Case ManagementCase Management

Fiona SmithFiona Smith

Senior SW, Alfred PsychiatrySenior SW, Alfred Psychiatry

Session OutlineSession Outline

HistoryHistory ModelsModels Recovery paradigm Recovery paradigm MH Services in VictoriaMH Services in Victoria QuestionsQuestions

Case Management - HistoryCase Management - History Case Management is described in the Case Management is described in the

literature as a response to the literature as a response to the consequences of deinstitutionalisation – consequences of deinstitutionalisation – beginning in the US in the 1950’s through beginning in the US in the 1950’s through to the 1980’s. to the 1980’s.

In response to the growing need for In response to the growing need for community-based services for people community-based services for people with psychiatric conditions the National with psychiatric conditions the National Institute of MH established the Institute of MH established the Community Support ProgramCommunity Support Program

HistoryHistory

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

Models of Case ManagementModels of Case Management

Brokerage – functions include:Brokerage – functions include:

1.1. AssessmentAssessment

2.2. PlanningPlanning

3.3. Linking to servicesLinking to services

4.4. Monitoring andMonitoring and

5.5. AdvocacyAdvocacy A limitation of this model is that the CM A limitation of this model is that the CM

is expected to connect clients to required is expected to connect clients to required services without acting as clinicians.services without acting as clinicians.

Models cont…Models cont…

Clinical case Management. Services are Clinical case Management. Services are provided in four broad areas:provided in four broad areas:

1.1. Initial phase – engagement, assessment, Initial phase – engagement, assessment, planning.planning.

2.2. Environmental interventions – linkage Environmental interventions – linkage with community resources, consultation with community resources, consultation with families and other caregivers, with families and other caregivers, maintenance and expansion of social maintenance and expansion of social networks, collaboration with medial networks, collaboration with medial personnel, advocacy.personnel, advocacy.

Models cont… Models cont…

Clinical Case Management ….Clinical Case Management …. Patient Interventions – individual Patient Interventions – individual

psychotherapy, training in psychotherapy, training in independent living skills, independent living skills, psychoeducationpsychoeducation

Patient – environment interventions Patient – environment interventions – crisis intervention and monitoring.– crisis intervention and monitoring.

Models cont… Models cont…

Assertive Community Treatment – Assertive Community Treatment – created in the 1970’s by Stein and created in the 1970’s by Stein and Test. Originally called Program for Test. Originally called Program for Assertive Community Treatment. Assertive Community Treatment. Basic tenets include:Basic tenets include:

1.1. Low client to staff ratios eg. 10:1 Low client to staff ratios eg. 10:1 rather than 30:1 or more.rather than 30:1 or more.

2.2. Services provided in the community Services provided in the community – clients’ own environment.– clients’ own environment.

ModelsModels

ACT cont…ACT cont… Caseloads shared across clinicians rather Caseloads shared across clinicians rather

than individual caseloadsthan individual caseloads 24 hour coverage24 hour coverage Majority of services provided by the team Majority of services provided by the team

(not brokered)(not brokered) Time unlimited service.Time unlimited service. The best research I can find supports this The best research I can find supports this

as the most effective model for MH service as the most effective model for MH service clients. Why?clients. Why?

Strengths Perspective – Why?Strengths Perspective – Why? Focus is on capacities and potentialities of Focus is on capacities and potentialities of

service users. service users. It concentrates on enabling clients to It concentrates on enabling clients to

articulate and work towards their hopes articulate and work towards their hopes for the future.for the future.

According to Saleebey (1997) the According to Saleebey (1997) the strengths perspective formula is simple – strengths perspective formula is simple – ‘mobilise clients’ strengths (talent, ‘mobilise clients’ strengths (talent, knowledge, capacities) in the service of knowledge, capacities) in the service of achieving their goals and visions and the achieving their goals and visions and the clients will have a better quality of life on clients will have a better quality of life on their terms’.their terms’.

Strengths Perspective cont..Strengths Perspective cont..

The words empowerment, resilience and membership are The words empowerment, resilience and membership are important language within the strength perspective.important language within the strength perspective.

Empowerment Empowerment imperative requires clinicians help clients to imperative requires clinicians help clients to become aware of the tensions and conflicts that oppress and become aware of the tensions and conflicts that oppress and limit them and help them free themselves from these limit them and help them free themselves from these restraints.restraints.

Resilience Resilience reflects the skills, abilities, knowledge and insight reflects the skills, abilities, knowledge and insight that accumulate over time as people struggle to surmount that accumulate over time as people struggle to surmount adversity and meet challenges, and it is an ongoing and adversity and meet challenges, and it is an ongoing and developing fund of energy and skill that can be used in current developing fund of energy and skill that can be used in current struggles.struggles.

MembershipMembership reflects the fact that people need to be citizens – reflects the fact that people need to be citizens – responsible and valued members in a viable group or responsible and valued members in a viable group or community. To be without membership is to be alienated and community. To be without membership is to be alienated and to be at risk of marginalization and oppression,to be at risk of marginalization and oppression,

Models cont…Models cont…

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

Models cont…Models cont…

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

Active Ingredients of Effective CMActive Ingredients of Effective CM

A combination of the strengths A combination of the strengths approach and ACT. (Rapp and Goscha, approach and ACT. (Rapp and Goscha, 2004)2004)

Case Managers deliver as much of the Case Managers deliver as much of the ‘help’ or service as possible.‘help’ or service as possible.

Natural community resources are the Natural community resources are the primary partners.primary partners.

Work is in the community.Work is in the community. Individual and team case management Individual and team case management

works.works.

Active Ingredients cont…Active Ingredients cont…

Case Managers have primary Case Managers have primary responsibility for a person’s services. responsibility for a person’s services.

Case Managers can be para Case Managers can be para professionals. Supervisors should be professionals. Supervisors should be experienced professionals.experienced professionals.

Case loads should be small to allow for Case loads should be small to allow for a relatively high frequency of contact.a relatively high frequency of contact.

The service should be time-unlimited, The service should be time-unlimited, if necessary.if necessary.

Active Ingredients cont…Active Ingredients cont…

People need access to familiar People need access to familiar persons 24/7.persons 24/7.

Case Managers should foster choice.Case Managers should foster choice.

Therapeutic AllianceTherapeutic Alliance

””The alliance process is one that promotes The alliance process is one that promotes partnerships with patients and facilitates self partnerships with patients and facilitates self management through active engagement of management through active engagement of the patient in the treatment process” (I. the patient in the treatment process” (I. Howgego et al, 2002).Howgego et al, 2002).

““The working alliance is integral to both The working alliance is integral to both service delivery and clinical practice. It service delivery and clinical practice. It provides a focus on patient outcomes as provides a focus on patient outcomes as opposed to systemic outcomes, as it is a opposed to systemic outcomes, as it is a collaborative process that centres on patient collaborative process that centres on patient needs and goals versus clinician generated needs and goals versus clinician generated goals” goals”

RecoveryRecovery It’s likely that the term ‘recovery’ first It’s likely that the term ‘recovery’ first

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

Recovery cont…Recovery cont… Most of the contemporary literature on recovery Most of the contemporary literature on recovery

comes out of the US.comes out of the US. Patricia Deegan (1988) – ‘Recovery is a process, a Patricia Deegan (1988) – ‘Recovery is a process, a

way of life, an attitude, and a way of approaching the way of life, an attitude, and a way of approaching the day’s challenges. It is not a perfectly linear process.’day’s challenges. It is not a perfectly linear process.’

Ridgway (2001) – ‘… a series of journey’s that Ridgway (2001) – ‘… a series of journey’s that include: a reawakening of hope after despair; a include: a reawakening of hope after despair; a movement to active participation in life from movement to active participation in life from withdrawal, a shift to active engagement a active withdrawal, a shift to active engagement a active coping rather than passive adjustment … a coping rather than passive adjustment … a transformation from alienation to a sense of meaning transformation from alienation to a sense of meaning and purpose.’and purpose.’

Recovery manual (1994) – see quoteRecovery manual (1994) – see quote

Recovery cont…Recovery cont…

Literature explores themes of hope Literature explores themes of hope empowerment and meaningful activity.empowerment and meaningful activity.

A 2003 Australian study looked at the A 2003 Australian study looked at the factors consumers identified as factors consumers identified as important to recovery … determination important to recovery … determination to get better – 74%, finding their own to get better – 74%, finding their own way to mange their illness – 64% and way to mange their illness – 64% and recognising the need to help recognising the need to help themselves – 54%themselves – 54%

Mental Health Services in VictoriaMental Health Services in Victoria

The Area Mental Health Service.The Area Mental Health Service. Psychiatric Disability Rehabilitation Psychiatric Disability Rehabilitation

and Support Services (PDRSS).and Support Services (PDRSS). Statewide Specialist Services.Statewide Specialist Services.

The Area MH ServiceThe Area MH Service

Is geographically determined.Is geographically determined. Child and Adolescent MH Services – Child and Adolescent MH Services –

ages 0 – 18.ages 0 – 18. Adult Services – ages 16 – 64.Adult Services – ages 16 – 64. Aged Psychiatry Services – ages 65 Aged Psychiatry Services – ages 65

and over. and over.

Area MH Service – Adult Area MH Service – Adult CommunityCommunity

Primary Mental Health and Early Primary Mental Health and Early Intervention TeamIntervention Team

Continuing Care Teams (CCT)Continuing Care Teams (CCT) Homeless Outreach Psychiatric Service Homeless Outreach Psychiatric Service

(HOPS)(HOPS) Mobile Support and Treatment Service Mobile Support and Treatment Service

(MSTS)(MSTS) Community Care Unit (CCU)Community Care Unit (CCU) Dual Diagnosis ServiceDual Diagnosis Service Secure Extended CareSecure Extended Care

Area MH Service – Adult AcuteArea MH Service – Adult Acute

CAT/TriageCAT/Triage In Patient UnitsIn Patient Units Consultation and LiaisonConsultation and Liaison