Discuss the role of the case manager within a community mental health team and assess to what degree this approach is being used in your area.
Abul Hussain (UK) December 2000
Community Mental Health and Social Work
This essay will be written in two parts. Firstly, and in the main, I will discuss the advent of case management (CM) and some of the theoretical issues associated with it. This will aim to explore some of the principles and models underpinning the idea and how it is generally understood to be an effective system of providing community mental health care. Secondly, the discussion will look critically at the way in which case management approach is realised within a local community mental health team in UK. This will aim to explore some of the professional dilemmas surrounding the realities of case management.
The concept of CM as a system of providing quality care for the mentally ill grew from the era of deinstitutionalisation during the 1960’s in the United States and arrived in Britain in late 1980’s. This was a period when large psychiatric hospitals were closed down and people were treated in the community. The community care move was a response to the growing concern and social policy pressure over people becoming institutionalised and less able to cope with normal life and dependant on the routine and narrow confines of long stay institutions (Meredith, 1995). With the lack of promotion of independence, choice and fulfilment, the process of institutionalisation was understood to be of great disadvantage for people with serious mental illness (SMI) and had devastating consequences for families. Stein (1991) (cited in Stanford & Gouray, 1996: 32) referred to long stay hospitals as "warehouse for human beings who have been discarded by society". At the same time, many pressure groups heavily criticised the community care move arguing that it was based more on economic reasons of shifting the burden of care from the state to the community rather than humanitarian grounds (Young, 1995). Soon after the move, it was recognised that people who suffered from SMI were also disadvantaged by secondary impairment, including difficulty with interpersonal skills, dependence on family or institution and limited in coping with skills such as budgeting, using public transport, shopping, cooking etc. It was argued that, in order to provide a suitable service to people with SMI and increasing long term success, services needed to provide a comprehensive package, ideally delivered by one person namely a case manager. This brought to light that the role of case manager. CM included not only the general management of symptoms and administration of medication but a whole range of functions that impacted on social functioning (Sandford & Gournay, 1996). It was the earlier works of Stein & Test (1980) who carried out studies on use of psycho-social perspectives with discharged patients in transitional living and reducing hospitalisation that paved the way for CM to become the alternative to hospital treatment.
The basic idea of CM was then meant to match and co-ordinate different services for psychiatric patients living in the community in an attempt to promote fulfilment of life (Challis, 1990) (cited in Lee et al 1998). Michell & Reaghard (1996) (cited in Chan et al, 2000), claimed that the purpose of CM was to serve as a patient advocate by means of increasing co-ordination of services. Bergen (1992) (cited in Lee et al, 1998) notes that CM is about choice and empowerment for people and to achieve this case managers needed to be accessible in acting as advocates and flexible in the management of resources. Case management was taken as a process of extended community services required to care for discharged psychiatric patients to help overcome the barriers of fragmented, duplicated and uncoordinated services (Giuliano & Poirier, 1991) (cited in Lee et al, 1998). Marion et al (1997) contend that CM is about engaging people with SMI who would otherwise be at risk of losing contact with services and is a recognition that these people at are risk of being unable to cope with factors either arising from mental health problems or social circumstances. Case management thus can be best understood by a summary offered by Lee et al (1998:936): "….case management model therefore promotes a seamless, integrated transition and ensures continuity of care once the patients returns to the community". While case management was thought to be the cornerstone of quality care with an emphasis on co-ordination of services, there has been little consensus in the literature about what is actually being introduced under the banner of CM . Many writers have noted how the absence of clear understanding of CM has been an obstacle in moving forward with CM practice (Lee et al, 1998; Chan et al, 2000). Lamb (1992) notes that the lack of clarity is because the practice of CM has expanded very rapidly in recent years in response to strong pressure to find new methods of care delivery as well as saving cost of care. According to Lamb, this generates a sense of eagerness to implement CM even when the outcome needed to be achieved in the process of care is not carefully considered. Thornicroft (1991) (cited in Lee et al, 1998) on the other hand, argues that lack of consistency in meaning arises as a result of the many ways in which the principles of CM can be implemented. This point implies that, it is the different functions and values case managers bring to the process of CM that adds to the elusive nature of the definition. Critiques of CM have also stated that the philosophic underpinnings of CM has become somewhat unclear arguing that with its overemphasis on resource co-ordination it has over time become a consumer-driven initiative to help government contain high rising health care cost instead of it being recovery focused (Rohde, 1997). The criticisms here will be revisited in the latter part of the essay. Despite this confusion, writers have put forward varying interpretations of the CM model found in the literature.
The American Nurses Association (1998) (cited in Lee et al, 2000), along with Onyett (1992) and Bergen (1992), define the process of CM to include various roles and responsibilities. According to them, the CM process ranges from comprehensive assessment and need identification, to design and implementation of care packages, monitoring, evaluation or reassessment/review. The case manager is also responsible for case closure and referral, if necessary. It is believed that these stages/phases are carried out to respond to individualised needs of patients and their families thus assure service needs are met. This also includes case finding, goal setting and educating (Robinson et al (1992) (cited in Lee et al 1998) and so as a case manager, the role is to develop and manage a plan of care for a specific patient through patients engagement and co-ordination with community resources. Meisler & Midyette (1994) (cited in Lee et al 1998) adds to this by asserting that the CM role is not only to overall manage, but also covers financial accountability in terms of evaluating and monitoring costs and resources. In this respect, Suber (1994) has it that being knowledgeable of the resources available and possessing the ability to match resources and patient needs are also important features of CM. He further states that case managers need to have an ability to communicate and work well with others in securing services to meet needs. Case managers also have a proactive role to collaborate with multi-disciplinary teams, they serve as patient liaison, offer clinical support and expertise, co-ordinate consultation and encourage patients and family participation in the process of care. Underpinning most CM approaches or styles is a shared set of goals (Marshall et al, 1997): (a) maintain contact with patients; (b) reduce the frequency and duration of hospital admission; and (c) improve clinical and social outcomes. Case management is delivered in many different ways. For the purpose of this essay I will discuss two models.
In the brokerage model; other wise known as the advocacy model, the emphasis is more on networking and mobilising resources in an attempt to link patients to needed services and supports in community agencies (Huxley, 1993). This approach is known as the standard form of CM where the care manger arranges a package of care for the patient and monitors its implementation. The main feature of this model is to increase the patients’ access to a variety of community services, help patients with keeping appointments, organise housing placements and making appropriate referrals to other agencies. The focus then is less on meaningful relationship building with patients or therapeutic relations skills but more on care co-ordination and budgetary responsibilities. With this model, there is a recognition that people with SMI are empowered when they have choices in the way their needs can be met. Thus the emphasis is on protecting rights and working on behalf of the patient for more, appropriate and better services (Huxley, 1993). There is an attempt to make sure that existing services meet needs and provide care to agreed service specification. With this approach there is also a lot more inter-agency joint working, making agency agreements and valuing the contribution of other agencies in planing of care (Coulshed, 1991).
On the other hand, in the assertive outreach model or other wise known as ACT (Assertive Community Treatment) there is a slightly different but a more proactive and reach out type focus. Here there is a shift in view in the way people with SMI are generally understood and locus of care is arranged. Unlike the brokerage model which has a more general reflection on CM in government policy (Marshall, 1996), ACT model of assertive outreach in UK has a more direct relationship with the Department of Health 1998 White Paper entitled ‘Modernising Mental Health Services: Safe, Sound and Supportive’ (Ryan, 1999). The inclusion of this approach at government level was a significant reflection of government’s response to greater security of the public and ‘risk’ following the high profile Christopher Clunis incident in 1992. The National Service Framework also uses the term assertive outreach and is now a central feature of mental health policy. In Onyett’s (1992) definition an emphasis is placed on the assertive outreach model to both co-ordinate and individualise care, which is either delivered through one individual worker or a team as a whole share responsibility. With the ACT model there is a recognition that there needs to be an aggressive response to mental health problems in an attempt to actively seek out people with SMI who are in need of services and to prevent these people from dropping out of services (Sandford & Gournay, 1996). This notion of rapid response to mental health care and patient engagement is perhaps better reflected in government’s own definition (Department of Health, 1998) (cited in Ryan, 1999:1): ‘Assertive outreach is an active approach to treatment and care for those who are at risk of being readmitted to psychiatric hospital. Such people are typically hard to engage because of their negative experiences of statutory services. Assertive outreach ensures that treatment is delivered early enough to prevent the patients’ condition from worsening at their own territory in the community’.
On a close look at the model a number of themes are found. These include, engaging high-risk patients with severe and complex needs who are resistant to contacting services; avoiding unnecessary hospital admission and therefor assistance is given for patients to stay at home in their community. Direct contacts are made where and whenever (out-of-hour) that is best suitable for the patient and thereby increasing the chance of engagement with the service; and focusing on optimising the rehabilitation potential of the patient by delivering multi-disciplinary intervention that enhance psychosocial functioning of the patient. Allness and Knoedler (1998) (cited in Ryan, 1999) bring to our notice some of the psychosocial aims of the ACT. These include, helping with motivation to preserve and remain involved in life; optimising the home environment; attend appointments with patients; developing coping skills to meet the demands of community living; assisting with housing and practical needs; and cognitive behavioural interventions to increase medication compliance and symptoms management. With the ACT model it is generally believed that because the lack of motivation and social withdrawal are frequent aspects of most people with SMI, this non-office based and intensive team approach involvement is needed in the engagement and promotion of peoples’ psycho-social functioning and thus improve quality of life.
In practice the CM idea is imposed on, particularly the local community mental health team (CMHT) I work for in Tower Hamlets, in the form of the care programme approach (CPA) and care management model. While there are no clear reasons as to why the CM model does not appear as a distinct model of practice, the workers unofficially execute aspects of both the brokerage and ACT model within the conventional framework. However, the workers do this with great restraint given the climate in which CMHT’s are expected to operate. In my experience there are many socio-political factors, which inhibit the CM process and add to the dubious nature of community care work. These include, workers over burdened with case loads; lack of funding and specialist service provision; problems of collaboration; and the inevitable discrimination generated through structural ignorance towards multiculturalism. The theme of assessment, service provisions, care co-ordination and in general the notion of independence and choice often talked about in the CM function, has become a contentious activity (Marshall, 1996). Given the high number of caseloads the individual worker has to deal with and the bureaucratic mushrooming of paperwork, it becomes difficult to monitor and review ‘quality’ of care provided. The tasks of taking note of micro but significant features of, say patients’ limitations in coping or complex interpersonal difficulties, thus become time constrained and so arduous to fulfil. As a result the focus of care shifts from ‘needs’ or ‘change’ to a one of organisational responsibility, accountability and frequency (Adams et al, 1998). Therefore does the process of standardisation mean less individualisation? When workers are stressed out with having to make some four to five home visits a day and then write up the outcome upon their return and then possibly explore community resources to meet newly identified need, is there real time to plan or think of quality?
The lack of adequate funding and appropriate services poses another threat to effective management of integrated transition and continuity of care. Often it is found that once a need is identified workers have to struggle with the scarcity of adequate resources to meet complex and enduring needs in an anti-discriminatory and empowering manner (Adams et al, 1998; MIND 1999). Are individuals then being made to fit into the services, rather than the other way round? When resources become scarce does the distribution of services become conditional? Does the notion of ‘tailoring’ a package of care then become a rhetoric than a reality? The idea of collaboration, or networking and mobilising resources in the language of the brokerage model, is another factor towards what Trevillion (1996(a):103) phrases ‘the reconciling what is ultimately the irreconcilable’. The common socio-professional climate of conflicting duties and unclear boundaries including differences in values, language, priority and perception of the problem are factors, which make the process of co-ordination and developing and managing a plan of care difficult to implement (Banks, 1995; Hugman & Smith, 1995). In Trevillion’s (1996(b)) terms among the different community organisation there is the lack of ‘mutual understanding’ that also adds to the problem. The organisational conflicts often prevents effective partnership work thus the process disempowers patients in engaging with the wider spectrum of community services and gain control through a means that meets their needs in a creative and multi-inclusive manner (MIND, 1999). On the other hand, in reconciliation of this problem there has been a move towards uniformity of procedures to meet needs of all client group but in doing so they have lost some of the unique features needed to meet individual needs (Trevillion, (1996(a)). What happened to the promise of CM being a means to match resources with patient needs to promote empowerment through choice?
Similarly, with assessments, it is also found that with the rapid growth in multi-ethnic societies, my team and mental health services in general are failing to adequately understand the health and care needs among patients’ who come from non-western background (Robinson, 1996; MIND, 1999). As a result patient from these communities are discriminated against and systematically made to keep a distance from receiving mental health support that is culturally incompetent (Kareem & Littlewood, 1992; Fernando, 1995). In these instances, how is CM to improve the clinical and social outcome of patients’ from different communities who are existentially a part of the wider societal and medical oppression and may be resistant towards receiving help? Does the goal of engagement then become exclusive to certain groups?
While the above factors may not hinder some of the key goals of CM, which is to maintain patient contact with services and develop meaningful relationships to prevent relapse and hospitalisation, other queries come to mind. Given the overall climate of resource scarcity and the urgency of appropriately reintegrating and stabilising patients into the community, can the process of CM within a CMHT capacity intervene appropriately and at an opportune time to produce maximum benefit, which lead to a holistic improvement in human functioning? It is the wider context in which mental health care operates that need to be considered if the ambitious ideas of CM is to be meaningfully understood and implemented as alternative to mental hospital.
Abul Hussain (UK) December 2000
Community Mental Health and Social Work
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