Transcript Case Management

Case Management
Fiona Smith
Senior SW, Alfred Psychiatry
Session Outline





History
Models
Recovery paradigm
MH Services in Victoria
Questions
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
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.
Models of Case Management

1.
2.
3.
4.
5.

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.
Models cont…

1.
2.
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.
Models cont…



Clinical Case Management ….
Patient Interventions – individual
psychotherapy, training in independent
living skills, psychoeducation
Patient – environment interventions –
crisis intervention and monitoring.
Models cont…

1.
2.
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.
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?
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’.
Strengths Perspective cont..

The words empowerment, resilience and membership are important
language within the strength perspective.

Empowerment imperative requires clinicians help clients to become

Resilience reflects the skills, abilities, knowledge and insight that

Membership reflects the fact that people need to be citizens –
aware of the tensions and conflicts that oppress and limit them and
help them free themselves from these restraints.
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.
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,
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.
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’.
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.
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.
Active Ingredients cont…


People need access to familiar persons
24/7.
Case Managers should foster choice.
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”
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 reorganise 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.’
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
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%
Mental Health Services in Victoria



The Area Mental Health Service.
Psychiatric Disability Rehabilitation and
Support Services (PDRSS).
Statewide Specialist Services.
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.
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
Area MH Service – Adult Acute



CAT/Triage
In Patient Units
Consultation and Liaison