Intake Policy as a Community Organization Tool Solomon E. Feldman, Ph.D. Marshall Jacobson, M.A.

ABSTRACT: The intake policy of an agency is presented as an integral part of an agency's impact upon community organization and hence as crucial in the effectiveness and efficiency with which it carries out the mission of total community care. Three possible models for intake policy are elaborated: direct service, extended community management, and extensive community development. Under the latter model the judicious development, communication, and implementation of intake policy are evaluated in terms of impact in creating productive community ferment and thus fostering a community-wide examination of and involvement in the development of adequate services.

In many instances the policies regulating the flow of cases handled by an agency are unevaluated products of the Topsy-like growth and synthesis of professional zeal, the unique competencies and preferences of the staff, momentary expediencies, and tradition. Often it is assumed that intake policy procedures have only one purpose, the statement of who is eligible for service and the specification of the available services. There is minimal articulation of potential effects of the development, communication, and implementation of an agency's intake policy upon community organization (CO). By CO in this context we are referring to an interdependent involvement of local, lay, and professional persons in the planning, execution, and maintenance of comprehensive services providing continuity of care to those needing it. It is the major thesis of this paper that the pattern of CO will have both short- and long-term consequences upon the realization of an agency's goals and that the impact of intake policy upon CO must be weighed heavily if an agency hopes to maximize its potential ameliorative and preventive effectiveness. Among the several ways in which a community and agency may relate, three models can be identified which reflect basic, but not mutually exclusive, goals that may be entertained with regard to community development. The Dr. Feldman is an Associate Professor in the Psychology Department of Northern Illinois University, DeKalb, Ill., and serves as a Psychological Consultant to the H. Douglas Singer Zone Center, Rockford, Ill. Mr. Jacobson is a social worker who serves as Assistant Executive Director, Jewish Federation and Council of Greater Kansas City. Community Mental Health Journal, Vol. 5 (1), 1969

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models to be elaborated upon are the direct service, extended community management, and extensive community development models. DIRECT SERVICE MODEL This model has a minimum of identifiable CO goals. Very simply, the basic consideration is that the agency has a mission to provide direct services. The agency's intake policy is not developed to initiate any change in the community's social structure as it bears upon mutual problems. Under this model, community participation is narrow and primarily limited to the members of the board of directors who may aid in developing general agency policy. The agency's accountability to the public for financial support requires it to maintain professional standards congruent with an aura of efficient output of services to the entire community. Toward this end, the agency's program often is communicated to the community as being broad and extensive. Since the lay community may be led to believe that total programming is present and that most, if not all, needs are being met, a "comfortable community" is a natural consequence. An "open door" intake policy is frequently belied by the fact that for many clients the door is a revolving one. Obviously there will be instances of individual cases which fall outside the province of the actual resources of the agency. The handling, or rather lack of handling, of these cases is a potential source of community discomfort. However, an agency will typically adopt coping mechanisms that stave off full feedback of its limitations to the community. As with many defensive strategies, they will be minimally articulated by their users. Among the various techniques employed are secondrate substitutes, going through the motions of remediation, selective use of the waiting-list, passive resistance via such ploys as impractical scheduling of working clients, and too rapid institutionalization. While direct refusal of service may be an infrequently used technique, it is more likely to be employed for those cases who, because of socioeconomic status, are least likely to be effective in fermenting community discomfort. Thus the delusion of all-encompassing service may persist, and the anxiety required to initiate change in the community care apparatus is slow in developing. The agency, to protect its image, will be reluctant to initiate i ~ L .~. r . . .t~V~JLLJL.LLt,,L-change lIl ........ lll~[i:tlZ{~ 1. . . policy . . 1. as a ~,u r,-, ~A_~ L v u i . ~_^ " l L ~ : agency c a r l fear tJ,L^~ ..... nity will not only become concerned with the situational deficiencies pinpointed by intake change, but will also become angry at the agency. This anger is justified in the sense that the agency was at least partly responsible for some of the inappropriate assumptions developed in the community. The most likely and comfortable vehicle for change, under this model, is through the role of service giver. The agency may attempt to initiate and publicize new services which are typically closely related to the ones that are presently given. It is unlikely that this agency will assume the lead in such things as promoting treatment alternatives and supports within the

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community or in initiating major innovations. Any participation in CO will be an afterthought which is seen as adjunctive to "major goals," rather than as an integral part of the agency's operative plan. As such it is hardly likely that the agency will be effective in fostering the community mobilization necessary for the development of a truly encompassing community care apparatus. EXTENDED COMMUNITY MANAGEMENT MODEL This model has developed from the recognition of the critical shortage of mental health professionals and the growing understanding that case management can be extended to other types of professionals within the community, e.g., family physicians, educators, and others. The intake policy is clearly structured to include the mandate that referring professionals in the community have a sustained involvement in the diagnostic and treatment processes. The primary, albeit short-range, CO goal that evolves from this intake policy is a focus upon change within the professional group of the community. The implicit assumption of this model is that change within the professional group will filter through the entire community and thus, in the long run, will foster the development of an encompassing and viable community care apparatus. With this model the agency and collaborating professionals more readily can see themselves in a joint undertaking. Consequently agencies, having been provided sympathetic spokesmen, are less likely to sweep agency role deficiencies under the rug of professional isolationism. Conversely, the cooperating professionals are more likely to recognize community care shortcomings, be disturbed by them, and engage in constructive and cooperative attempts to implement change. It should be noted that preceding this Valhalla of cooperation between agency and professionals there is a strong tendency for discord to occur regarding the agency's demands of case specific involvement by the referring professionals. In this "finger pointing" stage, the professionals are defensive about their own role and responsibility and often accuse the agency of negating its responsibility. Not until this "finger pointing" is openly identified and dealt with can the agency and professional move toward truly cooperative efforts. One of the major problems in this model, however, is the secondary involvement of the social and political leadership outside the professional group. This is particularly an issue since it is the lay community which must bear the financial responsibility for any change in the community's care apparatus. Depending upon the ability of the professional to communicate as an individual or through a professional organization, this model may be a wise expedient as a transitional method of CO. However, its efficiency depends heavily on the continued motivation, the range of entries to the community, and the communication skills of the professionals involved.

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Finally, it runs the danger of encountering resistance within the community to the extent that this mode of attempting to institute change runs counter to the normal channels of developing community sanctions. EXTENSIVE COMMUNITY DEVELOPMENT MODEL The agency which utilizes the extensive community development model is found at the polar end of the spectrum when contrasted to the direct service agency. While the former model includes a direct service program, this program is conceived as being secondary to the efforts of the agency to foster an integration of multiple treatment alternatives within the community. The realization that any one agency cannot, need not, and should not provide every needed service is the motivating force that will gear the agency to the development, communication, and implementation of an intake policy that will catalyze the process of CO which, it is hoped, eventually will produce a comprehensive community care system. In addition to the possibility of sampling the prevalence of untreated cases within the community, careful study of the flow rates within an established agency and from the community to other agencies, e.g. state hospitals, provides ample evidence that the agency cannot provide all the ameliorative, no less preventative, services to all the population groups within the community. Even without consideration of such things as flow rates, there are other reasons that argue against a sole emphasis upon a direct service mission. There are many resources within the community, e.g. schools, general practitioners, courts, and even the home, which potentially can be used more efficiently and effectively in changing symptomatic behavior than can a doctor-patient model of treatment. Although the direct service and extended community management models do not demand a commitment to a "medical model of treatment," the extensive community management model would seem to foster more flexible treatment approaches. Similarly, the conception of disordered behavior as occurring within a social context would be brought into focus more clearly. Concentrating on an established agency, the realization that the services offered fall short of fulfilling the directive given or assumed by the agency, that many community members are either going untreated or are being extruded from the community, should make competent professions feel uncomfortable in their role as service givers. This discomfort in turn can motivate the agency to refocus its strategy and begin thinking through the use of intake policies in the development of a program that approaches total community service. Any new policy that is to be instrumental in effecting community change must clearly delineate and communicate to the client population that will be served by the agency the services that will be provided this population. This is contrasted to individual decision-making and communication within the context of the planning of services for a specific client. It is suggested that

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the most effective vehicle for CO is a clear restriction on intake, a restriction in keeping with the actual effective treatment alternatives available to the agency, rather than a blanket offer of help. Following a decision by the agency's staff and its board of directors that there will be restrictions upon populations serviced and services offered, the specific limitations must be set. Study of the agency's current services, the services provided by other agencies in the community, community needs, and who would best profit from various services, provide the grist for these deliberations. Except for consideration of other community agencies and total community needs, what has been said so far minimally differentiates the strategies of an agency committed to an extensive community development model from the strategies of a restrictive agency which has no CO goals. It is in the communication and implementation of intake policy that differences are most evident. In the extensive community development model, the restrictive intake policy is explicitly and loudly communicated to other agencies, adjunctive professionals, and the lay public. If the service mandate prior to the change was conceived as very broad, the initial negative reactions will include the complaint that these restrictions will tend to increase the number of untreated cases and the number of exclusions from the community. Anger and hostility toward the agency will be a common bond between the general lay community and other agencies and professionals within the community who are no longer able to find easy access to referral within the community. Most typically, attempts at CO prior to actual implementation of policy, where tlle change is clearly set in motion but is programmed in steps, does little to mitigate this anger. This attempt may, in fact, increase hostility as pressures upon the agency to alter the proposed policy changes are rebuffed. To proceed toward its goal of CO, agency personnel must develop thick but not insensitive hides. It must be borne in mind constantly that the anger and hostility directed at the agency stems from the frustration that can be welded into an agent of community change. As discomfort was important in changing the service perspective of the agency staff, so too the agency can use this discomfort in effecting change in the network of services within the community. The staff of the agency must prepare themselves for frequent tests of commitment to follow through on its new intake policy. "Inappropriate" cases must be rejected with an empathetic understanding of the resultant frustration. Interagency collaboration to find temporizing strategies to cope with the consequent gaps in the community care apparatus have to be tempered by the necessity for continued community ferment until effective CO has evolved. By standing firm within the context of its new program, the agency will demonstrate the kind of services it is giving and will at the same time highlight the areas where services are not being offered and should be. Although many of these gaps were present before the change in intake policy,

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they are now brought into bold relief, e.g. unwed mothers, learning disabilities, family crisis. Essential to the success of this attempt at CO is that the direct service offered by the agency be of the highest quality and provide the promised services to the client groups specified by intake policy. The agency should be prepared to meet with other professionals and various lay individuals in the community to explain the new program in detail. The "finger pointing" must be redirected to a problem-solving orientation. The service gaps within the community must be identified and alternative ways of filling these gaps, whether by the development of new agencies or the refocusing of the service of existing agencies in the community, must be listed. To effect lasting CO and because it still remains the "source" of frustration, the agency must adopt a consultive role. It cannot dictate goals or means; the community must have final say on the priority of needs and the ways in which these are to be met. The accusation that this strategy is a manipulative attempt by one group of individuals within the community cannot be rejected. However, it must be assumed that the justification is a competent appraisal of community needs and resources to meet the needs, if appropriate community mobilization takes place. Additionally, while one group may provide the prod, the mobilized community will select from the alternatives available and create new alternatives. In keeping with the legitimate use of community ferment, one could even suggest the creation and withdrawal of new services or the treatment of new populations, with the hope that the community can find ways to make permanent the best of these new approaches. Before long the agency should find a legitimate place in the community "power" structure so that more direct approaches are possible. While the community gains an extensive care system, the agency gains a realistic mandate, broad community sanctions for its operations, and more direct access to feedback about its effectiveness. Certainly these conditions are important not only for professional satisfaction but in implementing treatment strategies such as limited hospitalization, continued community linkage, extended aftercare, environmental manipulation, and the teaching of the techniques of modifying disturbed behavior to various agents and members of the community. While much of what has been said has referred to an established agency, many of the points can be applied readily in the planning of an agency n e w to the community. Countering the seductive temptation of bold promises of unlimited service, intake policy can and should be clearly delineated and communicated in terms of the goal of mobilizing CO to maximize the range and effectiveness of treatment alternatives. It is also possible that with creative planning a new agency may forego the luxury of being the target of community hostility and find other methods to mobilize community action. With either an established or a new agency, proper consideration and implementation of intake policies can only lead to greater satisfaction in the agency and the community.