Definition
Case management assigns the administration of care for an outpatient individual with a serious mental illness to a single person (or team); this includes coordinating all necessary medical and mental health care, along with associated supportive services.
Purpose
Case management tries to enhance access to care and improve the continuity and efficiency of services. Depending on the specific setting and locale, case managers are responsible for a variety of tasks, ranging from linking clients to services to actually providing intensive clinical or rehabilitative services themselves. Other core functions include outreach to engage clients in services, assessing individual needs, arranging requisite support services (such as housing, benefit programs, job training), monitoring medication and use of services, and advocating for client rights and entitlements.
Case management is not a time-limited service, but is intended to be ongoing, providing clients whatever they need whenever they need it, for as long as necessary.
Historical background
Over the past 50 years, there have been fundamental changes in the system of mental health care in America. In the 1950s, mental health care for persons with severe and persistent mental illnesses (like schizophrenia, bipolar disorder, severe depression, and schizoaffective disorder) was provided almost exclusively by large public mental hospitals. Created as part of a reform movement, these state hospitals provided a wide range of basic life supports in addition to mental health treatment, including housing, meals, clothing and laundry services, and varying degrees of social and vocational rehabilitation.
During the latter half of the same decade, the introduction of neuroleptic medication provided symptomatic management of seriously disabling psychoses. This breakthrough, and other subsequent reforms in mental health policy (including the introduction of Medicare and Medicaid in 1965 and the Supplemental Security Income [SSI] program in 1974), provided incentives for policy makers to discharge patients to the community and transfer state mental health expenditures to the federal government.
These advances—coupled with new procedural safeguards for involuntary patients, court decisions establishing the right to treatment in the least restrictive setting, and changed philosophies of care—led to widespread deinstitutionalization. In 1955 there were 559,000 persons in state hospitals; by 1980, that number had dropped to 132,000. According to the most recent data from the U.S. Center for Mental Health Services, while the number of mental health organizations providing 24-hour services (hospital inpatient and residential treatment) more than doubled in the United States from 1970 to 1998, the number of psychiatric beds provided by these organizations decreased by half.
As a result of deinstitutionalization policies, the number of patients discharged from hospitals has risen, and the average length of stay for newly admitted patients has decreased. An increasing number of patients are never admitted at all, but are diverted to a more complex and decentralized system of community-based care. Case management was designed to remedy the confusion created by multiple care providers in different settings, and to assure accessibility, continuity of care, and accountability for individuals with long-term disabling mental illnesses.
Models of case management
The two models of case management mentioned most often in the mental health literature are assertive community treatment (ACT) and intensive case management.
A third model, clinical case management, refers to a program where the case manager assigned to a client also functions as their primary therapist.
Assertive community treatment
The ACT model originated in an inpatient research unit at Mendota State Hospital in Madison, Wisconsin in the late 1960s. The program’s architects, Arnold Marx, M.D., Leonard Stein, M.D. and Mary Ann Test, Ph.D., sought to create a “hospital without walls.” In this model, teams of 10–12 professionals— including case managers, a psychiatrist, nurses, social workers, and vocational specialists—are assigned ongoing responsibility 24 hours a day, seven days a week, 365 days a year, for a caseload of approximately 10 clients with severe and persistent mental illnesses.
ACT uses multidisciplinary teams, low client-to-staff ratios, an emphasis on assertive outreach, provision of in-vivo services (in the client’s own setting), an emphasis on assisting the client in managing their illness, assistance with ADL (activities of daily living) skills, emphasis on relationship building, and emotional support, crisis intervention (as necessary) and an orientation, whenever possible, towards providing clients with services rather than linking them to other providers.
Compared to other psychosocial interventions the program has a remarkably strong evidence base. Twenty-five randomized controlled clinical trials have demonstrated that these programs reduce hospitalization, homelessness, and inappropriate hospitalization; increase housing stability; control psychiatric symptoms; and improve quality of life, especially among individuals who are high users of mental health services. The ACT model has been implemented in 33 states.
Intensive case management
Intensive case management practices are typically targeted to individuals with the greatest service needs, including individuals with a history of multiple hospitalizations, persons dually diagnosed with substance abuse problems, individuals with mental illness who have been involved with the criminal justice system, and individuals who are both homeless and severely mentally ill.
A recent (2002) mail survey of 22 experts found that while intensive case management shares many critical ingredients with ACT programs, its elements are not as clearly articulated. Another distinction between intensive case management and ACT appears to be that the latter relies more heavily on a team versus individual approach. In addition, intensive case managers are more likely to “broker” treatment and rehabilitation services rather than provide them directly. Finally, intensive case management programs are more likely to focus on client strengths, empowering clients to fully participate in all treatment decisions.
Clinical case management
A meta-analytic study comparing ACT and clinical case management found that while the generic approach resulted in increased hospital admissions, it significantly decreased the length of stay. This suggests that the overall impact of clinical case management is positive. Consistent with prior research, the study concluded that both ACT and high-quality clinical case management should be essential features of any mental health service system. One of the greatest tragedies of deinstitutionalization has been that most families, without any training or support, often become de facto case managers for their family members.
Case management for children and adolescents
Case management is also used to coordinate care for children with serious emotional disturbances—diagnosed mental health problems that substantially disrupt a child’s ability to function socially, academically, and emotionally. Although not a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the handbook published by the American Psychiatric Association used by mental health professionals to diagnose mental disorders, the term “serious emotional disturbance” is commonly used by states and the federal government to identify children with the greatest service needs. While the limited research on case management for children and youth with serious emotional disturbances has been primarily focused on service use rather than clinical outcomes, there is growing evidence that case management is an effective intervention for this population.
Case management models used for children vary considerably. One model, called “wraparound,” helps families develop a plan to address the child’s individual needs across multiple life domains (home and school, for example). Research on the effectiveness of this model is still in an early stage. Another model, known as the children and youth intensive case management or expanded broker model had been evaluated in two controlled studies. Findings suggest that this broker/advocacy model results in behavioral improvements and fewer days in hospital settings.
Conclusion
In recent years, many case management programs have expanded their teams to successfully utilize consumers as peer counselors and family members as outreach workers. The programs have also been adapted to serve older individuals with severe and persistent mental illnesses. While the ACT model offers the strongest evidential base for its effectiveness, research into the clinical and service system outcomes of this and other models of case management is ongoing.
The effectiveness of any case management program depends upon the availability of high-quality treatment and support services in a given community, the structure and coordination of the service system, and on the ability of an individual or family to pay for care either through private insurance or (more often) through public benefit and entitlement programs. With recent policy directives from the Centers for Medicaid and Medicare Services (formerly the Health Care Financing Administration or HCFA) promoting the use of Medicaid funds for ACT, more states are funding case management through Medicaid. While some policy makers express concern about costs, the expense of these programs is usually offset by the savings realized from keeping patients out of jails, hospitals, and emergency rooms. Compared to traditional outpatient programs, case management also offers a level of care that is far more comprehensive and humane for a disabled population.