Contradictions in case management: client-centered theory and directive practice with frail elderly

New long-term care legislation and managed care legitimate case management for gatekeeping and advocacy for frail elderly. Qualitative in-depth interviews with case managers who are social workers and nurses were used to address the question: To what extent is client-centered theory reflected in case management practice? Differences between reported client-centered theory and directive practice were identified by five themes: (a) client wishes versus system constraints; (b) the paradox of working to keep clients home versus the perceived inevitability of nursing home placement; (c) client centeredness versus the case manager's care plan; (d) client self-determination versus strategies of persuasion; (e) informing the client about case management versus the reality of practice. Ethical implications, competing demands, and environmental constraints are discussed. Suggestions are made to better integrate client-centered theory with directive practice.