Hierarchical logistic regression was used with the results of a factorial vignette survey of a national sample of case managers for the disabled elderly in Medicaid home- and community-based services waiver programs. The effects of client, case manager, and agency factors on case managers' out-of-home placement decisions in response to hypothetical case studies were estimated. Results show that client preferences, workload, and division of labor affect the probability that a case manager will recommend an out-of-home placement, controlling for client's physical and cognitive disability and the available resources. Significant variation among individuals was found. Implications of the findings are discussed.