lives of the teenage parents or their children.

Program Management Can Help by Taking the Lead in Developing Suitable Services

To be effective at getting teenage parents into appropriate education, training, and employment, case managers must be aware of and have access to suitable services.  Program managers can play an important role in creating these "service-access" conditions.  Managers in the demonstration did this in two ways that provide a model for managers of teenage parent units under the JOBS program.

Most importantly, program managers actively promoted contacts between their case management units and other public and community agencies that offered services of potential use to teenage parents.  In effect, they "marketed" the Teenage Parent Demonstration program to other programs that could serve demonstration participants.  Representatives of other agencies -- such as those offering housing assistance, drug abuse treatment, summer job placement, special services for Hispanics, psychological counseling, tutoring, etc.  -- were invited to the demonstration offices.  In this way, case managers became more familiar with the specific services available in the community, and could broaden the options they considered as they developed client self-sufficiency plans.  In addition, such meetings developed personal contacts between case managers and other service providers; such contacts helped staff overcome bureaucratic problems that could arise as they sought to gain entry to a particular service for individual clients.

Program managers also found it important to try to affect the characteristics of services available to program participants.  Some pre-existing community services were not ideally suited to the needs of teenage parents.  For example, program managers found that community GED programs serving the public at large were more geared to adults' needs and did not always offer the supportive environment needed by teenage parents.  They found shortages of child care for infants and a lack of job training for the Spanish-speaking.  Issues such as these had to be addressed by program managers rather than by individual case managers.

Program managers worked with other service providers to get them to tailor their services to teenagers' needs, modifying entrance requirements, altering class schedules, expanding certain classes, reserving slots, and even providing special services for teenage parents at the demonstration site.  For example, one program worked out an arrangement to reserve child care slots in local centers for the infant children of teenage parents.  In two programs, local community college or school district officials agreed to run ABE and GED classes at the program offices.  A local Hispanic community center in one site began to offer a life skills workshop in Spanish.  A job training provider in another site, on an experimental basis, lowered the reading-skill entrance requirements for its office skills course and offered extra basic skills instruction in an attempt to increase the number of teenage parents who could qualify for training.  To overcome a shortage of job training for Hispanic clients with limited English proficiency, one program worked with the local JTPA agency to identify and fund some on-the-job training positions with Spanish- speaking employers.

Case Managers Need Strong Supervision

Case managers in the Teenage Parent Demonstration were in effect called upon to function in some respects as social workers, although their employment backgrounds and formal training in many instances had not fully prepared them for such roles.  They were expected to be effective in individual counseling, to develop and oversee suitable service plans for clients, and to maintain thorough documentation of casework.  Strong supervisors can help case managers meet this challenge.

Above all, supervisors can help case managers develop and apply sound casework methods.  Demonstration staff pointed out several issues of particular concern.  For example, case managers sometimes needed help defining the limits of appropriate intervention for individual clients.  Some clients' needs were so extreme that they could consume large portions of a case managers' time and draw case managers into attempts to deal with problems that required much greater clinical expertise or specialized resources than they disposed of themselves.  Case managers' supervisors needed to help their staff recognize the limits of their roles and the need either to call on other available resources or acknowledge their inability to solve some problems.

A second concern cited by demonstration staff is avoiding over-reliance on routine approaches to planning for client activities.  In addition to regular individual supervision, program managers tried other supervisory techniques to deal with such concerns.  In Camden, for example, they used case conferences, at which groups of case managers presented individual "problem cases" to their supervisors and other case managers; discussion of individual cases was found useful in identifying creative solutions and in identifying when limits had to be placed on case management intervention.

Strong supervision was also important to promote rigorous and consistent maintenance of case files.  This was particularly true because the programs all used automated case management systems designed to maintain data on client activities.  Because the systems were to generate data for research as well as purely operational purposes, they imposed broad data requirements that in some cases were not fully understood by case managers.  In addition, these systems defined data requirements in very structured form rather than in more flexible formats such as case narrative.  Although demonstration research needs are somewhat unusual, the problems of defining and implementing methods for maintaining structured data on participant activities are already clear in the states' implementation of the JOBS programs.  The demonstration experience made it clear that these problems can be minimized if the case management unit supervisor is thoroughly versed in data definitions, committed to the goal of maintaining consistent data on program participants, and systematic about conducting ongoing reviews of case managers' files and refresher training.

Program Managers Need to Understand, Monitor, and Control Caseloads

The single most important factor affecting case managers' ability to work effectively with clients is the size of their caseloads, but care must be taken to define a caseload measure that reasonably reflects workload.  In the demonstration, for example, the overall number of teenage parents assigned to case managers rose to an average of 100-115 in the New Jersey programs and to about 140 in Chicago.  However, teenage parents entered the demonstration gradually over time, so case managers gradually built up their caseloads over time.  As a result, this "gross" caseload size included clients in a variety of stages of participation: developing self-sufficiency plans, participating in workshops, or engaged in a major program activity (education, training, or employment).  This gross measure also included individuals who were not participating because they had been sanctioned, had gone off AFDC, or had been temporarily deferred from program requirements.⁽⁸⁾ 

Defining the acceptable limits of caseload size thus requires monitoring the number of cases that are no longer active, as well as judging how much case manager attention is required for clients in different stages of participation.

Demonstration managers monitored (with varying degrees of precision) the size of their staff's active caseloads rather than broader measures of total assigned caseload.  Managers may of course choose varying definitions of "active" to gauge the workload burden on case managers.  Program managers and staff, for example, voiced a range of views about whether sanctioned and deferred cases should be included in an "active caseload" measure.  On the one hand, many sanctioned and deferred clients have virtually no contact with case managers.  On the other hand, in some instances case managers must devote substantial time to such cases, trying to pressure and coax sanctioned clients back into participation or reevaluating deferrals.  One reasonable definition of "activity" for measuring case manager workload is to include clients who are developing self-sufficiency plans, participating in workshops, education, training or employment, sanctioned or pending sanction action, and to exclude only cases that are deferred or off AFDC.  By this measure, caseloads in the demonstration rose on average to roughly 60-65 in the New Jersey programs and 80-85 in Chicago.

The demonstration experience suggests that active caseloads around the maximum reached in Chicago stretch the capacities of case managers to perform the full range of functions described earlier.  Evaluation staff noted temporary staff morale problems and staff concerns about their inability to monitor their clients' status when caseloads rose to their peak in Chicago.  Many factors are likely to impinge on managers' ability to determine their staff's caseloads, of course.  However, the demonstration experience suggests the importance of monitoring not only gross caseload but a net active caseload measure, and using that information to make decisions about staff size and distribution of clients among case managers.

Program Managers Can Help to Maintain Staff Morale and Stability

Given the central role that case management staff are likely to play in a teenage parent program of the sort undertaken in the demonstration, it is important that program managers do what they can to maintain staff morale and stability as part of an overall strategy to promote staff effectiveness.  The stress of working with clients in crisis, with clients who at times resist help, in positions demanding great responsibility and initiative but with relatively little professional status, is a constant factor that program managers must recognize and counter.  They can do so by concerning themselves with staff recognition, professional development, and the nature of work assignments.

Case managers need to be recognized for their accomplishments and efforts, as do all of us.  Recognition can come in many forms.  Supervisors need to follow the most elementary rule of telling staff directly that they notice and appreciate a particular effort or a successful piece of progress with a particular client, or an approach to organizing case management work.  Formal occasions can be created in which case managers' efforts and accomplishments are recognized, such as staff awards and visits by top agency officials.  Occasions that highlight client successes, such as award lunches, can also contribute to staff recognition, for they give opportunities for individual staff to be publicly thanked and share in the success of their clients.  Given the research objectives of the demonstration, researchers periodically conducted conferences with case management staff to gather their perceptions and opinions about case management and program operations; similar consultations by program and policy officials, even in an ongoing program, can convey to line staff the importance of their professional experience.

The way that managers define case management staff's assignments can also affect morale.  Some demonstration staff found case manager participation in leading program workshops a desirable change of pace from constant casework, as long as it could be scheduled to be only a periodic burden on individual case managers.  Leading special events for clients -- outings to the theater, to museums, or even to go shopping outside familiar neighborhoods -- created some variety for case managers as well.  Some case managers were given -- or created for themselves -- areas of special responsibility or expertise which gave them special roles.  One case manager, for example, was particularly interested in the use of the automated case tracking system, and was treated as a local "consultant" by other case managers.  Some case managers became particularly aware of certain types of services, and could offer advice to others.  Site managers found it useful to encourage staff to develop special expertise and take pride in it.

Finally, it is important to find ways to develop the professional qualifications and skills of the case management staff.  Staff retreats were used in the Chicago program to provide calm settings for ongoing training, review of program policy and procedures, and respite from daily routine.  Training sessions demonstrate to staff the willingness of management to invest in them.  Case management supervisors need to follow up on training by giving staff feedback on their application of training -- to remind them of material and guidance they were given in training, and to help them identify situations in which they can sharpen their case management methods.

ENDNOTES

1.  Project Advance completed intake for the research sample in September 1989, and Teen Progress in March 1990.  All three programs, however, continued beyond those dates to enroll new participants (who will not be included in the formal impact analysis research), in order to maintain the program environment affecting the research sample.  In all three sites, the demonstration programs are being absorbed, under various strategies, into the regular JOBS program.

2.  The first paper dealt with identifying teenage AFDC parents and enrolling them in mandatory employment and training programs.  The second paper dealt with the design of program workshops for teenage parents.  See the project report list for complete citations of these two papers and other reports based on the Teenage Parent Demonstration.

3.  In Chicago, child care counseling was performed by case managers themselves.

4.  The design and content of these workshops are described in an earlier paper in this series.

5.  In Illinois, the sanction for such a recipient reduced the standard of need from $565 to $468, but the payment level, set below the standard of need, went from $268 to $212.

6.  Case managers adhered to demonstration policy by giving clients clear reminders of their obligation to report income to the income maintenance unit, but refrained from referring to the IM unit their unconfirmed hunches about possible unreported income.

7.  Demonstration procedures called for regular reminder notices to sanctioned teenage parents, but it does not appear that these procedures were systematically followed.  Sending out such notices would have been most feasible using the sites' automated case management systems, but using the systems for this purpose would have required maintaining accurate data on sanction statuses.  This was an area in which the demonstration staff had considerable difficulty maintaining accurate and properly structured data.

8.  Clients could be deferred and not required to participate for a brief period after the birth of a child or for reasons of illness or incapacity.