"Getting on the program meant I could finally get a mammogram. I had always put that sucker off because they want $55 up front. With the program I got the mammogram and a wellness check. I even got a physical. And it was more than all that. It was the way I stopped worrying all the time that somebody in the family was going to get sick."

- Carolyn Heart, CHP member

By the end of the program's first year, the number of members begins to drop.

CHP appears to be going backwards, and problems with enrollment are compounded by strains in case management. The first case manager has left. The operations group wants more aggressive case management, frequent follow-ups over the phone, and more frequent face-to-face meetings between the case manager and CHP members.

The new case manager tells the operations group that she will stress to CHP members the importance of transitioning to permanent health care by finding a job that provides that benefit.

The membership of the operations group changes in the second year as Bruce Greenberg, the new CEO of Partners, joins the group: "When I first saw CHP, I thought, 'It seems like a socialist program, and I hate things like that. Nearly 40% of the budget was going to administration and case management. That's a terrible cost-benefit situation.

"The operations group felt case management was such a big part of the program, and nobody wanted to question it, but I lobbied hard against it. I thought that it was intrusive. Nobody wants some white person in an office telling them how to live their life. And when the case manager would talk about making 40 phone calls to a member to set up an appointment and never getting a return call, I thought, 'Why are you calling back so much? If they don't want what you have to offer, fine. I also questioned the wisdom of limiting the definition of 'community' or neighborhood to a specific geographic location."

Janine Chambers: "Some of the confusion at Turning Point came out of the perception that the goal of case management was to get people into jobs. But that's way too huge. We want goals like helping people know how to talk to a placement officer, and we didn't define that clearly enough. We had not thought through what case management should do - to help people clarify, to help them take inventory of their assets, to help them with their own capacities."

Conrad Damian: "The thing that troubled me was the split between trying to provide health care and trying to tell people how to live. It would have been better if they'd concentrated on health care.

"When they started doing case management, I think they were surprised at how many people didn't necessarily want to live like them, to move into the middle class; and they might have been surprised at how many people didn't have the skills to make that move.

Pat Hancock, Supervisor at Turning Point: "When the program first started, I thought that they wanted us to say, 'Get a job.' But they targeted the poorest neighborhood in the city where a lot of people don't have the necessary skills to go out and get a job with benefits.

"And the neighborhood was skeptical because of the perception that this was some kind of government freebie that had strings attached. So even though CHP pushed hard in the neighborhood, some people that were approached didn't value what was being offered. They felt that if the program was good, why was it difficult for us to get people to sign up. Plus the forms that are used are so detailed and there's too many of them, especially the one on health status and needs assessment. One of the questions asks, 'Is it important to you to go on vacations?' Another one asks 'Is it important to join clubs?' These are people living in the southeast neighborhood. They're too busy trying to survive to worry about taking vacations and joining clubs.

"If members go into case management and set unrealistic goals, like getting a job with insurance, they're set up for failure, and they don't want to fail. They don't like the way that feels. So they avoid the case manager if they can, and the first case manager we had felt overwhelmed."

Janine Chambers: "In a community there are resources that people are not aware of, and as you become aware of what's out there, things become manageable. It's the case manager's job to open doors, to turn on light bulbs. The case manager is looking to establish relationships, to discover what links the member already has in the community."