Case Management

1. Case Management Fiona Smith Senior SW, Alfred Psychiatry

2. Session Outline • History • Models • Recovery paradigm • MH Services in Victoria • Questions

3. Case Management - History • Case Management is described in the literature as a response to the consequences of deinstitutionalisation – beginning in the US in the 1950’s through to the 1980’s. • 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

4. 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.

5. 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.

6. 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.

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

8. Models cont… • Assertive Community Treatment – created in the 1970’s by Stein and Test. Originally called Program for Assertive Community Treatment. Basic tenets include: • Low client to staff ratios eg. 10:1 rather than 30:1 or more. • Services provided in the community – clients’ own environment.

9. 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?

10. 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’.

11. 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,

12. 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.

13. 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’.

14. 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.

15. Active Ingredients cont… • Case Managers have primary responsibility for a person’s 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.

16. Active Ingredients cont… • People need access to familiar persons 24/7. • Case Managers should foster choice.

17. 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”

18. Recovery • It’s likely that the term ‘recovery’ first appeared in the literature in the 1970’s – 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.’

19. 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 day’s challenges. It is not a perfectly linear process.’ • Ridgway (2001) – ‘… a series of journey’s 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

20. 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%

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

22. 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.

23. 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

24. Area MH Service – Adult Acute • CAT/Triage • In Patient Units • Consultation and Liaison