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Precipitants of Case Management from an International Perspective
International Journal of Law and Psychiatry, Vol. 23, No. 3–4, pp. 419–428, 2000 Copyright © 2000 Elsevier Science Ltd Printed in the USA. All rights reserved 0160-2527/00 $–see front matter
PII S0160-2527(00)00040-6
Precipitants of Case Management from an International Perspective Phyllis Solomon*
Introduction In the United States, over the last 25 years, case management has come to have a prominent role in the mental health service delivery system. More recently, other countries are adopting or adapting U.S. case management practice interventions. This article will examine the precipitants that facilitate the emergence of case management across nations, followed by an assessment of the factors that influence the selection of the case management model to be provided. This analysis will be framed in an historical context of the origins and evolution of case management in the United States. Origins of Case Management in the United States Deinstitutionalization, which has become an international phenomenon, was initially greeted with a great deal of optimism in the United States, where this movement first began (Holloway & Carson, 1998; Holloway, McLean, & Robertson, 1991; Oliver, Huxley, Bridges, & Mohamad, 1996). This enthusiasm was predicated on the belief that psychopharmacological agents would stabilize the behavioral symptoms of those with severe psychiatric disorders; and after a short transition period, with the provision of minimal community care, mainly medication management, these patients would be integrated into the community. The first patients to leave these psychiatric institutions were those with families (Freeman & Simmons, 1963). Families served a similar function to the “total institution” of the psychiatric hospital, where all the human needs of the patients as well as their treatment requirements were provided for within the confines of the facility (Solomon, 1998). Families provided for the basic survival needs of their ill relative and ensured that all that was required for the returning patient was obtained. Those needs that could not be directly met within the family context were sought and coordinated by family *Professor, School of Social Work, University of Pennsylvania, Philadelphia, PA, USA. Address correspondence and reprint requests to Phyllis Solomon, University of Pennsylvania, Philadelphia, PA 19104, USA; E-mail: [email protected] 419
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members from other resources in the community. Consequently, families naturally evolved into serving as their ill relative’s de facto case manager (Intagliata, Willer, & Egri, 1986). As the movement progressed and those patients without families or with families who were unable to serve these coordinating and survival functions were released, it became apparent that the newly created community mental health centers were unable to fulfill all the functions previously offered by public psychiatric hospitals (Bachrach, 1976; Solomon, 1976). Concurrently, with the development of the mental health centers, there was an expansion of human service programs that were categorically funded to serve highly focused purposes. This resulted in an extremely “complex, fragmented, duplicative, and uncoordinated” social service network (Intagliata, 1982, p. 655). This service delivery system was difficult for anyone to navigate, but even more so for individuals with a severe mental illness who are often cognitively, socially, and functionally impaired and who easily become overstimulated when confronted with numerous choices and much information. In response to this situation, “a new group of providers evolved whose job focused on helping former mental patients ‘survive’ in the community by navigating the community mental health and social service systems” (Pescosolido, Wright, & Sullivan, 1995, p. 38). By late 1970, when the U.S. National Institute of Mental Health promoted the development of a community support system for all communities, case management was considered the lynch pin of this system of services (Intagliata & Baker, 1983; Solomon, 1999; Pescosolido et al., 1995). Thus, case management is one strategy for integration of services (Mechanic, 1991). Promotion of this position was furthered almost a decade later when legislation required the inclusion of case management in state plans for mental health clients who received substantial amounts of public funds. Over the past two decades, case management has evolved and matured. It is now widely accepted throughout the United States as an essential service for those with severe mental illness. The Roots of Case Management When case management first arose in the United States, it was perceived as a new innovation. However, this was an established management strategy used throughout health and human services, as well as industry (Lurie, 1978). The term itself is drawn from the fields of social work and administration (Ozarin, 1978; Sledge, Astrachan, Thompson, Rakfeldt, & Leaf, 1995). Case management has long been the primary management device “in every organized arrangement that heals, rehabilitates, cares for, or seeks change for persons with social, physical, or mental deficits” (Ozarin, 1978, p. 165). Consequently, it is a mechanism that is employed within complex organizations where individuals require the services of various components or specialties, such as within hospitals, or within or across service delivery systems, where separate agencies or entities offer differing services (Lurie, 1978). Case management is not unlike social casework and community health nursing (Netting, 1992). One of the early innovations as a community alternative to psychiatric hospitalization was the delivery of care to patients in their homes by public health nurses (Pasa-
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manick, Scarpitti, & Dinitz, 1967). This approach was the foundation of case management for individuals with severe mental illness. Case management is a rather ubiquitous term that lacks clear operationalization in the United States, as well as in other countries (Bachrach, 1989; Solomon, 1998; Wolf, 1997). Basically, case management is a mechanism that employs strategies for service integration to achieve continuity of service and receipt of needed resources based on an assessment of client needs by designating an individual or team of individuals as both responsible and accountable for carrying out the process. The nature of the process is contingent not only on the assessment of client needs, but also the availability of and accessibility to existing resources in the service environment. The Evolution and Functions of Case Management The broker or generalist case management model was the first approach to emerge in the United States in direct response to the need to assist patients released from the state psychiatric hospital in navigating the maze of services. The broker model serves purely a coordinating function by assisting the patients to link with services and resources, monitor the receipt of services, and advocate for the obtainment of essential resources for the patient (Intagliata, 1982). However, in the pure form of totally brokering services without some provision of supportive counseling is rare. This model is an office-based approach that is still widely practiced in the United States. Although this model is adequate for individuals with less severe disability, there was an increasing recognition of the need for more intensive services for those with more severe psychiatric disabilities. In response to this awareness, the Assertive Community Treatment (ACT) model has become prominent in the United States and implemented in such countries as England (Marks et al., 1994), Germany (Rossler et al., 1992); Australia (Hoult, Reynolds, CharbonneauPowis, Weakes, & Briggs, 1983; Hoult, Rosen, & Reynolds, 1984;) and Canada (Wayslenki, Goering, Lemire, Lindsey, & Lancee, 1993; Wilson, Tien, & Eaves, 1995). The ACT model is based on a service innovation developed in Madison, Wisconsin entitled Program for Assertive Community Treatment (PACT), which was intended to be an alternative to psychiatric hospitalization. This was designed as a comprehensive treatment package with three shifts a day, 7 days a week, and delivered by a multidisciplinary team of professionals. The idea was to replicate the hospital in the community by having a multidisciplinary team provide all the services a client needed in the client’s own environment. The ACT services have modified this program, but retain the multidisciplinary aspect; 24-hour coverage (with night coverage frequently provided by a local crisis service); community-based service delivery rather than officebased; shared caseloads; and with most services delivered by the team in vivo, with few brokered from elsewhere in the community. These services are usually time unlimited and have low staff-to-client ratios. This is a costly service that requires a good deal of training. Consequently, although this model has much research to indicate its efficacy (Meuser et al., 1998; Scott & Dixon, 1995) and is currently being promoted in the United States by the National Alliance for the Mentally Ill (a family advocacy organization), in actual practice, this is pro-
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vided on a limited basis. Specialized forms of ACT have been developed that focus on defined populations, such as forensic clients or substance abusers, or on specified objectives such as increasing competitive employment (Solomon, 1998). Recently a new model, intensive case management (ICM), has emerged which is usually reserved for high utilizers of services (Shern, Surles, & Waizer, 1989). This model employs many of the same features as ACT, such as low client-to-staff ratios, assertive outreach, delivery of services in the client’s environment, and practical assistance and training in skills of daily living. The major distinction between this model and ACT is that the former usually does not have a multidisciplinary team and caseloads are not shared, although in some instances case managers are configured as a team, such as two case managers (Holloway & Carson, 1998; Mueser et al., 1998). This model is growing in popularity in the United States, but does have greater reliance on the service delivery system than ACT. Therefore, ICM necessitates more coordination of other services, but requires fewer modifications within the delivery system. There appears to be unrealistic expectations that intensive case management approaches can compensate for an inadequate service system. Given that in most instances, other than ACT, case management relies on the system of services for resources for their clients, case management is only as good as the service system in which it is embedded (Stein, 1992). In addition to the broker model, some version of intensive case management is widely practiced in the United States. Other models have also emerged that have different emphasizes, but are practiced on a more limited basis. The strengths model focuses on strengths rather than deficits and uses resources outside of the mental health system in order to achieve community integration (Rapp, 1993, 1995). The rehabilitation model emphasizes delivering case management based on the desires and goals determined by the client and accessing resources that compensate for environmental barriers and client deficits (Hodge & Draine, 1993; Solomon, 1992). Clinical case management incorporates skill teaching and administrative functions of the previous models, but also includes psychotherapy as an essential component of the service (Kanter, 1989; Lamb, 1980; Roach, 1993). Personal growth and recovery from, or adaptation to, the illness is also emphasized (Kanter, 1989). All the models discussed thus far are provider models, predominately in the public sector, with some movement into the private arena (Strausbaugh, 1997). More recently, a purchaser model of case management has developed. In this regard, case management is essentially synonymous with utilization review, which is performed by an insurer or a managed care company. A representative of the insurer or managed care company proposes lower-cost alternative treatments to the clinician on behalf of the client (Sledge et al., 1995). In contrast to the public sector provider case management approaches where the goal is to increase access to care and ultimately increase service utilization, the private purchaser approach is to control cost by limiting resource use and choosing less expensive alternatives, such as community-based care instead of hospitalization (Sledge et al., 1995). These various models are not mutually exclusive within a given geographical location as well as within a given agency, for more than one model may be prac-
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ticed within the same organizational entity. For example, it is not uncommon for an agency to provide broker case management to the vast majority of their clients, and have one ACT team for a specialized group of clients. Similarly, with the public sector mental health programs moving into managed care, the purchaser approach may also be instituted as well. It is likely that this purchaser case manager will influence the practice of these provider models. For example, who receives case management, with what intensity (i.e., what model of case management) and for how long will be determined by the purchaser rather than the provider. This separation of purchaser and provider case manager is comparable to what has emerged in England (Davies et al., 1995; Ryan, Ford, & Clifford, 1991; Shepherd et al., 1996). Precipitants of Case Management With this as background, an assessment of the factors that influence the emergence of case management as a provider approach in the United States as well as elsewhere can be analyzed. A major factor that is quite evident from the U.S. experience is that an orientation of community-based care for individuals with severe mental illness can precipitate the need for a responsible and accountable entity to coordinate, link to, and advocate for resources and services for this disabled population. Closure of public hospitals or reductions in inpatient use is not necessarily essential for this community-based focus to arise, but clearly plays a primary role. For example, in the Netherlands there has been an increased emphasis on community-based care for the psychiatric population, but no commensurate closure of hospitals or reductions in inpatient utilization. Yet, case management services have begun to develop in this country (Wolf, 1997). Regardless of the pathway to community-based care, non-hospitalbased treatment is an impetus to the development of case management. Even a focus on community-based care itself is probably not enough to warrant the development of case management. It seems that a community-oriented ideology coupled with highly complex service delivery systems of health, mental health, and social services may be necessary for the emergence of case management (Aviram, 1996; Rossler, Salize, & Riecher-Rossler, 1996; Wolf, 1997). As a result of categorical funding and specialized services, there are multiple agencies providing differing services with some agencies providing a duplication of services offered by other agencies. With numerous specialized agencies, the system becomes overly complicated to manage by someone who is not very knowledgeable about the available services and resources. Furthermore, the service delivery systems are highly fragmented, as they are categorized by funding sources, target population to be served, and type of service to be provided. Even well-informed families of the clients may not have the essential expertise to maneuver and access these complex service system. Consequently, such complexity, that is also uncoordinated, requires particular training and expertise to manage. However, if the approach to serving individuals with severe mental illness is in residential facilities that are small-scale total institutions, such as nursing homes in the United States, there is less need for assistance in coordinating a multiplicity of services. Although, when some of services and entitlements are provided outside such facilities, staff of the facility may serve some of these case management functions as well.
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In societies with less-complex service delivery systems or less-specialized services, where families undertake a greater responsibility for their ill relatives, which is generally derived from cultural beliefs and expectations, families may function as de facto case managers for their relatives. This is commonly the situation in developing countries, particularly more agrarian cultures. However, as these societies become more urbanized and industrialized, accommodating disabled individuals who cannot functionally contribute to the family may require more specialized programs. With increased complexity of service delivery system, the functions that are served by case management may be required. These factors are the impetuses to the development of case management at the provider level when the objective is to assist disabled individuals to obtain the services, supports, and resources that they need to survive and improve their functioning and quality of life. Consequently, case management in this context is to increase access to needed and available resources and to overcome barriers to the receipt of these services. However, when the primary objective is to reduce cost while still maintaining the former objective, these factors continue their relevance to the emergence of case management. But the approach to case management from the purchaser perspective has different incentives to serving the client than from the provider perspective. The purchasers’ incentives are to save funds or remain within the specified fund allocation, whereas the providers’ incentives are to obtain whatever resources it takes to achieve improvement in their clients. The provider’s service plan is of course tempered by the client’s benefits and eligibility for services. Therefore, some service and resource substitution does occur in the development of a service plan. However, an additional factor that precipitates the rise of case management at the purchaser level is based on the belief that this is an effective strategy for achieving cost savings. The assumption is that the purchaser case manager can assist clients to meet their assessed needs with less expensive, but equally effective service and treatment alternatives. For case management to arise it is unlikely that any one factor will be the impetus. It seems that an interaction of these factors is necessary for a case management service to emerge. In addition, even if the need exists for case management services, unless there is a mechanism for funding the service, it is unlikely that case management will develop. Factors Influencing Model Selection One of the first considerations in selecting a case management approach is the nature of the target population to be served. This includes an assessment of the functioning of the clients and the degree of assistance that is necessary for them to meet their needs. The ability to meet client needs is contingent on the functional capability of the client, environmental supports and resources, including benefits, service availability, and cultural receptivity to the service. In addition, the size of the target population has to be taken into account. For example, ACT has been reserved for the most functionally disabled of those with severe mental illness. Modifications of ACT, such as the addition of an employment or substance abuse specialist is dependent on the designated ob-
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jectives of the case management service and on the targeted subpopulation of those with severe psychiatric disorders to be served. The specific objectives of the case management service are a major factor in the determination of an approach to be selected. Further delineation is undertaken as to whether the objectives are in terms of service provision or cost control. Therefore, even at the provider level, if an ACT model is to be selected, consideration of the specific service objectives will determine the disciplines to be represented on the service team or the ACT adaptation to be selected. System administrators as opposed to the providers may have different objectives, resulting in a system level purchaser case management being selected in conjunction with a specific provider model. Available financial and human resources also influence the selection determination. With limited resources of either funds or personnel, the determination may be to implement more than one model, such as an ACT team for a very specified subpopulation of the target group and intensive or broker case management for others. Due to its high cost and specialized personnel requirements, ACT teams in the United States have been implemented on a limited basis. In areas with few psychiatrists, it may not be feasible to assign a psychiatrist to an ACT service. Some countries are more inclined to use nurses as case managers, due to a tradition of more public health nursing or the need for the team to incorporate nursing functions, such as medication management (McCrone, Beecham, & Knapp, 1994; Muijen, Cooney, Strathdee, Bell, & Hudson, 1994). Other countries may use general practitioners as case managers, based on their established service structure (Wood & Anderson, 1994). Hence, qualifications and training of the personnel required by the model as well as the existing service structure will influence the determination of the model selected. The nature of funding may also influence whether case management can be implemented. For example, at one time in some states in the United States, case management services were not reimbursable under the public medical insurance system. Without financial resources, it is not possible to provide a case management service. Furthermore, the degree of service penetration desired will influence what approach and whether more than one approach is implemented. For example, whether case management is to be implemented on a system-wide basis or as an experimental service innovation will influence case management selection. The rate of penetration may be stipulated by governmental policy or legislation, leaving fewer degrees of freedom in making decisions regarding case management service selection. For example, when national legislation in the United States stipulated that case management was to be provided to all mental health clients who receive substantial public funds, this defined a rather large target population for the service. This resulted in some locations subgrouping the population in order to provide more intensive case management services to some and less intensive to others. This approach requires a means for assessing the service level that will most benefit specific clients. Empirical research offers guidance in selecting a case management approach for a defined population. In some places, scientific evidence may be essential to convincing policy-makers and administrators for allocating or reallo-
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cating resources to pay for the service. In an era of cost containment globally, accountability is a high priority for the selection of service provision. Conclusions Given that case management emerged in the United States in response to effectively serve a population with a multiplicity of needs in a fragmented, uncoordinated, and highly specialized service environment, it is logical that as these factors occur elsewhere, a similar need arises. Other countries have turned to U.S. models for adaptation. However, before determining the type of case management service to implement, countries need to consider the research on case management and assess the validity of the findings in light of the objectives to be served and their own service and cultural environment. Further evolution of case management is continuing to take place in the United States, given the need for cost containment of mental health costs. Case management can no longer be of indeterminate length nor of high intensity for all target population members. As a consequence, a means to determine the model of case management service as appropriate for a given client is required (Hodge & Geisler, 1997). This is an international issue as well, given the global need for cost containment of health services. Research in the United States is beginning to address the issue of when to transfer clients from more intensive to less intensive case management, while maintaining functional gains (Rosenheck & Neale, 1998; Salyers et al., 1998). With more than one model of case management being provided to the same clients, such as a delivering both a provider and a purchaser model, conflict between the two approaches may well arise. To some extent their goals may be antithetical. The provider model emphasizes providing whatever services are needed for as long as they are needed, while the purchaser model focuses on providing less expensive alternatives with very clear time limits. Since the United States is further advanced in the case manager provider domain, hopefully other countries can learn from the United States Similarly, England is more experienced in the arena of the purchaser case manager model, and, therefore, is in a position to offer beneficial information in this regard. References Aviram, U. (1996). Mental health services in Israel at a crossroads: Promises and pitfalls of mental health services in the context of the new national health insurance. International Journal of Law and Psychiatry, 19, 327–372. Bachrach, L. (1976). Deinstitutionalization: An analytical and sociological perspective. Rockville, MD: National Institute of Mental Health, U.S. Department of Health, Education, and Welfare. Bachrach, L. (1989). Case management: Toward a shared definition. Hospital and Community Psychiatry, 40, 883–884. Davies, S., Taylor, R., & Thornicroft, G. (1995). Trends in assertive community mental health services in the United Kingdom. Continuum, 2, 171–183. Freeman, H., & Simmons, O. (1963). The mental patient comes home. New York: John Wiley and Sons. Hodge, M., & Draine, J. (1993). Development of support through case management. In R. Flexer & P. Solomon (Eds.), Psychiatric rehabilitation in practice (pp. 155–169). Boston: Andover Medical Publishers. Hodge, M., & Geisler, L. (1997). Case management practice guidelines for adults with severe and persistent mental illness. Rockville, MD: National Association of Case Management and Community Support Program, Substance Abuse and Mental Health Services Administration.
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Holloway, F., & Carson, J. (1998). Intensive case management for the severely mentally ill. British Journal of Psychiatry, 172, 19–22. Holloway, F., McLean, E., & Robertson, J. (1991). Case management. British Journal of Psychiatry, 159, 142–148. Hoult, J., Reynolds, I., Charbonneau-Powis, M., Weakes, P., & Briggs, J. (1983). Psychiatric hospital versus community treatment: The results of a randomised trial. Australian and New Zealand Journal of Psychiatry, 17, 160–167. Hoult, J., Rosen, A., & Reynolds, I. (1984). Community oriented treatment compared to psychiatric hospital oriented treatment. Social Science and Medicine, 18, 1005–1010. Intagliata, J. (1982). Improving the quality of community care for the chronically mentally disabled: The role of case management. Schizophrenia Bulletin, 6, 655–674. Intagliata, J., & Baker, F. (1983). Factors affecting case management services for the chronically mentally ill. Administration in Mental Health, 11, 75–91. Intagliata, J., Willer, B., & Egri, G. (1986). Role of the family in case management of the mentally ill. Schizophrenia Bulletin, 12, 699–708. Kanter, J. (1989). Clinical case management: Definition, principles, components. Hospital and Community Psychiatry, 40, 361–368. Lamb, H. R. (1980). Therapist-case managers: More than brokers of service. Hospital and Community Psychiatry, 31, 762–764. Lurie, N. (1978). Case management. In J. Talbott (Ed.), The chronic patient (pp. 159–164). Washington, DC: American Psychiatric Association. Marks, I., Connolly, J., Muijen, M., Audine, B., McNamee, G., & Lawrence, R. (1994). Home-based versus hospital-based care for people with serious mental illness. British Journal of Psychiatry, 165, 179–194. McCrone, P., Beecham, J., & Knapp, M. (1994). Community psychiatric nurse teams: Cost-effectiveness of intensive support versus generic care. British Journal of Psychiatry, 165, 218–221. Mechanic, D. (1991). Strategies for integrating public mental health services. Hospital and Community Psychiatry, 42, 797–801. Meuser, K., Bond, G., Drake, R., & Resnick, S. (1998). Models of community care for severe mental illness: A review of research on case management. Schizophrenia Bulletin, 24, 37–74. Muijen, M., Cooney, M., Strathdee, G., Bell, R., & Hudson, A. (1994). Community psychiatric nurse teams: Intensive support versus generic care. British Journal of Psychiatry, 165, 211–217. Netting, F. (1992). Case management: Service or symptom. Social Work, 37, 160–164. Oliver, J., Huxley, P., Bridges, K., & Mohamad, H. (1996). Quality of Life and mental health services. London: Rutledge. Ozarin, L. (1978). The pros and cons of case management. In J. Talbott (Ed.), The chronic mental patient (pp. 165–170). Washington, DC: American Psychiatric Association. Pasamanick, B., Scarpitti, F., & Dinitz, S. (1967). Schizophrenics in the community: An experimental study in the prevention of hospitalization. New York: Appleton-Century-Crofts. Pescosolido, B., Wright, E., & Sullivan, W. (1995). Communities of care: A theoretical perspective on case management models in mental health. Advances in Medical Sociology, 6, 37–79. Rapp, C. (1993). Theory, principles, and methods of strengths model of case management. In M. Harris & H. Bergman (Eds.), Case management for mentally ill patients: Theory and practice (pp. 143–181). Langhorne, PA: Harwood. Rapp, C. (1995). The active ingredients of effective case management: A research synthesis. Unpublished manuscript, University of Kansas School of Social Work. Roach, J. (1993). Clinical case management with severely mentally ill adults. In M. Harris & H. Bergman (Eds.), Case management for mentally ill patients (pp. 17–40). Langhorne, PA: Harwood. Rosenheck, R., & Neale, M. (1998). Intersite variation in the impact of intensive psychiatric community care on hospital use. American Journal of Orthopsychiatry, 68, 191–200. Rossler, W., Loffler, W., Fatkenheuer, B., & Riecher-Rossler, A. (1992). Does case management reduce the rehospitalization rate? Acta Psychiatrica Scandanavia, 86, 445–449. Rossler, W., Salize, H., & Riecher-Rossler, A. (1996). Changing patterns of mental health care in Germany. International Journal of Law and Psychiatry, 19, 391–411. Ryan, P., Ford, R., & Clifford, P. (1991). Case management and community care. London: Research and Development For Psychiatry. Salyers, M., Masterton, T., Fekete, D., Picone, J., & Bond, G. (1998). Transferring clients from intensive case management: Impact on client functioning. American Journal of Orthopsychiatry, 68, 233–245.
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Scott, J., & Dixon, L. (1995). Assertive community treatment and case management for schizophrenia. Schizophrenia Bulletin, 21, 659–668. Shepherd, G., Muijen, M., Hadley, T., & Goldman, H. (1996). Effects of mental health services reform on clinical practice in the United Kingdom. Psychiatric Services, 47, 1351–1355. Shern, D., Surles, R., & Waizer, J. (1989). Designing community treatment systems for the most seriously mentally ill: A state administrative perspective. Journal of Social Issues, 45, 105–117. Sledge, W., Astrachan, B., Thompson, K., Rakfeldt, J., & Leaf, P. (1995). Case management in psychiatry: An analysis of tasks. American Journal of Psychiatry, 152, 1259–1265. Solomon, P. (1976). The use and misuse of state mental hospitals. Journal of Applied Social Sciences, 1, 31–44. Solomon, P. (1992). The efficacy of case management services for severely mentally disabled clients. Community Mental Health Journal, 28, 163–180. Solomon, P. (1998). The conceptual and empirical base of case management for adults with severe mental illness. In J. Williams & K. Ell (Eds.), Advances in mental health research: Implications for practice (pp. 482–497). Washington, DC: NASW Press. Solomon, P. (1999). The evolution of service innovations for adults with severe mental illness. In D. Biegel & A. Blum (Eds.), Innovation in practice and service delivery across the lifespan (pp. 147–168). New York: Oxford University Press. Stein, L. (1992). On the abolishment of the case manager. Health Affairs, 11, 172–177. Strausbaugh, J. (1997). Public moneysaver: Telecare’s intensive case management approach. Behavioral Health Management, March/April, 30–32. Wayslenki, D., Goering, P., Lemire, D., Lindsey, S., & Lancee, W. (1993). Hostel outreach program: Assertive case management for homeless mentally ill persons. Hospital and Community Psychiatry, 44, 848–853. Wilson, D., Tien, G., & Eaves, D. (1995). Increasing the community tenure of mentally disordered offenders: An assertive case management program. International Journal of Law and Psychiatry, 18, 61–69. Wolf, J. (1997). Case management in the Netherlands: The gap between words and deeds. Continuum, 4, 65–79. Wood, K., & Anderson, J. (1994). The effect on hospital admissions of psychiatric case management involving general practitioners: Preliminary results. Australian and New Zealand Journal of Psychiatry, 28, 223–229.
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Precipitants of Case Management from an International Perspective Phyllis Solomon*
Introduction In the United States, over the last 25 years, case management has come to have a prominent role in the mental health service delivery system. More recently, other countries are adopting or adapting U.S. case management practice interventions. This article will examine the precipitants that facilitate the emergence of case management across nations, followed by an assessment of the factors that influence the selection of the case management model to be provided. This analysis will be framed in an historical context of the origins and evolution of case management in the United States. Origins of Case Management in the United States Deinstitutionalization, which has become an international phenomenon, was initially greeted with a great deal of optimism in the United States, where this movement first began (Holloway & Carson, 1998; Holloway, McLean, & Robertson, 1991; Oliver, Huxley, Bridges, & Mohamad, 1996). This enthusiasm was predicated on the belief that psychopharmacological agents would stabilize the behavioral symptoms of those with severe psychiatric disorders; and after a short transition period, with the provision of minimal community care, mainly medication management, these patients would be integrated into the community. The first patients to leave these psychiatric institutions were those with families (Freeman & Simmons, 1963). Families served a similar function to the “total institution” of the psychiatric hospital, where all the human needs of the patients as well as their treatment requirements were provided for within the confines of the facility (Solomon, 1998). Families provided for the basic survival needs of their ill relative and ensured that all that was required for the returning patient was obtained. Those needs that could not be directly met within the family context were sought and coordinated by family *Professor, School of Social Work, University of Pennsylvania, Philadelphia, PA, USA. Address correspondence and reprint requests to Phyllis Solomon, University of Pennsylvania, Philadelphia, PA 19104, USA; E-mail: [email protected] 419
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members from other resources in the community. Consequently, families naturally evolved into serving as their ill relative’s de facto case manager (Intagliata, Willer, & Egri, 1986). As the movement progressed and those patients without families or with families who were unable to serve these coordinating and survival functions were released, it became apparent that the newly created community mental health centers were unable to fulfill all the functions previously offered by public psychiatric hospitals (Bachrach, 1976; Solomon, 1976). Concurrently, with the development of the mental health centers, there was an expansion of human service programs that were categorically funded to serve highly focused purposes. This resulted in an extremely “complex, fragmented, duplicative, and uncoordinated” social service network (Intagliata, 1982, p. 655). This service delivery system was difficult for anyone to navigate, but even more so for individuals with a severe mental illness who are often cognitively, socially, and functionally impaired and who easily become overstimulated when confronted with numerous choices and much information. In response to this situation, “a new group of providers evolved whose job focused on helping former mental patients ‘survive’ in the community by navigating the community mental health and social service systems” (Pescosolido, Wright, & Sullivan, 1995, p. 38). By late 1970, when the U.S. National Institute of Mental Health promoted the development of a community support system for all communities, case management was considered the lynch pin of this system of services (Intagliata & Baker, 1983; Solomon, 1999; Pescosolido et al., 1995). Thus, case management is one strategy for integration of services (Mechanic, 1991). Promotion of this position was furthered almost a decade later when legislation required the inclusion of case management in state plans for mental health clients who received substantial amounts of public funds. Over the past two decades, case management has evolved and matured. It is now widely accepted throughout the United States as an essential service for those with severe mental illness. The Roots of Case Management When case management first arose in the United States, it was perceived as a new innovation. However, this was an established management strategy used throughout health and human services, as well as industry (Lurie, 1978). The term itself is drawn from the fields of social work and administration (Ozarin, 1978; Sledge, Astrachan, Thompson, Rakfeldt, & Leaf, 1995). Case management has long been the primary management device “in every organized arrangement that heals, rehabilitates, cares for, or seeks change for persons with social, physical, or mental deficits” (Ozarin, 1978, p. 165). Consequently, it is a mechanism that is employed within complex organizations where individuals require the services of various components or specialties, such as within hospitals, or within or across service delivery systems, where separate agencies or entities offer differing services (Lurie, 1978). Case management is not unlike social casework and community health nursing (Netting, 1992). One of the early innovations as a community alternative to psychiatric hospitalization was the delivery of care to patients in their homes by public health nurses (Pasa-
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manick, Scarpitti, & Dinitz, 1967). This approach was the foundation of case management for individuals with severe mental illness. Case management is a rather ubiquitous term that lacks clear operationalization in the United States, as well as in other countries (Bachrach, 1989; Solomon, 1998; Wolf, 1997). Basically, case management is a mechanism that employs strategies for service integration to achieve continuity of service and receipt of needed resources based on an assessment of client needs by designating an individual or team of individuals as both responsible and accountable for carrying out the process. The nature of the process is contingent not only on the assessment of client needs, but also the availability of and accessibility to existing resources in the service environment. The Evolution and Functions of Case Management The broker or generalist case management model was the first approach to emerge in the United States in direct response to the need to assist patients released from the state psychiatric hospital in navigating the maze of services. The broker model serves purely a coordinating function by assisting the patients to link with services and resources, monitor the receipt of services, and advocate for the obtainment of essential resources for the patient (Intagliata, 1982). However, in the pure form of totally brokering services without some provision of supportive counseling is rare. This model is an office-based approach that is still widely practiced in the United States. Although this model is adequate for individuals with less severe disability, there was an increasing recognition of the need for more intensive services for those with more severe psychiatric disabilities. In response to this awareness, the Assertive Community Treatment (ACT) model has become prominent in the United States and implemented in such countries as England (Marks et al., 1994), Germany (Rossler et al., 1992); Australia (Hoult, Reynolds, CharbonneauPowis, Weakes, & Briggs, 1983; Hoult, Rosen, & Reynolds, 1984;) and Canada (Wayslenki, Goering, Lemire, Lindsey, & Lancee, 1993; Wilson, Tien, & Eaves, 1995). The ACT model is based on a service innovation developed in Madison, Wisconsin entitled Program for Assertive Community Treatment (PACT), which was intended to be an alternative to psychiatric hospitalization. This was designed as a comprehensive treatment package with three shifts a day, 7 days a week, and delivered by a multidisciplinary team of professionals. The idea was to replicate the hospital in the community by having a multidisciplinary team provide all the services a client needed in the client’s own environment. The ACT services have modified this program, but retain the multidisciplinary aspect; 24-hour coverage (with night coverage frequently provided by a local crisis service); community-based service delivery rather than officebased; shared caseloads; and with most services delivered by the team in vivo, with few brokered from elsewhere in the community. These services are usually time unlimited and have low staff-to-client ratios. This is a costly service that requires a good deal of training. Consequently, although this model has much research to indicate its efficacy (Meuser et al., 1998; Scott & Dixon, 1995) and is currently being promoted in the United States by the National Alliance for the Mentally Ill (a family advocacy organization), in actual practice, this is pro-
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vided on a limited basis. Specialized forms of ACT have been developed that focus on defined populations, such as forensic clients or substance abusers, or on specified objectives such as increasing competitive employment (Solomon, 1998). Recently a new model, intensive case management (ICM), has emerged which is usually reserved for high utilizers of services (Shern, Surles, & Waizer, 1989). This model employs many of the same features as ACT, such as low client-to-staff ratios, assertive outreach, delivery of services in the client’s environment, and practical assistance and training in skills of daily living. The major distinction between this model and ACT is that the former usually does not have a multidisciplinary team and caseloads are not shared, although in some instances case managers are configured as a team, such as two case managers (Holloway & Carson, 1998; Mueser et al., 1998). This model is growing in popularity in the United States, but does have greater reliance on the service delivery system than ACT. Therefore, ICM necessitates more coordination of other services, but requires fewer modifications within the delivery system. There appears to be unrealistic expectations that intensive case management approaches can compensate for an inadequate service system. Given that in most instances, other than ACT, case management relies on the system of services for resources for their clients, case management is only as good as the service system in which it is embedded (Stein, 1992). In addition to the broker model, some version of intensive case management is widely practiced in the United States. Other models have also emerged that have different emphasizes, but are practiced on a more limited basis. The strengths model focuses on strengths rather than deficits and uses resources outside of the mental health system in order to achieve community integration (Rapp, 1993, 1995). The rehabilitation model emphasizes delivering case management based on the desires and goals determined by the client and accessing resources that compensate for environmental barriers and client deficits (Hodge & Draine, 1993; Solomon, 1992). Clinical case management incorporates skill teaching and administrative functions of the previous models, but also includes psychotherapy as an essential component of the service (Kanter, 1989; Lamb, 1980; Roach, 1993). Personal growth and recovery from, or adaptation to, the illness is also emphasized (Kanter, 1989). All the models discussed thus far are provider models, predominately in the public sector, with some movement into the private arena (Strausbaugh, 1997). More recently, a purchaser model of case management has developed. In this regard, case management is essentially synonymous with utilization review, which is performed by an insurer or a managed care company. A representative of the insurer or managed care company proposes lower-cost alternative treatments to the clinician on behalf of the client (Sledge et al., 1995). In contrast to the public sector provider case management approaches where the goal is to increase access to care and ultimately increase service utilization, the private purchaser approach is to control cost by limiting resource use and choosing less expensive alternatives, such as community-based care instead of hospitalization (Sledge et al., 1995). These various models are not mutually exclusive within a given geographical location as well as within a given agency, for more than one model may be prac-
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ticed within the same organizational entity. For example, it is not uncommon for an agency to provide broker case management to the vast majority of their clients, and have one ACT team for a specialized group of clients. Similarly, with the public sector mental health programs moving into managed care, the purchaser approach may also be instituted as well. It is likely that this purchaser case manager will influence the practice of these provider models. For example, who receives case management, with what intensity (i.e., what model of case management) and for how long will be determined by the purchaser rather than the provider. This separation of purchaser and provider case manager is comparable to what has emerged in England (Davies et al., 1995; Ryan, Ford, & Clifford, 1991; Shepherd et al., 1996). Precipitants of Case Management With this as background, an assessment of the factors that influence the emergence of case management as a provider approach in the United States as well as elsewhere can be analyzed. A major factor that is quite evident from the U.S. experience is that an orientation of community-based care for individuals with severe mental illness can precipitate the need for a responsible and accountable entity to coordinate, link to, and advocate for resources and services for this disabled population. Closure of public hospitals or reductions in inpatient use is not necessarily essential for this community-based focus to arise, but clearly plays a primary role. For example, in the Netherlands there has been an increased emphasis on community-based care for the psychiatric population, but no commensurate closure of hospitals or reductions in inpatient utilization. Yet, case management services have begun to develop in this country (Wolf, 1997). Regardless of the pathway to community-based care, non-hospitalbased treatment is an impetus to the development of case management. Even a focus on community-based care itself is probably not enough to warrant the development of case management. It seems that a community-oriented ideology coupled with highly complex service delivery systems of health, mental health, and social services may be necessary for the emergence of case management (Aviram, 1996; Rossler, Salize, & Riecher-Rossler, 1996; Wolf, 1997). As a result of categorical funding and specialized services, there are multiple agencies providing differing services with some agencies providing a duplication of services offered by other agencies. With numerous specialized agencies, the system becomes overly complicated to manage by someone who is not very knowledgeable about the available services and resources. Furthermore, the service delivery systems are highly fragmented, as they are categorized by funding sources, target population to be served, and type of service to be provided. Even well-informed families of the clients may not have the essential expertise to maneuver and access these complex service system. Consequently, such complexity, that is also uncoordinated, requires particular training and expertise to manage. However, if the approach to serving individuals with severe mental illness is in residential facilities that are small-scale total institutions, such as nursing homes in the United States, there is less need for assistance in coordinating a multiplicity of services. Although, when some of services and entitlements are provided outside such facilities, staff of the facility may serve some of these case management functions as well.
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In societies with less-complex service delivery systems or less-specialized services, where families undertake a greater responsibility for their ill relatives, which is generally derived from cultural beliefs and expectations, families may function as de facto case managers for their relatives. This is commonly the situation in developing countries, particularly more agrarian cultures. However, as these societies become more urbanized and industrialized, accommodating disabled individuals who cannot functionally contribute to the family may require more specialized programs. With increased complexity of service delivery system, the functions that are served by case management may be required. These factors are the impetuses to the development of case management at the provider level when the objective is to assist disabled individuals to obtain the services, supports, and resources that they need to survive and improve their functioning and quality of life. Consequently, case management in this context is to increase access to needed and available resources and to overcome barriers to the receipt of these services. However, when the primary objective is to reduce cost while still maintaining the former objective, these factors continue their relevance to the emergence of case management. But the approach to case management from the purchaser perspective has different incentives to serving the client than from the provider perspective. The purchasers’ incentives are to save funds or remain within the specified fund allocation, whereas the providers’ incentives are to obtain whatever resources it takes to achieve improvement in their clients. The provider’s service plan is of course tempered by the client’s benefits and eligibility for services. Therefore, some service and resource substitution does occur in the development of a service plan. However, an additional factor that precipitates the rise of case management at the purchaser level is based on the belief that this is an effective strategy for achieving cost savings. The assumption is that the purchaser case manager can assist clients to meet their assessed needs with less expensive, but equally effective service and treatment alternatives. For case management to arise it is unlikely that any one factor will be the impetus. It seems that an interaction of these factors is necessary for a case management service to emerge. In addition, even if the need exists for case management services, unless there is a mechanism for funding the service, it is unlikely that case management will develop. Factors Influencing Model Selection One of the first considerations in selecting a case management approach is the nature of the target population to be served. This includes an assessment of the functioning of the clients and the degree of assistance that is necessary for them to meet their needs. The ability to meet client needs is contingent on the functional capability of the client, environmental supports and resources, including benefits, service availability, and cultural receptivity to the service. In addition, the size of the target population has to be taken into account. For example, ACT has been reserved for the most functionally disabled of those with severe mental illness. Modifications of ACT, such as the addition of an employment or substance abuse specialist is dependent on the designated ob-
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jectives of the case management service and on the targeted subpopulation of those with severe psychiatric disorders to be served. The specific objectives of the case management service are a major factor in the determination of an approach to be selected. Further delineation is undertaken as to whether the objectives are in terms of service provision or cost control. Therefore, even at the provider level, if an ACT model is to be selected, consideration of the specific service objectives will determine the disciplines to be represented on the service team or the ACT adaptation to be selected. System administrators as opposed to the providers may have different objectives, resulting in a system level purchaser case management being selected in conjunction with a specific provider model. Available financial and human resources also influence the selection determination. With limited resources of either funds or personnel, the determination may be to implement more than one model, such as an ACT team for a very specified subpopulation of the target group and intensive or broker case management for others. Due to its high cost and specialized personnel requirements, ACT teams in the United States have been implemented on a limited basis. In areas with few psychiatrists, it may not be feasible to assign a psychiatrist to an ACT service. Some countries are more inclined to use nurses as case managers, due to a tradition of more public health nursing or the need for the team to incorporate nursing functions, such as medication management (McCrone, Beecham, & Knapp, 1994; Muijen, Cooney, Strathdee, Bell, & Hudson, 1994). Other countries may use general practitioners as case managers, based on their established service structure (Wood & Anderson, 1994). Hence, qualifications and training of the personnel required by the model as well as the existing service structure will influence the determination of the model selected. The nature of funding may also influence whether case management can be implemented. For example, at one time in some states in the United States, case management services were not reimbursable under the public medical insurance system. Without financial resources, it is not possible to provide a case management service. Furthermore, the degree of service penetration desired will influence what approach and whether more than one approach is implemented. For example, whether case management is to be implemented on a system-wide basis or as an experimental service innovation will influence case management selection. The rate of penetration may be stipulated by governmental policy or legislation, leaving fewer degrees of freedom in making decisions regarding case management service selection. For example, when national legislation in the United States stipulated that case management was to be provided to all mental health clients who receive substantial public funds, this defined a rather large target population for the service. This resulted in some locations subgrouping the population in order to provide more intensive case management services to some and less intensive to others. This approach requires a means for assessing the service level that will most benefit specific clients. Empirical research offers guidance in selecting a case management approach for a defined population. In some places, scientific evidence may be essential to convincing policy-makers and administrators for allocating or reallo-
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cating resources to pay for the service. In an era of cost containment globally, accountability is a high priority for the selection of service provision. Conclusions Given that case management emerged in the United States in response to effectively serve a population with a multiplicity of needs in a fragmented, uncoordinated, and highly specialized service environment, it is logical that as these factors occur elsewhere, a similar need arises. Other countries have turned to U.S. models for adaptation. However, before determining the type of case management service to implement, countries need to consider the research on case management and assess the validity of the findings in light of the objectives to be served and their own service and cultural environment. Further evolution of case management is continuing to take place in the United States, given the need for cost containment of mental health costs. Case management can no longer be of indeterminate length nor of high intensity for all target population members. As a consequence, a means to determine the model of case management service as appropriate for a given client is required (Hodge & Geisler, 1997). This is an international issue as well, given the global need for cost containment of health services. Research in the United States is beginning to address the issue of when to transfer clients from more intensive to less intensive case management, while maintaining functional gains (Rosenheck & Neale, 1998; Salyers et al., 1998). With more than one model of case management being provided to the same clients, such as a delivering both a provider and a purchaser model, conflict between the two approaches may well arise. To some extent their goals may be antithetical. The provider model emphasizes providing whatever services are needed for as long as they are needed, while the purchaser model focuses on providing less expensive alternatives with very clear time limits. Since the United States is further advanced in the case manager provider domain, hopefully other countries can learn from the United States Similarly, England is more experienced in the arena of the purchaser case manager model, and, therefore, is in a position to offer beneficial information in this regard. References Aviram, U. (1996). Mental health services in Israel at a crossroads: Promises and pitfalls of mental health services in the context of the new national health insurance. International Journal of Law and Psychiatry, 19, 327–372. Bachrach, L. (1976). Deinstitutionalization: An analytical and sociological perspective. Rockville, MD: National Institute of Mental Health, U.S. Department of Health, Education, and Welfare. Bachrach, L. (1989). Case management: Toward a shared definition. Hospital and Community Psychiatry, 40, 883–884. Davies, S., Taylor, R., & Thornicroft, G. (1995). Trends in assertive community mental health services in the United Kingdom. Continuum, 2, 171–183. Freeman, H., & Simmons, O. (1963). The mental patient comes home. New York: John Wiley and Sons. Hodge, M., & Draine, J. (1993). Development of support through case management. In R. Flexer & P. Solomon (Eds.), Psychiatric rehabilitation in practice (pp. 155–169). Boston: Andover Medical Publishers. Hodge, M., & Geisler, L. (1997). Case management practice guidelines for adults with severe and persistent mental illness. Rockville, MD: National Association of Case Management and Community Support Program, Substance Abuse and Mental Health Services Administration.
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