The International Journal of Psychosocial Rehabilitation
A Critical Analysis of the Literature
Grech, E. (2002) Case management: a critical analysis of the literature.
International Journal of Psychosocial Rehabilitation. 6, 89-98
This article reviews a variety of case management models have been developed over the past two decades. The clinical case management model is a response to the problems inherent in identifying these resources. It thus recognises that case managers may need to provide services directly and hence act as clinicians. Assertive community treatment models are characterised by more frequent client contact and is provided by a multi-disciplinary team with services delivered in the community rather than by and individual in the clinician’s office. The differences between ACT and intensive case management are reviewed. The ACT model of case management in the United Kingdom takes a historical perspective and is discussed in terms of the wider social context. The UK700 group study found substantial improvements in hospitalisation rates only when the team had medical control over the discharge of clients. However, no significant gains in social functioning or mental state were discovered. They conclude that "the policy of advocating intensive case management for patients with severe psychosis is not supported. In contrast, Marshall and Lockwood (1998) find that ACT results in reductions in both frequency and duration of admissions and proves superior to standard case management in maintaining contact with service users. In reviewing the literature on case management in the UK, broad differences in models become apparent. However, these differences may be more due to social and political factors than clinical outcomes between the models.
Throughout the 1980’s and early 1990’s, psychiatric hospitals in Britain underwent a period of closure and reduction in bed numbers. Seen as "warehouses for human beings who have been discarded by society" (Stein, 1991 cited in Sandford and Gournay, 1996) these large institutions were the subject of a social policy that reflected the fears of many health care professionals. Institutionalisation was seen as greatly disadvantaging the individual sufferer of serious mental illness and was thought to be responsible, in part, for compounding many of the negative symptoms of schizophrenia (Brennan et al, 2000). Currently, the number of psychiatric beds in Britain is some seventy four percent less than at its peak in 1954 (Lamb, 1997). Emerging from the United States in the 1960’s, during a period of similar de-institutionalisation, case management evolved as an alternative to hospitalisation.
King et al (2000) detail the problems inherent in attempting to arrive at a working definition of case management and describe how little is known about its service organisation and process. Many sources highlight the fact that case management is not a cohesive philosophy or disciplined set of ideas (Chan et al, 2000). A significant influence of national culture is evident in both approaches to research and definitions of case management (Burns et al, 2001). Gournay (2000) observes how terms such as assertive community treatment, case management and home treatment are used interchangeably. It appears that even among researchers, some confusion regarding these terms exists and is thus reflected in the literature. However, Sledge et al (1995) attempt to arrive at a lexicon definition and in so doing reveal that implicit in the term "management" is the "definition of authority over the conduct of work and the control of resources." They refer to the fragmentation of services and the absence of a general linkage between hospitalisation and community care. Hence, despite this apparent lack of clarity in definition, the object of case management can be regarded as the coordination of services in a way that ensures their integration and continuity for individual sufferers.
A variety of case management models have been developed over the past two decades and are detailed by Mueser et al (1998). The Broker model, one of the first to emerge, places emphasis on assessing the needs of clients, treatment planning and referring on to other agencies. This model, also known as standard case management, views the manager as the client’s advocate who is responsible for coordinating between various services and for the ongoing monitoring of care. There is an assumption that in acting as a "broker" the case manager does not require any specific clinical skills, but rather the ability to match available resources with needs.
The clinical case management model is a response to the problems inherent in identifying these resources. It thus recognises that case managers may need to provide services directly and hence act as clinicians. The model identifies four broad areas; an initial phase of engagement, assessment and planning; environmental interventions involving the use of community resources, maintenance of support networks, family work and advocacy; patient interventions such as counselling, development of independent living skills and education; and finally patient-environmental interventions such as monitoring and crisis intervention.
Designed as a package of care for sufferers of more severe mental disorders, assertive community treatment is characterised by more frequent client contact. It is provided by the multi-disciplinary team with services delivered in the community rather than the clinician’s office. Caseloads are low (about 10-15 clients), shared across clinicians and are not "brokered out" to other agencies. Twenty-four hour provision of care and assertive outreach is characteristic of this approach and services are generally regarded as time limited. However, Freeman (2000) finds that evidence from the United States indicates how ACT is most successful in reducing hospitalisation rates when a comprehensive and enduring approach is adopted. Similarly, Marks et al (1994) find that many clients require an assertive outreach approach indefinitely.
The differences between ACT and intensive case management are detailed by Gournay (2000) and are given greater emphasis than Mueser et al’s account. Other than the sharing of caseloads that occurs in ACT and not intensive case management, Mueser et al make little distinction between the two models. However, Gournay considers ACT to involve community work exclusively, whereas ICM includes working with other parts of the psychiatric service and the provision of care in a wider range of settings.
The development of case management in Britain can be traced to the publication of the Griffiths Report in 1988. Commissioned by the government following the killing of a social worker by a former client, the report recommended the transfer of all community care to local authorities. In response, the government published the White Paper Caring for People (Department of Health, 1989). It marked the development of the distinction between purchaser and provider and set out a framework for changes to community care, which included case management. The legal changes necessary for the implementation of the White Paper were established by the NHS and Community Care Act 1990. In Wales, the development of multidisciplinary community mental health teams was driven by the All Wales Mental Illness Strategy (Welsh Office, 1989).
The Care Programme Approach (CPA) was introduced as an attempt to standardise the delivery of community care services and provide guidance on how health authorities in England should meet the requirements of the NHS and Community Care Act 1990. Case management is widely used in the United Kingdom in response to the CPA guidance (Bowers, 1998). Anyone in contact with "specialist psychiatric services", including in-patients as well as those living in the community, should fall under the remit of the CPA. These services include psychiatrists, psychiatric nurses, counsellors, psychologists and mental health social workers. A systematic assessment of health and social care needs, detailed written care plans, a regular review system and the appointment of a key-worker are fundamental to the approach. Highly critical of the CPA, Marshall (1996) describes case management as a "dubious practice … underevaluated and ineffective" and asserts that its "astounding ability to flourish" against sparse favourable evidence and hence its apparent "immunity to scientific analysis", is indicative of the protection it receives as government policy.
In comparing case management to standard community care, Marshall et al (1997) draw a number of unfavourable conclusions. Although criticised for their exclusive study of the brokerage model (Shepherd, 1998), they find that whilst case management facilitates increased contact with psychiatric services, there are increases in rates of admission to hospital with a possible corresponding increase in the duration of stay. Similarly, despite the fact that improved compliance is reported, there is an absence of evidence to support improvements in mental state, social functioning and quality of life. They conclude that case management is "an intervention of questionable value, to the extent that it is doubtful whether it should be offered by community psychiatric services." These findings are supported by a randomised controlled study in London over an eighteen-month period. The study found that whilst a higher level of supervision lead to a reduction in loss of contact, the approach lead to an increased use of psychiatric beds (Tyrer et al, 1995).
Nonetheless, the Department of Health has emphasised the government’s commitment to the further development and on-going implementation of case management. The NHS Plan outlines the government’s agenda and pledges the establishment of 220 assertive outreach teams across the country by 2003 (Department of Health, 2000). However, many sources warn that this approach may be "no panacea" (Brimblecombe, 2001; Sainsbury Centre for Mental Health, 1999; Shepherd, 1998). Areas with the most comprehensive community services continue to depend upon the inpatient facilities of psychiatric hospitals to provide a secure and supportive environment for a minority of individuals.
Freeman’s account of the ACT model of case management in the United Kingdom takes a historical perspective and considers the wider social context. The Ritchie Inquiry (cited in Freeman, 2000) concluded that public support in the government’s community care project was diminishing due to the inability of the psychiatric services to meet the needs of severely disturbed and chaotic individuals. This resulted in another tragic killing of a member of the public. The inquiry called for highly intensive care, risk assessment and the training of key workers. Seen by some as a response that was both unconsidered and lacking in awareness (Marshall, 1999), the government published Modernising Mental Health Services: Safe, Sound and Supportive, a document containing the controversial statement "community care has failed" (Department of Health, 1998). Commenting that the document sets out "an extensive – and possibly unrealistic – wish list for improvement", the Sainsbury Centre for Mental Health (1999) warn against the potentially demoralising effects on both community staff and service users and stress that "it is vital to distinguish between political ‘spin’ and the substance of the strategy". Allot (1999) is critical of the government’s strategy for its lack of evidenced based recommendations. The Sainsbury Centre for Mental Health (1999) refer to a steady three percent decline in statistics relating to homicides committed by people with a mental disorder. Furthermore, a recent study in the United States suggests the sufferer of serious mental illness is fourteen times more likely to be the victim, rather than the perpetrator of a violent crime (Brekke, 2001). The study concludes "the risk associated with being in the community was higher than the risk these individuals posed to the community". Differences between the two cultures notwithstanding, it would seem that Brekke’s comments are pertinent to the UK.
In a major review, the Sainsbury Centre for Mental Health (1998) focused on the needs and aspirations of the seriously mentally ill, estimated at between 14-200 per hundred thousand of the adult population. Attempting to address this client group’s failure to engage with services, the review found a number of interrelated factors at play. For some individuals this failure to engage was due to the inappropriate nature of services, for others their individual experiences such as negative staff attitude. The report places attitude and style of working at the centre of an effective service. In accordance with research conducted in the United States (Williams et al, 1994) it stresses the ability of staff to empathise with some of the most alienated and dispossessed members of society. The Review concludes that it is impossible for community mental health teams to meet the needs of this group without the employment of an assertive outreach approach. However, the work of the UK700 group appears to stand in contrast with these conclusions.
McGrew and Bond (1995), cited in Dodd (2001), found a maximum caseload size of one staff member to ten clients allowed for the high level of contacts required to ensure meaningful interventions. However, in exploring the clinical effectiveness of ACT, the UK700 group discovered no correlation to caseload size, thus shedding doubt on one of its main principles (Burns et al, 1999). In a two year study the group found that teams working with small caseloads of around fifteen clients did not produce significantly different outcomes to those with caseloads of thirty and thus comment that "energy and investment should aim at the specific content of care … rather than its form and delivery." However, King et al (2000) comment that caseload size has a significant impact on the health care professional’s "self-perceived role performance". Acknowledging the controversies around this area, the Welsh Office (2001) use this evidence to assert a difference in approach from the assertive outreach practices outlined in governmental policy. They advise the "careful management" of caseloads in order to allow an "assertive approach" to occur. Furthermore, as confirmed by an inner London study conducted over a twenty-month period (Marks et al, 1994), the UK700 group found substantial improvements in hospitalisation rates only when the team had medical control over the discharge of clients. No significant gains in social functioning or mental state were discovered. They conclude that "the policy of advocating intensive case management for patients with severe psychosis is not supported" (Byford et al, 2000).
Supporting this argument is the work of the PRISM Psychosis Study. Here, Thornicroft et al (1998) whilst finding some improvement in social functioning and mental state, note that these differences are not significant when compared to less intensive models of case management. They conclude "there is little difference between the community mental health team models." In addition, unacceptable delays for community services effect thirty percent of inpatient beds, resulting in delayed discharge, and staff responsible for the delivery of community care have high sickness rates and low morale (Thornicroft and Goldberg, 1998).
In contrast, Marshall and Lockwood (1998) find that ACT results in reductions in both frequency and duration of admissions and proves superior to standard case management in maintaining contact with service users. When compared to traditional hospital based rehabilitation they find that it has no effect on mental state or social functioning. However, they conclude that for sufferers of serious mental illness ACT offers an effective alternative to both standard case management and hospital based rehabilitation. Their findings are questioned by Wasylenki (1998) since they do not address issues of homelessness or substance abuse problems. Lehman et al (1997) demonstrate how ACT can result in more stable housing and increased contact with psychiatric services by homeless people. Marshall and Lockwood do not indicate to what extent these factors influence their findings. Furthermore, whilst the reduction in admissions results in a reduction in hospital expenditure, this saving is offset by the additional cost of providing ACT. This is confirmed by Harrison-Read’s (1998) two-year study in an outer London Borough. Here, ACT failed to produce a significant saving in the cost of hospital bed use, yet doubled the spending on community care.
Many researchers appear preoccupied with the monetary savings made possible by the various models of case management (Byford et al, 2000; Harrison-Read, 1998; Latimer, 1999; Lehman et al, 1999; Llorca et al, 2001; McCrone et al, 1999; Rosenheck and Neale, 1998). Few question the assumption that mental health care and cost improvement plans are compatible. Hence, the notion that practitioners should strive towards an evidence based approach, not for the promotion of that which is scientifically valued in meeting the client’s needs, but rather to compete for seemingly scarce resources is left unchallenged.
User satisfaction with the principles of ACT and how they translate into practice is well documented (Gerber and Prince, 1999; Brimblecombe, 2001; Lloyd et al, 2000). The assumption that clinical practice and the criteria for judging clinical effectiveness emerge from social, political and economic interests underlies the work of Rohde (1997). He details how clinical intervention should centre around empowerment of the service user with priority given to the user’s right to voice opinions regarding the access to and delivery of mental health services. However, with some concern, Smith et al (1999) cite evidence from the United States that assertive outreach does not emphasis the importance of a therapeutic relationship, but rather the recording of contact with individual sufferers. In their opinion the wishes and rights of clients are ignored in favour of risk management and assessment. Threats of detention or punishment, infringement of privacy and the use of public toilets to administer depot medication are given as some of the worst examples of assertive outreach in the US. In examining the development of case management over the past thirty years, Rohde finds that the various models have evolved to accommodate the growth of the community mental health system following de-institutionalisation, at the abandonment of clients’ interests to improve their quality of life.
Inadvertently, authorities on assertive outreach in the United Kingdom offer descriptions of its accepted practices that may indicate the growth of a parallel system of coercion. "Housing departments, police stations, social security offices and inpatient units" are listed as examples of the client’s "own environment" and accepted as settings "where they feel most comfortable" (Sainsbury Centre for Mental Health, 2001).
Recognition of growing social inequality is increasingly commonplace, yet remains largely unacknowledged in the literature. Both the World Health Organisation (2001) and The Financial Times (Le Grand, 1999) refer to a gap between rich and poor that is greater than at any time since records began some 100 years ago. Brimblecombe (2001) comments that "few pioneers of home treatment … have appeared to take a clear philosophical stance on its meaning or ideals." Whilst undoubtedly true, it is hard to see how the absence of such an approach can be justified, given that the provision of case management is set against a backdrop of such a fundamentally unequal society.
In reviewing the literature on case management, broad differences in models become apparent. Low intensity models such as the brokerage system stand opposed to high intensity models such as ACT and ICM. Reasons for these differences are largely historical, yet interweave with both theoretical differences and differences in nuance and approach. The content of care, style of working and importance of staff training have emerged as recent themes in the literature (Sainsbury Centre for Mental Health, 1998; Burns et al, 1999). Whilst research into clinical effectiveness has proven somewhat contradictory, the evidence would appear to suggest that, with a degree of caution, assertive treatments may prove the way forward in caring for sufferers of severe mental illness in the community. However, it seems clear that the practice of case management may reduce, but will not remove the need for inpatient beds.
UK policy governs the development and application of case management and has been the subject of much criticism. This policy may be viewed in the context of specific political and social factors. Rather than evidence based considerations, governmental concern relating to a wide spread loss of faith in its ability to protect the public appears to drive case management policy. It could be said that in hiding its motivation to transfer the financial burden of care from the state to the community, the establishment has exploited the fear of institutionalisation held by many health care professionals.
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