Caseload Management: Choosing Suitable Clients in a Community Health Clinic Agency

Discretion in decision-making is a well-known but poorly understood phenomenon. This paper examines the contextual features influencing the exercise of discretion in screening and assigning clients in a community mental health agency. I develop a caseload management model to analyze the interplay between organizational circumstances, determinations of client suitability, and decision-making outcomes. This study finds: (1) Decisions are based on judgments of client suitability. (2) These assessments use stereotyped characterizations to typify clients as suitable. (3) The typifications serve as a means of limiting the allocations of scarce treatment resources. I describe the related common-sense reasoning and decision-making practices which I observed. The community mental health care system has experienced a rapid expansion in the United States since the 1950s. Federal legislation in the 1960s provided a major impetus for this growth through subsidies for the construction and staffing of comprehensive community mental health centers. Through 1975, over 600 of these agencies had received federal funds and been designated to provide services to community residents in local catchment areas. There was also a parallel proliferation of community care agencies funded privately and by local government. Although clientele varies from agency to agency, the community mental health system as a whole must deal with two distinct client populations, each with its own needs and demands: (1) Chronic mental patients have been discharged in large numbers from state mental hospitals. Although the philosophy of community care as more humane and effective (Bellak, 1963) provided an ideological justification for deinstitutionalization, Scull (1977) argues that fiscal considerations were most important. Bassuk and Gerson (1978) note that patients released from state-funded mental hospitals can be shifted onto federally-funded support programs. (2) A new class of clients has been created through "net widening" (Van Dusen, 1981), expanding the definition of those in need of mental health care. These clients are generally less seriously disturbed, seeking relief from self-perceived personal problems or referred by official agents of the criminal justice and social welfare systems. The major problem currently facing the U.S. community mental health system is its failure to care for the gravely disabled, whose release from mental hospitals was predicated on continuing community care (Chu and Trotter, 1974; Kirk and Thierren, 1975). The cost of treatment has been subsidized by public funds to lower barriers to utilization, but this has not alleviated underutilization by the chronically ill population (Buck and Hirschman, 1980). Increased utilization by the less disabled population has absorbed the available supply of services without satiating the demand. The consequence is that the two client populations must compete for a limited supply of services; not all who seek treatment are able to obtain it. When the demand for an agency's services exceeds its resources, several responses are possible. It can make clients wait, or try to reduce demand, for example by negotiating with referral sources (Lang, 1981) or discouraging self-referrals (Gereboff, 1981). Alternatively, the agency