Case management Case management By By Prof. Ki Ki- -Yan MAK - - PowerPoint PPT Presentation

Case management Case management

By By Prof.

• Prof. Ki

Ki-

• Yan MAK

Yan MAK

Introduction Introduction

• Need to coordinate different psychiatric

Need to coordinate different psychiatric services led to development of case services led to development of case management model management model

• Yet there is absence of a common

Yet there is absence of a common definition for all users. A general one is definition for all users. A general one is “ “A strategy for distributing and A strategy for distributing and coordinating services on behalf of coordinating services on behalf of patients patients” ” (

(Modrcin Modrcin et al, 1985 Case management with et al, 1985 Case management with psychiatrically disabled individuals. Lawrence, Kansas: Universi psychiatrically disabled individuals. Lawrence, Kansas: University of ty of Kansas) Kansas)

Historical development Historical development

• In the US, a rapid expansion of human service

In the US, a rapid expansion of human service programs programs – – specialized services for narrowly target specialized services for narrowly target groups, which result in many uncoordinated, groups, which result in many uncoordinated, fragmented, duplication services. Integration programs fragmented, duplication services. Integration programs are needed, and case management is one. are needed, and case management is one.

• Deinstitutionalisation

Deinstitutionalisation demand reasonable continuity of demand reasonable continuity of service in the community, but they developed service in the community, but they developed complicated adaptation problems in society. Case complicated adaptation problems in society. Case managers are opportune providers to fill the various managers are opportune providers to fill the various needs needs

• Ref:

Ref: Intagliata Intagliata, J (1982) , J (1982) Schiz Schiz Bull, 8, 655 Bull, 8, 655-

• 673

673

Historical development of Historical development of ACT ACT

• 1965

1965-

• 70 Arnold Ludwig, Arnold Marx & Mary Ann Test

70 Arnold Ludwig, Arnold Marx & Mary Ann Test implemented innovative inpatient psychosocial implemented innovative inpatient psychosocial programs to combat institutionalization at Mendota programs to combat institutionalization at Mendota State Hospital, Wisconsin, resulting in better hospital State Hospital, Wisconsin, resulting in better hospital adjustment & more ready for discharge. But no adjustment & more ready for discharge. But no improvement in community adjustment. Joined by improvement in community adjustment. Joined by Leonard Stein, intensive Leonard Stein, intensive postdischarge postdischarge community community aftercare program was provided, effective even for aftercare program was provided, effective even for disturbed symptomatic patients disturbed symptomatic patients

• 1970

1970-

• Total In

Total In-

• Community Treatment & Training in

Community Treatment & Training in Community Living, Assertive Community Treatment Community Living, Assertive Community Treatment Team, etc. were developed with positive results Team, etc. were developed with positive results

• Ref: Thompson et al (1990) Hosp &

Ref: Thompson et al (1990) Hosp & Comm Comm Psychiat Psychiat, 41, 625 , 41, 625-

• 634

634

Definition Definition

• A modality of health practice that, in

A modality of health practice that, in coordination with the traditional focus on coordination with the traditional focus on biological & psychological functioning, biological & psychological functioning, addresses the overall maintenance of the addresses the overall maintenance of the patient patient’ ’s physical and social environment with s physical and social environment with the goals of facilitating survival, personal the goals of facilitating survival, personal growth, community participation, and recovery growth, community participation, and recovery from or adaptation to the illness from or adaptation to the illness

• Kanter

Kanter, J (1989) Hosp & , J (1989) Hosp & Commun Commun Psychiat Psychiat, 40 361 , 40 361-

• 376

376

Hong Kong definition Hong Kong definition

• A systematic process of assessment,

A systematic process of assessment, service co service co-

• ordination, monitoring and
• rdination, monitoring and

evaluation through which the unique evaluation through which the unique needs of clients are met needs of clients are met

• Hospital Authority, 1995

Hospital Authority, 1995

Community psychiatric Community psychiatric nurses as case managers nurses as case managers

• Direct client nursing care at home (& injections

Direct client nursing care at home (& injections prn prn) )

• Continuity of care from hospital to community

Continuity of care from hospital to community

• Often have administrative training & should be able to

Often have administrative training & should be able to assess level of functioning & other needs including assess level of functioning & other needs including physical & psychological aspects physical & psychological aspects

• Used to 24 hours shift work, with ease to call on

Used to 24 hours shift work, with ease to call on medical/psychological support during crisis medical/psychological support during crisis

• Introduced to community nursing services (general) in

Introduced to community nursing services (general) in 1996 1996 (Mackenzie, et al, 1997 Evaluation of a pilot project to introdu

(Mackenzie, et al, 1997 Evaluation of a pilot project to introduce ce case management into community nursing services in Hong Kong. Th case management into community nursing services in Hong Kong. The e Chinese University of Hong Kong) Chinese University of Hong Kong)

Case managers Case managers

• In principle, every health care team member ca

In principle, every health care team member ca be a case manager, but matching the most be a case manager, but matching the most suitable person is essential for the success suitable person is essential for the success

• Initially case managers are to refer to,

Initially case managers are to refer to, coordinate and integrate various psychiatric coordinate and integrate various psychiatric services into a cohesive program best suited to services into a cohesive program best suited to the individual needs of the patients the individual needs of the patients

• Special features:

Special features: individualised individualised continuity of continuity of care, comprehensiveness (a variety of care, comprehensiveness (a variety of services), services), longitudinality longitudinality (over time), supportive (over time), supportive relationship with caregiver relationship with caregiver

Case management Case management functions & activities functions & activities

• Assessment: information collection & integration

Assessment: information collection & integration

• Linking: aware of resources & barriers for devising

Linking: aware of resources & barriers for devising treatment plan, support patient own responsibility treatment plan, support patient own responsibility

• Monitoring: notice changes though regular contact

Monitoring: notice changes though regular contact

• Assistance in daily living: encourage realistic

Assistance in daily living: encourage realistic independence, with direct/indirect assistance independence, with direct/indirect assistance

• Crisis intervention: identify early warning signs, timely

Crisis intervention: identify early warning signs, timely support support

• Advocacy: identify gaps & needs

Advocacy: identify gaps & needs

• NB collaboration between professionals & family

NB collaboration between professionals & family members members

• Ref:

Ref: Intagliata Intagliata et al (1986) et al (1986) Schiz Schiz Bull, 12, 700 Bull, 12, 700-

• 708

708

Principles of clinical case Principles of clinical case management management

• Continuity of care that address the patients need for an

Continuity of care that address the patients need for an extended period extended period

• Use of case management

Use of case management personalised personalised relationship (a relationship (a companion or guide rather than an agent) companion or guide rather than an agent)

• Titrating environmental support and structure (at

Titrating environmental support and structure (at

• ptimal level) to patient
• ptimal level) to patient’

’s changing needs s changing needs

• Flexibility tailor the intervention strategies to

Flexibility tailor the intervention strategies to accommodate the diverse needs accommodate the diverse needs

• Facilitating patient personal resourcefulness in self

Facilitating patient personal resourcefulness in self-

• management

management

• Kanter

Kanter, J (1989) Hosp & , J (1989) Hosp & Commun Commun Psychiat Psychiat, 40 361 , 40 361-

• 368

368

Models of case Models of case management management

• The broker model

The broker model

• The clinician model

The clinician model

• The Assertive Community Treatment

The Assertive Community Treatment model model

• The Intensive Case Management model

The Intensive Case Management model

• The strengths model

The strengths model

• The rehabilitation model

The rehabilitation model

• Ref:

Ref: Mueser Mueser et al, 1998 et al, 1998 Schiz Schiz Bull, 24, , 37 Bull, 24, , 37-

• 74

74

Modifications Modifications

• Modifications of all models for particular

Modifications of all models for particular needs needs

• Success not always replicable

Success not always replicable

• Can be extended to other psychiatric

Can be extended to other psychiatric disorders & less severe patients disorders & less severe patients

• Can be quite costly e.g. small patient

Can be quite costly e.g. small patient number number

Intensities of case Intensities of case management management

• Minimum

Minimum

• Outreach, client assessment, referral to service

Outreach, client assessment, referral to service providers providers

• Comprehensive

Comprehensive

• The above + advocacy for client, direct casework,

The above + advocacy for client, direct casework, developing natural support systems, reassessment, developing natural support systems, reassessment, advocacy for resource development, monitoring advocacy for resource development, monitoring quality, public education, crisis intervention quality, public education, crisis intervention

• Ref:

Ref: Intagliata Intagliata, J (1982) , J (1982) Schiz Schiz Bull, 8, 655 Bull, 8, 655-

• 67

67

Training of case managers Training of case managers

• Commitment & compassion

Commitment & compassion

• Professional & clinical skills

Professional & clinical skills

• Human services & bureaucratic skills

Human services & bureaucratic skills

• Team building & negotiating skills

Team building & negotiating skills

• Teaching & communication skills

Teaching & communication skills

• NB Basic qualifications & experience,

NB Basic qualifications & experience, plus in plus in-

• service training & adequate

service training & adequate supervision & personal support supervision & personal support

Optimal caseload Optimal caseload

• A balance between newly referred unstable patients

A balance between newly referred unstable patients and long and long-

• term stabilized cases. Depends on the

term stabilized cases. Depends on the availability and accessibility of supportive services. availability and accessibility of supportive services. Ranges from 5 (for high Ranges from 5 (for high-

• risk group e.g. acute psychotic

risk group e.g. acute psychotic patients) to 50 per manager patients) to 50 per manager (

(Kanter Kanter, J (1989) Hosp & , J (1989) Hosp & Commun Commun Psychiat Psychiat, 40 361 , 40 361-

• 368)

368)

• Too high caseload lead to managers becoming

Too high caseload lead to managers becoming reactive rather than proactive; always on the run with reactive rather than proactive; always on the run with little time to know the clients; to do things for clients little time to know the clients; to do things for clients instead of helping them independent; contact more instead of helping them independent; contact more determined by clients initiative, increased time to determined by clients initiative, increased time to document their efforts rather than time with clients document their efforts rather than time with clients (Baker

(Baker et al, 1980. Case Management Evaluation. et al, 1980. Case Management Evaluation. Tefco Tefco Services, Inc., Buffalo, Services, Inc., Buffalo, NY.) NY.)

Teamw ork Teamw ork

• Via multidisciplinary group or an agency

Via multidisciplinary group or an agency

• Advantages include

Advantages include

• 1) more continuous cover & coordination (as

1) more continuous cover & coordination (as unavailability of a single manager does not incapacitate unavailability of a single manager does not incapacitate the client) the client)

• 2) better planning based on more points of view,

2) better planning based on more points of view, important for maintaining energy & creativity in working important for maintaining energy & creativity in working with chronic clients with chronic clients

• 3) avoid isolation that may lead to burnout of the

3) avoid isolation that may lead to burnout of the manager who faces tedious, endless and emotionally manager who faces tedious, endless and emotionally draining problems draining problems

• Test , M (1979) in Stein L (ed.) Community Support Systems for t

Test , M (1979) in Stein L (ed.) Community Support Systems for the Long he Long-

• Term Patient. San Francisco, CA.

Term Patient. San Francisco, CA. Jossey Jossey-

• Bass, Inc. pp.15

Bass, Inc. pp.15-

• 23

23

Problems w ith teamw ork Problems w ith teamw ork

• Interagency suspicion & rivalry, with case

Interagency suspicion & rivalry, with case managers caught in the middle managers caught in the middle

• Incoordination

Incoordination between inpatient & outpatient between inpatient & outpatient service service

• Conflict with other members of the

Conflict with other members of the multidisciplinary team multidisciplinary team

• Role conflicts at work

Role conflicts at work

• Vulnerable to sickness & holidays, and burnout

Vulnerable to sickness & holidays, and burnout

• Other administrative, legal & financial problems

Other administrative, legal & financial problems

Core tasks of care Core tasks of care management management

• Identify patients

Identify patients

• Assess needs

Assess needs

• Design care package

Design care package

• Coordinate service delivery

Coordinate service delivery

• Monitor service delivery

Monitor service delivery

• Evaluate effectiveness of services

Evaluate effectiveness of services

• Modify care package

Modify care package

• Repeat cycle unless services no longer needed

Repeat cycle unless services no longer needed

ref: ref: Thornicroft Thornicroft et al (1995) in TS et al (1995) in TS Brugha Brugha (ed.) Social Support & Psychiatric (ed.) Social Support & Psychiatric

• Disorder. Cambridge
• Disorder. Cambridge Univ

Univ Press: Cambridge Press: Cambridge

Health economics of ACT Health economics of ACT

• Direct mental health Rx: in, out & day Rx

Direct mental health Rx: in, out & day Rx

• Indirect Rx: gen medical Rx, social services, vocational

Indirect Rx: gen medical Rx, social services, vocational training, recreational & training, recreational & avocational avocational

• Law enforcement (police & judicial, probation & parole)

Law enforcement (police & judicial, probation & parole) & fire dept. & fire dept.

• Maintenance: cash payments, subsidies, services for

Maintenance: cash payments, subsidies, services for basic needs (shelter, food, etc.) basic needs (shelter, food, etc.)

• Family burden: cash, lodging & services to patients,

Family burden: cash, lodging & services to patients, lost of earnings, time off & adjustment to work lost of earnings, time off & adjustment to work

• Total costs = volume of services x unit cost

Total costs = volume of services x unit cost

• Ref: based on *

Ref: based on *Weisbrod Weisbrod, BA (1983) J Health Politics, Policy & Law, 7, 808 , BA (1983) J Health Politics, Policy & Law, 7, 808-

• 845,

845, modifed modifed by Dickey et al (1986) Administration in Mental Health, 13, 189 by Dickey et al (1986) Administration in Mental Health, 13, 189-

• 201

201

Societal costs of ACT Societal costs of ACT

• Cost

Cost-

• accounting modified on

accounting modified on Weisbrod

• Weisbrod. Resource use

. Resource use & cost data were collected for mental & physical health, & cost data were collected for mental & physical health, social, law enforcement, other maintenance services & social, law enforcement, other maintenance services & family services in a mobile ACT in Madison, Wisconsin family services in a mobile ACT in Madison, Wisconsin (from clients & family members, private & public (from clients & family members, private & public agency records & insurance claim files); 94 participants agency records & insurance claim files); 94 participants (no stat diff with non (no stat diff with non-

• participants)

participants)

• Results: average societal costs were US$23,061 in

Results: average societal costs were US$23,061 in

• 1988. Maintenance costs were the largest share,
• 1988. Maintenance costs were the largest share,

followed by mental health Rx, family burden, indirect followed by mental health Rx, family burden, indirect Rx & law enforcement. 85% of the financing came from Rx & law enforcement. 85% of the financing came from the public sector the public sector

• Ref: Wolff, et al (1995)

Ref: Wolff, et al (1995) Psychiat Psychiat Services, 46, 898 Services, 46, 898-

• 906

906

Cost Cost -

• effectiveness of ACT

effectiveness of ACT

• Costs & Benefits Analysis is affected by

Costs & Benefits Analysis is affected by characteristics of various models*, the clients characteristics of various models*, the clients served, contextual factors (resources available served, contextual factors (resources available & financial incentives built in) & financial incentives built in)

• *affect resource management in 4 areas

*affect resource management in 4 areas -

• whether client or case manager is primarily

whether client or case manager is primarily responsible for directing the course of treatment, responsible for directing the course of treatment,

• whether reduction in hospitalization is a primary

whether reduction in hospitalization is a primary goal, goal,

• whether team management is used, &

whether team management is used, &

• how the size of caseloads is determined

how the size of caseloads is determined

• Ref: Clark & Fox (1993) Hosp &

Ref: Clark & Fox (1993) Hosp & Comm Comm Psychiat Psychiat, 44, 469 , 44, 469-

• 473

473

Hong Kong Hong Kong (Mak, KY &

Gow , L 1996)

• The employment of an aftercare social worker (generic,

The employment of an aftercare social worker (generic, non non-

• experienced at that time) for 30 chronic mentally ill

experienced at that time) for 30 chronic mentally ill patients discharged from half patients discharged from half-

• way

way-

• houses of the

houses of the Mental Health Association of Hong Kong Mental Health Association of Hong Kong

• Results:

Results: Cf Cf to 30 matched control, just initial contact to 30 matched control, just initial contact

• After 1

After 1st

st year: no difference

year: no difference

• After 2

After 2nd

nd year: still no difference in BPRS (clinical)

year: still no difference in BPRS (clinical)

• decreased

decreased rehospitlisation rehospitlisation due to relapses due to relapses

• Decreased ALOS

Decreased ALOS

• Increased employment (open or sheltered)

Increased employment (open or sheltered)

• Decreased reliance on Public Assistance

Decreased reliance on Public Assistance

• Decreased law

Decreased law-

• breaking

breaking behaviour behaviour

• Better QOL e.g. food & recreation

Better QOL e.g. food & recreation

• Cost

Cost-

• effective (despite increased expenditure (employment,

effective (despite increased expenditure (employment, instruction by researchers) instruction by researchers)

Hong Kong studies ( Hong Kong studies (Chan, S

Chan, S et al, 1999 J Advanced Nursing et al, 1999 J Advanced Nursing)

)

• In a controlled study using psychiatric

In a controlled study using psychiatric community nurses as case managers, community nurses as case managers, the experimental group had better mental the experimental group had better mental status & level of functioning, with clients status & level of functioning, with clients & & carers carers perceiving that the service was perceiving that the service was beneficial, beneficial, cf cf to conventional CPN to conventional CPN service; and no sig difference between service; and no sig difference between the costs the costs

Conclusion Conclusion

• Intensive care for certain severely disabled

Intensive care for certain severely disabled persons persons

• Personalised

Personalised care better than generic care care better than generic care

• Qualification of case manager depends on

Qualification of case manager depends on needs, multi needs, multi-

• handicap needs multi

handicap needs multi-

• disciplinary

disciplinary service service

• Optimal caseload, duration of care not clearly

Optimal caseload, duration of care not clearly defined defined

• Other rehab measures necessary

Other rehab measures necessary (comprehensive care) (comprehensive care)