Case Management

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Case Management

• Fiona Smith
• Senior SW, Alfred Psychiatry

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Session Outline

• History
• Models
• Recovery paradigm
• MH Services in Victoria
• Questions

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Case Management - History

• Case Management is described in the literature as
  a response to the consequences of
  deinstitutionalisation beginning in the US in
  the 1950s through to the 1980s.
• In response to the growing need for
  community-based services for people with
  psychiatric conditions the National Institute of
  MH established the Community Support Program

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History

• Case management was seen as the optimal way to
  co-ordinate the diversity of agencies clients
  would be referred to in the health and welfare
  sector.

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Models of Case Management

• Brokerage functions include
• Assessment
• Planning
• Linking to services
• Monitoring and
• Advocacy
• A limitation of this model is that the CM is
  expected to connect clients to required services
  without acting as clinicians.

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Models cont

• Clinical case Management. Services are provided
  in four broad areas
• Initial phase engagement, assessment, planning.
• Environmental interventions linkage with
  community resources, consultation with families
  and other caregivers, maintenance and expansion
  of social networks, collaboration with medial
  personnel, advocacy.

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Models cont

• Clinical Case Management .
• Patient Interventions individual psychotherapy,
  training in independent living skills,
  psychoeducation
• Patient environment interventions crisis
  intervention and monitoring.

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Models cont

• Assertive Community Treatment created in the
  1970s by Stein and Test. Originally called
  Program for Assertive Community Treatment. Basic
  tenets include
• Low client to staff ratios eg. 101 rather than
  301 or more.
• Services provided in the community clients own
  environment.

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Models

• ACT cont
• Caseloads shared across clinicians rather than
  individual caseloads
• 24 hour coverage
• Majority of services provided by the team (not
  brokered)
• Time unlimited service.
• The best research I can find supports this as the
  most effective model for MH service clients. Why?

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Strengths Perspective Why?

• Focus is on capacities and potentialities of
  service users.
• It concentrates on enabling clients to articulate
  and work towards their hopes for the future.
• According to Saleebey (1997) the strengths
  perspective formula is simple mobilise
  clients strengths (talent, knowledge,
  capacities) in the service of achieving their
  goals and visions and the clients will have a
  better quality of life on their terms.

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Strengths Perspective cont..

• The words empowerment, resilience and membership
  are important language within the strength
  perspective.
• Empowerment imperative requires clinicians help
  clients to become aware of the tensions and
  conflicts that oppress and limit them and help
  them free themselves from these restraints.
• Resilience reflects the skills, abilities,
  knowledge and insight that accumulate over time
  as people struggle to surmount adversity and meet
  challenges, and it is an ongoing and developing
  fund of energy and skill that can be used in
  current struggles.
• Membership reflects the fact that people need to
  be citizens responsible and valued members in a
  viable group or community. To be without
  membership is to be alienated and to be at risk
  of marginalization and oppression,

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Models cont

• Strengths based CM. Assumes that people with
  major psychiatric conditions should have equal
  membership within society. Rapp (1998)
  identifies four dimensions of equal membership
  equal access to resources, equal access to
  options and opportunities, equal power of
  individuals to choose and, people work and play
  in the same place others do.

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Models cont

• A number of papers report on literature searches
  of CM research. The most recent Rapp and Goscha
  (2004) suggests that the Brokerage model should
  be abandoned. This article highlights 10 Active
  Ingredients of Effective Case Management.

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Active Ingredients of Effective CM

• A combination of the strengths approach and ACT.
  (Rapp and Goscha, 2004)
• Case Managers deliver as much of the help or
  service as possible.
• Natural community resources are the primary
  partners.
• Work is in the community.
• Individual and team case management works.

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Active Ingredients cont

• Case Managers have primary responsibility for a
  persons services.
• Case Managers can be para professionals.
  Supervisors should be experienced professionals.
• Case loads should be small to allow for a
  relatively high frequency of contact.
• The service should be time-unlimited, if
  necessary.

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Active Ingredients cont

• People need access to familiar persons 24/7.
• Case Managers should foster choice.

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Therapeutic Alliance

• The alliance process is one that promotes
  partnerships with patients and facilitates self
  management through active engagement of the
  patient in the treatment process (I. Howgego et
  al, 2002).
• The working alliance is integral to both service
  delivery and clinical practice. It provides a
  focus on patient outcomes as opposed to systemic
  outcomes, as it is a collaborative process that
  centres on patient needs and goals versus
  clinician generated goals

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Recovery

• Its likely that the term recovery first
  appeared in the literature in the 1970s
  Manfred Bleuler (1978) It was advantageous to
  many of our participants to be suddenly or
  gradually left to depend on themselves. It
  usually turned out that the capacity of the
  patient to bring about his own recovery was
  greater that it had been estimated to be. At
  times patients would re-organise their lives in
  an eccentric or even pathological fashion yet,
  in such a way that they really fared better that
  under circumstances that would have been deemed
  appropriate by the doctors and the social
  workers.

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Recovery cont

• Most of the contemporary literature on recovery
  comes out of the US.
• Patricia Deegan (1988) Recovery is a process,
  a way of life, an attitude, and a way of
  approaching the days challenges. It is not a
  perfectly linear process.
• Ridgway (2001) a series of journeys that
  include a reawakening of hope after despair a
  movement to active participation in life from
  withdrawal, a shift to active engagement a active
  coping rather than passive adjustment a
  transformation from alienation to a sense of
  meaning and purpose.
• Recovery manual (1994) see quote

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Recovery cont

• Literature explores themes of hope empowerment
  and meaningful activity.
• A 2003 Australian study looked at the factors
  consumers identified as important to recovery
  determination to get better 74, finding their
  own way to mange their illness 64 and
  recognising the need to help themselves 54

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Mental Health Services in Victoria

• The Area Mental Health Service.
• Psychiatric Disability Rehabilitation and Support
  Services (PDRSS).
• Statewide Specialist Services.

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The Area MH Service

• Is geographically determined.
• Child and Adolescent MH Services ages 0 18.
• Adult Services ages 16 64.
• Aged Psychiatry Services ages 65 and over.

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Area MH Service Adult Community

• Primary Mental Health and Early Intervention
  Team
• Continuing Care Teams (CCT)
• Homeless Outreach Psychiatric Service (HOPS)
• Mobile Support and Treatment Service (MSTS)
• Community Care Unit (CCU)
• Dual Diagnosis Service
• Secure Extended Care

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Area MH Service Adult Acute

• CAT/Triage
• In Patient Units
• Consultation and Liaison