Case management is a professional practice currently implemented in France. It is addressed to elderly persons living in community whose social and medical situation is regarded as particularly complex. Case managers have to assess needs in order to plan and coordinate necessary services. They assure a long term intensive follow-up. Furthermore, they promote the integration of the health care system by identifying malfunctions on their territories, as expected by the “MAIA” model. The emergence of this new practice raises specific ethical challenges, because of case managers’ two missions, patient-centered and system-centered. The aim of this study is to propose a coherent framework for case management ethics, based upon an analysis of case managers’ values, attitudes and practices. This study is based on one qualitative inquiry, allowing a continuous dialogue between observed facts and ethical theories, according to the approach of integrated empirical ethics. Our data collection contains in-depth interviews with case managers, semi-standardized interviews with some of their “pilots”, focus groups and a written questionnaire. This French survey is completed with a “case study” in order to assess the consequences of different organizational contexts on professionals’ ethics. We have therefore performed focus groups in Canada (Sherbrooke) and Germany (Greifswald). Our data analysis leads us to identify the individualization of relationships as a core value of case management. The commitment of the professionals in a care relationship helps them to face the dilemma between client’s protection and client’s empowerment. They rely on this relationship to negotiate with the client a care project that makes sense in terms of his/her life story. However, this individualized relationship can conflict with the standardization, necessary for the equity and the effectiveness of the health care system. Hence, the development of a professional ethics for case managers implies handling both, their clinical client-centered role and their systemic role. The balance between these two missions has to be elaborated in terms of an organizational ethics, consistent with the ethics of the professionals and guaranteeing the respect of the clients’ right, specific to each health care system.
Values, attitudes and practices of case managers in gerontology : a professional ethics under construction