Case Management
Case Management
Case management for children and adolescents
Definition
Case management is a system for managing and delivering health care with the goal of improving the quality and continuity of care and decreasing health care costs. Case management includes coordinating all necessary medical and mental health care as well as any associated support services.
Purpose
Case management tries to enhance access to care and improve the continuity and efficiency of services. Depending on the specific setting and locale, case managers are responsible for a variety of tasks, ranging from linking clients to services to actually providing intensive clinical or rehabilitative services themselves. Other core functions include outreach to engage clients in services, assessing individual needs, arranging requisite support services (such as housing, benefit programs, job training), monitoring medication and use of services, and advocating for client rights and entitlements.
Case management is not a time-limited service, but is intended to be ongoing, providing clients whatever they need whenever they need it, for as long as necessary.
Historical background
Over the past 50 years, there have been fundamental changes in the system of mental health care in America. In the 1950s, mental health care for people with severe and persistent mental illnesses (like schizophrenia, bipolar disorder, severe depression, and schizoaffective disorder ) was provided almost exclusively by large public mental hospitals. Created as part of a reform movement, these state hospitals provided a wide range of basic life supports in addition to mental health treatment, including housing, meals, clothing, and laundry services, and varying degrees of social and vocational rehabilitation .
During the latter half of the same decade, the introduction of neuroleptic medication provided symptomatic management of seriously disabling psychoses. This breakthrough, and other subsequent reforms in mental health policy (including the introduction of Medicare and Medicaid in 1965 and the Supplemental Security Income [SSI] programin1974), provided incentives for policy makers to discharge patients to the community and transfer state mental health expenditures to the federal government.
These advances—coupled with new procedural safeguards for involuntary patients, court decisions establishing the right to treatment in the least restrictive setting, and changed philosophies of care—led to widespread deinstitutionalization . In 1955, there were 559,000 people in state hospitals; by 1980, that number had dropped to 132,000. According to the most recent data from the U.S. Center for Mental Health Services, although the number of mental health organizations providing 24-hour services (hospital inpatient and residential treatment) more than doubled in the United States from 1970 to 1998, the number of psychiatric beds provided by these organizations decreased by half.
As a result of deinstitutionalization policies, the number of patients discharged from hospitals has risen, and the average length of stay for newly admitted patients has decreased. An increasing number of patients are never admitted at all, but are diverted to a more complex and decentralized system of community-based care. Case management was designed to remedy the confusion created by multiple care providers in different settings, and to assure accessibility, continuity of care, and accountability for individuals with long-term disabling mental illnesses.
Models of case management
The two models of case management mentioned most often in the mental health literature are assertive community treatment (ACT) and intensive case management. A third model, clinical case management, refers to a program where the case manager assigned to a client also functions as their primary therapist.
Assertive community treatment
The ACT model originated in an inpatient research unit at Mendota State Hospital in Madison,
Wisconsin, in the late 1960s. The program’s architects, Arnold Marx, MD, Leonard Stein, MD, and Mary Ann Test, PhD, sought to create a “hospital without walls.” In this model, teams of 10–12 professionals— including case managers, a psychiatrist , nurses, social workers , and vocational specialists—are assigned ongoing responsibility 24 hours a day, 7 days a week, 365 days a year, for a caseload of approximately 10 clients with severe and persistent mental illnesses.
ACT uses multidisciplinary teams with low client-to-staff ratios, emphasizes assertive outreach, provides in-vivo services (in the client’s own setting), emphasizes assisting clients in managing their illness, assists with activities of daily living (ADL) skills, and emphasizes relationship building, emotional support, crisis intervention (as necessary), and an orientation, whenever possible, toward providing clients with services rather than linking them to other providers.
Compared to other psychosocial interventions the program has a remarkably strong evidence base. Twenty-five randomized controlled clinical trials have demonstrated that these programs reduce hospitalization, homelessness, and inappropriate hospitalization; increase housing stability; control psychiatric symptoms; and improve quality of life, especially among individuals who are high users of mental health services. The ACT model has been implemented in 33 states.
Intensive case management
Intensive case management practices are typically targeted to individuals with the greatest service needs, including individuals with a history of multiple hospi-talizations, people dually diagnosed with substance abuse problems, individuals with mental illness who have been involved with the criminal justice system, and individuals who are both homeless and severely mentally ill.
In 2000, Richard Schaedle and Irwin Epstein conducted a survey of 22 experts and found that although intensive case management shares many critical ingredients with ACT programs, its elements are not as clearly articulated. Another distinction between intensive case management and ACT appears to be that the latter relies more heavily on a team versus individual approach. In addition, intensive case managers are more likely to “broker” treatment and rehabilitation services rather than provide them directly. Finally, intensive case management programs are more likely to focus on client strengths, empowering clients to fully participate in all treatment decisions.
Clinical case management
A meta-analytic study comparing ACT and clinical case management found that although the generic approach resulted in increased hospital admissions, it significantly decreased the length of stay. This suggests that the overall impact of clinical case management is positive. Consistent with prior research, the study concluded that both ACT and high-quality clinical case management should be essential features of any mental health service system. One of the greatest tragedies of deinstitutionalization has been that most families often become de facto case managers for their family members, without any training or support.
Case management for children and adolescents
Case management is also used to coordinate care for children with serious emotional disturbances— diagnosed mental health problems that substantially disrupt a child’s ability to function socially, academically, and emotionally. Although not a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the handbook published by the American Psychiatric Association and used by mental health professionals to diagnose mental disorders, the term “serious emotional disturbance” is commonly used by states and the federal government to identify children with the greatest service needs. Although the limited research on case management for children and youth with serious emotional disturbances has been primarily focused on service use rather than clinical outcomes, there is growing evidence that case management is an effective intervention for this population.
Case management models used for children vary considerably. One model, called “wraparound,” helps families develop a plan to address the child’s individual needs across multiple life domains (home and school, for example). Research on the effectiveness of this model is still in an early stage. Another model, known as the children and youth intensive case management or expanded broker model, had been evaluated in two controlled studies. Findings suggest that this broker/advocacy model results in behavioral improvements and fewer days in hospital settings.
Conclusion
In recent years, many case management programs have expanded their teams to successfully utilize consumers as peer counselors and family members as outreach workers. The programs have also been adapted to serve older individuals with severe and persistent mental illnesses. While the ACT model offers the
KEY TERMS
Medicaid —A program jointly funded by state and federal governments that reimburses hospitals and physicians for the care of individuals who cannot pay for their own medical expenses. These individuals may be in low-income households or may have chronic disabilities.
Medicare —A federally funded health insurance program for individuals aged 65 and older, and certain categories of younger people with disabilities.
Meta-analysis —The statistical analysis of a large collection of analyses from individual studies for the purpose of integrating the findings.
Neuroleptic —Another name for the older antipsychotic medications, such as haloperidol (Haldol) and chlorpromazine (Thorazine).
Psychosis (plural: psychoses) —A severe state that is characterized by loss of contact with reality and deterioration in normal social functioning; examples are schizophrenia and paranoia. Psychosis is usually one feature of an overarching disorder, not a disorder in itself.
Supplemental Security Income —A federal program that provides cash to meet basic needs for food, shelter, and clothing for aged, blind, and disabled individuals who have little or no income.
strongest evidential base for its effectiveness, research into the clinical and service system outcomes of this and other models of case management is ongoing.
The effectiveness of any case management program depends upon the availability of high-quality treatment and support services in a given community, the structure and coordination of the service system, and on the ability of an individual or family to pay for care either through private insurance or (more often) through public benefit and entitlement programs. With recent policy directives from the Centers for Medicaid and Medicare Services (formerly the Health Care Financing Administration or HCFA) promoting the use of Medicaid funds for ACT, more states are funding case management through Medicaid. Although some policy makers express concern about costs, the savings realized from keeping patients out of jails, hospitals, and emergency rooms usually offsets the expense of these programs. Compared to traditional outpatient programs, case management also offers a level of care that is far more comprehensive and humane for a disabled population.
Resources
BOOKS
Cesta, Toni G., Hussein A. Tahan, and Lois F. Fink. The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice. 2nd ed. St. Louis: Mosby Publishing, 2002.
Mullahy, Catherine. The Case Manager’s Handbook. 3rd ed. Boston: Jones and Bartlett Publishers, 2004.
Nathan, Peter E., and Jack M. Gorman, eds. A Guide to Treatments that Work. 2nd ed. New York: Oxford University Press, 2002.
Roessler, Richard T., and Stanford E. Rubin, eds. Case Management and Rehabilitation Counseling: Procedures and Techniques. 4th ed. Austin, TX: PRO-ED, 2006.
Summers, Nancy. Fundamentals of Case Management Practice: Skills for the Human Services. 2nd ed. Belmont, CA: Wadsworth Publishing, 2005.
PERIODICALS
Angell, Beth, and Colleen Mahoney. “Reconceptualizing the Case Management Relationship in Intensive Treatment: A Study of Staff Perceptions and Experiences.” Adminstration and Policy in Mental Health and Mental Health Services Research 34.2 (Mar. 2007): 172–88.
Buck, Page Walker, and Leslie B. Alexander. “Neglected Voices: Consumers with Serious Mental Illness Speak About Intensive Case Management.” Adminstration and Policy in Mental Health and Mental Health Services Research 33.4 (July 2006): 470–81.
Coviello, Donna M., and others. “The Effectiveness of Outreach Case Management in Re-Enrolling Discharged Methadone Patients.” Drug and Alcohol Dependence 85.1 (Oct. 2006): 56–65.
Hsieh, Chang-Ming. “Using Client Satisfaction to Improve Case Management Services for the Elderly.” Research on Social Work Practice 16.6 (Nov. 2006): 605–12.
King, Robert. “Intensive Case Management: A Critical Re-Appraisal of the Scientific Evidence for Effectiveness.” Adminstration and Policy in Mental Health and Mental Health Services Research 33.5 (Sept. 2006): 529–35.
Rosenthal, David A., and others. “A Survey of Current Disability Management Practice: Emerging Trends and Implications for Certification.” Rehabilitation Counseling Bulletin 50.2 (Winter 2007): 76–86.
Sells, Dave, and others. “The Treatment Relationship in Peer-Based and Regular Case Management for Clients With Severe Mental Illness.” Psychiatric Services 57.8 (Aug. 2006): 1179–84.
OTHER
PACT Across America. National Alliance for the Mentally Ill. “Assertive Community Treatment (ACT)” (accessed April 7, 2002). <http://www.nami.org/about/pact.htm>.
Irene S. Levine, PhD
Ruth A. Wienclaw, PhD