A Discussion
on The Role
of Case Management within Community Mental Health
Abul Hussain (UK) December 2000
Community Mental Health and Social Work
This article is written
in two parts. Firstly, and in
the main, the discussion focuses on the advent of case management (CM) and
some of the theoretical issues associated with it.
This aims to explore some of the principles and models underpinning
the idea and how it is generally understood to be an effective system of
providing community mental health care. Secondly, the discussion looks
critically at the way in which case management approach is realised within
a local community mental health team in UK.
This aims to explore some of the professional dilemmas surrounding
the realities of case management.
The concept of CM as a
system of providing quality care for the mentally ill grew from the era of
de-institutionalisation during the 1960’s in the United States and
arrived in Britain in late 1980’s.
This was a period when large psychiatric hospitals were closed down
and people were treated in the community.
The community care move was a response to the growing concern and
social policy pressure over people becoming institutionalised and less
able to cope with normal life and dependant on the routine and narrow
confines of long stay institutions (Meredith, 1995).
With the lack of promotion of independence, choice and fulfilment,
the process of institutionalisation was understood to be of great
disadvantage for people with serious mental illness (SMI) and had
devastating consequences for families. Stein (1991) (cited in Stanford & Gouray, 1996: 32)
referred to long stay hospitals as “warehouse for human beings who have
been discarded by society”. At
the same time, many pressure groups heavily criticised the community care
move arguing that it was based more on economic reasons of shifting the
burden of care from the state to the community rather than humanitarian
grounds (Young, 1995). Soon
after the move, it was recognised that people who suffered from SMI were
also disadvantaged by secondary impairment, including difficulty with
interpersonal skills, dependence on family or institution and limited in
coping with skills such as budgeting, using public transport, shopping,
cooking etc. It was argued that, in order to provide a suitable service to
people with SMI and increasing long term success, services needed to
provide a comprehensive package, ideally delivered by one person namely a
case manager. This brought to
light that the role of case manager. CM included not only the general
management of symptoms and administration of medication but a whole range
of functions that impacted on social functioning (Sandford & Gournay,
1996). It was the earlier
works of Stein & Test (1980) who carried out studies on use of
psychosocial perspectives with discharged patients in transitional living
and reducing hospitalisation that paved the way for CM to become the
alternative to hospital treatment.
The basic idea of CM was
then meant to match and co-ordinate different services for psychiatric
patients living in the community in an attempt to promote fulfilment of
life (Challis, 1990) (cited in Lee et
al 1998). Michell & Reaghard (1996) (cited in Chan et
al, 2000) claimed that the purpose of CM was to serve as a patient
advocate by means of increasing co-ordination of services. Bergen (1992) (cited in Lee et
al, 1998) notes that CM is about choice and empowerment for people and
to achieve this case managers needed to be accessible in acting as
advocates and flexible in the management of resources.
Case management was taken as a process of extended community
services required to care for discharged psychiatric patients to help
overcome the barriers of fragmented, duplicated and uncoordinated services
(Giuliano & Poirier, 1991) (cited in Lee et
al, 1998). Marion et al (1997) contend that CM is about engaging people with SMI who
would otherwise be at risk of losing contact with services and is a
recognition that these people at are risk of being unable to cope with
factors either arising from mental health problems or social
circumstances. Case
management thus can be best understood by a summary offered by Lee et
al (1998:936): “….case management model therefore promotes a
seamless, integrated transition and ensures continuity of care once the
patients returns to the community”.
While case management was thought to be the cornerstone of quality
care with an emphasis on co-ordination of services, there has been little
consensus in the literature about what is actually being introduced under
the banner of CM . Many writers have noted how the absence of clear
understanding of CM has been an obstacle in moving forward with CM
practice (Lee et al, 1998; Chan et al, 2000). Lamb
(1992) notes that the lack of clarity is because the practice of CM has
expanded very rapidly in recent years in response to strong pressure to
find new methods of care delivery as well as saving cost of care.
According to Lamb, this generates a sense of eagerness to implement
CM even when the outcome needed to be achieved in the process of care is
not carefully considered. Thornicroft
(1991) (cited in Lee et al,
1998) on the other hand, argues that lack of consistency in meaning arises
as a result of the many ways in which the principles of CM can be
implemented. This point
implies that, it is the different functions and values case managers bring
to the process of CM that adds to the elusive nature of the definition.
Critiques of CM have also stated that the philosophic underpinnings
of CM has become somewhat unclear arguing that with its overemphasis on
resource co-ordination it has over time become a consumer-driven
initiative to help government contain high rising health care cost instead
of it being recovery focused (Rohde, 1997). The criticisms here will be
revisited in the latter part of the essay.
Despite this confusion, writers have put forward varying
interpretations of the CM model found in the literature.
The American Nurses
Association (1998) (cited in Lee et
al, 2000), along with Onyett (1992) and Bergen (1992), define the
process of CM to include various roles and responsibilities.
According to them, the CM process ranges from comprehensive
assessment and need identification, to design and implementation of care
packages, monitoring, evaluation or reassessment/review.
The case manager is also responsible for case closure and referral,
if necessary. It is believed
that these stages/phases are carried out to respond to individualised
needs of patients and their families thus assure service needs are met. This also includes case finding, goal setting and educating
(Robinson et al (1992) (cited in
Lee et al 1998) and so as a case
manager, the role is to develop and manage a plan of care for a specific
patient through patients engagement and co-ordination with community
resources. Meisler &
Midyette (1994) (cited in Lee et al
1998) adds to this by asserting that the CM role is not only to overall
manage, but also covers financial accountability in terms of evaluating
and monitoring costs and resources. In
this respect, Suber (1994) has it that being knowledgeable of the
resources available and possessing the ability to match resources and
patient needs are also important features of CM.
He further states that case managers need to have an ability to
communicate and work well with others in securing services to meet needs.
Case managers also have a proactive role to collaborate with
multi-disciplinary teams, they serve as patient liaison, offer clinical
support and expertise, co-ordinate consultation and encourage patients and
family participation in the process of care.
Underpinning most CM approaches or styles is a shared set of goals
(Marshall et al, 1997): (a)
maintain contact with patients; (b) reduce the frequency and duration of
hospital admission; and (c) improve clinical and social outcomes.
Case management is delivered in many different ways.
For the purpose of this essay I will discuss two models.
In the brokerage
model;
other wise known as the advocacy model, the emphasis is more on networking
and mobilising resources in an attempt to link patients to needed services
and supports in community agencies (Huxley, 1993).
This approach is known as the standard form of CM where the care
manger arranges a package of care for the patient and monitors its
implementation. The main
feature of this model is to increase the patients’ access to a variety
of community services, help patients with keeping appointments, organise
housing placements and making appropriate referrals to other agencies.
The focus then is less on meaningful relationship building with
patients or therapeutic relations skills but more on care co-ordination
and budgetary responsibilities. With this model, there is a recognition that people with SMI
are empowered when they have choices in the way their needs can be met.
Thus the emphasis is on protecting rights and working on behalf of the
patient for more, appropriate and better services (Huxley, 1993). There is an attempt to make sure that existing services meet
needs and provide care to agreed service specification. With this approach
there is also a lot more inter-agency joint working, making agency
agreements and valuing the contribution of other agencies in planning of
care (Coulshed, 1991).
On the other hand, in
the assertive outreach model or other wise known as ACT (Assertive
Community Treatment) there is a slightly different but a more proactive
and reach out type focus. Here
there is a shift in view in the way people with SMI are generally
understood and locus of care is arranged.
Unlike the brokerage model which has a more general reflection on
CM in government policy (Marshall, 1996), ACT model of assertive outreach
in UK has a more direct relationship with the Department of Health 1998
White Paper entitled ‘Modernising Mental Health Services: Safe, Sound
and Supportive’ (Ryan, 1999). The
inclusion of this approach at government level was a significant
reflection of government’s response to greater security of the public
and ‘risk’ following the high profile Christopher Clunis incident in
1992. The National Service Framework also uses the term assertive outreach
and is now a central feature of mental health policy. In Onyett’s (1992)
definition an emphasis is placed on the assertive outreach model to both
co-ordinate and individualise care, which is either delivered through one
individual worker or a team as a whole share responsibility.
With the ACT model there is a recognition that there needs to be an
aggressive response to mental health problems in an attempt to actively
seek out people with SMI who are in need of services and to prevent these
people from dropping out of services (Sandford & Gournay, 1996). This
notion of rapid response to mental health care and patient engagement is
perhaps better reflected in government’s own definition (Department of
Health, 1998) (cited in Ryan, 1999:1): ‘Assertive outreach is an active
approach to treatment and care for those who are at risk of being
readmitted to psychiatric hospital. Such
people are typically hard to engage because of their negative experiences
of statutory services. Assertive outreach ensures that treatment is
delivered early enough to prevent the patients’ condition from worsening
at their own territory in the community’.
On a close look at the
model a number of themes are found. These
include, engaging high-risk patients with severe and complex needs who are
resistant to contacting services; avoiding unnecessary hospital admission
and therefore assistance is given for patients to stay at home in their
community. Direct contacts are made where and whenever (out-of-hour) that
is best suitable for the patient and thereby increasing the chance of
engagement with the service; and focusing on optimising the rehabilitation
potential of the patient by delivering multi-disciplinary intervention
that enhance psychosocial functioning of the patient. Allness and Knoedler (1998) (cited in Ryan, 1999) bring to
our notice some of the psychosocial aims of the ACT. These include, helping with motivation to preserve and remain
involved in life; optimising the home environment; attend appointments
with patients; developing coping skills to meet the demands of community
living; assisting with housing and practical needs; and cognitive
behavioural interventions to increase medication compliance and symptoms
management. With the ACT
model it is generally believed that because the lack of motivation and
social withdrawal are frequent aspects of most people with SMI, this
non-office based and intensive team approach involvement is needed in the
engagement and promotion of peoples’ psycho-social functioning and thus
improve quality of life.
In practice the CM idea
is imposed on, particularly the local community mental health team (CMHT)
I work for in Tower Hamlets, in the form of the care programme approach
(CPA) and care management model. While
there are no clear reasons as to why the CM model does not appear as a
distinct model of practice, the workers unofficially execute aspects of
both the brokerage and ACT model within the conventional framework.
However, the workers do this with great restraint given the climate
in which CMHT’s are expected to operate.
In my experience there are many socio-political factors, which
inhibit the CM process and add to the dubious nature of community care
work. These include, workers
over burdened with case loads; lack of funding and specialist service
provision; problems of collaboration; and the inevitable discrimination
generated through structural ignorance towards multiculturalism.
The theme of assessment, service provisions, care co-ordination and
in general the notion of independence and choice often talked about in the
CM function, has become a contentious activity (Marshall, 1996).
Given the high number of caseloads the individual worker has to
deal with and the bureaucratic mushrooming of paperwork, it becomes
difficult to monitor and review ‘quality’ of care provided.
The tasks of taking note of micro but significant features of, say
patients’ limitations in coping or complex interpersonal difficulties,
thus become time constrained and so arduous to fulfil.
As a result the focus of care shifts from ‘needs’ or
‘change’ to a one of organisational responsibility, accountability and
frequency (Adams et al, 1998). Therefore
does the process of standardisation mean less individualisation?
When workers are stressed out with having to make some four to five
home visits a day and then write up the outcome upon their return and then
possibly explore community resources to meet newly identified need, is
there real time to plan or think of quality?
The lack of adequate
funding and appropriate services poses another threat to effective
management of integrated transition and continuity of care.
Often it is found that once a need is identified workers have to
struggle with the scarcity of adequate resources to meet complex and
enduring needs in an anti-discriminatory and empowering manner (Adams et
al, 1998; MIND 1999). Are
individuals then being made to fit into the services, rather than the
other way round? When resources become scarce does the distribution of
services become conditional? Does the notion of ‘tailoring’ a package
of care then become a rhetoric than a reality?
The idea of collaboration, or networking and mobilising resources
in the language of the brokerage model, is another factor towards what
Trevillion (1996(a): 103) phrases ‘the reconciling what is ultimately
the irreconcilable’. The
common socio-professional climate of conflicting duties and unclear
boundaries including differences in values, language, priority and
perception of the problem are factors, which make the process of
co-ordination and developing and managing a plan of care difficult to
implement (Banks, 1995; Hugman & Smith, 1995).
In Trevillion’s (1996(b)) terms among the different community
organisation there is the lack of ‘mutual understanding’ that also
adds to the problem. The
organisational conflicts often prevents effective partnership work thus
the process disempowers patients in engaging with the wider spectrum of
community services and gain control through a means that meets their needs
in a creative and multi-inclusive manner (MIND, 1999). On the other hand, in reconciliation of this problem there
has been a move towards uniformity of procedures to meet needs of all
client group but in doing so they have lost some of the unique features
needed to meet individual needs (Trevillion, (1996(a)). What happened to
the promise of CM being a means to match resources with patient needs to
promote empowerment through choice? Similarly,
with assessments, it is also found that with the rapid growth in
multi-ethnic societies, my team and mental health services in general are
failing to adequately understand the health and care needs among
patients’ who come from non-western background (Robinson, 1996; MIND,
1999). As a result patient from these communities are discriminated
against and systematically made to keep a distance from receiving mental
health support that is culturally incompetent (Kareem & Littlewood,
1992; Fernando, 1995, Hussain, 2000).
In these instances, how is CM to improve the clinical and social
outcome of patients’ from different communities who are existentially a
part of the wider societal and medical oppression and may be resistant
towards receiving help? Does
the goal of engagement then become exclusive to certain groups?
While the above factors
may not hinder some of the key goals of CM, which is to maintain patient
contact with services and develop meaningful relationships to prevent
relapse and hospitalisation, other queries come to mind. Given the overall climate of resource scarcity and the
urgency of appropriately reintegrating and stabilising patients into the
community, can the process of CM within a CMHT capacity intervene
appropriately and at an opportune time to produce maximum benefit, which
lead to a holistic improvement in human functioning?
It is the wider context in which mental health care operates that
need to be considered if the ambitious ideas of CM is to be meaningfully
understood and implemented as alternative to mental hospital.
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About the author:
Abul Hussain (UK) © December 2000
abulh@dsl.pipex.com
Community Mental Health and Social Work
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