Methods: This study uses three ethnographic methods common to street-level organizational analysis: observation; interviewing; and archival research. Over a twelve-month period, the author spent 1100 hours observing the day-to-day routines of street-level workers in a community mental health organization, using field notes to track emerging patterns of practice. Semi-structured interviews were conducted with 53 case managers and agency administrators to understand the challenges workers faced. Interviews were also conducted with 11 state policymakers and stakeholders to provide high-level accounts of how mental health policy changed in Illinois between 2008 and 2011. Field notes, transcriptions, and archival documents were analyzed thematically and continuously using NVivo.
Results: This study finds that within a climate of fiscal austerity, new public management implemented in the Medicaid program came into direct conflict with three core missions of community mental health services: to enhance access, promote consumer-driven programming, and enable social integration. Access to services was curtailed by new austerity measures and routinized under new managerial arrangements. Consumers had less voice in shaping programming. And services that adhere to manual protocols and produce measurable outcomes replaced those that were harder to commoditize but that foster the goal of social integration. When workers sponsor consumer-driven programming and social activities, they did so at an increased cost to themselves. The tension between managerial reform and mission produced a work setting that is stressful and antagonistic, enhancing fatigue and turnover.
Conclusions and Implications: This study looked at how reform is actively remade through informal organizational processes of financial and managerial restructuring, attending to the street-level response to state-level policy. Its findings are especially important for community mental health research, which has traditionally lacked an organizational lens for understanding service implementation. This study provides organizational insight into the gap between macro-level policies and real-world practice, illuminating the ways in which service delivery in nonprofit settings is shaped by political, financial, and managerial reform under Medicaid.